7.2 Depression Post ABI

 

Case Study (continued)

As mentioned earlier the patient appears to be depressed and is not responding to her family when they come to visit.  The patient is also menopausal.

Describe the difficulties in distinguishing between depression and frontal lobe syndrome post ABI.

1.    Many of the symptoms of depression mimic those of frontal lobe syndrome post ABI.  The following may be seen:

  • Impaired concentration
  • Reduced fluency of speech
  • Apathy
  • Inattentiveness
  • Delayed responses to questions
  •  A striking lack of inhibition, including socially inappropriate behavior (anger, agitation, aggression) 1
  •  Depression 2

2.    Many of the same features will be seen in depression.

3.    As well frontal lobe syndrome and depression can overlap whereby depression is seen as part of the frontal lobe syndrome.

7.2.1 The Beck Depression Inventory

Describe the Beck Depression Inventory (BDI).

  1. Designed to identify the presence of depression and to provide a quantitative express of its intensity 15.
     
  2. The BDI follows a forces choice format in which respondents must choose one of the 4 self-evaluative statements for each item in the inventory.
     
  3. Designed to evaluate 21 symptoms of depression.
     
  4. Each item is rated on a 4 point intensity scale with overall scores from 0-63.
     
  5. A score of 10 is generally accepted as indicating the presence of depression which scores of 10-18, 19-24, and 30-63 have commonly been used to classify mild, moderate and severe depression17;18; thus0-19 = no or minimal depression; 10-18 = mild to moderate depression; 19-29 = moderate to severe depression; > 29 = severe depression.
  • Within the ABI/TBI population the prevalence of depression ranges from 33-42%, with rates falling 3 years post injury 13.  
     
  • Depression has been found in approximately 26% of the ABI survivors 30 years post injury 14.
     
  • The Beck Depression Inventory is commonly used to measure depression post ABI.

What are the advantages of the Beck Depression Inventory?

  1. Short and simple measure of depression 19.
     
  2. Does not require formal training to administer.
     
  3. Does not heavily rely on the somatic symptoms of depression, making the BDI suitable for use with stroke patients 17.
     
  4. BDI has been tested with ABI/TBI patients 20

What are the disadvantages of the Beck Depression Inventory?

  1. Although the standardized cutoff is optimal for use with stroke populations, it has been found to yield a high rate of misdiagnoses (approx. 31%) among stroke patients 17.
     
  2. Some stroke patients have been reported to have difficulty with the BDIs forced choice format 21.

For a more detailed discussion on the BDI please see ERABI/Assessment of Outcomes Following Acquired/Traumatic Brain Injury.

7.2.2  Treatment of Depression

What medications would be recommended to treat her depression?

  1. SSRIs would be considered the first line of treatment for depression post ABI.
     
  2. SSRIs have the added benefit of treating other mood states such as anxiety and agitation.
     
  3. Tricyclic antidepressants can be used  but are generally not ideal due to a high incidence of side effects, in particular depression.
     
  4. May serve an added benefit of treating pain and sleep disturbance, in addition to depression.
  • For those who have been diagnosed with depression following an ABI, various non-pharmacological and pharmacological treatments have been suggested. 
     
  • For pharmacological treatments SSRI medications are considered the first line of treatment 22
     
  • Non-pharmacological treatments may include exercise, psychotherapy or other forms of counseling. 
     
  • Both patients and their caregivers should be made aware of the risk of depression and patients should be monitored for depression 22.

Summarize the medication that are used to treat depression post ABI.

 

Summary of medication used to teat depression post ABI.

 

Anti- depressants post ABI

Reason

Amount Given

Effect

Levels of Evidence

Citalopram23

To assist with the reduction of depression, anxiety and to improve overall mood

10 mg per day was administered.  Along with this 600 mg per day of carbamazepine was given to patients.

Citalpram and carbamazepine may help in the treatment of mood disorders resulting from an ABI.

Level 4

Sertraline24

Sertraline was given to reduce major depression

Patients began taking 25mg/day but at the end of the 8 weeks some had their doses increased to 200mg daily.  Increases in medication occurred only if the patient was tolerating the drug.  

Depression decreased while on sertraline

Level 2

Desipramine25

To help reduce depression

Desipramine was given to those who had sustained an ABI.  150 mg per day was given for the first 30 days.  This was increased (if needed) to 300 mg per day during the 2nd month.

Desipramine assists in reducing depression and improving mood post injury.

Level 2

Although these medications assisted in improving mood and decreasing depression post injury, more study is needed on each treatment.

For more details on the effectiveness of these medications please see ERABI/Mental Health Issues Post ABI.