8. Mental Health Issues

Laura Rees PhD, Shannon Janzen MSc, Rachel Anderson BSc, Margaret Weiser PhD, Joshua Wiener BSc, Robert Teasell MD, Shawn Marshall MD 

Chapter 8 Abbreviations

Although mood is an internal subjective state, it is often inferred from our posture, behaviours, and the way we choose to express ourselves. Mood disorders such as agitation, major depression, and various anxiety disorders including post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD) may occur following an acquired brain injury (ABI) and are associated with suffering, worsening of other ABI sequela, and poorer outcomes (Bedard et al. 2003; Berthier et al. 2001; Jorge 2005; Jorge & Starkstein 2005). Post ABI, depression is often seen once the implications of the injury become apparent. This may be a reaction to the injury or the result of the neurological changes that have taken place. For some, depression will develop within months of the injury but for others it will be a few years before clinical symptoms are diagnosed (Deb et al. 1999).

Silver et al. (2001) conducted 5034 interviews with individuals who had been diagnosed with a psychiatric disorder; 361 had a severe brain injury. Analysis of their data indicated the most prevalent issues were major alcohol and drug abuse or dependence (34%) and depression (11.1%). These findings are similar to those reported by other researchers (Deb et al. 1999; Hibbard et al. 1998; van Reekum et al. 1996). Individuals who experience depression post ABI may report feeling tired, helpless, hopeless, socially withdrawn, and having difficulty concentrating.  

Depression is often accompanied by anxiety and aggressive behaviours. Of note, those who develop aggression early in their recovery are at a higher risk for developing depression, which has been found to impact their length of stay in rehabilitation and their overall recovery (Jean-Bay 2000). Depression can exaggerate the effects of ABI and interfere with progress made during rehabilitation.

PTSD has been largely studied in those who have sustained a mild traumatic brain injury (TBI), particularly in military personnel; however, more recent work has also considered PTSD in the context of moderate and severe injuries. Population-based TBI samples report nearly 18% of individuals post TBI met criteria for PTSD (Barker-Collo et al. 2013). Individuals with co-morbid PTSD and TBI may experience cognitive impairment and sleep disruptions, along with anxiety and depressive symptoms (Barker-Collo et al. 2013).

Suicidal ideation and attempts are also more frequent among the TBI population. Rates of suicidal ideation (23-28%) (Mackelprang et al. 2014; Simpson & Tate 2002; Tsaousides et al. 2011) and attempts (26%) (Simpson & Tate 2005) are high post TBI, but can be further augmented through the presence of emotional disturbance and substance abuse (Simpson & Tate 2005).

Challenging behaviour following a brain injury occurs with a relatively high frequency (25-50%) (Baguley et al. 2006). Challenging behaviours include: non-compliance with treatment, anger, agitation, verbal and/or physical aggression, difficulties with emotional regulation and depression. The emergence of these behaviours likely arises from injury to the frontal lobes (and more specifically the orbitofrontal areas) resulting in disinhibited behaviour and lack of recognition of the consequences of one’s behaviour. Behavioural management and pharmacological techniques are often used to address these challenges. Each has been used with varying levels of success.

Few investigators have examined predictors of aggressive symptoms following brain injury, although it has been suggested that disinhibition and depression may result in aggressive behaviour in some individuals with brain injury (Backhaus et al. 2010; Kim 2002; Seel et al. 2010). In a sample of 228 patients with moderate to severe brain injury, Baguley et al. (2006) found depression and younger age to be predictors of aggression following brain injury at 6, 24, and 60 months. Severe levels of aggression may be more evident than previously reported, but due to the lack of consistency in how aggression is measured comparing study results may be difficult (Baguley et al. 2006).

Addictive behaviours (alcohol and narcotics abuse and gambling) have been shown to be a serious problem for some individuals both pre and post ABI. Various studies have looked at the incidence of these behaviours and have found that 30 to 60% of individuals who sustain an ABI have a dependence issues (Jorge & Starkstein 2005). Many individuals relapse post injury, often within the first or second year. Alcohol abuse has also been linked to major depression both pre (Dikmen et al. 2004; Seel et al. 2010) and post injury (Jorge & Starkstein 2005), although it remains unclear as to which problem evolved first, the alcohol abuse or the depression. Affective symptoms such as depression and anxiety along with aggression, agitation and addictive behaviours appear to be important determinants of functional and quality of life outcomes. They frequently cause significant distress for individuals with brain injury, their family members, and may result in diminished access to services. This module will review the evidence for both pharmacological and non-pharmacological treatments of depression, anxiety, suicidal ideation, OCD, PTSD aggression and agitation, difficulties in emotional regulation and addictive behaviours post ABI.