Depression (major depressive disorder) is a common and serious medical illness associated with feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
Depression
Overview
Definition
Prevalence
Depression is the most common psychiatric condition following ABI. Depression occurring within the first year has been noted in 27%-61% of individuals with ABI. 1
Etiology
- Most common cause is a sense of loss
- Neurochemical alterations
- Abnormalities of the hypothalamic-pituitary axis
- Metabolic abnormalities in the anterior cingulate gyrus and/or ventrolateral, dorsolateral prefrontal cortex
Risk Factors
- Female gender
- Location of injury
- Pre-existing mental health condition
- TBI severity
- Personality type
- Family and social support
- Psychological stressors
- Family history of depression
Clinical Features
Studies examining depression following ABI have noted that depression or depressive symptoms can begin within the first three months of injury but the risk of developing depression post-ABI remains high for years after injury and may present much later.
- Difficulty concentrating
- Depressed mood most of the day
- Loss of interest or pleasure in most or all activities
- Insomnia or hypersomnia
- Significant weight loss or weight gain (e.g., 5% within a month) or decrease or increase in appetite nearly every day
- Psychomotor slowing or agitation nearly every day that is observable by others
- Fatigue or low energy
- Decreased ability to concentrate, think, or make decisions
- Thoughts of worthlessness or excessive or inappropriate guilt
- Recurrent thoughts of death or suicidal ideation, or a suicide attempt
Assessment
History
- History of present illness
- Depressive symptoms and their context
- Suicide risk
- General medical illness
- Family history
- Social history
- Assess sleep hygiene
- Assess for hallucinations/delusions
- Assess use of alcohol/drugs
- Assess for symptoms/signs of mania
Physical Exam
- Mental status exam
- Physical exam
- Neurological exam
- Cognitive assessment
Screening
INESSS-ONF Clinical Practice Guideline Recommendations
Individuals with traumatic brain injury (TBI) should be screened on a regular basis for depression using an appropriate screening tool. Depression screening tools should not be used as the sole indication for initiation of treatment. Diagnosis should always involve a full assessment as well as the clinical judgment of a specialist experienced in managing individuals with TBI.2
PHQ-9
- Scores of 5 or higher are reasonable cut off points for identifying people with potential major depression
HADS
- This test is typically self-administered.
- Both sections of the assessment (anxiety and depression) use the same scoring range to determine the severity of the symptoms: 0-7 “Normal”, 8-10 “Borderline Abnormal”, 11-21 “Abnormal.”
Diagnostic Testing
DSM-5
- Diagnostic testing is done by a psychiatrist or psychologist)
Laboratory Investigations
There are no specific laboratory investigations for depression.
Diagnosis
- DSM-5
- Consult psychiatry if resistant to treatment or suicidal
Diagnostic Criteria
DSM-5 Criteria for Persistent Depressive Disorder
Depressed mood for most of the day, for more days than not, for two years or longer
Presence of two more of the following during the same period:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Impaired concentration or indecisiveness
- Hopelessness
Never without symptoms for more than two months.
Differential Diagnosis
- Endocrine disorder: hypothyroidism, hypoadrenalism, hyperadrenalism
- Severe anemia
- Dysthymic Disorders
- Bipolar disorder
- Other features of traumatic brain injury – fatigue, reduced motivation, cognitive disorders, loss of appetite, agitation, insomnia, chronic pain – which overlap with clinical features of depression
Complications
- Weight loss
- Reduced participation in rehabilitation
- Interference with relationships
- Reduced independence
- Suicide
Management
INESSS-ONF Clinical Practice Guideline Recommendations
Individuals with traumatic brain injury who have been diagnosed with a depressive disorder should receive appropriate treatment, which can consist of non-pharmacological treatments including psychological intervention/counselling and exercise.2
Non-pharmacological Interventions
Cognitive-Behavioural Therapy
Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy where individuals learn strategies to identify, question, change, and accept thoughts, beliefs, or emotions which cause them significant distress in their daily life.
Mindfulness-Based Stress Reduction
Mindfulness-based stress reduction (MBSR) typically incorporates mindful meditation, body awareness, and yoga with the goal of promoting relaxation and stress management.
Psychotherapy
Psychotherapy aims to improve an individual’s thoughts, behaviors, beliefs, or emotions to benefit their social skills, relationships, mental health, and well-being. Specific forms of psychotherapy have been discussed in previous sections (CBT, MBSR).
Music Therapy
Music therapy is based upon the hypothesis that music encourages more harmonious cerebral activity given the involvement of both hemispheres in processing musical stimuli. 4 As guided by a music therapist, the therapy can involve a combination of listening, singing, and playing instruments.
Physical Activity
The positive impact of physical activity on mood has been well-established in the general population. 5 There is evidence that exercise is an effective therapy for depression in patients without ABI. 6,7
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation is a fairly novel technique for the treatment of mood disorders. It has shown promising results in populations without TBI, but the effectiveness is not entirely clear. 8
Rehabilitation Programs
Despite not incorporating psychotherapy or focusing on psychological outcomes, rehabilitation programs may improve mood following ABI.
| Intervention | Effect | Level of Evidence |
|---|---|---|
| CBT* versus waitlist control | + | 1a Effective treatment for depression compared to waitlist controls post TBI. |
| CBT* versus psychotherapy | - | 1a No more effective than supportive psychotherapy as a treatment for depression post TBI. |
| CBT with motivational interviewing | C | 1b CBT combined with motivational interviewing or non-directive counseling may be equally effective treatments for depression post TBI. |
| CBT* versus controls | C | 2 CBT compared to controls, may improve adaptive coping but may not reduce depressive symptoms post TBI. |
| CBT over phone or in person | + | 1b CBT effective when delivered over the phone or in person. |
| Mindfulness-based stress reduction* | + | 1b Mindfulness-based stress reduction may be an effective treatment for depression post TBI compared to usual care. |
| Psychotherapy | + | 4 Neuro-systemic psychotherapy is an effective treatment for depression post TBI. |
| Music Therapy | + | 2 Music therapy reduces symptoms of depression post ABI compared to standard rehabilitation. |
| Aerobic Exercise | C | C Aerobic exercise may not be effective in reducing symptoms of depression. |
| Tai Chi | + | 1a Tai Chi may improve mood compared to wait-list controls following TBI. |
| Transcranial magnetic stimulation | + | 1b Repetitive transcranial magnetic stimulation may improve depression. |
| Psychosocial rehabilitation program | + | 4 Psychosocial rehabilitation may reduce depressive symptoms following TBI. |
| Community-based rehabilitation program | - | 4 Community-based rehabilitation alone does not change depression scores in patients after ABI. |
*Recommended by the INESSS-ONF Clinical Practice Guidelines
Pharmacological Interventions
Selective Serotonin Reuptake Inhibitors (first-line therapy)
Serotonin Norepinephrine Reuptake Inhibitors
- Duloxetine
- Milnacipran
- Venlafaxine
Tricyclic Antidepressants
- Amitriptyline
- Nortriptyline
- Desipramine
Anticonvulsants
- Carbamazepine
Psycho-Stimulants
- Methylphenidate
| Intervention | Effect | Level of Evidence |
|---|---|---|
| Sertraline* | C | 1b Conflicting evidence as to whether sertraline is a more effective treatment than placebo for major depression post TBI. |
| Desipramine* | + | 2 Desipramine may be an effective treatment for major depression post TBI compared to placebo. |
| Citalopram* and Carbamazepine | + | 4 Combination of citalopram and carbamazepine may be an effective treatment for major depression post TBI. |
| Methylphenidate* | + | 1b Methylphenidate may be an effective treatment for major depression post TBI compared to placebo. |
*Recommended by the INESSS-ONF Clinical Practice Guidelines
Surgical Interventions
No surgical interventions are relevant.
Algorithm
A potential management strategy for the management of depression and anxiety following an ABI, taken from the International Committee on Mental Health in Cystic Fibrosis. 3
Resources
INESSS-ONF Clinical Practice Guidelines
ERABI Module
ERABI Clinical Guidebook
MD-CALC
References
1. Zafonte, R., ed. Brain Injury Medicine; Principles and Practice. 2nd ed. New York: Demos Medical Publishing; 2013:1034-1052.
2. ONF-INESSS. Clinical Practice Guideline for the Rehabilitation of Adults with Modarate to Severe TBI. 2015.
3. Quittner A, Abbott J, M Georgiopoulos A, et al. International Committee on Mental Health in Cystic Fibrosis: Cystic Fibrosis Foundation and European Cystic Fibrosis Society consensus statements for screening and treating depression and anxiety. Vol 712015.
4. Besson M, Schon D. Comparison between language and music. Annals of the New York Academy of Sciences. 2001;930:232-258.
5. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. Journal of psychosomatic research. 1993;37(6):565-574.
6. Kvam S, Kleppe CL, Nordhus IH, Hovland A. Exercise as a treatment for depression: A meta-analysis. Journal of Affective Disorders. 2016;202:67-86.
7. Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Journal of psychiatric research. 2016;77:42-51.
8. Brunoni AR, Chaimani A, Moffa AH, et al. Repetitive Transcranial Magnetic Stimulation for the Acute Treatment of Major Depressive Episodes: A Systematic Review With Network Meta-analysis. JAMA psychiatry. 2017;74(2):143-152.