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Depression, Anxiety, and Suicidality in Individuals With Chronic Traumatic Brain Injury Before and During the COVID-19 Pandemic: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study

Published:January 09, 2023DOI:https://doi.org/10.1016/j.apmr.2022.10.017

      Abstract

      Objective

      To examine the prevalence, severity, and correlates of depression, anxiety, and suicidal ideation in people with traumatic brain injury (TBI) assessed before and during the COVID-19 pandemic.

      Design

      Retrospective cohort study using data collected through the Traumatic Brain Injury Model Systems (TBIMS) network at 1, 2, 5, 10, 15, 20, 25, or 30 years post TBI.

      Setting

      United States–based TBIMS rehabilitation centers with telephone assessment of community residing participants.

      Participants

      Adults (72.4% male; mean age, 47.2 years) who enrolled in the TBIMS National Database and completed mental health questionnaires prepandemic (January 1, 2017 to February 29, 2020; n=5000) or during pandemic (April 1, 2022 to June 30, 2021; n=2009) (N=7009).

      Interventions

      Not applicable.

      Main Outcome Measures

      Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 questionnaire.

      Results

      Separate linear and logistic regressions were constructed with demographic, psychosocial, injury-related, and functional characteristics, along with a binary indicator of COVID-19 pandemic period (prepandemic vs during pandemic), as predictors of mental health outcomes. No meaningful differences in depression, anxiety, or suicidal ideation were observed before vs during the COVID-19 pandemic. Correlations between predictors and mental health outcomes were similar before and during the pandemic.

      Conclusions

      Contrary to our predictions, the prevalence, severity, and correlates of mental health conditions were similar before and during the COVID-19 pandemic. Results may reflect generalized resilience and are consistent with the most recent findings from the general population that indicate only small, transient increases in psychological distress associated with the pandemic. While unworsened, depression, anxiety, and suicidal ideation remain prevalent and merit focused treatment and research efforts.

      Keywords

      List of abbreviations:

      GAD-7 (General Anxiety Disorder-7), PHQ-9 (Patient Health Questionnaire-9), TBI (traumatic brain injury), TBIMS (Traumatic Brain Injury Model Systems)
      The COVID-19 pandemic–associated mitigation strategies created massive societal disruption in 2020. Access to routine health services, jobs and volunteering opportunities, leisure and socialization, and cultural and religious practices was limited. In addition to the pandemic, 2020 sparked a racial justice movement in the United States with protests that may have further affected individuals' mental and physical health. A survey of American adults
      • Czeisler M
      • Lane R
      • Petrosky E
      • et al.
      Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      found that 40% of individuals reported at least 1 adverse mental or behavioral health condition during the pandemic, including depression, anxiety, posttraumatic stress, or substance abuse.
      The pandemic and related events may have differentially affected persons living with disabilities secondary to traumatic brain injury (TBI). At baseline, people with TBI already experience higher rates of psychological distress than others. The overall prevalence of depression is 38% in people with TBI, 3.41 times greater than in controls without TBI.
      • Osborn A
      • Mathias J
      • Fairweather-Schmidt A.
      Depression following adult, non-penetrating traumatic brain injury: a meta-analysis examining methodological variables and sample characteristics.
      Clinically significant anxiety is present in 37% of people with TBI.
      • Osborn A
      • Mathias J
      • Fairweather-Schmidt A.
      Prevalence of anxiety following adult traumatic brain injury: a meta-analysis comparing measures, samples and postinjury intervals.
      Prevalence of suicidal ideation ranges from 7%-10%, and past-year suicide attempts occur in 0.8%-1.7% of cases.
      • Fisher L
      • Pedrelli P
      • Iverson G
      • et al.
      Prevalence of suicidal behaviour following traumatic brain injury: longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems.
      Preliminary research is mixed on how the pandemic has affected the mental health of people living with TBI. In May and June 2020, Morrow et al
      • Morrow E
      • Patel N
      • Duff M.
      Disability and the COVID-19 pandemic: a survey of individuals with traumatic brain injury.
      surveyed 47 participants in the chronic phase of moderate-severe TBI and compared responses with noninjured peers. One-third said their brain injury made coping with the pandemic more difficult, identifying social isolation as a key barrier to coping with it. However, the study was small, and no comparison could be made with prepandemic baselines for their population. In another study of 134 patients with physical disabilities related to neurologic disorders,
      • Dalise S
      • Tramonti F
      • Armienti E
      • et al.
      Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities.
      fewer negative psychological effects were found. These individuals seemed to manifest resilience in the face of pandemic-related social isolation. The authors questioned if this unexpected result had a dubiously reassuring origin—that people with physical disabilities were “already in lockdown.”
      The objective of the current study was to determine the changes in anxiety, depression, and suicidality in individuals with chronic TBI during the COVID-19 pandemic compared with before the pandemic. A secondary aim is to explore interactive predictors during the COVID-19 pandemic such as disability severity, rural residence, minority race status, and history of substance abuse on the mental health status of anxiety, depression, and suicidal ideation in individuals with chronic TBI. The Traumatic Brain Injury Model Systems (TBIMS) National Database
      • Dijkers M
      • Harrison-Felix C
      • Marwitz J.
      The Traumatic Brain Injury Model Systems: history and contributions to clinical service and research.
      is well suited to address these aims because participants are followed longitudinally at least every 5 years post TBI. Standardized measures of depression, anxiety, and suicidal ideation are completed at each time point, facilitating the examination of rates and severities of these conditions before and during the pandemic. Based on preliminary studies
      • Czeisler M
      • Lane R
      • Petrosky E
      • et al.
      Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      ,
      • Morrow E
      • Patel N
      • Duff M.
      Disability and the COVID-19 pandemic: a survey of individuals with traumatic brain injury.
      ,
      • Dalise S
      • Tramonti F
      • Armienti E
      • et al.
      Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities.
      of the general US population indicating elevated rates of mental health problems during the COVID-19 pandemic period, these authors hypothesized that self-reported depression, anxiety, and suicidal ideation would be elevated among people with TBI when assessed during the COVID-19 pandemic period relative to the preceding years. We further hypothesized that greater disability, rural residence, history of substance abuse, and minoritized race would be more strongly associated with anxiety, depression, and suicidal ideation during the COVID-19 pandemic than before.

      Methods

      Participants

      Participants were a subset of enrollees in the TBIMS National Database, a multicenter, longitudinal cohort of individuals who receive inpatient rehabilitation for TBI.
      • Dijkers M
      • Harrison-Felix C
      • Marwitz J.
      The Traumatic Brain Injury Model Systems: history and contributions to clinical service and research.
      Inclusion criteria for the TBIMS are age at injury of 16 years or older; moderate-severe TBI [defined as posttraumatic amnesia >24 hours, trauma-related intracranial neuroimaging abnormalities, loss of consciousness >30 minutes, or Glasgow Coma Scale score in the emergency department <13]; and received acute care hospitalization within 72 hours followed by inpatient rehabilitation in designated TBIMS facilities. For the present analyses, we restricted the sample to those eligible for follow-up (postinjury year 1, 2, 5, 10, 15, 20, 25, or 30) between January 1, 2017, and June 30, 2021, with Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) collected during the follow-up. Only their first session was retained for participants who completed multiple follow-up sessions during this period. For comparisons, we divided our sample into 2 independent cross-sectional groups, "prepandemic" and "during pandemic," for comparisons. Prepandemic was defined as data collected from January 1, 2017, to February 29, 2020. During pandemic was defined as data collected between April 1, 2020, and June 30, 2021. Data collected in March 2020 were excluded because this was a transition period of the onset of the pandemic. Human participant research approval was received from each center's Institutional Review Boards.

      Measures

      The primary outcomes were depression and anxiety (PHQ-9 and GAD-7, respectively) at each assessment epoch (postinjury years 1, 2, 5, 10, 15, 20, 25, and 30). The PHQ-9 is a 9-item self-report measure scored from "0=not at all" to "3=nearly every day," with a total score of 0 to 27.
      • Kroenke K
      • Spitzer R
      • Williams J.
      The PHQ-9: validity of a brief depression severity measure.
      The PHQ-9 is a reliable and valid indicator of depression severity and probable major depression in people with TBI. For this study, the PHQ-9 was scored in 3 ways: a total score (0-27), a cutoff of 10 or higher for moderate-severe depression, and suicidal ideation item score >0 indicating thoughts of being better off dead or of hurting oneself within the past 2 weeks.
      The GAD-7 questionnaire
      • Spitzer R
      • Kroenke K
      • Williams J
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      asks participants to rate 7 questions using the stem, "Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?" and scores on an ordinal scale with 4 categories: "0=not at all," "1=several days," "2=more than half the days (>7)," and "3=nearly every day." Total possible scores range from 0-21. Both the PHQ-9 and GAD-7 include a final question about symptom-related impairment, that is, how difficult these problems (endorsed symptoms) have made it for them to do their work, take care of things at home, or get along with other people. Responses are on a 0-3 scale, from not difficult at all to extremely difficult.
      Several demographic, psychosocial, injury-related, and functional characteristics were considered as predictive variables for depression and anxiety, including participants' age at follow-up, sex, race and ethnicity, education level, cause of injury, disability, employment status, marital status, household income, urbanicity, and problematic substance use. Sex was used as a binary variable. Race and ethnicity were categorized as American Indian/Alaska Native, Asian, Black, Hispanic, White, and other. Education level was classified as less than a high school diploma, high school diploma or General Education Development, and greater than a high school diploma. Cause of injury was grouped as vehicular, violence, falls, and other. Disability was measured with the Disability Rating Scale, with possible scores ranging from 0-29. Employment status was examined as employed, student, unemployed, and other. Marital status was categorized as single/never married, married, divorced, separated, and widowed. The region of residence was grouped as rural, urban, or suburban. Problematic substance use in the past month (dichotomized as yes or no) was defined as heavy alcohol consumption (ie, >14 drinks/month for male participants and > 7 drinks/month for female participants), use of illicit drugs, or binge drinking.
      Centers for Disease Control and Prevention
      Behavioral risk factor. Surveillance system user’s guide.
      ,
      Substance Abuse and Mental Health Services Administration
      National household survey on drug abuse: population estimates.

      Data analysis

      Preliminary analyses were conducted in SPSS Version 28a and R Version 4.0.4.b Chi-square tests for categorical variables and independent samples t tests for continuous variables were used to compare sample characteristics between participants retained in analyses and those excluded and compare sample characteristics between participants by pandemic period. Pearson correlations, point-biserial correlations, and φ coefficients were used to evaluate associations between demographic, psychosocial, injury-related, and functional characteristics with depression and anxiety symptoms in the full sample and separately by pandemic period.
      To evaluate the hypothesis that the pandemic period would be independently associated with greater depression and anxiety symptoms, separate linear and logistic regression models were constructed with demographic, psychosocial, injury-related, and functional characteristics, along with a binary indicator of the pandemic period (prepandemic vs during pandemic), as predictors of 4 outcomes: (1) total depression symptoms (linear regression), (2) above cutoff >10 for moderate-severe depression (logistic regression), (3) suicidal ideation > never (logistic regression), and (4) total anxiety symptoms (linear regression). There were no missing data on any outcome variables or the pandemic period predictor by design. Missing data on predictors ranged from 0%-8.2%, although only 2 covariates (ie, household income, disability rating) had more than 2% missing data; covariate missingness was uncorrelated with values on mental health outcomes or with other covariate values (r’s <±0.05). For regression models, complete case analysis (n=5805; 82.8%) was used over maximum likelihood approaches, which would not have applied well to demographic or injury-related variable imputation; participants with complete data did not systematically differ from those with incomplete data on any model variables (r’s <±0.05). Given our large sample size and ability to detect very small associations at α<0.01, we emphasized effect size rather than statistical significance. Effect sizes were evaluated using φ (binary variables) and Cramer's V (categorical variables) for the chi-square tests and using Pearson correlations (r, continuous variables) and Cohen's d for t tests. In regression analyses, effect sizes were evaluated using semipartial correlations and odds ratios for linear and logistic regression models. We conducted a post hoc analysis of the symptom-related functional impairment questions from the PHQ-9 and GAD-7.

      Results

      Sample

      A sample of 9388 TBIMS participants was assessed between October 1, 2017, and June 30, 2021. Of these, 237 were excluded because of follow-up occurring during March 2020, and 2142 were excluded because of missing PHQ-9 or GAD-7 data, leaving a final sample of 7009 participants. Reasons for missing PHQ-9 or GAD-7 data were ineligibility for the administration of these measures because of reporting by an unknown or proxy source (n=1733), missing data (n=405), being lost to follow-up (n=3), and withdrawal from the study (n=1). Characteristics of the total sample and those excluded are displayed in table 1. The demographic characteristics of those eligible but not included resembled those of the analytical sample. A greater proportion of retained participants were older, were White, had higher educational attainment, were employed, and reported a higher household income than participants who were excluded, but these differences were small in magnitude. Disability ratings were much lower among those included vs excluded from the analytical sample, likely because participants must complete the PHQ-9 and GAD-7 themselves rather than by proxy interview.
      Table 1Comparisons of included and excluded participants
      IncludedExcludedEffect Size
      CharacteristicN = 7009n = 2379
      Demographic characteristics, n (%)
      Sex (male)5075 (72.4)1796 (75.7)0.03
      Age at follow-up47.2 (16.7)50.7 (19.5)0.10
       Early adult (16-34 y)1904 (27.2)602 (25.4)
       Early middle (35-44 y)1504 (21.5)437 (18.4)
       Late middle (45-64 y)2377 (34.0)704 (29.7)
       Late adulthood (>64 y)1215 (17.4)628 (26.5)
      Race and ethnicity0.11
       American Indian/Alaska Native30 (0.4)17 (0.7)
       Asian186 (2.7)84 (3.5)
       Black1154 (16.5)466 (19.6)
       Hispanic690 (9.9)375 (15.8)
       Other racial or ethnic group78 (1.1)37 (1.6)
       White4866 (69.5)1393 (58.7)
      Education0.15
       Less than high school827 (11.8)516 (22.9)
       High school or GED2149 (30.7)763 (33.8)
       Greater than high school4021 (57.5)978 (43.3)
      Employment status0.19
       Employed3048 (43.6)508 (23.1)
       Student150 (2.1)31 (1.4)
       Other (ie, homemaker, retired)2910 (41.6)1365 (62.0)
       Unemployed890 (12.7)296 (13.5)
      Marital status0.07
       Single, never married2619 (37.5)947 (41.7)
       Married2564 (36.7)713 (31.4)
       Divorced1266 (18.1)386 (17.0)
       Separated250 (3.6)69 (3.0)
       Widowed294 (4.2)156 (6.9)
      Household income0.15
       <$25K2114 (32.9)862 (49.2)
       $25K to <$50K1536 (23.9)389 (22.2)
       $50K to <$100K1580 (24.6)326 (18.6)
       $100K to <$150K678 (10.5)97 (5.5)
       $150K to <$200K252 (3.9)33 (1.9)
       >$200K274 (4.3)46 (2.6)
      Urbanicity0.06
       Rural1971 (28.6)522 (23.5)
       Urban2701 (39.2)998 (44.9)
       Suburban2226 (32.3)701 (31.6)
      Injury-related characteristics, n (%)
      Follow-up period0.12
       Year 11641 (23.4)747 (31.4)
       Year 2514 (7.3)261 (11.0)
       Year 51384 (19.7)470 (19.8)
       Year 101479 (21.1)401 (16.9)
       Year 151169 (16.7)296 (12.4)
       Year 20616 (8.8)146 (6.1)
       Year 25137 (2.0)42 (1.8)
       Year 3069 (1.0)16 (0.7)
      Cause of injury0.09
       Motor vehicle3853 (55.0)1061 (44.9)
       Fall1681 (24.0)731 (30.9)
       Violence656 (9.4)284 (12.0)
       Other cause812 (11.6)287 (12.1)
      Disability rating, mean ± SD2.1±2.15.4±4.4−1.19
      Problematic substance use (yes), n (%)2065 (29.7)377 (19.5)−0.09
      Mental health symptoms
       Depression symptoms, mean ± SD5.0±5.55.3±5.6−0.06
       Above (10) depression cutoff, n (%)1272 (18.2)43 (21.2)0.01
       Any suicidal thoughts, n (%)518 (7.4)33 (12.5)0.04
       Anxiety symptoms, mean ± SD3.9±5.14.2±5.0−0.06
      COVID-19 time frame
       During COVID-19 pandemic, (%)2009 (28.7)548 (25.6)−0.03
      NOTE. Excluded participants had incomplete PHQ-9 or GAD-7 or completed follow-up during March 2020. Effect sizes are φ or Cramer's V for categorical variables and Cohen's d for continuous variables.
      Abbreviation: GED, General Education Development.

      Correlations overall and by pandemic period

      The participants’ demographic, psychosocial, injury-related, and functional characteristics were similar across the pandemic period (Table 2). The only meaningful difference between participants during the 2 periods was follow-up timing, with a greater proportion of earlier follow-ups (eg, year 2, year 5) among prepandemic participants than during pandemic participants. This difference was likely because of our selection strategy, which retained only the first occurrence of a participant's follow-up data collection.
      Table 2Sample descriptive statistics
      Pre-COVID-19During COVID-19Effect Size
      Characteristicn=5000n=2009
      Demographic characteristics
      Sex (male), n (%)3623 (72.5)1452 (72.3)0.00
      Age at follow-up (y), mean ± SD46.9±16.848.1±16.40.07
       Early adult (16-34 y)1863±28.3577±22.6
       Early middle (35-44 y)1281±19.5607±23.8
       Late middle (45-64 y)2165±32.9847±33.2
       Late adulthood (>64 y)1274±19.4522±20.4
      Race and ethnicity, n (%)0.02
       American Indian/Alaska Native21 (0.4)9 (0.4)
       Asian128 (2.6)58 (2.9)
       Black803 (16.1)351 (17.5)
       Hispanic504 (10.1)186 (9.3)
       Other racial or ethnic group56 (1.1)22 (1.1)
       White3486 (69.7)1380 (68.8)
      Education, n (%)0.01
       Less than high school595 (11.9)232 (11.6)
       High school or GED1520 (30.5)629 (31.4)
       Greater than high school2876 (57.6)1145 (57.1)
      Employment status, n (%)0.03
       Employed2181 (43.7)867 (43.2)
       Student115 (2.3)35 (1.7)
       Other (ie, homemaker, retired)2091 (41.9)819 (40.8)
       Unemployed605 (12.1)285 (14.2)
      Marital status, n (%)0.02
       Single, never married1892 (37.9)727 (36.3)
       Married1814 (36.4)750 (37.4)
       Divorced902 (18.1)364 (18.2)
       Separated170 (3.4)80 (4.0)
       Widowed211 (4.2)83 (4.1)
      Household income, n (%)0.04
       <$25K1548 (33.5)566 (31.2)
       $25K to <$50K1120 (24.2)416 (22.9)
       $50K to <$100K1111 (24.0)469 (25.9)
       $100K to <$150K480 (10.4)198 (10.9)
       $150K to <$200K166 (3.6)86 (4.7)
       >$200K195 (4.2)79 (4.4)
      Urbanicity, n (%)0.00
       Rural1404 (28.6)567 (28.6)
       Urban1928 (39.2)773 (39.0)
       Suburban1584 (32.2)642 (32.4)
      Injury-related characteristics, n (%)
      Follow-up period0.21
       Year 11152 (23.0)489 (24.3)
       Year 2484 (9.7)30 (1.5)
       Year 51123 (22.5)261 (13.0)
       Year 101012 (20.2)467 (23.2)
       Year 15736 (14.7)433 (21.6)
       Year 20370 (7.4)246 (12.2)
       Year 2587 (1.7)50 (2.5)
       Year 3036 (0.7)33 (1.6)
      Cause of injury0.04
       Motor vehicle2698 (54.0)1155 (57.5)
       Fall1251 (25.1)430 (21.4)
       Violence459 (9.2)197 (9.8)
       Other cause586 (11.7)226 (11.3)
      Disability rating, mean ± SD2.0±2.12.1±2.1−0.07
      Problematic substance use (yes), n (%)1516 (30.6)549 (27.6)−0.03
      Mental health symptoms
       Depression symptoms, mean ± SD5.0±5.64.8±5.40.03
       Above (10) depression cutoff, n (%)919 (18.4)355 (17.7)−0.01
       Any suicidal thoughts, n (%)382 (7.6)136 (6.8)−0.02
       Anxiety symptoms, mean ± SD3.9±5.13.9±5.00.00
      Abbreviation: GED, General Education Development.
      There was no evidence of meaningful differences in depression symptom severity, the prevalence of moderate-severe depression, endorsement of suicidal ideation, or anxiety symptom severity by the pandemic period. Furthermore, average depression and anxiety symptom scores throughout the full assessment period (October 1, 2017, to June 30, 2021) were relatively stable (fig 1).
      Fig 1
      Fig 1Depression and anxiety symptoms from October 2017 to June 2021. Quarterly total PHQ-9 scores (A) and quarterly total GAD-7 scores (B) are relatively stable during the study period. The shaded area corresponds with data collected during the COVID-19 pandemic. Data collected during March 2020, while presented here, were excluded from analyses.
      Tables 3 and 4 show correlations between the predictors and mental health outcomes for the full sample and separated by the pandemic period. Being in late adulthood, being employed, being married, or having a higher household income were associated with less depression. Greater disability was associated with higher depression symptom severity, with a medium-sized effect. A similar pattern of associations was found when moderate-severe depression was the outcome. Small associations were observed between a greater likelihood of endorsing suicidal ideation and lower household income and greater disability. Regarding anxiety scores, older age, being employed, being married, having a higher household income, and not having a history of problematic substance use were associated with lower symptom severity, and the magnitude of these relationships was small. There was a medium-sized relationship between disability and anxiety symptom severity in which greater disability was associated with higher anxiety symptom severity.
      Table 3Demographic, injury-related, and psychosocial correlates with mental health outcomes, full sample (N=7009)
      CharacteristicPHQ-9 TotalPHQ-9 CutoffAny SIGAD-7 Total
      Sex (female vs male)−0.07−0.030.01−0.08
      Age (vs all other)
       Early adult (16-34 y)0.040.030.030.09
       Early middle (35-44 y)0.020.020.030.05
       Late middle (45-64 y)0.030.020.010.00
       Late adulthood (>64 y)−0.11−0.08−0.07−0.16
      Race and ethnicity (vs all other)
       American Indian/Alaska Native0.040.030.030.02
       Asian−0.01−0.010.02−0.02
       Black0.070.060.040.07
       Hispanic0.030.020.010.04
       Other racial group0.000.000.010.01
       White−0.07−0.07−0.05−0.08
      Education (vs all other)
       Less than high school0.060.050.040.07
       High school or GED0.060.050.030.05
       Greater than high school−0.09−0.08−0.05−0.09
      Employment (vs all other)
       Employed−0.18−0.14−0.08−0.13
       Student0.010.000.000.01
       Other (ie, homemaker, retired)0.100.080.030.05
       Unemployed0.120.100.070.13
      Marital status (vs all other)
       Single, never married0.060.040.040.08
       Married−0.12−0.10−0.07−0.12
       Divorced0.060.050.040.04
       Separated0.060.060.030.07
       Widowed−0.02−0.02−0.01−0.04
      Household income−0.22−0.18−0.10−0.21
      Urbanicity
       Rural−0.010.000.01−0.01
       Urban0.020.01−0.010.03
       Suburban−0.01−0.010.00−0.02
      Follow-up period−0.04−0.03−0.03−0.04
      Cause of injury (vs all other)
       Motor vehicle0.030.020.020.05
       Fall−0.05−0.04−0.03−0.07
       Violence0.040.040.010.04
       Other cause−0.01−0.010.00−0.01
      Disability rating0.380.300.170.31
      Problematic substance use at follow-up0.080.060.070.11
      NOTE. PHQ-9 cutoff is ≥10; any SI indicates endorsed any suicidal ideation (PHQ-9 item >never).
      Abbreviations: GED, General Education Development; SI, suicidal ideation.
      Table 4Demographic, injury-related, and psychosocial correlates with mental health outcomes by COVID-19 era
      Pre-COVID-19 (n=5000)During COVID-19 (n=2009)
      CharacteristicPHQ-9 TotalPHQ-9 CutoffAny SIGAD-7 TotalPHQ-9 TotalPHQ-9 CutoffAny SIGAD-7 Total
      Sex (female vs male)−0.07−0.030.01−0.08−0.05−0.030.02−0.07
      Age (vs all other)−0.10−0.07−0.06−0.17−0.09−0.06−0.06−0.15
       Early adult (16-34 y)0.040.030.030.090.050.020.030.10
       Early middle (35-44 y)0.040.030.040.07−0.010.00.010.02
       Late middle (45-64 y)0.020.020.00−0.010.050.030.010.02
       Late adulthood (>64 y)−0.12−0.09−0.08−0.16−0.11−0.07−0.06−0.15
      Race and ethnicity (vs all other)
       American Indian/Alaska Native0.050.030.040.030.020.030.010.01
       Asian−0.02−0.020.02−0.020.000.010.00−0.02
       Black0.070.070.050.080.060.050.020.06
       Hispanic0.040.030.010.040.010.010.000.04
       Other racial group0.010.000.010.03−0.01−0.02−0.01−0.02
       White−0.08−0.07−0.06−0.09−0.05−0.05−0.02−0.06
      Education (vs all other)
       Less than high school0.080.060.050.080.020.030.010.04
       High school or GED0.050.040.040.050.070.05−0.020.06
       Greater than high school−0.10−0.08−0.07−0.10−0.07−0.070.01−0.08
      Employment (vs all other)
       Employed−0.19−0.15−0.09−0.14−0.15−0.12−0.05−0.10
       Student0.010.010.010.02−0.010.00−0.01−0.01
       Other (ie, homemaker, retired)0.110.080.040.050.070.070.020.03
       Unemployed0.120.100.080.130.120.070.040.03
      Marital status (vs all other)
       Single, never married0.050.040.030.080.080.050.040.10
       Married−0.12−0.10−0.08−0.12−0.13−0.11−0.07−0.14
       Divorced0.070.050.040.040.050.050.030.04
       Separated0.060.050.030.050.080.090.030.09
       Widowed−0.01−0.010.00−0.02−0.06−0.06−0.03−0.07
      Household income−0.23−0.18−0.11−0.21−0.20−0.16−0.06−0.18
      Urbanicity
       Rural0.000.000.02−0.02−0.010.00−0.03−0.01
       Urban0.01−0.01−0.030.020.050.040.050.05
       Suburban0.000.010.01−0.01−0.04−0.05−0.02−0.04
      Follow-up period−0.03−0.03−0.03−0.02−0.06−0.04−0.03−0.07
      Cause of injury (vs all other)
       Motor vehicle0.020.020.020.050.040.020.010.05
       Fall−0.05−0.04−0.03−0.07−0.06−0.04−0.02−0.08
       Violence0.060.050.020.050.010.00−0.020.03
       Other cause−0.02−0.02−0.01−0.020.010.010.02−0.01
      Disability rating0.390.320.170.320.360.270.160.28
      Problematic substance use at follow-up0.100.070.080.130.040.030.030.06
      NOTE. PHQ-9 cutoff is ≥10; any SI indicates any suicidal ideation (PHQ-9 item >never).
      Abbreviations: GED, General Education Development; SI, suicidal ideation.
      There was no evidence that the pandemic period influenced the relationships between these predictors and mental health outcomes—correlations were similar in magnitude during each assessment period (see table 4). Further, among participants assessed during the pandemic, there were no meaningful associations between rural residence, history of substance abuse, or minoritized race and ethnicity and any mental health outcomes.

      Regressions: predictors of mental health symptom severity

      To examine the unique predictive ability of the pandemic period on mental health outcomes, separate regression analyses were conducted for each outcome (Tables 5 and 6). Given no evidence for moderation during the pandemic period in bivariate analyses, only the main effects were examined. In the depression symptoms model, the unique effect emerged as a medium-sized positive association between disability and depression symptom severity. When predicting the likelihood of moderate-severe depression symptoms, being in late adulthood compared with early adulthood offered reduced odds, while greater disability and substance use history were associated with a small increase in moderate to severe depression. After all other predictors were controlled. Late relative to early adulthood protected against endorsing suicidal ideation; at the same time, greater disability and a history of problematic substance use demonstrated independent associations with greater odds of suicidal ideation. Small, independent relationships emerged between being in late adulthood relative to early adulthood or having less disability and reporting lower anxiety symptom severity. COVID-19 pandemic period was not associated with any of the mental health outcomes assessed (table 7).
      Table 5Depression severity outcomes multiple regression models
      PHQ-9 Symptom SeverityAbove Depression CutoffAny Suicidal Ideation
      βSErspβSEORβSEOR
      Sex (ref. male)0.790.150.060.220.081.25−0.120.130.89
      Age (ref. early adult)
       Early middle (35-44 y)0.110.200.010.100.111.110.230.161.26
       Late middle (45-64 y)−0.200.20−0.010.010.111.01−−0.090.160.91
       Late adulthood (>64 y)−1.790.27−0.08−0.620.160.54−1.090.260.34
      Race and ethnicity (ref. White)
       American Indian/Alaska Native2.010.960.020.640.451.901.040.532.84
       Asian−0.130.420.00−0.030.260.970.190.361.20
       Black0.180.190.010.160.101.180.270.141.31
       Hispanic−0.180.24−0.01−0.010.130.99−0.010.190.99
       Other racial or ethnic group0.270.610.01−0.040.360.960.310.451.36
      Education (ref. less than high school)
       High school or GED0.280.230.010.100.121.10−0.020.160.98
       Greater than high school0.410.230.020.220.131.240.040.171.04
      Employment status (ref. unemployed)
       Employed−0.920.22−0.05−0.260.120.77−0.380.170.69
       Student−0.590.49−0.01−0.130.270.88−0.350.400.71
       Other (ie, homemaker, retired)−0.650.23−0.03−0.200.110.82−0.210.150.81
      Marital status (ref. married)
       Single, never married−0.080.18−0.010.020.111.02−0.050.160.95
       Divorced0.520.200.030.220.111.250.200.161.22
       Separated0.600.370.020.290.191.340.090.271.09
       Widowed−0.380.36−0.01−0.150.220.860.200.321.22
      Household income−0.410.06−0.08−0.230.040.80−0.150.060.86
      Urbanicity (ref. rural)
       Urban0.200.170.01−0.010.100.990.010.141.01
       Suburban0.140.170.010.070.101.070.120.141.13
      Follow-up period−0.160.04−0.05−0.080.020.93−0.080.030.92
      Cause of injury (ref. motor vehicle)
       Fall−0.310.21−0.02−0.170.100.84−0.130.150.88
       Violence−0.110.24−0.01−0.050.130.96−0.230.180.79
       Other cause−0.310.21−0.02−0.140.120.87−0.080.180.92
      Disability rating0.930.040.310.330.021.390.250.031.28
      Problematic substance use1.000.150.080.410.081.500.530.111.71
      COVID-19 era−0.290.14−0.02−0.110.080.90−0.220.120.81
      R2adjusted=0.20Nagelkerke pseudo R2=0.19Nagelkerke pseudo R2=0.11
      NOTE. rsp=semipartial correlation.
      Abbreviations: GED, General Education Development; OR, odds ratio; ref. reference.
      Table 6Anxiety symptom severity outcome multiple regression model
      GAD-7 Symptom Severity
      CharacteristicBSErsp
      Sex (ref. male)1.040.140.09
      Age (ref. early adult)
       Early middle (35-44 y)−0.130.19−0.01
       Late middle (45-64 y)−0.760.19−0.05
       Late adulthood (>64 y)−2.330.25−0.11
      Race and ethnicity (ref. White)
       American Indian/Alaska Native0.190.910.00
       Asian−0.300.40−0.01
       Black0.310.180.02
       Hispanic−0.170.22−0.01
       Other racial or ethnic group0.510.570.01
      Education (ref. less than high school)
       High school or GED−0.160.22−0.01
       Greater than high school−0.110.21−0.01
      Employment status (ref. unemployed)
       Employed−0.940.21−0.05
       Student−0.950.46−0.03
       Other (ie, homemaker, retired)−0.770.21−0.04
      Marital status (ref. married)
       Single, never married−0.190.17−0.01
       Divorced0.210.190.01
       Separated0.600.340.02
       Widowed−0.490.34−0.02
      Household income−0.360.06−0.08
      Urbanicity (ref. rural)
       Urban0.330.160.03
       Suburban0.170.160.01
      Follow-up period−0.110.04−0.04
      Cause of injury (ref. motor vehicle)
       Fall−0.320.16−0.02
       Violence−0.170.22−0.01
       Other cause−0.460.20−0.03
      Disability rating0.690.030.25
      Problematic substance use1.090.140.10
      COVID-19 era−0.070.14−0.01
      R2adjusted=0.17
      NOTE. rsp=semipartial correlation.
      Abbreviations: GED, General Education Development; OR, odds ratio; ref. reference.
      Table 7Functional impairment due to depression and anxiety
      VariablePre-COVID-19During COVID-19
      Depression symptoms
      PHQ-9 impairment (all participants)
       Not at all difficult62.261.1
       Somewhat difficult28.028.9
       Very difficult6.76.8
       Extremely difficult3.03.1
      PHQ-9 impairment (only participants who endorse any PHQ-9 symptoms)
       Not at all difficult49.847.9
       Somewhat difficult37.238.7
       Very difficult8.99.1
       Extremely difficult4.04.2
      Anxiety symptoms
      GAD-7 impairment (all participants)
       Not at all difficult66.063.3
       Somewhat difficult25.427.8
       Very difficult5.65.8
       Extremely difficult3.03.0
      GAD-7 impairment (only participants who endorse any GAD-7 symptoms)
       Not at all difficult46.645.7
       Somewhat difficult39.941.2
       Very difficult8.88.6
       Extremely difficult4.84.5
      NOTE. People who skipped the item because they reported no symptoms were recoded to the "not difficult at all" response.

      Discussion

      The current study revealed no significant differences in depression, anxiety, or suicidality between individuals with TBI eligible for the study assessed before and during the COVID-19 pandemic. Predictors of these mental health symptoms also remained consistent between the 2 periods. Furthermore, there was no significant difference in functional impairment related to depression and anxiety before and during the pandemic. This pattern of results is similar to that which has been observed in individuals with multiple sclerosis and spinal cord injury,
      • Chiaravalloti N
      • Amato M
      • Brichetto G
      • et al.
      The emotional impact of the COVID-19 pandemic on individuals with progressive multiple sclerosis.
      • Capuano R
      • Altieri M
      • Bisecco A
      • et al.
      Psychological consequences of COVID-19 pandemic in Italian MS patients: signs of resilience?.
      • Alschuler K
      • Roberts M
      • Herring T
      • Ehde DM.
      Distress and risk perception in people living with multiple sclerosis during the early phase of the COVID-19 pandemic.
      • Mikolajczyk B
      • Draganich C
      • Philippus A
      • et al.
      Resilience and mental health in individuals with spinal cord injury during the COVID-19 pandemic.
      but may appear to contrast with the findings in the general population,
      • Ren Y
      • Qian W
      • Li Z
      • et al.
      Public mental health under the long-term influence of COVID-19 in China: geographical and temporal distribution.
      • Papadopoulou A
      • Efstathiou V
      • Yotsidi V
      • et al.
      Suicidal ideation during COVID-19 lockdown in Greece: prevalence in the community, risk and protective factors.
      • Shi L
      • Lu Z
      • Que J
      • et al.
      Prevalence of and risk factors associated with mental health symptoms among the general population in China during the coronavirus disease 2019 pandemic.
      • Murata S
      • Rezeppa T
      • Thoma B
      • et al.
      The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers.
      in whom higher levels of depression, anxiety, and suicidality were described. Still, a few important distinctions need to be considered.
      About 1700 individuals with PHQ-9 or GAD-7 data from a proxy source were eliminated—a sizeable number of individuals whose disability may have precluded them from response. Our findings may not reflect the experience of all individuals with TBI and are restricted to those who were at the minimum able to respond to PHQ-9 or GAD-7.
      The timing of the study period needs to be closely considered. In the general population, symptoms of anxiety and depression increased in March 2020 but soon returned to prepandemic levels.
      • Robinson E
      • Sutin A
      • Dal M
      • Jones A.
      A systematic review and meta-analysis of longitudinal cohort studies comparing mental health before versus during the COVID-19 pandemic in 2020.
      In our study, we eliminated data from March 2020 because of a lack of clarity regarding the specific timing of the collected data. Additionally, the PHQ-9 and GAD-7 have the participant refer to the past 2 weeks. Because data collection depended on the precise timing of the declaration of COVID-19 as a global pandemic, these data could not be assigned accurately to the relevant epochs.
      While the findings suggest that the COVID-19 pandemic did not have a detectable harmful effect on the mental health of those with TBI, our findings are consistent with levels of psychological distress in this population reported in other studies.
      • Osborn A
      • Mathias J
      • Fairweather-Schmidt A.
      Prevalence of anxiety following adult traumatic brain injury: a meta-analysis comparing measures, samples and postinjury intervals.
      ,
      • Fisher L
      • Pedrelli P
      • Iverson G
      • et al.
      Prevalence of suicidal behaviour following traumatic brain injury: longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems.
      ,
      • Bombardier CH
      • Fann JR
      • Temkin NR
      • Esselman PC
      • Barber J
      • Dikmen SS.
      Rates of major depressive disorder and clinical outcomes following traumatic brain injury.
      The prevalence of suicidal ideation in the general population is 4%,

      Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH data review. Available at: https://www.samhsa.gov/data/. Accessed January 22, 2022.

      but in our cohorts, the prevalence stayed between 20%-30% (fig 2). While disability rating had a medium correlation with depression and anxiety, the strength of the association was relatively stable through COVID-19. Others
      • Dalise S
      • Tramonti F
      • Armienti E
      • et al.
      Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities.
      have similarly found that greater disability due to neurologic diseases may not be associated with changes in mental health during COVID-19 and speculated that some of these individuals were already restricted and socially isolated. Our findings echo this sentiment.
      Fig 2
      Fig 2Proportion of participants above depression symptom threshold (PHQ-9 ≥ 10) and endorsement of any suicidal ideation across data collection quarters.

      Implications

      This study highlights the ongoing high rates of anxiety, depression, and suicidal ideation for individuals with TBI. Future studies should consider the experience of individuals whose disability precludes participation in surveys.

      Study limitations

      A few limitations should be considered. Analyses were limited to those variables collected for the TBIMS data set, and some variables that may contribute to mental health during the pandemic were not available for study (eg, measures of resilience, health care utilization, family support, use of religion and spirituality for coping). The importance of social determinants of health is increasingly appreciated in the study of neurologic disabilities,
      • Dobson R
      • Marshall C
      • Noyce A.
      Social determinants of neurological disease: tackling inequalities.
      and additional variables (eg, neighborhood socioeconomic status, access to community resources) capturing these potential effects should be included in future work. No control group was available, so we could not draw direct comparisons between trends in the TBI and general populations. Finally, the TBIMS enrolls only individuals who receive acute inpatient TBI rehabilitation. Thus, it is unknown if these findings generalize to individuals with TBI without access to specialized care, such as those from minoritized backgrounds or with limited financial resources.

      Conclusions

      Symptoms of depression, anxiety, and suicidality have shown little change overall during the COVID-19 pandemic in included TBIMS enrollees. At the aggregate level, these results may be regarded positively. Contrary to expectations, we did not find changes in depression, anxiety, and suicidality in this population during this time period.

      Suppliers

      SPSS Version 28; IBM.
      • a.
        SPSS Version 28; IBM.

      References

        • Czeisler M
        • Lane R
        • Petrosky E
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 1049-1057
        • Osborn A
        • Mathias J
        • Fairweather-Schmidt A.
        Depression following adult, non-penetrating traumatic brain injury: a meta-analysis examining methodological variables and sample characteristics.
        Neurosci Biobehav Rev. 2014; 47: 1-15
        • Osborn A
        • Mathias J
        • Fairweather-Schmidt A.
        Prevalence of anxiety following adult traumatic brain injury: a meta-analysis comparing measures, samples and postinjury intervals.
        Neuropsychology. 2016; 30: 247-261
        • Fisher L
        • Pedrelli P
        • Iverson G
        • et al.
        Prevalence of suicidal behaviour following traumatic brain injury: longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems.
        Brain Inj. 2016; 30: 1311-1318
        • Morrow E
        • Patel N
        • Duff M.
        Disability and the COVID-19 pandemic: a survey of individuals with traumatic brain injury.
        Arch Phys Med Rehabil. 2021; 102: 1075-1083
        • Dalise S
        • Tramonti F
        • Armienti E
        • et al.
        Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities.
        Eur J Phys Rehabil Med. 2021; 57: 158-165
        • Dijkers M
        • Harrison-Felix C
        • Marwitz J.
        The Traumatic Brain Injury Model Systems: history and contributions to clinical service and research.
        J Head Trauma Rehabil. 2010; 25: 81-91
        • Kroenke K
        • Spitzer R
        • Williams J.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Spitzer R
        • Kroenke K
        • Williams J
        • Löwe B.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Centers for Disease Control and Prevention
        Behavioral risk factor. Surveillance system user’s guide.
        Centers for Disease Control and Prevention,   Atlanta, Georgia1998
        • Substance Abuse and Mental Health Services Administration
        National household survey on drug abuse: population estimates.
        Substance Abuse and Mental. U.S. Department of Health and Human Services, Rockville, Maryland2018
        • Chiaravalloti N
        • Amato M
        • Brichetto G
        • et al.
        The emotional impact of the COVID-19 pandemic on individuals with progressive multiple sclerosis.
        J Neurol. 2021; 268: 1598-1607
        • Capuano R
        • Altieri M
        • Bisecco A
        • et al.
        Psychological consequences of COVID-19 pandemic in Italian MS patients: signs of resilience?.
        J Neurol. 2021; 268: 743-750
        • Alschuler K
        • Roberts M
        • Herring T
        • Ehde DM.
        Distress and risk perception in people living with multiple sclerosis during the early phase of the COVID-19 pandemic.
        Mult Scler Relat Disord. 2021; 47102618
        • Mikolajczyk B
        • Draganich C
        • Philippus A
        • et al.
        Resilience and mental health in individuals with spinal cord injury during the COVID-19 pandemic.
        Spinal Cord. 2021; 59: 1261-1267
        • Ren Y
        • Qian W
        • Li Z
        • et al.
        Public mental health under the long-term influence of COVID-19 in China: geographical and temporal distribution.
        J Affect Disord. 2020; 277: 893-900
        • Papadopoulou A
        • Efstathiou V
        • Yotsidi V
        • et al.
        Suicidal ideation during COVID-19 lockdown in Greece: prevalence in the community, risk and protective factors.
        Psychiatry Res. 2021; 297113713
        • Shi L
        • Lu Z
        • Que J
        • et al.
        Prevalence of and risk factors associated with mental health symptoms among the general population in China during the coronavirus disease 2019 pandemic.
        JAMA Netw Open. 2020; 3e2014053
        • Murata S
        • Rezeppa T
        • Thoma B
        • et al.
        The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers.
        Depress Anxiety. 2021; 38: 233-246
        • Robinson E
        • Sutin A
        • Dal M
        • Jones A.
        A systematic review and meta-analysis of longitudinal cohort studies comparing mental health before versus during the COVID-19 pandemic in 2020.
        J Affect Disord. 2022; 296: 567-576
        • Bombardier CH
        • Fann JR
        • Temkin NR
        • Esselman PC
        • Barber J
        • Dikmen SS.
        Rates of major depressive disorder and clinical outcomes following traumatic brain injury.
        JAMA. 2010; 303: 1938-1945
      1. Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH data review. Available at: https://www.samhsa.gov/data/. Accessed January 22, 2022.

        • Dobson R
        • Marshall C
        • Noyce A.
        Social determinants of neurological disease: tackling inequalities.
        Lancet Neurol. 2022; 21: 122-123