A.   Emotional distress, including depression and/or anxiety, is present in a substantial number of persons with mild-to-severe traumatic brain injury (TBI) [1–4]. Information on epidemiology, classification, etiology, and pathophysiology of mood disorders following TBI can be found in Chapter 53. This chapter will focus on screening for mood disorders in persons with moderate-to-severe TBI.

B.   Mood disorders are often underdiagnosed and undertreated in persons with TBI, due to their overlap with the cognitive and behavioral symptoms of TBI [5].

C.   Use of rating scales to screen for emotional distress in medical settings has been recommended to avoid undertreating, but also to prevent overdiagnosis that can lead to unnecessary medication [6].

D.   Accurate use of screening in medical settings serving persons with TBI requires understanding of the potential for under- or overdiagnosing emotional distress in a population with cognitive and behavioral impairments.

A.   Screening—assessment of symptoms in order to guide treatment and/or detect potential for mood disorder; often uses cut-off scores to indicate how consistent symptom presence and severity is with diagnostic criteria for mood disorders; does not enable diagnosis, but indicates the need for more comprehensive assessment that can result in diagnosis

B.   Diagnosis—assessment aimed at establishing the presence or absence of disease; is the result of multiple inputs, including review of records, formal psychiatric or psychological assessments, clinical interview, proxy interview, and so on; established using formal diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM)

C.   Sensitivity—ability of a measure to correctly detect presence of depression or anxiety; typically determined by comparison with a gold standard, such as confirmed diagnosis of depression or anxiety, often via a structured diagnostic interview

D.   Specificity—ability of a measure to correctly identify the absence of depression or anxiety; that is, not falsely identifying someone as having depression or anxiety when they do not

E.   Positive predictive value—probability that a person meeting the cut-off for depression or anxiety on a screening measure actually has the disorder

F.   Negative predictive value—probability that a person who does not meet the cut-off for depression or anxiety on a screening measure does not have the disorder

A.   The gold standard for diagnosis of emotional distress is to use formal diagnostic criteria, such as the DSM, currently in its 5th edition [7], or the World Health Organization’s International Classification of Diseases [8].

B.   Several structured interviews exist to assist with determining whether a person’s symptoms meet the diagnostic criteria for specific psychiatric disorders, such as major depressive disorder or generalized anxiety disorder. The most commonly used diagnostic interviews in persons with TBI are the Structured Clinical Interview (SCID) (currently available for DSM-IV with the DSM-5 version in preparation) [9], the MINI-International Neuropsychiatric Interview (MINI) [10], and the Schedules Clinical Assessment in Neuropsychiatry (SCAN) [11]. The SCID is based on the diagnostic criteria of the DSM, while the MINI and SCAN are based on a combination of DSM criteria and those of the World Health Organization’s International Classification of Disorders (ICD).

C.   Advantages—use interview to assess frequency and severity of symptoms required to meet diagnostic criteria; allows for probing to obtain exact information necessary, including fluctuation of symptoms over time; map directly on to diagnostic criteria.

D.   Disadvantages—long and require expert staff to administer; can be impacted by cognitive deficits in person with injury, including impaired awareness and impaired memory.

E.   Diagnostic interviews that probe for information over a shorter time frame, like the past 2 weeks, tend to yield higher estimates than those probing for information over longer periods (past 2 weeks to a month), perhaps due to impaired recall across longer time periods [3].

A.   Advantages—quick to administer; many can be given by phone or mailed to patients ahead of time; can be used as a basis of referral for more comprehensive assessment and diagnosis via structured diagnostic interviews; can detect subclinical emotional distress associated with TBI, that may not require medication, but could still respond to counseling, support groups, and so on.

B.   Disadvantages—cannot be used to diagnose; varying rates of specificity, sensitivity, and positive and negative predictive values for detecting presence of mood disorders, such as depression or anxiety.

C.   The most commonly used self-report measures of depression and evidence for their usefulness in screening for depression in persons with TBI are described in Table 52.1. All of these measures have adequate internal reliability and good concurrent validity, as indicated by acceptable correlations with other measures of symptom severity. They differ with respect to their sensitivity, specificity, and positive and negative predictive values with respect to distinguishing persons with TBI who do or do not meet diagnostic criteria for depression or anxiety.

A.   The evidence supports counting all symptoms endorsed by persons with TBI toward a diagnosis of depression, rather than attempting to subtract symptoms that overlap with sequelae of TBI [38]. Standard diagnostic criteria for depression and anxiety should be applied to persons with TBI [2].

B.   Self-report can be impacted by impaired awareness, which is common among persons with TBI, particularly during the early stages of recovery [39]. Therefore, these measures should be used with caution during inpatient rehabilitation. A score below the cut-off during inpatient rehabilitation should be followed up with another screening following discharge, as emotional distress may increase as persons with TBI become more aware of injury-related impairments and associated life changes.

C.   Impaired memory can impact recall of symptoms, particularly when the time interval assessed is longer (e.g., past 2 weeks to a month versus past week) [3].

D.   Impaired attention can result in the patients with TBI having difficulty holding the response options in their minds when questionnaires are being administered verbally. Providing them with written response options, perhaps on laminated cards, can help to compensate for attention problems.

E.   Higher rates of emotional distress have been found when a self-report measure is mailed to persons with TBI to complete at home versus when it is completed over the phone [3]. This may reflect a social desirability effect, or the patient being reluctant to admit verbally to symptoms.