Serotonergic antidepressants and cognitive behavioral interventions appear to have the best preliminary evidence for treating depression following TBI. One study reported results of holistic, interdisciplinary milieu therapy, including individual and group treatment in a day program targeted to a wide range of cognitive and psychosocial outcomes (Svendsen et al., 2004). The 2 patients who partially responded to initial treatment eventually responded to maintenance ECT. Johnston M.V. There is the most evidence supporting the use of sertraline and citalopram. Phenelzine (Nardil) A monoamine oxidase inhibitor (MAOI) which inactivates a naturally occurring enzyme which breaks down the neurotransmitters serotonin, norepinephrine and dopamine. DSM-III-R criteria for neuropsychiatric conditions; Retrospective study of ECT 3 times per week (total no. Spielman L. Flanagan S. Ginsberg A. Engmann C. Egan M. Ambrose F. Greenwald B. Koponen S. Taiminen T. Portin R. Himanen L. Isoniemi H. Heinonen H. Hinkka S. Tenovuo O. Axis I and II psychiatric disorders after traumatic brain injury: A 30-year follow-up study. Based on the best evidence available to guide pharmacological treatment, it is advisable to start with low doses of medications with slow titration toward a therapeutic response, being cognizant of adverse effects that may be more common in neurologically-injured patients (e.g., seizures, sedation, and cognitive dysfunction), and using depression measures that have been validated in the TBI population, such as the Patient Health Questionnaire-9 depression scale (PHQ-9) (Fann et al., 2005). Esper R.M. The aim of this systematic review was to critically evaluate the evidence on interventions for depression following traumatic brain injury (TBI) and provide recommendations for clinical practice and future research. The small sample size, short study duration, and attenuated dosage titration limit the ability to draw firm conclusions from this study. Are SNRIs more effective than SSRIs? There was one evidence class I study, one class II study, two class III studies, and nine class IV studies. Cuijpers P. van Straten A. Wamerdam L. Problem solving therapies for depression: A meta-analysis. Ashman T.A. McMillan T. Brief mindfulness training for attentional problems after traumatic brain injury: A randomised control treatment trial. U.S. Food and Drug Administration. Am J Psychiatry. Finkelstein E.A. House A. Xia J. Fann J.R. Uomoto J.M. New evidence suggests that antidepressant medication may be no more effective than placebo in this population. Sparling M.B. Arndt S.V. Are depressive symptoms nonspecific in patients with acute stroke? The ePub format is best viewed in the iBooks reader. More-commonly prescribed antidepressants in this category include trazodone, mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd) and bupropion (Forfivo XL, Wellbutrin SR, others). Krieger CA (expert opinion). And sometimes a combination of medicines may be an option. Neuropsychol Rev. As noted earlier, both biomedical and psychosocial factors contribute to MDD in people with TBI. The societal cost of TBI, including direct medical costs and indirect costs, has been estimated at $60 billion in the year 2000 in the U.S. alone (Finkelstein et al., 2006). If we combine this information with your protected Based on the current evidence, we identify gaps in the literature and make recommendations for clinical care and future research. There was considerable variability in the treatment models used in this set of studies. MeSH Cifu D.X. Traditional MAOIs are not recommended due to a lack of efficacy data and potentially serious side effects, particularly when dietary restrictions are not adhered to in a population with a high rate of cognitive difficulties. Open trial of donepezil for 3mo: 5mg/d for 1mo, then 10mg/d for 2mo, Nonsignificant reduction in HADS depression scores from baseline (6.84.4) to 3mo (5.03.0); significant improvement in processing speed, learning, and attention on neuropsychological testing, Open trial of moclobemide (450600mg/d), either as a single dose or 3 divided doses, for 36wk, Baseline HAM-D=23.4 (range 1729), mean HAM-D reduction was 81%; 23/26 defined as responders (HAM-D<10 or 50% reduction); irritability scores dropped by 57% and pain scores dropped by 39%, Open trial of citalopram (20mg/d) and carbamazepine (600mg/d) for 12wk, Open trial of citalopram at 20mg/d for 6wk (n=29) or 2050mg/d for 10wk (n=26), At 6wks (n=54), 27.7% responded (50% drop in HAM-D), and 24.1% remitted (HAM-D<7); at 10wk (n=26), 46.2% responded and 26.9% remitted, Open trial of sertraline (50100mg) for 46wk, Marked clinical response in patient with major depressive-like episode (BDI-II dropped from 30 to 10); some improvement in 2 patients with depressive features (BDI-II dropped from 16 to 9 in one patient; the other was untestable), RCT of Flexys Neurotherapy System of biofeedback (EEG recording with photic feedback) for 25 sessions over 58wk (6 active treatment and 6 wait-list controls), Significantly greater pre-post improvement on BDI in intervention group (22.59.9 to 7.05.3) versus control group (16.79.8 to 16.212.2); within subjects (n=12) BDI scores significantly improved from pre-treatment (19.311.1) to post-treatment (7.96.9) and 3-mo follow-up (7.86.7), Chronic depression diagnosed by professional or self-response to local newspaper, unresponsive to antidepressant, Open 2-group study of magnetic field (1-microtesla burst once a week for 6wk); 7 subjects across left frontal lobe (3 dropped out); 7 subjects across bilateral temporal lobes, BDI scores significantly decreased from baseline (19.78.6) to 6wk (14.15.2) and 6wk after end of treatment (15.17.6); no difference between regions of application of magnetic field, Persistent or frequently intermittent depression diagnosed by physician, unresponsive to antidepressant, Open study of magnetic field (1-microtesla burst, once a week for 5wk) across bilateral temporal lobes, Significant decrease in BDI over 5wk: mean 339 to 179; SCL-90 depression scale dropped by 1.5 SD, but not statistically significant, Severe TBI with multiple injuries and significant pain, Classical Chinese medicine acupuncture points on limbs and thorax, No change in pre-post HADS depression (7/21) or anxiety (9/21) score, despite subjective improvement in anxiety and mood, and significant improvement in pain scores. The rate of non-responders at the end of the follow-up period was lower in the treatment groups compared with placebo (odds ratio = 0.42, 95% confidence interval: 0.15-1.17); this difference was not statistically significant (p = 0.10). The limited data available on pharmacotherapy for depression after TBI do not provide definitive evidence of efficacy for any specific class of medications. Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. 1Departments of Psychiatry and Behavioral Sciences, Rehabilitation Medicine, and Epidemiology, University of Washington, Seattle, Washington. Thompson R.S. However, in this study more than 50% of participants dropped out of treatment, and the results were based only on analysis of pre- to post-treatment scores from 13 who remained. In the subgroup analysis according to the antidepressant used in the included studies, there was a trend towards statistical significance for sertraline only (odds ratio = 0.28, 95% confidence interval: 0.08-1.03; p = 0.05); this was not evident in the study that reported the use of citalopram (odds ratio = 0.83; 95% confidence interval: 0.15-4.64; p = 0.84). These include monoamine oxidase inhibitors (MAOIs). Depression following traumatic brain injury. Psychiatric illness following traumatic brain injury in an adult health maintenance organization population. "If you have a stroke, the glial cells, the white cells in the brain, release these . In subgroup analysis of the studies that reported mean Hamilton Depression Rating Scale score differences between treatment and control groups in both baseline and endpoint evaluations, the pooled mean difference was reduced from 2.11 (95% confidence interval: -1.25 to 5.46) to -2.36 (95% confidence interval: -5.59 to 0.87), in favour of the treatment group, though not statistically significant (p = 0.06). It may manifest as agitation . Joseph A.B. In a case series by Cassidy and co-workers (Cassidy, 1989), of fluoxetine treatment for MDD with melancholia after moderate to severe TBI (also not included in the evidence table because it relied on subjective reports of depressive symptoms by staff, patients, and family members), 50% complained of sedation, and 3 of 8 patients complained of anxiety. doi: 10.1001/jama.2010.599. The evidence for depression treatments after neurological insult is scarcer, although at least one Cochrane review has examined treatments for depression after stroke (Hackett et al., 2008). The mean Beck Depression Inventory-II (BDI-II) score in the Bedard and Persinger (Bedard and Persinger, 2003) study (18.4) was consistent with mild depression. Many types of antidepressants are available to treat depression, including: Most antidepressants are generally safe, but the U.S. Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. We argue that this finding should not change practice, i.e., patients who present with depression after TBI should still be considered for antidepressant treatment, because they may (1) benefit from robust placebo effects, (2) benefit from an alternative or adjunctive medication if the agent prescribed first does not achieve a depression remission, and (3) make improvements that are not captured well by traditional depression outcome measures, which are confounded by TBI sequelae. American Journal of Nursing. 8600 Rockville Pike Patients with mild TBI are especially appropriate for antidepressant therapy because they, on average, more closely resemble patients with no known TBI history enrolled in typical primary Major Depressive Disorder clinical trials than patients enrolled in TBI trials in placebo-controlled trials published to date. Interventions that involve explicit teaching, behavior change, and/or environmental manipulations cannot typically be hidden from the patient or the treater; thus the removal of bias by using standard blinding procedures, such as placebo treatment, is not straightforward (see also Hart et al., 2008). In terms of development and validation of outcome measures, more attention should be paid to measures of depression that do not require verbal self-report, particularly for participants with severe cognitive or linguistic impairments. Some of the most common antidepressants prescribed include Fluoxetine hydrochloride (Prozac), Sertraline (Zoloft), Fluvoxamine (Luvox), and Venlafaxine (Effexor). The agents that were studied included tricyclic antidepressants (TCAs: amitriptyline and desipramine), monoamine oxidase inhibitors (MAOIs: phenelzine and meclobemide), and selective serotonin reuptake inhibitors (SSRIs: fluoxetine, sertraline, and citalopram). Bogyi A.M. Safety and efficacy of ECT in patients with head injury a case series. It's been more than a year now. Antidepressant drugs. Irritability and pain scores also improved, and 4 patients dropped out due to gastrointestinal side effects. Clinical trials for hidradenitis suppurativa, Coping with the stress of hidradenitis suppurativa, Coping with the emotional ups and downs of psoriatic arthritis, Creating a hidradenitis suppurativa care team. Main body: How to tell if a loved one is abusing opioids. Significant cognitive impairment was not reported in this small case series. Her depression is a result of her injury, it seems, and she just can't seem to kick it. Amitriptyline versus other types of pharmacotherapy for depression. A new study found that antidepressants can help brain cells grow and survive after brain trauma, and can even lead to improved [] Anson and Ponsford (Anson and Ponsford, 2006) reported that their 5-week group CBT-based treatment had no significant overall effects on coping style, mood, or adjustment, in 33 persons with primarily severe TBI. Documented Search Protocols for Treating Depression in Persons with TBI.