Risk factors for depressive symptoms after mild-to-moderate traumatic brain injury

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.

Prevalence and Correlates of Depressive Symptoms Within 6 Months After First-Time Mild Traumatic Brain Injury

OBJECTIVE

Depressive symptoms are among the most common neuropsychiatric sequelae of mild traumatic brain injury (mTBI). Very few studies have compared correlates of depressive symptoms within the first 6 months of injury in cohorts experiencing their first TBI. The authors investigated whether the correlates of depressive symptoms (being female, older, lower education, having brain lesions, experiencing worse postconcussive symptoms, and incomplete functional recovery) that have been established in populations with moderate to severe TBI were the same for individuals with first-time mTBI within the first 6 months of recovery.

METHODS

Two hundred seventeen individuals with first-time mTBI were divided into subgroups-new-onset depressive symptoms, recurrent depressive symptoms, prior depression history only, and never depressed-and compared on clinical and demographic variables and the presence of postconcussive symptoms and functional recovery at 3 and 6 months.

RESULTS

New-onset depressive symptoms developed in 12% of the cohort, whereas 11% of the cohort had recurrent depressive symptoms. Both depressive symptoms groups were more likely to comprise women and persons of color and were at higher risk for clinically significant postconcussive symptoms and incomplete functional recovery for the first 6 months postinjury.

CONCLUSIONS

Presence of depressive symptoms after first-time mTBI was associated with persistent postconcussive symptoms and incomplete functional recovery in the first 6 months. Adding to the existing literature, these findings identified correlates of depressive symptom development and poor outcomes after mTBI, thus providing further evidence that mTBI may produce persistent symptoms and functional limitations that warrant clinical attention.

Exploration of the Relationship Between Concussions and Depression Symptoms, Anxiety Symptoms, and Hazardous Drinking Among a Sample of College Students

Objective: In clinical and athlete populations, research has found that experiencing a concussion (or traumatic brain injury) is correlated with experiencing other psychiatric conditions, including depression and alcohol problems. However, less is known about concussion comorbidity in other population segments. The purpose of this study is to examine the relationships between concussions and depression symptoms, anxiety symptoms, and hazardous drinking among a large sample of college students (N = 1776) enrolled in a mandatory health course. Methods: This study used an online health survey to examine concussion frequency (informal and formal diagnoses), sports-related concussions, depression symptoms, anxiety symptoms, and hazardous drinking in the sample. Bivariate and multivariate analyses were conducted to examine comorbid relationships between concussion frequency and the dependent variables of interest (anxiety symptoms, depression symptoms, and hazardous drinking). Results: We found that 691 (39.1%) participants indicated having at least one concussion. Analyses indicated that concussion frequency scores of both formal or informal diagnoses were significantly associated with scores of depression symptoms, anxiety symptoms, and hazardous drinking. When examining concussion frequency scores of only formal diagnoses, only hazardous drinking evidenced a statistically significant relationship. In addition, participants who had a sports concussion had significantly higher concussion frequency scores and hazardous drinking scores than those who have had a concussion that was not sport-related. Conclusions: The comorbid concussion relationships found in this study are consistent with those observed in clinical and athlete populations. It is important for college health professionals to be aware that concussion comorbidity is not limited to the athlete population and can impact the entire student body.

Psychiatric mimics of neurosurgical disorders

Every year there are about 22.6 million people in need of neurosurgical care around the world, and one or several interventions are required to save lives and restore functional losses in more than half of these cases (13.8 million). Most neurosurgical interventions are performed in patients with traumatic brain and spinal cord injuries, strokes, central nervous system (CNS) tumors, hydrocephalus, and epilepsy. In addition to neurological symptoms, many CNS disorders are often accompanied by cognitive and/or behavioral changes. Physical and psychological symptoms can be intertwined as follows: 1) neurological symptoms may be manifested as a result of complex psychological processes; 2) psychological disorders may be manifested as neurological symptoms; 3) neurological disorders commonly cause secondary psychological responses; 4) psychological disorder may be induced more or less directly by an organic brain disease. In the present paper, we focus on the psychiatric conditions occurring in the patients with neurosurgical disorders who either get prepared for surgery or have already received it.

The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.

Perceived Injustice After Mild Traumatic Brain Injury

OBJECTIVE

To examine perceived injustice and its associations with self-reported symptoms and return to work at 3 months after injury in a prospectively recruited sample of patients with mild traumatic brain injury (mTBI).

DESIGN

Observational study.

SETTING

TBI outpatient unit.

PARTICIPANTS

Adult patients aged 18 to 68 years with mTBI (n = 100) or orthopedic injury ([OI]; n = 34).

MAIN MEASURES

The Injustice Experience Questionnaire (IEQ) and its associations with the Rivermead Post Concussion Questionnaire (RPQ), Beck Depression Inventory-Second Edition (BDI-II), PTSD Checklist-Civilian Version (PCL-C), and Pain Visual Analog Scale (PVAS). Information on injury-related characteristics, compensation seeking and litigation, and return-to-work status was also collected.

RESULTS

Median IEQ total score was 3 (range, 0-23) in the mTBI group and 2.5 (range, 0-25) in the OI group. In the mTBI group, IEQ was significantly correlated with RPQ (rs = 0.638, P < .01), BDI-II (rs = 0.612, P < .01), PCL-C (rs = 0.679, P < .01), and PVAS (rs = 0.232, P < .05). The association between IEQ and PCL-C (rs =0.797, P < .01) and BDI-II (rs = 0.395, P < .05) was also found in the OI group. In both groups, patients who were still on sick leave at 3 months after injury tended to report higher perceived injustice (IEQ total score) than patients who had returned to work or studies. However, this difference did not reach statistical significance.

CONCLUSIONS

Perceived injustice is associated with self-reported symptoms in patients with mTBI. Our results suggest that perceived injustice could be a relevant construct to consider in clinical management of patients with mTBI. Also, perceived injustice could be a potential target for psychological interventions promoting recovery after mTBI.

The Marcus Institute for Brain Health: an integrated practice unit for the care of traumatic brain injury in military veterans

PRIMARY OBJECTIVE

Traumatic brain injury (TBI) is a signature wound of recent Unites States military conflicts. The National Intrepid Center of Excellence (NICoE) has demonstrated that interdisciplinary care is effective for active-duty military personnel with TBI and related psychological health conditions. This paper details how the Marcus Institute for Brain Health (MIBH), established in 2017 as an Integrated Practice Unit (IPU), is founded on the NICoE model and is dedicated to interdisciplinary care for Veterans with persistent symptoms due to TBI and psychological comorbidities.

RESEARCH DESIGN

A highly integrated group of clinicians from diverse disciplines combine their expertise to offer comprehensive evaluation, intensive outpatient treatment, and program outcomes evaluation.

METHODS AND PROCEDURES

The role of each discipline in the provision of care, and the regular interaction of all clinicians, are delineated. A strong connection to academic medicine is maintained so that clinical research and education complement patient care.

MAIN OUTCOMES AND RESULTS

Over three hundred veterans and family members have received treatment at the MIBH. Program evaluation is underway.

CONCLUSIONS

As the understanding of TBI and related psychological conditions continues its rapid evolution, the expert interdisciplinary care at the MIBH has great promise as a Veteran counterpart of the NICoE.

Allostatic Load and Its Impact on Health: A Systematic Review

INTRODUCTION

Allostatic load refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity. When environmental challenges exceed the individual ability to cope, then allostatic overload ensues. Allostatic load is identified by the use of biomarkers and clinical criteria.

OBJECTIVE

To summarize the current knowledge on allostatic load and overload and its clinical implications based on a systematic review of the literature.

METHODS

PubMed, PsycINFO, Web of Science, and the Cochrane Library were searched from inception to December 2019. A manual search of the literature was also performed, and reference lists of the retrieved articles were examined.We considered only studies in which allostatic load or overload were adequately described and assessed in either clinical or non-clinical adult populations.

RESULTS

A total of 267 original investigations were included. They encompassed general population studies, as well as clinical studies on consequences of allostatic load/overload on both physical and mental health across a variety of settings.

CONCLUSIONS

The findings indicate that allostatic load and overload are associated with poorer health outcomes. Assessment of allostatic load provides support to the understanding of psychosocial determinants of health and lifestyle medicine. An integrated approach that includes both biological markers and clinimetric criteria is recommended.

Stress and the brain: Perceived stress mediates the impact of the superior frontal gyrus spontaneous activity on depressive symptoms in late adolescence

Identifying factors for the prediction of depression is a long-standing research topic in psychiatry and psychology. Perceived stress, which reflects the tendency to appraise one's life situations as stressful and overwhelming, has emerged as a stable predictor for depressive symptoms. However, the neurobiological bases of perceived stress and how perceived stress influences depressive symptoms in the healthy brain remain largely unknown. Here, we investigated these issues in 217 healthy adolescents by estimating the fractional amplitude of low-frequency fluctuations (fALFFs) via resting-state functional magnetic resonance imaging. A whole-brain correlation analysis showed that higher levels of perceived stress were associated with greater fALFF in the left superior frontal gyrus (SFG), which is a core brain region for cognitive control and emotion regulation-related processes. Mediation analysis further indicated that perceived stress mediated the link between the fALFF in the left SFG and depressive symptoms. Importantly, our results remained significant even when excluding the influences of head motion, anxiety, SFG gray matter structure, and school environment. Altogether, our findings suggested that the fALFF in the left SFG is a neurofunctional marker of perceived stress in adolescents and revealed a potential indirect effect of perceived stress on the association between the SFG spontaneous activity and depressive symptoms.

Do Exercisers With Musculoskeletal Injuries Report Symptoms of Depression and Stress?

CONTEXT

Sports injuries in athletes can lead to negative emotional responses in terms of anger, anxiety, confusion, and sadness. Severe injuries can be understood as a stressful life event with increased levels of psychological distress, but injury assessment and rehabilitation typically focus on somatic symptoms.

OBJECTIVE

The primary aim of this study was to estimate the prevalence of depression and emotional stress and to measure self-rated health in regular exercisers presenting to a sports medicine clinic with musculoskeletal injury. The secondary aim was to identify psychosocial factors associated with depression in injured exercisers and the potential need for psychological counseling.

DESIGN

A cross-sectional survey study.

SETTING

A sports medicine clinic for injuries of the foot, knee, or shoulder.

PARTICIPANTS

Regular exercisers with present injuries (N = 694) and exercisers without injuries (N = 494). Regular exercisers were defined as those undertaking moderate exercise at least once a week.

INTERVENTION

A questionnaire survey completed on paper by patients in a sports medicine clinic and a web-based version completed by online sports communities.

MAIN OUTCOME MEASURES

Participants completed the Major Depression Inventory, Perceived Stress Scale, health-related quality of life, and questions on sociodemographics, exercise habits, and injury history.

RESULTS

Symptoms of depression were reported by 12% of injured exercisers and 5% of noninjured controls (P < .001). Clinical stress was found in 30% of injured exercisers and 22% of controls (P = .002), and the EQ-5D-5L Visual Analog Scale score was lower for injured (69 [SD = 19]) than noninjured exercisers (87 [SD = 13], P < .001). Injured exercisers with symptoms of depression reported high stress levels and impaired daily functioning, were younger, and were more likely to have over 10 days injury-related work absence.

CONCLUSIONS

The authors recommend psychological assessment of exercisers attending a sports medicine clinic for musculoskeletal injury and a supplemental clinical psychological interview for suspected depression or stress-related psychopathology.

Mindfulness-Based Versus Health Promotion Group Therapy After Traumatic Brain Injury

The current pre- and posttest intervention study is designed for individuals with chronic symptoms and stress associated with mild-to-moderate traumatic brain injury (TBI). The researchers' intent was to evaluate whether an 8-week mindfulness-based group therapy compared to health promotion active control group therapy reduces chronic stress, TBI symptoms, and depressive symptoms. Significant mean reductions in chronic stress and TBI depressive and general symptoms for individuals in the mindfulness group compared to the active control group were present, according to paired t test analyses. Further, while controlling for baseline scores, the mindfulness-based intervention group change score was greater compared to the control group using regression analyses. Results suggest that mindfulness-based group intervention for individuals with chronic difficulties after TBI is feasible and effective. Further study of this cost-effective and self-management approach to stress and symptom management is warranted and has the potential to be a broad-based intervention for early therapy after injury. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 26-33.].

Prevention Strategies in Post-TBI Depression in Older Adults: A Case Study

PURPOSE

The purpose of this study was to describe a theoretically focused intervention aimed toward chronic stress and depressive symptom management that is coordinated by a case manager and delivered within a home environment by the caregiver.

PRIMARY PRACTICE SETTING

Home care, community setting.

METHODS

A case study of an older adult with traumatic brain injury (TBI) secondary to a fall who had significant allostatic load at the time of his injury. "Allostatic load" is a theoretical construct that suggests the brain is experiencing chronic strain on its systems that flexibly respond to stressors. Sustained allostatic load can contribute to chronic conditions and poor outcomes.

FINDINGS

Through actions with the family as caregivers, the case manager was able to coordinate a structured home setting and gradual resumption of social activities for this older adult. Focus was on establishing structure, meaningful social interactions, and positive home experiences that maximized the older adult's interests and capacity and mitigated chronic stress. Gradually, the older adult returned to his preinjury capacity and lives independently within the family home.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The case management process has the potential to mitigate stressors and improve depression management through family-focused care. Although there is limited guidance on prevention of depression, this approach resulted in attainment of safe home care, no hospital readmissions, and return to previous lifestyle for the older adult. This could be useful in the prevention of post-TBI depression.

Melatonin concentrations in serum of primary glaucoma patients

AIM

To determine whether glaucoma patients exhibit an abnormal melatonin concentration in serum and the effects of psychiatric disorders caused by glaucoma in melatonin secretion.

METHODS

A sample of 80 primary angle-closure glaucoma (PACG) patients, 120 primary open angle glaucoma (POAG) patients, and 120 normal controls were enrolled in this study. All the participants were asked to complete the following questionnaires: Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS), and self-rating depression scale (SDS). Variance analysis was used to compare the subscores between the groups. After that, we chose 58 patients with primary glaucoma and 20 non-glaucoma control patients to collect their serum samples at 7-10 a.m. Serum melatonin levels were measured using enzyme linked immunosorbent assay (ELISA).

RESULTS

Of all participants, the scores of PSQI, SAS, and SDS in PACG and POAG group were 9.38±0.40, 46.08±8.99, 51.11±10.72 and 7.43±0.35, 45.42±9.87, 49.04±12.24 respectively, significantly higher than those in control group (4.16±0.28, 35.49±9.18, 40.31±13.08). The serum melatonin levels in PACG (37.29±2.99 pg/mL) and POAG (35.97±3.64 pg/mL) were significantly higher than the controls (29.96±3.94 pg/mL) (P<0.001). But no difference was found between the PACG and POAG (P=0.216). Glaucoma patients with sleep disorders, anxiety and depression were more likely resulting in the increase of melatonin levels.

CONCLUSION

There is a significant increase in serum melatonin levels in glaucoma patients compared to the controls especially in glaucoma patients with psychiatric disorders such as sleep disorders, anxiety and depression.

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.

Negative impact of litigation procedures on patient outcomes four years after severe traumatic brain injury: results from the PariS-traumatic brain injury study

PURPOSE

To analyze the effect of litigation procedures on long-term outcomes in severe traumatic brain injury.

MATERIALS AND METHODS

Prospective observational follow-up of an inception cohort including 504 adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France, with initial, one- and four-year outcomes measures.

RESULTS

Four years after the traumatic brain injury, 147 patients, out of 257 who survived the acute phase, were assessed. Among these patients, 53 patients declared being litigants and 78 nonlitigants (litigation status was unknown in 16 cases). Sociodemographic characteristics, type of injury and initial severity did not differ significantly between litigants and nonlitigants, except for Injury Severity Score (worse in litigants) and the proportion of road traffic accidents (higher in litigants). One- and four-year outcomes were significantly worse in litigants for autonomy, participation, psychiatric and cognitive function but not quality of life (measured with the Glasgow Outcome Scale-Extended, the working activity status, the Brain Injury Community Rehabilitation Outcome, the Hospital Anxiety and Depression scale, the Neurobehavioral Rating Scale-revised and the Quality of Life after Brain Injury, respectively). Multivariate analyses highlighted litigation procedure as an independent significant predictor of lower autonomy, participation and psychiatric function and tended to predict lower cognitive function, but not lower quality of life, after adjustment for pretrauma characteristics, Injury Severity Score, road traffic accidents and work-related accident status.

CONCLUSIONS

Patients with severe traumatic brain injury have a worse prognosis when involved in a litigation procedure and require special attention in clinical practice. Implications for rehabilitation The influence of litigation procedure on health and social outcomes in severe traumatic brain injury is a major issue that entail numerous levels of complexities. A wide range of interactions and factors related to the prolonged process of litigation against a third party may influence recovery. Results from the PariS-Traumatic Brain Injury study suggest that patients with a severe Traumatic Brain Injury who are involved in a litigation procedure within French jurisdiction compensation scheme have a worse prognosis than patients who do not. Health professionals should be aware of the potential adverse effects of litigation procedures on recovery, and provide appropriate interventions and information to patients and families in such cases.

Gender Differences in the Longitudinal Association between Work-Related Injury and Depression

Little is known about gender differences in the association between occupational injury and depression. We investigated the bidirectional association and gender differences between work-related injury and depression using the same cohort in the US Medical Expenditure Panel Survey (MEPS). In Analysis 1, the association of occupational injury and subsequent depression was investigated from 35,155 employees without depression. Analysis 2 included 32,355 participants without previous injury and examined the association of depression and work-related injury. The multivariable-adjusted odds ratio was estimated using a discrete time-proportional odds model. Male workers who had experienced workplace injury were more vulnerable to post-injury depression than non-injured male workers (OR = 2.35, 95% CI: 1.52, 3.65). Female workers with depression were more prone to get injured at the workplace than the non-depressed female workers (OR = 1.44, 95% CI: 1.07, 1.96). These results did not hold in the reverse direction for both genders. Workers compensation benefit was positively associated with the risk of post-injury depression among males, whereas anti-depressant medication and duration of depression were related to workplace injury among females. Gender differences in the direction and associated factors of the relationship between occupational injury and depression highlight the need for gender-specific intervention to the vicious cycle of workplace injury and depression.

Depression Trajectories during the First Year after Traumatic Brain Injury

Major depression is prevalent after traumatic brain injury (TBI) and associated with poor outcomes. Little is known about the course of depression after TBI. Participants were 559 consecutively admitted patients with mild to severe TBI recruited from inpatient units at Harborview Medical Center, a Level I trauma center in Seattle, WA. Participants were assessed with the Patient Health Questionnaire-9 (PHQ-9) depression measure at months 1-6, 8, 10, and 12 post-injury. We used linear latent class growth mixture modeling (LCGMM) of PHQ-9 total scores to identify homogeneous subgroups with distinct longitudinal trajectories. A four-class LCGMM had good fit indices and clinical interpretability. Trajectory groups were: low depression (70.1%), delayed depression (13.2%), depression recovery (10.4%), and persistent depression (6.3%). Multinomial logistic regression analyses were used to distinguish trajectory classes based on baseline demographic, psychiatric history, and clinical variables. Relative to the low depression group, the other three groups were consistently more likely to have a pre-injury history of other mental health disorders or major depressive disorder, a positive toxicology screen for cocaine or amphetamines at the time of injury, and a history of alcohol dependence. They were less likely to be on Medicare versus commercial insurance. Trajectories based on LCGMM are an empirical and clinically meaningful way to characterize distinct courses of depression after TBI. When combined with baseline predictors, this line of research may improve our ability to predict prognosis and target groups who may benefit from treatment or secondary prevention efforts (e.g., proactive telephone counseling).

Personality Assessment Inventory profiles of veterans: Differential effects of mild traumatic brain injury and psychopathology

OBJECTIVE

Neuropsychiatric complaints often accompany mild traumatic brain injury (mTBI), a common condition in post-deployed Veterans. Self-report, multi-scale personality inventories may elucidate the pattern of psychiatric distress in this cohort. This study investigated valid Personality Assessment Inventory (PAI) profiles in post-deployed Veterans.

METHOD

Measures of psychopathology and mTBI were examined in a sample of 144 post-deployed Veterans divided into groups: healthy controls (n = 40), mTBI only (n = 31), any mental health diagnosis only (MH; n = 25), comorbid mTBI and Posttraumatic Stress Disorder (mTBI/PTSD; n = 23), and comorbid mTBI, PTSD, and other psychological diagnoses (mTBI/PTSD/MDD+; n = 25).

RESULTS

There were no significant differences between the mTBI and the control group on mean PAI subscale elevation, or number of subscale elevations above 60T or 70T. The other three groups had significantly higher overall mean scores, and more elevations above 60 and 70T compared to both controls and mTBI only. The mTBI/PTSD/MDD+ group showed the highest and most elevations. After entering demographics, PTSD, and number of other psychological diagnoses into hierarchical regressions using the entire sample, mTBI history did not predict mean PAI subscale score or number of elevations above 60T or 70T. PTSD was the only significant predictor. There were no interaction effects between mTBI and presence of PTSD, or between mTBI and total number of diagnoses.

CONCLUSIONS

This study suggests that mTBI alone is not uniquely related to psychiatric distress in Veterans, but that PTSD accounts for self-reported symptom distress.

Prevalence, natural course and predictors of depression 1 year following traumatic brain injury from a population-based study in New Zealand

OBJECTIVE

Depression is common post-TBI, yet has not been studied longitudinally, nor at a population level. This study examined prevalence of depression in a population-based sample across the first year post-TBI.

DESIGN AND METHODS

Prospective follow-up of 315 adults (>16 years) with assessments (Hospital Anxiety Depression Scale, DSM-IV criteria) at 1-, 6- and 12-months post-TBI. Demographic and injury-related predictors of depression at 1-year post-TBI were also explored.

RESULTS

The number of individuals identified as depressed reduced significantly between baseline and 12-months post-TBI from 21-12.4% using the HADS and 49-34% using DSM-IV criteria; with only 10 of the 28 individuals initially meeting criteria on the HADS continuing to do so at 12-month follow-up. Meeting HADS depression criteria was linked to pre-morbid depression and/or anxiety; while those meeting DSM-IV criteria were older, but not significantly so.

CONCLUSIONS

The findings suggest depression is common post-TBI and that clinicians/researchers use caution in its diagnosis, as existing criteria have significant overlap with common TBI sequels.

A longitudinal pilot study of depressive symptoms in concussed and injured/nonconcussed National Collegiate Athletic Association Division I student-athletes

CONTEXT

Depression, which affects millions of Americans each year, among them collegiate student-athletes, can be caused by a wide range of circumstances, including sport-related injuries.

OBJECTIVE

To longitudinally examine the extent to which National Collegiate Athletic Association Division I student-athletes demonstrated postinjury depressive symptoms.

DESIGN

Descriptive epidemiologic study.

SETTING

National Collegiate Athletic Association Division I collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

Concussed, injured/nonconcussed, and healthy Division I collegiate student-athletes (aged 18-22 years) competing in men's basketball, football, and wrestling and women's basketball, soccer, and volleyball.

MAIN OUTCOME MEASURE(S)

Participants completed the Center for Epidemiologic Studies Depression Scale at baseline and at 1 week, 1 month, and 3 months postinjury. We measured differences in depressive scores among concussed, injured/nonconcussed, and healthy participants. Longitudinal changes in postconcussion depressive symptoms were also examined.

RESULTS

No differences in baseline depressive symptoms among subgroups were noted. After an increase between baseline and 1 week (4.3, 95% confidence interval [CI] = 0.41, 8.16, P = .02), depressive symptoms in the concussion group decreased between 1 week and 1 month (-2.7, 95% CI = -4.96, -0.47, P = .01) and between 1 week and 3 months (-4.0, 95% CI = -6.50, -1.49, P = .004). The injured/nonconcussed group showed differences between baseline and 1 week (4.6, 95% CI = 1.08, 8.17, P = .009) and between baseline and 1 month (3.2, 95% CI = -0.05, 6.30, P = .03). No significant differences were present in depressive symptoms between concussed participants and injured/nonconcussed participants at any of the postinjury time points.

CONCLUSIONS

Depression may present as a postinjury sequela in Division I collegiate athletes. Athletes who sustain a concussion or other injury resulting in time lost from practice or competition need to be observed carefully for signs and symptoms that may indicate depression. Tools such as the Center for Epidemiologic Studies Depression Scale can be valuable in helping clinicians to recognize and manage depressive symptoms in these individuals.

Contribution of psychological trauma to outcomes after traumatic brain injury: assaults versus sporting injuries

Clinical research into outcomes after traumatic brain injury (TBI) frequently combines injuries that have been sustained through different causes (e.g., car accidents, assaults, and falls), the effect of which is not well understood. This study examined the contribution of injury-related psychological trauma—which is more commonly associated with specific types of injuries—to outcomes after nonpenetrating TBI in order to determine whether it may be having a differential effect in samples containing mixed injuries. Data from three groups that were prospectively recruited for two larger studies were compared: one that sustained a TBI as a result of physical assaults (i.e., psychologically traumatizing) and another as a result of sporting injuries (i.e., nonpsychologically traumatizing), as well as an orthopedic control group (OC). Psychosocial and emotional (postconcussion symptoms, injury-related stress, and depression), cognitive (memory, abstract reasoning, problem solving, and verbal fluency), and functional (general outcome; resumption of home, social, and work roles) outcomes were all assessed. The TBI(assault) group reported significantly poorer psychosocial and emotional outcomes and higher rates of litigation (criminal rather than civil) than both the TBI(sport) and OC groups approximately 6 months postinjury, but there were no differences in the cognitive or functional outcomes of the three groups. The findings suggest that the cause of a TBI may assist in explaining some of the differences in outcomes of people who have seemingly comparable injuries. Involvement in litigation and the cause of an injury may also be confounded, which may lead to the erroneous conclusion that litigants have poorer outcomes.

Mechanisms of extracellular signal-regulated kinase/cAMP response element-binding protein/brain-derived neurotrophic factor signal transduction pathway in depressive disorder

The extracellular signal-regulated kinase/cAMP response element-binding protein/brain-derived neurotrophic factor signal transduction pathway plays an important role in the mechanism of action of antidepressant drugs and has dominated recent studies on the pathogenesis of depression. In the present review we summarize the known roles of extracellular signal-regulated kinase, cAMP response element-binding protein and brain-derived neurotrophic factor in the pathogenesis of depression and in the mechanism of action of antidepressant medicines. The extracellular signal-regulated kinase/cAMP response element-binding protein/brain-derived neurotrophic factor pathway has potential to be used as a biological index to help diagnose depression, and as such it is considered as an important new target in the treatment of depression.

Exploring the experiences of people with the dual diagnosis of acquired brain injury and mental illness

PRIMARY OBJECTIVE

People with the dual diagnosis of acquired brain injury and mental illness (ABI/MI) are vulnerable to a range of negative life experiences, which has received limited attention in the literature. The objective of the project described in this paper was to identify and describe these experiences in order to distinguish barriers and facilitators to successful rehabilitation and recovery.

RESEARCH DESIGN

The project used qualitative methodologies.

METHODS AND PROCEDURES

The 15 participants were eight people with ABI/MI, two family members and five support workers. Nineteen interviews were conducted. Analysis of these interviews produced a set of five key themes, with each theme elaborated by a set of descriptive issues.

MAIN OUTCOMES AND RESULTS

The five themes were loss, personal development, occupation, family and services. The experiences of people with ABI/MI were strongly negative. They faced more barriers than facilitators to recovery. Current policies and practices were inadequate.

CONCLUSIONS

Enhanced stakeholder collaboration and co-ordination and a more individualized, long-term perspective on the needs of people with ABI/MI are recommended to guide future policy and practice. Future research on quality-of-life, wellbeing, community inclusion and participation in ordinary life was recommended.

The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury

AIM

To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.

METHOD

This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.

RESULTS

Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).

INTERPRETATION

HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.

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.

Depression as a psychosocial consequence of occupational injury in the US working population: findings from the medical expenditure panel survey

BACKGROUND

Empirical evidence describing the psychosocial consequences of occupational injury is still limited. The effect of occupational injury on depression might pose unique challenges in workers compared with other kinds of injury. This study aimed to assess the differential impact of workplace injury compared with non-workplace injury on depression over time, and to identify the potential risk factors associated with post-injury depression in the US working population.

METHODS

Using pooled panel data from the Medical Expenditure Panel Survey 2000-2006, a total of 35,155 workers aged 18-64 years who had been followed for about 18 months in each panel were analyzed. Injuries in the 4-5 months before baseline, and subsequent depression incidence during follow-up, were identified using ICD-9 codes for the medical conditions captured in personal interviews. A discrete time-proportional odds model was used.

RESULTS

A total of 5.5% of workers with occupational injury at baseline reported depression at follow-up, compared with 4.7% of workers with non-occupational injury and 3.1% of workers without injuries. Those with occupational injuries had more severe injuries and required longer treatment, compared with those with non-occupational injuries. Only 39% of workers with workplace injuries were paid Workers' Compensation (WC). The association between injury and depression appeared to be stronger for workplace injury, and the adjusted odds ratio for depression was 1.72 for those with occupational injury (95% CI: 1.27-2.32), and 1.36 for those with non-occupational injury (95% CI: 1.07-1.65) compared with the no-injury group, after controlling for relevant covariates. Occupational injury was associated with higher odds of developing depression over time. WC as a source of medical payment was associated with 33% higher odds of developing depression (95% CI: 1.01-1.74). Part-time work, shorter job tenure, and long working hours were independently associated with post-injury depression risk.

CONCLUSIONS

Workers with occupational injury were more likely to become depressed than those with non-occupational injury. The psychosocial consequences of occupational injury, including depression, deserve further exploration to adequately support those injured at work. This finding also emphasizes a need for early intervention to reduce the burden of depression associated with occupational injury.

Assessment of co-occurring disorders in veterans diagnosed with traumatic brain injury

AIMS

The co-occurrence of psychiatric disorders and other somatic disorders poses a significant challenge for the individual clinician working with veterans who report a history of mild traumatic brain injury (mTBI). In this article, common co-occurring symptoms and disorders will be described in relation to the population of veterans with mTBI, using a retrospective analysis of data from initial screening and secondary level evaluation for traumatic brain injury (TBI) in an urban Veteran's Affairs Medical Center.

PARTICIPANTS

Four hundred two veterans of the recent conflicts who received secondary level evaluation for TBI following positive TBI screening.

OUTCOMES

Significant differences were detected in symptom reporting between those who screened positive and those who screened negative on psychiatric screening. Those with positive posttraumatic stress disorder and depression screens endorsed more cognitive and affective symptoms; individuals screening positive for alcohol abuse did not report significantly more symptoms. Individuals without positive psychiatric screens reported fewer symptoms than those with positive screens. Consideration of these data in the context of a clinical case will be used to elucidate the challenge this presents to the clinical team.

CONCLUSION

The presence of co-occurring disorders should be considered in the etiology of a veteran's continued symptomatic complaints following TBI.

Chronic stress, somatic and depressive symptoms following mild to moderate traumatic brain injury

Despite advances in research on symptoms, stress, and depression after traumatic brain injury, there has been limited focus on the collective relationships between neurocognitive performance, chronic stress, and somatic and depressive symptoms. Guided by our adaptation of the allostatic load theory, we examined relationships between chronic stress, somatic and depressive symptoms, and cognitive performance using the Immediate Postconcussion Assessment and Cognitive Testing cognitive battery. Only somatic symptoms and chronic stress explained variation in depressive symptoms (R(2) = .71, P < .0001), not neurocognitive performance, preinjury, or injury-specific variables. Our findings suggest that increased chronic stress and somatic symptoms can contribute significantly to depressive symptoms after mild to moderate traumatic brain injury.

Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury

OBJECTIVE

To determine relationships among chronic stress, fatigue-related quality of life (QOL-F), and related covariates after mild to moderate traumatic brain injury (TBI).

DESIGN

Observational and cross-sectional.

PARTICIPANTS

A total of 84 community-dwelling individuals with mild to moderate TBI recruited from multiple out patient rehabilitation clinics assessed on average 15 months after injury.

METHOD

Self-report surveys and chart abstraction.

MEASURES

Neurofunctional Behavioral Inventory, Perceived Stress Scale-14, Impact of Events Scale, McGill Pain Short-form Scale, and modified version of the Fatigue Impact Scale.

RESULTS

QOL-F was associated with somatic symptoms, perceived situational stress, but not with event-related stress (posttraumatic stress disorder symptoms) related to index TBI, preinjury demographic, or postinjury characteristics. Somatic symptoms and chronic situational stress accounted for 42% of the variance in QOL-F.

CONCLUSIONS

QOL-F in community-dwelling individuals with mild to moderate TBI is associated with chronic situational stress and somatic symptoms. Symptom management strategies may need to include general stress management to reduce fatigue burden and improve quality of life.

Are self-reported symptoms of executive dysfunction associated with objective executive function performance following mild to moderate traumatic brain injury?

BACKGROUND AND OBJECTIVE

We examined the relationship between self-reported pre- and post-injury changes in executive dysfunction, apathy, disinhibition, and depression, and performance on neuropsychological tests of executive function, attention/processing speed, and memory in relation to mood levels and effort test performance in individuals in the early stages of recovery from mild to moderate traumatic brain injury (TBI).

METHOD

Participants were 71 noncombat military personnel who were in a semiacute stage of recovery (<3 months post injury) from mild to moderate TBI. Pre- and post-TBI behaviors were assessed with the Frontal Systems Behavior Scale (FrSBe; Grace & Malloy, 2001 ) and correlated with levels of depressive symptoms, effort test performance, and performance on objective measures of attention, executive function, and memory.

RESULTS

Self-reported symptoms of executive dysfunction generally failed to predict performance on objective measures of executive function and memory, although they predicted poorer performance on measures of attention/processing speed. Instead, higher levels of depressive symptomatology best predicted poorer performance on measures of executive function and memory. However, the relationship between memory performance and TBI symptoms was no longer significant when effort performance was controlled.

CONCLUSIONS

Our findings suggest that, among individuals in early recovery from mild to moderate TBI, self-reported depressive symptoms, rather than patients' cognitive complaints, are associated with objective executive function. However, self-reported cognitive complaints may be associated with objectively measured inattention and slow processing 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.

Empowerment of personal injury victims through the internet: design of a randomized controlled trial

BACKGROUND

Research has shown that current claims settlement process can have a negative impact on psychological and physical recovery of personal injury (PI) victims. One of the explanations for the negative impact on health is that the claims settlement process is a stressful experience and victims suffer from renewed victimization caused by the claims settlement process. PI victims can experience a lack of information, lack of involvement, lack of 'voice', and poor communication. We present the first study that aims to empower PI victims with respect to the negative impact of the claims settlement process by means of an internet intervention.

METHODS/DESIGN

The study is a two armed, randomized controlled trial (RCT), in which 170 PI victims are randomized to either the intervention or control group. The intervention group will get access to a website providing 1) an information module, so participants learn what is happening and what to expect during the claims settlement process, and 2) an e-coach module, so participants learn to cope with problems they experience during the claims settlement process. The control group will get access to a website with hyperlinks to commonly available information only. Participants will be recruited via a PI claims settlement office. Participants are included if they have been involved in a traffic accident which happened less than two years ago, and are at least 18 years old.The main study parameter is the increase of empowerment within the intervention group compared to the control group. Empowerment will be measured by the mastery scale and a self-efficacy scale. The secondary outcomes are perceived justice, burden, well being, work ability, knowledge, amount of damages, and lawyer-client communication. Data are collected at baseline (T0 measurement before randomization), at three months, six months, and twelve months after baseline. Analyses will be conducted according to the intention-to-treat principle.

DISCUSSION

This study evaluates the effectiveness of an internet intervention aimed at empowerment of PI victims. The results will give more insight into the impact of compensation proceedings on health over time, and they can have important consequences for legal claims settlement. Strengths and limitations of this study are discussed.

TRIAL REGISTRATION

Netherlands Trial Register NTR2360.

Depression among white and nonwhite caregivers of the chronically critically ill

PURPOSE

The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms.

MATERIALS AND METHODS

This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge.

RESULTS

Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race.

CONCLUSIONS

Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.

Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury

OBJECTIVE

To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes.

DESIGN

Systematic review.

METHODS

We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies.

RESULTS

One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder.

CONCLUSIONS

Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.

Subjective fatigue, mental effort, and attention deficits after severe traumatic brain injury

OBJECTIVE

Although fatigue is one of the most frequent complaints of individuals with traumatic brain injury (TBI), its mechanisms remain poorly understood. The objective of this study was to assess the relationships between subjective mental fatigue, mental effort, attention deficits, and mood after severe TBI.

METHODS

and participants. A total of 27 patients with subacute/chronic severe TBI were compared with matched controls. Patients first rated their baseline subjective fatigue on the Fatigue Severity Scale (FSS) and on the Visual Analog Scale for Fatigue (VAS-F). Mood was assessed with the Montgomery and Asberg Depression Rating Scale (MADRS). Then, they performed a long-duration selective attention task, separated in 2 parts. Fatigue on the VAS-F was assessed again between the 2 parts and at the end of the attention task. Patients were also asked to rate on the VAS the level of subjective mental effort devoted to the task.

RESULTS

Patients reported a higher baseline fatigue than controls. They performed significantly poorer on the selective attention task. Significant correlations were found in the group with TBI between attention performance, mental effort, and subjective fatigue. Depression did not significantly correlate with fatigue.

DISCUSSION AND CONCLUSIONS

These findings suggest that patients with more severe attention deficits have to produce higher levels of mental effort to manage a complex task, which may increase subjective fatigue, in line with the coping hypothesis.

Psychological and biological correlates of fatigue after mild-to-moderate traumatic brain injury

Relationships between chronic perceived stress, cortisol response (area under the curve) and posttraumatic brain injury fatigue were examined with persons from outpatient settings. Seventy-five injured persons with traumatic brain injury and their relatives/significant others participated in this cross-sectional study. Using interviews and self-reported data from the Neurofunctional Behavioral Inventory, the Perceived Stress Scale, the Profile of Mood States-Fatigue subscale, the McGill Pain Scale, as well as self-collection of salivary cortisol over a 12-hour period (N = 50), we found that perceived chronic stress explained 40% of the variance in fatigue until depressive symptoms and pain were in the model. Hypocortisolemia was evident. Somatic symptom frequency and perceived chronic stress represented 50% of the variability in post-TBI fatigue. Fatigue and stress management interventions, as suggested in the Centers for Disease Control Acute Concussion guidelines, may be beneficial in reducing this common symptom.

Functional Status, Chronic Stress, and Cortisol Response After Mild-to-Moderate Traumatic Brain Injury

It is well known that individuals experience difficulties with depressive symptoms and functional status after traumatic brain injury. However, it is unclear what the relationship is between these 2 phenomena and whether there is a biological explanation for. In this secondary analysis, we examined whether depressive symptoms explained postinjury functional status and whether chronic stress and salivary cortisol influenced this relationship. Participants included 75 persons within 24 months of their injury dates who were evaluated or treated in specialty clinics. All participants and a family member or significant other completed survey data, and 50 of the participants provided cortisol data. Results indicated that chronic stress, measured using Cohen's Perceived Stress Scale, completely mediated the relationship between depressive symptoms, measured using the Center for Epidemiological Studies Depression Scale, and psychological functioning, measured using the Patient Competency Rating Scale. Furthermore, those who provided cortisol data displayed hypocortisolemia in their 12-hr profile. Results from this analysis suggest that interventions focused on addressing the chronic stress experience may be important in limiting depressive symptoms and improving psychological functioning. Longitudinal study of this phenomenon is required to understand the progression of chronic stress after traumatic brain injury.