The clinical utility of the Beck Depression Inventory after traumatic brain injury

COOK technology to support meal preparation following a severe traumatic brain injury: a usability mixed-methods single-case study in a real-world environment

INTRODUCTION

Following a traumatic brain injury (TBI), meal preparation may become challenging as it involves multiple cognitive abilities and sub-tasks. To support this population, the Cognitive Orthosis for coOKing (COOK) was developed in partnership with an alternative residential resource for people with severe TBI. However, little is known about the usability of this technology to support people with TBI living in their own homes.

METHODS

A usability study was conducted using a mixed-methods single-case design with a 35-year-old man with severe TBI living alone at home. The number of assistances provided, time taken and the percentage of unnecessary actions during a meal preparation task were documented nine times to explore the usability of COOK. Interviews were also conducted with the participant to document his satisfaction with COOK. Potential benefits were explored via the number of meals prepared per week.

RESULTS

The usability of COOK was shown to be promising as the technology helped the participant prepare complex meals, while also reducing the number of assistances needed and the percentage of unnecessary actions. However, several technical issues and contextual factors influenced the efficiency and the participant's satisfaction with COOK. Despite improving his self-confidence, COOK did not help the participant prepare more meals over time.

CONCLUSION

This study showed that COOK was easy to use and promising, despite technical and configuration issues. Results suggest the importance of further technological developments to improve COOK's usability and fit with the needs of people with TBI living in their own homes.

Predictors and Functional Outcomes Associated With Longitudinal Trajectories of Anxiety and Depression from 2 to ≥36 Months After Moderate to Severe Traumatic Brain Injury

This study investigated longitudinal trajectories of anxiety and depressive symptoms following moderate-severe traumatic brain injury (TBI), predictors of the trajectories, and associations with 1-year return to productivity. One hundred forty-eight patients with moderate-severe TBI were assessed at 2, 5, 12, and ≥36 months post-injury on the Beck Anxiety Inventory and the Beck Depression Inventory. Clinical interviews obtained information about demographics, injury characteristics, and 1-year return to productivity. Latent growth mixture modeling identified trajectories of anxiety and depression across time. The three-step method identified predictors of trajectories, and χ2 analyses determined associations between trajectories and 1-year return to productivity. Analyses revealed that four-class models of anxiety and depression best fit the data. Most individuals had stable minimal (67%) or low (18%) levels of anxiety over time. Two other subsets of individuals were classified by anxiety that worsened rapidly (7%) or improved in the 1st year but worsened by 3 years post-injury (9%). Similarly for the depression trajectories, most individuals had stable minimal (70%) or low (10%) levels of depression over time. Others had depression that worsened rapidly (12%) or was delayed, with onset 1-year post-injury (8%). Predictors of worsening anxiety and depression included younger age, less education, and male gender. Those with worsening anxiety or depression were less likely to return to productivity by 1-year post-injury. There is a significant burden of anxiety (15%) and depression (20%) in the 3 years after moderate-severe TBI. Future research targeting at-risk patients may help to improve quality of life and functional recovery.

Executive function improvement in response to meta-cognitive training in chronic mTBI / PTSD

Objective

We tested Goal Management Training (GMT), which has been recommended as an executive training protocol that may improve the deficits in the complex tasks inherent in life role participation experienced by those with chronic mild traumatic brain injury and post-traumatic stress disease (mTBI/PTSD). We assessed, not only cognitive function, but also life role participation (quality of life).

Methods

We enrolled and treated 14 individuals and administered 10 GMT sessions in-person and provided the use of the Veterans Task Manager (VTM), a Smartphone App, which was designed to serve as a "practice-buddy" device to ensure translation of in-person learning to independent home and community practice of complex tasks. Pre-/post-treatment primary measure was the NIH Examiner, Unstructured Task. Secondary measures were as follows: Tower of London time to complete (cTOL), Community Reintegration of Service Members (CRIS) three subdomains [Extent of Participation; Limitations; Satisfaction of Life Role Participation (Satisfaction)]. We analyzed pre-post-treatment, t-test models to explore change, and generated descriptive statistics to inspect given individual patterns of change across measures.

Results

There was statistically significant improvement for the NIH EXAMINER Unstructured Task (p < .02; effect size = .67) and cTOL (p < .01; effect size = .52. There was a statistically significant improvement for two CRIS subdomains: Extent of Participation (p < .01; effect size = .75; Limitations (p < .05; effect size = .59). Individuals varied in their treatment response, across measures.

Conclusions and Clinical Significance

In Veterans with mTBI/PTSD in response to GMT and the VTM learning support buddy, there was significant improvement in executive cognition processes, sufficiently robust to produce significant improvement in community life role participation. The individual variations support need for precision neurorehabilitation. The positive results occurred in response to treatment advantages afforded by the content of the combined GMT and the employment of the VTM learning support buddy, with advantages including the following: manualized content of the GMT; incremental complex task difficulty; GMT structure and flexibility to incorporate individualized functional goals; and the VTM capability of ensuring translation of in-person instruction to home and community practice, solidifying newly learned executive cognitive processes. Study results support future study, including a potential randomized controlled trial, the manualized GMT and availability of the VTM to ensure future clinical deployment of treatment, as warranted.

Depression Severity Is Different in Dysosmic Patients Who Have Experienced Traumatic Brain Injury Compared with Those Who Have Not

Traumatic brain injury (TBI) in humans can result in olfactory, cognitive, and affective changes. Surprisingly, research on the consequences of TBI often did not control for olfactory function in the investigated groups. Consequently, the affective or cognitive differences might be misleading as related rather to different olfactory performance than to a TBI experience. Hence, our study aimed to investigate whether TBI occurrence would lead to altered affective and cognitive functioning in two groups of dysosmic patients, one with TBI experience and one without. In total, 51 patients with TBI experience and 50 controls with varied causes of olfactory loss were thoroughly examined in terms of olfactory, cognitive, and affective performance. Student t-tests demonstrated that the only significant difference between the groups appeared in the depression severity, with TBI patients being more depressed (t = 2.3, p = 0.011, Cohen's d = -0.47). Regression analyses further showed that TBI experience was significantly associated with depression severity (R2 = 0.05, F [1, 96] = 5.5, p = 0.021, beta = 1.4). In conclusion, the present study showed that TBI experience is linked to depression, which is more pronounced compared to individuals with olfactory loss without TBI.

Return to work following mild traumatic brain injury: Psychological and cognitive factors in a litigating sample in the post acute stage of recovery

The purpose of this study was to investigate return to work (RTW) rates following a single uncomplicated mild Traumatic Brain Injury (mTBI) in the post-acute stage in the context of active litigation. More specifically, we sought to determine what psychological and/or cognitive factors predict a RTW after mTBI. Archival data were obtained from a random sample of litigating patients (n = 125; 54% female; mean age: 42.96 (SD = 12.74) who were referred to a private practice for a neuropsychological examination regarding their disability status following a single uncomplicated mTBI. A hierarchical regression analysis was used to assess the predictive value of emotional symptoms and cognition with respect to RTW status. Approximately 50% of the sample did not RTW. Attentional deficits (rs = -0.248) and depressive symptoms (rs = 0.248) were significantly associated with RTW. A hierarchical regression analysis found that depressive symptoms (p < .05) were associated with RTW outcomes. These findings suggest that individuals with increased depressive symptoms are more likely to demonstrate poor RTW outcomes in the post-acute stages of mTBI. These results are of interest to clinicians as they underscore the importance of screening and early intervention for depressive symptoms following a single uncomplicated mTBI in the post-acute stages in litigating samples.

Survey of depressive symptomatology in brain injury resulting from intimate partner violence

OBJECTIVE

A high prevalence of depression exists in specific sub-samples of survivors of brain injury (BI) sustained from intimate partner violence (IPV). However, the experience of depression by survivors of IPV-related BI from general civilian populations remains unclear. This study documents the symptom profile of depression reported by individuals who screened positive for sustaining an IPV-related BI.

METHODS

36 individuals who screened positive for possible IPV-related BI completed the Beck Depression Inventory-2^nd Edition (BDI-II). Subscales characterizing the nature of the symptoms were created. Frequency and descriptive statistics were calculated for item responses on the BDI-II. Participants were also assigned to high or low symptom severity groups to examine between-group differences.

RESULTS

Participants endorsed experiencing somatic symptoms more severely than self-evaluative and affective symptoms. Additionally, self-evaluative and cognitive symptoms correlated with total BDI-II scores for the high symptom severity group but not for the low symptom severity group.

CONCLUSIONS

The findings highlight somatic symptoms of depression, in particular as a common experience among survivors of IPV-related BI. Further, self-evaluative and cognitive symptoms may be more sensitive in detecting depression after IPV-related BI. These results may aid in the development of guidelines to better diagnose and treat depression in IPV-related BI.

Extracting Apathy From Depression Syndrome in Traumatic Brain Injury by Using a Clustering Method

OBJECTIVE

Depression and apathy are common after traumatic brain injury (TBI), and different intervention strategies are recommended for each. However, a differential diagnosis can be difficult in clinical settings, especially given that apathy is considered to be a symptom of depression. In this study, the investigators aimed to isolate apathy from depression among patients with TBI and to examine whether apathy is exclusively associated with the amount of daily activity, as previously reported in the literature.

METHODS

Eighty-eight patients with chronic TBI completed the Japanese versions of the 21-item Beck Depression Inventory-II (BDI-II) and the Starkstein Apathy Scale (AS). Daily activity was measured with a 24-hour life log. A hierarchical cluster analysis was applied to divide the BDI-II data into separable components, and components' correlations with results of the AS and 24-hour life log scale were evaluated.

RESULTS

The BDI-II and AS revealed that 37 patients (42.0%) had both depression and apathy. BDI-II data were classified into four separate clusters (somatic symptoms, loss of self-worth, affective symptoms, and apathy symptoms). Loss of self-worth and apathy symptoms subscores were significantly positively correlated with total AS score (r=0.32, p=0.002, and r=0.52, p<0.001, respectively). The apathy symptoms subscore was significantly correlated with the amount of daily activity (r=-0.29, p=0.009).

CONCLUSIONS

The findings suggest that the BDI-II can differentiate between apathy and depression among patients with TBI, which is essential when selecting intervention options. Moreover, apathy symptoms predicted patients' real-life daily activity.

Influence of Concomitant Extracranial Injury on Functional and Cognitive Recovery From Mild Versus Moderateto Severe Traumatic Brain Injury

OBJECTIVE

To determine the effect of extracranial injury (ECI) on 6-month outcome in patients with mild traumatic brain injury (TBI) versus moderate-to-severe TBI.

PARTICIPANTS/SETTING

Patients with TBI (n = 135) or isolated orthopedic injury (n = 25) admitted to a UK major trauma center and healthy volunteers (n = 99).

DESIGN

Case-control observational study.

MAIN MEASURES

Primary outcomes: (a) Glasgow Outcome Scale Extended (GOSE), (b) depression, (c) quality of life (QOL), and (d) cognitive impairment including verbal fluency, episodic memory, short-term recognition memory, working memory, sustained attention, and attentional flexibility.

RESULTS

Outcome was influenced by both TBI severity and concomitant ECI. The influence of ECI was restricted to mild TBI; GOSE, QOL, and depression outcomes were significantly poorer following moderate-to-severe TBI than after isolated mild TBI (but not relative to mild TBI plus ECI). Cognitive impairment was driven solely by TBI severity. General health, bodily pain, semantic verbal fluency, spatial recognition memory, working memory span, and attentional flexibility were unaffected by TBI severity and additional ECI.

CONCLUSION

The presence of concomitant ECI ought to be considered alongside brain injury severity when characterizing the functional and neurocognitive effects of TBI, with each presenting challenges to recovery.

Psychological distress and line-of-duty head injuries in firefighters

BACKGROUND

Head injuries are common injury in the fire service; however, very little data exist on the risks this may pose to the development of post-traumatic stress disorder (PTSD) and depression in this high-risk population.

AIMS

Our study aimed to compare levels of PTSD and depression symptoms in firefighters with a line-of-duty head injury, non-line-of-duty head injury and no head injury.

METHODS

In this cross-sectional study, we assessed current PTSD and depression symptoms as well as retrospective head injuries.

RESULTS

Seventy-six per cent of the total sample reported at least one head injury in their lifetime. Depression symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to those with no head injury, but not compared to those who sustained a non-line-of-duty head injury. Depression symptoms did not differ between firefighters with a non-line-of-duty head injury and those with no head injury. PTSD symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to both firefighters with no head injury and those with a non-line-of-duty head injury.

CONCLUSIONS

We found that firefighters who reported at least one line-of-duty head injury had significantly higher levels of PTSD and depression symptoms than firefighters who reported no head injuries. Our findings also suggest head injuries sustained outside of fire service could have less of an impact on the firefighter's PTSD symptom severity than head injuries that occur as a direct result of their job.

Effects of neurological music therapy on behavioural and emotional recovery after traumatic brain injury: A randomized controlled cross-over trial

Traumatic brain injury (TBI) causes deficits in executive function (EF), as well as problems in behavioural and emotional self-regulation. Neurological music therapy may aid these aspects of recovery. We performed a cross-over randomized controlled trial where 40 persons with moderate-severe TBI received a 3-month neurological music therapy intervention (2 times/week, 60 min/session), either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. The evidence from this RCT previously demonstrated that music therapy enhanced general EF and set shifting. In the current study, outcome was assessed with self-report and caregiver-report questionnaires performed at baseline, 3-month, 6-month, and 18-month stages. The results showed that the self-reported Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage and the effect was maintained in the 6-month follow-up. No changes in mood or quality of life questionnaires were observed. However, a qualitative content analysis of the feedback revealed that many participants experienced the intervention as helpful in terms of emotional well-being and activity. Our results suggest that music therapy has a positive effect on everyday behavioural regulation skills after TBI.

"Tomorrow is the busiest day of the week": Executive functions mediate the relation between procrastination and attention problems

We examined whether executive functions (EFs) mediate the relation between procrastination and attention-deficit/hyperactivity disorder (ADHD) symptoms in college students. Participants: One hundred fourteen undergraduates were recruited for study participation. Methods: Participants completed measures of academic performance, procrastination, ADHD symptoms, EFs (as measured by five EF facets: time management, organization/problem-solving, restraint, motivation, and emotion regulation), and common comorbid concerns for college students between May 2017 and May 2018. A mediational framework was utilized to examine the associations among procrastination, EFs, and four ADHD symptoms domains. Results: Results indicated that both procrastination and GPA correlated with EFs and three ADHD symptom domains. While EFs mediated the association between procrastination and ADHD symptoms, follow-up analyses suggested that self-management of time and organization/problem-solving are the specific pathways through which procrastination is indirectly associated with ADHD symptoms. Conclusions: Promising areas for future research and potential intervention targets are discussed.

An Integrative Neuro-Psychotherapy Treatment to Foster the Adjustment in Acquired Brain Injury Patients-A Randomized Controlled Study

Adjustment disorders (AjD) with depressive symptoms following an acquired brain injury (ABI) is a common phenomenon. Although brain injuries are increasing more and more, research on psychological therapies is comparably scarce. The present study compared, by means of a randomized controlled trial (RCT), a newly developed integrative treatment (Standard PLUS) to a standard neuropsychological treatment (Standard). Primary outcomes were depressive symptoms assessed with the Beck Depression Inventory (BDI-II) at post-treatment and 6-month follow-up assessment. In total, 25 patients (80% after a stroke) were randomized to one of the two conditions. Intention-to-treat analyses showed that the two groups did not significantly differ either at post-treatment nor at follow-up assessment regarding depressive symptoms. Both treatments showed large within-group effect sizes on depressive symptoms. Regarding secondary outcomes, patients in the Standard PLUS condition reported more emotion regulation skills at post-assessment than in the control condition. However, this difference was not present anymore at follow-up assessment. Both treatments showed medium to large within-group effects sizes on most measures for patients suffering from an AjD after ABI. More research with larger samples is needed to investigate who profits from which intervention.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial

OBJECTIVE

To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression.

PARTICIPANTS

A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy.

MEASURES

Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment.

RESULTS

No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups.

CONCLUSIONS

Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Non-pharmacological interventions for depression in adults and children with traumatic brain injury

BACKGROUND

Following traumatic brain injury (TBI) there is an increased prevalence of depression compared to the general population. It is unknown whether non-pharmacological interventions for depression are effective for people with TBI.

OBJECTIVES

To investigate the effectiveness of non-pharmacological interventions for depression in adults and children with TBI at reducing the diagnosis and severity of symptoms of depression.

SEARCH METHODS

We ran the most recent search on 11 February 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), three other databases and clinical trials registers. Relevant conference proceedings and journals were handsearched, as were the reference lists of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of non-pharmacological interventions for depression in adults and children who had a TBI.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search results, then assessed risk of bias and extracted data from the included trials. The authors contacted trial investigators to obtain missing information. We rated the overall quality of the evidence of the primary outcomes using the GRADE approach.

MAIN RESULTS

Six studies met the inclusion criteria, with a total of 334 adult participants. We identified no studies that included children as participants. All studies were affected by high risk of bias due to a lack of blinding of participants and personnel; five studies were affected by high risk of bias for lack of blinding of outcome assessors. There was high or unclear risk of biases affecting some studies across all the Cochrane risk of bias measures.Three studies compared a psychological intervention (either cognitive behaviour therapy or mindfulness-based cognitive therapy) with a control intervention. Data regarding depression symptom outcome measures were combined in a meta-analysis, but did not find an effect in favour of treatment (SMD -0.14; 95% CI -0.47 to 0.19; Z = 0.83; P = 0.41). The other comparisons comprised of single studies of depression symptoms and compared; cognitive behaviour therapy versus supportive psychotherapy (SMD -0.09; 95% CI -0.65 to 0.48; Z = 0.30; P = 0.77); repetitive transcranial magnetic stimulation plus tricyclic antidepressant (rTMS + TCA) versus tricyclic antidepressant alone (SMD -0.84; 95% CI -1.36 to -0.32; Z = 3;19, P = 0.001); and a supervised exercise program versus exercise as usual (SMD -0.43; 95% CI -0.88 to 0.03; Z = 1.84; P = 0.07). There was very-low quality evidence, small effect sizes and wide variability of results, suggesting that no comparisons showed a reliable effect for any intervention.Only one study mentioned minor, transient adverse events from repetitive transcranial magnetic stimulation.

AUTHORS' CONCLUSIONS

The review did not find compelling evidence in favour of any intervention. Future studies should focus on participants with a diagnosed TBI and include only participants who have a diagnosis of depression, or who record scores above a clinical cutoff on a depression measure. There is a need for additional RCTs that include a comparison between an intervention and a control that replicates the effect of the attention given to participants during an active treatment.

Changes in impaired self-awareness after acquired brain injury in patients following intensive neuropsychological rehabilitation

The objective of this study was to investigate changes in self-awareness impairments in outpatients with acquired brain injury (ABI) and the effects these changes have on rehabilitation. Participants were 78 patients with ABI (8.3 years post-injury) who followed an intensive outpatient neuropsychological rehabilitation programme. This longitudinal study comprised pre (T1) and post (T2) measurements and a one-year follow-up (T3). Thirty-eight patients completed the study. The main outcome domains were self-awareness, depressive symptoms, psychological and physical dysfunction, and health-related quality of life (HRQoL). Patients were divided into three awareness groups: underestimation, accurate estimation, and overestimation of competencies. Most patients who underestimated their competencies at the start of treatment accurately estimated their competencies directly after treatment (9 out of 11 patients). These patients also exhibited the largest treatment effects regarding depressive symptoms, psychological and physical dysfunction, and HRQoL. Most patients with impaired self-awareness (i.e., overestimation of competencies) at the start of treatment continued to overestimate their competencies after treatment (10 out of 14 patients). These patients exhibited a significant decrease in depressive symptoms but no other treatment effects. The results indicate that changes in outcome are related to changes in awareness, which underline the importance of taking into account different awareness groups with respect to treatment effects.

Mood disorders after TBI

In this article, we examine the epidemiology and risk factors for the development of the most common mood disorders observed in the aftermath of TBI: depressive disorders and bipolar spectrum disorders. We describe the classification approach and diagnostic criteria proposed in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders. We also examine the differential diagnosis of post-TBI mood disorders and describe the mainstay of the evaluation process. Finally, we place a special emphasis on the analysis of the different therapeutic options and provide guidelines for the appropriate management of these conditions.

Predicting health-related quality of life 2 years after moderate-to-severe traumatic brain injury

AIMS

To describe health-related quality of life (HRQL) 2 years after moderate-to-severe traumatic brain injury (TBI) and to assess predictors of HRQL.

MATERIALS AND METHODS

A prospective cohort study of 91 patients, aged 16-55 years, admitted with moderate-to-severe TBI to a trauma referral centre between 2005 and 2007, with follow-up at 1 and 2 years. Mean age was 31.1 (SD = 11.3) years, and 77% were men. Injury severity was evaluated by the Glasgow Coma Scale (GCS), head CT scan (using a modified Marshall Classification), Injury Severity Score (ISS) and post-traumatic amnesia (PTA). The Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), Beck Depression Inventory (BDI) and Medical Outcomes 36-item Short Form Health Survey (SF-36) were administered at follow-up visits. The main outcome measures were the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36.

RESULTS

HRQL appears to be relatively stable between 1 and 2 years after injury. In the multivariate linear regression, younger age (β = -0.20, P = 0.032), more severe TBI (β = 0.28, P = 0.016), more severe overall trauma (β = 0.22, P = 0.026), higher levels of community integration (β = 0.36, P = 0.019) and higher positive change in PCS scores from 1 to 2 years (β = 0.41, P < 0.001) predicted better self-reported physical health 2 years post-TBI. Lower scores for depression (β = -0.70, P < 0.001) and a higher positive change in MCS scores (β = 0.62, P < 0.001) predicted better self-reported mental health.

CONCLUSIONS

Future interventions should focus on aspects related to HRQL that are more easily modified, such as physical functioning, home and social integration, productivity, and mental and emotional status.

Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders

Psychophysiological investigations of traumatic brain injury (TBI) are being conducted for several reasons, including the objective of learning more about the underlying physiological mechanisms of the pathological processes that can be initiated by a head injury. Additional goals include the development of objective physiologically based measures that can be used to monitor the response to treatment and to identify minimally symptomatic individuals who are at risk of delayed-onset neuropsychiatric disorders following injury. Research programs studying TBI search for relationships between psychophysiological measures, particularly ERP (event-related potential) component properties (e.g., timing, amplitude, scalp distribution), and a participant's clinical condition. Moreover, the complex relationships between brain injury and psychiatric disorders are receiving increased research attention, and ERP technologies are making contributions to this effort. This review has two objectives supporting such research efforts. The first is to review evidence indicating that TBI is a significant risk factor for post-injury neuropsychiatric disorders. The second objective is to introduce ERP researchers who are not familiar with neuropsychiatric assessment to the instruments that are available for characterizing TBI, post-concussion syndrome, and psychiatric disorders. Specific recommendations within this very large literature are made. We have proceeded on the assumption that, as is typically the case in an ERP laboratory, the investigators are not clinically qualified and that they will not have access to participant medical records.

Depressive symptoms and concussions in aging retired NFL players

We examined the relationship between a remote history of concussions with current symptoms of depression in retired professional athletes. Thirty retired National Football League (NFL) athletes with a history of concussion and 29 age- and IQ-matched controls without a history of concussion were recruited. We found a significant correlation between the number of lifetime concussions and depressive symptom severity using the Beck Depression Inventory II. Upon investigating a three-factor model of depressive symptoms (affective, cognitive, and somatic; Buckley et al., 2001) from the BDI-II, the cognitive factor was the only factor that was significantly related to concussions. In general, NFL players endorsed more symptoms of depression on all three Buckley factors compared with matched controls. Findings suggest that the number of self-reported concussions may be related to later depressive symptomology (particularly cognitive symptoms of depression).

Impact of pharmacological treatments on cognitive and behavioral outcome in the postacute stages of adult traumatic brain injury: a meta-analysis

Pharmacological treatments that are administered to adults in the postacute stage after a traumatic brain injury (TBI) (≥4 weeks after injury) have the potential to reduce persistent cognitive and behavioral problems. While a variety of treatments have been examined, the findings have yet to be consolidated, hampering advances in the treatment of TBI. A meta-analysis of research that has investigated the cognitive and behavioral effects of pharmacological treatments administered in the later stage after TBI was therefore conducted. The PubMed and PsycINFO databases were searched, and Cohen d effect sizes, percent overlap, and failsafe N statistics were calculated for each treatment. Both randomized controlled trials and open-label studies (prospective and retrospective) were included. Nineteen treatments were investigated by 30 independent studies, comprising 395 participants with TBI in the treatment groups and 137 control subjects. When treated in the postacute period, 1 dopaminergic agent (methylphenidate) improved behavior (anger/aggression, psychosocial function) and 1 cholinergic agent (donepezil) improved cognition (memory, attention). In addition, when the injury-to-treatment interval was broadened to include studies that administered treatment just before the postacute period, 2 dopaminergic agents (methylphenidate, amantadine) showed clinically useful treatment benefits for behavior, whereas 1 serotonergic agent (sertraline) markedly impaired cognition and psychomotor speed.

Measuring depression and PTSD after trauma: common scales and checklists

Traumatic injury is an important public health problem secondary to high levels of morbidity and mortality. Injured survivors face several physical, emotional, and financial repercussions that can significantly impact their lives as well as their family. Depression and posttraumatic stress disorder (PTSD) are the most common psychiatric sequelae associated with traumatic injury. Factors affecting the prevalence of these psychiatric symptoms include: concomitant TBI, the timing of assessment of depression and PTSD, the type of injury, premorbid, sociodemographic, and cultural factors, and co-morbid medical conditions and medication side effects. The appropriate assessment of depression and PTSD is critical to an understanding of the potential consequences of these disorders as well as the development of appropriate behavioural and pharmacological treatments. The reliability and validity of screening instruments and structured clinical interviews used to assess depression and PTSD must be considered. Common self-report instruments and structured clinical interviews used to assess depression and PTSD and their reliability and validity are described. Future changes in diagnostic criteria for depression and PTSD and recent initiatives by the National Institute of Health regarding patient-reported outcomes may result in new methods of assessing these psychiatric sequelae of traumatic injury.

Hope, dispositional optimism and severity of depression following traumatic brain injury

PRIMARY OBJECTIVE

To investigate the extent in which two coping variables-hope and dispositional optimism-are related to depression severity amongst individuals who have sustained traumatic brain injury (TBI).

METHODS AND PROCEDURES

Sixty-five participants were administered the Beck Depression Inventory (BDI), the Adult Hope Scale (AHS), the Life Orientation Test-Revised (LOT-R) and a demographic and injury-related data questionnaire. In addition, relevant injury-related data was collected from the medical records.

MAIN OUTCOMES AND RESULTS

High levels of depression were experienced in the study sample, while hope and dispositional optimism were significantly lower in comparison to the general population. The correlation patterns indicate that both hope and dispositional optimism negatively correlated with participants' depression levels and that they showed significant positive correlations with each other. In the case of mild depression, the hope-Pathways sub-scale of the AHS was the only variable negatively correlated to it, while in moderate-to-severe depression all coping variables were negatively correlated to it. Regression analysis revealed that the AHS and LOT-R, but not the demographic and injury-related variables, predicted depression severity.

CONCLUSIONS

Clinical implications in referring persons with TBI with mild vs. severe depression to rehabilitation programmes are discussed.

A narrative review of the Beck Depression Inventory (BDI) and implications for its use in an alcohol-dependent population

The findings from the present study reveal that the Beck Depression Inventory (BDI) is a reliable and valid instrument for measuring depression in a variety of populations. This realization should enable nurses and other health professionals to utilize the tool with added confidence and assurance. * The main finding was that the BDI would probably be a reliable and valid screening tool in an alcohol-dependent population. This conclusion appears to echo the relationship that alcohol consumption generally has with depression. This finding is important to those practitioners using the BDI in this population in that it provides further evidence to enhance their practical experience. Abstract A psychometric evaluation of the Beck Depression Inventory (BDI) was carried out on contemporary studies to ascertain its suitability for use in an alcohol-dependent population. Three criteria were used for this: factor analysis, test-retest reliability and internal consistency reliability. Factor analysis revealed that its structure is consistent with either two or three factor models, depending on the population. Test-retest results concluded that the correlation coefficient remained above the recommended threshold and internal consistency reliability highlighted alpha coefficient results consistently above suggested scores, leading to the conclusion that the BDI is probably an effective screening tool in an alcohol-dependent population.

Psychiatric disorders following traumatic brain injury: their nature and frequency

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 post-injury without reliance on history of psychiatric problems to predict who is at risk, so that appropriate intervention can be offered.

A clinical pathway including psychotherapy approaches for managing emotional difficulties after acquired brain injury

Emotional difficulties, such as anxiety and depression, are common after acquired brain injury in adults and can influence long-term outcome. Diagnosis in a brain injury context can be difficult. Ideally, rehabilitation approaches should consider the specific treatment of anxiety and depression as well and may include pharmacotherapy, individual psychotherapy, and family interventions. Psychotherapy, especially in regards to longer-term adjustment to brain injury, may have an important adjunctive role in treatment approaches, but adaptations of techniques may be needed. A clinical pathway is described which can help to raise clinicians awareness, as well as increase detection rates and consideration of the specific role of individual psychotherapy in this clinical population. However, an important caveat is that clinical pathways should not serve as a substitute, but rather a facilitator, for the process of reasoning about individual patients in everyday clinical practice.

Attention and depressive symptoms in chronic phase after traumatic brain injury

OBJECTIVE

To study whether attention deficits differ between TBI (traumatic brain injury) patients with and without depressive symptoms.

METHOD

The study group (n = 61, mean age = 59 years) consisted of symptomatic TBI patients injured on average 30 years earlier. They were studied with a broad range of attention tasks including computerized methods. The patients were divided into those with depressive symptoms (n = 32) and those without (n = 29), according to the short form of the Beck depression scale with a cut-off score of 5. In addition, a diagnosis of major depression was applied according to the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (n = 6). The groups with depression or depressive symptoms were compared with the non-depressed TBI patients and with an age- and education-matched healthy control group (n = 31).

RESULTS

Cognitive methods that require flexibility (Trail making B, Card sorting, Word fluency) and working memory (Subtraction test) were sensitive to discriminate TBI patients without depressive symptoms from the control subjects (p < 0.001). Only a few methods were able to discriminate the TBI patients with depressive symptoms from those without (p < 0.001 for Simple reaction time, p < 0.003 for Vigilance test). The depressed TBI patients (assessed by SCAN) did not differ from the non-depressed TBI patients in attention functions.

CONCLUSIONS

The results suggest that problems in complex attention processing are more specific to TBI, while slowness in simple psychomotor speed and impaired sustained attention may be mostly related to depressive symptoms in patients with chronic TBI sequelae.

Feedback of brain-imaging findings: Effect on impaired awareness and mood in acquired brain injury

PRIMARY OBJECTIVE

To investigate the utility of feedback of brain-imaging findings as an intervention for improving impaired awareness, depression and anxiety levels.

RESEARCH DESIGN AND METHODS

A prospective within-subjects repeated measures design was used with an intervention sample of 17 adults with acquired brain injury. Baseline and post-intervention measures included self-report and questionnaire-based self-awareness instruments and self-report questionnaires for depression and anxiety. Participants also completed a range of neuropsychological tests.

INTERVENTION

The intervention consisted of a session where a Consultant Neurologist explained the findings of brain scans in terms of pathological findings and possible neurobehavioural outcome.

RESULTS

Scores on measures of unawareness and two of three mood measures decreased significantly following the intervention. This improvement was maintained at 2-week follow-up.

CONCLUSION

Individuals with an acquired brain injury may benefit from a feedback procedure where the findings of brain scans are presented.

Use of the beck depression inventory-II (BDI-II) with persons with traumatic brain injury: Analysis of factorial structure

PRIMARY OBJECTIVE

To determine the factorial structure of the BDI-II in a TBI sample and possible predictor variables of depression following TBI.

RESEARCH DESIGN

Principle components analysis with orthogonal rotation and linear regression analyses.

METHODS AND PROCEDURES

Fifty-one individuals with traumatic brain injury (TBI) participated in this study. The factorial structure of the BDI-II, a 21-item self-report measure of depression, was examined with individuals in the early stages following TBI. Time since injury, severity of injury, location of lesion and previous substance abuse were examined as possible predictors of depression following TBI.

RESULTS

A three-factor structure of the BDI-II was found for the TBI sample, which included Negative Self-Evaluation, Symptoms of Depression and Vegetative Symptoms of Depression. Time since injury was the only significant predictor of depression following TBI.

CONCLUSION

Using the BDI-II, symptoms of depression after TBI fall into three key categories. With time since injury being the only significant predictor of depression following TBI, it appears that the depression could be more of a result of psychosocial factors than neurobiological factors. It was concluded that BDI-II can be useful in identifying symptoms of depression in the early stages following TBI.

Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury

OBJECTIVES

Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives.

DESIGN

This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI.

SETTING

This study was completed at a Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Participants were veterans eligible to receive VA health care services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV).

RESULTS

We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%).

CONCLUSIONS

Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.

An examination of the factor structure of the Beck Depression Inventory-II in a neurorehabilitation inpatient sample

The Beck Depression Inventory-II (BDI-II) is widely used for assessing depression in neurorehabilitation. Given the concern that the somatic items might be misleading, we examined its factor structure in 353 inpatients. Exploratory factor analysis was undertaken to compare two- to five-factor solutions. Confirmatory factor analysis was then used to test the best exploratory solutions for goodness of fit on a subsample. Both provided strong support for a general depression factor and two specific factors, one somatic and one cognitive/affective. The BDI-II provides a meaningful score of overall depression, and it can also yield two subscores-one measuring somatic symptoms and the other measuring psychological symptoms of depression. To avoid confusing the common symptoms of neurological disability with depression in neurorehabilitation, clinicians need to consider all three scores carefully. (JINS, 2009, 15, 142-147.).

A randomized trial of modafinil for the treatment of fatigue and excessive daytime sleepiness in individuals with chronic traumatic brain injury

BACKGROUND

This study examines the efficacy of modafinil in treating fatigue and excessive daytime sleepiness in individuals with traumatic brain injury (TBI).

METHODS

A single-center, double-blind, placebo-controlled cross-over trial, where 53 participants with TBI were randomly assigned to receive up to 400 mg of modafinil, or equal number of inactive placebo tablets. Main eligibility criteria were being at least 1 year post-TBI severe enough to require inpatient rehabilitation. The primary outcome measures were fatigue (Fatigue Severity Scale, FSS) and daytime sleepiness (Epworth Sleepiness Scale, ESS).

RESULTS

After adjusting for baseline scores and period effects, there were no statistically significant differences between improvements seen with modafinil and placebo in the FSS at week 4 (-0.5 +/- 1.88; P = .80) or week 10 (-1.4 +/- 2.75; P = .61). For ESS, average changes were significantly greater with modafinil than placebo at week 4 (-1.2 +/- 0.49; P = .02) but not at week 10 (-0.5 +/- 0.87; P = .56). Modafinil was safe and well tolerated, although insomnia was reported significantly more often with modafinil than placebo (P = .03).

CONCLUSIONS

While there were sporadic statistically significant differences identified, a clear beneficial pattern from modafinil was not seen at either week 4 or week 10 for any of the 12 outcomes. There was no consistent and persistent clinically significant difference between treatment with modafinil and placebo.

Expressive electronic journal writing: freedom of communication for survivors of acquired brain injury

In addition to the impaired ability to effectively communicate, adults with acquired brain injury (ABI) also experience high incidences of depression, social isolation, and decreased quality of life. Expressive writing programs have been shown to be effective in alleviating these concomitant impairments in other populations including incarcerated inmates (Lane, Writing as a road to self-discovery, F & W, Cincinnati 1993). In addition, computer applications such as email have been suggested as an effective means of improving communication and social isolation in adults with brain injury (Sohlberg et al. [2003]. Brain Injury, 17(7), 609-629). This investigation examines the effects of on-line expressive journal writing on the communication, emotional status, social integration and quality of life of individuals with brain injury.

The impact of motivation on neuropsychological performance in sports-related mild traumatic brain injury

The current project examined the impact of differential motivation on baseline versus post-mild traumatic brain injury (MTBI) neuropsychological measures in athletes. Collegiate athletes were administered a neuropsychological battery prior to and post-MTBI. High Motivation at Baseline (HMB) and Suspect Motivation at Baseline (SMB) groups were established for each measure based on whether baseline performance fell +/- one or more standard deviations from the mean of the given measure. Greater improvement was expected in the SMB group than the HMB group given hypothesized differences in baseline motivation. In repeated measures analysis of covariance (ANCOVA) that removed achievement performance, the SMB groups demonstrated greater improvement than the HMB groups for the Trail Making Test A & B (TMT-A & B), Digit Span, and Stroop-Color Word (Stroop-CW) tests. Also, the percentage of participants who improved according to reliable change indices was greater for the SMB groups on the TMT-A & B, Stroop-CW, and the Vigil. These findings are likely due to lower motivation in the SMB group for each test. However, results also suggest that some tests may be relatively unaffected by motivation. These data may have clinical implications and point to the need for better methods of identifying athletes with suspect motivation at baseline.

Ethical Issues Associated With the Assessment of Exaggeration, Poor Effort, and Malingering

The use of effort tests is standard practice in forensic neuropsychology. There is a tremendous amount of good information available in test manuals and the research literature regarding the proper and responsible use of these tests. However, it is clear that there are numerous ethical issues and considerations associated with the assessment of exaggeration, poor effort, and malingering. Many of these issues are discussed, and recommendations are provided.

Treatment of depression following traumatic brain injury

Depression is a common consequence of traumatic brain injury (TBI), and is a source of substantial distress and disability for persons with TBI and their families. This article offers a practical approach to the evaluation and treatment of this condition. Diagnostic and etiologic considerations relevant to this issue are reviewed first. Next, somatic therapies for posttraumatic depression, including antidepressant medications and electroconvulsive therapy, are discussed. Use of these therapies is also considered in the context of the common medical and neurological comorbidities among persons with TBI. Finally, psychosocial interventions relevant to the care of persons with posttraumatic depression are presented.

The Role of Self-Discrepancy Theory in Understanding Post–Traumatic Brain Injury Affective Disorders

This pilot study examined the utility of self-discrepancy theory (SDT) in explaining post-traumatic brain injury (TBI) depression and anxiety. The SDT model was expanded to include the discrepancy between the postinjury self and the preinjury self. Study participants were 21 individuals with mild to severe TBI residing in the community, who completed the Selves Interview, the Selves Adjective Checklist, the Beck Depression Inventory-II and the Beck Anxiety Inventory. Strong correlations were found between affective distress and self-discrepancies, as measured by the checklist. Scores on the interview were not related to affective distress. The findings suggest that further research is merited to examine the utility of the SDT in addressing issues of post-TBI depression and anxiety.

Symptom checklist-90 revised scores in persons with traumatic brain injury: affective reactions or neurobehavioral outcomes of the injury?

The goal of this study was to examine the concurrent validity of the Symptom Checklist-90 Revised (SCL-90-R) as a measure of emotional distress among persons with traumatic brain injuries (TBI). Following previous studies, the scale was divided into a "Brain Injury Subscale" (BIS), composed of items that are confounded with the neurobehavioral outcomes of TBI, and a "Non Brain Injury Subscale" (NBIS), composed of items unrelated to the neurobehavioral outcomes. The scores of 94 persons with TBI were analyzed on the two subscales. Although more frequently endorsed, the BIS items were equally related to the cognitive and behavioral outcomes of the injury and to the respondents' affective dispositions. The same pattern of correlations was evident with the NBIS items. In addition, both scales were predicted by measures of emotional reactions to the injury. These results were interpreted as supporting the validity of the SCL-90-R as a measure of emotional distress among persons with brain injuries.

The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients

OBJECTIVE

To examine the concurrent validity of the Beck Depression Inventory-Short Form (BDI-SF) to detect moderate and severe depressive episodes according to the International Classification of Diseases, 10th edition (ICD-10) criteria in inpatients with heterogeneous medical conditions and to set cut-off scores for its use in medical wards.

METHODS

One hundred and fifty-five patients [53% female; mean age (+/- S.D.) = 49.5 (+/- 17) years; mean number of years of education (+/- S.D.) = 6 (+/- 4) years] consecutively admitted to the adult medical wards in a General Hospital were interviewed during the first 72 h of hospitalization. The Clinical Interview Schedule [CIS] was used to make ICD-10 psychiatric diagnoses. All patients completed the BDI-SF. A "receiver operating characteristics" (ROC) curve was obtained and the sensitivity, specificity, positive and negative predictive values were calculated for different cut-off points of the BDI-SF.

RESULTS

High sensitivity and negative predictive value (NPV) were obtained with a cut-off score of 9/10 (sensitivity = 100%, specificity = 83.1%, NPV = 100%). High sensitivity and positive predictive value (PPV) were obtained with a cut-off score of 13/14 (sensitivity = 93.5%, specificity = 96%, PPV = 85.3%). The area under the ROC curve was 98.4% (95% Confidence Interval = 0.97-1.00).

CONCLUSIONS

The BDI-SF is a valid instrument for detecting moderate and severe depression in medical inpatients. For screening purposes, a 9/10 cut-off score is indicated, but if a high specificity is desired, a 13/14 cut-off score is warranted.