Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study

Long-Term Risk for Mood and Anxiety Disorders After Pediatric Traumatic Brain Injury: A Population-Based, Birth Cohort Analysis

OBJECTIVE

To determine whether exposure to traumatic brain injury (TBI) before 10 years of age is associated with development of a mood or anxiety disorder by 25 years of age, and whether sex or injury severity influences this risk.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

A total of 5518 persons born from January 1, 1976, through December 31, 1982.

DESIGN

Population-based, birth cohort study. Children sustaining TBI before 10 years of age (index date) were confirmed by manual record review and classified by injury severity using the Mayo Classification System. Each TBI case was age- and sex-matched to 2 referents from the same birth cohort without a history of TBI at the index date. Cox proportional hazards models were fit to compare the risk of a subsequent clinically diagnosed mood or anxiety disorder by 25 years of age between TBI cases and referents. Separate analysis was performed stratified by sex and injury severity.

MAIN MEASURES

Incidence of mood and anxiety disorders determined through clinical diagnostic codes and manual record review.

RESULTS

The study included 562 children (238 females [42.3%] and 324 males [57.7%]) with TBI before 10 years of age (mean [SD] age at TBI: 4.7 [2.8] years). At least 1 mood or anxiety disorder was diagnosed for 115 persons with TBI and 215 referents. No statistically significant association existed between childhood TBI status and anxiety disorder (adjusted hazard ratio [aHR], 1.01 [95% confidence interval (CI), 0.71-1.43]; P = .97) or mood disorder (aHR, 1.16 [95% CI, 0.92-1.47]; P = .21). However, females who sustained TBI had a significantly increased risk of a subsequently diagnosed mood disorder compared with age-matched female referents (aHR, 1.40 [95% CI, 1.04-1.89]; P = .03).

CONCLUSIONS

This study suggests that isolated TBI before 10 years of age is not significantly associated with an increased risk of anxiety or mood disorder by 25 years of age, though females may be at an increased risk.

The Role of Neuroinflammation in Neuropsychiatric Disorders Following Traumatic Brain Injury: A Systematic Review

BACKGROUND

Neuropsychiatric symptoms are common following traumatic brain injury (TBI), but their etiological onset remains unclear. Mental health research implicates neuroinflammation in the development of psychiatric disorders. The presence of neuroinflammatory responses after TBI thus prompts an investigation of their involvement in the emergence of neuropsychiatric disorders postinjury.

OBJECTIVE

Review the literature surrounding the role of neuroinflammation and immune response post-TBI in the development of neuropsychiatric disorders.

METHODS

A search of scientific databases was conducted for original, empirical studies in human subjects. Key words such as "neuroinflammation," "TBI," and "depression" were used to identify psychopathology as an outcome TBI and the relation to neuroinflammatory response.

RESULTS

Study results provide evidence of neuroinflammation mediated post-TBI neuropsychiatric disorders including anxiety, trauma/stress, and depression. Inflammatory processes and stress response dysregulation can lead to secondary cell damage, which promote the development and maintenance of neuropsychiatric disorders postinjury.

CONCLUSION

This review identifies both theoretical and empirical support for neuroinflammatory response as feasible mechanisms underlying neuropsychiatric disorders after TBI. Further understanding of these processes in this context has significant clinical implications for guiding the development of novel treatments to reduce psychiatric symptoms postinjury. Future directions to address current limitations in the literature are discussed.

Mood Disorders in Young People With Acquired Brain Injury: An Integrated Model

Purpose/Objective

Young people with paediatric acquired brain injury (pABI) are twice as likely to develop a mood disorder as their peers, frequently have significant unmet socio-emotional needs, and are at over double the risk of going on to use adult mental health services. Recent years have seen significant advances in the development of interventions for young people with mood disorders. However, evidence-based approaches to mood disorders in pABI are lacking and surprisingly little work has evaluated clinical and neuro-developmental models of mood disorders in this population.

Method

We review the literature regarding key mechanisms hypothesised to account for the increased vulnerability to mood disorders in pABI: First, we summarise the direct neurocognitive consequences of pABI, considering the key areas of the brain implicated in vulnerability to mood disorders within a neurodevelopmental framework. Second, we outline five key factors that contribute to the heightened prevalence of mood disorders in young people following ABI. Finally, we synthesise these, integrating neuro-cognitive, developmental and systemic factors to guide clinical formulation.

Results and Implications

We present a framework that synthesises the key mechanisms identified in our review, namely the direct effects of pABI, neurocognitive and neuroendocrine factors implicated in mood and anxiety disorders, maladaptive neuroplasticity and trauma, structural and systemic factors, and psychological adjustment and developmental context. This framework is the first attempt to provide integrated guidance on the multiple factors that contribute to elevated life-long risk of mood disorders following pABI.

Region-Dependent Modulation of Neural Plasticity in Limbic Structures Early after Traumatic Brain Injury

Traumatic brain injury (TBI)-induced disruptions in synaptic function within brain regions and across networks in the limbic system may underlie a vulnerability for maladaptive plasticity and contribute to behavioral comorbidities. In this study we measured how synaptic proteins respond to lateral fluid percussion injury (FPI) brain regions known to regulate emotion and memory, including the basolateral amygdala (BLA), dorsal and ventral hippocampus (DH, VH), and medial prefrontal cortex (PFC). We investigated proteins involved in regulating plasticity, including synaptic glutamatergic a-amino-3-hydroxy5-methyl-4-isoxazolepropionic acid (AMPA; GluA1, GluA2) and N-methyl-D-aspartate (NMDA; NR1, NR2A, NR2B) receptor subunits as well as inhibitory gamma-aminobutyric acid (GABA) synthetic enzymes (GAD67, GAD65) via western blot. Adult male rats received a mild-moderate lateral FPI or sham surgery and ipsi- and contralateral BLA, DH, VH, and PFC were collected 6 h, 24 h, 48 h, and 7 days post-injury. In the ipsilateral BLA, there was a significant decrease in NR1 and GluA2 24 h after injury, whereas NR2A and NR2B were increased in the contralateral BLA at 48 h compared with sham. GAD67 was increased ipsilaterally at 24 h, but decreased contralaterally at 48 h in the BLA. In the DH, both NMDA (NR2A, NR2B) and GABA-synthetic (GAD65, GAD67) proteins were increased acutely at 6 h compared with sham. GAD67 was also robustly increased in the ipsilateral VH at 6 h. In the contralateral VH, NR2A significantly increased between 6 h and 24 h after FPI, whereas GAD65 was decreased across the same time-points in the contralateral VH. In the medial PFC at 24 h we saw bilateral increases in GAD67 and a contralateral decrease in GluA1. Later, there was a significant decrease in GAD67 in contralateral PFC from 48 h to 7 days post-injury. Collectively, these data suggest that lateral FPI causes a dynamic homeostatic response across limbic networks, leading to an imbalance of the proteins involved in plasticity in neural systems underlying cognitive and emotional regulation.

Stem Cell Therapy for Pediatric Traumatic Brain Injury

There has been a growing interest in the potential of stem cell transplantation as therapy for pediatric brain injuries. Studies in pre-clinical models of pediatric brain injury such as Traumatic Brain Injury (TBI) and neonatal hypoxia-ischemia (HI) have contributed to our understanding of the roles of endogenous stem cells in repair processes and functional recovery following brain injury, and the effects of exogenous stem cell transplantation on recovery from brain injury. Although only a handful of studies have evaluated these effects in models of pediatric TBI, many studies have evaluated stem cell transplantation therapy in models of neonatal HI which has a considerable overlap of injury pathology with pediatric TBI. In this review, we have summarized data on the effects of stem cell treatments on histopathological and functional outcomes in models of pediatric brain injury. Importantly, we have outlined evidence supporting the potential for stem cell transplantation to mitigate pathology of pediatric TBI including neuroinflammation and white matter injury, and challenges that will need to be addressed to incorporate these therapies to improve functional outcomes following pediatric TBI.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Psychiatric Disorders After Traumatic Brain Injury: A Nationwide Population-Based Cohort Study and the Effects of Rehabilitation Therapies

OBJECTIVE

To investigate the risk of psychiatric disorders after traumatic brain injury (TBI), and to clarify whether the post-TBI rehabilitation was associated with a lower risk of developing psychiatric disorders.

DESIGN

A register-based, retrospective cohort design.

SETTING

Using data from the National Health Insurance Research Database of Taiwan, we established an exposed cohort with TBI and a nonexposed group without TBI matched by age and year of diagnosis between 2000 and 2015.

PARTICIPANTS

This study included 231,894 patients with TBI and 695,682 patients without TBI (N=927,576).

INTERVENTIONS

Rehabilitation therapies in TBI patients.

MAIN OUTCOME MEASURES

A multivariable Cox proportional hazards regression model was used to compare the risk of developing psychiatric disorders.

RESULTS

The incidence rate of psychiatric disorders was higher in the TBI group than the control group. Compared with the control group, the risk of psychiatric disorders in the TBI group was twofold (hazard ratio [HR]=2.072; 95% confidence interval [95% CI], 1.955-2.189; P<.001). Among the participants with TBI, 49,270 (21.25%) had received rehabilitation therapy and had a lower risk of psychiatric disorders (HR=0.691; 95% CI, 0.679-0.703; P<.001). In the subgroup analysis, the medium- to high-level intensity rehabilitation therapy was associated with lower risks of psychiatric disorder (HR=0.712 and 0.568, respectively), but there was no significant finding in the low-intensity group.

CONCLUSIONS

We found that TBI was associated with a high risk for developing psychiatric disorders, and that the post-TBI rehabilitation significantly reduced the risk of psychiatric disorders in a dose-dependent manner.

Elevated levels of serum, but not salivary, brain-derived neurotrophic factor following mild traumatic brain injury in collegiate athletes post return-to-play

Brain-derived neurotrophic factor (BDNF) helps restore neuronal function following mild traumatic brain injury. BDNF levels can be obtained in blood serum and more recently in saliva. However, the relationship between serum and salivary BDNF is poorly understood—especially in relation to alterations in BDNF levels following mild traumatic brain injury. In this study, serum and salivary BDNF were collected from a sample of 42 collegiate student athletes. Half of the participants were recently cleared by a physician and/or an athletic trainer to return-to-play after experiencing a sports-related concussion. The other half had not experienced a concussion within the past year and were matched by age, sex, sport, and time of sample. Results suggest that incidences of depression, anxiety, and stress were all elevated in the concussion group, relative to the control participants. When controlling for stress-related negative affect, serum BDNF was elevated in the concussion group. However, there was no difference in salivary BDNF. Serum and salivary BDNF were uncorrelated across the entire sample. Yet, these measures of BDNF were correlated in the concussion group, but not the control group. In sum, serum BDNF is elevated in concussion post return-to-play; however, further research is needed to explore the utility of salivary BDNF following concussion.

National population-based data on the incidence, prevalence, and psychiatric comorbidity of eating disorders in Taiwanese adolescents and young adults

OBJECTIVE

Nationwide data on eating disorders (EDs) among East Asian populations are scarce. This study aimed to estimate the prevalence, incidence, and psychiatric comorbidities of EDs in Taiwan.

METHOD

Drawing from the National Health Research Institute database, we identified the study subjects aged 11-34 years who received an ED diagnosis during ambulatory visits or hospitalization from 2001 to 2012. We analyzed the subjects by age and gender. Diagnoses for comorbid psychiatric disorders were entered in the analysis only if they occurred within 1 year before or after the ED diagnosis date. Rates were age- and sex-adjusted to the average population within the study period.

RESULTS

The estimated mean annual incidence was approximately 11.11 (95% CI 10.51-11.72) per 100,000 residents, and the 1 year prevalence was 20.87 (95% CI 20.05-21.70) per 100,000 residents, with evidence of female predominance (female/male ratio = 10.95, 95% CI = 8.97-13.36). Incidence and prevalence peaked at ages 20-24 in females and at ages 25-29 in males. Both rates nearly doubled within a decade. Specifically, the anorexia nervosa trend recently stabilized in females and decreased in males, while that for bulimia nervosa increased in both females and males. The most common comorbid diagnoses were anxiety (53%) and major depressive disorders (22%).

DISCUSSION

The incidence and prevalence of EDs were lower in Taiwan than in Western countries. However, these rates were rapidly rising, notably in males. The majority of Taiwanese ED patients also received a diagnosis for various psychiatric comorbidities, a finding worthy of clinical attention.

Associations between a history of traumatic brain injuries and conduct disorder during youth in a population sample of Canadian adults

This study describes the association between history of traumatic brain injury (TBI) and childhood symptoms of conduct disorder (CD). Data were based on telephone interviews with 6048 respondents derived from the 2011-2013 cycles of a representative cross-sectional survey of adults aged 18+ years in Ontario, Canada. TBI was defined as loss of consciousness for at least 5min or overnight hospitalization due to injury symptoms. Symptoms of CD before 15 years of age were assessed using five items based on the DSM-IV. Adults who reported a history of TBI reported odds 3 times higher for possible CD before 15 years of age. Odds remained significant even when age, sex, marital status, income, and education were statistically controlled. The nature of this data precludes determining if TBI occurred before or following CD symptoms. Nonetheless, the co-occurrence of a history of TBI with symptoms of CD supports the recommendation that practitioners be vigilant in assessing the history of both CD and TBI when diagnosing and treating one of these conditions. These findings do not exclude the possibility that TBI during childhood or youth may be interfering with brain development and could co-occur with conduct behaviors in both the short and long term.

Anxiety and Mood Clinical Profile following Sport-related Concussion: From Risk Factors to Treatment

Conceptual models for assessing and treating sport-related concussion (SRC) have evolved from a homogenous approach to include different clinical profiles that reflect the heterogeneous nature of this injury and its effects. There are six identified clinical profiles, or subtypes from SRC, and one such clinical profile is the anxiety/mood profile. Athletes with this profile experience predominant emotional disturbance and anxiety following SRC. The purpose of this targeted review was to present an overview of the empirical evidence to support factors contributing to the anxiety/mood profile, along with methods of evaluation and treatment of this clinical profile following SRC. We discuss the potential underlying mechanisms and risk factors for this clinical profile, describe comprehensive assessments to evaluate concussed athletes with an anxiety/mood clinical profile, and explore behavioral and other interventions for treating these athletes. Although there is limited, but growing empirical evidence for the anxiety/mood clinical profile following SRC, understanding this clinical profile is germane for clinicians who are treating athletes with emotional sequelae after SRC.

Minor head injury: limiting patient exposure to ionizing radiation, risk stratification, and concussion management

PURPOSE OF REVIEW

We review recommendations from recent publications on the evaluation of minor head trauma. We focus on the risks of radiation from computed tomographies (CTs), the establishment of patient risk stratifications to help guide the necessity of emergent neuroimaging, and current thoughts regarding concussions.

RECENT FINDINGS

Pediatric minor head injury is a common complaint in ambulatory settings. There is a significant amount of parental and practitioner anxiety regarding prognosis and whether or not to obtain CT imaging. New evidence has demonstrated the significant harmful effects of ionizing radiation. Recent studies have risk-stratified patients to identify those at risk of clinically important traumatic brain injury, to minimize the exposure to ionizing radiation for those who are at a low risk of any significant disorder.

SUMMARY

Pediatric minor head injury is a common complaint, but the vast majority of those injured will suffer no significant consequences. The Pediatric Emergency Care Applied Research Network has created an algorithm to identify minor head trauma patients who require emergent head CTs versus those at low risk who do not require neuroimaging. Additionally, in recent years there has been an increase in the occurrence of concussions. We describe the characteristics of concussions, appropriate management, and the return-to-play guidelines.

Traumatic brain injury and affective disorder: A nationwide cohort study in Taiwan, 2000-2010

BACKGROUND

Studies investigating the relationship between head injury and the subsequent onset of affective disorders often show conflicting results.

AIMS

To investigate the risk of affective disorders following traumatic brain injury in a large Taiwanese cohort.

METHOD

This retrospective cohort study makes use of the National Health Insurance Research Database. A cohort containing 68,376 individuals who experienced traumatic brain injury (TBI) during 2000-2010 and had no prior history of mental disorders before the injury was identified. Using Cox Proportional Hazards regression, the subsequent risk of affective disorders was determined.

RESULTS

TBI was associated with a higher risk of both bipolar disorder (Hazard Ratio [HR]=1.42, 95% Confidence Interval [CI]=[1.26, 1.59]) and major depression (HR=1.41, 95% CI=[1.28, 1.54]). More severe injury was associated with greater risk. The first year following the injury was the highest risk period for major depression, while the highest risk period for bipolar disorder was delayed until two to four years following the injury.

LIMITATIONS

Using a claims database, we were unable to assess confounding variables that were not contained in the data set.

CONCLUSIONS

The elevated risks of affective disorders after TBI speak to the psychiatric need of individuals who suffer from brain injury. Early detection and timely intervention may help prevent secondary and tertiary disability associated with head trauma.

Cognitive rehabilitation groups: A thematic analysis of feasibility and perceived benefits for clients with moderate to severe traumatic brain injury living in the Western Cape

Background

Traumatic brain injury (TBI) has a significant impact on the burden of care within the South African setting, impacting on the individual, the family, and the community as a whole. Often the consequences of TBI are permanent, resulting in numerous financial and emotional stressors.

Objective

This research focusses on the experience of outpatient cognitive rehabilitation groups for individuals who have suffered moderate to severe brain injuries within the South African setting.

Method

Participants with moderate to severe brain injury were required to attend five cognitive rehabilitation groups and engage in a semistructured interview. Qualitative data were examined via thematic analysis, to determine participants’ subjective experiences of group participation.

Results

There is a need within the South African setting for cognitive rehabilitation and support groups for individuals who have experienced a TBI. The benefits were notable for both the individuals attending and their support systems. In spite of the benefits there were notable limitations to attendance, including financial restrictions and transport limitations.

Conclusion

According to participants and their families, there is a scarcity of resources within the Western Cape for clients who have sustained a TBI. Despite limitations in capacity to attend there appears to be a need for structured outpatient cognitive rehabilitation programmes integrating the complex cognitive and emotional challenges faced by individuals with TBI and their families.