Psychiatric Challenges in the First 6 Years After Traumatic Brain Injury: Cross-Sequential Analyses of Axis I Disorders

Past Studies

Past Studies yielded limited understanding of how to predict which individuals with TBI will develop Axis I psychiatric disorders, including mood and anxiety disorders, such as depression, phobias, posttraumatic stress disorder (PTSD), and obsessive compulsive disorders. The TBI population has a high prevalence for these disorders, with major depression the most frequent, followed by substance abuse, PTSD and then other anxiety disorders. Reports of psychiatric disorders prior to TBI have been consistently unreported or inaccurately estimated. Prevalence rates have not been substantiated and information often does not indicate the onset or resolution of these psychiatric disorders following TBI. It has been difficult to identify when people are most susceptible, post-injury, to having a psychiatric episode. It is important to know the time when disorders are likely to surface so that appropriate, time-relevant interventions can be developed. Cognitive and emotional impairments are the biggest barriers to successful community integration and independent functioning. 

This Study

This Study examines the frequency of Axis I disorders in people with TBI during the first six years post-injury. The following questions were used to obtain information: Are there any demographic differences between individuals with and without Axis I diagnoses after TBI? What are the cross-sectional (representative sample of the whole) differences in Axis I diagnoses across ages and years during the post-injury period (how long?) What is the longitudinal (long-term) change over time in Axis I diagnoses? What is the impact of age at injury, time posting (injury to time of assessment), and time in the study on Axis I diagnoses?

One hundred eighty-eight individuals with TBI from Mt. Sinai Hospital, New York City, participated in this study as well as individuals recommended by state brain injury associations and individuals recruited from newspaper advertisements, RTC website, and word-of-mouth. All participants were adults who sustained a TBI between March 1995 and December 2000, lived in the community at the time of enrollment, self-identified their TBI, were three to six years post-injury, 18-80 years of age, residents of the United States, and able to answer interviewers’ questions. After the initial assessment, participants were re-evaluated at 12 and 24 months. Eighty-three participants were assessed at 36 months. Telephone screening was used to determine eligibility for the study, obtain baseline information and determine any Axis I diagnoses prior to injury, since injury or currently using DSM-IV criteria (psychiatric assessment tool) for the structured clinical interviews. This study targeted major depression, posttraumatic stress disorder (PTSD), panic, obsessive-compulsive disorder, phobias and substance abuse.

Three predictors of outcome were analyzed: participant’s age, time since injury at first assessment; and differences of age at first assessment point from age at injury. The greatest number of participants were single, white males with a high school education, earning $0 to $20,000 per year. The pre-injury prevalence rates for individuals with TBI were higher than community base rates for both depression and substance abuse but were equivalent for PTSD and other types of anxiety disorders. Although substance abuse decreased post-injury, depression and various anxiety disorders, especially PTSD increased. All Axis I disorders decreased and remained stable for those who had a third assessment. Significantly more women were depressed, had PTSD and other anxiety disorders, and more men met criteria for substance abuse. Participants with Axis I diagnoses prior to TBI continued with these diagnoses while those who had no prior disorders did not. Data shows that there is a greater frequency in all disorders for all post-injury years and suggest that the first year may be the most vulnerable time as all groups showed an increase.

Who May Be Affected By These Findings

Persons with brain injury and their families, health professionals, community providers, caregivers and researchers.

Caveats

This study provided important information about the psychiatric challenges faced by people with TBI. Further research is needed to determine lifetime patterns and address factors that predict which individuals with TBI will have chronic Axis I episodes throughout their lives, and additional investigation needed to explore functional impacts of Axis I disorders on quality of life.

Bottom Line

Although there is a high incidence of Axis I disorders (depression, PTSD, other anxiety disorders, substance abuse) in people with TBI, these disorders decrease over time. The study showed that the time of injury had little impact on Axis I diagnoses. Pre-injury history of psychiatric disorders could be predictive of post-injury psychiatric disorders.

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