Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury (2009) / Chapter Skim
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8 PSYCHIATRIC OUTCOMES
8 PSYCHIATRIC OUTCOMES
Pages 265-300
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From page 265... ...
In addition to the possibility that TBI leads to psychiatric sequelae through nonspecific psychologic factors or through more specific brain injury–related factors, there is evidence that prior psychiatric illness may predispose to TBI, which in turn could increase the risk of recurrence or exacerbation of previous psychiatric conditions (Fann et al., 2002)
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From page 266... ...
Psychiatric illnesses were ascertained by using the presence of psychiatric diagnoses, filling of prescriptions for psychiatric medications, and utilization of psychiatric services. In the first year after a moderate to severe TBI, 49% of the patients had evidence of psychiatric illnesses compared with 34% in the mild-TBI group and 18% in the comparison group; this reflected a significantly increasing risk of psychiatric illness with severity of TBI.
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From page 267... ...
A lifetime history of depression was assessed on the basis of a structured telephone interview with the veteran or his proxy; participants who responded affirmatively to any of three questions regarding mood also were given a modified version of the Diagnostic Interview Schedule for depression to decide on a DSM-IV diagnosis of major depression. The lifetime odds of major depression was significantly increased in veterans with TBI compared with controls (odds ratio [OR]
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From page 268... ...
There were no significant differences between TBI patients with and without major depression in demographic variables or the use of alcohol or other drugs. Those with TBI and major depression had a significantly higher frequency of a personal history of mood disorders (p = 0.01)
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From page 269... ...
Summary and Conclusion The committee reviewed four primary and five secondary studies of mood disorders -- major depression -- and findings were consistent. The preponderance of studies found that groups with TBI (mild, moderate, or severe)
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From page 270... ...
; moderate to severe TBI, RR, 2.1 (95% CI, 1.3–3.3) Subjects with mild TBI showed chronic likelihood of psychiatric illness
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From page 271... ...
7–12 mo: mild TBI, RR, 2.2 (95% CI, 1.4–3.6) ; moderate to severe TBI, RR, 4.6 (95% CI, 1.8– 11.7)
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From page 272... ...
(95% CI, 1.17–2.04) accident major depression at hospitalized with occurred during time of enlistment pneumonia or military service; Lifetime risk of laceration, puncture, (3)
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From page 273... ...
Jorge et al., Cohort 91 consecutive Closed head Major depression Mood disorders, None 2004 patients with TBI injury (mild, associated with major depressive but without spinal- moderate, anxiety symptoms, disorders cord injury severe) Present State significantly more compared with 27 Examination, SCID frequent in TBI injured patients Severe TBI: clinical, patients than in without TBI also GCS, 3–8; neuropsychologic, patients without consecutively moderate TBI: brain-imaging brain injuries: after admitted into two GCS 9–12 or variables TBI, 47 (51.6%)
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From page 274... ...
Major depression significantly associated with comorbid anxiety disorder (76.7% vs 20.4%; p < 0.001) and decreased frontal brain volume and left frontal gray matter in first year after injury Hoge et al., Cohort Anonymous survey Mild PTSD Of 124 with LOC, 95% males; After adjustment for 2008 of 4,618 soldiers, of 43.9% met criteria 55.5% under 30 PTSD and depression, whom 2,714 (59%)
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From page 275... ...
general health, US Army soldiers with other missed workdays, responded 3–4 mo injuries more doctor visits, after return from 1- higher numbers of year Iraqi outcomes or deployment symptoms NOTE: CDC = Centers for Disease Control and Prevention, CI = confidence interval, DIS = Diagnostic Interview Schedule, DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, GCS = Glasgow Coma Scale, HMO = health-maintenance organization, ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification, LOC = loss of consciousness, PTA = posttraumatic amnesia, SCID = Structured Clinical Interview for DSM-IV diagnoses, TBI = traumatic brain injury, WWII = World War II.
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From page 276... ...
The cause of death of 75 of the patients with severe TBI who had recovered sufficiently to leave the hospital and walk unassisted was compared with the 1960 death rates in a population of similar sized in England and Wales. Three of the TBI patients died of suicide compared with one in the general population (SMR, 3 -- not significant)
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From page 277... ...
recruited 172 consecutive outpatients with TBI over a 24month period at the Brain Injury Rehabilitation Unit of the Liverpool Hospital in Sydney, Australia. All patients were 16–65 years old, had sustained their injuries at least 12 months earlier, and were able to able to respond to questions in English.
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From page 278... ...
278 GULF WAR AND HEALTH The committee concludes, on the basis of its evaluation, that there is inadequate/insufficient evidence to determine whether an association exists between TBI and attempted suicide.
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From page 279... ...
TABLE 8.2 Psychologic Outcomes -- TBI and Suicide Health Outcomes Study or Outcome Comments or Reference Design Population Type of TBI Measures Results Adjustments Limitations Lewin et al., Retrospective Consecutive series of Severe, in mostly Vital status; for N, 3; SMR, 3.0 (not Age, maximal Only 2% loss to 1979 cohort 7,000 patients with closed, but 178 (consecutive significant) central neural followup head injuries complicated by series)
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From page 280... ...
(11,766) Women had higher rates of suicide than men in three diagnostic groups; mortality greater in patients injured at age of 21–60 years than in those injured when younger or older NOTE: CI = confidence interval, ICD = International Classification of Diseases, MVC = motor-vehicle crash, PTA = posttraumatic amnesia, SMR = standardized mortality ratio, TBI = traumatic brain injury.
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From page 281... ...
who were evaluated for ASD 2–25 days after trauma. A psychiatric assessment at 6 months after injury included an assessment of ASD through the Acute Stress Disorder Interview and of PTSD through the PTSD module of the Composite International Diagnostic Interview (CIDI)
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From page 282... ...
About 3–4 months after returning from Iraq, 4,618 soldiers were sent a questionnaire covering injury sustained during combat, combat intensity, physical symptoms, major depression, and PTSD. Mild TBI sustained during combat was determined on the basis of the occurrence of at least one of the following three symptoms: losing consciousness (knocked out)
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From page 283... ...
returned the questionnaire, which included the Brief Traumatic Brain Injury Screen to detect mild TBI and the 17-item PTSD checklist. Twelve percent of the veterans who returned the questionnaire reported a history consistent with mild TBI.
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From page 284... ...
The primary studies, which were conducted in military personnel who served in the Gulf War, reported statistically significant associations between TBI and PTSD, but two of the secondary studies found no difference in prevalence with anxiety disorders or PTSD. In contrast, the primary studies conducted in civilian populations did not find an association between TBI and PTSD although an association could not be excluded on the basis of the findings of the secondary studies.
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From page 285... ...
for first 4 weeks after injury, inability to answer questions, non-English speaking Bryant and Prospective 46 TBI (32 male, 14 Mild TBI with PTSD module At 6 mo after None Head injury ascertained Harvey, cohort female) , 59 non-TBI LOC, PTA <24 from CIDI and trauma, 20% of at time arrived at hospital 1999b (31 male, 28 female)
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From page 286... ...
286 Health Outcomes or Study Outcome Comments or Reference Design Population Type of TBI Measures Results Adjustments Limitations Same consecutively of non-TBI Good followup over 6population as admitted into major patients met mo period Bryant and trauma hospital, criteria for Harvey, followed up 6 mo PTSD (p value Overlapping of PCS, 1999a after trauma; 83% of not reported) PTSD symptoms cohort followed to 6 mo No difference between those Exclusions: drug or with and those narcotic analgesia without PTSD (except codeine)
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From page 287... ...
or no event examined brain injury (118) and were 18–70 Data on mild TBI and years old were non-TBI controls pooled; followed 1 year after relationship between injury recall and PTSD assessed; therefore, Exclusions: injuries uninformative for mild due to self-harm, IV TBI drug use, current psychotic disorder Hoge et al., Cohort Anonymous survey Mild PTSD Of 124 (4.9%)
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From page 288... ...
, combat mild TBI (prevalence ratio, 2.37; 95% CI, 1.72– 3.28) Postconcussive symptoms strongly associated with PTSD score NOTE: CAPS = Clinician-Administered PTSD Scale, CIDI = Composite International Diagnostic Interview, ISS = Injury Severity Score, IV = intravenous, LOC = loss of consciousness, MVA = motor-vehicle accident, OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, PCS = postconcussive symptom, PTA = posttraumatic amnesia, PTSD = posttraumatic stress disorder, TBI = traumatic brain injury.
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From page 289... ...
The committee reviewed the literature in this area and found primary studies whose methods were scientific and whose outcomes can be accepted with confidence; these studies are supplemented by secondary studies of suitable rigor that are not definitive. AGGRESSIVE BEHAVIORS Primary Studies Two primary studies found that TBI is associated with subsequent aggressive behavior, but one primary study found no effect of TBI on criminal conviction.
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From page 290... ...
consecutively admitted into two Iowa hospitals. Severity of brain injury was measured according to the GCS and PTA and classified with the TCDB.
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From page 291... ...
They hypothesized that lesions to the prefrontal cortex impair the ability to sustain "managerial knowledge" and bias behavior away from plans and social rules toward aggressive and violent behavior. DRUG AND ALCOHOL ABUSE DISORDERS Secondary Studies Many studies have shown a relationship between drug and alcohol use and TBI, and it is generally accepted that drug and alcohol use precedes the TBI and increases the risk of head injury.
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From page 292... ...
The risk of psychiatric illness was significantly increased after mild and moderate-severe TBI. Increased ORs were observed especially in patients with no prior history of psychiatric illness, within the first year after TBI: the OR was 2.1 (95% CI, 1.6–2.6)
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From page 293... ...
Alcohol and Drug Abuse The committee concludes, on the basis of its evaluation, that there is limited/suggestive evidence of an association between TBI and decreased drug and alcohol use, as compared with preinjury levels, in the 1–3-year period following the TBI. Psychosis The committee concludes, on the basis of its evaluation, that there is limited/suggestive evidence of an association between moderate or severe TBI and psychosis.
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From page 294... ...
; Normal orthopedic military hospitals vs and ISS; mild reasons, criminal moderate TBI, controls
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From page 295... ...
al., 2003 cohort closed head injury determined behavior assessed TBI patients admitted into with GCS, with Overt presented with University of Iowa Traumatic Aggression Scale; aggressive hospitals and clinics, Coma Data mood, anxiety behavior Iowa Methodist Bank; mild disorders assessed during first 6 Medical Center; 26 (50) , moderate by psychiatrist mo compared patients with (19)
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From page 296... ...
brain injuries, 500 from Criminal controls noninjured Finnish Register convicted of WWII veterans as crimes (NS) controls NOTE: AIS = Abbreviated Injury Scale, CI = confidence interval, GCS = Glasgow Coma Scale, HMO = health-maintenance organization, ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification, ISS = Injury Severity Score, NS = not significant, OR = odds ratio, TBI = traumatic brain injury, WWII = World War II.
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From page 297... ...
1999b. Postconcussive symptoms and posttraumatic stress disorder after mild traumatic brain injury.
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From page 298... ...
2005. Alcohol misuse and mood disorders following traumatic brain injury.
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From page 299... ...
2008. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder.
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From page 300... ...
1997. Posttraumatic stress disorder in patients with traumatic brain injury and amnesia for the event.
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