| | Functional Limitations and Depression After Traumatic Brain Injury: Examination of the Temporal RelationshipPresented to the International Neuropsychological Society, February 2007, Portland, OR. Abstract Pagulayan KF, Hoffman JM, Temkin NR, Machamer JE, Dikmen SS. Functional limitations and depression after traumatic brain injury: examination of the temporal relationship. ObjectiveTo examine the temporal relationship between self-reported injury-related functional limitations and depressive symptomatology after traumatic brain injury (TBI). DesignA longitudinal cohort study with 3 evaluation points. SettingA level I trauma center. ParticipantsAdolescents and adults (N=135) with complicated mild to severe TBI (72% had complicated mild injuries) who were recruited within 24 hours of injury and then completed the measure at all 3 time points. InterventionsNot applicable. Main Outcome MeasuresSickness Impact Profile and Center for Epidemiological Studies−Depression Scale. ResultsIndividuals who reported more depressive symptomatology consistently endorsed more injury-related difficulties, showing the strong relationship between depression and perceived psychosocial functioning. Examination of these relationships over time revealed that increased depressive symptomatology follows higher levels of perceived injury-related changes but that reports of injury-related changes are not associated with earlier depression. These findings suggest a unidirectional temporal relationship between these variables. ConclusionsPerceived changes in daily functioning appear to influence emotional well-being over time after TBI. However, depressive symptoms do not appear to negatively impact individuals' perception of later functioning. These results further our understanding of the complicated relationship between these variables and may have important implications for treatment of depression after TBI. List of Abbreviations: CES-D, Center for Epidemiological Studies−Depression, CT, computed tomography, GCS, Glasgow Coma Scale, QOL, quality of life, SIP, Sickness Impact Profile, TBI, traumatic brain injury, TFC, time to follow commands DEPRESSION IS THE MOST common psychiatric difficulty after TBI, with studies using nonselect samples estimating that depression is present in 30% of persons with TBI in the first year postinjury.1, 2, 3 This compares with rates of 2% to 4% in the general population and 5% to 10% among primary care patients.4, 5 Furthermore, studies of long-term outcomes have noted high rates of depression as far out as 10 to 20 years postinjury.6 Depression has been linked with poor functional outcome, including reduced QOL, increased report of health-related impairment, decreased employment, and decreased community integration, and has been speculated to impact motivation to participate in rehabilitation.7, 8, 9 This association holds when depression categorization is based on a structured interview and when it is based on patient's self-report of depressive symptomatology.8 Given the strong relationship that has been found between depression and functional outcome, it is important to gain a better understanding of the directionality of this relationship to develop more efficacious interventions. It is possible that the people who experience considerable changes in functioning secondary to the TBI are experiencing emotional distress in reaction to the injury-related sequelae. Alternatively, it has frequently been found that, relative to nondepressed people, those with depression tend to focus on negative information about themselves and attend to their shortcomings more than their strengths.10, 11, 12, 13 In the case of TBI, it is possible that self-perceptions of injury-related difficulties are being impacted by depression such that depressed individuals may be attending to their weaknesses or injury-related changes as opposed to their strengths or retained abilities, thus leading to higher reported levels of injury-related difficulties. However, the nature of the relationship between these variables is unclear because previous research in the area has largely used cross-sectional designs. Increased understanding of the temporal relationship among these variables, including whether a change in 1 factor precedes a change in the other factor, would permit targeted treatments that may have more effectiveness over the long-term. One approach to begin to answer this question is to use a cross-lagged panel design (fig 1). This method allows the exploration of the temporal relationship among 2 longitudinally measured variables, thus providing preliminary information about directionality without requiring experimental manipulation.14, 15, 16 On the most basic level, the cross-lagged panel design involves comparing the correlation between variable A (depressive symptomatology in our study) at time 1 and variable B (functional limitation in our study) at time 2 (rA1B2) with the correlation between functional limitation (variable B) at time 1 and depressive symptomatology (variable A) at time 2 (rB1A2). The results of this comparison provide information about both the relative effect of depressive symptomatology on later change in reported functional limitations and the reverse relationship.17 However, the cross-lagged panel design also identifies other important relationships that produce extraneous variance. If not controlled for, this variance could lead to an incorrect conclusion about the potential temporal relationship. In particular, synchronous correlations (ie, the relationship between depressive symptomatology and functional limitation measured at the same time point) and autocorrelations (ie, the relationship between the depressive symptomatology measured at different time points) (see fig 1) have been identified as sources of extraneous variance and can be controlled for in this study.15 For example, a high correlation between depressive symptomatology at time 1 and functional limitation at time 2 may be artificially raised by the fact that functional limitation measured at time 2 is highly related to functional limitation measured at time 1 (autocorrelation). In addition, any relationship that exists between depressive symptomatology and functional limitation at either time 1 or time 2 (synchronous correlations) can influence the relationship as well. Therefore, all relationships need to be included to most accurately examine the temporal relationship between the 2 variables. Overall, there are relatively few studies that have investigated both outcome and depression from the perspective of the person with TBI at multiple time points postinjury. To our knowledge, there are no published investigations of the temporal precedence between these variables. In the present study, a sample of patients who were enrolled within 24 hours of injury and followed for 1 year were evaluated. The aims of this study were (1) to determine whether individuals with clinically significant levels of depressive symptomatology report more injury-related difficulties than those without clinically significant levels of depression and (2) to explore the directionality of that relationship. Methods  Participants Participants were adolescents and adults with complicated mild to severe TBI who were consecutively admitted to a level I trauma center between 1991 and 1995. These participants are a subsample of the 379 participants who met all eligibility requirements and were enrolled in a randomized, placebo-controlled, and double-blinded investigation of the efficacy of valproate in preventing posttraumatic seizures. This trial found that valproate does not prevent late posttraumatic seizures and does not have any effect, positive or negative, on neuropsychologic functioning.18, 19 Furthermore, valproate did not affect outcome as measured by the SIP.20 The present study included all persons with TBI who completed the SIP and the CES-D at 1, 6, and 12 months postinjury (N=135). An additional 40 people completed these measures at 6 and 12 months but did not have complete data at 1 month postinjury. Many of these participants were too severely injured to complete the measures that soon after injury. Thus, as expected, the excluded individuals were more severely injured than those in the included sample (P<.01), but the sample did not differ in any demographic characteristics. Participants from the larger study were not included for a variety of reasons including that they were not followed past the 6-month time point because of budgetary constraints, were lost to follow-up or died, had incomplete data, English was not their first language, or they were physically unable to complete the SIP. The original clinical trial and the secondary use of these data were approved by the Institutional Review Board of the University of Washington. Measures Basic demographic information was collected from the persons with TBI at 1 month postinjury. Brain injury severity was evaluated with the GCS21 in the emergency department and TFC. TFC is operationally defined as the time from injury to when a person is able to consistently follow simple commands (ie, GCS motor scale score of 6). Outcome measure The SIP22 is a measure of health-related QOL that consists of 136 items assessing health-related limitations in 12 domains (sleep and rest, emotional behavior, body care and movement, home management, mobility, social interaction, ambulation, alertness behavior, communication, work, recreation and pastimes, eating). This measure was administered at 1, 6, and 12 months postinjury. For the purposes of this study, a total score was calculated that used all of the subscales except emotional behavior because of its overlap in content with the measure of depression (CES-D). Scores range from 0 to 100 and represent percent dysfunction reported by the person with TBI. Depression measure The CES-D23 is a 20-item self-report measure of depressive symptoms. Persons with TBI were asked to report frequency of symptoms that occurred within the past week (0 is <1d/wk; 1 is 1–2d/wk; 2 is 3–4d/wk; 3 is 5–7d/wk). Scores are added together to yield a total score ranging from 0 to 60, with higher scores indicating more depression. As outlined in Dikmen et al,1 a score of 16 or more indicates mild or clinically significant depressive symptoms,24, 25 scores from 21 to 26 suggest moderate depressive symptoms,26, 27, 28 and scores of 27 or higher indicate severe depressive symptomatology and probable major depression.29, 30, 31 The reliability of this measure for assessing depressive symptomatology in general, clinical, and cross-cultural populations has been well established.32, 33, 34 The validity of the CES-D has been shown with moderate to high correlations with the Hamilton Depression Rating Scale and high correlations with the Depression Scale of the Symptom Checklist−90.35 Data Analyses Initial analyses of the relationship between depressive symptomatology and functional limitations over time involved a series of 4 regression analyses. These regressions used all available participants (out of the total sample of 175) to explore the relationship between early depressive symptomatology and later functional limitations (and vice versa). Next, the direction of the relationship between depression and self-reported limitations was investigated with the longitudinal sample (N=135) by using a cross-lagged panel analysis, as discussed in the Introduction section. This method allows for the investigation of the temporal relationship among all of these variables in a single model. This method was used recognizing that newer methods such as generalized estimating equations and linear mixed models have been developed to analyze longitudinal data. However, these newer methods have not yet been expanded to address the question of determining temporal precedence of 2 variables. Cross-lagged panel analysis is a method that has been developed and used in the literature to attempt to uncover possible causal relationships without experimental intervention, taking into account the relationships that exist among variables over time. High correlations between each variable (CES-D score, SIP score) over time are controlled for by calculating residualized scores for the 6- and 12-month time points.36 For example, 6-month scores were regressed on corresponding 1-month scores (eg, CES-D score at 6 months was regressed onto CES-D score at 1 month), and 12-month scores were regressed onto 6-month scores (eg, the SIP score at 12 months was regressed on the SIP score at 6 months). For simplicity, these residual values were labeled to designate the time period that they represent, such as CES-D1-6 and SIP6-12 for the 2 examples provided earlier, respectively. The autocorrelations, synchronous correlations, and cross-lagged correlations were then calculated with these residualized values. Then, hierarchical multiple regressions were conducted to evaluate the cross-lagged relationships of interest while controlling for the variance associated with other variables in the cross-lagged panel. Results Demographic information for the longitudinal sample (N=135) is presented in table 1. As is typical for TBI, the sample consisted mostly of young males with a high school education. The majority of participants were white. Injury severity based on depth of coma ranged from mild to severe. Most were in the milder range because some individuals with more severe injuries were still too impaired at 1 month postinjury to be tested. However, those with GCS scores in the mild range should be considered to have a complicated mild injury37 because everyone in this study with a GCS in the mild range also had an abnormality on CT scan. Age ranged from 14 to 89 years. | | |  | Variables | n (%) | |
|---|
| Categoric variables | | | |  Sex | | | | Male | 108(80) | | | Female | 27(20) | | | Race | | | | White | 117(87) | | | Black | 10(7) | | | Other | 8(6) | | | GCS score | | | | Complicated mild (13–15) | 90(67) | | | Moderate (9–12) | 27(20) | | | Severe (3–8) | 8(6) | | | Missing | 10(7) | | | Time to follow commands | | | | ≤24h | 95(70) | | | 25h–6d | 22(16) | | | 7–13d | 14(10) | | | ≥14d | 4(3) | | | Continuous variables | Mean ± SD | | | Age (y) | 37±14 | | | Education(y) | 12.7±2 | | | | |
Pattern and prevalence of symptoms On the SIP, a higher score indicates more injury-related difficulties. Overall, fewer injury-related limitations were reported over time (mean 1mo ± SD, 20±14; mean 6mo ± SD, 10±11; mean 12mo ± SD, 8±11). Mean depressive symptoms ± SD were relatively stable over time (1mo, 15±10; 6mo, 13±11; 12mo, 12±12), but the overall percentage of individuals reporting clinically significant (≥16) levels of depressive symptomatology on the CES-D decreased over time, from 44% at 1 month, to 36% at 6 months, to 29% at 12 months. The examination of depression in individual cases revealed numerous different patterns of depressive symptomatology, with some participants reporting fewer symptoms over time, some reporting increased symptoms over time, and some staying basically the same. Relationship between depressive symptoms and SIP scores Figure 2 shows the relationship between depressive symptoms on the CES-D and difficulties endorsed on the SIP. Subjects whose self-report of depressive symptoms exceeded the level of clinical significance (CES-D score ≥16) reported higher levels of difficulties on the SIP (P<.01) than those who did not report clinically significant levels of depressive symptoms (CES-D score <16). As a first step toward examining the relationship between depressive symptomatology and functional limitations, regression analyses were conducted by using all available participants at each time point. Four regression analyses were conducted to evaluate the relationship between early depression and later functional limitations and vice versa. The first regression, with 6-month functional limitations as the dependent variable and 1-month depression and 1-month functional limitations as predictors, was significant overall (F2,132=36.8, P<.01). However, early depression was not a significant predictor of later functional limitations in this model (P>.05). Similarly, depression at 6 months was not a significant predictor of functional limitations at 12 months postinjury (P>.05), although again the overall model was significant (F2,172=142.3, P<.01). In contrast, functional limitations at 1 month postinjury were a significant predictor of depression at 6 months postinjury (P<.01), and functional limitations at 6 months postinjury were a significant predictor of depression at 12 months postinjury (P<.01). Both of these models were also significant overall (F2,132=23.4, F2,172=63, respectively, P<.01). Cross-lagged panel analysis As a first step to examining the temporal relationship between SIP and CES-D scores, residualized scores as defined in the Data Analysis section were created. These residualized values control for the high correlation between the scores across time points. The cross-lagged panel design containing the correlations between these residualized scores is presented in figure 3. Of particular interest to this study are the cross-lagged correlations. This figure shows that depressive symptoms endorsed on the CES-D at 1 year postinjury are significantly associated with earlier reports of health-related impairments on the SIP (P<.05). In contrast, the association between early depression and later health-related difficulties on the SIP was very weak and nonsignificant. In terms of the other types of correlations, the SIP residualized score was unrelated to the later SIP residualized value, and the early CES-D score was unrelated to the later CES-D score (autocorrelations). In contrast, the SIP and CES-D values at each time point were moderately and significantly correlated (synchronous correlations). Regression analyses were conducted to further explore the cross-lagged relationship between depressive symptomatology and reported health-related limitations. In the first regression, presented in table 2, the dependent variable was CES-D6-12 and the independent variable of interest was SIP1-6. The residualized values are used in all of the regressions. SIP1-6 was a significant predictor of CES-D6-12, even after controlling for the variance associated with both later injury-related limitations (SIP6-12) and earlier depressive symptomatology (CES-D1-6). This suggests that early injury-related impairment on the SIP was associated with later depressive symptomatology. | | | | Model | B | SE B | R2 | ΔR2 | P⁎ | |
|---|
| Model 1: dependent variable is CES-D6-12 | | | | | | | | Step 1 | | | | | | | | SIP6-12 | .66 | .12 | | | | | | CES-D1-6 | .01 | .08 | .20 | | | | | Step 2 | | | | | | | | SIP1-6 | .37 | .10 | .28 | .08 | <.001 | | | Model 2: dependent variable is SIP total6-12 | | | | | | | | Step 1 | | | | | | | | SIP1-6 | –.13 | .06 | | | | | | CES-D6-12 | .32 | .05 | .23 | | | | | Step 2 | | | | | | | | CES-D1-6 | .06 | .06 | .23 | .005 | >.05 | | | | |
A second regression was conducted to explore the reverse relationship, answering the question of whether early depression predicts a higher level of injury-related limitations. Consistent with the insignificant cross-lagged correlation, CES-D1-6 was not a significant predictor after accounting for the variance associated with both later depressive symptomatology (CES-D6-12) and earlier health-related limitations (SIP1-6). Discussion The primary goals of this study were to confirm the relationship between reported levels of depressive symptomatology and psychosocial functioning and then to examine the predominant direction of this relationship. Overall, 44% of the sample reported clinically significant depressive symptomatology at 1 month postinjury; this declined to 29% by 1 year postinjury. Subjects who reported more depressive symptomatology consistently endorsed more injury-related difficulties, clearly showing the strong relationship between depression and functional impairment. Second, analysis of the data by using the cross-lagged panel design provided evidence for a stronger relationship between early level of injury-related impairment and later depressive symptomatology than the reverse temporal relationship (ie, early depressive symptomatology and later increase in perceived injury-related limitations). A similar trend in the data was evident when the relationship between depression and functional limitations was explored in the larger sample that included participants who were missing data at 1 month postinjury. To our knowledge, this is the first study to use longitudinal assessments to examine the question of temporal precedence in the relationship between depression and functional outcome. These results provide a picture that suggests that depressive symptomatology at 1 year, above and beyond what was seen at 6 months, is preceded by perceived injury-related difficulties. However, the reverse was not true; early depressive symptomatology was not an indicator for reported level of injury-related limitations at a later date. This finding has significant treatment implications. It has been consistently noted that depression is associated with decreased functional outcome after TBI, including increased divorce rates as well as reduced QOL, social activity, social support, community integration, participation in activities of daily living, and poorer rehabilitation outcomes.7, 8, 9, 38, 39, 40, 41, 42, 43, 44, 45 Given the functional improvement typically seen with the remittance of depressive symptomatology in otherwise healthy people,46, 47 it is often thought that functioning among individuals with TBI will improve if the depression is treated. Or, conversely, it is thought that depression is contributing to or causing the decreased functioning. The results of our study suggest that the functional limitations precede depression, whereas evidence for the reverse relationship was not found in this sample. This suggests that both the functional limitations and depressive symptoms need to be addressed because treating only the depression may not have the anticipated positive effect of increasing daily functioning. Given that comprehensive treatment approaches that address a combination of physical, cognitive, and emotional variables are rare,48 a possibility would be to combine pharmacologic treatment with individual and family psychotherapy49 that is targeted at developing compensatory strategies and coping skills for the functional difficulties that are most distressing to the person with TBI. Identifying particular limitations that may place a person at risk for depression could lead to early detection of problems and potentially facilitate treatment. Furthermore, future research should explore the complicated and possibly circular relationship between functional limitations, depressive symptomatology, and rehabilitation services. One possible model is that depressive symptomatology (found in this study to follow reported functional limitations) leads to reduced participation in therapies,50 which limits the functional improvement in the person with TBI and contributes to persisting depression. To improve participation and, ultimately, outcome among these individuals, the complex interaction between awareness of deficits, depressive symptomatology, and associated thought processes (eg, attending to shortcomings or negative injury-related changes more than strengths) and cognitive limitations associated with brain injury must be taken into consideration during treatment. Study Limitations There are several limitations of this study that should be noted. The first has to do with injury severity. As is consistent with the epidemiology, the unselected cases with CT abnormalities in the parent study had more cases with GCS scores in the mild range than in the moderate or severe ranges. Furthermore, people who were too impaired to complete the SIP and CES-D at 1 month postinjury were excluded from the present study. Thus, this sample consists primarily of subjects with complicated mild injury (ie, GCS scores of 13–15 with CT abnormalities). This severity is considered to be similar to those with moderately severe brain injury.37 Future research should examine whether this relationship holds in a more severely injured sample. However, preliminary analyses of individuals who were unable to respond at the 1-month time period suggest a similar pattern of findings for the final 2 time points. Second, this study lacked external validation of the self-reported depressive symptomatology. However, using self-report measures could also be viewed as a strength of this study, as previous researchers have noted, “it is the subjective impairment which represents distressing reality for these patients and dictates their psychological adjustment.”51(p14) The perspective of the person with TBI has also been emphasized as important to improving treatment and outcome after TBI.52, 53 Furthermore, previous studies have shown a good relationship between self-reported depressive symptomatology and diagnoses based on the Structured Clinical Interview for DSM-IV Disorders in TBI and other disorders,9, 54, 55 which suggests that people with TBI can accurately report on their own symptoms. Another potential limitation is that the CES-D, a widely used and valid measure of depressive symptomatology, does not permit diagnostic classification of individuals. Thus, an area that deserves further exploration is the relationship between major depression, subsyndromal depression, and functional outcome. Depression after TBI is heterogeneous, including different origins, symptom presentation, and course over time.9, 56 The results of our study support the concept of a reactive depression among some individuals at 1 year postinjury. However, further investigation of the subtypes of depression is needed to gain a more in-depth understanding of the relationship between these variables. Finally, the current method of analysis, cross-lagged panel design, was used recognizing that newer methods to manage longitudinal data have been developed. However, these newer methods, such as generalized estimating equations and linear mixed models, do not answer the question of temporal precedence. Structural equation modeling methods developed in social sciences may also provide avenues to further explore these relationships but require larger sample sizes to examine the relationships across each time period. Additional research is ultimately needed to confirm these relationships. Such a design could include treating depression and examining changes in function or improving function and evaluating changes in depression. Conclusions This study addressed the question of whether a person's perceptions of injury-related difficulties are elevated because of increased depressive symptomatology or whether increased reported functional limitations are followed by decreased mood. The results support the latter conclusion. Research is needed to see if this finding can be replicated in people with more severe injuries, at different points since injury, and with more objective assessments of depressive symptomatology and health-related limitations. 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a Department of Rehabilitation Medicine, University of Washington, Seattle, WA b Department of Neurological Surgery, University of Washington, Seattle, WA c Department of Biostatistics, University of Washington, Seattle, WA  Correspondence to Kathleen Farrell Pagulayan, PhD, VA Puget Sound Health Care System, 1660 S Columbian Way, S-116 MHC, Seattle, WA 98108
Supported by the National Institute of Neurological Disorders and Stroke, National Institutes of Health (grant no. RO1 NS19643) and the National Center for Medical Rehabilitation Research, National Institutes of Health (grant no. F32 HD048030). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprints are not available from the author. PII: S0003-9993(08)00479-6 doi:10.1016/j.apmr.2008.03.019 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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