Anxiety and depression disorders 5 years after severe injuries: a prospective follow-up study

Perceptions About Writing by Adults With Moderate or Severe Traumatic Brain Injury

PURPOSE

Writing challenges can cause ongoing distress and limit resumption of pre-injury activities following traumatic brain injury (TBI); however, little TBI research or clinical practice addresses written communication. Understanding the writing perceptions and experiences of adults engaged in intensive, inpatient rehabilitation following hospital discharge for TBI is an initial step in addressing this situation.

METHOD

Transcendental phenomenology served to structure this qualitative research. Six adults between 2 and 6 months post-TBI participated in a common experience of writing about a personal memorable event. Standardized test scores and symptom ratings provided descriptive information about participants. Additionally, participants completed the Neurobehavioral Symptom Inventory and NASA Task Load Index and engaged in semistructured interviews to describe writing perceptions and experiences.

RESULTS

Data analysis revealed themes and subthemes about writing perceptions, challenges, and support strategies. Participants varied in their perceptions of post-injury writing changes. Test results revealed areas of challenge for all participants, but only half reported awareness of writing changes. Those aware of changes differed from other participants regarding word retrieval, memory, and concentration as well as overall effort expended, frustration, and performance quality. Although all participants relied on writing supports, only one had adjusted multiple writing strategies following injury.

CONCLUSIONS

Some adults with TBI are aware of writing changes while receiving posthospital, inpatient rehabilitation services, but others deny such changes. This differs from reports concerning later recovery stages, perhaps because few functional writing opportunities arise during rehabilitation. Application of compensatory strategies specific to post-injury writing challenges is unlikely while awareness remains limited.

Informal Written Language Analysis Methods: Case Examples of Adults With Traumatic Brain Injury

PURPOSE

Written expression challenges following traumatic brain injury (TBI) in adults have received little clinical attention but can substantially affect quality of life and the success of reintegration efforts. Assessment tools and procedures are lacking despite the likelihood of post-TBI problems with microstructure (e.g., productivity, spelling accuracy) and macrostructure (e.g., topic adherence, organization) aspects of written language. The lack of standardized procedures forces reliance on informal methods to determine writing strengths and challenges.

METHOD

A combination of assessment procedures allowed for evaluation of the productivity and efficiency, adherence to writing conventions (e.g., spelling, sentence structure, punctuation), and macrostructure organization (e.g., story grammar, topic adherence) of written narratives collected from five adults with TBI.

RESULTS

Use of multiple assessment methods revealed disparate writing challenges across the five case examples. The differing writing profiles underscore the necessity of evaluating multiple aspects of written narratives.

CONCLUSIONS

The described analysis methods can help clinicians determine areas of strength and challenge in written work generated by adults with TBI. Examination of multiple aspects of writing is key to garnering a comprehensive appraisal of post-TBI writing.

Reduced power spectra of heart rate variability are correlated with anxiety in patients with mild traumatic brain injury

Anxiety is one of the most frequently diagnosed emotional disorders after a mild traumatic brain injury (mTBI); however, predictors of anxiety after an mTBI remain uncertain. Recent research indicated that anxiety is associated with abnormalities in the autonomic nervous system (ANS) which can be evaluated by a power spectral analysis of heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV could correlate with the occurrence of anxiety in mTBI patients. We recruited 165 Taiwanese patients diagnosed with an mTBI and 82 volunteer healthy controls from three affiliated hospitals of Taipei Medical University during 2010-2014. The Beck Anxiety Inventory (BAI) was assessed at the 1st, 6th, and 12th weeks. We found that mTBI patients were more vulnerable to anxiety compared to healthy controls. The power spectral density of HRV was significantly lower in mTBI patients than in healthy controls. A correlation analysis indicated that anxiety was negatively significantly correlated with low- and high-frequency power at the 6th week. Our study suggests the clinical usefulness of HRV as a potential noninvasive tool for evaluating later anxiety in mTBI patients.

A comprehensive conceptual framework for road safety strategies

Road safety strategies (generally called Strategic Highway Safety Plans in the USA) provide essential guidance for actions to improve road safety, but often lack a conceptual framework that is comprehensive, systems theory based, and underpinned by evidence from research and practice. This paper aims to incorporate all components, policy tools by which they are changed, and the general interactions between them. A framework of nine mutually interacting components that contribute to crashes and ten generic policy tools which can be applied to reduce the outcomes of these crashes was developed and used to assess 58 road safety strategies from 22 countries across 15 years. The work identifies the policy tools that are most and least widely applied to components, highlighting the potential for improvements to any individual road safety strategy, and the potential strengths and weaknesses of road safety strategies in general. The framework also provides guidance for the development of new road safety strategies, identifying potential consequences of policy tool based measures with regard to exposure and risk, useful for both mobility and safety objectives.

Neurological and psychiatric aspects of emotion

Neurological and psychiatric aspects of emotions have been the focus of intense research for the past 30 years. Studies in both acute (e.g., stroke, traumatic brain injury (TBI)) and chronic (e.g., dementia, Parkinson's disease) neurological disorders demonstrated a high frequency of both depression and apathy. Studies in stroke and TBI reported a significant association between lesion location and depression. Both depression and apathy are significant predictors of poor recovery among patients with brain injuries, and of steeper cognitive and functional decline among patients with neurodegenerative disorders. Poor insight and judgment are frequently found among patients with brain injury or degeneration. There is increasing evidence that damage to specific brain regions, such as the ventromedial prefrontal cortex, is associated with inappropriate emotional reactions in social contexts and diminished anxiety and concern for the future. In severe cases, behavioural changes may also include poor decision-making in the social realm, deficits in goal-directed behavior, and lack of insight into these changes. Future studies will validate specific diagnostic criteria for the various cognitive, emotional, and behavioral problems reported among patients with neurological disorders, which may result in more specific and effective treatments.

Functional outcome after road-crash injury: description of the ESPARR victims cohort and 6-month follow-up results

OBJECTIVE

It is essential to know about the long-term consequences of road crashes involving corporal injury in order to adopt relevant public health measures.

METHODS

The ESPARR cohort comprises 1168 road-crash victims, aged 16 or over, managed in hospitals in the Rhône administrative départment (France). It is based on the Registry of Road Traffic Casualties, which has been collecting exhaustive data since 1995. Two groups are monitored: mild to moderate (M-AIS 1 or 2) and severe (M-AIS > or =3). Patients were interviewed at the point of primary care, between 1 October 2004 and 31 July 2006. 6 months later, their state of health and presence of pain were compared. Multivariate analysis (logistic regression) was performed to identify factors related to residual pain.

RESULTS

Adults of the cohort were compared to the road crash population as a whole recorded over the same period in the same area. At 6 months post-accident, only 31.9% of victims deemed their health status to have entirely returned to normal; 63.8% of mild to moderate and 89.2% of severe cases reported residual pain, but neither pain frequency nor intensity correlated with M-AIS. Residual pain was related to lower limb injuries (OR=1.6; 95% CI=1.1-2.4). After adjustment, pain was essentially related to age, seriousness of the lesions and a stay in a rehabilitation unit.

CONCLUSION

The ESPARR cohort provides a unique opportunity in France to describe the trajectory of a road crash victim, in terms both of care and rehabilitation and of resumption of work and personal activity.

A randomized controlled trial of sertraline for the treatment of depression in persons with traumatic brain injury

OBJECTIVE

To examine the efficacy of sertraline in the treatment of depression after traumatic brain injury (TBI).

DESIGN

Double-blind, randomized controlled trial.

SETTING

Research center at a major urban medical center.

PARTICIPANTS

Subjects were a referred and volunteer sample of 52 participants with TBI, a diagnosis of major depression disorder (MDD), and a score on the Hamilton Rating Scale for Depression (HAM-D) of 18 or greater. The majority of the sample was male (58%), had less than 14 years of education (73%), had incomes below $20,000 (82%), and were from minority backgrounds (75%). Approximately one third of the sample had mild brain injuries, and two thirds had moderate to severe brain injuries. The mean age was 47+/-11, and the mean time since injury was 17+/-14 years. One participant withdrew from the study because of side effects.

INTERVENTION

Daily oral sertraline in doses starting at 25mg and increasing to therapeutic levels (up to 200mg) or placebo for 10 weeks.

MAIN OUTCOME MEASURES

The HAM-D, the Beck Anxiety Inventory, and the Life-3 quality of life (QOL).

RESULTS

No statistically significant differences were found at baseline between drug and placebo groups on baseline measures of depression (24.8+/-7.3 vs 27.7+/-7.0), anxiety (16.4+/-12.3 vs 24.0+/-14.9), or QOL (2.96+/-1.0 vs 2.9+/-0.9). The income level of those receiving placebo was significantly lower than those participants receiving medication. Analyses of covariance revealed significant changes from preintervention to posttreatment for all 3 outcome measures (P<.001) but no group effects. Random-effects modeling did not find any significant difference in patterns of scores of the outcome measures between the placebo and medication groups.

CONCLUSIONS

Both groups showed improvements in mood, anxiety, and QOL, with 59% of the experimental group and 32% of the placebo group responding to the treatment, defined as a reduction of a person's HAM-D score by 50%.

Outcome From Serious Injury in Older Adults

PURPOSE

To analyze the research published in peer-reviewed journals between 1996 and 2005 about factors affecting the physical outcomes of older adults after serious traumatic injury.

ORGANIZING CONSTRUCT

Twenty-seven primary research studies published in the last 10 years pertained to in-hospital and long-term outcomes of serious injury among older adults. Research specific to isolated hip injury, traumatic brain injury, and burn trauma was excluded.

METHODS

An integrative review of research published between January 1996 and January 2005 was carried out to examine the relationship between older age and outcome from severe injury. MEDLINE, BIOSIS previews, CINAHL, and PsycINFO databases were searched using the MeSH terms: injury, serious injury, trauma and multiple trauma, and crossed with type, severity, medical/surgical management, complication, outcome, mortality, morbidity, survival, disability, quality of life, functional status, functional recovery, function, and placement.

FINDINGS

Older adults in these studies had higher short- and long-term mortality than did younger adults. The relationship between older age and poorer outcome persisted when adjusting for injury severity, number of injuries, comorbidities, and complications. At the same time, injury severity, number of injuries, complications, and gender each independently correlated with increased mortality among older adults. The body of research is limited by overreliance on retrospective data and heterogeneity in definitional criteria for the older adult population.

CONCLUSIONS

Additional research is needed to clarify the contributory effect of variables such as psychosocial sequelae and physiologic resilience on injury outcome. The field of geriatric trauma would benefit from further population-based prospective investigation of the determinants of injury outcome in older adults in order to guide interventions and acute care treatment.

Natural history of depression in traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI).

DESIGN

Inception cohort longitudinal study.

SETTING

Level I trauma center.

PARTICIPANTS

Consecutive admissions of 283 adults with moderate to severe TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores.

CONCLUSIONS

High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI.

Musculoskeletal recovery 5 years after severe injury: long term problems are common

Five years after severe injury (ISS>15), usually involving several body regions, 158 patients were assessed regarding their musculo-skeletal recovery. An earlier paper in this journal about this study 'Injury 29 (1998) 55' showed that when considering the main body regions causing long term disability, 45% were due to bony injuries to the extremities, pelvis and shoulder girdle. We analysed these body areas regarding the degrees of disability and pain and also for problems with activities of daily living, work, sport and mobility. All patients with unstable pelvic fractures had moderate or severe persisting disability and chronic pain. Functional problems with activities of daily living, work, sport and mobility were reported in 28, 86, 100 and 100% of patients, respectively. Patients with stable pelvic fractures had persisting disability in 54% of cases, which was mild in 42% and moderate or severe in 12% of patients. In patients with stable pelvic fractures 54% had chronic pain, which was mild in 24% of patients and moderate or severe in 30% of patients. Functional problems with mobility, work and sport were reported in 38, 19 and 19% of patients, respectively. Patients with shoulder girdle injuries had persisting disability in 48% of cases which was mild in 24% and moderate or severe in 24% of patients. In patients with shoulder girdle injuries 45% had chronic pain, which was mild in 14% and moderate or severe in 31% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 38, 28, 38 and 38% of patients respectively. Patients with upper limb fractures had persisting disability in 66% of cases which was mild in 34% of patients and moderate or severe in 32% of patients. Chronic pain was present in 62% of these cases, which was mild in 32% and moderate or severe in 34% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 31, 45, 48 and 66% of patients, respectively. Patients with lower limb fractures had persisting disability in 84% of cases, which was mild in 16% and moderate or severe in 68% of patients. Chronic pain was present in 80% of these cases, which was mild in 24% and moderate or severe in 56% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 40, 56, 64 and 76% of patients, respectively. Patients with multiple extremity injuries or combinations of pelvic and lower extremity or shoulder girdle and upper extremity injuries were much more likely to have continuing disability compared with those sustaining single bone injuries of that limb. This high disability rate reflecting treatment in 1989-1990, raises the question of whether our present policy of earlier and better fixation and rehabilitation of fractures in severely injured patients (ISS>15) can improve these results.