MTBI and Depression
Traumatic brain injury (TBI) occurs as a result of force to the skull or brain. The probability of receiving a TBI is increased if one is participates in a number of sports such as professional football in the National Football League (NFL) and in a number of vocations such being in the military. The results of a TBI include a number of cognitive and emotional symptoms (McCrea, 2008). One of the most common emotional sequale of TBI is depression. This paper argues that depression associated with mild TBI (mTBI) is a public, not personal concern.
Traumatic Brain Injury
A TBI occurs when there is damage to the brain as a result of an application of an external mechanical force (Parikh, Koch, & Naraya, 2007). All TBI’s fall under the label of head injury, whereas not all head injuries result in a TBI (McCrea, 2008). The most common types of external forces are some type of impact (usually from or with another object), acceleration and/or deceleration forces that result in the brain being moved about within the cranium, or actual penetration by some object. When a TBI occurs the brain functions are permanently or temporarily disrupted. The extent of any actual structural damage to the brain may not be detectable evident with the current scanning methods depending on the severity of the TBI. A non-traumatic brain injury would not involve the application of external mechanical force to the head such as having a stroke or a brain disease.
The classification of a TBI is most often based on one of three factors (Parikh, Koch, & Naraya, 2007): (1) the severity of the injury as rated clinically from behavioral data, (2) the anatomical location or the features of the damage (e.g., frontal TBI or diffuse axonal injury), and (3) the type of mechanism involved which are typically divided into either closed head injury (no brain penetration) or penetrating head injury (brain penetration by means of an object of some type breaching the cranium).
The severity of TBI classification is most often broken down into three different categories: mild, moderate, and severe TBI (McCrea, 2008). However, there are several different classification criteria that are somewhat different in the criteria designed to categorize a particular level of severity. The three most commonly used criteria for classifying TBI severity are (McCrea, 2008):
1. The score of a clinical measure known as the Glasgow Coma Scale (GCS), which is a clinician rated tool that grades the level of consciousness of the person with the injury on a scale of three to fifteen. The scoring of the scale is based on verbal responses, motor responses, and eye-opening reactions (Parikh, Koch, & Naraya, 2007).
2. The presence and duration of a loss of consciousness (LOC).
3. And the presence and duration of post traumatic amnesia (PTA), which occurs when the person with the TBI has difficulty recalling relevant personal facts and temporal information.
GCS scores are generally consistent throughout rating systems with a score of 13 or greater designating a mild TBI (mTBI), 9-12 moderate, and a score of eight or less as a severe TBI (Parikh, Koch, & Naraya, 2007). The other two criteria can vary considerably depending on the system; however, the Department of Veterans Affairs uses a duration of PTA of less than a day and an LOC of up to 30 minutes for mTBI (Department of Defense and Department of Veterans Affairs. 2008). Part of the difficulty with the Department of Veterans Affairs criteria is that penetrating head injuries that are quite severe structurally may not produce a significant LOC or PTA.
The Effects of mTBI
Typically mTBI is referred to in lay terms as a concussion. Concussions are not uncommon in contact sports such as football and with veterans (McCrea, 2008). For example, McCrea (2008) reports results of a health survey of retired NFL players: 61% of all respondents reported experiencing a concussion, the mean number of concussions during their career was 2.1, but 24% of the respondents sustained three or more concussions over their career and 71% reported returning to play on the same day. Sixteen percent believed that the concussions had permanent effects. With respect to military personal Finkel, Yerry, Scher, and Choi (2012) reported that in 2010 alone over 2500 individuals in the armed forces received an mTBI.
One of the most common occurrences following an mTBI is post concussion syndrome (PCS; McCrea, 2008). PCS symptoms consist of headaches, memory loss, fatigue, depression, and other symptoms. It has been estimated to occur in between 30-80% of those having an mTBI (McCrea, 2008). The neuropathology of PCS is difficult to describe because most cases of mTBI do not have positive physical findings in the brain. However, while in 85% of PCS sufferers the symptoms abate within a year, 15% still display cognitive and emotional difficulties more than a year following their mTBI. Depression is common in these individuals (McCrea, 2008).
The symptoms and even the diagnosis of PCS have generated some controversy, with some claiming that PCS is a psychiatric manifestation and not a legitimate organic disorder. However, the symptom profile is consistent across individuals and PCS is a serious concern for many clinicians who treat TBI (McCrea, 2008).
Depression in mTBI
The depression in mTBI tends to involve more irritability and atypical features at first but eventually is indistinguishable from depression in other individuals (McCrea, 2008). While some may wrongly believe that the depression associated with an mTBI in former athletes such as NFL players and in veterans is a personal issue, especially those that believe that these individuals knew the risks of the situations that predisposed then to getting an mTBI, this view is quite short sighted. The depression associated with mTBI is a public health concern. There are several reasons for this:
1. Depression is a serious mental disorder that is characterized by an wide-ranging decrease in mood which is often accompanied decreased low self-esteem, a loss of interest or decreases in pleasure in normally enjoyable activities, decreases in productivity, health issues, and a risk for suicide (Sadock & Sadock, 2007).
2. In the United States the probability of having a major depressive episode within any given year is three to five percent for males and eight to ten percent for females (American Psychiatric Association [APA], 2000). Epidemiological studies have demonstrated that major depression, regardless of the etiology, is nearly twice as common in women as men (APA, 2000).
3. People with depression are 30 times more likely to successfully commit suicide than people who are not depressed. Depressed people are also five times more likely to abuse drugs and alcohol (Hawton, 1992).
4. People with depression are significantly more likely to develop other kinds of health issues and make numerous visits to doctors, clinics, and emergency rooms (Sadock & Sadock, 2007).
5. Clinical depression is the principal cause of medical disability for people in the age range of 14 to 44 years of age (Stewart et al., 2003).
6. People with depression lose 5.6 hours of productive work for every week they are depressed; half of this productivity loss is due to increased absenteeism and increased use short-term disability. In any 30 day period employed depressed workers will use 1.5 to 3.2 more short-term disability days than nondepressed people (Stewart et al., 2003).
7. Up to 80% of those who are depressed are significantly impaired in their daily functioning (Sadock & Sadock, 2007).
8. Overall, depression results in to an average of seven fewer weeks of work each year, a 20% loss of potential income, and a lifetime loss of an estimated $300, 000 for each family that has a family member with depression (Smith & Smith, 2010).
9. The cost of depression from increased usage of medical services and lost productivity has been estimated at more than 83 billion dollars each year, which exceeds the cost of the war in Afghanistan (Greenberg, et al., 2003). But this is not a fixed cost as these costs reoccur year after year and rise as the cost of medical treatments rise and wages increase.
The battle with clinical depression has been an ongoing war that clinicians and policy makers have recognized as difficult -but potentially winnable. Thus, clinical depression is considered a public health concern and not just a personal matter. The reduction in the quality of life of depressed people, their families, and others around them combined with the tremendous economic burden that depression forces on society is enough to make everyone concerned about the effects of clinical depression. The cost of untreated depression represents is widespread and spreads to people in all walks of life and people at every level of society and affect nearly every person and every family in America.
Still, some might argue, as mentioned above, that athletes and ex-military personal were well aware of the situations that they placed themselves in prior to their predicament. Depression as a result or as a symptom of mTBI or PCS is a personal issue, not a societal one. Let us review the facts:
1. The depressive symptoms that occur in PCS are virtually identical to the depressive symptoms associated with other mental disorders or even depression associated with terminal medical conditions (Silverberg & Iverson, 2011).
2. There no known study that can identify the depression in PCS as being distinct from the very same clinical depression that is so costly to society.
3. Smokers with lung cancer often develop depressive symptoms (Sadock & Sadock, 2007). The medical profession would be ridiculed and punished if these patients were told that their cancer is a personal concern and that lung cancer is not a public concern. Likewise, their depression, which is directly related their use of a substance, could have been avoided if they did not contract cancer. Would anyone argue that lung cancer or related symptoms are a personal and not public issue? Hopefully not.
4. Similarly any number of public health issues such as addiction, HIV, heart disease, diabetes, and many others represent costly medical conditions to society that could easily be prevented or lessened by simple lifestyle changes in those who suffer from them. Few would argue that these conditions are personal and not public concerns.
5. The depression associated with the above medical conditions would also be a public concern and not simply a personal matter.
6. Therefore, the depression that occurs in those with mTBI is also a serious public concern.
In conclusion, a mild traumatic brain injury (mTBI) is a defined clinical syndrome that results from trauma to the brain, often referred to as a concussion. One of the consequences of living with an mTBI is developing post concussion syndrome (PCS). PCS, while somewhat controversial, includes a number of physical, cognitive, and emotional symptoms. Emotional symptoms often consist of depression. Some might take the position that the symptoms resulting from PCS represent a personal concern for the patient, and therefore the depression associated with PCS is not a public health concern. However, this paper has demonstrated that the depression in PCS is no different than clinical depression as a mental health issue. Moreover, other public health concerns such as ling cancer are not considered personal concerns because they could have been avoided by a personal decision on the part of the patient. Clinical depression is a public concern due to the vast costs it extracts from society. Depression, no matter what the origin, is a public health concern.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorders, IV- Text Revision. Washington, DC: Author.
Department of Defense and Department of Veterans Affairs (2008). Traumatic brain injury task force. Retrieved on July 13, 2012 from http://www.cdc.gov/nchs/data/icd9/Sep08TBI.pdf.
Finkel, A.G., Yerry, J., Scher, J. & Choi, Y.S. (2012). Headaches in soldiers with mild traumatic brain injury: findings and phenomenologic descriptions. Headache 52(6), 957- 965.
Greenberg, P.E., Kessler, R.C., Birnbaum, H.G., Leong, S.A., Lowe, S.W., Berglund, P.A., et al. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64, 1465-1475.
Hawton, K. (1992). Suicide and attempted suicide. In E.S. Paykel (Ed.) Handbook of affective disorders (pp. 635-650). New York: Guilford Press.
McCrea, M.A. (2008). Mild TBI and postconcussion syndrome. New York: Oxford University Press.
Parikh, S., Koch, M., & Naraya, R.K. (2007). Traumatic brain injury. International Anesthesiology Clinics, 45(3), 119-135.
Sadock, B.J. & Sadock, V.A., (2007). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (10th edition). Philadelphia: Lippincott Williams
Silverberg, N.D. & Iverson, G.L. (2011). Etiology of the post-concussion syndrome: Physiogenesis and Psychogenesis revisited. NeuroRehabilitation, 29(4), 317-329.
Smith, J.P., & Smith, G.C. (2010). Long-term economic costs of psychological problems during childhood. Social Science & Medicine, 71, 110-115.
Stewart, W.F., Ricci, J.A., Chee, E., Hahn, S.R., & Morganstein, D. (2003). Cost of lost productive work time among U.S. workers with depression. Journal of the American Medical Association, 289, 3135-3144.
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