Traumatic brain injuries (TBIs) are caused by physical force or trauma to the head which may be the result of sports injuries, motor accidents, falls, explosives, or violence.[1] Common symptoms of TBI can range from headaches to seizures, as well as the loss of consciousness for hours at a stretch. A TBI can be classified as mild, moderate, or severe using the Glasgow Coma Scale (GCS), on the basis of the level of consciousness of a patient immediately following an injury.[2] Although a mild TBI may not show up on a CT (computed tomography) scan or on an MRI (magnetic resonance imaging) scan, we can still, fortunately, diagnose mild TBI due to the advancements in diagnostic tools. For instance, Diffusion Tensor Imaging detects damage to white matter in the brain, hence allowing the detection of subtle changes in the brain structure which could otherwise go unnoticed.
Although a brain injury is recognised as having a high likelihood of leading to cases of mortality, its significant role in the development of psychiatric disorders such as depression is often overlooked.[3] Follow-up care is essential for patients to manage symptoms of mental illness that may have developed as a result of physical injury; especially with head injuries being one of the most common causes of death in people aged 1-40 years old the UK. Post-injury changes in mood, personality or behaviour are often expected; however, the development of depressive disorders is not a certainty after sustaining a TBI.
A common assumption made is that once a mild traumatic brain injury (mTBI) has physically healed, the patient is 'back to normal'. This, however, fails to consider the psychological impact that the mTBI has had on the individual, which can last much longer. After suffering from a TBI, approximately 1 in 5 patients experience symptoms of mental illness.[4] The Centre for Mental Health found that 1.3 million people continue to live with the physiological and psychological effects of brain injury, costing the UK economy £15 billion annually due to the expenses of social care, and medical treatments.[5] One of the more common psychiatric disorders following a TBI is Major depressive disorder (MDD). As defined by the American Psychiatric Association, depression is “a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and, or a loss of interest in activities once enjoyed.”[6]
Physical changes in the brain, emotional changes due to brain injury, and a genetic predisposition to depression are some of the possible factors that can contribute to depression after a TBI.[7] It is important to note that up to 56% of individuals can suffer from symptoms of depression from up to ten weeks post-injury[8], and that there is a higher risk of developing depression in 20-30 years following the brain injury.[9] Although TBIs are not the definitive cause of the incidence of depression in patients, a cluster of similar symptoms among this demographic suggests that the injury could have been the trigger which leads to depression.
Nonetheless, can TBI-associated depression be prevented? A study by Jorge et al. on the use of Sertraline for TBI-associated depression offers hope for prevention.[10] Sertraline is an antidepressant that increases the levels of Serotonin (a mood-enhancing chemical) in the brain. At the Baylor College of Medicine, a double-blind clinical trial was conducted on 94 patients, who suffered from mild to severe TBIs. They were either given a placebo or Sertraline. Both the participants and researchers were unaware of which ‘drug’ they received. The study found that Sertraline appeared to be effective in preventing the onset of depression following a TBI. It is important to note that there have been contradictory findings from different trials, and this study must be replicated using a larger, more representative sample of patients to ensure the real efficacy of the drug. Sertraline, being a selective serotonin reuptake inhibitor (SSRIs), targets the imbalance of serotonin; however, it is only one of many drugs used to treat depression. There are many other types of drug treatments, including norepinephrine reuptake inhibitors, dopamine reuptake blocker and tetracyclic antidepressants.
Alternative treatments include a psychotherapeutic approach, which consists of the use of cognitive-behavioural therapy (CBT) to help people alter their maladaptive thoughts, thus influencing how they think and behave. Physical activity is also used in conjunction to treat depression. During exercise, endorphins are released, which then releases proteins called growth factors which allow neurons to grow and form new connections among them in the hippocampus. This improves brain function and helps us feel better emotionally. [11]
Following the popular sentiment that prevention is better than a cure, it is crucial to understand what we can do to prevent the psychological symptoms following TBI. The first rather obvious measure is reducing the chances of sustaining trauma to your head. While easier said than done, contact sports such as boxing and rugby will inevitably result in some physical injury. Wearing adequate protection and not ignoring the signs of injury are vital for prevention. It is also crucial to remember to consult a doctor to prevent the development of potential long-term complications, even after feeling physically well after sustaining a brain trauma. The brain is a delicate organ; thus, even a seemingly minor injury can have long-lasting effects.
Links to support those living with a brain injury:
[1] [2] Harvard Medical School. (2014). Mild Traumatic Brain Injury. Retrieved from Psychiatry Neuroimaging Laboratory.
[3] Lawrence T, Helmy A, Bouamra O, et alTraumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortalityBMJ Open 2016;6:e012197. doi: 10.1136/bmjopen-2016-012197
[4] Stein MB et al. (2019). Posttraumatic stress disorder and major depression after civilian mild traumatic brain injury: A TRACK-TBI study. JAMA Psychiatry.
[5] Barber, D., Woodhouse, J., Powell, T., Long, R., Beard, J., Kennedy, S., . . . Sutherland, N. (2019). Acquired brain injury. House of Commons Library.
[6] Parekh, R., MD. (2017). What Is Depression? Retrieved August 22, 2020, from https://www.psychiatry.org/patients-families/depression/what-is-depression
[7] Fann, J., Hart, T., & Schomer, K. (2009). Treatment for Depression after Traumatic Brain Injury: A Systematic Review. Journal of Neurotrauma, 26(12). doi:https://doi.org/10.1089/neu.2009.1091
[8] Singh, R., Mason, S., Lecky, F., & Dawson, J. (2017). Prevalence of depression after TBI in a prospective cohort: The SHEFBIT study. Brain Injury, 84-90.
[9] Jones, M., & Jorge, R. E. (2019, April 24). Depression Following TBI Can It Be Prevented?
[10] Jorge, R. E., Acion, L., & Burin, D. I. (2016). Sertraline for Preventing Mood Disorders Following Traumatic Brain Injury: A Randomized Clinical Trial. JAMA Psychiatry, 73(10), 1041–1047. doi:10.1001/jamapsychiatry.2016.2189
[11] Harvard Health Publishing. (2019, March 25). Exercise is an all-natural treatment to fight depression. Harvard Health. https://www.health.harvard.edu/mind-and-mood/exercise-is-an-all-natural-treatment-to-fight-depression
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