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Corresponding author: Joukje van der Naalt, MD, PhD, Dept of Neurology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
To investigate the relation of postconcussive complaints, anxiety, and depression with vocational outcome in patients with traumatic brain injury (TBI) of various severities and to assess sex differences.
Design
A prospective cross-sectional cohort study.
Setting
Level I trauma center.
Participants
Adults (N=242) with TBI of various severity.
Interventions
Not applicable.
Main Outcome Measures
Extended Glasgow Outcome Scale, return to work (RTW), Head Injury Symptom Checklist, and Hospital Anxiety and Depression Scale.
Results
In 67% of the patients, complaints were present; 22% were anxious, and 18% were depressed. The frequency of complaints increased significantly with injury severity, in contrast to anxiety and depression. Frequencies of patients with anxiety and depression (9% and 5%) were lower with complete RTW than with incomplete RTW (42% and 37%; P<.001). Patients with minor TBI with complaints were more anxious (50% vs 27%; P<.05) and depressed (46% vs 23%; P<.05) compared with patients with other severity categories and patients with incomplete RTW (67% vs 36% and 60% vs 30%, respectively). A higher percentage of women with minor TBI were depressed (45% vs 13%; P=.01) and had incomplete RTW (50% vs 18%; P<.05) compared with men. Multiple regression analysis showed that injury severity, complaints, anxiety, and depression were all predictive of RTW (explained variance 45%). In all severity categories, anxiety and depression were predictive of RTW, complaints, and sex only for minor TBI.
Conclusions
Anxiety and depression are related to vocational outcome after TBI, with a different profile in the minor TBI category, partly due to sex differences.
Traumatic brain injury (TBI) is a prominent cause of neurologic and psychosocial dysfunction, constituting a worldwide public health issue. In the United States alone, an annual incidence of 1.4 million patients is reported, the majority being young adults with mild TBI.
In mild TBI, most patients recover within 3 to 6 months without any further medical treatment and resume previous work or activities. However, a subgroup of these patients has persistent postconcussive complaints.
Although certain complaints can be underpinned by pathology, for instance, memory complaints resulting from objective memory deficits, other factors are identified that may influence the persistence of postconcussive complaints, such as previous TBI, preinjury psychiatric or personality problems, coping style, and sex differences.
In the present study, we focused on the relation with anxiety and depression. In several studies, a relation was found between the presence of postconcussive complaints and anxiety and depression in mild to moderate TBI
Postconcussional disorder following mild to moderate traumatic brain injury: anxiety, depression, and social support as risk factors and comorbidities.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
; however, the causal relation is not clear. It is likely that anxiety and depression result in a lower sense of well-being and increased problem-focused behavior, which manifests itself in an increased expression of complaints. However, it also seems plausible that overexpression of complaints contributes to the causation of emotional distress.
In various studies, depression and anxiety disorders were found after TBI, with varying rates.
have recently reported that 53% of the patients hospitalized for TBI of various severity suffer from major depressive disorder during the first year after the accident. Furthermore, they found that these patients were at a higher risk of developing a comorbid anxiety disorder. However, the relation with injury severity was not reported. In other studies investigating this relation, results have been inconclusive so far.
Therefore, more research is required to identify the exact relation of injury severity with anxiety and depression after TBI.
Postconcussive complaints are known to interfere with the resumption of work and other previous activities. Residual complaints are present even in the majority of patients with mild to moderate TBI resuming work completely.
More often, symptoms of anxiety and depression are found in patients who become unemployed after TBI than in those who are working. Although several studies found evidence for anxiety and depression to be a consequence of increased functional and vocational limitations, little is known about the direct influence of anxiety and depression on vocational outcome.
The influence of sex differences on outcome after TBI is under debate. Most frequently, women have shown poorer outcomes, a higher incidence of postconcussive complaints, and an increased susceptibility to affective disorders than do men after TBI.
In summary, the amount of complaints, anxiety, and depression are identified as factors having an influence on long-term vocational outcome after TBI, but the exact relations between these factors and injury severity are unclear so far. The main goal of the present study was to investigate how postconcussive complaints, anxiety, and depression are related to each other and to vocational outcome for different injury severity categories of TBI. In addition, the influence of sex differences was explored.
Methods
Patients
All patients with TBI included in this study were admitted to the University Medical Centre Groningen, a level 1 trauma center, in the period from 2005 to 2011. Exclusion criteria were age younger than 15 years and previous TBI (ie, any TBI in medical history). TBI was defined according to the criteria used by the American Congress of Rehabilitation Medicine with at least a period with loss of consciousness or loss of memory for events (posttraumatic amnesia).
Glasgow Coma Scale (GCS) score and posttraumatic amnesia were determined on admission by a medical specialist and documented prior to admission by emergency medical personnel in the field. With this score, 3 severity groups were defined: minor (GCS score=15), mild (GCS score=13–14), and moderate-to-severe TBI (GCS score=3–12). This subdivision was made in agreement with other studies considering that the majority of patients sustain a minor or mild TBI.
Disentangling the minor from the mild category might provide valuable information about the differences between these groups. Considering the overall less favorable outcome of patients with moderate and severe TBI, these categories were combined.
Outcome was determined by an experienced trauma neurologist (J.vdN.) unaware of injury variables: at 6 months±2 weeks for patients with minor and mild TBI and 12 months±4 weeks for patients with moderate-severe TBI. The questionnaires for complaints, anxiety, and depression were filled in at the moment of outcome. Only patients with an extended Glasgow Outcome Scale score of higher than 2 were included. Data were obtained in compliance with the ethical regulations of our institute. Computed tomography (CT) on admission was done in 233 patients; in 9 patients (4%), CT data were not available. Scoring was done according to the Marshall criteria. Overall, 61% showed CT abnormalities (81% minor abnormalities), with 29%, 55%, and 99%, respectively, in the minor, mild, and moderate-severe TBI categories.
Only 3 patients were involved in receiving compensation for their injuries, which is unlikely to affect our findings.
Outcome measures
Vocational outcome was determined in patients between the ages of 16 and 65 years (N=215). Return to work (RTW) was scored in 4 categories: (0) previous work or study resumed, (1) previous work or study resumed, but with lower demands or part-time, (2) previous work or study not resumed, different work on a significantly lower level, and (3) not working. For analysis, a dichotomy was used for the separate RTW categories: “complete RTW” (category 0) and “incomplete RTW” (categories 1–3).
Separate postconcussive symptoms were scored as follows: never (0), sometimes (1), and often (2). For analysis of most frequently occurring separate symptoms, a dichotomy was used: “symptoms” (scores 1–2) and “no symptoms” (score 0). The severity of postconcussive complaints was defined as the sum of the separate symptom scores. The presence of postconcussive complaints was defined as reporting 2 or more symptoms, regardless of severity. For analysis, a dichotomy was used: “complaints” (≥2 symptoms) and “no complaints” (<2 symptoms). The symptom checklist also contained 2 items that are not considered to be posttraumatic complaints. A positive answer on both items was regarded as an indicator of an increased tendency to complain, that is, expressing disproportional complaints. Assessment of anxiety and depression was done with the Hospital Anxiety and Depression Scale (HADS).
Total scores were noted, and the presence of anxiety and/or depression was defined as 7 or more points on the HADS list for either anxiety or depression-like symptoms. For analysis, the total scores were dichotomized into “anxiety” (≥7) and “no anxiety” (<7) and “depression” (≥7) and “no depression” (<7).
Data analysis
For statistical analysis, the Statistical Package for the Social Sciences (SPSSa) version 17.0 was used. Data analysis was performed on the dichotomized variables as explained in the Methods section. Correlations between variables were determined by Spearman correlation coefficients. For frequency analysis, chi-square tests were used. Binary logistic regression was applied for the determination of predictors of outcome defined by RTW. For all statistical tests, the overall alpha level was set at .05. However, if there were multiple comparisons, Bonferroni-Holm corrections were applied.
Results
In total, 242 patients were included in this study (patient characteristics listed in table 1).
Frequencies of patients with complaints, anxiety, and/or depression are depicted in table 2. In total, 67% of the patients experienced complaints, with increased frequencies of patients with complaints related to the severity of injury (χ2=10.6; P<.01). Most frequently reported separate symptoms for the total study population were fatigue (53%), forgetfulness (50%), poor concentration (44%), drowsiness (42%), and dizziness (40%). Only 2% of the patients showed a tendency to express disproportional complaints without significant differences regarding the severity of injury. Of the total group, 22% was anxious, 18% was depressed, and 12% was both anxious and depressed. No significant differences were found between the 3 categories of severity.
Table 2Frequencies of patients with postconcussive complaints, anxiety, and/or depression in several TBI categories
Presence of complaints correlated significantly with the presence of anxiety (r=.67, P<.01) and depression (r=.74, P<.01). The frequency of patients with anxiety was significantly higher in the group of patients with complaints than in the group without complaints (31% vs 4%; χ2=23.0, P<.001), and this was also the case for depression (27% vs 0%; χ2=26.6, P<.001). Patients with anxiety or depression did not show a significant tendency to express disproportional complaints (8% and 9%) compared with those without anxiety or depression (1% and 2%, respectively).
Regarding patients without complaints, in the minor category, 4% were anxious, compared with the mild (5%) and moderate-to-severe category (0%). Depression was completely absent in patients without complaints.
Regarding patients with complaints, frequencies of patients with either anxiety or depression for different subcategories of injury severity are depicted in figure 1. Significantly higher frequencies of either anxiety or depression in the minor category than in the other categories were seen.
Fig 1Anxiety and depression in patients with postconcussive complaints represented by categories of severity, with asterisk expressing differences between groups with P<.05.
Regarding complaints in patients with anxiety, 94% of the patients reported postconcussive complaints compared with 59% in the group without anxiety (P<.001). Regarding complaints in patients with depression, all the patients reported complaints compared with 60% in the groups without complaints (P<.001). No differences were found between injury severity subcategories.
RTW related to complaints, anxiety, and depression
In 215 patients, RTW was determined with complete RTW in 62%, RTW with lower demands or part-time in 22%, RTW with different work on a lower level in 7%, and not working in 8%. Incomplete RTW correlated significantly (P<.01) with the presence of complaints (r=.47), anxiety (r=.38), and depression (r=.40).
Regarding complaints in the total patient group, the percentage of patients with complaints and incomplete RTW was 94% compared with 47% in those with complete RTW (χ2=48.4, P<.001). Regarding TBI subcategories, the frequency of patients with complaints increased significantly with injury severity in the group with complete RTW, with 38%, 43%, and 70% for the minor, mild, and moderate-to-severe categories (χ2=7.5, P<.05), in contrast to the group of patients with incomplete RTW (93%, 100%, and 88% respectively, P=.12).
Regarding anxiety or depression in the total patient group, a higher percentage of patients with incomplete RTW was anxious (42%) compared with patients with complete RTW (9%; χ2=31.7, P<.001); the same was also found for depression (37% vs 5%) (χ2=34.9, P<.001).
Regarding the frequencies of patients with either anxiety or depression for RTW in the different subcategories of injury severity, results are depicted in figure 2. In minor TBI with incomplete RTW, the frequency of patients with anxiety or depression was significantly higher than in the other severity categories.
Fig 2Anxiety and depression in (A) patients with complete RTW and (B) patients with incomplete RTW, with asterisk expressing differences between groups with P<.05.
In the total group, 80% of the women and 62% of the men reported complaints (χ2=3.9, P=.009) and 51% of the women and 66% of the men resumed work completely (χ2=4.0, P=.046) (table 3). Regarding subcategories, only in the minor category, women showed significantly less frequent complete RTW (50%) than did men (82%) (χ2=5.2, P=.022). Also, only in patients with minor TBI, a significantly higher frequency of patients with depression was found in women than in men (45% vs 13%) (χ2=6.6, P=.01). The above-mentioned findings were significant at the Bonferroni-Holm corrected alpha level. For anxiety or both anxiety and depression, no significant differences were found between sexes in all severity categories.
Univariate logistic regression of the total group showed GCS score (odds ratio [OR]=1.53, confidence interval [CI] 1.22–1.92, P<.001), presence of complaints (OR=13.62, CI 5.61–33.06, P<.001), anxiety (OR=7.34, CI 3.69–14.62, P<.001), and depression (OR=8.41, CI 3.89–18.15, P<.001) separately as predictors of RTW. Multivariate logistic regression analysis of the total group revealed GCS score (OR=1.58, CI 1.17–2.13, P<.01), presence of complaints (OR=8.45, CI 3.06–23.36, P<.001), anxiety (OR=3.44, CI 1.36–8.74, P<.01), and depression (OR=3.28, CI 1.17–9.16, P<.05) as predictors of RTW, with an estimated explained variance of 45% (Nagelkerke R2) when adjusted for age and sex.
Separate univariate analyses with presence of complaints, anxiety, depression, and sex as independent variables were performed for every category of injury severity and showed anxiety and depression as predictors of RTW in all categories. The presence of complaints (OR=22.00, CI 2.60–186.34, P<.01) and sex (OR=.19, CI .05–.70, P<.05) were predictors of RTW only in minor TBI.
Discussion
The objectives of the present study were to investigate the relation between postconcussive complaints, anxiety, depression, and vocational outcome defined by RTW in different injury severity categories of TBI and to examine possible sex influences. The main finding of this study is that in patients with postconcussive complaints, or incomplete RTW, anxiety and depression were more frequent, especially in the group with minor TBI.
Frequencies of self-reported postconcussive complaints in different injury severity categories vary between studies.
In our study, 2 in 3 patients had persistent postconcussive complaints, with increasing frequency of complaints with the severity of injury. Anxiety was present in 22%, depression in 18%, and both anxiety and depression in 12% of the patients.
Patients with persistent postconcussive complaints were more likely to report anxiety and depression than were patients without complaints. Notably, none of the patients without postconcussive complaints were depressed. However, we found that nearly every patient with either anxiety or depression reported complaints. This is consistent with the observation that depression can lead to misdiagnosis of postconcussive complaints given the possible overlap in symptoms.
Postconcussional disorder following mild to moderate traumatic brain injury: anxiety, depression, and social support as risk factors and comorbidities.
As all self-report measures in our study were obtained at the same time it could be argued that correlations among the self-report measures do simply indicate that those who complained more on 1 measure complained more on another measure. However, we did not find evidence for an increased tendency to complain, that is, to express disproportional complaints, because in the total patient group only 2% of the patients answered positive regarding the items on the symptom checklist controlling for this tendency. Furthermore, those patients who were anxious or depressed according to the HADS were not more inclined to express disproportional complaints than were those who were not anxious or depressed. Therefore, we conceive scores on the HADS in this group of patients with TBI as a valid measure of anxiety and depression and not as the result of a general tendency to express complaints.
Postconcussive complaints are related to psychological, social, and behavioral factors.
When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
In the current study, emotional distress was found to be related to reports of persistent postconcussive complaints, especially in the least severely injured individuals. It is remarkable that frequencies of patients with complaints increased with injury severity whereas the frequencies of patients with anxiety and depression appeared higher in the minor category than in the other categories, particularly notable in the presence of postconcussive complaints. Negative perceptions, beliefs, and interpretation of injury have a significant influence on the extent of postconcussive complaints after mild TBI.
When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury.
It seems plausible that anxiety and depression in patients with minor TBI are related to illness perception and to self-awareness. Research has shown that patients with mild TBI who had negative perceptions and beliefs about their injury 2 weeks after trauma were at higher risk to express persistent complaints 6 months after injury.
When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury.
Self-awareness is the ability to perceive one's behavioral, cognitive, and functional impairments accurately, and impairment of self-awareness is common after severe TBI. Impairment of self-awareness in severe TBI is related to frontal lesions.
Indices of impaired self-awareness in traumatic brain injury patients with focal frontal lesions and executive deficits: implications for outcome measurement.
Although the interaction between self-awareness and emotional distress after TBI is complex, higher levels of self-awareness seem to be associated not only with higher levels of anxiety and depression
on the condition that the coping style is adequate.
In the current study, impaired vocational outcome appeared to be associated with emotional distress, especially at the milder end of the TBI spectrum. The percentage of patients with incomplete RTW increased with increasing injury severity, which is in agreement with the literature.
Our finding of incomplete RTW related to the presence of postconcussive complaints, with concomitant anxiety and depression, is also in concordance with other studies.
However, it is rather conspicuous that the minor TBI category contained a significantly higher number of patients with anxiety or depression, particularly evident with incomplete RTW. As mentioned earlier, these findings may also be attributed to higher levels of self-awareness and the interaction with maladaptive coping styles in patients with minor TBI. Furthermore, because the determination of vocational outcome is partly based on patient self-report, it is theoretically possible that patients' report of incomplete work resumption might be a reflection of a tendency to complain about the nature of their job. However, the evaluation of work resumption was done by an interviewer who asked the patient in detail about the actual work situation regarding working hours and quality of work, and consequently determined on what level RTW had taken place. Nevertheless, we agree that assessment based on self-report contains the possibility that this may not entirely reflect the actual work situation. It would certainly be better to include a more objective judgment of work status, for instance, by the employer, but this was not feasible in the present study and neither is this standard procedure when RTW is investigated.
Indices of impaired self-awareness in traumatic brain injury patients with focal frontal lesions and executive deficits: implications for outcome measurement.
we found that even in patients with moderate to severe TBI, RTW based on self-report was a quite accurate reflection of their actual situation, unless it concerned patients with focal frontal injuries.
The present study revealed that regarding injury severity, especially women with minor injury report emotional distress and appear to have work-related problems. Previous studies have yielded that women in general are inclined to report symptoms more often than men and that women are more susceptible to affective disorders after TBI.
We also found a significantly higher frequency of women patients with postconcussive complaints in the whole TBI group in accordance with other studies. Remarkably, when injury severity was taken into account, we found that only in the minor TBI category women exhibited significantly more depression than did men. Inadequate coping styles, which appear to be more prevalent among women with mild TBI,
Our results also showed a higher frequency of patients with incomplete RTW among women than among men. However, when examining the different subcategories of severity specifically, only in the minor category the frequency of patients with complete RTW was significantly reduced in women. Moreover, only in the minor category univariate regression analysis revealed female sex as a disadvantageous prognostic factor for RTW. These findings raised the challenging assumption whether this subcategory of patients with TBI could contain more risk factors resulting in reduced work resumption and more emotional distress.
We have demonstrated that in patients with TBI, vocational outcome is influenced by injury severity (GCS score), postconcussive complaints, and emotional problems. This relation is complex, and it is likely that there is a reciprocal interaction, which is also reflected in our results. Multivariate regression analysis revealed anxiety and depression as predictors of RTW. Clearly, more research is merited to explore the causal relation between anxiety, depression, and vocational outcome and the factors associated with sustainability of work. In most studies, RTW is defined by the moment of work resumption neglecting the level of work and the fact that long-term outcome studies revealed that 10% to 20% are not working in the same job anymore. Also, the relation of RTW with injury severity, self-awareness, and coping styles has to be explored. In particular, a topic for further research is to explore whether women patients with minor TBI use more nonproductive coping styles than do the other categories and whether this is somehow linked to differences in illness perception and self-awareness.
Study limitations
A limitation of this study was the lack of a control group to investigate differences in complaints between patients with TBI and general trauma although complaints were corrected for preinjury occurrence. Furthermore, the role of education was not determined although type of work as assessed in the outcome session could be regarded as a derivative measure of level of education. In this study, we used a categorization that more specifically subdivides the mild TBI category and aggregates the moderate and severe TBI category. We are aware that consequently our results may be less comparable to other studies on this subject. However, most recent studies have favored to combine the moderate and severe categories considering the overall less favorable outcome. The reported CT abnormalities in patients with minor and mild TBI might suggest that a considerable portion of them would be classified as “complicated mild TBI” with outcomes more closely comparable to those of patients with moderate TBI. In this case, determining recovery within 6 months for this group may not be appropriate. However, complicated mild TBI is defined as those patients with GCS scores of 13 to 15 with contusions or impression fracture on CT. Recently in a cohort of patients with mild TBI, it was found that only parenchymal dame (contusions and diffuse axonal injury) was related to outcome.
In our cohort, the CT abnormalities comprised mainly Marshall classification 2 defined by generalized edema, or small contusions without midline shift or compression of basal cisterns. Thus, in our cohort, the patients with minor and mild TBI are not regarded as a high-risk group justifying the determination of outcome at 6 months. Therefore, separating the minor category has provided valuable information offering the challenging view that this category may need more tailored therapy than do the other categories, regarding the persistence of postconcussive complaints with anxiety and depression. However, caution is necessary for the generalizability of our results to the larger population of outpatients with mild TBI who are not admitted to the hospital.
Conclusions
The present study underlines specific characteristics in the least severely injured patients, which are usually not noticed in the larger mild TBI category represented in other studies. Therefore, these results may have implications for clinicians, as this subgroup might benefit from a more tailor-made approach. Even though patients appear to be recovered after injury, emotional problems may still be present, interfering with vocational outcome. Future studies are necessary to obtain a better understanding of sex-related influences of anxiety and depression on vocational outcome and more specifically the role of inappropriate coping styles, particularly after minor TBI.
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The epidemiology and impact of traumatic brain injury: a brief overview.
Postconcussional disorder following mild to moderate traumatic brain injury: anxiety, depression, and social support as risk factors and comorbidities.
The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury.
When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury.
Indices of impaired self-awareness in traumatic brain injury patients with focal frontal lesions and executive deficits: implications for outcome measurement.
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.
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