Você está na página 1de 9

J Head Trauma Rehabil

Vol. 24, No. 5, pp. 324–332


Copyright c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Psychiatric Disorders Following


Traumatic Brain Injury: Their Nature
and Frequency
Rochelle Whelan-Goodinson, DPsych; Jennie Ponsford, PhD; Lisa Johnston, PhD;
Fiona Grant, PhD

Objectives: To retrospectively establish the nature and frequency of Axis I psychiatric disorders pre- and post-TBI.
Participants: One hundred participants who were 0.5 to 5.5 years post mild to severe TBI and 87 informants,
each evaluated at a single time point. Main Measure: The Structured Clinical Interview for DSM-IV Disorders
(SCID-I). Results: Preinjury, 52% received a psychiatric diagnosis, most commonly substance use disorder (41%),
followed by major depressive disorder (17%) and anxiety (13%). Postinjury, 65% received a diagnosis, of which
major depression became the most common (45%), followed by anxiety (38%) and substance use disorder (21%).
Frequency of depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and phobias
rose from preinjury to postinjury. More than two-thirds of postinjury depression and anxiety cases were novel and
showed poor resolution rates. Few novel cases of substance use disorder were noted. Psychotic disorders, somatoform
disorders, and eating disorders occurred at frequencies similar to those in the general population. Conclusions: A
high frequency of postinjury psychiatric disorders was evident up to 5.5 years postinjury, with many novel cases of
depression and anxiety. Individuals with TBI should be screened for psychiatric disorders at various time points post-
injury without reliance on history of psychiatric problems to predict who is at risk, so that appropriate intervention
can be offered. Keywords: anxiety, brain injuries, depression, psychotic disorders

T RAUMATIC BRAIN INJURIES (TBI) are among


the leading causes of death and disability in indi-
viduals under the age of 45 years, most commonly young
disorders, from 8% to 18%.11,15 In the Australian general
population, prevalence rates for depression and anxiety
over a 12 month interval are approximately 5.7% and
males.1 Brain injury is often diffuse and bilateral, com- 9.7%, respectively, and 2.2% to 3.5% for substance use
monly including frontotemporal regions, limbic system, disorders.16 Comorbidity between anxiety and depres-
basal ganglia, and hippocampus and causing cognitive, sion is high; 1 in 3 people with an anxiety disorder also
behavioral, and emotional changes. Such changes dis- has an affective disorder. Few TBI studies have examined
rupt the lives of these young people, affecting their abil- a range of psychiatric disorders, most having focused
ity to establish independence, a vocation, and relation- on depression.2,7,10,14 Two studies have attempted to as-
ships, potentially leading to loss of self-esteem.2–4 sess Axis II personality disorders in TBI participants.7,17
A proportion of those with TBI develop psychiatric However, brain injury is an exclusionary criterion for
problems postinjury. Variable frequencies of psychiatric Diagnostic and Statistical Manual-IV (DSM-IV) diagno-
disorders have been reported at various time points fol- sis of a personality disorder. Furthermore, certain per-
lowing TBI, those for depression and anxiety ranging sonality changes may be symptoms of frontal lobe
from 14% to 77%,2,5–13 and for substance use from injury.
4.9% to 28%.2,7,10,11,14 High rates of current depres- Some studies2,7,10,11,18–20 have identified high fre-
sion and anxiety have also been reported, from 10% to quencies of preinjury psychiatric disorders, ranging from
46%,2,7,10,11 as have high rates of current substance use 18% to 51%; however, others have excluded people with
a preinjury psychiatric diagnosis.9,21–23 Only 3 known
studies have used semistructured or structured clini-
Author Affiliations: School of Psychology, Psychiatry and Psychological
Medicine, Monash University, Melbourne, Australia (Drs Whelan- cal interviews to establish preinjury psychiatric diag-
Goodinson and Ponsford and Ms Grant), Monash-Epworth Rehabilitation noses, and all found higher rates of such diagnoses
Research Centre, Epworth Hospital, Melbourne, Australia (Drs Ponsford postinjury.7,10,11 Participants in these studies were inter-
and Johnston), and National Trauma Research Institute, Melbourne,
Australia (Dr Ponsford). viewed at wide-ranging follow-up intervals—on average
3, 8, and 48 years postinjury, respectively. Retrospective
Corresponding Author: Jennie Ponsford, PhD, Department of Psychology,
Monash University, Clayton, Victoria 3800, Australia (jennie.ponsford@ recall of preinjury psychiatric symptoms may be unre-
med.monash.edu.au). liable at such long times after injury, particularly given
324
Psychiatric Disorders Following Traumatic Brain Injury 325

the likely presence of cognitive impairments. Arguably, tor retardation,33–35 potentially leading to overestima-
significant others should be consulted to improve relia- tion of prevalence of certain disorders. On the other
bility, which these studies appear not to have done. hand, cognitive deficits leading to lack of self-awareness
The variability in reported frequencies of preinjury or denial may result in underdiagnosis of disorders.36
and postinjury disorders may be related to variable tim- The clinical interview is important to establish accurate
ing of assessment, often within the same study. Studies and reliable diagnoses by distinguishing symptoms due
have included participants with injuries sustained from to brain injury from those due to a psychiatric disorder.
1 to 227 days,23 1 to 37 years,10 and 27 to 48 years7 DSM-based clinical interviews have been shown to have
previously, while other studies have focused only within high sensitivity and specificity in identifying depressed
the first year postinjury.2,13,24,25 Jorge12 studied symp- TBI participants, particularly in comparison with a de-
toms of depression between 1 and 12 months postinjury pression rating scale.34 Such measures have not been
and found that for 40% of those who were initially de- frequently employed in studies of individuals with TBI,
pressed, depression resolved within the year, while 18% possibly because of the time involved in administration
of those not depressed at initial interview had devel- and scoring.
oped depression by 1 year. They suggested that acute In summary, the wide range in frequency of psy-
onset depression may be associated with injury-related chiatric disorders reported across studies may be at-
biological changes in the brain, whereas delayed onset tributable to variability in diagnostic instruments, study
depression may be associated with a growing awareness design, cultural differences, or personal and injury-
of injury-related disability. Studies conducted over only related characteristics of the participants, including pres-
1 year after injury arguably do not fully capture long- ence of preinjury psychiatric disorders, injury severity,
term emotional issues. and time postinjury. The aim of this study, which is the
Ashman14 found that the incidence of mood and anx- first in a series, was to examine the frequency of pre- and
iety disorders rose from preinjury to the first year postin- post-TBI Axis I psychiatric disorders, established on the
jury and was then relatively stable 2 and 3 years postin- basis of structured clinical interview based on DSM-IV
jury. Two other studies have shown psychotic disorders criteria and verified by a significant other. Participants
to have an average latency to onset of 41/2 years fol- had mild to severe TBI sustained 0.5 to 5.5 years
lowing TBI26,27 although the method of diagnosis was previously.
unclear in these studies. Studies of post-TBI substance
use indicate an initial decline in frequency of use in METHODS
the first year postinjury but a return to levels similar to
preinjury in subsequent years.18,20,28–30 Hibbard’s10 and Participants
Koponen’s7 findings of high frequencies of psychiatric One hundred participants with mild to severe TBI sus-
disorders many years postinjury suggest that such disor- tained between 6 months and 5.5 years previously were
ders develop and persist over very long periods of time. recruited from the database of all admissions of patients
Hence it would seem important to sample various time with head injury to the referring hospital, which pro-
points after injury. vided rehabilitation under a no-fault accident compen-
The severity of injuries has also varied widely from one sation system. The majority had incurred moderate to
study to another, as have the measures used to establish very severe TBI, and most were injured in road accidents
injury severity. Studies of depression in groups of per- or workplace accidents. All had been discharged from in-
sons with predominantly mild TBI have generally found patient care. Eligibility criteria were: (1) minimum age 17
lower frequencies of DSM-diagnosed depression, rang- years at time of injury and maximum of 75 years at time
ing from 12.8% to 16.6%. Sample size has also limited of interview; (2) having sufficient proficiency in English
the generalizability of findings from some studies that to complete the interview; (3) no history of previous TBI
have used samples of fewer than 50 participants.9,11,31,32 or serious neurological disorder such as stroke, epilepsy,
Previous studies have been conducted in North brain tumor, or neurodegenerative disease. Patients with
America, the United Kingdom, and Finland. There may a premorbid psychiatric history were not excluded.
be cultural differences in coping styles, emotional ex-
pression, stigma associated with injury and mental ill-
Demographics
ness, and attitudes toward substance use, as well as
differences in availability of treatment. This may also Demographic information for study participants is
contribute to variability in findings. given in Table 1. The “average” participant was a 37-year-
Rating scales document clinical symptoms, some old male with just less than 12 years of education, who
of which may be the direct result of the TBI rather was now 3 years postinjury. Mean length of hospital stay
than of depression or anxiety, including sleep distur- was 41.59 days (SD, 27.59; range, 5–134). Participants
bance, concentration problems, fatigue, or psychomo- had a mean lowest Glasgow Coma Scale (GCS) score of
www.headtraumarehab.com
326 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

TABLE 1 Demographic data by mean years postinjury; mean, SD, and range

Year postinjury
1 2 3 4 5 Totala
Variable (0.5–1.49) (1.5–2.49) (2.5–3.49) (3.5–4.49) (4.5–5.50) (0.5–5.5)

Glasgow Coma Score


Mean 8.53 8.50 8.53 8.40 9.53 9.10
SD 4.35 4.29 4.35 4.22 3.85 4.12
Range 3–14 3–14 3–14 3–14 3–14 3–14
PTA (days)
Mean 23.90 19.40 13.30 23.28 24.20 20.77
SD 22.53 17.77 14.09 17.34 15.68 17.85
Range 1–77 1–62 1–49 1–63 2–56 1–77
Age at assessment
Mean 38.00 35.00 40.95 35.10 36.85 37.18
SD 16.96 11.82 16.61 11.97 13.31 14.19
Range 19–67 19–60 19–74 20–61 21–65 19–74
Education, y
Mean 12.10 11.72 11.58 11.40 11.65 11.70
SD 2.71 3.04 2.80 2.09 2.74 2.65
Range 7–17 8–18 6–16 8–16 6–16 6–18
Gender
Male 75% 70% 75% 70% 65% 71%
Female 25% 30% 25% 30% 35% 29%
Depression present (n) 4 10 11 10 11 χ 2 = 7.01, df = 4,
P = .14
Anxiety present (n) 4 7 10 9 8 χ 2 = 4.50, df = 4,
P = .34
Any disorder present (n) 9 12 14 15 15 χ 2 = 5.71, df = 4,
P = .22

Abbreviation: PTA, posttraumatic amnesia.


a For n = 100, average time postinjury was 2.98 years, SD = 1.47, range 0.5–5.5.

9.10, with 35% scoring 13 to 14, 20% scoring 9 to 12, and were obtained from all participants’ medical files, which
45% scoring 3 to 8. Mean duration of posttraumatic am- most often included a full neuropsychological assess-
nesia (PTA) was 20.77 days (SD, 17.85; range, 1–77). Nine ment and psychiatric history. The clinical computerized
percent had a PTA duration of less than 24 hours, 20% version of the Structured Clinical Interview for DSM-IV
had a PTA of 1 to 7 days, 42% a PTA of 8 to 27 days, and disorders (SCID-I) was used to assess frequency, comor-
29% had a PTA greater than 28 days. There were no statis- bidity, and resolution over time of psychiatric disorders.
tically significant differences among each year postinjury It was administered twice—first, retrospectively to deter-
group (see Table 1), or between the present sample and mine lifetime preinjury psychiatric diagnoses, and sec-
the 57 participants who declined, or between the present ond, to identify postinjury psychiatric diagnoses, both
sample and the main database group on gender (χ 2 2 = current and resolved.
.025, P = .876), education (t = 1.705, df = 596, P = The SCID-I contains over 37 Axis I diagnoses, cover-
.089, 2-tailed), PTA (U = 27052.50, N1 = 99, N2 = 570, ing mood disturbances, anxiety disorders, schizophre-
P = .860, 2-tailed), GCS (U = 28334.00, N1 = 96, N2 = nia and other psychotic disorders, substance use dis-
592, P = .963, 2-tailed), or age (U = 29273.50, N1 = 100, orders, somatoform conditions, eating disorders, and
N2 = 620, P = .371, 2-tailed), indicating that the current adjustment disorders.37 “Depressive disorders” refers to
sample was a representative group of participants based dysthymia and major depressive disorders; DSM-based
on demographic- and injury-related variables. specifiers of mild, moderate, and severe were docu-
mented. The “substance use disorder” category refers to
Measures alcohol and nonalcohol abuse or dependence disorders.
Demographic- and injury-related information and A “novel disorder” refers to a specific disorder occurring
psychiatric history were initially obtained via a post-TBI that has never occurred before in that person’s
semistructured interview. With consent, further details lifetime.
Psychiatric Disorders Following Traumatic Brain Injury 327

Procedures RESULTS
Ethics approval was obtained from the hospital Frequency of preinjury disorders
through which participants were recruited. An indepen-
Table 2 displays the number of participants with prein-
dent researcher identified patients injured between July
jury Axis I diagnoses. Among those with a documented
2000 and July 2005, who were 0.5 to 5.5 years postinjury.
pre-TBI psychiatric history, all but one participant’s self-
Of the 720 participants in the database, 550 met eligibil-
report of preinjury psychiatric history were consistent
ity criteria. In order to have a sample representative of a
with medical file reports. However, some participants
range of time points postinjury, eligible participants were
without a documented history reported premorbid psy-
divided into 5 groups who were at different time points
chiatric symptoms, which warranted a retrospective di-
postinjury (0.5–1.49, 1.5–2.49, 2.5–3.49, 3.5–4.49, and
agnosis. It seems, therefore, that some individuals with
4.5 to 5.5 years postinjury). Within each year level,
TBI had undiagnosed preinjury psychiatric disorders.
individual Statistical Product and Service Solutions
Prior to injury, 52% had a psychiatric disorder; 28%
(SPSS) codes were entered into a random number gen-
had only 1 diagnosis, whereas 24% had more than 1 di-
erator program from the Web site www.random.org. Par-
agnosis. Preinjury alcohol dependence disorder was the
ticipants were contacted sequentially until there were 5
most common single diagnosis (29%); however, other
equal groups of consenting participants, with 20 partic-
substance use disorders were also common, with a total
ipants in each group on average 1 to 5 years postinjury
of 41% falling into these categories. Major depressive
(see Table 1). Fifty-seven people refused participation or
disorder was the second most frequent preinjury disor-
did not return messages. The primary researcher then
der (17%). Preinjury anxiety disorders were also common
contacted each consenting person and arranged a meet-
(13%).
ing either at home or at the hospital. Written informed
consent was obtained from all participants. Participants
identified a significant other (someone who knew the Frequency of postinjury disorders
patient well prior to and postinjury), who was also in-
Following TBI, 65% of the current sample met crite-
terviewed about the survivor’s past and current emo-
ria for at least 1 diagnosis. Twenty-seven percent received
tional state using the SCID-I, either at the same time or
a single diagnosis, whereas 38% received multiple diag-
by phone. Thirteen people either declined to nominate
noses. Table 2 displays the breakdown of postinjury di-
a significant other or the significant other declined to
agnoses. Postinjury major depression was the most com-
be interviewed. In the 87 cases where significant others
mon diagnosis (45%), whereas there was only one case
were interviewed, while not every symptom reported was
of dysthymia.
identical, there was 100% agreement between diagnoses
Anxiety (38%) was the second most common diag-
obtained from interviews with the pairs of participants.
nosis. Frequencies of individual disorders were greater
To determine interrater reliability, 12 of the 100 partic-
than the overall figure of 38%, as some participants had
ipants were also assessed in person by a clinical psychol-
more than 1 anxiety disorder. Generalized anxiety dis-
ogist (L.J.) trained in administering the SCID-I. Both
order (GAD) was the most commonly diagnosed anx-
administrators had completed psychopathology courses
iety disorder (17%), followed by posttraumatic stress
as part of their doctoral training and both completed a
disorder (PTSD; 14%). Specific phobia (7%), panic dis-
2-day training program in administration of the SCID-I
order (with or without agoraphobia, 6%), and social
under the supervision of an experienced clinical psy-
phobia (6%) occurred with similar frequency. Only 1
chologist (F.G.). Administration took between 30 and
person was diagnosed with obsessive-compulsive dis-
150 minutes, depending upon the complexity of the
order (OCD) and 1 with agoraphobia. Three people
interviewee’s responses. The 12 participants obtained
received postinjury diagnoses of a psychotic disorder,
diagnoses within the categories of substance-use dis-
1 had an eating disorder, and 1 a somatoform disorder.
orders and anxiety disorders, and the two administra-
Twenty-one percent met criteria for a postinjury sub-
tors obtained perfect agreement within these categories,
stance use disorder. Alcohol dependence was the most
both for current and for preinjury diagnoses (Cohen’s
common (14%), followed by nonalcohol substance de-
κ = 1.0).
pendence (7%), alcohol abuse (3%), and nonalcohol sub-
stance abuse (2%). Marijuana was the most commonly
Data analysis
used drug (45%), followed by stimulants (20%), opioids
Data were analyzed using SPSS 14 for Windows. Fre- (15%), and cocaine (5%). The remaining 15% of the
quency measures were obtained for preinjury and postin- group were polydrug users.
jury disorders, both current and resolved. Chi-square Comparison of the rate of disorders in the first year
analyses were used to compare frequencies of psychiatric after injury with that in the subsequent years indicated
disorders from 1 to 5 years postinjury. that the frequency of depressive disorders in the first year
www.headtraumarehab.com
328 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

TABLE 2 Number of people (N = 100) with SCID-diagnosed psychiatric disorders pre-


and post-TBI, novel post-TBI disorders, and breakdown of disorders

Psychiatric disorder Pre-TBI Post-TBI Novel disorders


Number of participants with disorder
Depression 17 46 33
Any anxiety disorder 13 38 28
Any psychotic disorder 1 3 3
Substance use disorders 41 21 3
Somatoform disorder 0 1 1
Eating disorders 2 1 0
Number of disorders
Major depression 17 45 32
Dysthymia 0 1 1
GAD 5 17 13
PTSD 4 14 10
Specific phobia 0 7 7
Panic disorder 1 6 5
Social phobia 2 6 4
OCD 1 1 1
Agoraphobia 1 1 0
Substance-induced anxiety disorder 1 0 0
Substance-induced psychotic disorder 1 0 0
Schizoaffective disorder 0 1 1
Psychotic disorder NOS 0 2 2
Alcohol abuse disorder 7 3 2
Alcohol dependence disorder 29 14 1
Nonalcohol substance abuse disorder 5 2 0
Nonalcohol substance dependence disorder 12 7 3

Abbreviations: GAD, generalized anxiety disorder; NOS, not otherwise specified; OCD, obsessive-compulsive disorder; PTSD, posttrau-
matic stress disorder; SCID, Structured Clinical Interview for DSM-IV disorders; TBI, traumatic brain injury.

postinjury was significantly lower than in subsequent Few new onset substance use disorders were evident;
years (χ 2 = 6.80, df = 1, P = .012). This result ap- only 3 of 21 people developed a postinjury substance use
proached significance for anxiety (χ 2 = 3.43, df = 1, disorder with no prior history. Two cases of novel alco-
P = .075) and for any disorder (χ 2 = 4.40, df = 1, P = hol abuse disorder were found; 1 of these people had a
.064). preinjury nonalcohol substance disorder. Of those with
postinjury alcohol dependence, 1 was a novel disorder,
Novel disorders following TBI 10 had alcohol dependence at the time of injury, and 3
had a history of alcohol dependence prior to injury but
Numerous participants experienced depressive disor-
were not dependent at the time of injury. There were
ders and anxiety disorders for the first time following
no new cases of nonalcohol substance abuse; 1 case was
injury (see “novel disorders” column, Table 2). Of the
ongoing and 1 had relapsed. Of the 7 people with non-
46 people who experienced a depressive disorder postin-
alcohol substance dependence, 3 were novel disorders
jury, 33 had developed depression for the first time. A
and 4 were present prior to injury.
further 7 were depressed at the time of the accident, and
6 had a preinjury history of depression, which was in
Current and comorbid disorders
remission at the time of injury.
Of the 38 people who experienced anxiety disorder Table 3 shows Australian prevalence rates for psychi-
postinjury, 28 were new onset. For GAD, 13 were new atric disorders where available.16 Given that the average
cases, 3 were ongoing, and 1 was a relapse of a previously participant was male, aged 37, prevalence rates for males
resolved disorder. Ten people experienced PTSD as a of this age group are also provided. Of the 46 partici-
novel disorder; the other 4 cases were current at the time pants found to have depression at any time postinjury,
of injury. All diagnoses of specific phobia and psychotic 34 (74%) were depressed at the time of assessment (see
disorders were novel, and 5 of 6 cases of panic disorder Table 3); therefore, 12 cases of depression had been re-
were novel, as were 4 of 6 cases of social phobia. solved by the time of interview. Of these participants
Psychiatric Disorders Following Traumatic Brain Injury 329

TABLE 3 Number of participants (N = 100) with current and resolved psychiatric disor-
ders post-TBI and 12-month Australian prevalence rates (where available)

Australian rates
Postinjury disorders
General Males
Disorder Current %a Resolved %b population %c Males %d 35–44 %
Number of participants with disorder (N)
Depressive 34 12 5.1 3.4 6.0
Anxiety 36 2 9.7 7.1 8.3
Substance use 17 4 7.7 11.1 12
Psychotic 2 1
Somatoform 1 0
Eating 0 1
Number of disorders (N)
GAD 14 3 3.1 2.4
PTSD 11 3 3.3 2.3
Specific phobia 7 0
Panic disorder 6 0 1.3 0.6
Social phobia 6 0 2.7 2.4
OCD 1 0 0.4 0.3
Agoraphobia 1 0 1.1 0.7
Schizoaffective 1 0
Psychotic NOS 1 1
Alcohol abuse 2 1 3 4.3
Alcohol dependence 10 4 3.5 5.1
Nonalcohol substance abuse 2 0 3.5
Nonalcohol substance dependence 5 2 2.2

Abbreviations: GAD, generalized anxiety disorder; NOS, not otherwise specified; OCD, obsessive-compulsive disorder; PTSD,
posttraumatic stress disorder; TBI, traumatic brain injury.
a “Current %” refers to number of participants with current diagnoses divided by total number of participants (N = 100) multiplied by

100.
b “Resolved %” refers to number of resolved diagnoses divided by total number of participants (N = 100) multiplied by 100.
c Rates are for disorders that occurred in the last 12 months, males and females, 18 years and above.16
d Prevalence rates are for disorders that occurred in the previous 12 months for males 18 years and above.16

with current depression, 5 were in partial remission, ders fell preinjury to postinjury, postinjury substance use
4 had mild symptoms, 12 had moderate symptoms, disorders tended to be current (see Table 3).
and 13 had severe symptoms at the time of assessment.
Eight people with current depression had a comorbid Treatment
substance use disorder (23.5%), and 25 had a comorbid
anxiety disorder (73.5%). Of the 45 participants with Twenty-three of the 45 participants with current de-
current depression and/or anxiety, 23 (51.1%) were re- pression and/or anxiety (51.1%) were being treated with
ceiving medication and/or counseling. medication and/or psychological therapy, as compared
Of the 38 people with postinjury anxiety disorders, with 31.3% (n = 5) of those for whom depression or
only 2 cases had resolved by the time of interview (see anxiety had resolved at time of assessment.
Table 3). All cases of specific phobia, panic disorder,
social phobia, OCD, agoraphobia, and somatoform dis- DISCUSSION
order were current. High current frequencies were also This study aimed to examine the frequency of psychi-
found for the remaining anxiety disorders, as 14 of 17 atric disorders in an Australian sample of 100 individuals
cases (82%) of post-TBI GAD were current, and 11 of with mild to severe TBI 0.5 to 5.5 years postinjury, using
14 cases (79%) of the PTSD cases were current. Six peo- a DSM-based structured clinical interview to establish
ple with anxiety (16.7%) had a comorbid substance use diagnoses. A significant other was also interviewed in
disorder. 87% of cases. Reliability of participant’s self-report was
Of the 3 diagnosed postinjury psychotic disorders, 2 demonstrated.
were current. The 1 eating disorder was in remission. The current study found a high proportion of prein-
Although the overall frequency of substance use disor- jury and postinjury psychiatric disorders (52% and 65%,
www.headtraumarehab.com
330 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

respectively). Preinjury, depression and substance use be a compensatory strategy for poor memory following
disorders were most common (17% and 41%, respec- TBI.10 However, in order to meet DSM-IV criteria for
tively). These findings are consistent with most previous diagnosis of OCD, this behavior must be attributed to
TBI studies.10,11,18 The frequency of preinjury anxiety adherence to a rigid set of rules in order to avoid negative
disorders in this study (13%) was the same as that found consequences (anxiety), rather than memory problems
by Hibbard.10 Frequencies of most preinjury psychiatric causing repeated checks to ensure safety.
disorders in the current study were much higher than No other known studies of individuals with TBI have
those in the Finnish Koponen7 study, in which there screened for eating disorders or somatoform disorders.
were no preinjury depressive disorders, GAD, or nonal- Agoraphobia, eating disorders, somatoform disorders,
cohol substance disorders. However, given that partici- and psychotic disorders all occurred at frequencies sim-
pants in that study were at least 27 years postinjury, it ilar to those in the general population, suggesting that
is possible that their retrospective account of premor- these are not common consequences of TBI. However,
bid diagnoses was unreliable. Furthermore, all TBIs oc- it is also possible that the current study lacked the power
curred between 1950 and 1971, at a time when mental to detect any change in frequency of such disorders. In
health disorders were relatively less well recognized and addition, there were 3 new cases of psychotic disorders,
acknowledged. There may also be cultural differences and given previous findings of onset of psychosis more
influencing expression of emotion and/or substance use than 4 years postinjury,26,27 one cannot rule out the pos-
patterns. sibility of psychotic disorders developing over a longer
Following TBI, 65% of participants received at least 1 time frame.
psychiatric diagnosis. Again, depression was the most Frequencies of substance use disorders decreased
common diagnosis in 46% in the first 5 years af- from 41% preinjury to 21% postinjury, with few novel
ter injury, a frequency consistent with some previous cases. This trend has previously been noted in the
studies.10,11,14 High current rates of depression were literature.10,20 Frequencies of comorbidity were high—
found (34%), which were substantially higher than the of those with current depression and anxiety disorders,
Australian comparison rates.16 Seventy-two percent of 23.5% and 16.7%, respectively, also had a substance use
depressive disorders were novel disorders, suggesting disorder. Current substance use disorders occurred in
that the presence of preinjury psychiatric disorders is 17% of participants, which is much higher than their
not the only influential factor. As with the general pop- occurrence in the general population.16 High rates of
ulation, there was also a high frequency of comorbid- alcohol consumption are not unique to the TBI popu-
ity of current depressive and anxiety disorders (73.5%). lation and are indeed typical of the young male demo-
Only half with current depression and/or anxiety were graphic population from which they are drawn.20 How-
receiving treatment. Other studies have reported lower ever, given the severity of brain injury in this group, the
frequencies of depression and anxiety,2,18,25 but all in- amount of alcohol being consumed is potentially much
volved follow-up in the first year after injury. In the more harmful and therefore of concern. It is important
current study, there was a trend for the frequency of to institute measures to discourage those who engaged
psychiatric disorders to rise between 1 and 4 years in heavy substance use preinjury from returning to this,
postinjury. This increase may be associated with factors following TBI.
such as improved insight into the effects of the injury The findings of this study must be interpreted within
over time, growing despondence at the lack of phys- the context of certain limitations, most notably its retro-
ical/emotional/vocational progress, financial hardship, spective, cross-sectional design, a limitation also present
or decrease in professional support over time. in most previous studies. In the present investigation,
The number of participants with anxiety disorders rose stratified random sampling was used to ensure inclusion
from 13% to 38% postinjury, with a total of 52 diag- of equal and representative groups on average 1 to 5 years
noses. Of those with an anxiety disorder post-TBI, 74% after injury. However, this design does not allow for pre-
had developed novel anxiety disorders, most commonly cise examination of the timing of onset of disorders.
GAD and PTSD, followed by specific and social pho- As previously discussed, the referring hospital treated
bias and panic disorder. Anxiety disorders showed poor patients referred for rehabilitation under a no-fault ac-
resolution, with 95% of cases current at the time of as- cident compensation system, so the sample comprised
sessment. Frequencies of most current anxiety disorders a high proportion of individuals with moderate to very
were all much higher than in the general population16 severe TBI, the majority of whom incurred injuries in
but were generally within the ranges reported in previous motor vehicle or work-related accidents. Therefore, the
studies of persons with TBI.10,11,14 However, the cur- findings of the current study may not be generalizable
rent reported frequency of OCD (1%) was much lower across the entire spectrum of severity of TBI, particu-
than a previous study that reported an incidence of 15%; larly mild TBI, or those not referred for rehabilitation.
it was suggested that checking-rechecking behavior may Despite the use of a stratified random sampling method,
Psychiatric Disorders Following Traumatic Brain Injury 331

the possibility of some selection bias cannot be ruled Few studies have used measures such as the SCID-I
out. It may be that certain people were more or less to establish preinjury and postinjury diagnoses. On the
motivated to participate, depending on their emotional basis of the high degree of concordance between inter-
state. It would also be of interest in future studies with view results and medical records, the current study has
a stratified time postinjury design to consider whether demonstrated the appropriateness of this measure for use
patients with a shorter or longer time postinjury were in the TBI population. Given the range of disorders that
more or less inclined to participate. This information occur in this group, it is recommended that psychiatric
was not available for the current study. One could also screening cover a broad range of diagnoses.
question the reliability of retrospective reports of prein- This study has highlighted that TBI creates a risk
jury symptoms experienced up to 51/2 years previously. for development of several psychiatric disorders, par-
The involvement of a significant other in verifying re- ticularly depression and anxiety, in a significant pro-
ported symptoms mitigated against this. Clearly, it will portion of those who had no previous psychiatric his-
be important to follow up these findings with a prospec- tory. That this finding was obtained in a group that
tive study, conducted over a longer time frame than that had access to comprehensive rehabilitation supports the
used in the previous 1-year outcome studies to date. need for a greater focus on prevention and treatment
The sample studied was predominantly male (71%). of these problems both within and outside rehabilita-
Although this gender imbalance is typical of the TBI tion programs. Clearly, practitioners cannot rely solely
population, it may have influenced the frequency on preinjury history of psychiatric problems to predict
of observed disorders. The majority of studies have postinjury problems. Moreover, many who experience
found no gender differences in frequencies of postin- anxiety and depression may not recognize or report it.
jury depression.2,7,10,13,18,39,40 However, females may It is therefore vital that community-based health pro-
be more likely to be diagnosed with an anxiety fessionals are trained to recognize the symptoms and
disorder.10,13,14 Males have been more often diagnosed signs of these conditions in an individual with TBI and
with a substance use disorder in both the TBI and the are provided with strategies and resources with which
general population.14,20 to address them, including the availability of skilled
Preexisting emotional and substance abuse problems psychological or psychiatric intervention. Patients and
have been associated with a greater likelihood of TBI.3 families should be informed regarding symptoms of
Numerous interdependent factors contribute to the like- depression and anxiety. TBI follow-up clinics should
lihood of having a TBI and to the development of a men- conduct routine long-term screening for such disor-
tal health disorder; it is possible that the same groups ders. Education about the implications of substance use
are at risk for both conditions. Young men account for a following brain injury is also of vital importance. In-
large proportion of the population with brain injury, and vestigation of the factors associated with the develop-
arguably the frequencies of depression and substance ment of these disorders would assist in identifying those
use may be higher in this subgroup than the population most at risk, so that they may be targeted for assess-
norms against which they have been compared. A demo- ment and intervention. This represents the focus of the
graphically matched control group should be considered subsequent study in this series by Whelan-Goodinson
in future studies. et al.41

REFERENCES

1. Jennett B. Epidemiology of head injury. J Neurol Neurosurg Psychi- 7. Koponen S, Taiminen T, Portin R, et al. Axis I and II psychiatric
atry. 1996;60:362–369. disorders after traumatic brain injury: a 30-year follow-up study.
2. Deb S, Lyons I, Koutzoukis C, Ali I, McCarthy G. Rate of psy- Am J Psychiatry. 2002;159:1315–1321.
chiatric illness 1 year after traumatic brain injury. Am J Psychiatry. 8. Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom
1999;156:374–378. rates of depression after traumatic brain injury: a comprehensive
3. Ponsford J, Sloan S, Snow P. Traumatic Brain Injury: Rehabilitation examination. Brain Inj. 2001;15:563–576.
for Everyday Adaptive Living. Hove, Sussex, UK: Psychology Press, 9. van Reekum R, Bolago I, Finlayson MAJ, Garner S, Links
Ltd; 1995. PS. Psychiatric disorders after traumatic brain injury. Brain Inj.
4. MacMillan PJ, Hart RP, Martelli MF, Zasler ND. Pre-injury sta- 1996;10:319–327.
tus and adaptation following traumatic brain injury. Brain Inj. 10. Hibbard MR, Uysal S, Kelpler K, Bogdany J, Silver J. Axis I psy-
2002;16:41–49. chopathology in individuals with traumatic brain injury. J Head
5. Varney NR, Martzke JS, Roberts RJ. Major depression in patients Trauma Rehabil. 1998;13:24–39.
with closed head injury. Neuropsychology. 1987;1:7–9. 11. Fann JR, Katon WJ, Uomoto JM, Esselman PC. Psychiatric disor-
6. Rosenthal M, Christensen BK, Ross TP. Depression following trau- ders and functional disability in outpatients with traumatic brain
matic brain injury. Arch Phys Med Rehabil. 1998;79:90–103. injuries. Am J Psychiatry. 1995;152:1493–1499.

www.headtraumarehab.com
332 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

12. Jorge R, Robinson RG, Starkstein SE, Arndt SV. Depression and lowing traumatic brain injury: a chart-based descriptive and case-
anxiety following traumatic brain injury. J Neuropsychiatry Clin control study. Psychol Med. 2001;31:231–239.
Neurosci. 1993;5:369–374. 28. Sparadeo FR, Gill D. Effects of prior alcohol use on head injury
13. Levin HS, Brown SA, Song JX, et al. Depression and posttraumatic recovery. J Head Trauma Rehabil. 1989;4:75–82.
stress disorder at three months after mild to moderate traumatic 29. Corrigan JD, Rust E, Lamb-Hart GL. The nature and extent of
brain injury. J Clin Exp Neuropsychol. 2001;23:754–769. substance abuse problems in persons with traumatic brain injury.
14. Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, J Head Trauma Rehabil. 1995;10:29–46.
Gordon WA. Psychiatric challenges in the first 6 years after trau- 30. Kreutzer JS, Witol AD, Sander AM, et al. A prospective longitu-
matic brain injury: cross-sequential analyses of Axis I disorders. dinal multicenter analysis of alcohol use pattern among persons
Arch Phys Med Rehabil. 2004;85(4)(suppl 2):S36–S42. with traumatic brain injury. J Head Trauma Rehabil. 1996;11:58–69.
15. Jorge R, Starkstein SE, Arndt S, Moser D, Crespo-Facorro B, 31. Glenn MB, O’Neil-Pirozzi T, Goldstein R, Burke D, Jacob L. De-
Robinson RG. Alcohol misuse and mood disorders following trau- pression amongst outpatients with traumatic brain injury. Brain
matic brain injury. Arch Gen Psychiatry. 2005;62:742–749. Inj. 2001;15:811–818.
16. Australian Institute of Health and Welfare. National Health Priority 32. Robinson RG, Boston JD, Starkstein SE, Price TR. Comparison
Areas Report: Mental Health 1998. Canberra, Australian Capital of mania and depression after brain injury: causal factors. Am J
Territory, Australia: Australian Institute of Health and Welfare, Psychiatry. 1988;145:172–178.
Cat No PHE 13 Heath and AIHW; 1999. 33. Warden D, Labbate L. Posttraumatic stress disorder and other anx-
17. Hibbard MR, Bogdany J, Uysal S, et al. Axis II psychopathology iety disorders. In: Silver J, McAllister TW, Yudofsky SC, eds. Text-
in individuals with traumatic brain injury. Brain Inj. 2000;14:45– book of Traumatic Brain Injury. Washington, DC; London: Ameri-
61. can Psychiatric Publishing; 2005:231–243.
18. Fedoroff JP, Starkstein SE, Forrester AW, et al. Depression in 34. Jorge R, Robinson RG, Arndt S. Are there symptoms that are spe-
patients with acute traumatic brain injury. Am J Psychiatry. cific for depressed mood in patients with traumatic brain injury.
1992;149:918–923. J Nerv Ment Dis. 1993;181:91–99.
19. Drubach DA, Kelly MP, Winslow MM, Flynn JP. Substance abuse 35. Green A, Felmingham K, Baguley I, Slewa-Younan S, Simpson S.
as a factor in the causality, severity and recurrence rate of traumatic The clinical utility of the Beck Depression Inventory after trau-
brain injury. Md Med J. 1993;42:989–993. matic brain injury. Brain Inj. 2001;15:1021–1028.
20. Ponsford J, Whelan R, Bahar-Fuchs A. Alcohol and drug use 36. Robinson RG, Jorge R. Mood disorders. In: Silver J, McAllister
following traumatic brain injury: a prospective study. Brain Inj. TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washing-
2007;21:1385–1392. ton, DC; London: American Psychiatric Publishing; 2005:201–
21. Dawson DR, Levine B, Schwartz M, et al. Quality of life fol- 212.
lowing traumatic brain injury: a prospective study. Brain Cogn. 37. First MB, Spitzer RL, Gibbon M, et al. Computer-Assisted SCID
2000;44:35–39. Clinician Version (CAS-CV): Software Manual. Washington, DC:
22. Dicker BG. Pre-injury behavior and recovery after a minor head American Psychiatric Publishing; 2004.
injury: a review of the literature. J Head Trauma Rehabil. 1989;4:73– 38. American Psychiatric Association. Diagnostic and Statistical Manual
81. of Mental Disorders. 4th ed, text rev. Washington, DC: American
23. Rapoport MJ, McCullagh S, Streiner D, Feinstein A. The clinical Psychiatric Association; 2000.
significance of major depression following mild traumatic brain 39. Jorge R, Robinson RG, Arndt SV, Starkstein SEForrester
injury. Psychosomatics. 2003;44:31–37. AWGeisler F. Depression following traumatic brain injury: a 1
24. Deb S, Lyons I, Koutzoukis C. Neuropsychiatric sequelae one year longitudinal study. J Affect Disord. 1993;27:233–243.
year after a minor head injury. J Neurol Neurosurg Psychiatry. 40. Seel RT, Kreutzer JS, Rosenthal M, Hammond FMCorrigan JD-
1998;65:899–902. Black K. Depression after traumatic brain injury: a National In-
25. Jorge R, Robinson RG, Starkstein SE. Influence of major depres- stitute on Disability and Rehabilitation Research Models Systems
sion on 1 year outcome in patients with traumatic brain injury. J multicenter investigation. Arch Phys Med Rehabil. 2003;84:177–
Neurosurg. 2004;8:726–733. 184.
26. Fujii DE, Ahmed I. Risk factors in psychosis secondary to trau- 41. Whelan-Goodinson R, Ponsford J, Schonberger M. Predictors
matic brain injury. J Neuropsychiatry Clin Neurosci. 2001;13:61–69. of psychiatric disorders following traumatic brain injury. J Head
27. Sachdev P, Smith JS, Cathcart S. Schizophrenia-like psychosis fol- Trauma Rehabil. In press.

Você também pode gostar