In addition to screening for depression among mTBI patients, consistent screening for mTBI among patients with psychiatric symptoms should be mandated, Dr. Ashman said. Such screening is especially important in practices involving populations where “hidden TBI” is known or suspected to be common such as athletes and the elderly.
The treatment of depression secondary to mTBI should be approached from a multidisciplinary perspective. “When possible, individuals with TBI should have a neuropsychological evaluation to determine the nature and extent of the cognitive impairments and plan treatment,” Dr. Ashman and colleagues wrote in a review article of the neurobehavioral consequences of traumatic brain injury.
“Remediation, which may be coupled with psychotherapy, can then be provided by rehabilitation psychologists or neuropsychologists, in conjunction with speech therapists, occupational therapists and other rehabilitation professionals” (Mt. Sinai J. Med. 2006;73:999–1005).
No medication has received approval from the Food and Drug Administration for the treatment of any neuropsychiatric consequence of mTBI, but antidepressant therapy has been shown to improve mood and, potentially, cognitive performance in these patients.
In a 2001 study, for example, Dr. Fann and colleagues conducted an 8-week, nonrandomized, single-blind, placebo run-in trial of sertraline in a group of 15 patients with mTBI and depression.
The investigators conducted neuropsychological testing before and after the treatment trial. Compared with baseline, depression scores improved significantly, as did measures of psychomotor speed, recent verbal memory, recent visual memory, and general cognitive efficacy improved with treatment, the authors wrote.
When pharmacotherapy is considered in this population, it is essential to start medications at low doses and to titrate slowly because of the potential susceptibility to adverse cognitive effects, Dr. Ashman said.
It is best to avoid medications that are highly sedative and those that have deleterious effects on the central nervous system, she noted.
Finally, education is a key component of depression management in mTBI. Education after mTBI for the patient as well as family, friends, employers, and others, should begin early and include an explanation of the range of possible symptoms, the usual time course for resolution, and the potential for long-term problems, according Dr. David B. Arciniegas of the University of Colorado, Denver.
Also, “the clinician should offer validation of the person's experience of symptoms,” and couple the validation with the development of realistic goals aimed at returning to normal activities, he said.
PERSPECTIVE
Until recently, mild traumatic brain injury was presumed to be not very important for generating long-term symptoms or problems. In fact, this consideration was a huge source of contention among those who granted disability status of patients with mild TBI.
Also, disagreement prevailed within legal circles about various injury-related lawsuits, as most companies did not want to pay for the post-mTBI headaches, symptoms of depression, insomnia, and so forth.
Similarly, mTBI has been underconsidered as a source of psychiatric symptoms among mental health clinicians. Few psychiatrists routinely ask patients about mTBI.
This mind-set might be exacerbated by the fact that when there is no loss of consciousness associated with a head injury, individuals often don't seek medical care, and by the measures used to gauge the severity of head trauma and the nomenclature used to describe it.
The term “mild” with respect to traumatic brain injury does not reflect the severity of the injury, but rather the length of time the individual experiences postinjury confusion or disorientation.
On the Glasgow Coma Scale, an injury causing less than 30 minutes of altered consciousness is deemed mild. To patients, families, and even clinicians, that connotation might minimize the awareness of the potential for long-term symptoms.
Since neuroimaging has become more readily available and the science has become more specific, mTBI and the possibility of postinjury symptoms have recently gained more traction. But there is still no way to show cause and effect between mTBI and the broad range of neuropsychiatric symptoms that have been attributed to it.
Until research catches up with reality, the best way to manage psychiatric symptoms in mTBI patients is to first identify such patients through routine history and, educate the patient and family, validate the patient's symptoms, and treat with therapy and medication.