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ORIGINAL ARTICLE
ABSTRACT
Introduction: Traumatic brain injury(TBI) is a major cause of disability. Depression is one of the major squeal of TBI in
both inpatient and outpatient populations. Depression is associated with numerous negative outcomes, thus affecting
qualityoflife(QOL) adversely in these patients. Addressing depression in treatment regimen of TBI may improve QOL
of these patients.
Objective: The present study is designed to evaluate the role of sertraline in post TBI depression and its impact on QOL.
Materials and Methods: Eighty male patients with post TBI depression were included in the study among the 250male
patients of mild to moderate TBI recruited for the evaluation. Half of the patients were given sertraline 50mg PO, whereas
other half served as control without sertraline treatment. Participants were assessed on Glasgow Coma scale, Patient Health
Questionnaire9(PHQ9) and World Health Organization QOL(WHOQOL) at regular interval till the end of 6months.
Result: Depression was found in 35.6% of total patients recruited. Most of the patients(63.1%) were below 35years
of age. Depression was more common in mild TBI cases than those with moderate TBI(53.7% vs. 46.25%, P=0.04).
Left side brain injury(56.25%) with cerebral contusions was more commonly associated with depression(P=0.04).
Patients in sertraline group responded well to treatment with significant improvement in mod symptoms(PHQ9 score
14.883.603vs. 5.332.98, P=0.04)). All the four domains of QOL improved significantly in sertraline group than
the control group with sertraline treatment.
Conclusion: Management of TBI should also focus on treatment of associated mood symptoms, which is likely to be
associated with poor QOL in these patients. Sertraline has been found to be effective in the treatment of depression with
significant improvement in QOL in TBI patients.
Key words: Depression, quality of life, traumatic brain injury
Introduction
Traumatic brain injury(TBI) is a major cause of disability.[1] One
of the major sequelae of TBI is depression in both inpatient
and outpatient populations.[2] Most studies in this regard
have included a majority of patients with moderate to
severe injuries, though patients with mild injuries also have
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DOI:
10.4103/1793-5482.146597
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Measures
In this study, the interview was focused on assessment of
severity of TBI, depression and QOL using GCS, PHQ9 and
WHOQOLBREF.
Glasgow Coma scale,[20] an extensively used clinical scale for
assessing the depth and duration of impaired consciousness
and coma. Three aspects of behavior are independently
measuredmotor responsiveness, verbal performance, and
eye opening. These can be evaluated consistently by doctors
and nurses and recorded on a simple chart which has proved
practical both in a neurosurgical unit and in a general hospital.
The scale facilitates consultations between general and special
units in cases of recent brain damage, and is useful also in
defining the duration of prolonged coma.
Depression was assessed by administering the 9item PHQ9,
a selfreport version of PRIMEMD11 which assesses the
presence of MDD using modified DSMIV criteria. There is
Asian Journal of Neurosurgery
Vol.9, Issue 4, OctoberDecember 2014
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Statistical analysis
Data were checked for normality, outliers, and missing data.
No imputation of missing data was performed. Statistical
analyses were performed by correlation analyses(Pearson and
Spearman) and Chisquare tests analyses.
Results
A total of 250male patients of TBI were recruited in this
study. About 35.6% of the 250patients were found to have
depression(n=89). Nine out of 89 depressive patients dropped
out from the study(10.11%). Finally, 80patients(32%) of TBI
with depression constituted the study sample.
Asian Journal of Neurosurgery
Vol.9, Issue 4, OctoberDecember 2014
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Control
Total
16
8
7
7
2
0
12
14
6
5
2
1
28
22
13
12
4
1
0.06
34
3
3
0
46
3
0
1
70
6
3
1
0.19
WHOQOL
17
23
26
14
43
37
0.04
12
10
18
12
9
19
24
19
37
0.96
11
24
5
16
21
3
27
45
8
0.4
Case
Control
Total
11
13
1
4
3
5
0
14
10
5
3
0
3
1
25
23
6
7
3
8
1
2
4
1
0
1
2
11
2
4
0
0
0
3
7
4
8
1
0
1
5
18
At start of study
Cases
Control
At end of study
Cases
Control
Mean
SD
14.88
13.2
3.603
3.107
0.22
5.33
6.29
2.987
3.221
0.04
PHQ9
CT scan findings
Mean
SD
38.88
40
11.882
10.997
0.66
39.5
45.3
14.338
14.848
0.07
47.6
45.95
15.751
14.789
0.6
37.43
44.45
12.683
10.261
0.08
45.38
33.5
11.816
12.635
0.001
47.23
39.13
16.623
13.354
0.01
58.15
40.65
18.565
20.202
0.001
43.55
39.6
13.027
11.845
0.16
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Discussion
Our study population was implicitly closed to the age of
distribution of TBI in general adult male population. The age
range was 18-86years with a mean age of 31.83years in the
intervention group and 32.95years in the control group.
Similar age distribution have been reported in earlier studies
by Verma etal.[25] and Jain etal.[4]
Out of 250 TBI patients, 35.6% patients developed depression.
This finding is supported by earlier studies, wherein depression
has been reported between 15% and 77% in post TBI patients
shortly after or well into the future.[4,69] This finding was
considerably less than the 77% reported by Varney etal.,[16]
who used DSMIII criteria, Conversely, these findings were
considerably more than the 14% reported by Deb et al.[26]
who relied on ICD10 diagnostic criteria. This variation in
prevalence rates may have been caused by methodological
issues including differences in depression assessment tools
used in the research, the time course of depression assessment,
and differences in injury severity of persons with TBI(mild
vs. severe injuries). This finding gets the robust support from
the study by Jorge etal.,[8] who reported that mood disorders
were significantly more frequent in patients who sustained
TBIs than in patients with similar background characteristics
who underwent similar level of stress but who did not sustain
brain injury. TBI has been consistently associated with damage
to the prefrontal cortex, basal ganglia, and the white matter
tract that connect these structures. Depression may be related
to the same physiologic mechanism.
Depression was more common in mild TBI patients than those
with moderate severity. This may be explained by the fact
that mild TBI patients are more likely to retain their cognitive
functions intact, thus are capable of acknowledging their
deficits caused by trauma. They may also explain their mood
symptoms explicitly as they experience it which may not be
the case with moderate or severe trauma.
The study data also support the relationship between duration
of head injury and depression. Incidence of depression was
higher(46.25%) in patients sustaining injury more than
6months back. This was supported by Varney etal., 1987[16]
who interviewed 120patients following TBI and found half
of the TBI patients not manifesting depression until at least
6months after injury. The notion supporting this fact is that as
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who were not given sertraline. The objective of this study was
the participant perspective, which is the normal perspective in
QOL studies. This perspective, however relies upon participants
having sufficient cognitive awareness to provide insight into
their own condition for meaningful assessments.[26]
Our study shows that the intervention group with sertraline
treatment improved significantly in terms of QOL in all the four
domains, whereas control group without sertraline treatment
further deteriorated in all the domains of QOL. Fann et al.,
2000[33] conducted an 8week, nonrandomized, singleblind,
placebo runin trial of sertraline on 15patients diagnosed
with major depression between 3 and 24months after a mild
TBI. On the Hamilton Rating Scale for Depression, 13(87%)
had a decrease in score of50%(response), and 10(67%)
achieved a score of7(remission) by week 8 of sertraline.
There was statistically significant improvement in psychological
distress, anger and aggression, functioning and post concussive
symptoms with treatment. However, Ashmann etal.,2009,[31]
found no statistically significant differences at baseline between
sertralline group and placebo groups on baseline measures of
depression(24.87.3vs. 27.77.0) or QOL(2.961.0vs.
2.90.9). There has been an understanding that the
psychological consequences especially depression are likely to
affect different aspects of QOL independently as it may lead to
poor participation in productive and healthy living, decreased
social and leisure activities, reduced sexual interest, poor drug
compliance further deteriorating the existing problem. The
overall improvement in QOL in these patients may be explained
by the improvement in depression with sertraline treatment.
Conclusion
Depression is common than a chance occurrence and may
lead to poor QOL in already compromised post TBI patients.
Antidepressant like sertraline has been found effective in
treating associated mood symptoms in this population.
Treatment of depression following TBI may significantly
improve functioning in different domains of QOL including
physical, psychological, social and environmental domains.
Given the myriad stressors that can affect a patients
physical, social, work, and family functioning, the finding
that pharmacological treatment of depression can improve
functioning in these areas is especially salient.
Limitations
There were several limitations in the present study.
Assessment of depression and its effect with sertraline was
based upon subjective experience that may have resulted
in underreporting or overreporting of symptoms. It is
recognized; however that subjective experience provides
only partial and sometimes inaccurate information regarding
the disease. Severe TBI cases were not included, due to their
inability to comprehend the directions. Hence the present
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References
1.
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