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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 23-27

Predictors of depression among patients having post traumatic brain injury


1 M Sc Nursing student, MOSC College of Nursing, Kolenchery, Ernakulam, Kerala, India
2 Associate Professor, College of nursing, AIIMS, Bhubaneswar, India
3 Associate Professor, Department of Psychiatry, MOSC Hospital, Kolenchery, Ernakulam, Kerala, India

Date of Web Publication10-Jul-2019

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-1505.262501

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  Abstract 


Introduction: Traumatic Brain Injury (TBI) is associated with multiple neuropsychiatry sequelae, including problems with cognition, emotion and behaviour.The present study was undertaken to assess the cognitive dysfunction and severity of depression among patients with post Traumatic Brain Injury.
Materials and Methods: The quantitative, descriptive cross sectional survey design on 154 patients with post TBI, attending followup OPD were enrolled. The Hamilton Rating Scale for Depression (HAMD) was used. Result revealed that 37.7% of subjects had mild depression, 34.4% had moderate depression whereas 27.9% didn’t report any depressive symptoms. The significant predictors of depression were gender (OR =3.80, 95% CI=1.50-9.63) nuclear family (OR=3.00, 95% CI=1.19-7.56), severity of injury (OR =7.13, 95% CI= 1.90-26.76) and job loss (OR=0.12, 95% CI=0.03- 0.41). Conclusion: Patients with TBI are at great risk for developing depression. Nurses should be trained in using standardized scales to identify depression and to refer for the treatment accordingly. Screening and early identification of depression among post TBI patients helps in the prompt treatment which ensures faster recovery and improvement in their quality of life.

Keywords: Traumatic Brain Injury, Cognitive Dysfunction, Depression


How to cite this article:
Varghese M, Baby RS, Nisha A, Sreekumar G. Predictors of depression among patients having post traumatic brain injury. Indian J Psy Nsg 2018;15:23-7

How to cite this URL:
Varghese M, Baby RS, Nisha A, Sreekumar G. Predictors of depression among patients having post traumatic brain injury. Indian J Psy Nsg [serial online] 2018 [cited 2022 Oct 6];15:23-7. Available from: https://www.ijpn.in/text.asp?2018/15/1/23/262501




  Introduction: Top


Traumatic Brain Injury (TBI) is one of the assaults to the brain that can cause severe complications to a person’s normal function , Brain Injury can cause many kinds of physical, cognitive and behavioral or emotional impairments those could be either temporary or permanent . Depressive disorder appears to be the most prevalent psychiatric disorder after TBI, with a point prevalence rate over 25%. The reported period prevalence of depression within the first year is 33% to 42% and within the first seven years post injury is 61%. The increased risk of depression is also present among those with mild TBI. There is also an increased risk of suicide subsequent to TBI, with one study reporting that 10% reported suicidal ideation at one year post TBI and 15% attempted suicide by 5 years post-injury.

Depression is associated with a threefold decrease in adherence to medical regimens in patients with chronic illness. In persons with neurological and medical conditions, depression may exacerbate neuropsychological impairment and slows the pace of cognitive recovery. Depression post TBI is associated with worse global outcomes, poor social functioning during the first year post TBI and lower health related quality of life, even after controlling for demographic, medical and neuropsychological factors. The persons post TBI with depression lasting more than six months exhibit deterioration in social functioning and performance of activities of daily living. Depressed TBI patients also report more severe post-concussive symptoms like headache, blurred vision, dizziness and memory impairment, compared to non-depressed TBI patients . Major depression is a frequent complication of TBI that hinders a patient’s recovery. It is associated with executive dysfunction, negative effect, and prominent anxiety symptoms. Depression reduces quality of life, impairs ability to function in social and work roles and causes self-doubt and difficulty taking action, all of which can delay recovery from TBI. Patients, clinical care providers, families and support organizations need to know the degree to which depression after TBI is a threat so that anticipatory guidance and care planning can incorporate strategies to address risk of depression or prevent onset. Health care providers need to know when and how best to screen TBI patients for depression, so that treatment can be instituted early and the quality of life of the patients can be improved .

Objectives of the study were 1) To assess the severity of depression among patients with post traumatic brain injury and 2)To identify the predictors of depression among post traumatic brain injury patients


  Materials and Methods Top


Study was conducted at a tertiary care hospital after obtaining formal permission from concerned authorities and ethical committee. One hundred and fifty four subjects with mild and moderate brain injury were selected consecutively from Neurosurgery OPD, MOSC Medical College Hospital, Kolenchery, if they fulfilled the inclusion criteria of the patients who are diagnosed with Mild ( GCS 9-12) or Moderate Traumatic Brain Injury (GCS 13-15), with post traumatic brain injury period of more than three months, aged 18-60 years and accompanied by a family member. After details of the study were explained the subjects were allowed to read the patient information sheet and consent was taken except from the patients with previous history of psychiatric or neuro disorders. The Hamilton Rating Scale for Depression (HAMD) was used to assess the severity of depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss and somatic symptoms.


  Results Top


Description of Demographic and illness related variables of subjects

As depicted in [Table 1], most of the subjects (66.2%) belonged to the age group of 40-60 years, 33.8 % of the subjects were in the age group of 20-40 years. Among the subjects 66.2 % were females. With respect to the type of family, majority of the subjects (62.3 %) belonged to the nuclear family. More than half of the subjects (51.3%) were educated below 12th standard level, 24.0% of subjects were graduates, 21.4% of subjects were educated up to primary level of education and 3.2% of subjects didn’t receive any formal education respectively. About the primary caregivers of the subjects, most of them (59.1%) had their spouses as their primary care givers. Regarding the support person, majority of the subjects (61.0%) had two or above support persons and 39.0% had one support person.
Table 1: Frequency and percentage distribution of demographic and clinical characteristics of the subjects n = 154

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According to type of injury, 56.5 % of subjects presented with the history of fall and 43.5 % had TBI as a result of RTA, 69.5 % had mild brain injury and 30.5 % had moderate brain injury. About the duration, majority of the subjects (53.9%) had their injuries from one to ten years and 46.1% had less than one year, out of them 45.5 % were using at least one substance occasionally and 54.5% of subjects were not using. At the time of injury, only 0.6% of subjects were under the influence of substance whereas 99.4% of subjects were not under the influence of any substance. As a result of brain injury, 33.8% of subjects had lost their job and 66.2% of subjects had their job. None of the subjects had any history of focal brain diseases. Out of 154 subjects 19.5% were getting treatment for medical illness where as 80.5% were not on any treatment.

The significant socio-demographic and clinical variables after univariate analysis were plotted into the regression model for identifying the predictors of depression among subjects with TBI. As depicted in the [Table 2], the variables predicting depression among subjects were gender, type of family, severity of injury and job loss as a result of injury. The strong independent predictors (Odds ratio greater than 3) of depression among subjects were moderate severity of injury(OR=7.13, 95%CI =1, 90-26.76, p <0.004), female gender (OR= 3.80, 95%CI =1.50-9.63, p=0.005), nuclear family (OR= 3.00, 95% CI =1.19-7.56, p<0.02) and job loss (OR=0.12, 95% CI =0.03-0.41, p <0.001) respectively.
Table 2: Predictors of depression using binary logistic regression model

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Thus it can be interpreted that the subjects who were having moderate severity of injury had 7.13 times more odds of

As depicted in [Figure 1], Depression scores revealed, 53 subjects (37.7%) had mild depression and 34.4% had moderate depression and forty three subjects (27.9%) had no depression post TBI.
Figure 1: Presence of Depression among patients with post traumatic brain injury

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developing depression as compared to mild brain injury(p<0.004). The female subjects had 3.80 times more odds of developing depression (p=0.005) compared to the males. The subjects who were from a nuclear family had 3.00 times more odds of developing depression (p<0.02) as compared to the subjects who were from a joint family. The independent factor that lowers the risk of depression (Odds ratio less than 1) was loss of job (OR= 0.12). The subjects without job loss have lessen the risk of developing depression as compared to the subjects with job loss (p<0.001).


  Discussion Top


Present study findings suggest that the most post TBI subjects (72.0% ) had depression and 27.0% had no depression. Going by severity of depression 37.7 % of the subjects had mild depression, 34.4 % had moderate depression and 27.9% of the subjects had no depression. Similar findings were reported by Hibbard MR et. al (1998), that after TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders. TBI is a risk factor for subsequent disabilities. It is clear that the Patients with TBI are at greater risk for developing depressive symptoms in more than half of patients post TBI. It might be because TBI impairs the ability to function in work related and social roles and difficulty taking action which affects the person’s quality of life adversely. These findings are supported by the studies done by Perry DC , Busch CR , Nini S and Fedoroff JP .

The predictors of depression in the present study were gender ((Females 0R=3.803, p=0.005), family (Nuclear 0R=3.002, p=0.020), severity of TBI (moderate OR = 7.130, p=0.004) and Job loss (0R=0.124, p<0.001). Gender and depression: present study reveals that the female subjects had 3.80 times more odds of developing depression (p=0.005) compared to the males.Similar findings were reported by Cnossen MC et.al , 2017 and Bombardier CH et.al (2010) that the predictors of depression were female gender, pre-injury depression, postinjury unemployment and lower brain volume. It might be due to unemployment of females who were living in nuclear family probably due to poor support system. Type of Family: the subjects who were from nuclear family had three times more odds of developing depression (p<0.02) as compared to the subjects who were from a joint family. It might be due to the poor support system. No studies were found with family related findings. Loss of Job after injury: the subjects without job loss, had lesser risk of developing depression as compared to the subjects with job loss (p<0.001). Supporting findings were reported by Cnossen MC et.al11(2017), that the predictors of depression were female gender, pre-injury depression, post-injury unemployment and lower brain volume. The study shows that having a job acted as a protective factor to decrease the severity of depression. Subjects with job loss had tendency to get into depression. It might be due to the financial crisis to meet the needs of the self as well as the family and being aware of the impaired ability of the subjects to perform in different work roles compared to pre-injury status.

Severity of Traumatic Brain Injury: studies done by Holsinger et al . (2002) Levine and Grossman et.al , Max et.al , Barker- Colloet.al reported that severity of TBI was a strong predictor of post TBI depression. Study done by Glenn et.al and Dikmen et.al reported that mild TBI patients had more depression when compared to moderate severity of brain injury. The present study findings also shows severity of brain injury as the strongest predictor of depression.The Subjects who were having moderate severity of brain injury had 7.13 times more odds of developing depression (p<0.004) as compared to mild brain injury. In present study, the subjects who were having moderate severity of brain injury had also associated contributory factors such as loss of job and living in nuclear family. In the present study most of the subjects experiencing moderate depression were those subjects who had lost their job due to the cognitive dysfunction related to the brain injury. Lack of family support and having financial burden of unexpected treatment expenses hinder the normal recouping mechanism from crisis situation, thereby aggravating their depression.

Recommendations: Case control studies can be undertaken to compare the depression

And qualitative study can be undertaken to explore the subjective experience of people experiencing depression after TBI.


  Conclusion Top


Patients with TBI are at greater risk for developing depression and it affects the cognitive functioning, impairs ability to function in social and occupational roles, which can delay recovery from TBI. Nurses working in neuro units should be trained in using standardized scales to identify depression and to refer for the treatment accordingly. Screening and early identification of depression among post TBI patients could help in prompt treatment which ensures faster recovery and improvement in their quality of life.


  Acknowledgement Top


We express our heartfelt gratitude towards Principal, MOSC College of Nursing management of MOSC Medical College Hospital, Kolenchery and the statistics department, our colleagues and all the subjects who participated in this study for their kind co-operation and goodwill.



 
  References Top

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American speech, language and hearing association. Traumatic Brain Injury.http://www.nioh.ac.zaw.  Back to cited text no. 2
    
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