- SELF STUDY MODULES
- 1. Intro to TBI
- 2. Communication
- 3. Skills for independence
- 4. Cognitive changes
- 5. Behaviour changes
- 6. Sexuality
- 7. Case management
- 8. Supervising staff
- 9. Mobility & motor control
- 10. Mental health & TBI:
- 11. Mental health problems
and TBI: diagnosis
- 12. Working with Families
after Traumatic Injury:
- 10.0 Aims
- 10.0A Take the PRE-Test
- 10.1 Mental health & mental illness
- 10.2 Why identify mental health problems after TBI
- 10.3 Why a person might get a mental health problem
- 10.4 The brain and mental health problems
- 10.5 Types of mental health problems after a TBI
- a) Depression
- b) Psychosis
- c) Anxiety
- d) Personality change
- 10.6 Fatigue and problems initiating activities
- 10.7 Issues in using:
- a) Drugs & alcohol
- b) Pain killers
- c) Natural therapies
- 10.8 Treatment challenges
- 10.9 Who to see - services available
- 10.10 Take home messages
- 10.11 Resource
- 10.12 Take the POST-test
- i) Many meanings
- ii) Depressive
- iii) Depression
- iv) From a
- v) Reactive
- vi) Managing
i) The many meanings of "depression"
One of the most common mental health problems that you can get after a brain injury is a condition called depression.
"Depression" is a very tricky word because it has different meanings.
"Depression" can describe a symptom - I feel depressed.
"Depression" can also be part of an illness a person can; for example, with schizophrenia have depressive symptoms.
"Depression" is also used by psychiatrists and psychologists as a description of an illness - a depressive illness.
These many uses of the word "depression" can be confusing.
If I say - Oh I feel depressed todaythat does not necessarily mean I have a depressive illness.
It is usually the job of the psychiatrist or psychologist to make the diagnosis of a depressive illness.
Image: The Starry NightVincent van Gogh 1889
ii) Depressive illnesses
When psychiatrists talk about depression they use a number of different words to describe different types of depressive illnesses but the common ones that a psychiatrist might talk about are:
- a major depression
- a minor depressive illness.
Psychiatrists use these terms to try to communicate to other doctors or health professionals what we mean as psychiatrists. The types of treatments we might use are also often influenced by the type of diagnosis a person has.
Depression can be a reaction to a situation.
For example: our boyfriend leaves us or someone who we really care about dies, and we might develop a depressive reaction.
Depression however can also be a biochemical imbalance.
There are particular chemicals in the brain that are important for our mood. If we get a disturbance in that balance of chemicals we can develop a depressive illness.
iii) Depression and brain injury
Often depression that people get after a brain injury is a combination of chemical/biological changes and a reaction to the person’s new situation.
We know that depression is a lot more common after a brain injury. Studies estimate that up to one third of people suffer from depression following brain injury.
Depression is common in the community - about 1 in every 10 people will at some stage get a depressive illness.
If you have a brain injury your risk for depression increases by about 2 to 3 times that of the community rate. Therefore a lot of people who have had a brain injury are going to, at some time, develop a depressive illness and they are going to need treatment.
The earlier after the brain injury a person develops depression the more likely it is going to be due to a disturbance of chemicals in the brain which has happened as a result of the brain injury.
Depression is probably one of the most common types of mental health problems that someone will have after a brain injury.
iv) Depression due to a chemical imbalance
If the mental health problem, the depression, is due to a chemical imbalance it is often going to start fairly early.
The typical picture you see is someone has:
- emerged from posttraumatic amnesia (the confused state that follows waking from unconsciousness)
- they are now starting to remember things
- they are having their rehabilitation
- they are going along quite well
Within a few weeks they start to get very depressed, they become much more negative, they do not think they are going to get better.
Sometimes they will find that they have problems with sleeping, their appetite will change, they might lose weight, they become more teary than they were, and they will really slow down in everything that they do.
While they are getting better in the general recovery from their brain injury they seem to be getting worse in their mood - and that is often because they have this chemical imbalance, they have a major depression.
v) Reactive depression
The reactive type of depression after brain injury tends to happen much later. Usually around the two year mark.
If you have had a brain injury you will be aware that most of the time the doctors will say to you that we cannot say how well you are going to get or how much of a recovery you have had until about two years after your brain injury.
The two year mark after brain injury has been determined by rehabilitation specialists because research shows this is the time by when most of the recovery happens.
In the first two years there is ongoing recovery of brain function. It does not mean people do not get better after the two year mark it is just that the rate of recovery is slower. We do not notice the changes as much. A lot of the recovery that happens after two years tends to be an adaption to the changes from the brain injury.
In many patients with a reactive depression what has happened is that they have gone along and they have thought - oh the two years are not here yet I will keep getting better, I will keep getting better - and come the two year mark they have still some problems and they get very depressed and very sad.
What they are doing is they are mourning or grieving for the loss of the person that they were and the things that they cannot do any more and struggling with. Whenever anyone loses something important to them they can feel grief. When someone loses who they are, what they can do, or even someone very close to them people can get depressed for a period of time.
Sometimes the reactive depression can be so severe that it causes a biochemical imbalance in the brain.
Which is the odd one out in these different uses of the word depression?
When is a depression from a chemical imbalance likely to start for a person with a traumatic brain injury?
When is a reactive depression likely to start for a person with a traumatic brain injury?
vi) Managing depression
For reactive depression counselling or a treatment called cognitive behaviour therapy is thought to be the most effective treatment. Psychologists, psychiatrists and general practitioners can be trained in doing cognitive behaviour therapy and counselling.
It is very important that treatment involve some form of physical exercise or that the person is active and engaged in activities as much as possible, The physical activation component of treatment has been shown to be effective at preventing the depression becoming worse.
Other components of treatment that have been found to be effective are:
- Therapy partners: family members, spouses, care workers or other people that know you well may be included in the treatment. They can remind you of key messages from the therapy sessions and prompt you to use strategies
- Using reminders: these might be written notes, a journal or messages you might keep on your phone to remind you of key concepts from therapy.
Antidepressants are the commonest treatment for the biochemical depression and for the more serious types of depression. Antidepressants are always prescribed by a doctor, be it a rehabilitation specialist, the psychiatrist or the family doctor.
Common names of antidepressants are:
Most of these antidepressants are very easy to prescribe and the family doctors typically start this medication. Antidepressants are fairly well tolerated. There is no medication that does not have any side effects. But typically the side effects only last a short time before they go away if you persist with taking the medicine.
Tips when taking antidepressants
The positive effect can take weeks
If you take an antidepressant and think you are going to feel better straight away you are going to be disappointed.
Antidepressants are going to change the level of chemicals in the brain and to do this it takes some time, so most people do not start to feel better with antidepressants for at least a week if not longer. Sometimes after a brain injury it can take six weeks before the antidepressants start to work. One of the important things that you need to remember is that if you have been prescribed antidepressants you need to keep taking them even if you do not feel better immediately.
Usually when you are started on an antidepressant the doctor will see you about a week to two weeks after you have started the medicine to see how you are going. Hopefully by then any side effects that you have from the treatment will go away.
Do not stop suddenly
Do not stop the tablets suddenly as this can make you feel really sick.
One of the important things to remember with an antidepressant is once it starts to work and you feel a lot better you just cannot stop it. If you stop it very suddenly the underlying chemical imbalance will come back really quickly. Most people have to take antidepressants for about 9 to 12 months if not longer to stay well.
Treatment with antidepressants may last a couple of years
Sometimes after a brain injury the treatment needs to be for about two years. Generally when the depression has improved a little most people will have cognitive behaviour therapy with a psychologist. This will be to help the person to develop some strategies to stop the depression coming back when the doctor tells them that they can stop taking the antidepressants.
Alcohol and antidepressants
If you have a depressive illness and you are prescribed antidepressants then alcohol is going to make the antidepressants less effective. If you are drinking a lot of alcohol because you want to try to feel better, and alcohol numbs your feeling, the alcohol is going to stop your antidepressants from working so you need to stop drinking your alcohol. However, once you are well you might want to go out; you can then have a drink or two with your medication but no more than two drinks. Antidepressants are usually then quite safe in combination with alcohol in small quantities occasionally. You should always talk to your doctor about alcohol and your tablets.
One antidepressant that is not safe with alcohol is the medication called Tryptanol (also known as Endep). Some of the more old fashioned antidepressants are also not safe with alcohol. I encourage you to talk to your doctor who has prescribed the antidepressant about whether or not it is safe for you to have one or two drinks once you are well with your tablets.
If a person were being treated with antidepressants for a depressive illness, how long does it typically take before noticing a reduction in depressive symptoms?