Why This Depression Is Different

The Journey Starts With Me

When my son was 17, he was hit by a drunk driver in a crash that killed his girlfriend and left him with a complicated mild traumatic brain injury. It changed his entire life trajectory in the blink of an eye that lasted a lifetime.

As his physical recovery progressed, as he was moved from the ICU to a step-down unit to home, and as he worked hard in physical therapy, I gradually became aware that Neil was depressed. I say gradually because his entire personality seemed to change. He went from gregarious and surrounded by friends to stony and silent. The boy who got straight A’s without trying now struggled to achieve B’s. What should have been the time of his life—prom! graduation! college!—was now one long struggle.

In my mother’s mind, my son had every reason to be depressed: His girlfriend was dead. Their planned future together evaporated. He wondered aloud if he could still even become the teacher he’d always wanted to be. The one reason for his depression that I hadn’t really given much credence to was the brain injury itself.

How the Presentation of TBI Depression Is Different

Diagnosing depression in TBI survivors is important. One reason is the sheer number of survivors out there with psychiatric disorders. About 40% of persons experiencing TBI will suffer from two or more psychiatric disorders including anxiety, depression, panic disorders, and alcohol abuse, with depression being the most common.

Diagnosis may be complicated by the fact that many people with undiagnosed TBI depression may not even associate their injury with their depressive symptoms. When I was giving keynote addresses to Brain Injury Associations and later, when I edited a Chicken Soup for the Soul anthology about traumatic brain injury, I was repeatedly told stories of trauma survivors who were treated for their physical accident-related injuries like lacerations and broken bones and discharged to their homes without anyone even mentioning the possibility of brain injury. (I was initially only told of my son’s shattered leg and need for hospitalization and surgery. They told me his head CT scan was “just a precaution.”) Some folks may only be diagnosed with their TBI after going to their primary care doctor for symptoms of confusion, lack of concentration, and sleep disturbances. As we know, symptoms of TBI and its related depression overlap, making diagnosis of each complex and delicate. But diagnosis of TBI is key because early treatment and rehabilitation of the brain injury has been shown to reduce the risk of development of future psychiatric disorders.

Making the distinction between TBI related depression and idiopathic disease is critical but the differences between the two entities can be subtle. TBI depression can also look different from depression not associated with brain injury. While some features—sadness, anhedonia, and disturbances in sleep, concentration, and appetite—are similar, TBI depression is more likely to co-exist with anxiety and aggressive behaviors.

How Treatment of TBI Depression Differs From Idiopathic

The distinction is important because often traditional anti-depressant treatments will not work in TBI survivors. While SSRIs remain a first-line treatment, where to go if these modalities are ineffective does differ in the TBI population. Neuromodulating interventions such as repetitive transcranial magnetic stimulation (rTMS) is showing great promise in the treatment of medication-resistant depression in TBI survivors. The area most frequently targeted, the dorsolateral prefrontal cortex, has been noted in functional imaging studies to be associated with depression.

Awareness Is Key

It has been almost 20 years since my son suffered his traumatic brain injury. He is doing well, teaching high school mathematics and partnered with a wonderful woman. He still suffers from depression and anxiety but manages them well. Treatments have advanced since his injury and our understanding continues to evolve. Awareness of the differences in presentation and treatment between TBI-related and idiopathic depression remain key.

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