A prospective evaluation of psychiatric disorders following moderate to severe traumatic brain injury

Psychiatric disorders are common following traumatic brain injury (TBI) and have a negative impact on functional and psychosocial outcome. Unfortunately, our understanding of psychiatric disorders following TBI is limited. Specifically, the critical periods for disorder development, expected trajectory and risk factors are ill defined, as no studies have prospectively examined a range of Axis I psychiatric disorders beyond the first year post-injury; this is particularly the case for posttraumatic stress disorder (PTSD). Despite an established evidence-base suggesting that the quality of the family environment (i.e., levels of expressed emotion [EE]) is associated with the development and course of many psychiatric disorders, research in TBI has been extremely limited. The primary aims of the current research were to: 1) prospectively examine the frequency and course of a broad range of Axis I disorders during the first five years post-injury; 2) investigate the demographic, pre-injury and injury-related factors associated with post-injury psychiatric disorders; 3) describe the evolution of PTSD following TBI; 4) examine the demographic, pre-injury, injury-related and concurrent factors associated with injury-related PTSD; and 5) investigate the utility of family EE in predicting the emergence of psychiatric disorders following TBI. Participants with moderate to severe TBI were recruited from consecutive inpatient admissions to a rehabilitation hospital in Melbourne, Australia. Participants completed a baseline assessment soon after injury and were reassessed at 3, 6 and 12 months, 2, 3, 4 and 5 years post-injury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID-I) was used to diagnose psychiatric disorders. Measures of psychosocial function, quality of life, and family EE were also administered. In the first five years post-injury, 75.2% of participants with TBI were diagnosed with a psychiatric disorder. Between one and four years post-injury, disorder frequencies exceeded demographically adjusted population rates. Mood, anxiety and substance-use disorders were the most common and were highly comorbid, with low rates of psychotic, somatoform, adjustment, and eating disorders. Post-injury mood and anxiety disorders typically emerged without a pre-injury history, whilst post-injury substance-use disorders were commonly pre-existing. The majority (77.8%) of participants with a post-injury psychiatric disorder were diagnosed within the first year post-injury. Onset of PTSD was frequently delayed, emerging between 6 and 12 months post-injury. Anxiety disorders showed greater resolution than mood or substance-use disorders; within anxiety disorders, PTSD was associated with the most chronic/recurrent course. Results of regression analyses indicated that post-injury psychiatric disorders were associated with a pre-injury psychiatric history, sustaining an accident-related limb injury and report of high sensitivity to family criticism following injury. Post-injury mood, anxiety and substance-use disorders were associated with a history of the same diagnostic class prior to injury. Substance-use disorders were also predicted by male gender, younger age and fewer years of education. Examination of post-injury PTSD revealed associations with shorter post-traumatic amnesia duration (PTA), concurrent psychiatric comorbidity, and poorer psychosocial functioning and quality of life following injury. This research has demonstrated that individuals with TBI experience high rates of psychiatric disorders for several years following injury. Findings also illustrate that whilst premorbid psychiatric history is a strong indicator of risk, demographic, injury-related and familial factors might also promote the early identification of vulnerable individuals. Nonetheless, there is a need for routine psychiatric screening and evidence-based treatment to be integrated into rehabilitation practices for all individuals following TBI, particularly during the first year post-injury when most cases emerge.