Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury

Abstract

IMPORTANCE Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.OBJECTIVE To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI). DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study. MAIN OUTCOMES AND MEASURES Probable PTSD (PTSD Checklist for DSM-5 score, Ն33) and MDD (Patient Health Questionnaire-9 Item score, Ն15) at 3, 6, and 12 months postinjury. RESULTS Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk. CONCLUSIONS AND RELEVANCEAfter mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations

“…Although reported rates of VA service utilization were comparable between rural and urban groups, discordantly higher morbidity rates highlight a need for increased rural access to community resources 38 and to prevent further decline using maladaptive coping mechanisms, such as alcohol. 19,21,38 Importantly, the services required are "low-tech," primarily encompassing mental health, and community resources. For this reason, targeted interventions aimed at reintegration and patient education are of particular importance.…”

“…18 Lack of health care engagement in the setting of persistent symptoms can present significant challenges to have deleterious impacts to socioeconomic self-sufficiency and cause development of maladaptive coping mechanisms. [19][20][21][22][23][24] Recovery in rural and/or low-resource settings presents additional challenges for rehabilitation and training for both patients and providers. 23,24 Understanding unique considerations in rural health care utilization after mTBI/concussion is critical to improve access and reduce health care burden.…”

An integrated perspective linking physiological and psychological consequences of mild traumatic brain injury

“…Interestingly, chronic stress can (also) be measured in hair samples. In fact, differences in long-term hair cortisol levels have been found between various mental illness such as major depressive disorder, anxiety disorders and post-traumatic stress disorder, illnesses which are also quite common after mild TBI [44,55]. Since hair grows approximately 1 cm per month, hair analysis is also informative of the cortisol levels before and after a stressful event, which makes it possible to investigate stress before and after mTBI, and more specifically, to investigate whether pre-injury stress levels are associated with chronic stress after injury.…”

Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations

“…Perhaps most detrimental for the long-term outcomes of rural pediatric TBI patients is the decreased utilization of mental health services [20]. Psychiatric sequelae following TBI are prevalent, well-documented, and can profoundly and permanently impact the patient's quality of life and economic productivity [30][31][32]. The development of PTSD and major depressive disorder are also linked to demographic risk factors, such as trauma secondary to violence, and lower education levels [30].…”

“…Psychiatric sequelae following TBI are prevalent, well-documented, and can profoundly and permanently impact the patient's quality of life and economic productivity [30][31][32]. The development of PTSD and major depressive disorder are also linked to demographic risk factors, such as trauma secondary to violence, and lower education levels [30]. Given the overlap between the rural population and these risk factors, rural pediatric TBI patients may be most at risk for the development of secondary psychiatric symptoms.…”