Pharmacological and non-pharmacological interventions of depression after traumatic brain injury: A systematic review

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population

BACKGROUND

Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems.

AIMS

To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness.

METHOD

Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews.

RESULTS

Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured.

CONCLUSIONS

More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

Adverse Childhood Experiences and Offending as a Function of Acquired Brain Injury Among Men in a High Secure Forensic Psychiatric Hospital

BACKGROUND

Acquired brain injury (ABI) is a serious problem that disproportionately affects individuals in correctional services, but relatively little is known about ABI risks and correlates in forensic psychiatric services.

METHODS

We conducted a retrospective chart review of all admissions to a high secure forensic hospital in Ontario, Canada from January 2009 to December 2012 (n = 637) and collected data on ABI, psychiatric diagnoses, developmental disadvantage, criminal offending, and in-hospital aggression. A k-means cluster analysis was employed to assess risk factors by which men with ABI could be identified and multivariate general linear models were used to identify ABI-related differences in offending history and in-hospital aggression.

RESULTS

One-fifth of the men had a documented ABI indicator. Based on our cluster analysis, ABI was more likely to be identified by greater adverse childhood experiences (ACEs), more health problems from pregnancy to childhood, and lower socioeconomic status, suggesting that ABI within the forensic context is associated with greater developmental disadvantage. Men with ABI had more serious pre-admission offences, but not more serious admission offences or in-hospital aggression. Men with ABI were more likely than those without to have higher scores on the Violence Risk Appraisal Guide or to be diagnosed with mood and personality disorders, and less likely to have a schizophrenia diagnosis, suggesting an association between ABI and general mental health pathologies but not with psychotic illness.

CONCLUSIONS

The disadvantage of ABI among men in forensic psychiatric hospitals is most likely evinced in antisocial behaviour rather than serious mental illness. Given that ACEs are likely to precede or co-occur with ABI, strategies that mitigate ACEs hold promise for ABI prevention.

Effectiveness of Pharmacotherapy for Depression after Adult Traumatic Brain Injury: an Umbrella Review

Symptoms of depression are common following traumatic brain injury (TBI), impacting survivors' ability to return to work, participate in leisure activities, and placing strain on relationships. Depression symptoms post TBI are often managed with pharmacotherapy, however, there is little research evidence to guide clinical practice. There have been a number of recent systematic reviews examining pharmacotherapy for post TBI depression. The aim of this umbrella review was to synthesize systematic reviews and meta-analyses of the effectiveness of pharmacotherapy for the management of post TBI depression in adults. Eligible reviews examined any pharmacotherapy against any comparators, for the treatment of depression in adults who had sustained TBI. Seven databases were searched, with additional searching of online journals, Research Gate, Google Scholar and the TRIP Medical Database to identify published and unpublished systematic reviews and meta-analyses in English up to May 2020. A systematic review of primary studies available between March 2018 and May 2020 was also conducted. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. The results are presented as a narrative synthesis. Twenty-two systematic reviews were identified, of which ten reviews contained a meta-analysis. No new primary studies were identified in the systematic review. There was insufficient high quality and methodologically rigorous evidence to recommend prescribing any specific drug or drug class for post TBI depression. The findings do show, however, that depression post TBI is responsive to pharmacotherapy in at least some individuals. Recommendations for primary studies, systematic reviews and advice for prescribers is provided. Review Registration PROSPERO (CRD42020184915).

Extracting Apathy From Depression Syndrome in Traumatic Brain Injury by Using a Clustering Method

OBJECTIVE

Depression and apathy are common after traumatic brain injury (TBI), and different intervention strategies are recommended for each. However, a differential diagnosis can be difficult in clinical settings, especially given that apathy is considered to be a symptom of depression. In this study, the investigators aimed to isolate apathy from depression among patients with TBI and to examine whether apathy is exclusively associated with the amount of daily activity, as previously reported in the literature.

METHODS

Eighty-eight patients with chronic TBI completed the Japanese versions of the 21-item Beck Depression Inventory-II (BDI-II) and the Starkstein Apathy Scale (AS). Daily activity was measured with a 24-hour life log. A hierarchical cluster analysis was applied to divide the BDI-II data into separable components, and components' correlations with results of the AS and 24-hour life log scale were evaluated.

RESULTS

The BDI-II and AS revealed that 37 patients (42.0%) had both depression and apathy. BDI-II data were classified into four separate clusters (somatic symptoms, loss of self-worth, affective symptoms, and apathy symptoms). Loss of self-worth and apathy symptoms subscores were significantly positively correlated with total AS score (r=0.32, p=0.002, and r=0.52, p<0.001, respectively). The apathy symptoms subscore was significantly correlated with the amount of daily activity (r=-0.29, p=0.009).

CONCLUSIONS

The findings suggest that the BDI-II can differentiate between apathy and depression among patients with TBI, which is essential when selecting intervention options. Moreover, apathy symptoms predicted patients' real-life daily activity.

Traumatic brain injury and mood disorders

Traumatic brain injury is an increasing cause of morbidity worldwide. Neuropsychiatric impairments, such as behavioral dysregulation and depression, have significant impacts on recovery, functional outcomes, and quality of life of patients with traumatic brain injuries. Three patient cases, existing literature, and expert opinion are used to select pharmacotherapy for the treatment of target symptoms while balancing safety and tolerability.

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Nutritional interventions to improve neurophysiological impairments following traumatic brain injury: A systematic review

Traumatic brain injury (TBI) accounts for significant global health burden. Effects of TBI can become chronic even following mild injury. There is a need to develop effective therapies to attenuate the damaging effects of TBI and improve recovery outcomes. This literature review using a priori criteria (PROSPERO; CRD42018100623) summarized 43 studies between January 1998 and July 2019 that investigated nutritional interventions (NUT) delivered with the objective of altering neurophysiological (NP) outcomes following TBI. Risk of bias was assessed for included studies, and NP outcomes recorded. The systematic search resulted in 43 of 3,748 identified studies met inclusion criteria. No studies evaluated the effect of a NUT on NP outcomes of TBI in humans. Biomarkers of morphological changes and apoptosis, oxidative stress, and plasticity, neurogenesis, and neurotransmission were the most evaluated NP outcomes across the 43 studies that used 2,897 animals. The risk of bias was unclear in all reviewed studies due to poorly detailed methodology sections. Taking these limitations into account, anti-oxidants, branched chain amino acids, and ω-3 polyunsaturated fatty acids have shown the most promising pre-clinical results for altering NP outcomes following TBI. Refinement of pre-clinical methodologies used to evaluate effects of interventions on secondary damage of TBI would improve the likelihood of translation to clinical populations.

Non-pharmacological interventions for depressive disorder in patients after traumatic brain injury: A protocol for a systematic review and network meta-analysis

BACKGROUND

Depressive disorder has gradually become one of the most commonly reported disabling psychiatric complication that occurs after traumatic brain injury (TBI). Currently classical antidepressant medications may not have the same effectiveness in patients with TBI as in patients without TBI. Non-pharmacological interventions have been considered to be effective for managing depressive symptoms or treating depressive disorder. But to date the comparative effectiveness of various types of non-pharmacological interventions has been synthesized in few studies, the evidence remains inconclusive. Thus, the purpose of this systematic review and network meta-analyses is to summarize high-quality evidence and identify the most effective non-pharmacological intervention when applied to treat the depressive disorder in patients after TBI.

METHODS

The comprehensive literature search in electronic database including PubMed, Ovid Medline, Cochrane Library, Web of Science database, Embase Database, China National Knowledge Infrastructure (CNKI), and Wanfang Data Chinese database from inception to the search date. Only high-quality randomized controlled trials (RCTs) that have used non-pharmacological interventions to treat depressive disorder after TBI will be considered. Two independent reviewers will identify eligible studies, extract and manage data information, and then determine methodical quality of included studies. Overall efficacy will be assessed as primary outcome. Secondary outcomes involved treatment response, remission rate, overall acceptability, tolerability of treatment, social functioning, occurrence of adverse events, and suicide-related outcome. Cochrane risk of bias assessment tool will be adopted to assess the risk of bias. Study heterogeneity will be measured by the I statistic. Traditional pairwise meta-analyses will be performed using STATA, while WinBUGS with GeMTC package of R software will be used to carry out network meta-analysis.

RESULTS

This systematic review will examine the relative efficacy, effectiveness, safety, tolerability and acceptability of non-pharmacological interventions, and then to identify the most effective non-pharmacological intervention for depressive disorder after TBI.

EXPECTED CONCLUSION

Our work could be used to give clinical recommendations for practice guideline developers, psychiatrist, neurologist, policymakers, researchers as well as individual with depressive disorder after TBI, and will also identify gaps in knowledge that could be the subject of future research.

ETHICS AND DISSEMINATION

Neither ethics approval nor patient informed consent is necessary since this protocol was designed based on the existing literature. The results will be disseminated electronically or in print through publications in peer-reviewed scientific journal.

INPLASY REGISTRATION

INPLASY202080022.

Depression Comorbid With Stroke, Traumatic Brain Injury, Parkinson's Disease, and Multiple Sclerosis: Diagnosis and Treatment

Depression is common among patients with neurologic disorders, and it has long been considered more difficult to treat than depression in the general population. In this review, the authors consider challenges in the diagnosis and treatment of depression among patients with stroke, traumatic brain injury, Parkinson's disease, and multiple sclerosis. For each disorder, the authors discuss the epidemiology and time course of depression as well as review the physiologic and psychological etiologies of depression. In addition, for each disorder, they review screening tools and diagnostic considerations, including differential diagnosis; discuss etiological factors, both neurobiological and psychological; and assess evidence for various depression treatments, including pharmacologic, psychosocial, and neuromodulatory therapies. The evidence suggests that depression is common among patients with neurologic disorders and that it is crucial for general psychiatrists to provide treatment for this population.