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elationship between specific components of a comprehensive programme and outcomes are difficult to
determine. In some studies mood may not be the primary focus of an intervention programme, but may
improve as part of a rehabilitation programme that is addressing the factors that are contributing to the
development or maintenance of a mood disorder. For example, someone who is depressed as a result of
inability to return to work may be supported through a vocational rehabilitation programme to gain some
form of employment, with an associated improvement in mood. So while the therapeutic intervention was
not a traditional treatment for mood disorder (pharmacological or psychotherapy), improvement in mood
is a secondary outcome.
6.2.1 DEPRESSION
A survey of 666 people after TBI reported that 27% of the participants reported five or more symptoms of
depression. 109 Another large single cohort study found higher rates in a sample of 559 participants followed
for up to a year post injury. They found that 53.1% of their sample met criteria for depression at some point
in the year after injury, almost eight times the rate in the general population who did not have a brain injury.
At any one point in time around 20-30% of participants were depressed. 108
Pharmacological interventions
A systematic review of 13 studies (n=301) of pharmacological agents to treat depression in patients following
TBI identified only small studies which varied widely in design, diagnostic and outcome assessment, severity
of brain injury, and time post injury. The authors concluded that there was insufficient evidence on which
to base strong recommendations. 15 However, based on weak evidence and expert opinion, the use of
sertraline in clinical practice was suggested. One RCT with 99 participants found evidence that prophylactic
administration of sertraline reduced the incidence of depression in the first year after a head injury, but
overall rates of depression were lower than usual, and no conclusions can be drawn regarding who benefits
most from the intervention. 110
The evidence relating to the pharmacological treatment of depression after brain injury is inconclusive and
no specific recommendation can be made. A systematic review showed that antidepressant treatment is
more effective than placebo in treating depression in the context of a wide range of neurological conditions
including stroke, Parkinson’s disease, epilepsy, multiple sclerosis and brain injury, although this review which
included 20 RCTs only involved one study with patients who had suffered brain injury. Of eight adverse
effects reported to be associated with antidepressant use only dry mouth was statistically more common
in intervention groups than controls (odds ratio 2.41, 95% CI 1.32 to 4.40). 111
Psychological interventions
6 • Rehabilitation of behavioural and emotional disorders
A systematic review of interventions in patients following TBI included eight studies, most of which were
uncontrolled, and which involved widely different treatment models. Although all studies included both
pre- and post-treatment measures of depressive symptoms (an inclusion criterion for this review), none
of them were designed specifically to evaluate treatments for depression. The authors concluded that no
recommendations regarding psychological interventions could be made. They noted that depression was
improved in the context of multimodal interventions and that cognitive behavioural interventions appeared
to have the best preliminary evidence, but in the absence of clear evidence relating to the specific individual
elements which might impact on depressive symptoms among these complex treatments, many of which
were deliberately multifaceted and not directly targeted at depression originally, no specific recommendations
could be made. 15
Three RCTs of telephone counselling interventions reported different findings. One study of people after
admission to an ED found no significant benefit of the telephone intervention (five phone calls over a 12-week
period) in terms of psychological symptoms at six months. 112 By contrast, another trial reported significant
benefit in people with more severe injury who received seven calls over nine months when followed up at
one year. 113 A third, multicentre, study found no effect of a scheduled telephone intervention over either
one or two years although this study did not separate data on depression and anxiety. 11
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