One intuitively knows that experiencing a brain injury is often painful and terrifying; the fact that it can lead to the onset of depression, however, is a lesser known but equally serious concern. Dr. Roberta Diddel, a clinical psychologist and member of the adjunct faculty in the Psychology Department at Rice University, focuses on the treatment of individuals with mental health issues and cognitive disorders. In particular, she administers care to patients with cognitive disorders due to traumatic brain injury (TBI). Dr. Diddel acquired a PhD in clinical psychology from Boston University and currently runs a private practice in Houston, Texas. Patients who experience TBI often experience depression; Dr. Diddel uses her understanding of how this disorder comes about to create and administer potential treatments.
Traumatic brain injury (TBI) affects each patient differently based on which region of the brain is damaged. If a patient has a cerebellar stroke, affecting the region of the brain which regulates voluntary motor movements, he or she might experience dizziness and have trouble walking. However, that patient would be able to take a written test because the injury has not affected higher order cognitive functions such as language processing and critical reasoning.
Dr. Diddel said, “Where you see depression the most is when there is a more global injury, meaning it has affected a lot of the brain. For example, if you hit your forehead in a car accident or playing a sport, you’re going to have an injury to the front and back parts of your brain because your brain is sitting in cerebrospinal fluid, causing a whiplash of sorts. In turn, this injury will cause damage to your frontal cortex, responsible for thought processing and problem solving, and your visual cortex, located in the back of your brain. When your brain is bouncing around like that, you often have swelling which creates intracranial pressure. Too much of this pressure prevents the flow of oxygen-rich blood to the brain. That can cause more diffuse brain injury.”
In cases where people experience severe brain injury such as head trauma due to an explosion or a bullet, surgeons may remove blood clots that may have formed in order to relieve intracranial pressure and repair skull fractures.4 They may also remove a section of the skull for weeks or months at a time to let the brain swell, unrestricted to the small, cranial cavity. That procedure alone significantly reduces the damage that occurs from those sorts of injuries and is especially useful in the battlefield where urgent care trauma centers may not be available.
Depression is a common result of TBI. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines depression as a loss of interest or pleasure in daily activities for more than two weeks, a change in mood, and impaired function in society.1 These symptoms are caused by brain-related biochemical deficiencies that disrupt the nervous system and lead to various symptoms. Usually, depression occurs due to physical changes in the prefrontal cortex, the area of the brain associated with decision-making, social behavior, and personality. People with depression feel overwhelmed, anxious, lose their appetite, and have a lack of energy, often because of depleted serotonin levels. The mental disorder is a mixture of chemical imbalances and mindstate; if the brain is not correctly functioning, then a depressed mindstate will follow.
Dr. Diddel mentioned that in many of her depressed patients, their lack of motivation prevents them from addressing and improving their toxic mindset. “If you’re really feeling bad about your current situation, you have to be able to say ‘I can’t give in to this. I have to get up and better myself and my surroundings.’ People that are depressed are struggling to do that,” she said.
The causes of depression vary from patient to patient and often depends on genetic predisposition to the disease. Depression can arise due to physical changes in the brain such as the alterations in the levels of catecholamines, neurotransmitters that works throughout the sympathetic and central nervous systems. Catecholamines are broken down into other neurotransmitters such as serotonin, epinephrine, and dopamine, which are released during times of positive stimulation and help increase activity in specific parts of the brain. A decrease in these chemicals after an injury can affect emotion and thought process. Emotionally, the patient might have a hard time dealing with a new disability or change in societal role due to the trauma. Additionally, patients who were genetically loaded with genes predisposing them to depression before the injury are more prone to suffering from the mental disorder after the injury.2,3
Depression is usually treated with some form of therapy or antidepressant medication. In cognitive behavior therapy (CBT), the psychologist tries to change the perceptions and behavior that exacerbate a patient’s depression. Generally, the doctor starts by attempting to change the patient’s behavior because it is the only aspect of his or her current situation that can can described. Dr. Diddel suggests such practices to her patients, saying things like “I know you don’t feel like it, but I want you to go out and walk everyday.” Walking or any form of exercise increases catecholamines, which essentially increases the activity of serotonin in the brain and improves the patient’s mood. People who exercise as part of their treatment regimen are also less likely to experience another episode of depression.
The efficacy of antidepressant medication varies from patient to patient depending on the severity of depression a patient faces. People with mild to moderate depression generally respond better to CBT because the treatment aims to change their mindset and how they perceive the world around them. CBT can result in the patient’s depression gradually resolving as he or she perceives the surrounding stimuli differently, gets out and moves more, and pursues healthy endeavors. Psychologists usually begin CBT, and if the patient does not respond to that well, then they are given medication. Some medications increase serotonin levels while others target serotonin, dopamine, and norepinephrine; as a result, they boost the levels of neurotransmitters that increase arousal levels and dampen negative emotions. The population of patients with moderate to severe depressions usually respond better to antidepressant medication. Medication can restore ideal levels of neurotransmitters, which in turn encourages the patient to practice healthier behavior.
According to the Center for Disease Control and Prevention, the US saw about 2.5 million cases of traumatic brain injury in 2010 alone.5 That number rises every year and with it brings a number of patients who suffer from depression in the aftermath.5 Though the mental disorder has been studied for decades and treatment options and medications are available, depression is still an enigma to physicians and researchers alike. No two brains are wired the same, making it very difficult to concoct a treatment plan with a guaranteed success rate. The work of researchers and clinical psychologists like Dr. Diddel, however, aims to improve the currently available treatment. While no two patients are the same, understanding each individual’s depression and tailoring treatment to the specific case can vasty improve the patient’s outcome.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC, 2013.
- Fann, J. Depression After Traumatic Brain Injury. Model Systems Knowledge Translation Center [Online]. http://www.msktc.org/tbi/factsheets/Depression-After-Traumatic-Brain-Injury (accessed Dec. 28, 2016).
- Fann, J.R., Hart, T., Schomer, K.G. J. Neurotrauma. 2009, 26, 2383-2402.
- Mayo Clinic Staff. Traumatic Brain Injury. Mayo Clinic, May 15, 2014. http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/basics/treatment/con-20029302 (accessed Dec. 29, 2016).
- Injury Prevention and Control. Centers for Disease Control and Prevention. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html (accessed Dec. 29, 2016).