TBI associated with PTSD and Depression

Even MILD traumatic brain injuries (TBI) are associated with increased risk for PTSD and Depression…

Key PointsQuestion  Who is at greatest risk for developing mental health problems such as posttraumatic stress disorder (PTSD) or major depression after sustaining a mild traumatic brain injury (mTBI)?

Findings  In this cohort study of 1155 patients with mTBI and 230 patients with orthopedic injuries not involving the head, patients with mTBI were more likely to report PTSD and/or major depressive symptoms 3 and 6 months after injury. Among patients with mTBI, a number of preinjury (eg, prior mental health problems) and injury-related (eg, assault or other violent cause of injury in the case of PTSD) characteristics were associated with increased risk of mental health problems.

Meaning  Injury to the brain is associated with new onset or exacerbation of preexisting mental health problems in a substantial minority of patients; knowledge of risk factors can inform efforts at prevention, screening, diagnosis, and improved treatment.

Abstract

Importance  Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.

Objective  To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI).

Design, Setting, and Participants  Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study.

Main Outcomes and Measures  Probable PTSD (PTSD Checklist for DSM-5score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury.

Results  Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk.

Conclusions and Relevance  After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Introduction

It has been commonly assumed, even among many health care professionals, that mild traumatic brain injuries (mTBIs) virtually always resolve without sequelae.1 This assumption may contribute to these patients not receiving education about their injury at the time of injury and not receiving appropriate follow-up care after the acute injury.24 Whereas it is the case that symptoms in most patients with initial Glasgow Coma Scale (GCS) scores of 13 to 15 and negative computed tomography (CT) scan results do resolve in 1 to 3 months,3studies show that some patients have symptoms that persist for months beyond the acute injury.5,6 In nearly 25 000 nonmedically evacuated US soldiers returning from Afghanistan or Iraq between 2009 and 2014 and screened for mTBI, a substantial proportion (10%-30%) of those who screened positive had symptoms that persisted for at least 3 months postinjury.7 These and other data in civilians indicate that for many patients with mTBI, their course is not inevitably one of improvement.8,9

Mental health problems may be particularly salient features of nonrecovery from mTBI.1,10 In civilian patients hospitalized for an orthopedic injury, presence of comorbid mTBI was associated with an increased risk for posttraumatic stress disorder (PTSD) and depression 3 to 6 months postinjury.11 Even among healthy young athletes, premorbid psychological factors have been found to be highly relevant to postconcussive recovery.12 Among 50 US soldiers with concussive blast traumatic brain injuries (TBIs) followed up for 1 to 5 years, many had posttraumatic stress (PTS) and depressive symptoms that worsened over time.13 Preexisting mental disorder14 and mental health sequelae have been shown to be important determinants of overall functioning and quality of life after mTBI.1518 In US Army soldiers, deployment-related mTBI was associated with an increased risk for subsequent PTSD, as well as for major depressive disorder (MDD).19

Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them. In a study of 559 civilians consecutively admitted to a level 1 trauma center with TBI, preinjury history of MDD was associated with an increased risk for MDD.20 A retrospective review of medical records from 276 service members assigned to the United States Army Special Operations Command referred for mTBI evaluation found that premorbid PTS symptoms were associated with an increased risk for PTSD following a subsequent mTBI.21 In a 2017 systematic review of 26 observational studies of TBI, the authors found that female sex and preinjury depressive symptoms were predictive of MDD, whereas memory of the traumatic events and early PTS symptoms were predictive of PTSD.22

Taken together, these observations strongly suggest that mental health problems are common following a “mild” TBI and that there may be individual-specific and injury-specific factors that influence risk for these disorders. We hypothesized that factors (eg, antecedent mental disorder, prior TBI, cause of injury)23,24 observed in prior studies to increase risk for mental health and/or postconcussive symptoms, which are known to overlap with depressive and PTS symptoms,25,26 in patients with TBI would be predictive of PTSD and MDD status at 6 months postinjury, with similar risk factors observed at 3 and 12 months. To our knowledge, few studies have been designed and powered to ascertain prevalence of PTSD and MDD and examine hypothesized risk factors in a large, prospective longitudinal study of nonmilitary personnel. Given substantial differences in the nature and context of the injuries and postinjury circumstances of military and civilian personnel sustaining mTBIs,27 additional focus on these factors in a civilian cohort is needed.

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