Download Psychiatric Disorders Following Traumatic Brain Injury: Their Nature

J Head Trauma Rehabil
Vol. 24, No. 5, pp. 324–332
c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright 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 postinjury 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 individuals under the age of 45 years, most commonly young
males.1 Brain injury is often diffuse and bilateral, commonly including frontotemporal regions, limbic system,
basal ganglia, and hippocampus and causing cognitive,
behavioral, and emotional changes. Such changes disrupt the lives of these young people, affecting their ability to establish independence, a vocation, and relationships, potentially leading to loss of self-esteem.2–4
A proportion of those with TBI develop psychiatric
problems postinjury. Variable frequencies of psychiatric
disorders have been reported at various time points following TBI, those for depression and anxiety ranging
from 14% to 77%,2,5–13 and for substance use from
4.9% to 28%.2,7,10,11,14 High rates of current depression and anxiety have also been reported, from 10% to
46%,2,7,10,11 as have high rates of current substance use
Author Affiliations: School of Psychology, Psychiatry and Psychological
Medicine, Monash University, Melbourne, Australia (Drs WhelanGoodinson and Ponsford and Ms Grant), Monash-Epworth Rehabilitation
Research Centre, Epworth Hospital, Melbourne, Australia (Drs Ponsford
and Johnston), and National Trauma Research Institute, Melbourne,
Australia (Dr Ponsford).
Corresponding Author: Jennie Ponsford, PhD, Department of Psychology,
Monash University, Clayton, Victoria 3800, Australia (jennie.ponsford@
med.monash.edu.au).
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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
9.7%, respectively, and 2.2% to 3.5% for substance use
disorders.16 Comorbidity between anxiety and depression is high; 1 in 3 people with an anxiety disorder also
has an affective disorder. Few TBI studies have examined
a range of psychiatric disorders, most having focused
on depression.2,7,10,14 Two studies have attempted to assess Axis II personality disorders in TBI participants.7,17
However, brain injury is an exclusionary criterion for
Diagnostic and Statistical Manual-IV (DSM-IV) diagnosis of a personality disorder. Furthermore, certain personality changes may be symptoms of frontal lobe
injury.
Some studies2,7,10,11,18–20 have identified high frequencies of preinjury psychiatric disorders, ranging from
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 clinical interviews to establish preinjury psychiatric diagnoses, and all found higher rates of such diagnoses
postinjury.7,10,11 Participants in these studies were interviewed at wide-ranging follow-up intervals—on average
3, 8, and 48 years postinjury, respectively. Retrospective
recall of preinjury psychiatric symptoms may be unreliable at such long times after injury, particularly given
Psychiatric Disorders Following Traumatic Brain Injury
the likely presence of cognitive impairments. Arguably,
significant others should be consulted to improve reliability, which these studies appear not to have done.
The variability in reported frequencies of preinjury
and postinjury disorders may be related to variable timing of assessment, often within the same study. Studies
have included participants with injuries sustained from
1 to 227 days,23 1 to 37 years,10 and 27 to 48 years7
previously, while other studies have focused only within
the first year postinjury.2,13,24,25 Jorge12 studied symptoms of depression between 1 and 12 months postinjury
and found that for 40% of those who were initially depressed, depression resolved within the year, while 18%
of those not depressed at initial interview had developed depression by 1 year. They suggested that acute
onset depression may be associated with injury-related
biological changes in the brain, whereas delayed onset
depression may be associated with a growing awareness
of injury-related disability. Studies conducted over only
1 year after injury arguably do not fully capture longterm emotional issues.
Ashman14 found that the incidence of mood and anxiety disorders rose from preinjury to the first year postinjury and was then relatively stable 2 and 3 years postinjury. Two other studies have shown psychotic disorders
to have an average latency to onset of 41/2 years following TBI26,27 although the method of diagnosis was
unclear in these studies. Studies of post-TBI substance
use indicate an initial decline in frequency of use in
the first year postinjury but a return to levels similar to
preinjury in subsequent years.18,20,28–30 Hibbard’s10 and
Koponen’s7 findings of high frequencies of psychiatric
disorders many years postinjury suggest that such disorders develop and persist over very long periods of time.
Hence it would seem important to sample various time
points after injury.
The severity of injuries has also varied widely from one
study to another, as have the measures used to establish
injury severity. Studies of depression in groups of persons with predominantly mild TBI have generally found
lower frequencies of DSM-diagnosed depression, ranging from 12.8% to 16.6%. Sample size has also limited
the generalizability of findings from some studies that
have used samples of fewer than 50 participants.9,11,31,32
Previous studies have been conducted in North
America, the United Kingdom, and Finland. There may
be cultural differences in coping styles, emotional expression, stigma associated with injury and mental illness, and attitudes toward substance use, as well as
differences in availability of treatment. This may also
contribute to variability in findings.
Rating scales document clinical symptoms, some
of which may be the direct result of the TBI rather
than of depression or anxiety, including sleep disturbance, concentration problems, fatigue, or psychomo-
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tor retardation,33–35 potentially leading to overestimation of prevalence of certain disorders. On the other
hand, cognitive deficits leading to lack of self-awareness
or denial may result in underdiagnosis of disorders.36
The clinical interview is important to establish accurate
and reliable diagnoses by distinguishing symptoms due
to brain injury from those due to a psychiatric disorder.
DSM-based clinical interviews have been shown to have
high sensitivity and specificity in identifying depressed
TBI participants, particularly in comparison with a depression rating scale.34 Such measures have not been
frequently employed in studies of individuals with TBI,
possibly because of the time involved in administration
and scoring.
In summary, the wide range in frequency of psychiatric disorders reported across studies may be attributable to variability in diagnostic instruments, study
design, cultural differences, or personal and injuryrelated characteristics of the participants, including presence of preinjury psychiatric disorders, injury severity,
and time postinjury. The aim of this study, which is the
first in a series, was to examine the frequency of pre- and
post-TBI Axis I psychiatric disorders, established on the
basis of structured clinical interview based on DSM-IV
criteria and verified by a significant other. Participants
had mild to severe TBI sustained 0.5 to 5.5 years
previously.
METHODS
Participants
One hundred participants with mild to severe TBI sustained between 6 months and 5.5 years previously were
recruited from the database of all admissions of patients
with head injury to the referring hospital, which provided rehabilitation under a no-fault accident compensation system. The majority had incurred moderate to
very severe TBI, and most were injured in road accidents
or workplace accidents. All had been discharged from inpatient care. Eligibility criteria were: (1) minimum age 17
years at time of injury and maximum of 75 years at time
of interview; (2) having sufficient proficiency in English
to complete the interview; (3) no history of previous TBI
or serious neurological disorder such as stroke, epilepsy,
brain tumor, or neurodegenerative disease. Patients with
a premorbid psychiatric history were not excluded.
Demographics
Demographic information for study participants is
given in Table 1. The “average” participant was a 37-yearold male with just less than 12 years of education, who
was now 3 years postinjury. Mean length of hospital stay
was 41.59 days (SD, 27.59; range, 5–134). Participants
had a mean lowest Glasgow Coma Scale (GCS) score of
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TABLE 1
JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009
Demographic data by mean years postinjury; mean, SD, and range
Year postinjury
1
(0.5–1.49)
2
(1.5–2.49)
3
(2.5–3.49)
4
(3.5–4.49)
5
(4.5–5.50)
Totala
(0.5–5.5)
8.53
4.35
3–14
8.50
4.29
3–14
8.53
4.35
3–14
8.40
4.22
3–14
9.53
3.85
3–14
9.10
4.12
3–14
23.90
22.53
1–77
19.40
17.77
1–62
13.30
14.09
1–49
23.28
17.34
1–63
24.20
15.68
2–56
20.77
17.85
1–77
38.00
16.96
19–67
35.00
11.82
19–60
40.95
16.61
19–74
35.10
11.97
20–61
36.85
13.31
21–65
37.18
14.19
19–74
12.10
2.71
7–17
11.72
3.04
8–18
11.58
2.80
6–16
11.40
2.09
8–16
11.65
2.74
6–16
11.70
2.65
6–18
75%
25%
4
70%
30%
10
75%
25%
11
70%
30%
10
65%
35%
11
Anxiety present (n)
4
7
10
9
8
Any disorder present (n)
9
12
14
15
15
71%
29%
χ 2 = 7.01, df = 4,
P = .14
χ 2 = 4.50, df = 4,
P = .34
χ 2 = 5.71, df = 4,
P = .22
Variable
Glasgow Coma Score
Mean
SD
Range
PTA (days)
Mean
SD
Range
Age at assessment
Mean
SD
Range
Education, y
Mean
SD
Range
Gender
Male
Female
Depression present (n)
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
45% scoring 3 to 8. Mean duration of posttraumatic amnesia (PTA) was 20.77 days (SD, 17.85; range, 1–77). Nine
percent had a PTA duration of less than 24 hours, 20%
had a PTA of 1 to 7 days, 42% a PTA of 8 to 27 days, and
29% had a PTA greater than 28 days. There were no statistically significant differences among each year postinjury
group (see Table 1), or between the present sample and
the 57 participants who declined, or between the present
sample and the main database group on gender (χ 2 2 =
.025, P = .876), education (t = 1.705, df = 596, P =
.089, 2-tailed), PTA (U = 27052.50, N1 = 99, N2 = 570,
P = .860, 2-tailed), GCS (U = 28334.00, N1 = 96, N2 =
592, P = .963, 2-tailed), or age (U = 29273.50, N1 = 100,
N2 = 620, P = .371, 2-tailed), indicating that the current
sample was a representative group of participants based
on demographic- and injury-related variables.
Measures
Demographic- and injury-related information and
psychiatric history were initially obtained via a
semistructured interview. With consent, further details
were obtained from all participants’ medical files, which
most often included a full neuropsychological assessment and psychiatric history. The clinical computerized
version of the Structured Clinical Interview for DSM-IV
disorders (SCID-I) was used to assess frequency, comorbidity, and resolution over time of psychiatric disorders.
It was administered twice—first, retrospectively to determine lifetime preinjury psychiatric diagnoses, and second, to identify postinjury psychiatric diagnoses, both
current and resolved.
The SCID-I contains over 37 Axis I diagnoses, covering mood disturbances, anxiety disorders, schizophrenia and other psychotic disorders, substance use disorders, somatoform conditions, eating disorders, and
adjustment disorders.37 “Depressive disorders” refers to
dysthymia and major depressive disorders; DSM-based
specifiers of mild, moderate, and severe were documented. The “substance use disorder” category refers to
alcohol and nonalcohol abuse or dependence disorders.
A “novel disorder” refers to a specific disorder occurring
post-TBI that has never occurred before in that person’s
lifetime.
Psychiatric Disorders Following Traumatic Brain Injury
Procedures
RESULTS
Ethics approval was obtained from the hospital
through which participants were recruited. An independent researcher identified patients injured between July
2000 and July 2005, who were 0.5 to 5.5 years postinjury.
Of the 720 participants in the database, 550 met eligibility criteria. In order to have a sample representative of a
range of time points postinjury, eligible participants were
divided into 5 groups who were at different time points
postinjury (0.5–1.49, 1.5–2.49, 2.5–3.49, 3.5–4.49, and
4.5 to 5.5 years postinjury). Within each year level,
individual Statistical Product and Service Solutions
(SPSS) codes were entered into a random number generator program from the Web site www.random.org. Participants were contacted sequentially until there were 5
equal groups of consenting participants, with 20 participants in each group on average 1 to 5 years postinjury
(see Table 1). Fifty-seven people refused participation or
did not return messages. The primary researcher then
contacted each consenting person and arranged a meeting either at home or at the hospital. Written informed
consent was obtained from all participants. Participants
identified a significant other (someone who knew the
patient well prior to and postinjury), who was also interviewed about the survivor’s past and current emotional state using the SCID-I, either at the same time or
by phone. Thirteen people either declined to nominate
a significant other or the significant other declined to
be interviewed. In the 87 cases where significant others
were interviewed, while not every symptom reported was
identical, there was 100% agreement between diagnoses
obtained from interviews with the pairs of participants.
To determine interrater reliability, 12 of the 100 participants were also assessed in person by a clinical psychologist (L.J.) trained in administering the SCID-I. Both
administrators had completed psychopathology courses
as part of their doctoral training and both completed a
2-day training program in administration of the SCID-I
under the supervision of an experienced clinical psychologist (F.G.). Administration took between 30 and
150 minutes, depending upon the complexity of the
interviewee’s responses. The 12 participants obtained
diagnoses within the categories of substance-use disorders and anxiety disorders, and the two administrators obtained perfect agreement within these categories,
both for current and for preinjury diagnoses (Cohen’s
κ = 1.0).
Frequency of preinjury disorders
Data analysis
Data were analyzed using SPSS 14 for Windows. Frequency measures were obtained for preinjury and postinjury disorders, both current and resolved. Chi-square
analyses were used to compare frequencies of psychiatric
disorders from 1 to 5 years postinjury.
327
Table 2 displays the number of participants with preinjury Axis I diagnoses. Among those with a documented
pre-TBI psychiatric history, all but one participant’s selfreport of preinjury psychiatric history were consistent
with medical file reports. However, some participants
without a documented history reported premorbid psychiatric symptoms, which warranted a retrospective diagnosis. It seems, therefore, that some individuals with
TBI had undiagnosed preinjury psychiatric disorders.
Prior to injury, 52% had a psychiatric disorder; 28%
had only 1 diagnosis, whereas 24% had more than 1 diagnosis. Preinjury alcohol dependence disorder was the
most common single diagnosis (29%); however, other
substance use disorders were also common, with a total
of 41% falling into these categories. Major depressive
disorder was the second most frequent preinjury disorder (17%). Preinjury anxiety disorders were also common
(13%).
Frequency of postinjury disorders
Following TBI, 65% of the current sample met criteria for at least 1 diagnosis. Twenty-seven percent received
a single diagnosis, whereas 38% received multiple diagnoses. Table 2 displays the breakdown of postinjury diagnoses. Postinjury major depression was the most common diagnosis (45%), whereas there was only one case
of dysthymia.
Anxiety (38%) was the second most common diagnosis. Frequencies of individual disorders were greater
than the overall figure of 38%, as some participants had
more than 1 anxiety disorder. Generalized anxiety disorder (GAD) was the most commonly diagnosed anxiety disorder (17%), followed by posttraumatic stress
disorder (PTSD; 14%). Specific phobia (7%), panic disorder (with or without agoraphobia, 6%), and social
phobia (6%) occurred with similar frequency. Only 1
person was diagnosed with obsessive-compulsive disorder (OCD) and 1 with agoraphobia. Three people
received postinjury diagnoses of a psychotic disorder,
1 had an eating disorder, and 1 a somatoform disorder.
Twenty-one percent met criteria for a postinjury substance use disorder. Alcohol dependence was the most
common (14%), followed by nonalcohol substance dependence (7%), alcohol abuse (3%), and nonalcohol substance abuse (2%). Marijuana was the most commonly
used drug (45%), followed by stimulants (20%), opioids
(15%), and cocaine (5%). The remaining 15% of the
group were polydrug users.
Comparison of the rate of disorders in the first year
after injury with that in the subsequent years indicated
that the frequency of depressive disorders in the first year
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JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009
Number of people (N = 100) with SCID-diagnosed psychiatric disorders preand post-TBI, novel post-TBI disorders, and breakdown of disorders
TABLE 2
Psychiatric disorder
Number of participants with disorder
Depression
Any anxiety disorder
Any psychotic disorder
Substance use disorders
Somatoform disorder
Eating disorders
Number of disorders
Major depression
Dysthymia
GAD
PTSD
Specific phobia
Panic disorder
Social phobia
OCD
Agoraphobia
Substance-induced anxiety disorder
Substance-induced psychotic disorder
Schizoaffective disorder
Psychotic disorder NOS
Alcohol abuse disorder
Alcohol dependence disorder
Nonalcohol substance abuse disorder
Nonalcohol substance dependence disorder
Pre-TBI
Post-TBI
Novel disorders
17
13
1
41
0
2
46
38
3
21
1
1
33
28
3
3
1
0
17
0
5
4
0
1
2
1
1
1
1
0
0
7
29
5
12
45
1
17
14
7
6
6
1
1
0
0
1
2
3
14
2
7
32
1
13
10
7
5
4
1
0
0
0
1
2
2
1
0
3
Abbreviations: GAD, generalized anxiety disorder; NOS, not otherwise specified; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder; SCID, Structured Clinical Interview for DSM-IV disorders; TBI, traumatic brain injury.
postinjury was significantly lower than in subsequent
years (χ 2 = 6.80, df = 1, P = .012). This result approached significance for anxiety (χ 2 = 3.43, df = 1,
P = .075) and for any disorder (χ 2 = 4.40, df = 1, P =
.064).
Novel disorders following TBI
Numerous participants experienced depressive disorders and anxiety disorders for the first time following
injury (see “novel disorders” column, Table 2). Of the
46 people who experienced a depressive disorder postinjury, 33 had developed depression for the first time. A
further 7 were depressed at the time of the accident, and
6 had a preinjury history of depression, which was in
remission at the time of injury.
Of the 38 people who experienced anxiety disorder
postinjury, 28 were new onset. For GAD, 13 were new
cases, 3 were ongoing, and 1 was a relapse of a previously
resolved disorder. Ten people experienced PTSD as a
novel disorder; the other 4 cases were current at the time
of injury. All diagnoses of specific phobia and psychotic
disorders were novel, and 5 of 6 cases of panic disorder
were novel, as were 4 of 6 cases of social phobia.
Few new onset substance use disorders were evident;
only 3 of 21 people developed a postinjury substance use
disorder with no prior history. Two cases of novel alcohol abuse disorder were found; 1 of these people had a
preinjury nonalcohol substance disorder. Of those with
postinjury alcohol dependence, 1 was a novel disorder,
10 had alcohol dependence at the time of injury, and 3
had a history of alcohol dependence prior to injury but
were not dependent at the time of injury. There were
no new cases of nonalcohol substance abuse; 1 case was
ongoing and 1 had relapsed. Of the 7 people with nonalcohol substance dependence, 3 were novel disorders
and 4 were present prior to injury.
Current and comorbid disorders
Table 3 shows Australian prevalence rates for psychiatric disorders where available.16 Given that the average
participant was male, aged 37, prevalence rates for males
of this age group are also provided. Of the 46 participants found to have depression at any time postinjury,
34 (74%) were depressed at the time of assessment (see
Table 3); therefore, 12 cases of depression had been resolved by the time of interview. Of these participants
Psychiatric Disorders Following Traumatic Brain Injury
329
Number of participants (N = 100) with current and resolved psychiatric disorders post-TBI and 12-month Australian prevalence rates (where available)
TABLE 3
Australian rates
Postinjury disorders
Disorder
Number of participants with disorder (N)
Depressive
Anxiety
Substance use
Psychotic
Somatoform
Eating
Number of disorders (N)
GAD
PTSD
Specific phobia
Panic disorder
Social phobia
OCD
Agoraphobia
Schizoaffective
Psychotic NOS
Alcohol abuse
Alcohol dependence
Nonalcohol substance abuse
Nonalcohol substance dependence
General
population %c
Males %d
Males
35–44 %
12
2
4
1
0
1
5.1
9.7
7.7
3.4
7.1
11.1
6.0
8.3
12
3
3
0
0
0
0
0
0
1
1
4
0
2
3.1
3.3
2.4
2.3
1.3
2.7
0.4
1.1
0.6
2.4
0.3
0.7
3
3.5
3.5
2.2
4.3
5.1
Current %a
Resolved %b
34
36
17
2
1
0
14
11
7
6
6
1
1
1
1
2
10
2
5
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,
4 had mild symptoms, 12 had moderate symptoms,
and 13 had severe symptoms at the time of assessment.
Eight people with current depression had a comorbid
substance use disorder (23.5%), and 25 had a comorbid
anxiety disorder (73.5%). Of the 45 participants with
current depression and/or anxiety, 23 (51.1%) were receiving medication and/or counseling.
Of the 38 people with postinjury anxiety disorders,
only 2 cases had resolved by the time of interview (see
Table 3). All cases of specific phobia, panic disorder,
social phobia, OCD, agoraphobia, and somatoform disorder were current. High current frequencies were also
found for the remaining anxiety disorders, as 14 of 17
cases (82%) of post-TBI GAD were current, and 11 of
14 cases (79%) of the PTSD cases were current. Six people with anxiety (16.7%) had a comorbid substance use
disorder.
Of the 3 diagnosed postinjury psychotic disorders, 2
were current. The 1 eating disorder was in remission.
Although the overall frequency of substance use disor-
ders fell preinjury to postinjury, postinjury substance use
disorders tended to be current (see Table 3).
Treatment
Twenty-three of the 45 participants with current depression and/or anxiety (51.1%) were being treated with
medication and/or psychological therapy, as compared
with 31.3% (n = 5) of those for whom depression or
anxiety had resolved at time of assessment.
DISCUSSION
This study aimed to examine the frequency of psychiatric disorders in an Australian sample of 100 individuals
with mild to severe TBI 0.5 to 5.5 years postinjury, using
a DSM-based structured clinical interview to establish
diagnoses. A significant other was also interviewed in
87% of cases. Reliability of participant’s self-report was
demonstrated.
The current study found a high proportion of preinjury and postinjury psychiatric disorders (52% and 65%,
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JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009
respectively). Preinjury, depression and substance use
disorders were most common (17% and 41%, respectively). These findings are consistent with most previous
TBI studies.10,11,18 The frequency of preinjury anxiety
disorders in this study (13%) was the same as that found
by Hibbard.10 Frequencies of most preinjury psychiatric
disorders in the current study were much higher than
those in the Finnish Koponen7 study, in which there
were no preinjury depressive disorders, GAD, or nonalcohol substance disorders. However, given that participants in that study were at least 27 years postinjury, it
is possible that their retrospective account of premorbid diagnoses was unreliable. Furthermore, all TBIs occurred between 1950 and 1971, at a time when mental
health disorders were relatively less well recognized and
acknowledged. There may also be cultural differences
influencing expression of emotion and/or substance use
patterns.
Following TBI, 65% of participants received at least 1
psychiatric diagnosis. Again, depression was the most
common diagnosis in 46% in the first 5 years after injury, a frequency consistent with some previous
studies.10,11,14 High current rates of depression were
found (34%), which were substantially higher than the
Australian comparison rates.16 Seventy-two percent of
depressive disorders were novel disorders, suggesting
that the presence of preinjury psychiatric disorders is
not the only influential factor. As with the general population, there was also a high frequency of comorbidity of current depressive and anxiety disorders (73.5%).
Only half with current depression and/or anxiety were
receiving treatment. Other studies have reported lower
frequencies of depression and anxiety,2,18,25 but all involved follow-up in the first year after injury. In the
current study, there was a trend for the frequency of
psychiatric disorders to rise between 1 and 4 years
postinjury. This increase may be associated with factors
such as improved insight into the effects of the injury
over time, growing despondence at the lack of physical/emotional/vocational progress, financial hardship,
or decrease in professional support over time.
The number of participants with anxiety disorders rose
from 13% to 38% postinjury, with a total of 52 diagnoses. Of those with an anxiety disorder post-TBI, 74%
had developed novel anxiety disorders, most commonly
GAD and PTSD, followed by specific and social phobias and panic disorder. Anxiety disorders showed poor
resolution, with 95% of cases current at the time of assessment. Frequencies of most current anxiety disorders
were all much higher than in the general population16
but were generally within the ranges reported in previous
studies of persons with TBI.10,11,14 However, the current reported frequency of OCD (1%) was much lower
than a previous study that reported an incidence of 15%;
it was suggested that checking-rechecking behavior may
be a compensatory strategy for poor memory following
TBI.10 However, in order to meet DSM-IV criteria for
diagnosis of OCD, this behavior must be attributed to
adherence to a rigid set of rules in order to avoid negative
consequences (anxiety), rather than memory problems
causing repeated checks to ensure safety.
No other known studies of individuals with TBI have
screened for eating disorders or somatoform disorders.
Agoraphobia, eating disorders, somatoform disorders,
and psychotic disorders all occurred at frequencies similar to those in the general population, suggesting that
these are not common consequences of TBI. However,
it is also possible that the current study lacked the power
to detect any change in frequency of such disorders. In
addition, there were 3 new cases of psychotic disorders,
and given previous findings of onset of psychosis more
than 4 years postinjury,26,27 one cannot rule out the possibility of psychotic disorders developing over a longer
time frame.
Frequencies of substance use disorders decreased
from 41% preinjury to 21% postinjury, with few novel
cases. This trend has previously been noted in the
literature.10,20 Frequencies of comorbidity were high—
of those with current depression and anxiety disorders,
23.5% and 16.7%, respectively, also had a substance use
disorder. Current substance use disorders occurred in
17% of participants, which is much higher than their
occurrence in the general population.16 High rates of
alcohol consumption are not unique to the TBI population and are indeed typical of the young male demographic population from which they are drawn.20 However, given the severity of brain injury in this group, the
amount of alcohol being consumed is potentially much
more harmful and therefore of concern. It is important
to institute measures to discourage those who engaged
in heavy substance use preinjury from returning to this,
following TBI.
The findings of this study must be interpreted within
the context of certain limitations, most notably its retrospective, cross-sectional design, a limitation also present
in most previous studies. In the present investigation,
stratified random sampling was used to ensure inclusion
of equal and representative groups on average 1 to 5 years
after injury. However, this design does not allow for precise examination of the timing of onset of disorders.
As previously discussed, the referring hospital treated
patients referred for rehabilitation under a no-fault accident compensation system, so the sample comprised
a high proportion of individuals with moderate to very
severe TBI, the majority of whom incurred injuries in
motor vehicle or work-related accidents. Therefore, the
findings of the current study may not be generalizable
across the entire spectrum of severity of TBI, particularly mild TBI, or those not referred for rehabilitation.
Despite the use of a stratified random sampling method,
Psychiatric Disorders Following Traumatic Brain Injury
the possibility of some selection bias cannot be ruled
out. It may be that certain people were more or less
motivated to participate, depending on their emotional
state. It would also be of interest in future studies with
a stratified time postinjury design to consider whether
patients with a shorter or longer time postinjury were
more or less inclined to participate. This information
was not available for the current study. One could also
question the reliability of retrospective reports of preinjury symptoms experienced up to 51/2 years previously.
The involvement of a significant other in verifying reported symptoms mitigated against this. Clearly, it will
be important to follow up these findings with a prospective study, conducted over a longer time frame than that
used in the previous 1-year outcome studies to date.
The sample studied was predominantly male (71%).
Although this gender imbalance is typical of the TBI
population, it may have influenced the frequency
of observed disorders. The majority of studies have
found no gender differences in frequencies of postinjury depression.2,7,10,13,18,39,40 However, females may
be more likely to be diagnosed with an anxiety
disorder.10,13,14 Males have been more often diagnosed
with a substance use disorder in both the TBI and the
general population.14,20
Preexisting emotional and substance abuse problems
have been associated with a greater likelihood of TBI.3
Numerous interdependent factors contribute to the likelihood of having a TBI and to the development of a mental health disorder; it is possible that the same groups
are at risk for both conditions. Young men account for a
large proportion of the population with brain injury, and
arguably the frequencies of depression and substance
use may be higher in this subgroup than the population
norms against which they have been compared. A demographically matched control group should be considered
in future studies.
331
Few studies have used measures such as the SCID-I
to establish preinjury and postinjury diagnoses. On the
basis of the high degree of concordance between interview results and medical records, the current study has
demonstrated the appropriateness of this measure for use
in the TBI population. Given the range of disorders that
occur in this group, it is recommended that psychiatric
screening cover a broad range of diagnoses.
This study has highlighted that TBI creates a risk
for development of several psychiatric disorders, particularly depression and anxiety, in a significant proportion of those who had no previous psychiatric history. That this finding was obtained in a group that
had access to comprehensive rehabilitation supports the
need for a greater focus on prevention and treatment
of these problems both within and outside rehabilitation programs. Clearly, practitioners cannot rely solely
on preinjury history of psychiatric problems to predict
postinjury problems. Moreover, many who experience
anxiety and depression may not recognize or report it.
It is therefore vital that community-based health professionals are trained to recognize the symptoms and
signs of these conditions in an individual with TBI and
are provided with strategies and resources with which
to address them, including the availability of skilled
psychological or psychiatric intervention. Patients and
families should be informed regarding symptoms of
depression and anxiety. TBI follow-up clinics should
conduct routine long-term screening for such disorders. Education about the implications of substance use
following brain injury is also of vital importance. Investigation of the factors associated with the development of these disorders would assist in identifying those
most at risk, so that they may be targeted for assessment and intervention. This represents the focus of the
subsequent study in this series by Whelan-Goodinson
et al.41
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