Depression and Acquired or Traumatic Brain Injury - Fact Sheet

Depression is a common outcome following a brain injury. A person may be confronted with not returning to work, cognitive deficits that will never completely disappear, loss of friends, fatigue and difficulty with managing anger and frustration. On top of this they may have lost the strategies used in the past to combat depression and these will need to be re-learned.

A number of factors influence a person’s level of depression following a brain injury.

It is important to consider each of the following factors:

• Life situation
• Level of traumatic stress experienced
• Person’s perception of their life situation
• Personality, mental health state and emotional well-being before the injury
• Nature of the person’s brain injury
• Stage of recovery
• Other health conditions that may cause or exacerbate the symptoms of depression, e.g. heart disease or kidney failure

Signs and Symptoms

The common signs and symptoms of depression include changes in:

• Mood e.g. extreme sadness, despair, flat emotional reactions and irritability
• Thinking patterns e.g. a sense of hopelessness, pessimistic beliefs
• Behaviour patterns e.g. reduced attention to physical appearance, withdrawal
• Physical symptoms e.g. sleep disturbance, appetite changes, tiredness.

Some of the changes described are common symptoms following an acquired brain injury, which means it can be difficult to recognise the development of depression. People’s experience of depression usually occurs on a continuum ranging from very mild to very severe. The most important consideration is therefore the severity of the person’s depression and how long it lasts. Many people are able to self-manage their depression using strategies. Other people require psychological support or other forms of treatment from professionals.

One of the most important factors to consider when planning any treatment, or evaluating the success of a treatment strategy, is whether or not the person with depression feels as though they are in control of their own life. A feeling of not being in control makes any depression worse, or can lead to depression.

Endogenous and Exogenous Depression

Although the treatment approaches are usually similar, depression can be divided into exogenous (“reactive”) depression which occurs when life events overwhelm your ability to avoid depression and maintain good mental health, and endogenous (“organic”) depression which arises as a direct result of chemical processes in the brain.

Exogenous depression can be helped by anti-depressant medication, but addressing the causes through life changes or coping strategies will remove the need for medications.

Endogenous depression can be helped by life changes and coping strategies, but medical intervention will probably be necessary, sometimes life-long.

Personal Strategies for Coping with Depression

The following strategies have been suggested by people with acquired brain injury and may be useful.

• Having a nap
• Listening to music
• Watching television
• Working on a personal project
• Socialising
• Walking or other exercise
• Mental stimulation (which will also assist with cognitive rehabilitation)
• Scheduling activities and making short-term plans
• Self-Talk or thought challenging.

Self-Talk

Self-Talk is a useful technique for modifying inaccurate and upsetting thoughts. It requires the practised art of replacing upsetting thoughts with constructive explanations. For example instead of thinking, “I’m useless and I never get anything right,” the person can replace their thoughts with a constructive explanation such as, “My memory let me down, I will make better use of my diary in future.” A variation of Self-Talk is to prepare a rethink card. Rethink cards contain helpful coping statements for particular situations. The card can be carried around and read when the person notices unhelpful thoughts in certain situations e.g. a coping statement for being stared at while riding public transport: “People may stare at me because they are naturally curious about why I walk with a limp - that is part of human nature”.

Peer support

Do not underestimate the importance of social contact for the maintenance of good mental health, including depression. In his landmark book The Anatomy of Melancholy, first published in 1621, Robert Burton wrote “Observe this simple precept – be not solitary; be not idle.” Social contact, and in particular peer support, is often of immense help to someone with depression.

Your local brain injury association or mental health association can put you in touch with peer support groups for brain injury or for depression.

Exercise

Be not idle. Time and again, research indicates that exercise, alleviates the symptoms of depression. A major depressive disorder can not be treated by exercise alone, but every little bit helps and, particularly if you have an attack of the blues, getting moving can not only help you feel better but accelerate your rehabilitation.

If you are currently recovering from physical injury or physical deficits as a result of a brain injury, discuss any exercise program with your GP or rehabilitation team.

Treatment Approaches for Depression

It is common for some people to experience depression after a traumatic event and require additional treatment to the strategies suggested. Treatment options include the following:

Psychological therapy

This form of treatment is usually most effective with mild or moderate to severe forms of depression. In general, people with very severe forms of depression will require other interventions e.g. hospitalisation or medication. After a person’s state of mind has improved they may be more likely to benefit from psychological support to further reduce symptoms and provide ongoing management.

Antidepressant medication

Medication is often used in association with psychological therapy for the person with depression who does not respond well to psychological therapy. Medication may help to relieve depression by adjusting the chemical levels in the brain. Depression is often caused by an excess or a deficiency of particular chemicals in the brain. Such chemicals are created naturally within our bodies and influence our moods, thinking, behaviour, sleep, energy levels, appetite, concentration and other daily functions. In cases of depression, a doctor may suggest medication to address any chemical deficiency that may exist.

The choice of medication depends upon a range of considerations such as:

• Side effects
• The person’s previous response to medication
• Interaction with other medication being taken
• Safety in overdose

Most antidepressants take about two weeks before a person will notice any change in mental and physical state. Medication needs to be trialled for at least 4-6 weeks and should generally be taken for approximately 6-12 months even if the person feels better after a few months. People are advised to see a general practitioner or psychiatrist to discuss issues relating to medication.

Electro Convulsive Therapy (ECT)

Although it may have a bad reputation, particularly in the movies, ECT is an extremely effective and very safe treatment for severe depression. ECT works by passing an electric current through the scalp to the brain, inducing a seizure. The current is controlled to be safe for the heart, and the patient is given a general anaesthetic and a muscle relaxant to prevent convulsions. Although ECT does impair short term memory, this is minimised in modern practice by only treating one hemisphere of the brain.

ECT is usually used as a treatment of last resort – used only when depression has not responded to other treatments.

Suicide

Given the many difficulties faced by someone who has survived a brain injury, it can be quite common to feel suicidal at times. It is crucial to look for support or see a doctor during this period as appropriate support will normally allow the person to get through these deep depressive episodes.

The symptoms of suicide are not always the symptoms of depression. Warning signs to look for include:

• Making statements like ‘It would have been better if I had died’ or making threats about committing suicide
• Suddenly and unexpectedly becoming cheerful after a long period of depression (which may indicate the individual having decided to use suicide as a solution).
• If the person with Acquired Brain Injury has tried to commit suicide before, you should particularly be aware of cues and try to assist them to seek professional help.
• Having a plan for suicide, and the means to achieve it.

It is particularly important to realise that the existence of an achievable plan must be taken seriously. All suicidal comments need to be addressed, but having a plan and the means to achieve it is a sign that professional help needs to be sought as a matter of urgency. If the situation is critical, call 000.

For more information see our fact sheet, Suicide and brain injury .

Can a brain injury directly cause depression?

There is still debate over whether depression can be directly caused by an injury to the brain, rather than by the effects that the injury has upon the person and their life.

A study published online by Science magazine in 2007 reported that a link has been found between depression and a reduced level of activity in the hippocampus, a C-shaped region of the brain on the inside of the Temporal lobes which is also a key to short term memory. It was believed that the hippocampus plays a central role in affect (emotional experience), but the details are not yet understood. This result suggests that injury to the hippocampus may directly result in depression, but more research is needed to confirm this.

References and further information

• The Anatomy of Melancholy – Full text
• Beyond Blue: The National Depression Initiative
• Bran Pathway may underlie depression (Scientific American)