Traumatic brain injury (TBI) results in an increased risk for psychiatric illness, including mood and anxiety disorders, substance abuse, sleep disorders, and psychosis. As in the general population, mood disorders are most common, with depression being the most prevalent psychiatric disorder after TBI. Risk for depression spans the range of TBI severity. Anxiety disorders are also common and frequently coexist with depression. , Studies show that individuals with TBI experience all variants of anxiety disorders, including generalized anxiety disorder (GAD), panic disorder, specific phobias, and obsessive–compulsive disorder, with GAD being the most commonly reported anxiety disorder after TBI.
Depression and anxiety are associated with greater cognitive and functional impairment and can complicate recovery and increase TBI-related disability. Thus, timely identification and treatment of these disorders after TBI is critical to improving outcomes and psychosocial functioning.
In this chapter, we review prevalence, etiology, evaluation, and treatment of posttraumatic depression (PTD) and GAD, the two most common psychiatric disorders after TBI. Posttraumatic stress disorder (PTSD) is no longer classified as an anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and is covered separately in Chapter 39 .
Epidemiology
Previous studies on psychiatric outcomes after TBI feature considerable variability in prevalence of depression and anxiety disorders in the months and years postinjury, with prevalence rates of anxiety as high as 70% and rates of depressive disorders ranging from 25% to 50%. Methodological differences (e.g., study design, measures, injury severity classification, follow-up period) have contributed to variable findings regarding the prevalence of depression and anxiety after TBI. Longitudinal or prospective studies of depression and anxiety after TBI have mostly been limited to the first year postinjury but are generally methodologically more rigorous and valid, particularly when structured diagnostic interviews are employed. Some studies with longer follow-up periods have shown elevated rates of mood and anxiety disorders that increase in the first year postinjury and gradually decline over the next few years. Other investigations suggest that psychiatric disorders may continue to emerge after the first year postinjury. ,
Preinjury anxiety, depression, and substance abuse represent the most robust risk factors for postinjury depression and anxiety. , Unemployment and unstable employment are also risk factors for depression. , Some research suggests that a history of TBI may increase the risk of depression and anxiety, perhaps as a consequence of cumulative damage from multiple TBIs.
Etiology
There are numerous mechanisms whereby depression and anxiety may develop after TBI. Biological mechanisms and psychosocial and adjustment-related mechanisms may all play a role. Psychosocial factors may serve as stronger determinants of depression, especially as time since injury progresses. Biological or organic changes associated with TBI may also contribute to increased risk of mood and anxiety disorders. Focal and diffuse injuries to prefrontal and limbic circuits that regulate emotions may cause or contribute to increased risk for depression and anxiety.
Evaluation
Diagnostic criteria
The DSM-5 provides the current criteria for diagnosing major depression and GAD. For a diagnosis of major depression, the individual must be experiencing five or more symptoms listed in Table 38.1 during the same 2-week period, and at least one of the symptoms should be either depressed mood or loss of interest or pleasure. GAD shares some features and symptoms with depression but is largely characterized by excessive anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months. The individual finds it difficult to control worry and anxiety that is associated with at least three of the symptoms listed in Table 38.2 . In addition, for a diagnosis of major depression and GAD, the symptoms must cause the individual clinically significant distress or impairment in important areas of functioning, and they must also not be a result of substance abuse or another medical condition.
| Symptom Criterion (Symptoms most helpful in differentiating depressed and nondepressed persons with traumatic brain injury [TBI] are noted with a checkmark) | |
| ✓ |
| ✓ |
| |
| |
| |
| |
| ✓ |
| |
| ✓ |
| Symptom Criterion |
|
Differential diagnosis
Depression, anxiety, and other TBI-related sequelae share many common symptoms, including fatigue, irritability, poor concentration, and sleep disturbance, making differential diagnosis difficult. Current evidence indicates that organic TBI-related sequelae that overlap with depressive symptoms do not contribute to significant false-positive diagnoses of depression among those with TBI. As shown in Table 38.2 , symptoms such as feelings of hopelessness and worthlessness and difficulty enjoying activities may be most helpful in differentiating those who are depressed from those who may be experiencing other affective and somatic sequelae after TBI.
Other psychiatric conditions commonly associated with TBI, such as apathy, anxiety, emotional lability, and dysregulation, also require careful clinical consideration when making a differential diagnosis. As outlined in Table 38.3 , Seel et al. highlighted overlapping and differentiating features of depression and other common neuropsychiatric sequelae of TBI (e.g., anxiety, apathy, and emotional dysregulation) that may be helpful to keep in mind when evaluating individuals with TBI for these conditions.
| Feature | Depression | Anxiety | Apathy | Emotional Dysregulation |
|---|---|---|---|---|
| Mood | Sad, irritable, frustrated | Worried, distressed | Flat, lacks emotion | Frustrated, angry, tense |
| Activity Level | Low energy and activity | Restless, edgy | Lack of energy, initiative, activity | Impulsive |
| Physiological | Underaroused | Hyperaroused | Underaroused | Fluctuating arousal |
| Attitude | Loss of interest, pleasure | Overconcerned | Loss of interest, goals | Argumentative |
| Awareness | Overestimates problems | Overestimates problems | Underestimates problems | Underestimates problems |
| Cognitions | Rumination, focuses on loss, failure | Rumination, focuses on harm, danger | Lack concern about failure | Rumination |
| Coping Style | Active avoidance, social withdrawal | Active avoidance | Dependent, compliant | Uncontrolled outbursts |
Screening and assessment
Depression and anxiety—and psychiatric disorders in general—are frequently underdiagnosed and undertreated in persons with TBI, making early identification and management of these conditions paramount. Screening and assessment of depression and anxiety can be enhanced by using psychometrically sound measures. Suggested measures for these purposes are listed in Table 38.4 . Screening for these conditions should be a standard component of TBI assessment. Among those who screen positive, structured diagnostic interviews are the gold standard for diagnosis.
| Measure | Purpose | Description |
|---|---|---|
| Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Disorders (SCID–5) | Diagnostic | Semistructured interview guide for making major DSM-5 diagnoses; administered by a clinician or trained mental health professional who is familiar with the DSM-5 classification and diagnostic criteria |
| Patient Health Questionnaire-9 (PHQ-9) | Screening; symptom monitoring | Nine-item self-report measure of depression severity based on DSM-5 symptom criteria for depression; completed in 5 minutes; minimal training required |
| Beck Depression Inventory-II (BDI-II) | Screening; symptom monitoring | 21-item self-report measure of depression severity based on the DSM-5 symptom criteria for depression; completed in 5–10 minutes; minimal training required |
| Neurobehavioral Functioning Inventory (NFI) Depression Scale | Screening; symptom monitoring | 13-item self-report measure of frequency of depressive symptoms; completed in 5–10 minutes; minimal training required |
| Generalized Anxiety Disorder-7 (GAD-7) | Screening; symptom monitoring | 7-item self-report measure of anxiety severity based on DSM-5 symptom criteria for GAD; completed in 5 minutes; minimal training required |
| Brief Symptom Inventory-18 Item (BSI-18) | Screening; symptom monitoring | 18-item screen of psychological distress with a Global Severity Index (GSI), and three clinical subscales: somatization, anxiety, and depression; completed in 5 minutes; interpretation requires doctoral-level training in psychology |
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