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

The Role of Neuropsychology in Traumatic Brain Injury: Comprehensive Literature Review

Traumatic brain injury (TBI) is a major public health concern, often leading to significant behavioral and cognitive changes with subsequent impairment in daily functioning and personal interactions. The management of TBI involves a multidisciplinary approach. Neuropsychology has emerged as a critical discipline in assessing, diagnosing, treating, and rehabilitating individuals with TBI. Successful management also requires careful consideration of the patient's cognitive status. Therefore, clinicians must have a comprehensive understanding of the overall clinical picture of the patient at the cognitive and physical level. The primary aim of this research is to explore the role of neuropsychology in TBI management and rehabilitation thoroughly while providing an updated review of the literature. Various neuropsychological assessment tools used to evaluate cognitive functioning in individuals with TBI will be discussed in addition to their validity, reliability, and usefulness in identifying cognitive deficits and developing individualized treatment plans. The findings in this article will have significant implications on the clinical practice of neuropsychology in TBI patients, highlighting the importance of neuropsychological assessment in optimizing the management of this population. The need for increased awareness of neuropsychology among health care professionals, especially in the acute hospital setting, is growing along with the increase in diagnosis of TBI and its complications. Adequate understanding of the complex interplay between cognitive, emotional, and behavioral factors in TBI can inform the development of new interventions and treatment strategies, making it equally as important for patients and their families.

Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis

BACKGROUND

Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature.

METHODS

Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome.

RESULTS

Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT.

CONCLUSION

This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.

Utility of in-session assessments during cognitive behavioral therapy for depression after traumatic brain injury: Results from a randomized controlled trial

BACKGROUND

The development of depression after moderate to severe traumatic brain injury (TBI) is common. Cognitive-behavioral therapy (CBT) can be used to treat post-TBI depression, but the symptoms response is poorly described.

OBJECTIVE

This secondary analysis assessed: (1) the trajectory of depression symptoms up to 12 sessions of CBT, (2) which depressive symptom clusters were responsive to in-person and phone CBT, and (3) whether interim depression thresholds predict 16-week treatment response.

METHOD

This secondary analysis of the IRB-approved Life Improvement Following Traumatic Brain Injury trial included 100 adults with major depressive disorder (MDD) within ten years of moderate to severe traumatic brain injury from throughout the US. We used a combination of descriptive, graphical, and diagnostic accuracy methods.

RESULTS

Cardinal and cognitive-affective symptom clusters improved most from CBT over 16 weeks. At 8 and 16 weeks, the most responsive individual symptoms were anhedonia, depressed mood, and fatigue; the least responsive were sleep and appetite. PHQ-9 thresholds with a Negative Predictive Value greater than 0.7 for sessions 6, 7, and 8 were, respectively: >15, >10, and >9.

CONCLUSION

In-person and phone CBT led to similar symptom responses during treatment. Additionally, using PHQ-9 thresholds for predicting intervention response within eight sessions may help identify the need for treatment adjustments.

A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

Growth Hormone Deficiency following Traumatic Brain Injury in Pediatric and Adolescent Patients: Presentation, Treatment, and Challenges of Transitioning from Pediatric to Adult Services

Traumatic brain injury (TBI) is increasingly recognized, with an incidence of approximately 110 per 100,000 in pediatric populations and 618 per 100,000 in adolescent and adult populations. TBI often leads to cognitive, behavioral, and physical consequences, including endocrinopathies. Deficiencies in anterior pituitary hormones (e.g., adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropins, and growth hormone [GH]) can negatively impact health outcomes and quality of life post-TBI. This review focuses on GH deficiency (GHD), the most common post-TBI pituitary hormone deficiency. GHD is associated with abnormal body composition, lipid metabolism, bone mineral density, executive brain functions, behavior, and height outcomes in pediatric, adolescent, and transition-age patients. Despite its relatively frequent occurrence, post-TBI GHD has not been well studied in these patients; hence, diagnostic and treatment recommendations are limited. Here, we examine the occurrence and diagnosis of TBI, retrospectively analyze post-TBI hypopituitarism and GHD prevalence rates in pediatric and adolescent patients, and discuss appropriate GHD testing strategies and GH dosage recommendations for these patients. We place particular emphasis on the ways in which testing and dosage recommendations may change during the transition phase. We conclude with a review of the challenges faced by transition-age patients and how these may be addressed to improve access to adequate healthcare. Little information is currently available to help guide patients with TBI and GHD through the transition phase and there is a risk of interrupted care; therefore, a strength of this review is its emphasis on this critical period in a patient's healthcare journey.

The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders

We investigated the effectiveness of cognitive behavioural therapy (CBT) for patients with psychological disorders thought to be influencing recovery from elective and traumatic hand conditions. Demographic data and psychological assessment scores (Primary Health Questionnaire 9 (PHQ9), General Anxiety Disorder Assessment (GAD7), Impact of Event Scale (IES)) were prospectively collected before and after CBT treatment. One hundred and fourteen patients underwent CBT with 81 completing treatment. Full data was available for 78 (68%) patients. Mean age was 43 (range 13-84) and 63% were women. Sixty-one per cent had sustained a traumatic hand injury. PHQ9, GAD7 and IES scores decreased significantly following treatment. Many patients with hand conditions have associated psychological problems that may influence outcome. CBT in a hand unit setting appears to be an effective treatment. Further research with a control group should investigate whether CBT improves psychological health or if this may occur as patients recover from their physical hand disorder regardless of CBT.Level of evidence: IV.

Cognitive Behavioral Therapy Interventions for Adults With Traumatic Brain Injury (2013-2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions that address psychosocial, behavioral, and emotional skills for people with traumatic brain injury (TBI).

The Effectiveness of Supportive Psychotherapy on the Anxiety and Depression Experienced by Patients Receiving Fiberoptic Bronchoscope

Objectives

As the largest cohort of healthcare workers and nurses can practice as psychotherapists to integrate the psychotherapeutic interventions as part of routine care. The present study aims to evaluate the effectiveness of supportive psychotherapy (SPT) on patients who had been scheduled to undergo a fiberoptic bronchoscopy (FOB) procedure.

Methods

This study retrospectively analyzed 92 patients who underwent FOB, which was divided into the SPT group and usual-care group based on whether patients were given SPT interventions or not. The Patient Health Questionnaire-9 (PHQ-9) and Hospital Anxiety and Depression Scale (HADS) were used to determine the severity of depression and anxiety, as well as the 36-Item Short-Form Health Survey questionnaire (SF-36) to evaluate the health-related quality of life (HRQoL). Moreover, the patients' satisfaction was assessed based on the Likert 5-Point Scale.

Results

The baseline status of anxiety, depression, and HRQoL in patients was similar in the SPT group and the usual-care group with no significant difference. Both PHQ-9 score and HADS-D score in the SPT group after intervention were lower than that in the usual-care group, accompanied by the deceased HADS-A subscale. Moreover, the improved HRQoL was found in the patients undergoing FOB after SPT interventions as compared to those receiving conventional nursing care using the SF-36 score. Additionally, the patient satisfaction in the SPT group was higher than in the usual-care group.

Conclusions

The study demonstrated that anxiety and depression, as negative emotions, can be reduced by supportive psychotherapy in patients receiving FOB with improved mental health and satisfaction with nursing care.

A systematic review on integrated care for traumatic brain injury, mental health, and substance use

Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU.

Trial registration: Prospero Registration: CRD42018108343.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review

BACKGROUND

Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.

OBJECTIVE

There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.

METHOD

Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.

RESULTS

A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.

CONCLUSIONS

This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

Efficacy of Cognitive Training When Translated From the Laboratory to the Real World

INTRODUCTION

Research shows that cognitive performance and emotional well-being can be significantly strengthened. A high-performance brain training protocol, Strategic Memory Advanced Reasoning Training (SMART), was developed by cognitive neuroscientists at The University of Texas at Dallas Center for BrainHealth based on 25-plus years of scientific study. Randomized controlled trials with various populations have shown that training and use of nine "SMART" strategies for processing information can improve cognitive performance and psychological health. However, the multi-week intensive training used in the laboratory is not practical for widespread use outside the laboratory. This article examines the efficacy of SMART when translated outside the laboratory to two populations (military/veterans and law enforcement) that received SMART in condensed time frames.

MATERIALS AND METHODS

In two translation studies with healthy military personnel and veterans, 425 participants received between 6 and 10 hours of SMART over 2 days. In a third translation study, 74 healthy police officers received 9 hours of SMART over 3 days. Training was conducted by clinicians who taught the nine "SMART" strategies related to three core areas-strategic attention, integrated reasoning, and innovation-to groups of up to 25 participants. In all three translation studies, cognitive performance and psychological health data were collected before and immediately following the training. In one of the military/veteran studies, psychological health data were also collected 1 and 4 months following the training.

RESULTS

In both translations to military personnel and veterans, there were improvements in the complex cognitive domains of integrated reasoning (P < .0001) and innovation (P < .0001) immediately after undergoing SMART. In the translation to police officers, there were improvements in the cognitive domains of innovation (P = .02) and strategic attention (P = .005). Participants in all three translations saw statistically significant improvements in self-reported symptoms of psychological health. The improvements continued among a subset of participants who responded to the later requests for information.

CONCLUSIONS

The results of translating to these two populations provide evidence supporting the efficacy of SMART delivered in an abbreviated time frame. The improvements in two major domains of cognitive function demonstrate that strategies can be taught and immediately applied by those receiving the training. The immediate psychological health improvements may be transient; however, the continued improvements in psychological health observed in a subset of the participants suggest that benefits may be sustainable even at later intervals.

Therapeutic benefits of pharmacologic and nonpharmacologic treatments for depressive symptoms after traumatic brain injury: a systematic review and network meta-analysis

BACKGROUND

Depression is a common morbidity after traumatic brain injury. This network meta-analysis investigated the efficacy and tolerability of pharmacologic and nonpharmacologic interventions for depression after traumatic brain injury.

METHODS

We extracted randomized controlled trials examining pharmacologic or nonpharmacologic interventions with placebo- or active-controlled designs from PubMed, the Cochrane Library and ScienceDirect, from inception to October 30, 2018. We based study selection and extraction of a predefined list of variables on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, and conducted meta-analysis procedures using random effects modelling. Primary outcomes were changes in depressive symptom severity after pharmacologic or nonpharmacologic treatment; the secondary outcome was tolerability, reflected in overall patient dropout rates.

RESULTS

Our analysis of 27 randomized controlled trials (10 pharmacologic, total n = 483, mean age = 37.9 yr; 17 nonpharmacologic, total n = 1083, mean age = 38.0 yr) showed that methylphenidate had significantly superior efficacy compared to placebo or control (standardized mean difference -0.91, 95% confidence interval [CI] -1.49 to -0.33). Sertraline was associated with significantly lower tolerability (i.e., a higher dropout rate) compared to placebo or control (odds ratio 2.65, 95% CI 1.27 to 5.54). No nonpharmacologic treatment was more effective than the others, and we found no significant differences in tolerability (i.e., dropout rates) among the nonpharmacologic treatments.

LIMITATIONS

Heterogeneity in participant characteristics (e.g., comorbidities), study designs (e.g., trial duration) and psychopathology assessment tools, as well as small trial numbers for some treatment arms, could have been confounders.

CONCLUSION

The present network meta-analysis suggests that methylphenidate might be the best pharmacologic intervention for depressive symptoms related to traumatic brain injury. None of the nonpharmacologic interventions was associated with better improvement in depressive symptoms than the others or than control conditions. None of the pharmacologic or nonpharmacologic treatments had inferior tolerability compared to placebo or controls except for sertraline, which had significantly lower tolerability than placebo.

Hemispheric stroke: Mood disorders

Stroke causes many forms of disability, including emotional and mood disorders. Depression is the most common of these, affecting approximately one-third of stroke patients. Other disorders like mania, bipolar disorder, anxiety disorder, or apathy may also develop following stroke, although they are less common. The development of mood and emotional disorders is dependent on the severity of brain injury, the side of injury, and hemispheric location. Whereas a left hemispheric stroke often results in depression or a catastrophic reaction with anxiety, injury to the right hemisphere has predominantly been associated with the development of emotional indifference (anosodiaphoria) or euphoria. In this chapter, we discuss the mood disorders associated with hemispheric strokes and the neuropsychological mechanisms that might account for the clinical manifestations of these affective disorders.

Psychotherapy and Art Therapy: A pilot study of group treatment for patients with traumatic brain injury

Here we investigated the efficacy of group Psychotherapy and Art Therapy in rebuilding self-identity after traumatic brain injury (TBI), assessing their effects on psychological aspects in twelve patients with severe TBI. Overall, the results show an increased ability to adapt to the experiences of life as well as a higher level of awareness, social functioning and emotional autoregulation. Furthermore, patients exhibited a reduction in depressive symptoms and in the perception of physical problems. Results highlight the importance of treatments focusing on the patients' emotional needs, in addition to the classic rehabilitation (i.e. physiotherapy, cognitive therapy).

Effect of an in-home, family-inclusive rehabilitation programme on depressive symptoms in veterans with traumatic brain injury and its mediation by activity engagement

Background/Aims

Depression, the most common psychiatric sequela of traumatic brain injury in both civilians and veterans, produces serious and wide-ranging problems. Although medication and cognitive behavioural therapy are the most common treatments, some rehabilitation approaches designed to enhance functioning and/or community reintegration may decrease depression by facilitating active engagement in life – the key component of some depression therapies. The present secondary analysis of a community reintegration-focused rehabilitation programme for veterans with traumatic brain injury posed two questions: Did the programme affect depressive symptoms? If so, was this effect mediated by engagement in activities?

Methods

A secondary analysis was undertaken of an intervention study of 83 former members of the United States Armed Forces (veterans) with traumatic brain injury, who were interviewed in their homes. Depressive symptoms were assessed using the short-form Centre for Epidemiological Studies-Depression Scale, activity engagement using an 8-item subscale derived from the Community Reintegration of Injured Service Members Scale, and physical and emotional functioning using the SF-36V. Sociodemographic, medical and military characteristics were elicited during the first interview, and medical and military characteristics were identified through a medical chart review.

Results

Depressive symptoms significantly decreased among the veterans in the treatment group. That effect was mediated by activity engagement. Thus, the intervention's impact on depressive symptoms was attributable to the increased activity that it produced.

Conclusions

Research on rehabilitation that enhances engagement in activities should examine its possible benefits for improving mood.

The management of depression following traumatic brain injury: A systematic review with meta-analysis

BACKGROUND

Traumatic brain injury (TBI) is prevalent. Declining mortality has led to increasing survivors with chronic sequalae, including depression. With a lack of guidelines, this review aims to provide a comprehensive, evidence-based summary of the management of depression following TBI.

METHODS

Systematic searches were conducted for quasi-experimental and randomized controlled trials (RCTs) assessing pharmacotherapy, psychological interventions, and transcranial magnetic stimulation (TMS). Databases searched CENTRAL, Medline, Embase, CINAHL, PsycINFO, Web of Science, and ProQuest dissertations. Data extraction and risk-of-bias tools were used. Where possible, outcomes were combined into meta-analyses.

RESULTS

2719 studies were identified. After abstract screening and full-text reading, 34 remained. Prophylactic sertraline significantly reduced the odds of depression (OR (odds ratio) = 0.31 [95%CI (confidence interval) = 0.12 to 0.82]). Meta-analysis of RCT's showed TMS to have the greatest reduction in depression severity (SMD (Standardized-Mean-Difference) = 2.43 [95%CI = 1.24 to 3.61]). Stimulants were the only treatment superior to control (SMD = -1.03 [95%CI = - 1.6 to -0.47]).

CONCLUSION

Methylphenidate was the most effective pharmacotherapy. Sertraline appears effective for prevention. The efficacy of psychological interventions is unclear. TMS as a combination therapy appears promising. Heterogeneity of study populations and dearth of evidence means results should be interpreted cautiously.

A Multi-Site Study of Traumatic Brain Injury in Mexico and Colombia: Longitudinal Mediational and Cross-Lagged Models of Family Dynamics, Coping, and Health-Related Quality of Life

Latin America has high rates of traumatic brain injury (TBI), yet reduced mental and physical health outcomes due to limited rehabilitation services. To understand the psychosocial adjustment process in TBI patients in Latin America, the incorporation of cultural values including family-based variables is imperative. The current study examined relations among healthy family dynamics, coping, and mental and physical health related quality of life (HRQL) among a sample of TBI patients across three sites and two countries over the first 4 months post-injury. A sample of 109 acute TBI patients from Mexico and Colombia were recruited, and a series of longitudinal mediation and cross-lag panel analyses were run. Mental and physical HRQL were positively associated with each other, as well as healthy family dynamics and coping. Coping partially mediated the effects of healthy family dynamics on both mental and physical HRQL. Family dynamics showed the strongest cross-lag relationships with coping going from 2 months to 4 months. Similarly, coping showed the strongest cross-lag relationships with both mental and physical HRQL going from baseline to 2 months. Results provide empirical support for the importance of a rehabilitation workforce that has been trained in and can effectively implement family-based interventions for individuals with TBI in Latin America.

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.

A randomized controlled trial of acceptance and commitment therapy for psychological distress among persons with traumatic brain injury

Psychological distress is common in persons with traumatic brain injury (TBI) but treatments remain underdeveloped. This randomized controlled trial of Acceptance and Commitment Therapy (ACT) was designed to address this gap. Ninety-three persons with medically-documented complicated mild to severe TBI, normal-to-mildly impaired memory, and clinically significant psychological distress in the chronic phase of recovery were randomized to receive eight weeks of ACT (manualized with adaptations to address TBI-related cognitive impairments) or a single session of needs assessment, brief counseling/education, and referral. The ACT group showed significantly greater reduction of psychological distress (Brief Symptom Inventory 18) and demonstrated improvements in psychological flexibility and commitment to action (Acceptance and Action Questionnaire-II (AAQ-II) scores). The number of treatment responders (post-treatment BSI 18 GSI T scores <63) was larger in the ACT group than in the control group. Entry of AAQ-II scores into the model of between-group differences in BSI 18 GSI T scores indicated that core ACT processes explained the variance in treatment group outcomes. Provision of ACT reduces psychological distress in persons with TBI in the chronic phase of recovery when adaptations are made to accommodate TBI-related cognitive impairments. Additional clinical trials with a structurally equivalent control group are needed.

Improving well-being after traumatic brain injury through volunteering: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a novel intervention facilitating volunteer activity to improve well-being in individuals with traumatic brain injury (TBI).

DESIGN

Randomized two-arm controlled trial, with a wait-list control condition (ClinicalTrials.gov NCT#01728350).

SETTING

Community-based setting.

PARTICIPANTS

Seventy-four community-dwelling individuals at least 1-year post TBI, who had completed inpatient or outpatient TBI rehabilitation.

INTERVENTIONS

A novel intervention, HOPE - Helping Others through Purpose and Engagement, involving orientation/training and a 3-month volunteer placement for the participant, along with training for community agencies regarding TBI.

MAIN OUTCOME MEASURE(S

): Satisfaction With Life Scale (SWLS); Flourishing Scale (FS); Brief Symptom Inventory-18 (BSI-18); Scale of Positive and Negative Experience (SPANE); Purpose in Life subscale (one of six in the Ryff Scale of Psychological Well-Being - 54 item version).

RESULTS

There were significantly greater improvements in life satisfaction (SWLS) and self-perceived success (FS) in the intervention group compared to the control group. There were no significant treatment effects on the additional secondary measures of well-being, although they trended in a positive direction.

CONCLUSIONS

This study supports our primary hypothesis that individuals who take part in a volunteer intervention will demonstrate greater psychological well-being in comparison to a control group.

Predictors of Anxiety and Depression Symptom Improvement in CBT Adapted for Traumatic Brain Injury: Pre/Post-Injury and Therapy Process Factors

OBJECTIVES

The current study examined the association of demographic/preinjury, injury-related, and cognitive behavior therapy (CBT) process variables, with anxiety and depression symptom change in traumatic brain injury (TBI)-adapted CBT (CBT-ABI).

METHODS

The audio recordings of 177 CBT-ABI sessions representing 31 therapist-client dyads were assessed from the independent observer perspective on measures of working alliance, homework engagement, and therapist competency in using homework.

RESULTS

Linear regressions showed that older client age, longer post-TBI recovery period, better executive functioning, higher levels of client homework engagement, as well as higher levels of therapist competence in reviewing homework were associated with greater improvement in anxiety and/or depression symptoms.

CONCLUSIONS

CBT-ABI is a promising treatment for post-TBI depression and anxiety. The current study highlights how therapists can enhance CBT-ABI effectiveness, specifically: comprehensive facilitation of client homework engagement with emphasis on homework review, and accommodation of executive deficits. The current study also suggests that the role of client age and the length of post-TBI recovery period require further investigation.

The BrainACT study: acceptance and commitment therapy for depressive and anxiety symptoms following acquired brain injury: study protocol for a randomized controlled trial

BACKGROUND

Following an acquired brain injury, individuals frequently experience anxiety and/or depressive symptoms. However, current treatments for these symptoms are not very effective. A promising treatment is acceptance and commitment therapy (ACT), which is a third-wave behavioural therapy. The primary goal of this therapy is not to reduce symptoms, but to improve psychological flexibility and general well-being, which may be accompanied by a reduction in symptom severity. The aim of this study is to investigate the effectiveness of an adapted ACT intervention (BrainACT) in people with acquired brain injury who experience anxiety and/or depressive symptoms.

METHODS

The study is a multicenter, randomized, controlled, two-arm parallel trial. In total, 94 patients who survive a stroke or traumatic brain injury will be randomized into an ACT or control (i.e. psycho-education and relaxation) intervention. The primary outcome measures are the Hospital Anxiety and Depression Scale and the Depression Anxiety Stress Scale. Outcomes will be assessed by trained assessors, blinded to treatment condition, pre-treatment, during treatment, post-treatment, and at 7 and 12 months.

DISCUSSION

This study will contribute to the existing knowledge on how to treat psychological distress following acquired brain injury. If effective, BrainACT could be implemented in clinical practice and potentially help a large number of patients with acquired brain injury.

TRIAL REGISTRATION

Dutch Trial Register, NL691, NTR 7111. Registered on 26 March 2018. https://www.trialregister.nl/trial/6916.

Psychological Intervention in Traumatic Brain Injury Patients

Objective

To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury.

Methods

A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables.

Results

The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%).

Conclusions

CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.

Employment Status Among U.S. Military Veterans With Traumatic Brain Injury: Mediation Analyses and the Goal of Tertiary Prevention

For most individuals with traumatic brain injury (TBI), the ability to work is crucial to financial and psychological well-being. TBI produces a wide range of cognitive, physical, emotional, and interpersonal impairments that may undermine the ability to work. Employment is therefore a primary goal of TBI rehabilitation and has been the focus of extensive research. Although this literature has identified predictors of employment outcomes, few studies have examined the mechanisms that underlie these associations. Mediation analysis can identify these mechanisms, provide a more nuanced view of how predictors jointly affect rehabilitation outcomes, and identify predictors that, if treatable conditions, could be useful targets for tertiary prevention. Such efforts are aimed at reducing long-term impairments, disability, or suffering resulting from the injury. The study sample comprised 83 U.S. military veterans with TBI who had participated in a larger rehabilitation study and were interviewed in their homes. Bivariate tests revealed significant associations of employment with pain, cognitive functioning, self-rated health, depressive symptoms and physical functioning; the latter variable was operationalized in two ways—using the Patient Competency Rating Scale and the SF–36V physical functioning subscales. Because these physical functioning measures were highly intercorrelated (r = 0.69, p < 0.0001), separate regression models were conducted. In the hierarchical binary logistic regression models, predictors were entered in order of modifiability, with comorbidities (pain) entered in block 1, physical health/functioning sequelae in block 2, and depressive symptoms in block 3. In the regression using the SF-36V measure of physical functioning, pain's effect was mediated by the physical functioning/health predictors, with only physical functioning emerging as significant, but this effect was itself mediated by depressive symptoms. In the regression using the PCRS physical-function measure, only depressive symptoms emerged as a mediator of other effects. Findings underscore the central role of depression in the employment status of veterans with TBI, suggesting that negative effects of other problems/limitations could be mitigated by more effective treatment of depression. Thus, for many with chronic TBI who live with vocational limitations, outcomes may improve with lower depression. Findings argue for the wider use of mediation approaches in TBI research as a means of identifying targets for tertiary prevention of poor outcomes.

The Relations of Cognitive, Behavioral, and Physical Activity Variables to Depression Severity in Traumatic Brain Injury: Reanalysis of Data From a Randomized Controlled Trial

OBJECTIVE

To explore the relations of cognitive, behavioral, and physical activity variables to depression severity among people with traumatic brain injury (TBI) undergoing a depression treatment trial.

SETTING

Community.

PARTICIPANTS

Adults (N = 88) who sustained complicated mild to severe TBI within the past 10 years, met criteria for major depressive disorder, and completed study measures.

DESIGN

Randomized controlled trial.

METHODS

Participants were randomized to cognitive-behavioral therapy (n = 58) or usual care (n = 42). Outcomes were measured at baseline and 16 weeks. We combined the groups and used regressions to explore the relations among theoretical variables and depression outcomes.

MAIN MEASURES

Depression severity was measured with the Hamilton Depression Rating Scale and Symptom Checklist-20. Theory-based measures were the Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ), Environmental Rewards Observation Scale (EROS), and the International Physical Activity Questionnaire (IPAQ).

RESULTS

Compared with non-TBI norms, baseline DAS and ATQ scores were high and EROS and IPAQ scores were low. All outcomes improved from baseline to 16 weeks except the DAS. The ATQ was an independent predictor of baseline depression. An increase in EROS scores was correlated with decreased depression.

CONCLUSIONS

Increasing participation in meaningful roles and pleasant activities may be a promising approach to treating depression after TBI.

Neural correlates of reduced depressive symptoms following cognitive training for chronic traumatic brain injury

Depression is the most frequent comorbid psychiatric condition among individuals with traumatic brain injury (TBI). Yet, little is known about changes in the brain associated with reduced depressive symptoms following rehabilitation for TBI. We identified whether cognitive training alleviates comorbid depressive symptoms in chronic TBI (>6 months post-injury) as a secondary effect. Further, we elucidated neural correlates of alleviated depressive symptoms following cognitive training. A total of seventy-nine individuals with chronic TBI (53 depressed and 26 non-depressed individuals, measured using the Beck Depressive Inventory [BDI]), underwent either strategy- or information-based cognitive training in a small group for 8 weeks. We measured psychological functioning scores, cortical thickness, and resting-state functional connectivity (rsFC) for these individuals before training, immediately post-training, and 3 months post-training. After confirming that changes in BDI scores were independent of training group affiliation, we identified that the depressive-symptoms group showed reductions in BDI scores over time relative to the non-depressed TBI controls (p < .01). Within the depressive-symptoms group, reduced BDI scores was associated with improvements in scores for post-traumatic stress disorder, TBI symptom awareness, and functional status (p < .00625), increases in cortical thickness in four regions within the right prefrontal cortex (p_vertex  < .01, p_cluster <.05), and decreases in rsFC with each of these four prefrontal regions (p_vertex  < .01, p_cluster  < .0125). Overall, these findings suggest that cognitive training can reduce depressive symptoms in TBI even when the training does not directly target psychiatric symptoms. Importantly, cortical thickness and brain connectivity may offer promising neuroimaging markers of training-induced improvement in mental health status in TBI.

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

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

What are the complications and emerging strategies for preventing depression following traumatic brain injury?

INTRODUCTION

Depression is a common and disabling complication of traumatic brain injury (TBI). The high rates of post-TBI depression (PTBID) make this condition an important candidate for selective preventive interventions. Areas covered: The authors recently reported on the efficacy of sertraline, a selective serotonin reuptake inhibitor (SSRI), for the prevention of new cases of depression in the first six months after TBI. The authors review this and other studies on preventive strategies in PTBID as ascertained from a PubMed and citation search. The potential complications and barriers to the implementation of pharmacological prevention in patients with TBI are also discussed. Expert commentary: The prevention of depression in patients with TBI has received little attention relative to other medical conditions. Future studies are needed to confirm the benefit of SSRIs and investigate other pharmacological and non-pharmacological interventions, including in special groups of patients at greater risk of developing PTBID.

Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury

BACKGROUND

Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response.

METHOD

A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups.

RESULTS

Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) -2.07 to -0.06] and depression on the Depression Anxiety and Stress Scale (95% CI -5.61 to -0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04-3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT.

CONCLUSIONS

Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.

Longitudinal sex and stress hormone profiles among reproductive age and post-menopausal women after severe TBI: A case series analysis

PRIMARY OBJECTIVES

To describe hormone profiles for pre-/post-menopausal women, to monitor time to resumption of menstruation among pre-menopausal women and to describe cortisol associated LH suppression and phasic variation in other sex hormones over timeMethods and procedures: This study determined amenorrhea duration and characterized acute (days 0-7) and chronic (months 1-6) gonadotropins [luteinizing hormone and follicle stimulating hormone (LH, FSH)], sex hormones (progesterone, estradiol) and stress hormone (cortisol) profiles. Women were pre-menopausal (n = 3) or post-menopausal (n = 3). Among pre-menopausal women, menstrual cycle resolution and phase association (luteal/follicular) was monitored using self-report monthly reproductive history questionnaires. This study compared post-TBI hormone profiles, stratified by menopausal status, to hormone levels from seven controls and described 6- and 12-month outcomes for these women.

MAIN OUTCOMES AND RESULTS

Consistent with functional hypothalamic amenorrhea (FHA), menstruation resumption among pre-menopausal women occurred when serum cortisol normalized to luteal phase control levels. For post-menopausal women, serum cortisol reductions corresponded with resolution of suppressed LH levels.

CONCLUSIONS

The stress of TBI results in anovulation and central hypothalamic-pituitary-ovarian (HPG) axis suppression. Future work will examine acute/chronic consequences of post-TBI hypercortisolemia and associated HPG suppression, the temporal association of HPG suppression with other neuroendocrine adaptations and how HPG suppression impacts multidimensional recovery for women with TBI.

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.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.