Longitudinal Trajectories of Post-Concussive Symptoms Following Mild Traumatic Brain Injury.

BACKGROUND: Individuals recovering from mild traumatic brain injury (TBI) represent a heterogenous population that requires distinct treatment approaches. Identification of recovery trajectories improves our ability to understand the natural history of mild TBI recovery and develop targeted interventions. OBJECTIVE: To utilize group-based trajectory modeling (GBTM) to identify distinct patterns of symptom recovery following mild TBI in the first 6 months after mild TBI. METHODS: This study is comprised of 253 adults who presented to the emergency department with mild TBI and completed assessments for six-months post-injury. Patients were recruited for the prospective observational cohort study, HeadSMART. The primary outcome measure was the Rivermead Postconcussion Symptom Questionnaire. GBTM was used to identify longitudinal trajectories of recovery following mild TBI using Rivermead scores at baseline, one, three, and six months following diagnosis. RESULTS: Findings identified four distinct trajectories of symptom recovery follwing mild TBI including 9% of participants who were categorized with minimal acute symptoms that decreased over time, 45% with mild acute symptoms that decreased over time, 33% with relatively higher acute symptoms that decreased over time, and 13% with relatively higher acute symptoms that increased over time. CONCLUSIONS: GBTM identified four distinct trajectories of recovery following mild TBI and GBTM may be useful for research interventions that can alter recovery trajectories.

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.

Treatment Patterns of Anxiety and Posttraumatic Stress Disorder Following Traumatic Brain Injury.

OBJECTIVE: Symptoms of mental disorders are common, are underrecognized, and contribute to worse outcomes after traumatic brain injury (TBI). Post-TBI, prevalence of anxiety disorders and prevalence of posttraumatic stress disorder (PTSD) are comparable with that of depression, but evidence-based treatment guidelines are lacking. The investigators examined psychotropic medication use and psychotherapy patterns among individuals diagnosed with anxiety disorders and PTSD post-TBI. METHODS: Administrative claims data were used to compare the prevalence and patterns of pharmacotherapy and psychotherapy utilization among individuals diagnosed with an anxiety disorder or PTSD post-TBI. RESULTS: Among 207,354 adults with TBI, prevalence of anxiety disorders was 20.5%, and prevalence of PTSD was 0.6% post-TBI. Receipt of pharmacotherapy pre- and post-TBI (anxiety: pre-TBI=58.4%, post-TBI=76.2%; PTSD: pre-TBI=53.7%, post-TBI=75.2%) was considerably more common than receipt of psychotherapy (anxiety: pre-TBI=5.8%, post-TBI=19.1%; PTSD: pre-TBI=11.2%, post-TBI=36.0%). Individuals diagnosed with anxiety were 66% less likely to receive psychotherapy compared with individuals diagnosed with PTSD, although engagement in psychotherapy decreased faster over time among those with PTSD. Overall, psychotropic medication use and rates of antidepressant prescription use in the anxiety group were higher compared with those in the PTSD group. Benzodiazepines were the second most commonly prescribed medication class in the anxiety group, even though judicious use is warranted post-TBI. CONCLUSIONS: Further exploration of differences and risks associated with pharmacotherapy for anxiety and PTSD post-TBI is warranted to refine treatment guidelines. The low level of psychotherapy engagement suggests that barriers and facilitators to psychotherapy utilization post-TBI should be examined in future studies.

A Prognostic Model for Predicting One-Month Outcomes among Emergency Department Patients with Mild Traumatic Brain Injury and a Presenting Glasgow Coma Scale of Fifteen.

The lack of well-performing prognostic models for early prognostication of outcomes remains a major barrier to improving the clinical care of patients with mild traumatic brain injury (mTBI). We aimed to derive a prognostic model for predicting incomplete recovery at 1-month in emergency department (ED) patients with mTBI and a presenting Glasgow Coma Scale (GCS) score of 15 who were enrolled in the HeadSMART (Head Injury Serum Markers for Assessing Response to Trauma) study. The derivation cohort included 355 participants with complete baseline (day-of-injury) and follow-up data. The primary outcome measure was the Glasgow Outcome Scale Extended (GOSE) at 1-month and incomplete recovery was defined as a GOSE <8. At 1-month post-injury, incomplete recovery was present in 58% (n = 205) of participants. The final multi-variable logistic regression model included six variables: age in years (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.97-1.00), positive head CT (OR = 4.42; 95% CI: 2.21-9.33), history of depression (OR = 2.59; 95% CI: 1.47-4.69), and self-report of moderate or severe headache (OR = 2.49; 95% CI: 1.49-4.18), difficulty concentrating (OR = 3.17; 95% CI: 1.53-7.04), and photophobia (OR = 4.17; 95% CI: 2.08-8.92) on the day-of-injury. The model was validated internally using bootstrap resampling (1000 resamples), which revealed a mean over-optimism value of 0.01 and an optimism-corrected area under the curve (AUC) of 0.79 (95% CI: 0.75-0.85). A prognostic model for predicting incomplete recovery among ED patients with mTBI and a presenting GCS of 15 using easily obtainable clinical and demographic variables has acceptable discriminative accuracy. External validation of this model is warranted.

Treatment of Depression after Traumatic Brain Injury Reduces Risk of Neuropsychiatric Outcomes.

The objectives of this study were to identify characteristics associated with receipt of antidepressants for treatment of incident depression diagnosed following traumatic brain injury (TBI) and to assess the impact of receipt of treatment for depression on risk of other neuropsychiatric outcomes associated with TBI. We conducted a retrospective cohort study of individuals with TBI who were subsequently diagnosed with incident depression between 2008 and 2014 using data from the OptumLabs® Data Warehouse. We identified factors associated with receipt of antidepressants and compared risk of new diagnosis of alcohol dependence disorder, anxiety, insomnia, and substance dependence disorder between those who received antidepressants and those who did not over a maximum 2-year follow-up, controlling for duration of use and clinical and demographic characteristics. Of 9581 individuals newly diagnosed with depression following TBI, 4103 (43%) received at least one antidepressant. Moderate-severe TBI (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.39, 1.50), female sex (OR 1.21; 95% CI: 1.19, 1.24), diagnosis of Alzheimer's disease (OR 1.39; 95% CI: 1.35, 1.44), and anxiety (OR 1.35; 95% CI: 1.31, 1.38) were associated with receipt of antidepressants. Longer duration of antidepressant use was associated with decreased risk of newly diagnosed anxiety (hazard ratio [HR] 0.92; 95% CI: 0.89, 0.96), insomnia (HR 0.94; 95% CI: 0.91, 0.98), and substance dependence disorder (HR 0.92; 95% CI: 0.88, 0.97). These results provide evidence of a beneficial effect of antidepressant use on incidence of outcomes associated with poorer recovery from TBI.

The Behavioral Neuroscience of Traumatic Brain Injury.

Traumatic brain injury is a calamity of various causes, pathologies, and extremely varied and often complex clinical presentations. Because of its predilection for brain systems underlying cognitive and complex behavioral operations, it may cause chronic and severe psychiatric illness that requires expert management. This is more so for the modern epidemic of athletic and military brain injuries which are dominated by psychiatric symptoms. Past medical, including psychiatric, history, and comorbidities are important and relevant for formulation and management. Traumatic brain injury is a model for other neuropsychiatric disorders and may serve as an incubator of new ideas for neurodegenerative disease.

Receipt of Treatment for Depression Following Traumatic Brain Injury.

OBJECTIVE: Lack of evidence for efficacy and safety of treatment and limited clinical guidance have increased potential for undertreatment of depression following traumatic brain injury (TBI). METHODS: We conducted a retrospective cohort study among individuals newly diagnosed with depression from 2008 to 2014 to assess the impact of TBI on receipt of treatment for incident depression using administrative claims data. We created inverse probability of treatment-weighted populations to evaluate the impact of TBI on time to receipt of antidepressants or psychotherapy following new depression diagnosis during 24 months post-TBI or matched index date (non-TBI cohort). RESULTS: Of 10 428 individuals with incident depression in the TBI cohort, 44.7% received 1 or more antidepressants and 20.0% received 1 or more psychotherapy visits. Of 10 463 in the non-TBI cohort, 41.2% received 1 or more antidepressants and 17.6% received 1 or more psychotherapy visits. TBI was associated with longer time to receipt of antidepressants compared with the non-TBI cohort (average 39.6 days longer than the average 126.2 days in the non-TBI cohort; 95% confidence interval [CI], 24.6-54.7). Longer time to psychotherapy was also observed among individuals with TBI at 6 months post-TBI (average 17.1 days longer than the average 47.9 days in the non-TBI cohort; 95% CI, 4.2-30.0), although this association was not significant at 12 and 24 months post-TBI. CONCLUSIONS: This study raises concerns about the management of depression following TBI.

Establishment of a Patient-Centered Outcomes Research Network for Individuals with TBI and Neuropsychiatric Symptoms.

Aims: The overarching goal of this project was to establish a group comprised of a variety of TBI stakeholders for the purpose of: (1) determining facilitators and barriers in management of neuropsychiatric symptoms after TBI; (2) identifying strategies for maintaining a TBI PCOR network; (3) enumerating research topics related to TBI neuropsychiatry; and (4) highlighting policy changes related to TBI neuropsychiatry.Methods: Twenty-nine TBI stakeholders participated in focus group discussions. Qualitative analyses were conducted both manually and using Dedoose software.Results: Participant-identified barriers included stigma associated with experiencing neuropsychiatric symptoms and poor insurance coverage. Facilitators included treatment focused on education of neuropsychiatric symptoms after TBI and having a comprehensive caregiver plan. Best strategies for maintaining TBI PCOR network included having a well-defined project, continued regular meetings, and on-going education of network members. Pertinent research topics included TBI and aging, factors influencing outcomes after TBI, substance use disorders related to TBI, and effectiveness of telemental health services. Needed policy changes included making TBI neuropsychiatry education accessible to stakeholders and improving accessibility of TBI neuropsychiatric care.Conclusion: TBI stakeholders identified several facilitators of care for neuropsychiatric symptoms after TBI and suggested research topics and best practices for conducting PCOR in this area.

Incidence of New Neuropsychiatric Disorder Diagnoses Following Traumatic Brain Injury.

BACKGROUND: Neuropsychiatric disturbances (NPDs) are common following traumatic brain injury (TBI) and associated with poor recovery. Prior estimates of NPD following TBI failed to account for preexisting NPDs or potential confounding. METHODS: We estimated the risk of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, and alcohol and substance dependence disorder diagnoses associated with TBI using administrative claims data from a large insurer in the United States, 2008-2014. We calculated rates of new NPD diagnoses during the 12 months before and 24 months after TBI and estimated the risk of NPD following TBI using a difference-in-difference approach and adjusting for confounders. RESULTS: Before the TBI occurred, rates of NPD diagnoses were more than double in the TBI cohort (n = 207 354) relative to the no-TBI cohort (n = 414 708). TBI was associated with an increased risk of anxiety (rate ratio [RtR] = 1.08; 95% confidence interval [CI], 1.05-1.12) and PTSD (RtR = 1.41; 95% CI, 1.24-1.60) diagnoses. Rates of alcohol (RtR = 0.32; 95% CI, 0.30-0.34) and substance use disorder (RtR = 0.57; 95% CI, 0.55-0.59) diagnoses decreased following TBI. CONCLUSIONS: In this large national study, rates of NPD were much higher among individuals with TBI than those in a non-TBI cohort, even before the TBI took place. TBI was associated with an increased risk of anxiety and PTSD diagnoses. Results from this study also suggest that individuals who sustain TBI have increased contact with the healthcare system during the months prior to injury, providing a window for intervention, especially for individuals diagnosed with alcohol dependence disorder.

A 33-Year-Old Man with Progressive Diffuse and Focal Neuropsychiatric Signs without Localizing Correlates on Brain Imaging: A Systematic Approach to Diagnosis.

Introduction: Novel expensive diagnostic tests are rapidly emerging. However, the answer to the most complex clinical presentations is often inferred from a systematic approach to the differential diagnosis. This is especially the case in neuropsychiatric disorders that present with a mix of neurologic and psychiatric symptoms. This case report fills a gap in the literature by providing a systematic differential diagnosis of such neuropsychiatric presentations associated with non-focal brain imaging. Case Presentation: A 33-year-old African-American man presented with confusion, weakness, and tremors. He initially noted memory problems and over the following six months progressively became confused, developed speech difficulties and left sided weakness and tremors. On exam, he was predominantly abulic but with intermittent and extreme mood lability. He lacked insight and his attention was poor. He had mild facial weakness and spastic hemiparesis with action tremors on the left side. Magnetic Resonance Imaging of the brain demonstrated non-specific diffuse parenchymal volume loss. His serum and cerebrospinal fluid studies were positive for Rapid Plasma Reagin and Veneral Disease Research Laboratory tests, respectively, suggesting a diagnosis of paretic neurosyphilis. Conclusion: This is a case of a young man with neurosyphilis who presented with progressive subacute cognitive decline, associated with focal neurological signs but no focal lesions on brain imaging. Neurosyphilis is often misdiagnosed on medicine, psychiatry, and neurology inpatient units. In this report, we present an approach to conceptualize similar cases and provide a differential diagnosis that will help reach an accurate diagnosis more efficiently. Further, it raises awareness regarding neurosyphilis, a devastating but easily treatable condition.

Loss of Consciousness and Altered Mental State as Predictors of Functional Recovery Within 6 Months Following Mild Traumatic Brain Injury.

OBJECTIVE: The authors tested the hypothesis that a combination of loss of consciousness (LOC) and altered mental state (AMS) predicts the highest risk of incomplete functional recovery within 6 months after mild traumatic brain injury (mTBI), compared with either condition alone, and that LOC alone is more strongly associated with incomplete recovery, compared with AMS alone. METHODS: Data were analyzed from 407 patients with mTBI from Head injury Serum Markers for Assessing Response to Trauma (HeadSMART), a prospective cohort study of TBI patients presenting to two urban emergency departments. Four patient subgroups were constructed based on information documented at the time of injury: neither LOC nor AMS, LOC only, AMS only, and both. Logistic regression models assessed LOC and AMS as predictors of functional recovery at 1, 3, and 6 months. RESULTS: A gradient of risk of incomplete functional recovery at 1, 3, and 6 months postinjury was noted, moving from neither LOC nor AMS, to LOC or AMS alone, to both. LOC was associated with incomplete functional recovery at 1 and 3 months (odds ratio=2.17, SE=0.46, p<0.001; and odds ratio=1.80, SE=0.40, p=0.008, respectively). AMS was associated with incomplete functional recovery at 1 month only (odds ratio=1.77, SE=0.37 p=0.007). No association was found between AMS and functional recovery in patients with no LOC. Neither LOC nor AMS was predictive of functional recovery at later times. CONCLUSIONS: These findings highlight the need to include symptom-focused clinical variables that pertain to the injury itself when assessing who might be at highest risk of incomplete functional recovery post-mTBI.

Age differences in outcome after mild traumatic brain injury: results from the HeadSMART study.

This study longitudinally examined age differences across multiple outcome domains in individuals diagnosed with acute mild traumatic brain injury (mTBI). A sample of 447 adults meeting VA/DoD criteria for mTBI was dichotomized by age into older (≥65 years; n = 88) and younger (<65 years; n = 359) sub-groups. All participants presented to the emergency department within 24 hours of sustaining a head injury, and outcomes were assessed at 1-, 3-, and 6-month intervals. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), post-concussive symptoms (PCS) were ascertained with the Rivermead Post-Concussion Questionnaire (RPQ), and functional recovery from the Extended Glasgow Outcome Scale (GOSE). Mixed effects logistic regression models showed that the rate of change over time in odds of functional improvement and symptom alleviation did not significantly differ between age groups (p = 0.200-0.088). Contrary to expectation, older adults showed equivalent outcome trajectories to younger persons across time. This is a compelling finding when viewed in light of the majority opinion that older adults are at risk for significantly worse outcomes. Future work is needed to identify the protective factors inherent to sub-groups of older individuals such as this.

Patterns of Psychotropic Medication Use among Individuals with Traumatic Brain Injury.

The relationship between psychotropic medication use and traumatic brain injury (TBI) is not well understood. The objective of this study was to describe patterns of psychotropic medication use during the months before and after TBI and compare with a non-TBI cohort. We conducted a retrospective cohort study using administrative claims data for a commercially insured population from 2008 to 2014, and assessed monthly prevalence of psychotropic medication use by class before and after TBI (or matched index in the non-TBI controls). We tested time trends and quantified rates of increase using autoregressive models, and determined whether TBI impacted psychotropic medication use using difference-in-difference models. Compared with those without TBI (n = 414,708), individuals with TBI (n = 207,354) were more likely to receive any psychotropic medication both before (36.9% vs. 19.5%, p < 0.001) and after TBI (48.2% vs. 25.7%, p < 0.001). Prior to TBI, the rate of monthly increase in use of psychotropic medications in the TBI cohort was three to four times the rate observed in the non-TBI cohort, and was highest for antidepressants in both cohorts. After accounting for between-group and time trends, TBI was associated with increased use of several psychotropic medications including antipsychotics (rate ratio [RR] 1.08; 95% confidence interval [CI] 1.07, 1.09) and anxiolytics (RR 1.05; 95% CI 1.04, 1.06). Patterns of psychotropic medication use differed significantly between individuals with and without TBI. These results suggest that a better understanding of events leading up to and following TBI is needed to elucidate the role psychotropic medications play in the natural history of TBI.

Low-Frequency Right Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression After Traumatic Brain Injury: A Randomized Sham-Controlled Pilot Study.

OBJECTIVE: Major depression is the most common psychiatric sequela of traumatic brain injury (TBI), but effective treatment continues to be a challenge, with few studies providing guidance. METHODS: In a pilot study, the authors evaluated the effect size of low-frequency right-sided (LFR) repetitive transcranial magnetic stimulation (rTMS), compared with sham treatment, over the right dorsolateral prefrontal cortex (DLPFC) in patients (N=30) with TBI depression and co-occurring neuropsychiatric symptoms, including suicidal thoughts, anxiety, posttraumatic stress disorder, sleep disturbance, behavioral problems, and cognitive dysfunction. Exploratory analyses of diffusion tensor imaging pre- and postintervention were performed to determine the effect size of LFR rTMS on white matter integrity. RESULTS: Small (Hedge's g=0.19) and highly variable effects of LRF rTMS over right DLPFC in TBI depression were observed. Similarly, the effect of LFR rTMS for treatment of comorbid neuropsychiatric symptoms varied from small to moderate. CONCLUSIONS: These findings suggest that the observed effects of LFR rTMS over the right DLPFC in TBI depression and co-occurring neuropsychiatric symptoms are small, at best, and, preliminarily, that low-frequency right DLPFC stimulation has limited potential in this patient population. However, studies employing different rTMS parameters (e.g., type, location, frequency, duration) or other participant characteristics (e.g., TBI severity, chronicity, comorbidity, concurrent treatment) may potentially yield different responses.

Loss of consciousness and altered mental state predicting depressive and post-concussive symptoms after mild traumatic brain injury.

Objective: Limited studies exist on the association between loss of consciousness (LOC) and altered mental state (AMS) and development of depressive and post-concussive symptoms within six months after mild traumatic brain injury (mTBI). We tested the hypothesis that presence of both LOC and AMS predict the highest risk of symptoms within the first six months post-mTBI compared to either variable alone, and that LOC alone is more strongly associated with these symptoms. Research design: We analyzed data from 407 subjects with mTBI from the Head injury Serum Markers for Assessing Response to Trauma (HeadSMART) cohort, a prospective cohort of patients post-TBI presenting to two urban emergency departments. Results: There were higher rates of depressive (44%) and post-concussive symptoms (54%) at 1 month post-injury, among participants with both LOC and AMS compared to other groups. AMS was associated with depressive symptoms at one and six months (OR = 1.59, p = .038; OR = 1.60; p = .060) and post-concussive symptoms at one month (OR = 1.56, p = .053). LOC was associated only with post-concussive symptoms at one month (OR = 1.55;p = .048). Among those without LOC, AMS was associated with depressive symptoms at one month (OR = 2.24; p = .028). Conclusions: AMS predicts post-mTBI depressive symptoms both in the acute and chronic mTBI phases whereas LOC is a more sensitive predictor of post-concussive symptoms in the acute mTBI period.

Risk of Depression after Traumatic Brain Injury in a Large National Sample.

Depression is associated with poorer recovery after traumatic brain injury (TBI), yet awareness of depression risk post-TBI among providers and patients is low. The aim of this study was to estimate risk of depression post-TBI among adults 18 years of age and older and to identify risk factors associated with developing depression post-TBI. We conducted a retrospective, matched cohort study using claims data for privately insured and Medicare Advantage enrollees in a large U.S. health plan. Adults ≥18 years of age diagnosed with TBI (n = 207,354) with 12 months continuous insurance coverage pre-TBI and 24 months post-TBI were matched to controls without TBI (n = 414,708). We identified the presence of depression on any in- or outpatient claim occurring during the study period (both before and after TBI). Of the initial 622,062 individuals, 62,963 (10%) had depression pre-TBI and were excluded from incidence calculations. Incidence of depression post-TBI was 79.5 (95% confidence interval [CI], 78.5,80.5) per 1,000 person-years compared to 33.5 (95% CI, 33.1,34.0) per 1,000 person-years for those without TBI. The adjusted hazard ratio for depression post-TBI was 1.83 (95% CI, 1.79,1.86). We observed effect modification by sex and age, with males and older adults at increased risk. History of neuropsychiatric disturbances pre-TBI was the strongest predictor of depression post-TBI. Risk of depression increases substantially post-TBI. Groups at increased risk include those with a history of neuropsychiatric disturbances, older adults, and men. This study highlights the importance of long-term monitoring for depression post-TBI.

Influence of study population definition on the effect of age on outcomes after blunt head trauma.

OBJECTIVES: The purpose of this study was to assess whether study population definition influences the effect of age on outcomes after blunt head trauma. We hypothesized that examining 'all comers' receiving head computerized tomography after blunt head trauma, fewer older individuals would meet Veterans Administration and Department of Defense (VA/DoD) criteria for traumatic brain injury (TBI), and would, therefore, display better outcomes than younger cohorts. However, restricting to participants meeting VA/DoD criteria for TBI, we hypothesized that older individuals would have worse outcomes. METHODS: Data from a recently completed prospective cohort study were analysed with age dichotomized at 65 years. Logistic regression modelling, controlled for potential confounders including head trauma severity, was estimated to measure the effect of age on functional recovery, post-concussion symptoms (PCS), and depressive symptoms at 1-month post-TBI. RESULTS: Fewer older than younger individuals met VA/DoD criteria for TBI. Older individuals had better functional, PCS, and depressive outcomes at 1 month. Restricting to those meeting VA/DoD criteria for TBI, older individuals continued to have better functional and PCS outcomes but had outcomes comparable to younger on depressive symptoms. CONCLUSIONS: Contrary to our hypothesis, there was a tendency for older adults to have better outcomes than younger, independent of the diagnostic criteria applied.

Safety of Antidepressant Classes Used Following Traumatic Brain Injury Among Medicare Beneficiaries: A Retrospective Cohort Study.

OBJECTIVE: There is poor evidence supporting the use of any pharmacologic treatments for neuropsychiatric disorders following traumatic brain injury (TBI), especially among older adults. Informed by our recent characterization of psychotropic medication use among Medicare beneficiaries with TBI, the objective of this study was to compare the risk of several adverse events associated with use of the three most commonly used classes of antidepressants following TBI in this population. METHODS: We conducted a retrospective cohort study using administrative claims data from US Medicare beneficiaries hospitalized with TBI between 2006 and 2010 (n = 30,886). We assessed monthly selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), and tricyclic antidepressant (TCA) use. We identified adverse events associated with these drug classes that were available in administrative claims data from studies in TBI and non-TBI populations: seizures, hemorrhagic stroke, ischemic stroke, gastrointestinal bleed, hyponatremia, and fractures. We made comparisons between antidepressant classes to assess excess risk of each adverse event using discrete time analysis and controlling for potential confounders. RESULTS: SSRIs were the most commonly used of the antidepressant classes, followed by SNRIs and TCAs. We observed a total of 23,021 adverse events. Ischemic stroke was the most frequent (8296 events). Hemorrhagic stroke (1706 events) and seizures (1841) were least often observed. Compared with TCAs, SSRI use was associated with an increased risk of hemorrhagic stroke (risk ratio 2.47; 95% confidence interval 1.30-4.70). No other antidepressant class comparisons were associated with increased risk of adverse events. CONCLUSION: Compared with SSRIs, use of SNRIs and TCAs following hospitalization for TBI among Medicare beneficiaries was not associated with an increased risk of any of the studied adverse events. Compared to TCAs, SSRI use was associated with increased risk of hemorrhagic stroke. This information may help guide patients and prescribers in selecting antidepressants for older adults following TBI.

Poor sleep is linked to impeded recovery from traumatic brain injury.

Study Objectives: While disruptions in sleep are common after mild traumatic brain injury (TBI), the longitudinal relationships between sleep problems and global functioning after injury are poorly understood. Here, we prospectively investigate risk for functional impairment during the first 6 months of TBI recovery based on sleep onset insomnia symptoms and short sleep. Methods: Patients presenting to the Emergency Department (ED) at Johns Hopkins Hospital within 24 hours of head injury and evaluated for TBI were eligible for our study. Demographic and injury-related information were collected in the ED. Patients then completed in-person surveys and phone interviews to provide follow-up data on global functioning, sleep, and depressive symptoms at 1, 3, and 6 months post-injury. A total of 238 patients provided sufficient data for analysis, and hypotheses were tested using mixed effects modeling. Results: Sleep quality and global functioning improved over the 6 months of TBI recovery, but patients were at increased risk for functional impairment when sleeping poorly (odds ratio [OR] = 7.69, p < .001). Sleep onset insomnia symptoms and short sleep both independently corresponded to poor global functioning. Functional impairment was highest among those with both insomnia and short sleep (43%-79%) compared to good sleepers (15%-25%) and those with short sleep (29%-33%) or insomnia alone (33%-64%). A bidirectional relationship between sleep quality and functioning was observed. Conclusions: Functionally impaired patients diagnosed predominantly with mild TBI exhibit high rates of insomnia and short sleep, which may impede TBI recovery. Monitoring sleep after head injury may identify patients with poor prognoses and allow for early intervention to improve functional outcomes.

Risk Factors for New-Onset Depression After First-Time Traumatic Brain Injury.

BACKGROUND: Major depression after traumatic brain injury (TBI) has devastating consequences as it increases the risk of suicide, impairs overall quality of life, and affects interpersonal, occupational, and social functioning. Although the literature has reported factors associated with depression after TBI, very few studies have examined the prevalence and correlates focused on the development of new-onset depression (NOD) after first-time TBI. Our study aimed to identify TBI- and non-TBI-related factors associated with the development of NOD in the first year after TBI. METHODS: A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for the development of NOD at 3, 6, and 12 months. RESULTS: Frontal lobe functioning, frontal lesions, and pre-TBI/early post-TBI social impairment were not found to be predictors of development of NOD within the first year after injury. Decreased post-TBI social functioning as perceived by the subject at 3, 6, and 12 months was found to be associated with NOD at each of these time points, respectively. CONCLUSION: The study findings highlight the importance of psychotherapeutic interventions to address the individuals' overall perception of their social impairment in the early-TBI period. This may help decrease the progression of major depression within the first year after injury.