J Head Trauma Rehabil Vol. 24, No. 5, pp. 324–332 c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Psychiatric Disorders Following Traumatic Brain Injury: Their Nature and Frequency Rochelle Whelan-Goodinson, DPsych; Jennie Ponsford, PhD; Lisa Johnston, PhD; Fiona Grant, PhD Objectives: To retrospectively establish the nature and frequency of Axis I psychiatric disorders pre- and post-TBI. Participants: One hundred participants who were 0.5 to 5.5 years post mild to severe TBI and 87 informants, each evaluated at a single time point. Main Measure: The Structured Clinical Interview for DSM-IV Disorders (SCID-I). Results: Preinjury, 52% received a psychiatric diagnosis, most commonly substance use disorder (41%), followed by major depressive disorder (17%) and anxiety (13%). Postinjury, 65% received a diagnosis, of which major depression became the most common (45%), followed by anxiety (38%) and substance use disorder (21%). Frequency of depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and phobias rose from preinjury to postinjury. More than two-thirds of postinjury depression and anxiety cases were novel and showed poor resolution rates. Few novel cases of substance use disorder were noted. Psychotic disorders, somatoform disorders, and eating disorders occurred at frequencies similar to those in the general population. Conclusions: A high frequency of postinjury psychiatric disorders was evident up to 5.5 years postinjury, with many novel cases of depression and anxiety. Individuals with TBI should be screened for psychiatric disorders at various time points postinjury without reliance on history of psychiatric problems to predict who is at risk, so that appropriate intervention can be offered. Keywords: anxiety, brain injuries, depression, psychotic disorders

T

RAUMATIC BRAIN INJURIES (TBI) are among the leading causes of death and disability in individuals under the age of 45 years, most commonly young males.1 Brain injury is often diffuse and bilateral, commonly including frontotemporal regions, limbic system, basal ganglia, and hippocampus and causing cognitive, behavioral, and emotional changes. Such changes disrupt the lives of these young people, affecting their ability to establish independence, a vocation, and relationships, potentially leading to loss of self-esteem.2–4 A proportion of those with TBI develop psychiatric problems postinjury. Variable frequencies of psychiatric disorders have been reported at various time points following TBI, those for depression and anxiety ranging from 14% to 77%,2,5–13 and for substance use from 4.9% to 28%.2,7,10,11,14 High rates of current depression and anxiety have also been reported, from 10% to 46%,2,7,10,11 as have high rates of current substance use Author Affiliations: School of Psychology, Psychiatry and Psychological Medicine, Monash University, Melbourne, Australia (Drs WhelanGoodinson and Ponsford and Ms Grant), Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, Australia (Drs Ponsford and Johnston), and National Trauma Research Institute, Melbourne, Australia (Dr Ponsford). Corresponding Author: Jennie Ponsford, PhD, Department of Psychology, Monash University, Clayton, Victoria 3800, Australia (jennie.ponsford@ med.monash.edu.au).

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disorders, from 8% to 18%.11,15 In the Australian general population, prevalence rates for depression and anxiety over a 12 month interval are approximately 5.7% and 9.7%, respectively, and 2.2% to 3.5% for substance use disorders.16 Comorbidity between anxiety and depression is high; 1 in 3 people with an anxiety disorder also has an affective disorder. Few TBI studies have examined a range of psychiatric disorders, most having focused on depression.2,7,10,14 Two studies have attempted to assess Axis II personality disorders in TBI participants.7,17 However, brain injury is an exclusionary criterion for Diagnostic and Statistical Manual-IV (DSM-IV) diagnosis of a personality disorder. Furthermore, certain personality changes may be symptoms of frontal lobe injury. Some studies2,7,10,11,18–20 have identified high frequencies of preinjury psychiatric disorders, ranging from 18% to 51%; however, others have excluded people with a preinjury psychiatric diagnosis.9,21–23 Only 3 known studies have used semistructured or structured clinical interviews to establish preinjury psychiatric diagnoses, and all found higher rates of such diagnoses postinjury.7,10,11 Participants in these studies were interviewed at wide-ranging follow-up intervals—on average 3, 8, and 48 years postinjury, respectively. Retrospective recall of preinjury psychiatric symptoms may be unreliable at such long times after injury, particularly given

Psychiatric Disorders Following Traumatic Brain Injury the likely presence of cognitive impairments. Arguably, significant others should be consulted to improve reliability, which these studies appear not to have done. The variability in reported frequencies of preinjury and postinjury disorders may be related to variable timing of assessment, often within the same study. Studies have included participants with injuries sustained from 1 to 227 days,23 1 to 37 years,10 and 27 to 48 years7 previously, while other studies have focused only within the first year postinjury.2,13,24,25 Jorge12 studied symptoms of depression between 1 and 12 months postinjury and found that for 40% of those who were initially depressed, depression resolved within the year, while 18% of those not depressed at initial interview had developed depression by 1 year. They suggested that acute onset depression may be associated with injury-related biological changes in the brain, whereas delayed onset depression may be associated with a growing awareness of injury-related disability. Studies conducted over only 1 year after injury arguably do not fully capture longterm emotional issues. Ashman14 found that the incidence of mood and anxiety disorders rose from preinjury to the first year postinjury and was then relatively stable 2 and 3 years postinjury. Two other studies have shown psychotic disorders to have an average latency to onset of 41/2 years following TBI26,27 although the method of diagnosis was unclear in these studies. Studies of post-TBI substance use indicate an initial decline in frequency of use in the first year postinjury but a return to levels similar to preinjury in subsequent years.18,20,28–30 Hibbard’s10 and Koponen’s7 findings of high frequencies of psychiatric disorders many years postinjury suggest that such disorders develop and persist over very long periods of time. Hence it would seem important to sample various time points after injury. The severity of injuries has also varied widely from one study to another, as have the measures used to establish injury severity. Studies of depression in groups of persons with predominantly mild TBI have generally found lower frequencies of DSM-diagnosed depression, ranging from 12.8% to 16.6%. Sample size has also limited the generalizability of findings from some studies that have used samples of fewer than 50 participants.9,11,31,32 Previous studies have been conducted in North America, the United Kingdom, and Finland. There may be cultural differences in coping styles, emotional expression, stigma associated with injury and mental illness, and attitudes toward substance use, as well as differences in availability of treatment. This may also contribute to variability in findings. Rating scales document clinical symptoms, some of which may be the direct result of the TBI rather than of depression or anxiety, including sleep disturbance, concentration problems, fatigue, or psychomo-

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tor retardation,33–35 potentially leading to overestimation of prevalence of certain disorders. On the other hand, cognitive deficits leading to lack of self-awareness or denial may result in underdiagnosis of disorders.36 The clinical interview is important to establish accurate and reliable diagnoses by distinguishing symptoms due to brain injury from those due to a psychiatric disorder. DSM-based clinical interviews have been shown to have high sensitivity and specificity in identifying depressed TBI participants, particularly in comparison with a depression rating scale.34 Such measures have not been frequently employed in studies of individuals with TBI, possibly because of the time involved in administration and scoring. In summary, the wide range in frequency of psychiatric disorders reported across studies may be attributable to variability in diagnostic instruments, study design, cultural differences, or personal and injuryrelated characteristics of the participants, including presence of preinjury psychiatric disorders, injury severity, and time postinjury. The aim of this study, which is the first in a series, was to examine the frequency of pre- and post-TBI Axis I psychiatric disorders, established on the basis of structured clinical interview based on DSM-IV criteria and verified by a significant other. Participants had mild to severe TBI sustained 0.5 to 5.5 years previously. METHODS Participants One hundred participants with mild to severe TBI sustained between 6 months and 5.5 years previously were recruited from the database of all admissions of patients with head injury to the referring hospital, which provided rehabilitation under a no-fault accident compensation system. The majority had incurred moderate to very severe TBI, and most were injured in road accidents or workplace accidents. All had been discharged from inpatient care. Eligibility criteria were: (1) minimum age 17 years at time of injury and maximum of 75 years at time of interview; (2) having sufficient proficiency in English to complete the interview; (3) no history of previous TBI or serious neurological disorder such as stroke, epilepsy, brain tumor, or neurodegenerative disease. Patients with a premorbid psychiatric history were not excluded. Demographics Demographic information for study participants is given in Table 1. The “average” participant was a 37-yearold male with just less than 12 years of education, who was now 3 years postinjury. Mean length of hospital stay was 41.59 days (SD, 27.59; range, 5–134). Participants had a mean lowest Glasgow Coma Scale (GCS) score of www.headtraumarehab.com

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JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

Demographic data by mean years postinjury; mean, SD, and range Year postinjury 1 (0.5–1.49)

2 (1.5–2.49)

3 (2.5–3.49)

4 (3.5–4.49)

5 (4.5–5.50)

Totala (0.5–5.5)

8.53 4.35 3–14

8.50 4.29 3–14

8.53 4.35 3–14

8.40 4.22 3–14

9.53 3.85 3–14

9.10 4.12 3–14

23.90 22.53 1–77

19.40 17.77 1–62

13.30 14.09 1–49

23.28 17.34 1–63

24.20 15.68 2–56

20.77 17.85 1–77

38.00 16.96 19–67

35.00 11.82 19–60

40.95 16.61 19–74

35.10 11.97 20–61

36.85 13.31 21–65

37.18 14.19 19–74

12.10 2.71 7–17

11.72 3.04 8–18

11.58 2.80 6–16

11.40 2.09 8–16

11.65 2.74 6–16

11.70 2.65 6–18

75% 25% 4

70% 30% 10

75% 25% 11

70% 30% 10

65% 35% 11

Anxiety present (n)

4

7

10

9

8

Any disorder present (n)

9

12

14

15

15

71% 29% χ 2 = 7.01, df = 4, P = .14 χ 2 = 4.50, df = 4, P = .34 χ 2 = 5.71, df = 4, P = .22

Variable Glasgow Coma Score Mean SD Range PTA (days) Mean SD Range Age at assessment Mean SD Range Education, y Mean SD Range Gender Male Female Depression present (n)

Abbreviation: PTA, posttraumatic amnesia. a For n = 100, average time postinjury was 2.98 years, SD = 1.47, range 0.5–5.5.

9.10, with 35% scoring 13 to 14, 20% scoring 9 to 12, and 45% scoring 3 to 8. Mean duration of posttraumatic amnesia (PTA) was 20.77 days (SD, 17.85; range, 1–77). Nine percent had a PTA duration of less than 24 hours, 20% had a PTA of 1 to 7 days, 42% a PTA of 8 to 27 days, and 29% had a PTA greater than 28 days. There were no statistically significant differences among each year postinjury group (see Table 1), or between the present sample and the 57 participants who declined, or between the present sample and the main database group on gender (χ 2 2 = .025, P = .876), education (t = 1.705, df = 596, P = .089, 2-tailed), PTA (U = 27052.50, N1 = 99, N2 = 570, P = .860, 2-tailed), GCS (U = 28334.00, N1 = 96, N2 = 592, P = .963, 2-tailed), or age (U = 29273.50, N1 = 100, N2 = 620, P = .371, 2-tailed), indicating that the current sample was a representative group of participants based on demographic- and injury-related variables. Measures Demographic- and injury-related information and psychiatric history were initially obtained via a semistructured interview. With consent, further details

were obtained from all participants’ medical files, which most often included a full neuropsychological assessment and psychiatric history. The clinical computerized version of the Structured Clinical Interview for DSM-IV disorders (SCID-I) was used to assess frequency, comorbidity, and resolution over time of psychiatric disorders. It was administered twice—first, retrospectively to determine lifetime preinjury psychiatric diagnoses, and second, to identify postinjury psychiatric diagnoses, both current and resolved. The SCID-I contains over 37 Axis I diagnoses, covering mood disturbances, anxiety disorders, schizophrenia and other psychotic disorders, substance use disorders, somatoform conditions, eating disorders, and adjustment disorders.37 “Depressive disorders” refers to dysthymia and major depressive disorders; DSM-based specifiers of mild, moderate, and severe were documented. The “substance use disorder” category refers to alcohol and nonalcohol abuse or dependence disorders. A “novel disorder” refers to a specific disorder occurring post-TBI that has never occurred before in that person’s lifetime.

Psychiatric Disorders Following Traumatic Brain Injury Procedures

RESULTS

Ethics approval was obtained from the hospital through which participants were recruited. An independent researcher identified patients injured between July 2000 and July 2005, who were 0.5 to 5.5 years postinjury. Of the 720 participants in the database, 550 met eligibility criteria. In order to have a sample representative of a range of time points postinjury, eligible participants were divided into 5 groups who were at different time points postinjury (0.5–1.49, 1.5–2.49, 2.5–3.49, 3.5–4.49, and 4.5 to 5.5 years postinjury). Within each year level, individual Statistical Product and Service Solutions (SPSS) codes were entered into a random number generator program from the Web site www.random.org. Participants were contacted sequentially until there were 5 equal groups of consenting participants, with 20 participants in each group on average 1 to 5 years postinjury (see Table 1). Fifty-seven people refused participation or did not return messages. The primary researcher then contacted each consenting person and arranged a meeting either at home or at the hospital. Written informed consent was obtained from all participants. Participants identified a significant other (someone who knew the patient well prior to and postinjury), who was also interviewed about the survivor’s past and current emotional state using the SCID-I, either at the same time or by phone. Thirteen people either declined to nominate a significant other or the significant other declined to be interviewed. In the 87 cases where significant others were interviewed, while not every symptom reported was identical, there was 100% agreement between diagnoses obtained from interviews with the pairs of participants. To determine interrater reliability, 12 of the 100 participants were also assessed in person by a clinical psychologist (L.J.) trained in administering the SCID-I. Both administrators had completed psychopathology courses as part of their doctoral training and both completed a 2-day training program in administration of the SCID-I under the supervision of an experienced clinical psychologist (F.G.). Administration took between 30 and 150 minutes, depending upon the complexity of the interviewee’s responses. The 12 participants obtained diagnoses within the categories of substance-use disorders and anxiety disorders, and the two administrators obtained perfect agreement within these categories, both for current and for preinjury diagnoses (Cohen’s κ = 1.0).

Frequency of preinjury disorders

Data analysis Data were analyzed using SPSS 14 for Windows. Frequency measures were obtained for preinjury and postinjury disorders, both current and resolved. Chi-square analyses were used to compare frequencies of psychiatric disorders from 1 to 5 years postinjury.

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Table 2 displays the number of participants with preinjury Axis I diagnoses. Among those with a documented pre-TBI psychiatric history, all but one participant’s selfreport of preinjury psychiatric history were consistent with medical file reports. However, some participants without a documented history reported premorbid psychiatric symptoms, which warranted a retrospective diagnosis. It seems, therefore, that some individuals with TBI had undiagnosed preinjury psychiatric disorders. Prior to injury, 52% had a psychiatric disorder; 28% had only 1 diagnosis, whereas 24% had more than 1 diagnosis. Preinjury alcohol dependence disorder was the most common single diagnosis (29%); however, other substance use disorders were also common, with a total of 41% falling into these categories. Major depressive disorder was the second most frequent preinjury disorder (17%). Preinjury anxiety disorders were also common (13%). Frequency of postinjury disorders Following TBI, 65% of the current sample met criteria for at least 1 diagnosis. Twenty-seven percent received a single diagnosis, whereas 38% received multiple diagnoses. Table 2 displays the breakdown of postinjury diagnoses. Postinjury major depression was the most common diagnosis (45%), whereas there was only one case of dysthymia. Anxiety (38%) was the second most common diagnosis. Frequencies of individual disorders were greater than the overall figure of 38%, as some participants had more than 1 anxiety disorder. Generalized anxiety disorder (GAD) was the most commonly diagnosed anxiety disorder (17%), followed by posttraumatic stress disorder (PTSD; 14%). Specific phobia (7%), panic disorder (with or without agoraphobia, 6%), and social phobia (6%) occurred with similar frequency. Only 1 person was diagnosed with obsessive-compulsive disorder (OCD) and 1 with agoraphobia. Three people received postinjury diagnoses of a psychotic disorder, 1 had an eating disorder, and 1 a somatoform disorder. Twenty-one percent met criteria for a postinjury substance use disorder. Alcohol dependence was the most common (14%), followed by nonalcohol substance dependence (7%), alcohol abuse (3%), and nonalcohol substance abuse (2%). Marijuana was the most commonly used drug (45%), followed by stimulants (20%), opioids (15%), and cocaine (5%). The remaining 15% of the group were polydrug users. Comparison of the rate of disorders in the first year after injury with that in the subsequent years indicated that the frequency of depressive disorders in the first year www.headtraumarehab.com

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Number of people (N = 100) with SCID-diagnosed psychiatric disorders preand post-TBI, novel post-TBI disorders, and breakdown of disorders TABLE 2

Psychiatric disorder Number of participants with disorder Depression Any anxiety disorder Any psychotic disorder Substance use disorders Somatoform disorder Eating disorders Number of disorders Major depression Dysthymia GAD PTSD Specific phobia Panic disorder Social phobia OCD Agoraphobia Substance-induced anxiety disorder Substance-induced psychotic disorder Schizoaffective disorder Psychotic disorder NOS Alcohol abuse disorder Alcohol dependence disorder Nonalcohol substance abuse disorder Nonalcohol substance dependence disorder

Pre-TBI

Post-TBI

Novel disorders

17 13 1 41 0 2

46 38 3 21 1 1

33 28 3 3 1 0

17 0 5 4 0 1 2 1 1 1 1 0 0 7 29 5 12

45 1 17 14 7 6 6 1 1 0 0 1 2 3 14 2 7

32 1 13 10 7 5 4 1 0 0 0 1 2 2 1 0 3

Abbreviations: GAD, generalized anxiety disorder; NOS, not otherwise specified; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder; SCID, Structured Clinical Interview for DSM-IV disorders; TBI, traumatic brain injury.

postinjury was significantly lower than in subsequent years (χ 2 = 6.80, df = 1, P = .012). This result approached significance for anxiety (χ 2 = 3.43, df = 1, P = .075) and for any disorder (χ 2 = 4.40, df = 1, P = .064). Novel disorders following TBI Numerous participants experienced depressive disorders and anxiety disorders for the first time following injury (see “novel disorders” column, Table 2). Of the 46 people who experienced a depressive disorder postinjury, 33 had developed depression for the first time. A further 7 were depressed at the time of the accident, and 6 had a preinjury history of depression, which was in remission at the time of injury. Of the 38 people who experienced anxiety disorder postinjury, 28 were new onset. For GAD, 13 were new cases, 3 were ongoing, and 1 was a relapse of a previously resolved disorder. Ten people experienced PTSD as a novel disorder; the other 4 cases were current at the time of injury. All diagnoses of specific phobia and psychotic disorders were novel, and 5 of 6 cases of panic disorder were novel, as were 4 of 6 cases of social phobia.

Few new onset substance use disorders were evident; only 3 of 21 people developed a postinjury substance use disorder with no prior history. Two cases of novel alcohol abuse disorder were found; 1 of these people had a preinjury nonalcohol substance disorder. Of those with postinjury alcohol dependence, 1 was a novel disorder, 10 had alcohol dependence at the time of injury, and 3 had a history of alcohol dependence prior to injury but were not dependent at the time of injury. There were no new cases of nonalcohol substance abuse; 1 case was ongoing and 1 had relapsed. Of the 7 people with nonalcohol substance dependence, 3 were novel disorders and 4 were present prior to injury. Current and comorbid disorders Table 3 shows Australian prevalence rates for psychiatric disorders where available.16 Given that the average participant was male, aged 37, prevalence rates for males of this age group are also provided. Of the 46 participants found to have depression at any time postinjury, 34 (74%) were depressed at the time of assessment (see Table 3); therefore, 12 cases of depression had been resolved by the time of interview. Of these participants

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Number of participants (N = 100) with current and resolved psychiatric disorders post-TBI and 12-month Australian prevalence rates (where available) TABLE 3

Australian rates Postinjury disorders Disorder Number of participants with disorder (N) Depressive Anxiety Substance use Psychotic Somatoform Eating Number of disorders (N) GAD PTSD Specific phobia Panic disorder Social phobia OCD Agoraphobia Schizoaffective Psychotic NOS Alcohol abuse Alcohol dependence Nonalcohol substance abuse Nonalcohol substance dependence

General population %c

Males %d

Males 35–44 %

12 2 4 1 0 1

5.1 9.7 7.7

3.4 7.1 11.1

6.0 8.3 12

3 3 0 0 0 0 0 0 1 1 4 0 2

3.1 3.3

2.4 2.3

1.3 2.7 0.4 1.1

0.6 2.4 0.3 0.7

3 3.5 3.5 2.2

4.3 5.1

Current %a

Resolved %b

34 36 17 2 1 0 14 11 7 6 6 1 1 1 1 2 10 2 5

Abbreviations: GAD, generalized anxiety disorder; NOS, not otherwise specified; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder; TBI, traumatic brain injury. a “Current %” refers to number of participants with current diagnoses divided by total number of participants (N = 100) multiplied by 100. b “Resolved %” refers to number of resolved diagnoses divided by total number of participants (N = 100) multiplied by 100. c Rates are for disorders that occurred in the last 12 months, males and females, 18 years and above.16 d Prevalence rates are for disorders that occurred in the previous 12 months for males 18 years and above.16

with current depression, 5 were in partial remission, 4 had mild symptoms, 12 had moderate symptoms, and 13 had severe symptoms at the time of assessment. Eight people with current depression had a comorbid substance use disorder (23.5%), and 25 had a comorbid anxiety disorder (73.5%). Of the 45 participants with current depression and/or anxiety, 23 (51.1%) were receiving medication and/or counseling. Of the 38 people with postinjury anxiety disorders, only 2 cases had resolved by the time of interview (see Table 3). All cases of specific phobia, panic disorder, social phobia, OCD, agoraphobia, and somatoform disorder were current. High current frequencies were also found for the remaining anxiety disorders, as 14 of 17 cases (82%) of post-TBI GAD were current, and 11 of 14 cases (79%) of the PTSD cases were current. Six people with anxiety (16.7%) had a comorbid substance use disorder. Of the 3 diagnosed postinjury psychotic disorders, 2 were current. The 1 eating disorder was in remission. Although the overall frequency of substance use disor-

ders fell preinjury to postinjury, postinjury substance use disorders tended to be current (see Table 3). Treatment Twenty-three of the 45 participants with current depression and/or anxiety (51.1%) were being treated with medication and/or psychological therapy, as compared with 31.3% (n = 5) of those for whom depression or anxiety had resolved at time of assessment. DISCUSSION This study aimed to examine the frequency of psychiatric disorders in an Australian sample of 100 individuals with mild to severe TBI 0.5 to 5.5 years postinjury, using a DSM-based structured clinical interview to establish diagnoses. A significant other was also interviewed in 87% of cases. Reliability of participant’s self-report was demonstrated. The current study found a high proportion of preinjury and postinjury psychiatric disorders (52% and 65%, www.headtraumarehab.com

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respectively). Preinjury, depression and substance use disorders were most common (17% and 41%, respectively). These findings are consistent with most previous TBI studies.10,11,18 The frequency of preinjury anxiety disorders in this study (13%) was the same as that found by Hibbard.10 Frequencies of most preinjury psychiatric disorders in the current study were much higher than those in the Finnish Koponen7 study, in which there were no preinjury depressive disorders, GAD, or nonalcohol substance disorders. However, given that participants in that study were at least 27 years postinjury, it is possible that their retrospective account of premorbid diagnoses was unreliable. Furthermore, all TBIs occurred between 1950 and 1971, at a time when mental health disorders were relatively less well recognized and acknowledged. There may also be cultural differences influencing expression of emotion and/or substance use patterns. Following TBI, 65% of participants received at least 1 psychiatric diagnosis. Again, depression was the most common diagnosis in 46% in the first 5 years after injury, a frequency consistent with some previous studies.10,11,14 High current rates of depression were found (34%), which were substantially higher than the Australian comparison rates.16 Seventy-two percent of depressive disorders were novel disorders, suggesting that the presence of preinjury psychiatric disorders is not the only influential factor. As with the general population, there was also a high frequency of comorbidity of current depressive and anxiety disorders (73.5%). Only half with current depression and/or anxiety were receiving treatment. Other studies have reported lower frequencies of depression and anxiety,2,18,25 but all involved follow-up in the first year after injury. In the current study, there was a trend for the frequency of psychiatric disorders to rise between 1 and 4 years postinjury. This increase may be associated with factors such as improved insight into the effects of the injury over time, growing despondence at the lack of physical/emotional/vocational progress, financial hardship, or decrease in professional support over time. The number of participants with anxiety disorders rose from 13% to 38% postinjury, with a total of 52 diagnoses. Of those with an anxiety disorder post-TBI, 74% had developed novel anxiety disorders, most commonly GAD and PTSD, followed by specific and social phobias and panic disorder. Anxiety disorders showed poor resolution, with 95% of cases current at the time of assessment. Frequencies of most current anxiety disorders were all much higher than in the general population16 but were generally within the ranges reported in previous studies of persons with TBI.10,11,14 However, the current reported frequency of OCD (1%) was much lower than a previous study that reported an incidence of 15%; it was suggested that checking-rechecking behavior may

be a compensatory strategy for poor memory following TBI.10 However, in order to meet DSM-IV criteria for diagnosis of OCD, this behavior must be attributed to adherence to a rigid set of rules in order to avoid negative consequences (anxiety), rather than memory problems causing repeated checks to ensure safety. No other known studies of individuals with TBI have screened for eating disorders or somatoform disorders. Agoraphobia, eating disorders, somatoform disorders, and psychotic disorders all occurred at frequencies similar to those in the general population, suggesting that these are not common consequences of TBI. However, it is also possible that the current study lacked the power to detect any change in frequency of such disorders. In addition, there were 3 new cases of psychotic disorders, and given previous findings of onset of psychosis more than 4 years postinjury,26,27 one cannot rule out the possibility of psychotic disorders developing over a longer time frame. Frequencies of substance use disorders decreased from 41% preinjury to 21% postinjury, with few novel cases. This trend has previously been noted in the literature.10,20 Frequencies of comorbidity were high— of those with current depression and anxiety disorders, 23.5% and 16.7%, respectively, also had a substance use disorder. Current substance use disorders occurred in 17% of participants, which is much higher than their occurrence in the general population.16 High rates of alcohol consumption are not unique to the TBI population and are indeed typical of the young male demographic population from which they are drawn.20 However, given the severity of brain injury in this group, the amount of alcohol being consumed is potentially much more harmful and therefore of concern. It is important to institute measures to discourage those who engaged in heavy substance use preinjury from returning to this, following TBI. The findings of this study must be interpreted within the context of certain limitations, most notably its retrospective, cross-sectional design, a limitation also present in most previous studies. In the present investigation, stratified random sampling was used to ensure inclusion of equal and representative groups on average 1 to 5 years after injury. However, this design does not allow for precise examination of the timing of onset of disorders. As previously discussed, the referring hospital treated patients referred for rehabilitation under a no-fault accident compensation system, so the sample comprised a high proportion of individuals with moderate to very severe TBI, the majority of whom incurred injuries in motor vehicle or work-related accidents. Therefore, the findings of the current study may not be generalizable across the entire spectrum of severity of TBI, particularly mild TBI, or those not referred for rehabilitation. Despite the use of a stratified random sampling method,

Psychiatric Disorders Following Traumatic Brain Injury the possibility of some selection bias cannot be ruled out. It may be that certain people were more or less motivated to participate, depending on their emotional state. It would also be of interest in future studies with a stratified time postinjury design to consider whether patients with a shorter or longer time postinjury were more or less inclined to participate. This information was not available for the current study. One could also question the reliability of retrospective reports of preinjury symptoms experienced up to 51/2 years previously. The involvement of a significant other in verifying reported symptoms mitigated against this. Clearly, it will be important to follow up these findings with a prospective study, conducted over a longer time frame than that used in the previous 1-year outcome studies to date. The sample studied was predominantly male (71%). Although this gender imbalance is typical of the TBI population, it may have influenced the frequency of observed disorders. The majority of studies have found no gender differences in frequencies of postinjury depression.2,7,10,13,18,39,40 However, females may be more likely to be diagnosed with an anxiety disorder.10,13,14 Males have been more often diagnosed with a substance use disorder in both the TBI and the general population.14,20 Preexisting emotional and substance abuse problems have been associated with a greater likelihood of TBI.3 Numerous interdependent factors contribute to the likelihood of having a TBI and to the development of a mental health disorder; it is possible that the same groups are at risk for both conditions. Young men account for a large proportion of the population with brain injury, and arguably the frequencies of depression and substance use may be higher in this subgroup than the population norms against which they have been compared. A demographically matched control group should be considered in future studies.

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Few studies have used measures such as the SCID-I to establish preinjury and postinjury diagnoses. On the basis of the high degree of concordance between interview results and medical records, the current study has demonstrated the appropriateness of this measure for use in the TBI population. Given the range of disorders that occur in this group, it is recommended that psychiatric screening cover a broad range of diagnoses. This study has highlighted that TBI creates a risk for development of several psychiatric disorders, particularly depression and anxiety, in a significant proportion of those who had no previous psychiatric history. That this finding was obtained in a group that had access to comprehensive rehabilitation supports the need for a greater focus on prevention and treatment of these problems both within and outside rehabilitation programs. Clearly, practitioners cannot rely solely on preinjury history of psychiatric problems to predict postinjury problems. Moreover, many who experience anxiety and depression may not recognize or report it. It is therefore vital that community-based health professionals are trained to recognize the symptoms and signs of these conditions in an individual with TBI and are provided with strategies and resources with which to address them, including the availability of skilled psychological or psychiatric intervention. Patients and families should be informed regarding symptoms of depression and anxiety. TBI follow-up clinics should conduct routine long-term screening for such disorders. Education about the implications of substance use following brain injury is also of vital importance. Investigation of the factors associated with the development of these disorders would assist in identifying those most at risk, so that they may be targeted for assessment and intervention. This represents the focus of the subsequent study in this series by Whelan-Goodinson et al.41

REFERENCES 1. Jennett B. Epidemiology of head injury. J Neurol Neurosurg Psychiatry. 1996;60:362–369. 2. Deb S, Lyons I, Koutzoukis C, Ali I, McCarthy G. Rate of psychiatric illness 1 year after traumatic brain injury. Am J Psychiatry. 1999;156:374–378. 3. Ponsford J, Sloan S, Snow P. Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living. Hove, Sussex, UK: Psychology Press, Ltd; 1995. 4. MacMillan PJ, Hart RP, Martelli MF, Zasler ND. Pre-injury status and adaptation following traumatic brain injury. Brain Inj. 2002;16:41–49. 5. Varney NR, Martzke JS, Roberts RJ. Major depression in patients with closed head injury. Neuropsychology. 1987;1:7–9. 6. Rosenthal M, Christensen BK, Ross TP. Depression following traumatic brain injury. Arch Phys Med Rehabil. 1998;79:90–103.

7. Koponen S, Taiminen T, Portin R, et al. Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study. Am J Psychiatry. 2002;159:1315–1321. 8. Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination. Brain Inj. 2001;15:563–576. 9. van Reekum R, Bolago I, Finlayson MAJ, Garner S, Links PS. Psychiatric disorders after traumatic brain injury. Brain Inj. 1996;10:319–327. 10. Hibbard MR, Uysal S, Kelpler K, Bogdany J, Silver J. Axis I psychopathology in individuals with traumatic brain injury. J Head Trauma Rehabil. 1998;13:24–39. 11. Fann JR, Katon WJ, Uomoto JM, Esselman PC. Psychiatric disorders and functional disability in outpatients with traumatic brain injuries. Am J Psychiatry. 1995;152:1493–1499.

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JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

12. Jorge R, Robinson RG, Starkstein SE, Arndt SV. Depression and anxiety following traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1993;5:369–374. 13. Levin HS, Brown SA, Song JX, et al. Depression and posttraumatic stress disorder at three months after mild to moderate traumatic brain injury. J Clin Exp Neuropsychol. 2001;23:754–769. 14. Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis I disorders. Arch Phys Med Rehabil. 2004;85(4)(suppl 2):S36–S42. 15. Jorge R, Starkstein SE, Arndt S, Moser D, Crespo-Facorro B, Robinson RG. Alcohol misuse and mood disorders following traumatic brain injury. Arch Gen Psychiatry. 2005;62:742–749. 16. Australian Institute of Health and Welfare. National Health Priority Areas Report: Mental Health 1998. Canberra, Australian Capital Territory, Australia: Australian Institute of Health and Welfare, Cat No PHE 13 Heath and AIHW; 1999. 17. Hibbard MR, Bogdany J, Uysal S, et al. Axis II psychopathology in individuals with traumatic brain injury. Brain Inj. 2000;14:45– 61. 18. Fedoroff JP, Starkstein SE, Forrester AW, et al. Depression in patients with acute traumatic brain injury. Am J Psychiatry. 1992;149:918–923. 19. Drubach DA, Kelly MP, Winslow MM, Flynn JP. Substance abuse as a factor in the causality, severity and recurrence rate of traumatic brain injury. Md Med J. 1993;42:989–993. 20. Ponsford J, Whelan R, Bahar-Fuchs A. Alcohol and drug use following traumatic brain injury: a prospective study. Brain Inj. 2007;21:1385–1392. 21. Dawson DR, Levine B, Schwartz M, et al. Quality of life following traumatic brain injury: a prospective study. Brain Cogn. 2000;44:35–39. 22. Dicker BG. Pre-injury behavior and recovery after a minor head injury: a review of the literature. J Head Trauma Rehabil. 1989;4:73– 81. 23. Rapoport MJ, McCullagh S, Streiner D, Feinstein A. The clinical significance of major depression following mild traumatic brain injury. Psychosomatics. 2003;44:31–37. 24. Deb S, Lyons I, Koutzoukis C. Neuropsychiatric sequelae one year after a minor head injury. J Neurol Neurosurg Psychiatry. 1998;65:899–902. 25. Jorge R, Robinson RG, Starkstein SE. Influence of major depression on 1 year outcome in patients with traumatic brain injury. J Neurosurg. 2004;8:726–733. 26. Fujii DE, Ahmed I. Risk factors in psychosis secondary to traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2001;13:61–69. 27. Sachdev P, Smith JS, Cathcart S. Schizophrenia-like psychosis fol-

28. 29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

lowing traumatic brain injury: a chart-based descriptive and casecontrol study. Psychol Med. 2001;31:231–239. Sparadeo FR, Gill D. Effects of prior alcohol use on head injury recovery. J Head Trauma Rehabil. 1989;4:75–82. Corrigan JD, Rust E, Lamb-Hart GL. The nature and extent of substance abuse problems in persons with traumatic brain injury. J Head Trauma Rehabil. 1995;10:29–46. Kreutzer JS, Witol AD, Sander AM, et al. A prospective longitudinal multicenter analysis of alcohol use pattern among persons with traumatic brain injury. J Head Trauma Rehabil. 1996;11:58–69. Glenn MB, O’Neil-Pirozzi T, Goldstein R, Burke D, Jacob L. Depression amongst outpatients with traumatic brain injury. Brain Inj. 2001;15:811–818. Robinson RG, Boston JD, Starkstein SE, Price TR. Comparison of mania and depression after brain injury: causal factors. Am J Psychiatry. 1988;145:172–178. Warden D, Labbate L. Posttraumatic stress disorder and other anxiety disorders. In: Silver J, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC; London: American Psychiatric Publishing; 2005:231–243. Jorge R, Robinson RG, Arndt S. Are there symptoms that are specific for depressed mood in patients with traumatic brain injury. J Nerv Ment Dis. 1993;181:91–99. Green A, Felmingham K, Baguley I, Slewa-Younan S, Simpson S. The clinical utility of the Beck Depression Inventory after traumatic brain injury. Brain Inj. 2001;15:1021–1028. Robinson RG, Jorge R. Mood disorders. In: Silver J, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC; London: American Psychiatric Publishing; 2005:201– 212. First MB, Spitzer RL, Gibbon M, et al. Computer-Assisted SCID Clinician Version (CAS-CV): Software Manual. Washington, DC: American Psychiatric Publishing; 2004. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000. Jorge R, Robinson RG, Arndt SV, Starkstein SEForrester AWGeisler F. Depression following traumatic brain injury: a 1 year longitudinal study. J Affect Disord. 1993;27:233–243. Seel RT, Kreutzer JS, Rosenthal M, Hammond FMCorrigan JDBlack K. Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Models Systems multicenter investigation. Arch Phys Med Rehabil. 2003;84:177– 184. Whelan-Goodinson R, Ponsford J, Schonberger M. Predictors of psychiatric disorders following traumatic brain injury. J Head Trauma Rehabil. In press.