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Finally, depression can arise as individuals who have experienced TBI face new challenges in adapting to temporary or permanent disability, limitations, or changes in their professional, family, and community life Lukow et al. Understanding differences in these factors between men and women is critical to early identification and treatment for depression in order to maximize recovery following TBI. The Patient Health Questionnaire PHQ-9 is a powerful clinical tool to study depression; it is able to detect a wide range of depression symptoms Kroenke et al.
Importantly, the PHQ-9 has been shown to be a sensitive instrument in identifying depression in individuals with TBI, especially in the hospital context Dyer et al. The objective of this study was to assess depression, measured by the PHQ-9, in males and females 1 year following TBI.
We hypothesized that, compared with males, females will report more symptoms of depression, operationalized as mean PHQ-9 total score, as well as a higher severity of depression within each of the five PHQ-9 depression severity categories, at a 1-year follow-up assessment. The Rehabilitation Center is a specialty unit providing treatment to the most medically complex and acute traumatic brain-injured patients.
Demographic variables included sex, age, ethnicity, marital status, and employment status. All participants understood and provided informed consent to participate or, if unable, family or legal guardian understood and provided informed consent for the patient in accordance with the Declaration of Helsinki. Data regarding injury was collected via medical record abstraction by a research assistant.
At 1-year post-injury, a research assistant conducted follow-up assessments for data collection. The PHQ-9 Kroenke et al. Scores are totaled and are categorized into level of severity with higher scores indicating greater depressive symptoms 1—4: minimal depression, 5—9: mild depression, 10— moderate depression, 15— moderately severe depression, 20— severe depression. For each group, mean PHQ-9 total scores were calculated.
The percentages of individuals in each category of depression severity was calculated for each group. Two-sample Z -tests for proportions were then used to compare the categories of male versus female within each category of depression. The percentage of individuals who endorsed each of the 9-items of depressive symptoms was calculated for each group to provide an item analysis assessment. Two-sample Z -tests for proportions were then used to compare the proportion of males versus females for each item.
An independent sample t -test was used to cross check for mean PHQ-9 total scores, following an outlier and range check. Chi-squared tests were used to cross check all initial Z -tests run for depression severity categories and item analyses; the Bonferroni correction was applied to correct for any family-wise errors arising from multiple comparisons in the data analyses. A lower percentage of males Individuals with TBI are at a significantly higher risk compared to the general population for developing both acute and chronic depression Scholten et al.
Given the lethality concerns surrounding depression, raising awareness about the prevalence of depression in persons with TBI is especially important. Importantly, depression rates are increasing in parallel to the rising rates of TBI Oyesanya and Ward, Previous studies reveal that female survivors of TBI are at higher risk for developing depressive disorders than are male survivors Iverson et al. Other research, however, suggests that there are no gender differences in outcomes post-TBI Mushkudiani et al.
Investigators have found that younger women have better outcomes than do older women post-TBI; this may be attributable to the neuro-protective effects of hormones found in pre-menopausal women Kirkness et al. Despite conflicting results, researchers and clinicians alike are becoming aware of hormonal disturbances that often follow TBI Ghigo et al. Therefore, it is imperative for depression treatment care plans following TBI to be tailored to each gender specifically to address the physiological and hormonal differences between men and women who are affected by brain injury.
Investigators have suggested that TBI-related depression results from altered functional connectivity of a number of networks in the brain, including white matter abnormalities Isaac et al. Disruption to the neural circuitry between the limbic system and the prefrontal cortex, that results from diffuse axonal injury Inglese et al. A number of other factors, including various adjustment issues and unique barriers that accompany TBI recovery Moreno-Lopez et al.
Indeed, one of the most disabling symptoms of depression is lack of hope; depression, comorbid with TBI, is therefore a leading contributor to disability following TBI Oyesanya and Ward, These contributing factors for depression may help explain why gender differences are not as prevalent among those with TBI compared with the general population. Both males and females with a TBI experience life-altering changes that directly impact their quality of life and productivity. Future research is needed to quantify the extent to which depression emergence post-TBI is a direct result of structural and neurochemical changes that occur in the brain following the injury versus due to the associated barriers in TBI recovery attributable to suffering a TBI.
Interestingly, unlike the general population, the mild depression noted among both males and females with TBI in our study population suggest that depression is not gender-specific. Gender differences may be seen, however, in the manifestation of depression symptoms. We demonstrated that a greater percentage of men reported concentration difficulties, where depression was experienced through cognitive symptoms, while a higher percentage of women indicated sleep disturbance issues, reflecting more psychosomatic symptoms of depression.
These exploratory results are consistent with previous research demonstrating that depression symptoms are expressed differently in men and women; whereas men experience cognitive symptoms Alexandrino-Silva et al. These findings warrant further study in order to better understand depression following TBI and its unique impact on each gender. Moreover, our results indicate the need for early identification, active screening, and treatment of mood disorders in both genders equally to improve emotional functioning, reduce disability, promote recovery, and enhance quality of life following TBI.
While this study provides valuable gender comparison information regarding depression following TBI, limitations exist. Frost et al. It is also important to highlight that individuals in this study sample were slightly younger and more racially and ethnically diverse, compared with the Model Systems National Database as a whole Model Systems Knowledge Translation Center, Future research is needed to extend this study to assess depression in women and men with TBI across the country.
Finally, we used data from only one time point, as opposed to measuring depression over a series of time points, thus limiting our ability to assess spontaneous symptom recovery, relapse, or a change in depression over time. We plan to expand this research by analyzing data from the entire Model Systems National Database, and to assess depression at multiple time points, in order to more fully evaluate depression in women and men following TBI. LI is the last author and anchored and directed the project.
SL, first author collected the data, conceived of the clinical outcomes, wrote the majority of the manuscripts. All remaining authors contributed to both data interpretation and writing of the paper. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The subject recruitment and data acquisition team consisted of Laura Jamison and Ketra Toda. Albrecht, J. Depression among older adults after traumatic brain injury: a national analysis. Psychiatry 23, — Alexandrino-Silva, C. American Psychiatric Association Armed Forces Health Surveillance Center Armed Forces, Google Scholar. Barker-Collo, S.
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Prevalence, natural course and predictors of depression 1 year following traumatic brain injury from a population-based study in New Zealand. Brain Inj. Blennow, K.
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