TBI psychiatry — depression, aggression and the drug evidence (MEQ)

(i) Frequency and predictors. Of 559 adults hospitalised with complicated mild to severe TBI, 53.1% met criteria for major depression at least once in the first year. Risk was associated with depression at or before injury and lifetime alcohol dependence, and only 44% of those with depression received antidepressants or counselling.^[1]

(ii) Sertraline. In a prevention trial of 94 patients hospitalised for TBI, sertraline 100 mg/day for 24 weeks prevented depressive disorders with a number needed to treat of 5.9.^[3] In 62 adults with major depression within a year of complicated mild to severe TBI, sertraline was not superior to placebo on depression severity, response or remission over 12 weeks.^[2] French expert recommendations give SSRIs a grade B standard of proof for depression after TBI.^[4]

(iii) Aggression. Aggressive behaviour was found in 33.7% of TBI patients in the first 6 months and was associated with major depression, frontal lobe lesions, poor premorbid social functioning and substance abuse.^[5] Evidence is insufficient to standardise drug treatment: propranolol can improve aggression (grade B), carbamazepine and valproate are expert-consensus first line, and there is no evidence of efficacy for neuroleptics, whose use is for a crisis, not long term.^[4]

Acute agitation. Propranolol lowered the intensity of agitation and restraint use during initial hospitalisation after closed-head injury.^[7] In the acute period, amantadine, propranolol and anti-epileptics were the best-supported medications in a systematic review.^[8]

(iv) Non-drug care. Management of TBI-associated neuropsychiatric disorders should always include education, family involvement, supportive and behavioural psychotherapies, and cognitive rehabilitation.^[6]