Sertraline for Major Depression During the Year Following Traumatic Brain Injury: A Randomized Controlled Trial

Is Sertraline a Good Pharmacological Strategy to Control Anger? Results of a Systematic Review

Introduction: Extensive research has made it possible to conclude that dysfunctions in serotoninergic transmission are associated with a tendency toward violence and behavioral dysregulations in humans. In this regard, it has been suggested that selective serotonin reuptake inhibitors (SSRIs), such as sertraline, which regulate the serotonin system, might reduce proneness to violence. Aims: This review aims to explore changes in feelings of anger-state (e.g., irritability and hostility) and anger expression as primary outcomes after sertraline treatment. Methods: Based on PRISMA quality criteria for reviews, a literature search was carried out through PubMed, PsycINFO, Dialnet, Psicodoc, Web of Knowledge, and the Cochrane Library. Results: Initially, 605 publications were identified, removing 219 duplicate manuscripts and screening the titles and abstracts of the remaining 386 records. This process left 248 articles for full-text reading, finally including 15 entries. Thus, several empirical studies were included that employed different research designs. In this regard, we considered 3 case reports, 5 open clinical trials, and 7 randomized placebo-controlled trials. The majority of the studies were unanimous in concluding that a large percentage of patients with high irritability levels responded satisfactorily to sertraline treatment. In fact, their mood improved, and they experienced a reduction in irritability and anger expression after a few weeks of treatment (approximately two weeks). However, it was necessary to increase the sertraline dose after months of treatment to avoid exhaustion effects. Moreover, not all the patients responded to the treatment and it is particularly interesting that a small percentage of patients were refractory to treatment or even showed an increase in irritability after a few weeks of treatment. In those cases, it was necessary to discontinue the treatment or reduce the dose to the initial levels. Discussion: Although it is necessary to be cautious about the benefits of sertraline as a way to control anger and irritability, it is relevant to consider pharmacological strategies to reduce anger-state as coadjutant treatments to psychotherapy in order to promote lasting changes in violent populations.

Efficacy of sertraline in post-traumatic brain injury (post-TBI) depression and quality of life: A systematic review and meta-analysis of randomized controlled trials

The relative paucity of robust studies on pharmacological treatments for depression following traumatic brain injury precludes establishment of firm recommendations for its routine use in this population. The purpose of this study is to determine the efficacy and tolerability of sertraline in the treatment of post-TBI depression and improvement in quality of life. Randomized controlled trials (RCT) were identified by electronic search through PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Literatura Latino-Americana e do Caribe em Ciencas da Saude), Cochrane Library, Clinicaltrials.gov, and HERDIN (Health Research and Development Information Network database). Random effects meta-analysis of data for depression scale scores, treatment response, and quality of life scale scores was conducted. Four RCTs were included with a total of 224 patients. There were no significant mean differences in the Hamilton Depression Rating Scale (HAM-D17) scores (MD = 2.63, 95% CI [-1.32,6.57], p = 0.19), Maier subscale scores (MD = 0.88, 95% CI [-2.26, 4.01], p = 0.58), odds ratio of treatment response (OR = 1.04, 95% CI [0.13, 8.43], p = 0.97) and quality of life scale scores (SMD = -1.52, 95% CI [-5.65, 2.61], p = 0.47) between sertraline and placebo. The pooled evidence from four RCTs shows that sertraline is not superior to placebo in terms of improving depression and quality of life of patients with post-TBI depression. There is also insufficient evidence regarding its safety in this subset of patients.

Repetitive Transcranial Magnetic Stimulation with Resting-State Network Targeting for Treatment-Resistant Depression in Traumatic Brain Injury: A Randomized, Controlled, Double-Blinded Pilot Study

Repetitive transcranial magnetic stimulation (rTMS) has demonstrated antidepressant efficacy but has limited evidence in depression associated with traumatic brain injury (TBI). Here, we investigate the use of rTMS targeted with individualized resting-state network mapping (RSNM) of dorsal attention network (DAN) and default mode network (DMN) in subjects with treatment-resistant depression associated with concussive or moderate TBI. The planned sample size was 50 with first interim analysis planned at 20, but only 15 were enrolled before the study was terminated for logistical reasons. Subjects were randomized to 20 sessions of bilateral rTMS (4000 left-sided excitatory pulses, 1000 right-sided inhibitory pulses) or sham. Treatment was targeted to the dorsolateral prefrontal cluster with maximal difference between DAN and DMN correlations based on resting-state functional magnetic resonance imaging with individualized RSNM. Mean improvement in the primary outcome, Montgomery-Asberg Depression Rating Scale (MADRS), was 56% ± 14% (n = 9) with active treatment and 27% ± 25% (n = 5) with sham (Cohen's d = 1.43). One subject randomized to sham withdrew before starting treatment. There were no seizures or other significant adverse events. MADRS improvement was inversely correlated with functional connectivity between the right-sided stimulation site and the subgenual anterior cingulate cortex (sgACC; r = -0.68, 95% confidence interval 0.03-0.925). Active treatment led to increased sgACC-DMN connectivity (d = 1.55) and increased sgACC anti-correlation with the left- and right-sided stimulation sites (d = -1.26 and -0.69, respectively). This pilot study provides evidence that RSNM-targeted rTMS is feasible in TBI patients with depression. Given the dearth of existing evidence-based treatments for depression in this patient population, these preliminarily encouraging results indicate that larger controlled trials are warranted.

Serotonin 5-HT1A receptors modulate depression-related symptoms following mild traumatic brain injury in male adult mice

Traumatic brain injury is a complex phenomenon leading to neurological diseases and persistent disability that currently affects millions of people worldwide. Increasing evidence shows that a wide range of patients with mild traumatic brain injury (mTBI) suffer from depression during the initial stages of injury and the post-acute stages of recovery. However, the underlying mechanisms involved in depression following mTBI are still not fully understood. The aim of this study was to determine whether serotonin 5-hydroxytryptamine-1A (5-HT1A) receptor is involved in the regulation of depression-related behaviors following mild traumatic brain injury in mice. Mice with or without mTBI received intracerebroventricular injections of 5-HT1A receptor agonist (8-OH-DPAT) or antagonist (WAY-100635) for 5 days, then animals were subjected to behavioral tests. Four behavioral tests including novelty-suppressed feeding test, forced swim test, sucrose preference test and tail suspension test were used to evaluate depression-related symptoms in animals. Our results indicated that mTBI induction increased depression-like symptoms through altering serotonin 5-HT1A receptor activity in the brain. Activation of 5-HT1A receptor by a subthreshold dose of 8-OH-DPAT led to a significant decrease in depression-like behaviors, whereas blockade of 5-HT1A receptor by a subthreshold dose of WAY-100635 resulted in a considerable increase in depression-like phenotypes in mTBI-induced mice. The major strength of the present study is that depression-related symptoms were assessed in four behavioral tests. The present study supports the idea that disturbances in the function of serotonergic system in the brain following mTBI can play an important role in the regulation of depression-related behaviors.

Antidepressants for depression after concussion and traumatic brain injury are still best practice

BACKGROUND

Depression is a common complication of traumatic brain injury (TBI). New evidence suggests that antidepressant medication may be no more effective than placebo in this population.

MAIN BODY

Selective serotonin reuptake inhibitors are recommended as first-line treatment for depression in contemporary expert consensus clinical practice guidelines for management of TBI. This recommendation is based on multiple prior meta-analyses of clinical trials in depression after TBI as well as depression in the general population. The evidence is mixed. A recent clinical trial and new meta-analysis including that trial found no benefit of antidepressants for depression following TBI. We argue that this finding should not change practice, i.e., patients who present with depression after TBI should still be considered for antidepressant treatment, because they may (1) benefit from robust placebo effects, (2) benefit from an alternative or adjunctive medication if the agent prescribed first does not achieve a depression remission, and (3) make improvements that are not captured well by traditional depression outcome measures, which are confounded by TBI sequelae. Patients with mild TBI are especially appropriate for antidepressant therapy because they, on average, more closely resemble patients with no known TBI history enrolled in typical primary Major Depressive Disorder clinical trials than patients enrolled in TBI trials in placebo-controlled trials published to date.

CONCLUSION

TBI, and especially mild TBI, is not a contraindication for antidepressant therapy. Health providers should routinely screen and initiate treatment for depression after TBI.

Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study

IMPORTANCE

Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.

OBJECTIVE

To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI).

DESIGN, SETTING, AND PARTICIPANTS

Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study.

MAIN OUTCOMES AND MEASURES

Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury.

RESULTS

Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk.

CONCLUSIONS AND RELEVANCE

After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Psychopharmacology of traumatic brain injury

The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.

Placebo Effects in Traumatic Brain Injury

In recent years, several randomized controlled trials evaluating pharmaceutical treatments for traumatic brain injury (TBI) have failed to demonstrate efficacy over placebo, with both active and placebo arms improving at comparable rates. These findings could be viewed in opposing ways, suggesting on the one hand failure of the tested outcome, but on the other, representing evidence of robust placebo effects in TBI. In this article, we examine several of the primary psychological processes driving placebo effects (verbal suggestion, cognitive re-framing, interpersonal interactions, conditioning, therapeutic alliance, anxiety reduction) as well as placebo neurobiology (top-down cortical regulation, reward system activation, dopaminergic and serotonergic neurotransmission). We then extrapolate from the literature to explore whether something inherent in TBI makes it particularly responsive to placebos. Viewed as such here, placebos may indeed represent a powerful and effective treatment for a variety of post-TBI complaints.

Depression following a traumatic brain injury: uncovering cytokine dysregulation as a pathogenic mechanism

A substantial number of individuals have long-lasting adverse effects from a traumatic brain injury (TBI). Depression is one of these long-term complications that influences many aspects of life. Depression can limit the ability to return to work, and even worsen cognitive function and contribute to dementia. The mechanistic cause for the increased depression risk associated with a TBI remains to be defined. As TBI results in chronic neuroinflammation, and priming of glia to a secondary challenge, the inflammatory theory of depression provides a promising framework for investigating the cause of depression following a TBI. Increases in cytokines similar to those seen in depression in the general population are also increased following a TBI. Biomarker levels of cytokines peak within hours-to-days after the injury, yet pro-inflammatory cytokines may still be elevated above physiological levels months-to-years following TBI, which is the time frame in which post-TBI depression can persist. As tumor necrosis factor α and interleukin 1 can signal directly at the neuronal synapse, pathophysiological levels of these cytokines can detrimentally alter neuronal synaptic physiology. The purpose of this review is to outline the current evidence for the inflammatory hypothesis of depression specifically as it relates to depression following a TBI. Moreover, we will illustrate the potential synaptic mechanisms by which tumor necrosis factor α and interleukin 1 could contribute to depression. The association of inflammation with the development of depression is compelling; however, in the context of post-TBI depression, the role of inflammation is understudied. This review attempts to highlight the need to understand and treat the psychological complications of a TBI, potentially by neuroimmune modulation, as the neuropsychiatric disabilities can have a great impact on the rehabilitation from the injury, and overall quality of life.