Kate Rachel Gould

The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study

BACKGROUND Psychiatric disorders are common following traumatic brain injury (TBI). However, few studies have examined the course of disorder development and the influence of pre-injury psychiatric history. The present study aimed to examine the frequency of, and association between, psychiatric disorders occurring pre- and post-injury, and to examine the post-injury course of disorders. METHOD Participants were 102 adults (75.5% male) with predominantly moderate-severe TBI. Participants were initially assessed for pre-injury and current disorders, and reassessed at 3, 6 and 12 months post-injury using the Structured Clinical Interview for DSM-IV Disorders (SCID). RESULTS Over half of the participants had a pre-injury psychiatric disorder; predominantly substance use, mood, and anxiety disorders. In the first year post-injury, 60.8% of participants had a psychiatric disorder, commonly anxiety and mood disorders. Post-injury disorders were associated with the presence of a pre-injury history (p<0.01), with 74.5% of participants with a pre-injury psychiatric history experiencing a post-injury disorder, which commonly presented at initial assessment or in the first 6 months. However, 45.8% of participants without a pre-injury history developed a novel post-injury disorder, which was less likely to emerge at the initial assessment and generally developed later in the year. CONCLUSIONS Despite evidence that most post-injury psychiatric disorders represent the continuation of pre-existing disorders, a significant number of participants developed novel psychiatric disorders. This study demonstrates that the timing of onset may differ according to pre-injury history. There seem to be different trajectories for anxiety and depressive disorders. This research has important implications for identifying the time individuals are most at risk of psychiatric disorders post-injury.

The temporal relationship between depression, anxiety, and functional status after traumatic brain injury: a cross-lagged analysis.

Poor functional status and high rates of anxiety and depression have been reported in individuals who have sustained a traumatic brain injury (TBI). However, it is unclear whether psychiatric disorders after TBI are a cause or a consequence of functional limitations. The current study aimed to investigate the temporal relationship between anxiety, depression and functional impairment following TBI. The study has a prospective, longitudinal single-group design. Anxiety and depression, assessed using the Structured Clinical Interview for DSM-IV, and functional changes, assessed with the Glasgow Outcome Scale-Extended, were measured six and 12 months post-injury in 122 individuals who had sustained a TBI (79% male, mean age 35 years, mean duration of post-traumatic amnesia 24 days, mean Glasgow Coma Scale score 9.2). Cross-lagged analyses were conducted within a structural equation modelling framework. Functional changes six months post-injury predicted depression and anxiety one year after the injury. Anxiety and depression, in turn, were not predictive of later functional status. This study adds to our understanding of the temporal relationship between depression, anxiety and functional status after TBI. The results indicate the importance of supporting brain injured individuals in coping with the functional consequences of their injury in order promote psychological well-being.

Relationship between psychiatric disorders and 1-Year Psychosocial outcome following traumatic brain injury

Objective:To investigate the relationship of psychiatric functioning with psychosocial functioning at 1 year followingtraumatic brain injury (TBI), after controlling for relevant demographic, injury-related, and concurrent factors. Design:Prospective 1-year longitudinal study. Participants:Participants were 122 individuals with TBI and 88 proxy informants. Setting:Rehabilitation hospital. Main Measures:The Structured Clinical Interview for DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision)) Axis I Disorders, HospitalAnxiety and Depression Scale, Sydney Psychosocial Reintegration Scale, and Glasgow Outcome Scale-–Extended. Results:At 1 year postinjury, occupational activities were the area of most change after TBI followed by interpersonal relationships andindependent living skills, according to the Sydney Psychosocial Reintegration Scale. The majority of participants were rated as havingmoderate disability on the Glasgow Outcome Scale-–Extended. After controlling for relevant background factors, preinjury, acutepostinjury, and concurrent psychiatric disorders were significantly related to 1-year psychosocial outcome. Conclusion:Screening in the acute postinjury stage for presence of preinjury psychiatric history or current distress may help identify individualswho require more intensive rehabilitation and psychiatric support and more active postdischarge monitoring. Further research exploringpotential causal mechanisms for these findings is required.

Neuropsychological Deficits in Adolescent Unipolar Depression

Although neuropsychological deficits in adult depression are relatively well established, findings in children/adolescents have been inconsistent and thus require further investigation. The current study investigated verbal fluency (VF), cognitive speed, motor speed, and executive functions in adolescents with unipolar depression. Results indicated that adolescents with minor depression showed working memory deficits and poorer VF (letter task). Adolescents with major depression showed working memory deficits and processing speed deficits from the early stages of information processing to the later stages of motor output. Executive function deficits of set-shifting and response inhibition that are well established in adults were not found, but may reflect task differences. Thus, it appears that depression subtype or severity of symptoms may impact on neuropsychological functioning and may in part explain previous inconsistent results.

Predictive and associated factors of psychiatric disorders after traumatic brain injury: a prospective study.

Psychiatric disorders are common and often debilitating following traumatic brain injury (TBI). However, there is little consensus within the literature regarding the risk factors for post-injury psychiatric disorders. A 1-year prospective study was conducted to examine which pre-injury, injury-related, and concurrent factors were associated with experiencing a psychiatric disorder, diagnosed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, at 1 year post-injury. Participants were 122 adults with TBI and 88 proxy informants. Psychiatric disorders were common both pre-injury (54.1%) and at 12 months post-injury (45.9%). Results of regression analyses indicated individuals without a pre-injury psychiatric disorder or psychiatric symptomatology in the acute post-injury period were less likely to have a psychiatric disorder at 12 months post-injury. These findings confirm the importance of pre-injury history for the prediction of post-injury psychiatric disorders. Limb injury also emerged as a useful early indicator of later psychiatric disorder. Post-injury psychiatric disorders were associated with concurrent unemployment, pain, poor quality of life, and use of unproductive coping skills. The clinical implications of these findings are discussed.

Association between cognitive impairments and anxiety disorders following traumatic brain injury.

This study examined the association between cognitive impairment and anxiety disorders following traumatic brain injury (TBI). Sixty-six participants recruited from a rehabilitation hospital completed the Structured Clinical Interview for the DSM–IV (Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition) and cognitive tests at one year post injury. Prevalence of anxiety disorder was 27.3%. Logistic regression analyses revealed that the attention/working memory, information processing, and executive functions models were significantly associated with anxiety disorder. The memory model was not significant. Processing speed emerged as the strongest model associated with anxiety disorder. The role of cognitive impairment in the etiology of anxiety disorders after TBI is discussed, and treatment implications are explored.

Changes in self-reported pre- to postinjury coping styles in the first 3 years after traumatic brain injury and the effects on psychosocial and emotional functioning and quality of life

Objective:To examine the influence of self-reported preinjury coping on postinjury coping, psychosocial functioning, emotional functioning, and quality of life at 1 year following traumatic brain injury (TBI). Setting:Inpatient hospital and community. Participants:One hundred seventy-four participants with TBI. Design:Prospective, longitudinal design. Participants were assessed at 5 time points: after emerging from posttraumatic amnesia, and at 6, 12, 24, and 36 months postinjury. Main Measures:Coping Scale for Adults–Short Version; Quality of Life Inventory; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale. Results:High preinjury use of nonproductive coping style predicted high use of nonproductive coping, more anxiety, and lower psychosocial functioning at 1 year postinjury. Increased use of nonproductive coping and decreased use of productive coping predicted poorer psychosocial outcome at 1 year post-TBI. Use of both productive and nonproductive coping decreased in the first 6 to 12 months post-TBI relative to preinjury. Unlike productive coping, nonproductive coping reached preinjury levels within 3 years postinjury. Conclusion:The findings support identification of individuals at risk of relying on nonproductive coping and poorer psychosocial outcome following TBI. In addition, the results emphasize the need to implement timely interventions to facilitate productive coping and reduce the use of nonproductive coping in order to maximize favorable long-term psychosocial outcome.

A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury

BACKGROUND Psychiatric disorders commonly emerge during the first year following traumatic brain injury (TBI). However, it is not clear whether these disorders soon remit or persist for long periods post-injury. This study aimed to examine, prospectively: (1) the frequency, (2) patterns of co-morbidity, (3) trajectory, and (4) risk factors for psychiatric disorders during the first 5 years following TBI. METHOD Participants were 161 individuals (78.3% male) with moderate (31.2%) or severe (68.8%) TBI. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV, administered soon after injury and 3, 6 and 12 months, and 2, 3, 4 and 5 years post-injury. Disorder frequencies and generalized estimating equations were used to identify temporal relationships and risk factors. RESULTS In the first 5 years post-injury, 75.2% received a psychiatric diagnosis, commonly emerging within the first year (77.7%). Anxiety, mood and substance-use disorders were the most common diagnostic classes, often presenting co-morbidly. Many (56.5%) experienced a novel diagnostic class not present prior to injury. Disorder frequency ranged between 61.8 and 35.6% over time, decreasing by 27% [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65-0.83] with each year post-injury. Anxiety disorders declined significantly over time (OR 0.73, 95% CI 0.63-0.84), whilst mood and substance-use disorder rates remained stable. The strongest predictors of post-injury disorder were pre-injury disorder (OR 2.44, 95% CI 1.41-4.25) and accident-related limb injury (OR 1.78, 95% CI 1.03-3.07). CONCLUSIONS Findings suggest the first year post-injury is a critical period for the emergence of psychiatric disorders. Disorder frequency declines thereafter, with anxiety disorders showing greater resolution than mood and substance-use disorders.

FACTORS ASSOCIATED WITH POSTTRAUMATIC STRESS DISORDER FOLLOWING MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A PROSPECTIVE STUDY

This study prospectively examined the relationship between preinjury, injury‐related, and postinjury factors and posttraumatic stress disorder (PTSD) following moderate to severe traumatic brain injury (TBI).

The Evolution of Post-Traumatic Stress Disorder following Moderate-to-Severe Traumatic Brain Injury.

Increasing evidence indicates that post-traumatic stress disorder (PTSD) may develop following traumatic brain injury (TBI), despite most patients having no conscious memory of their accident. This prospective study examined the frequency, timing of onset, symptom profile, and trajectory of PTSD and its psychiatric comorbidities during the first 4 years following moderate-to-severe TBI. Participants were 85 individuals (78.8% male) with moderate or severe TBI recruited following admission to acute rehabilitation between 2005 and 2010. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Disorders (SCID-I), participants were evaluated for pre- and post-injury PTSD soon after injury and reassessed at 6 months, 12 months, 2 years, 3 years, and 4 years post-injury. Over the first 4 years post-injury, 17.6% developed injury-related PTSD, none of whom had PTSD prior to injury. PTSD onset peaked between 6 and 12 months post-injury. The majority of PTSD cases (66.7%) had a delayed-onset, which for a third was preceded by subsyndromal symptoms in the first 6 months post-injury. PTSD frequency increased over the first year post-injury, remained stable during the second year, and gradually declined thereafter. The majority of subjects with PTSD experienced a chronic symptom course and all developed one or more than one comorbid psychiatric disorder, with mood, other anxiety, and substance-use disorders being the most common. Despite event-related amnesia, post-traumatic stress symptoms, including vivid re-experiencing phenomena, may develop following moderate-to-severe TBI. Onset is typically delayed and symptoms may persist for several years post-injury.