Table 3.
Overview of Psychotherapeutic and Rehabilitation Intervention Studies for Depression in Persons with TBI (n = 8)
| Authors | AAN evidence level | Depression inclusion criteria | Total no. | TBI: n severity acuity | Depression entry criteria | Depression instruments | Design and intervention | Results and conclusions |
|---|---|---|---|---|---|---|---|---|
| Powell et al., 2002 | I | C | 110 | 110 At least moderate TBI (PTA >24 h or neurosurgical intervention); nearly all had PTA >1 wk; majority had PTA >1 mo 3 mo–20 y post-TBI; median 1.37 y |
No depression criteria 15% scored >13 on HADS pretreatment |
BICRO-39 Psychological well-being subscale rated by participants and caregivers given to 75 participants HADS given to 46 participants with sufficient cognitive ability |
RCT with masked outcome assessment Experimental = individualized, goal-planning-oriented multi-disciplinary team treatment in home or community setting, 2–6 h/wk for mean of 28 wk Control = information condition; 1 home visit with individualized resource booklet |
Primary outcome = Barthel Index and BICRO-39 at mean 2-y post-randomization; experimental > control on both measures (p < .005) 68% of experimental and 50% of control group improved on BICRO-39 psych subscale (p < 0.05) 50% of experimental and 54% of control group improved on HADS (ns) |
| McMillan, 2002 | II | C | 145 | 145 TBI (any severity) with attention complaints or deficits on neuropsychological testing; mean PTA ∼1 mo 3–12 mo post-TBI |
No depression criteria | HADS | RCT with masked outcome assessment Experimental = attention control training: five 45-min sessions supervised practice using audio tape for 4 wk; daily independent practice with tape Control 1 = physical fitness training with same amount of therapist contact and independent practice Control 2 = no treatment, no therapist contact |
Primary outcome not specified No significant group differences were found on HADS or other measures. Pre-treatment HADS 7 ± 5 ACT group, 5 ± 4 exercise group, 5 ± 4 control group; post-treatment HADS 5 ± 4 ACT group, 4 ± 4 exercise group, 6 ± 5 control group |
| Tiersky et al., 2005 | II | C | 20 | 20 Mild/moderate TBI (GCS >8, LOC ≤4 h); 40% had no LOC At least 1 y post-TBI; mean 6 y |
No specific depression criteria Inclusion: complaints of emotional distress on SCL-90-R |
SCL-90-R depression scale | RCT with masked outcome assessment Experimental = “comprehensive neuropsychological rehabilitation:” cognitive remediation (attention process training, memory notebook, problem solving) + CBT; two 50-min individualized sessions, w/daily 30-min homework, 3 × /wk × 11 wk Control = wait list/attention control × 11 wk, with a total of 2 or 3 45-min contacts from primary investigator |
Primary outcome = SCL-90-R GSI; experimental < control (p < .05) Depression scale on SCL-90-R, experimental < control (p < 0.05) Authors noted that post-treatment means remained above “caseness” levels |
| Anson and Ponsford, 2006 | IV | C | 33 | 33 Mean PTA 32 d; ∼90% had PTA <1 wk 46 d–7 y post-TBI |
No depression criteria | HADS | Pre-post-treatment design (data were pooled from two groups with different baselines) Experimental = CBT-based coping skills group, 10 sessions (two 90-min sessions/wk) over 5 wk + homework assignments Control = baseline phase × 5 wk |
Primary outcome not specified Change in HADS depression from pre- to post-treatment = ns (% change = 1.3 ± 41) Authors reported that several variables correlated with higher percentage of improvement in depression (e.g., greater self-awareness, less severe injury, higher premorbid intelligence) |
| Bedard et al., 2003 | IV | C | 13 | 13 Severity not noted At least 1 y post-TBI |
No depression criteria Exclusion: “major concurrent mental illness,” suicidal ideation |
BDI-II | Pre-post treatment design Experimental = weekly group × 12 wk based on mindfulness meditation Control = none; data from three treatment drop-outs used as comparison group |
Primary outcome not specified Change on BDI-II pre- (18.4 ± 12.2) to post-treatment (9.7 ± 10.6) = ns Group × time interaction for BDI-II approached significance (p = .06); treatment completers scored lower and treatment dropouts scored higher (worse) at follow-up |
| Gurr and Coetzer, 2005 | IV | C | 20 | 20 (13 for 3-mo follow-up) 9 mild, 3 moderate, 8 severe At least 6 mo post-TBI; range 7–474 mo |
No depression criteria Exclusion: “psychiatric conditions” |
HADS | Pre-post treatment design (data from a pretreatment baseline phase were presented but not analyzed) Experimental = CBT-based treatment focused on headache management; three weekly relaxation groups +6 30-min individual sessions every other week + 1 follow-up session Control = pre-treatment baseline × 10 wk (data presented but not analyzed) |
Primary outcome = headache frequency and intensity; decreased after treatment Change in HADS pre- (9.7 ± 4.1) to post-treatment (8.5 ± 4.6) = ns |
| Ownsworth, 2005 | IV | n/a | 1 | 1 Severe TBI; coma 6 d; PTA 12 d 4.5 y post TBI |
n/a | DASS | Case report with masked outcome assessment 13 weekly psychotherapy sessions with brain injury education and CBT skills with focus on defensive denial, plus attendance at three TBI group sessions |
Primary outcome not specified Pre-treatment depression on DASS extremely severe (34/42); 1 wk post-treatment depression in normal range (2/42) |
| Svendsen et al., 2004 | IV | C | 143 | 38 Severity not noted; eight had “pure frontal injury” per neuroimaging Acuity not noted |
No depression criteria Exclusion: “psychiatric or progressive neurodegenerative illness” |
EBIQ Depression subscale completed by participants and relatives | Pre-post treatment design Experimental = interdisciplinary, holistic day treatment administered in “classes” of 16 participants; daily for 4 mo + 8 mo close monitoring in community Control = none |
Primary outcome not specified EBIQ depression scores converted to z scores by comparing to uninjured controls; pre-treatment z = –1.1; post-treatment z = –0.5 Similar results for self and relative ratings Authors notes that z scores changed significantly pre- to post-treatment, but remained worse than controls |
Depression Inclusion Criteria
A. Prospectively enrolled depressed patients
B. Depressed patients retrospectively identified at baseline
C. Pre-post depression scores only, with no selection for depressed patients at baseline
ACT, Attention Control Training; GSI, General Symptom Index; AAN, American Academy of Neurology; DASS, Depression Anxiety Stress Scale; EBIQ, European Brain Injury Questionnaire; TBI, traumatic brain injury; BDI, Beck Depression Inventory; BICRO-39, Brain Injury Community Rehabilitation Outcome-39 scales; HADS, Hospital Anxiety and Depression Scale; LOC, loss of consciousness; SCL-90-R, Symptom Checklist-90-Revised; RCT, randomized controlled trial; PTA, post-traumatic amnesia; GCS, Glasgow Coma Scale; ns, not significant. n/a, not available; CBT, cognitive behavioral therapy.