Objectives:

The Vanderbilt Evidence-based Practice Center systematically reviewed evidence addressing key questions on depression after traumatic brain injury, including prevalence, optimizing timing and methods for diagnostic screening, and approaching treatment.

Data Sources:

We searched MEDLINE via the PubMed interface, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature and Published International Literature on Traumatic Stress for articles published in English.

Review Methods:

We included studies published from January 1966 to May 2010. We excluded those with fewer than 50 participants, participants age 16 or younger, or that did not address a key question. We identified 115 included publications: 14 were good quality, 74 were fair, and 27 poor.

Results:

The prevalence of depression after traumatic brain injury (TBI) was approximately 30 percent across multiple time points up to and beyond a year. Based on structured clinical interviews, on average 27 percent met criteria for depression 3 to 6 months from injury; 32 percent at 6 to 12 months; and 33 percent beyond 12 months. Higher prevalence measures were reported in many study populations.

Data are sparse to assess the relationship of severity, mechanism, or area of the brain injured to risk of depression. Few risk factors for depression have been studied across populations in models that adjust for confounding factors. Alcohol and substance use, coexisting illness or injury, degree of disability, and older age at injury may contribute to increased risk.

The literature is insufficient to determine whether tools validated in other populations for detecting depression appropriately identify individuals with depression after a TBI. Consideration of potential for coexisting psychiatric conditions is warranted. Anxiety disorders were the most common coexisting condition affecting 31 to 61 percent of those with depression after TBI. Post-traumatic stress disorder prevalence in the included literature suggests that it may also be common (37 percent). Little to no high-quality evidence is available about outcomes of treatment of depression after TBI. A single randomized controlled trial of sertraline showed nonsignificant improvements after 10 weeks.

Conclusions:

Considerable evidence finds depression to be common after all forms and severities of TBI. At all time points from injury, prevalence is higher than the estimated 8–10 percent in the general population. No evidence provides a basis for preferring one timeframe for screening over another, implying repeated screening is imperative. No evidence is available to guide treatment choices for depression after head injury.

Overall the evidence is low to guide screening and care for depression after TBI. Given at least 1.5 million TBIs per year with many potential consequences that impair quality of life and function, substantially greater efforts are warranted to understand the biologic causes, natural history, treatment, and prevention of depression after TBI.