Risk of Posttraumatic Stress Disorder and Major Depression After Mild Traumatic Brain Injury: A TRACK-TBI Study

JAMA Psychiatry. 2019;76(3):249-258

Many mild traumatic brain injury (mTBI) patients make a full recovery, but some continue to be symptomatic after head trauma. Patients with mental health diagnoses, including post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) appear to be at risk for new or worsening symptoms after head injury.

As part of the TRACK-TBI (Transforming Research and Clinical Knowledge in Traumatic Brain Injury) study, Stein et al. assessed PTSD and MDD symptoms using the PTSD Checklist (PCL-5, included in the DSM-5) and the Patient Health Questionnaire-9 item (PHQ-9) in mTBI patients compared to orthopedic trauma patients without evidence of head injury. Patients >17 years old who were seen within 24-hours of injury, had a clinical head CT, and fluent in English or Spanish were enrolled at 11 US level 1 trauma centers. All included mTBI patients had a Glascow Coma Score >13. The mTBI patients were evaluated 4 times: @baseline (shortly after initial evaluation), and 3, 6, and 12 months post-injury; the ortho trauma patients were assessed at baseline, 3 and 6 months. 1155 patients with mTBI and 230 patients with orthopedic injuries were assessed.

Patients with mTBI were more likely than ortho trauma patients to be admitted to the ICU (24.5% versus 7.4%), and more mTBI patients suffered violence or assault than ortho trauma patients (6.1% versus 1.0%). Both groups were closely matched for gender, race/ethnicity, employment and insurance status. The most common outcome (n=431) for mTBI patients was no PTSD or MDD. The second most common outcome (n=62) was having both probable PTSD (PCL-5 score of >33) and probable MDD (PHQ-9 score of >15). Other outcomes were observed less often. mTBI patients were more likely to suffer from probable MDD or PTSD at 3 months, and more likely to have probable PTSD at 6 months. Logical regression analysis showed that having less education, being black, having a previous mental health disorder, and having the mTBI from an assault or violent incident were all statistically significant risk factors for developing probable PTSD. The risk factors for developing probable MDD were similar, except violent mTBI was not associated with MDD. Loss of consciousness, post-traumatic amnesia, CT evidence of brain injury, hospital admission, employment status, and health insurance coverage were not significant for patient outcomes. These findings suggest factors associated with higher risk for persistent PTSD and/or MDD, and these mTBI patients may benefit from more follow up and additional interventions.

Katherine E. Wagner, MD
Hempstead, NY
Jamie S. Ullman, MD
Hempstead, NY