Development of depressive symptoms during early community reintegration after traumatic brain injury

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study

INTRODUCTION

This protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve psychosocial adjustment to TBI across different phases of injury (acute, postacute, and chronic), and (2) undertake an evaluation of efficacy, acceptability, and feasibility.

METHODS AND ANALYSIS

A three-stage mixed-methods research design will be used. The study will be undertaken across four postacute community-based neurorehabilitation and disability support services in Western Australia. Stage 1 (interviews and surveys) will use consumer-driven qualitative methodology to: (1) understand the recovery experiences and psychosocial challenges of people with TBI over key stages (acute, postacute, and chronic), and (2) identify required areas of psychosocial support to inform the psychoeducation platform development. Stage 2 (development) will use a Delphi expert consensus method to: (1) determine the final psychoeducation modules, and (2) perform acceptance testing of the myTBI platform. Finally, stage 3 (evaluation) will be a randomised stepped-wedge trial to evaluate efficacy, acceptability, and feasibility. Outcomes will be measured at baseline, postintervention, follow-up, and at final discharge from services. Change in outcomes will be analysed using multilevel mixed-effects modelling. Follow-up surveys will be conducted to evaluate acceptability and feasibility.

ETHICS AND DISSEMINATION

Ethics approval was granted by North Metropolitan Health Service Mental Health Research Ethics and Governance Office (RGS0000005877). Study findings will be relevant to clinicians, researchers, and organisations who are seeking a cost-effective solution to deliver ongoing psychoeducation and support to individuals with TBI across the recovery journey.

TRIAL REGISTRATION NUMBER

ACTRN12623000990628.

Impairments in Physiological Reactivity to Emotive Stimuli After Traumatic Brain Injury: A Systematic Review of Skin Conductance and Heart Rate Variability Evidence

OBJECTIVE

To examine evidence of impairments in physiological reactivity to emotive stimuli following traumatic brain injury (TBI).

METHODS

A search of PsychINFO, CINAHL (Cumulative Index to Allied Health Literature), Web of Science, EMBASE (Excerpta Medica dataBASE), and Scopus databases was conducted from 1991 to June 24, 2021, for studies comparing changes in skin conductance or heart rate variability to emotive stimuli between adults with TBI and controls. Two reviewers independently assessed eligibility and rated methodological quality.

RESULTS

Twelve eligible studies examined physiological reactivity to laboratory-based emotive stimuli, which included nonpersonal pictures/videos, posed emotion, stressful events, and personal event recall. Overall, 9 reported evidence that individuals with TBI experience lower physiological reactivity to emotive stimuli compared with healthy controls, although the findings varied according to the type and valence of emotional stimuli and physiological parameter. Most studies using nonpersonal pictures or videos found evidence of lower physiological reactivity in TBI participants compared with controls.

CONCLUSIONS

Based on laboratory-based studies, individuals with TBI may experience lower physiological reactivity to emotive stimuli. Further research is needed to investigate physiological responses to personally relevant emotional stimuli in real-world settings and to understand the interplay between physiological reactivity, subjective experiences, and behavior.

Apathy Level, Disinhibition, and Psychiatric Conditions Are Related to the Employment Status of People With Traumatic Brain Injury

IMPORTANCE

An understanding of the potential prognostic factors as they relate to the employment status of people with traumatic brain injury (TBI) is necessary so that occupational therapy practitioners can provide the most effective treatment.

OBJECTIVE

To examine the impact of apathy, disinhibition, and psychiatric conditions on employment status after TBI.

DESIGN

An observational study conducted from March 2015 to March 2020.

SETTING

Cognitive dysfunction clinics associated with two general hospitals in Japan.

PARTICIPANTS

Japanese people of working age (N = 110, ages 18-65 yr) with TBI. Outcomes and Measures: As an outcome indicator, each participant's employment status was rated on a 3-point scale (i.e., 3 = regular employment, 2 = welfare employment [employed as a person with disabilities or undergoing vocational training in the Japanese welfare employment system, for which a worker is paid under either system], 1 = unemployment). Psychiatric, neuropsychological, and physical assessments were measured as explanatory variables. The impact of various factors on employment status was investigated using linear discriminant regression analysis.

RESULTS

The level of apathy, disinhibition, and incidence of psychiatric conditions after TBI, as well as age and years postinjury, were related to employment status. Conclusion and Relevance: Although this is a cross-sectional study, interventions for apathy and disinhibition, as well as management of psychiatric conditions, are recommended to help improve employment status among people with TBI. What This Article Adds: The employment status of people with TBI is related more to apathy, disinhibition, and psychiatric conditions than to intelligence, memory function, or executive function.

Cohort profile: the Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT), Western Australia, 1991-2020

PURPOSE

Transition back into the community following acute management of acquired brain injury (ABI) is a critical part of recovery. Post-acute rehabilitation and transitional care can significantly improve outcomes. The Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT) is a novel whole-population cohort formed to better understand the needs of individuals with ABI receiving post-acute rehabilitation and disability services in Western Australia (WA), and to improve their outcomes. To do this a unique combination of (1) internal clinical/rehabilitation data, and (2) externally linked health data from the WA Data Linkage System was used, including hospitalisations, emergency department presentations, mental health service use and death records, to measure longitudinal needs and outcomes of individuals with ABI over 29 years, making this the largest, most diverse post-acute ABI cohort in Australia to date.

PARTICIPANTS

Whole-population cohort of individuals (n=1011) with an ABI who received post-acute community-based neurorehabilitation or disability support services through Brightwater Care Group from 1991 to 2020.

FINDINGS TO DATE

Comprehensive baseline demographic, clinical and rehabilitation data, outcome measures and linked health data have been collected and analysed. Non-traumatic brain injury (eg, stroke, hypoxia) was the main diagnostic group (54.9%, n=555), followed by traumatic brain injury (34.9%, n=353) and eligible neurological conditions (10.2%, n=103). Mean age at admission was 45.4 years, and 67.5% were men (n=682). The cohort demonstrated significant heterogeneity, socially and clinically, with differences between ABI groups across a number of domains.

FUTURE PLANS

ABI-RESTaRT is a dynamic whole-population cohort that will be updated over time as individuals enrol in the service. Future analyses will assess longitudinal brain injury outcomes, the changing health and social needs of individuals with ABI and evaluate and inform post-acute services to best support these individuals.

REGISTRATION

This cohort is not linked to a clinical trial, and is not registered.

Prevalence, Patterns, and Predictors of Multimorbidity in Adults With Acquired Brain Injury at Admission to Staged Community-Based Rehabilitation

OBJECTIVES

To describe the prevalence, patterns, and predictors of multimorbidity in adults with an acquired brain injury (ABI) on presentation to a community-based neurorehabilitation service.

DESIGN

Retrospective cohort study using routinely collected admissions and clinical data.

SETTING

Community-based neurorehabilitation.

PARTICIPANTS

Individuals (N=263) with non-traumatic brain injury (NTBI; n=187 [71.1%]) versus traumatic brain injury (TBI; n=76 [28.9%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comorbidity was defined as the co-occurrence of at least one chronic condition in conjunction with a primary diagnosis of ABI. Multimorbidity was defined as the co-occurrence of 2 or more chronic conditions across 2 or more body systems, in conjunction with a primary diagnosis of ABI.

RESULTS

Comorbidity was present in 72.2% of participants overall, whereas multimorbidity was present in 35.4% of the cohort. The prevalence of comorbidity (76% vs 63%; P=.036) and multimorbidity (40% vs 24%; P=.012) was higher in NTBI compared with participants with TBI. Participants with NTBI had a higher prevalence of physical health multimorbidities, including cardiovascular (44% vs 6%; P<.001) and endocrine (34% vs 10%; P=.002) disease, whereas participants with TBI had a higher prevalence of mental health conditions (79% vs 48%; P<.001). Depression (36.3%) and hypertension (25.8%) were the most common diagnoses. Increasing age was the only significant predictor of multimorbidity.

CONCLUSIONS

Most participants experienced multimorbidity. Effective management of multimorbidity should be included as part of individual rehabilitation for ABI and planning of resource allocation and service delivery. The results of this study can help guide the provision of treatment and services for individuals with ABI in community-based rehabilitation. Our study highlights access to mental health, cardiovascular, endocrine, and neurology services as essential components of rehabilitation for ABI.

[Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury

Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.

Exploring self-concept, wellbeing and distress in therapeutic songwriting participants following acquired brain injury: A case series analysis

Acquired brain injury (ABI) presents a significant threat to sense of self and necessitates a complex process of psychosocial adjustment. Self-concept changes remain understudied in the early stages of inpatient rehabilitation. The aim of the current study was to examine changes in self-concept, distress, wellbeing and functional skills for five inpatients undertaking a music therapy intervention within a subacute rehabilitation centre in Victoria, Australia. Participants completed a six-week, 12-session therapeutic songwriting programme to produce past-, current- and future-self-focused songs. A range of self-concept, subjective wellbeing and distress measures were completed pre-, mid- and post-intervention. A descriptive case series approach was applied to determine trends in pre-post scores for five individual cases. Participants showing the greatest gains across self-concept and subjective wellbeing indices also showed the greatest functional gains on the Functional Independence Measure (FIM) from admission to discharge. The current study highlights the importance of examining early changes in self-concept, wellbeing and distress in subacute rehabilitation, and suggests that individualised songwriting programmes warrant further research attention in neurological populations.

The effects of post-traumatic depression on cognition, pain, fatigue, and headache after moderate-to-severe traumatic brain injury: a thematic review

BACKGROUND

Post-traumatic depression (PTD) is one of the most common secondary complications to develop after moderate-to-severe traumatic brain injury (TBI). However, it rarely manifests singularly, and often co-occurs with other common TBI impairments.

OBJECTIVE

The objective of this thematic review is to evaluate studies examining the relationships between PTD and cognition, fatigue, pain, and headache among individuals with moderate-to-severe TBI.

RESULTS

We reviewed 16 studies examining the relationship between PTD and cognition (five articles), fatigue (five articles), pain (four articles), and headache (two articles). Two studies failed to identify the significant associations between PTD and neuropsychological test performance, while one study found a positive association. Two other studies found that early PTD was associated with later executive dysfunction. Studies on fatigue suggest it is a cause, not consequence, of PTD. Individuals with PTD tended to report more pain than those without PTD. Studies examining relationships between PTD and post-traumatic headache were equivocal.

CONCLUSIONS

Studies evaluating the effects of PTD on common TBI impairments have yielded mixed results. Evidence suggests PTD precedes the development of executive dysfunction, and a strong link exists between fatigue and PTD, with fatigue preceding PTD. Future prospective studies evaluating PTD relationships to pain and headache are warranted to elucidate causality.

A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges

Depression is one of the most common conditions to emerge after traumatic brain injury (TBI), and despite its potentially serious consequences it remains undertreated. Treatment for post-traumatic depression (PTD) is complicated due to the multifactorial etiology of PTD, ranging from biological pathways to psychosocial adjustment. Identifying the unique, personalized factors contributing to the development of PTD could improve long-term treatment and management for individuals with TBI. The purpose of this narrative literature review was to summarize the prevalence and impact of PTD among those with moderate to severe TBI and to discuss current challenges in its management. Overall, PTD has an estimated point prevalence of 30%, with 50% of individuals with moderate to severe TBI experiencing an episode of PTD in the first year after injury alone. PTD has significant implications for health, leading to more hospitalizations and greater caregiver burden, for participation, reducing rates of return to work and affecting social relationships, and for quality of life. PTD may develop directly or indirectly as a result of biological changes after injury, most notably post-injury inflammation, or through psychological and psychosocial factors, including pre injury personal characteristics and post-injury adjustment to disability. Current evidence for effective treatments is limited, although the strongest evidence supports antidepressants and cognitive behavioral interventions. More personalized approaches to treatment and further research into unique therapy combinations may improve the management of PTD and improve the health, functioning, and quality of life for individuals with TBI.

Changes in activity participation following traumatic brain injury

Traumatic brain injury (TBI) often results in impairments in cognitive skills as well as depression. As a result of these changes in cognition and mood, individuals with TBI may reduce their levels of participation and often report reduced health-related quality of life (HrQOL). The current study compares levels of past and present activity participation between healthy participants and persons with TBI using a client-centred approach in measurement. We additionally examine the relationship between activity participation, emotional functioning and HrQOL in persons with TBI. Fifty-two individuals with TBI who live in the community and 30 healthy age-matched controls performed a battery of cognitive tests and rated their affective symptomatology and activity participation (using the Activity Card Sort Test). Participants with TBI reported significantly lower current activity participation compared to controls. Current levels of activity and participation in the TBI sample were significantly related to age, time since injury, and HrQOL. Additionally, depressive symptomatology was significantly associated with HrQOL, but not with activity participation. Following TBI, levels of activity participation are reduced in most aspects of life, but more profoundly in social activities, high demand leisure activities and household activities. Additionally, high levels of depressive symptoms are associated with negative reports of HrQOL, regardless of current levels of activity participation.

The impact of self-awareness and depression on subjective reports of memory, quality-of-life and satisfaction with life following TBI

OBJECTIVE

To determine the relationship between self-awareness and depressive symptomatology with self-reports of memory, Quality-of-Life (QoL) and satisfaction with life in individuals with traumatic brain injury (TBI).

METHODS

Cross-sectional survey of 30 community dwelling adults, who sustained a TBI at least 1 year prior to study enrolment. Participants completed questionnaires to assess the constructs of depression, self-awareness, QoL, satisfaction with life and memory.

RESULTS

Symptoms of depression were significantly associated with self-reports of poor memory abilities, lower QoL and lower satisfaction with life. Additionally, higher levels of self-awareness were associated with lower ratings of QoL and reduced memory abilities and better strategy use regarding memory. However, when examining the contribution of each construct individually, depressive symptomatology, and not self-awareness, was significantly associated with subjective self-reports of memory, QoL and satisfaction with life.

CONCLUSIONS

This pattern of relationships illustrates that, when a person has a low level of depressive symptoms, his/her reports of QoL, memory and satisfaction with life will be more positive; however, he/she will demonstrate more difficulty with self-awareness. Thus, psychological aspects of recovery must, therefore, be taken into account when using self-reported measures in the evaluation of persons who have sustained TBI.

Neuroticism (not depressive symptoms) predicts memory complaints in some community-dwelling older adults

OBJECTIVES

To examine whether depressive symptoms are useful predictors of subjective memory complaints in community-dwelling older adults, beyond the predictive utility already provided by memory performance and characteristics of personality.

DESIGN

Using hierarchical regression, we examined the relationship between depressive symptoms and subjective memory complaints, controlling for age, gender, education, memory performance, conscientiousness, and neuroticism.

PARTICIPANTS

Community-dwelling older adults aged 66 to 90 years (N = 177) who responded to a newspaper advertisement for a memory study in Perth, Western Australia.

MEASUREMENTS

The General Frequency of Forgetting scale (for memory complaints), Depression Anxiety Stress Scales (for depressive symptoms), NEO-Five Factor Inventory (for conscientiousness and neuroticism), and the Visual Reproduction and Logical Memory subtests from the Wechsler Memory Scale-4th Edition (for visual and verbal memory).

RESULTS

The hierarchical regression analysis indicated that while depressive symptoms significantly predicted memory complaints after variance associated with age, gender, education, memory performance, and conscientiousness was partialled out, they accounted for almost none of the variance in complaints when neuroticism was partialled out.

CONCLUSIONS

The well-established relationship between depression and memory complaints may exist in some community-dwelling older adult populations only on account of the manner in which both are associated with neuroticism.

Development and Preliminary Psychometric Evaluation of the Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) for Brain Injury Rehabilitation

OBJECTIVE. The Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) is a brief measure developed to monitor client self-perceptions, motivation, and emotional reactions throughout rehabilitation. We describe the SPIRQ’s development and preliminary psychometric evaluation.

METHOD. One hundred five adults with traumatic brain injury attending two brain injury rehabilitation units completed the SPIRQ during occupational therapy sessions. A subset (n = 33) completed the SPIRQ twice over a 5- to 7-day interval to examine test–retest reliability.

RESULTS. Exploratory factor analysis yielded three factors: Changes in Self and Life Plans, Self in Rehabilitation, and Emotional Reactions. Their internal consistency was sound (αs = .72–.83). Test–retest reliability was generally acceptable (rs = .67–.81), and scores did not significantly change between testing occasions (p &gt; .05).

CONCLUSION. We found preliminary support for the SPIRQ scales’ reliability and construct validity. Future empirical evaluation and potential clinical applications of the SPIRQ in occupational therapy are discussed.