SAVANNAH, GA—Psychiatric comorbidity after traumatic brain injury (TBI) is common and, even after a mild injury, can have a serious impact on a patient's life. In research presented at the 19th Annual Meeting of the American Neuropsychiatric Association, Vani Rao, MD, and colleagues reported on the prevalence and impact of post-TBI depression, aggression, and sleep disturbances.
Aggression and Depression Post-TBI
In one study reported by Dr. Rao and colleagues, 27.9% of 68 patients evaluated within three months of their TBI experienced symptoms of aggression; those patients were also significantly more likely to have new-onset major depression, poorer social functioning, and an increased dependency for activities of daily living. The likelihood of aggression was increased with each of the correlates: 62-fold with post-TBI psychosocial impairment, eightfold with new-onset major depression, and by 8% with post-TBI dependence for activities of daily living.
“Aggression—more specifically verbal agitation—is common after TBI,” said Dr. Rao in an interview with Neurology Reviews. “It should not be ruled out as rude or bad behavior. Patients presenting with anger or agitation should be evaluated for depression, as early diagnosis and treatment of these conditions can lead to more effective recovery and rehabilitation.” Dr. Rao is an Associate Professor of Psychiatry at Johns Hopkins University in Baltimore and Medical Director of the Brain Injury Clinic at Johns Hopkins Bayview Medical Center.
The research team also suggested that damage to the frontotemporal lobe and basal ganglia may increase the risk of major depression after TBI. In a pilot study that examined brain metabolic ratios of N-acetyl aspartate to creatine and regional brain volumes, those areas showed significantly reduced function in 10 case participants who developed major depression following TBI, as compared with seven controls who did not.
None of the participants had a history of major depression, and the cases presented between three months and five years after TBI. The case participants were significantly older than the control participants (mean age, 52.4 vs 27.4). About 60% of case participants had moderate to severe TBI, and all controls had injuries of that severity. Gray matter volume was significantly reduced in the right frontal lobe among cases. Neuropsychologic tests showed significantly reduced frontal functioning and a trend toward reduced temporal functioning. Metabolism was also reduced in the right basal ganglia of the group with major depression. Dr. Rao noted that some of the findings may be secondary to the older age among cases, however.
Subdural frontal lesions were also identified as a risk factor for depression after mild TBI in a third study conducted by Dr. Rao’s group. Within 12 months of the injury, about one-quarter of the 30 patients were depressed; in addition to the increased frequency of subdural frontal lesions, they also had a higher anxiety score, medical comorbidity, increased frequency of verbal aggression, postconcussive syndrome, poorer social functioning than before TBI, and increased dependency for activities of daily living.
Sleep Disturbances After TBI
Sleep disturbances are another common occurrence after TBI and, as Dr. Rao and colleagues reported in a fourth study, mood disorders such as depression and anxiety disorders may play a role in their manifestation. Fifty-four patients reported that daytime sleepiness, sleep disturbance, awakening with shortness of breath or headache, and poor sleep adequacy were greater three months after TBI than before their injury. Hamilton Depression Scale and Clinical Anxiety Scale scores significantly predicted sleep adequacy, sleep disturbance, daytime sleepiness, and total sleep scores, explained the authors. They suggested that the treatment of patients with mood disorders following TBI might reduce subsequent sleep problems.
Dr. Rao noted that although neurologists and psychiatrists are aware of many post-TBI neuropsychiatric sequelae, the interrelated nature of these comorbidities suggests that patients would be better served if the two groups of specialists worked together to provide the comprehensive care that TBI patients require. “Early diagnosis and treatment not only can help [patients] in terms of improvement and stabilization in mood and behavior but can help with rehabilitation and recovery,” she added.
—Jessica Dziedzic