Major depressive disorder is markedly prevalent in patients with traumatic brain injury, developing in half of patients during the year after their injury in a single-center study, according to a report in the May 19 issue of JAMA.

This rate is nearly 8 times higher than that in the general population, and considerably higher than rates of 12% to 42% reported in previous high-quality studies that appear to have underestimated the problem, reported Charles H. Bombardier, Ph.D., and his associates at the University of Washington and Harborview Medical Center, Seattle.

Aggressive efforts are needed to educate clinicians about the importance of MDD in this population, they noted. Moreover, it would be advisable to integrate mental health services into standard TBI care and rehabilitation programs.

The investigators studied the issue because psychological impairments after TBI are significant causes of disability, yet the rates of MDD in this setting remain uncertain. More definitive studies could galvanize efforts to improve recognition and treatment of this important secondary condition, Dr. Bombardier and his colleagues said.

The study enrolled consecutive patients admitted with complicated mild to severe TBI to a level 1 trauma center in 2001-2005. Most of the participants were men who had been injured in vehicular crashes and had sustained complicated mild injuries. These subjects were assessed using the Patient Health Questionnaire (PHQ) depression and anxiety modules at baseline, monthly for 6 months, and bimonthly thereafter for 1 year. At 12 months, the participants were assessed using the European Quality of Life measure.

A total of 297 patients (53%) met criteria for MDD at some time during that interval, a rate nearly 8 times higher than that in the general population (7%). This also is higher than the rates reported in previous studies of TBI, which may be attributable to the fact that frequent assessments were conducted, and the investigators were able to capture the cases with transient (1-month) major depressive episodes, they said.

In addition, the sample was characterized by high rates of depression-related risk factors such as alcohol dependence and other preinjury mental health diagnoses, including posttraumatic stress disorder, Dr. Bombardier and his colleagues said (JAMA 2010;303:1938-45).

The median duration of depression was 4 months. There was no difference in the rate of depression between patients with mild TBI and those with severe TBI.

About half of the patients who developed depression did so within 3 months of their injury. This finding challenges the idea that poor awareness of impairment precludes depressive reactions during the first 6 months after injury. It also suggests that clinicians should take advantage of that early window of opportunity to identify and treat depression, or even to prevent it, the investigators noted.

MDD was associated with greater difficulty with mobility, usual activities, pain or discomfort, and role functioning. It was a significant predictor of comorbid anxiety, poor self-reported health, and lower quality of life.

About 16% of the subjects were depressed at the time they sustained the traumatic injury, and another 27% had a history of depression but were not depressed when injured.

The investigators cited several study limitations. For example, they said the presence or absence of major depressive disorder was based on telephone interviews using the PHQ-9, rather than more traditional diagnostic interviews such as the Structured Clinical Interview for DSM Disorders. Also, they said, the results might not be generalizable because the study was conducted at a single level I trauma center in the northwest region of the United States. Many of the patients were Medicaid recipients, and their ethnic/racial diversity was somewhat limited. Nevertheless, “aggressive efforts are needed to educate clinicians about the importance of MDD in this population,” they wrote.

The study was supported by the U.S. National Center for Medical Rehabilitation Research and the U.S. National Institutes of Health. Dr. Bombardier reported owning stock in Pfizer Inc.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

根据5月19日发表于《美国医学会杂志》(JAMA)上的一项单中心研究报告，创伤性颅脑损伤(TBI)患者的抑郁症(MDD)发生率显著，半数TBI患者在损伤后1年内出现MDD。

 

西雅图华盛顿大学Harborview医学中心的Charles H. Bombardier博士及其同事表示，这一发生率是一般人群发生率的近8倍，而且也明显高于既往高质量研究所报告的12%~42%的发生率。由此看来，既往研究似乎低估了这一问题。

 

他们指出，需要积极努力使临床医生意识到MDD在该患者人群中的重要性。此外，将心理健康服务整合入标准TBI护理和康复项目中是明智的做法。

 

研究者探讨该问题的原因在于TBI后的心理损害是致残的重要原因，而且此前也还不清楚MDD在TBI患者中的发生率。Bombardier博士及其同事表示，更多的明确研究有助于改善对这一重要继发疾病的认识和治疗。

 

该研究纳入的是一家1级创伤中心2001~2005年连续收治的并发轻度至重度TBI的患者。大部分受试者为因交通事故受伤且并发轻度TBI损伤的男性。在基线时、此后每个月(持续6个月)和每2个月(持续1年)，采用患者健康问卷(PHQ)的抑郁和焦虑模块对这些受试者进行评价。 在12个月时，采用欧洲生活质量指标对受试者进行评价。

 

研究者表示，共297例患者(53%)在这期间的某个时间点达到MDD诊断标准，这一发生率是一般人群(7%)的近8倍。该发生率也高于既往TBI研究所报告的发生率，其原因可能在于频繁进行评价以及研究者能够发现短暂性(1个月)抑郁症发作的病例。

 

此外，Bombardier博士及其同事表示，这些受试者具有许多抑郁相关危险因素，如酒精依赖和其他损伤前心理健康问题(包括创伤后应激障碍)(JAMA 2010;303:1938-45)。

 

抑郁的中位病程为4个月。轻度TBI患者与重度TBI患者的抑郁发生率无差异。

 

研究者指出，约半数患者在损伤3个月内出现抑郁。有观点认为，在损伤后最初6个月，患者对自身损伤认识不足可避免出现抑郁反应，而该研究结果对此提出了质疑。该研究还表明，临床医生应在早期阶段发现并治疗抑郁或甚至预防抑郁。

 

MDD与行动十分不便、日常活动、疼痛或不适以及角色功能相关。MDD是共病焦虑、自诉健康状况不佳和生活质量较差的显著预测因子。

 

约16%的受试者在发生创伤性损伤的时候出现抑郁，另27%的受试者有抑郁病史但在损伤时无抑郁。

 

研究者表示，该研究存在一定局限性。 例如，抑郁症的诊断是基于采用PHQ-9问卷的电话采访，而非基于更为传统的诊断采访，如DSM障碍的结构化临床采访(Structured Clinical Interview for DSM Disorders)。此外，他们表示，该结果不具有普遍意义，因为该研究仅在美国西北部的单个1级创伤中心开展。许多患者为医疗补助领取者，并且他们的民族/种族多样性较为有限。不过，他们写道，“我们需要积极努力以使临床医生意识到MDD在该患者人群中的重要性。”

 

该研究获美国国家医学康复研究中心和美国国立卫生研究院的支持。Bombardier博士声明持有辉瑞公司股份。

 

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