The public was shocked the day the news broke about football great Junior Seau’s death by suicide. Here was a man who was popular and successful, but who had suffered depression related to chronic traumatic brain injuries, a condition called CTE, sustained during his football career. Since his death in 2012 much more study has been conducted into the connection between traumatic brain injury, or TBI, and depression.
Still, understanding how a TBI on mental health is in its early research stages. More needs to be known about how the jolt or blow to the brain can change the way feelings or thoughts are processed. People who have sustained a TBI are susceptible to depression for up to a year, or more, after the injury. In fact, studies have reported that 15%-50% of individuals with a TBI go on to develop depressive disorder.
The more that is understood about the connection between TBI and depression, the more proactive individuals who experience such a trauma can be in preventing severe depression. Proactive steps to minimize the risk of depression will also reduce the risk of other serious outcomes, such as increased substance abuse or even suicide.
What is TBI?
A traumatic brain injury (TBI) happens after someone receives a violent blow to the head, or if an object, such as a bullet, has penetrated their brain tissue. Other causes include explosive blasts, sports injuries, car accidents, and falls. A TBI is rated mild to severe, with the mild versions possibly only having a temporary affect. The more serious TBI can result in physical damage to the brain tissue, which can cause long-term health complications or even death.
Symptoms of a TBI may be evident immediately, but some may experience a delay of days or weeks in experiencing the effects of the injury.
Symptoms of a mild TBI include:
- Temporary loss of consciousness for some
- No loss of consciousness, but being in a state of confusion or disorientation
- Speech problems
- Sleep disruption
- Blurred vision
- Ringing in the ears
- Sensitivity to light or sound
- Mood swings
- Memory problems
- Symptoms of anxiety or depression
Symptoms of a moderate to severe TBI include:
- Prolonged loss of consciousness
- Vomiting and nausea
- Convulsions or seizures
- Persistent headache
- Dilation of the pupil or pupils
- Loss of coordination
- Fluid draining from nose or ears
- Numbness in fingers and toes
- Profound mental confusion
- Slurred speech
- Agitation, combativeness
Approximately 1.7 million Americans will sustain a TBI in a given year, with 1.1% living with a TBI-related disability. The most serious effects of a TBI include coma, being left in a vegetative state, and brain death.
What are the Signs of Depression?
Major depressive disorder is a serious mental health condition that impacts about 17 million Americans annually. The symptoms of depression include:
- Persistent low mood, sadness, or hopelessness
- Sleep issues, such as either insomnia or hypersomnia
- Difficulty concentrating or making decisions
- Slowed motor movements and cognitive functioning
- Weight gain or loss
- Irrational feelings of shame or guilt
- Loss of interest in usual activities
- Thoughts of suicide
TBI and Depression
While TBI can cause a range of psychiatric disorders, major depressive disorder is the most common. A reported 33%-42% of individuals who sustain a TBI develop a depressive disorder within the first year following the injury. The heightened risk of developing depression after a TBI applies to both mild cases as well as moderate to severe injuries. Additionally, suicide risk is high in individuals with a TBI, with 10% reporting suicidal thoughts at one year, and 15% having attempted suicide by the five-year mark.
A TBI can lead to depression in two ways. The injury itself can cause neurological changes in the brain that increase the risk of depression, or the stress of recovering from the TBI itself can also add to the risk. In addition, some may attempt to self-medicate with alcohol or drugs, which could lead to a co-occurring substance use disorder and bring on depression.
Some of the factors that contribute to depression in TBI patients include:
- Damage to the frontal lobe of the brain, which may impact the executive functions like emotion regulation. The TBI may have also upset the balance of neurotransmitters, or brain chemistry.
- Individuals recovering from TBI may become depressed as they realize how their daily life has been altered. They may experience a loss of independence and struggle to accept that.
- Genetics can play a role. If the individual with the TBI has a family history of depression he or she may be at higher risk.
It is critical that individuals who have developed depression following a TBI be treated for the depressive disorder. Depression can cause the individual to regress after making progress in rehabilitation. Depression can cause impairment, where the individual will not be able to perform basic daily functions. In addition, post-TBI depression can cause psychosocial dysfunction, which can lead to isolating behaviors.
Therapies for Treating TBI and Depression
The primary treatment protocol for individuals with TBI and depression involves psychotherapy. These are evidence-based therapies that are proven to be effective in treating major depressive disorder. Therapy can be provided in either individual sessions or in small groups. Most patients will participate in both forms of therapy, as each type offers benefits. Psychotherapies used for TBI-related depression include:
Cognitive behavioral therapy. CBT helps individuals learn to recognize when they are having negative thoughts, which result in behaviors that contribute to the depression. Over time the individual will change the thought distortions and replace them with positive self-talk and more productive behaviors.
Mindfulness-based stress reduction. MBSR uses intensive mindfulness training to help patients focus on their present experience, such as body sensations, thoughts, mental states, emotions in a non-judgmental manner. MBSR uses a combination of mindfulness meditation, yoga, body awareness, and examining patterns of behavior, thoughts, and feelings.
Dialectical behavior therapy. DBT is a subtype of CBT that helps the individual learn to cope with stress, to improve relationships, and to better regulate emotions. DBT uses mindfulness techniques in addition to teaching distress tolerance and relationship skills.
Antidepressants can be effective in a certain percentage of the individuals with TBI-related depression. Of the antidepressants studied, Zoloft (sertraline) and Celexa (citalopram) are the ones that demonstrated the best response rates. Alternative therapies, such as the brain stimulation therapies like electroconvulsive therapy or transcranial magnetic stimulation have also been helpful to some patients. There are certain conditions that will disqualify some patients from brain stimulation techniques, however.
Can Depression be Prevented in People with TBI?
Since depression is so common among individuals with a TBI it makes sense that if depression can be prevented, it should be attempted. A meta-analysis that included a total of 6,214 participants found that when preventative actions were taken it resulted in a 21% decrease in major depressive disorder. With such encouraging results reported it encouraged a study to be undertaken that was specifically targeted towards individuals with TBI.
The double-blind, placebo controlled randomized study, published in the Psychiatric Times, involved 94 participants of which 2/3 had mild to moderate TBI. Over the course of the study period, in the group given the antidepressant Zoloft, 6.3% developed depression. In the placebo group the rate was 21.7% that developed depression. These findings suggest that depression can be prevented in individuals with a TBI through the prophylactic use of Zoloft. Additionally, each person must consider the potential side effects that can accompany antidepressants.
More About Depression Treatment
Individuals with TBI-related depression have treatment options. Depending on the severity of the depression and level of impairment, there are two basic settings for treating depression. For mild depression, the individual can obtain treatment, such as psychotherapy and antidepressant drug therapy, via a private practice mental health practitioner. There are also more intensive outpatient depression treatment centers, such as day treatment at a facility where several hours of therapy per week can be provided.
For individuals with more severe depressive disorder, including those who are experiencing suicidal thoughts, a residential mental health program would be an appropriate treatment option. The residential setting provides continuous round the clock care and support. These programs provide housing for the individual to enjoy a safe, serene space where they can focus on getting better. Treatment is more targeted and also more intensive. Each day the individual will participate in a schedule of therapeutic activities that will help them learn how to manage the symptoms of depression.
Treatment of those who have suffered a TBI and developed depression is an area of study that is in need of more attention. While some studies have confirmed that a combination of the antidepressant Zoloft combined with psychotherapy, such as CBT, can improve quality of life for these individuals, more extensive research is needed. Experts in the mental health field see a need for large, controlled studies that will dig deeper toward finding safe and efficacious methods to help individuals with TBI live a fuller life, free of depression.
The Treatment Specialist Offers Information About TBI and Depression
The Treatment Specialist is an online resource for informative articles on mental health conditions and treatment options for adults, teens, and families. Access our online HCQ-9 depression quiz here. For more information and guidance please contact the team at (866) 644-7911.