Identifying longitudinal trajectories of emotional distress symptoms 5 years after traumatic brain injury

Impact of Early Personal Resources on Long-Term Psychosocial Outcomes After Moderate-to-Severe Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To investigate the relationship between preinjury or early personal resources and long-term psychosocial outcomes following moderate-to-severe traumatic brain injury (TBI) and examine evidence for the stability of personal resources over time.

METHODS

The review protocol was registered with the International Register of Systematic Reviews (PROSPERO, Registration No. CRD4202341056). A search of PsycINFO, Cumulative Index to Allied Health Literature (CINAHL), MEDLINE, Scopus, and Web of Science was conducted from inception to February 23, 2023, for longitudinal studies involving adults with moderate-to-severe TBI that examined: (1) the relationship between preinjury or early personal resources (measured ≤6 months postinjury) and later psychosocial outcomes or (2) stability of personal resources over time with a minimum reassessment interval of 3 months. Two reviewers independently assessed eligibility and rated methodological quality of studies using a checklist informed by Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

A narrative synthesis was conducted on 14 eligible articles summarizing 12 studies (N = 826). Nine studies examined the impact of preinjury or early personal resources on long-term psychosocial outcomes, most typically at 12 months postdischarge. Out of 9 studies 7 indicated that self-reported preinjury or early personal resources, including productive coping, higher self-esteem and resilience, and lower neuroticism, were associated with better psychosocial outcomes. Evidence from 7 studies examining the stability of personal resources over time was generally mixed, with personality changes (eg, neuroticism, conscientiousness, and extraversion) more evident from informant ratings than self-ratings.

CONCLUSION

Preinjury or early personal resources may influence later psychosocial outcomes after TBI. Further research is needed to investigate the stability of personal resources and factors mediating or moderating change across the adjustment trajectory.

Subject and Family Perspectives from the Central Thalamic Deep Brain Stimulation Trial for Traumatic Brain Injury: Part II

This is the second paper in a two-part series describing subject and family perspectives from the CENTURY-S (CENtral Thalamic Deep Brain Stimulation for the Treatment of Traumatic Brain InjURY-Safety) first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury (msTBI). To participate, subjects were independently assessed to formally establish decision-making capacity to provide voluntary informed consent. Here, we report on post-operative interviews conducted after a successful trial of thalamic stimulation. All five msTBI subjects met a pre-selected primary endpoint of at least a 10% improvement in completion time on Trail-Making-Test Part B, a marker of executive function. We describe narrative responses of subjects and family members, refracted against that success. Interviews following surgery and the stimulation trial revealed the challenge of adaptation to improvements in cognitive function and emotional regulation as well as altered (and restored) relationships and family dynamics. These improvements exposed barriers to social reintegration made relevant by recoveries once thought inconceivable. The study's success sparked concerns about post-trial access to implanted devices, financing of device maintenance, battery replacement, and on-going care. Most subjects and families identified the need for supportive counseling to adapt to the new trajectory of their lives.

Uncovering the social determinants of brain injury rehabilitation

Social determinants of health (SDH), such as social isolation and loneliness, are often more frequently experienced in brain injury survivors. The paper explores the personal experiences of loneliness among brain injury survivors during lockdown to negate health inequalities and improve rehabilitation for this population in the future. Twenty-four brain injury survivors participated in semi-structured interviews and questionnaires relating to loneliness, resilience and wellbeing. Three themes (the experience of loneliness, loneliness during the pandemic and loneliness after the pandemic) explored survivors' experiences of loneliness generally post-brain injury, but also chronicle how these feelings developed in lockdown and survivors' feelings regarding society returning to 'normal'. Future interventions should focus on reframing survivors' beliefs regarding societal expectations and minimise the pressure they experience to keep up with their peers physically and emotionally. Additionally, we recommend creating accessible peer support options for all brain injury survivors as an important step for alleviating loneliness.

Impact of Sociodemographic, Premorbid, and Injury-Related Factors on Patient-Reported Outcome Trajectories after Traumatic Brain Injury (TBI)

Traumatic brain injury (TBI) remains one of the leading causes of death and disability worldwide. To better understand its impact on various outcome domains, this study pursues the following: (1) longitudinal outcome assessments at three, six, and twelve months post-injury; (2) an evaluation of sociodemographic, premorbid, and injury-related factors, and functional recovery contributing to worsening or improving outcomes after TBI. Using patient-reported outcome measures, recuperation trends after TBI were identified by applying Multivariate Latent Class Mixed Models (MLCMM). Instruments were grouped into TBI-specific and generic health-related quality of life (HRQoL; QOLIBRI-OS, SF-12v2), and psychological and post-concussion symptoms (GAD-7, PHQ-9, PCL-5, RPQ). Multinomial logistic regressions were carried out to identify contributing factors. For both outcome sets, the four-class solution provided the best match between goodness of fit indices and meaningful clinical interpretability. Both models revealed similar trajectory classes: stable good health status (HRQoL: n = 1944; symptoms: n = 1963), persistent health impairments (HRQoL: n = 442; symptoms: n = 179), improving health status (HRQoL: n = 83; symptoms: n = 243), and deteriorating health status (HRQoL: n = 86; symptoms: n = 170). Compared to individuals with stable good health status, the other groups were more likely to have a lower functional recovery status at three months after TBI (i.e., the GOSE), psychological problems, and a lower educational attainment. Outcome trajectories after TBI show clearly distinguishable patterns which are reproducible across different measures. Individuals characterized by persistent health impairments and deterioration require special attention and long-term clinical monitoring and therapy.

Community Integration and Associated Factors 10 Years after Moderate-to-Severe Traumatic Brain Injury

This study evaluated the impact of baseline injury characteristics and one-year functional level on the 10-year community integration outcomes for working-age patients with moderate-to-severe traumatic brain injury (TBI). Patients aged 16-55 and diagnosed with moderate-to-severe TBI within 24 h of injury were eligible for the study. Multivariable hierarchical linear regression was utilized to assess the impact of baseline characteristics and one-year functional measures on the mean Community Integration Questionnaire (CIQ) scores 10 years after injury. Of 133 original study participants, 97 survived 10 years, and 75 were available for this study. The mean total CIQ score changed positively from one to 10 years post-injury, from 18.7 (±5.5) to 19.8 (±4.8) (p = 0.04). The results suggested that age (β = -0.260, p = 0.013), FIM-Cognitive subscale (β = 0.608, p = 0.002), and the bodily pain subscale (BP) (β = 0.277, p = 0.017) of the SF-36 were significantly associated with the mean CIQ scores. In conclusion, this study demonstrated improved community integration from one to 10 years in a sample of working-age patients with moderate-to-severe TBI. The findings also showed that age, cognitive function, and bodily pain were significant predictors of long-term community integration, suggesting post-acute rehabilitation should focus on factors related to long-term risk and protective factors to improve long-term outcomes.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study

OBJECTIVE

To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS).

PARTICIPANTS

A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations.

DESIGN

Secondary analysis from multicenter prospective longitudinal study.

MAIN MEASURES

Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale.

RESULTS

The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores.

CONCLUSION

Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Trajectories of Posttraumatic Stress in Youths After Natural Disasters

IMPORTANCE

Disaster exposure is associated with the development of posttraumatic stress (PTS) symptoms in youths. However, little is known about how to predict which youths will develop chronic PTS symptoms after disaster exposure.

OBJECTIVE

To evaluate PTS symptom trajectories among youths after 4 major US hurricanes and assess factors associated with those trajectories.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used integrative data analysis to combine data from 4 studies of youths' responses to natural disasters (hurricanes Andrew [1992], Charley [2004], Ike [2005], and Katrina [2008]) at time points ranging from 3 to 26 months after the disasters. Those studies recruited and surveyed youths aged 6 to 16 years at schools via convenience sampling of schools near the path of destruction for each hurricane. This study was conducted from August 2017 to August 2020, and pooled data were analyzed from February 2019 to October 2020.

EXPOSURE

Experience of a natural disaster during the ages of 6 to 16 years.

MAIN OUTCOMES AND MEASURES

Posttraumatic stress symptoms were assessed using the University of California, Los Angeles, Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the UCLA PTSD-RI-Revised. Latent class growth analyses were used to evaluate the youths' PTS symptom trajectories and associated factors.

RESULTS

Among 1707 youths included in the study, the mean (SD) age was 9.61 (1.60) years, 922 (54%) were female, and 785 (46%) self-identified as White non-Hispanic. Four PTS symptom trajectories were identified: chronic (171 participants [10%]), recovery (393 [23%]), moderate-stable (563 [33%]), and low-decreasing (580 [34%]). Older youths were less likely to be in the chronic group; compared with the chronic group, each 1-year increase in age was associated with increased odds of being in the other groups (recovery: odds ratio [OR], 1.78 [95% CI, 1.29-2.48]; moderate-stable: OR, 1.94 [95% CI, 1.43-2.62]; and low-decreasing: OR, 2.71 [95% CI, 1.99-3.71]). Compared with males, females had higher odds of being in the chronic group than in any other group (recovery group: OR, 0.48 [95% CI, 0.26-0.91]; moderate-stable group: OR, 0.37 [95% CI, 0.21-0.64]; and low-decreasing group: OR, 0.25 [95% CI, 0.14-0.44]).

CONCLUSIONS AND RELEVANCE

In this cohort study, few youths reported chronic distress, and trajectories among most youths reflected recovery or low-decreasing PTS symptoms. Older age and identification as male were factors associated with decreased odds of a chronic trajectory. Youths with chronic or moderate-stable trajectories may benefit from intervention.

An Integrative Framework of Appraisal and Adaptation in Serious Medical Illness

Multiple randomized clinical trials have demonstrated that palliative care improves the quality of life of individuals with serious medical illness. Research also suggests that in patients with advanced cancer, palliative care's focus on symptom management, coping with illness, goals of care, and treatment decisions may be associated with improved patient quality of life in part by increasing patients' use of active (vs. passive) and approach-oriented (vs. avoidant) coping strategies. However, without a framework outlining the process that individuals with serious medical illness and their loved ones undergo, it is challenging to discern exactly where, how, and why palliative care may affect the serious medical illness experience. To address this gap, we propose a clinically applicable framework, derived from existing theory and research in the social and behavioral sciences. This framework, called the Integrative Framework of Appraisal and Adaptation in Serious Medical Illness, describes how patients and their loved ones cognitively and emotionally process the various events that may occur as they navigate serious medical illness and the end of life. The framework also describes how individuals and their loved ones use that event processing to determine next steps, while considering the impact of their surrounding external environment, their individual social roles, and their connections on this decision making. The framework presented in this article is intended to improve our ability to understand and care for individuals with serious medical illness and their loved ones, while stimulating further discussion and research to test and refine these ideas.

Trajectories of self-reported competency up to 10 years following moderate-to-severe traumatic brain injury

Objectives: To describe trajectories of self-reported functional competency up to 10 years following traumatic brain injury (TBI) and identify their predictors from baseline socio-demographic and injury severity characteristics.Design and methods: Data from 94 participants from a longitudinal cohort of patients with moderate-to-severe TBI were analyzed. Socio-demographic and injury severity data were recorded at baseline. Participants completed the Patient Competency Rating Scale (PCRS) at 1, 2, 5, and 10 years. Hierarchical linear modeling was used to examine PCRS trajectories over time and assess baseline predictors.Results: There was no significant change in average PCRS scores across the follow-up time points in the full sample. Emotional and cognitive competencies had the lowest mean scores. Gender, employment, and the interaction term between gender and time were significant predictors of PCRS trajectories. Females and those who were unemployed at the time of injury showed lower trajectories of self-reported competency.Conclusion: Self-reported competency remained stable from one-year post-injury for men only. Lower mean scores in the domains of emotional and cognitive competencies suggest a need for continued rehabilitation focus in the chronic phase after TBI. Special attention to women and individuals who are unemployed at the time of injury may be warranted.

The relationship between resilience, emotional distress, and community participation outcomes following traumatic brain injury

Purpose/Objective: To determine how resilience is associated with social participation outcomes in persons with traumatic brain injury (TBI), in the context of emotional distress, demographics, and injury-related factors.Setting: Individuals with a history of TBI recruited the following stay at three rehabilitation facilities in the USA.Participants: 201 community-dwelling persons with medically documented TBI ranging in severity from mild to severe.Design: Prospective cohort observational study. Data were collected at two time points, approximately 6 months apart.Main Measures: TBI-QOL; PART-OResults: Resilience at baseline was moderately to strongly correlated with baseline psychological distress variables (r_s= -.66) and social participation variables (r_s =.33 to.57). In regression analyses, resilience was directly associated with social participation outcomes and formed a significant interaction with emotional distress in some models. Resilience failed to show a relationship with social participation at 6-month follow-up, when controlling for baseline social participation.Conclusions: Though related to emotional distress, self-reported resilience makes a unique contribution to predicting outcomes over time following brain injury, and may impact the relationship between stress and negative participation outcomes. As such, it is possible interventions that promote resilience may mitigate distress and promote community integration.

Longitudinal depressive and anxiety symptoms of adult injury patients in Kenya and their risk factors

Background: Injuries account for a significant proportion of the health and economic burden for populations in low- and middle-income countries. However, little is known about psychological distress trajectories amongst injury survivors in low- and middle-income countries.Methods: Adult injury patients (n = 644) admitted to Kenyatta National Hospital in Nairobi, Kenya, were enrolled and interviewed in the hospital, and at 1, 2-3, and 4-7 months after hospital discharge through phone to assess depressive and anxiety symptoms and level of disability. Growth mixture modeling was applied to identify latent trajectories of depressive and anxiety symptoms.Results: Elevated depressive and moderate-level anxiety symptoms (13%) and low depressive and anxiety symptoms (87%) trajectories were found between hospitalization and up to seven months after hospital discharge. Being female, prior trauma experience, longer hospitalization, worse self-rated health status while in the hospital, and lack of monetary assistance during hospitalization were associated with the elevated symptoms trajectory. The higher symptoms trajectory associated with higher disability levels after hospital discharge and significantly lower proportion of resuming daily activities and work.Conclusion: The persistence of elevated depressive symptoms and associated reduced functioning several months after physical injury underscores the importance of identifying populations at risk for preventive and early interventions.Implications for RehabilitationHealth providers following up with injury survivors should screen for depressive and anxiety symptomsSpecial attention to women and people with a potential traumatic exposure historyIncorporation of evidence-based culturally adapted psychosocial interventions in rehabilitation and outpatient clinics.

Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury

Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [Mage = 44.41, SDage = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD 3.02, R 0.5-13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F(13, 211) = 9.93, p < 0.05, R2 = 0.38, adjusted R2 = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.

Trajectory of Functional Independent Measurements during First Five Years after Moderate and Severe Traumatic Brain Injury

A better understanding of long-term functional recovery process for patients with traumatic brain injury (TBI) facilitates effective rehabilitations. The aim of this study was to classify and characterize patients with moderate-to-severe TBI based on their functional trajectories up to 5 years post-injury. The study included 121 patients with moderate-to-severe TBIs (International Classification of Diseases, Tenth Revision [ICD-10], S06.0-S06.9), 16-55 years of age, and admitted at Trauma Referral Hospital within 24 h of injury between 2005 and 2007. Demographics and injury characteristics were documented at the admission, and functional status was recorded at 3 months and 1 and 5 years post-injury using Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) subscales. We used group-based trajectory models to classify patients' functional trajectories over a 5-year period. For FIM-M, three trajectories were identified: 8.2% of patients showed stable low recovery (13.6 ± 1.5, 17.9 ± 8.8, and 21.0 ± 17.9), 9.2% elevated good recovery (35.8 ± 14.5, 75.5 ± 12.4, and 85.5 ± 8.1), and 82.6% stable good recovery (89.0 ± 3.6, 90.3 ± 1.9, and 90.8 ± 1.0) at the three follow-up points, respectively. For FIM-C, four trajectories were revealed: 4.1% of patients showed stable low recovery (5.0 ± 0, 5.0 ± 0, and 5.0 ± 0), 12.6% delayed moderate recovery (8.9 ± 3.5, 20.6 ± 4.6, and 28.3 ± 3.8), 28.7% elevated good recovery (27.0 ± 3.8, 30.4 ± 7.3, and 31.1 ± 2.3), and 54.6% stable good recovery (32.8 ± 2.3, 34.6 ± 1.0, and 34.7 ± 1.0). The results suggest that three FIM-M and four FIM-C trajectories described various patterns of functional recovery 5 years after moderate-to-severe TBI, with stable good recovery being the most common trajectory. Identifying and characterizing the trajectory memberships should enable targeted rehabilitation programs, inform patient-centered care, and improve long-term outcomes.

Personal identity narratives of therapeutic songwriting participants following Spinal Cord Injury: A case series analysis

CONTEXT/OBJECTIVE

Spinal Cord Injury (SCI) patients face unique identity challenges associated with physical limitations, higher comorbid depression, increased suicidality and reduced subjective well-being. Post-injury identity is often unaddressed in subacute rehabilitation environments where critical physical and functional rehabilitation goals are prioritized. Therapeutic songwriting has demonstrated prior efficacy in promoting healthy adjustment and as a means of expression for post-injury narratives. The current study sought to examine the identity narratives of therapeutic songwriting participants.

DESIGN

Case-series analysis of the individual identity trajectories of eight individuals.

SETTING

Subacute rehabilitation facility, Victoria, Australia.

PARTICIPANTS

Eight individuals with an SCI; 7 males and 1 female.

INTERVENTION

Six-week therapeutic songwriting intervention facilitated by a music therapist to promote identity rehabilitation.

OUTCOME MEASURES

Identity, subjective well-being and distress, emotional state.

RESULTS

Three participants demonstrated positive trajectories and a further three showed negative trajectories; remaining participants were ambiguous in their response. Injury severity differentiated those with positive trajectories from those with negative trajectories, with greater injury severity apparent for those showing negative trends. Self-concept also improved more in those with positive trajectories. Core demographic variables did not however meaningfully predict the direction of change in core identity or wellbeing indices.

CONCLUSION

Identity-focused songwriting holds promise as a means of promoting healthy identity reintegration. Further research on benefits for those with less severe spinal injuries is warranted.

Bayesian PTSD-Trajectory Analysis with Informed Priors Based on a Systematic Literature Search and Expert Elicitation

There is a recent increase in interest of Bayesian analysis. However, little effort has been made thus far to directly incorporate background knowledge via the prior distribution into the analyses. This process might be especially useful in the context of latent growth mixture modeling when one or more of the latent groups are expected to be relatively small due to what we refer to as limited data. We argue that the use of Bayesian statistics has great advantages in limited data situations, but only if background knowledge can be incorporated into the analysis via prior distributions. We highlight these advantages through a data set including patients with burn injuries and analyze trajectories of posttraumatic stress symptoms using the Bayesian framework following the steps of the WAMBS-checklist. In the included example, we illustrate how to obtain background information using previous literature based on a systematic literature search and by using expert knowledge. Finally, we show how to translate this knowledge into prior distributions and we illustrate the importance of conducting a prior sensitivity analysis. Although our example is from the trauma field, the techniques we illustrate can be applied to any field.

Exploring the relationship between boredom proneness and self-control in traumatic brain injury (TBI)

Characterized as an agitated state in which the individual is motivated to engage in their environment but all attempts to do so fail to satisfy, boredom represents a disengaged attentional state that is associated with negative affect and poor self-control. There have been anecdotal reports of increased levels of boredom post-traumatic brain injury (TBI). For the first time, we provide objective evidence that TBI patients do indeed experience higher levels of boredom proneness. Hierarchical regression analyses showed that the presence and severity of head injury were a significant positive predictor of levels of boredom proneness and a negative predictor of self-control. As with healthy controls, TBI patients showed a strong negative correlation between boredom proneness and self-control-those with lower levels of self-control exhibited higher levels of boredom proneness. This was despite the fact that our TBI patients reported higher overall levels of self-control (probably concomitant with their older mean age). The TBI patients also showed strong positive correlations between boredom proneness and measures of physical aggression and anger. Together, this suggests that patients with TBI may be more susceptible to increased levels of boredom proneness and other negative affective states that arise as a consequence of failures of self-control.

Resilience and Other Possible Outcomes After Mild Traumatic Brain Injury: a Systematic Review

The relation between resilience and mild traumatic brain injury (TBI) outcome has been theorized but empirical studies have been scarce. This systematic review aimed to describe the research in this area. Electronic databases (Medline, CINAHL, PsychINFO, SPORTdiscus, and PILOTS) were searched from inception to August 2015 for studies in which resilience was measured following TBI. The search terms included 'TBI' 'concussion' 'postconcussion' 'resilience' and 'hardiness'. Inclusion criteria were peer reviewed original research reports published in English, human participants aged 18 years and over with brain injury, and an accepted definition of mild TBI. Hand searching of identified articles was also undertaken. Of the 71 studies identified, five studies were accepted for review. These studies were formally assessed for risk of bias by two independent reviewers. Each study carried a risk of bias, most commonly a detection bias, but none were excluded on this basis. A narrative interpretation of the findings was used because the studies reflected fundamental differences in the conceptualization of resilience. No studies employed a trajectory based approach to measure a resilient outcome. In most cases, the eligible studies assessed trait resilience with a scale and used it as a predictor of outcome (postconcussion symptoms). Three of these studies showed that greater trait resilience was associated with better mild TBI outcomes (fewer symptoms). Future research of the adult mild TBI response that predicts a resilient outcome is encouraged. These studies could yield empirical evidence for a resilient, and other possible mild TBI outcomes.

Depression Trajectories during the First Year after Traumatic Brain Injury

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