THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION AND SUICIDE - - PowerPoint PPT Presentation

THE SILENT EPIDEMIC OF TBI’S: LISTENING FOR DEPRESSION AND SUICIDE

SHAUNA HAHN, PMHNP, CBIS

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

OVERVIEW: SCOPE OF THE PROBLEM IN AMERICA

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION AND SUICIDE

MOST COMMON CAUSES OF TRAUMATIC BRAIN INJURY

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION AND SUICIDE

THE GOVERNOR’S TASK FORCE ON TRAUMATIC BRAIN INJURIES

▸ From 2004 to 2014, an annual average of 785 Oregonians died

from TBI and 2800 were hospitalized

▸ Currently, there are 266 students with TBIs with IEPs in the state

• f Oregon and approximately 5000 other students with TBIs who

require formal support like a 504 plan

▸ Approximately 4400 of incarcerated individuals have TBIs. This

accounts for 30% of the incarcerated population in Oregon!

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION AND SUICIDE

TASK FORCE: A SURVIVOR SPEAKS

▸ “After a brain injury you have an

identity trauma. We slip through the

• cracks. Many in the medical community

don’t know about brain injury. What resources are available? I have no idea…that’s a marketing and accessibility failure on the government’s part. Ideally, we’d have a case manager assigned to us.”

“HE TRIED TO GO BACK TO WORK, BUT BECAME SUICIDAL. HE WENT INTO A PSYCH

• WARD. BECAUSE OF HIS DEPRESSION, HIS

HEALTH STARTED DETERIORATING. IT WAS HARD TO FIND MENTAL HEALTH SUPPORT.”

GOVERNOR’S TASK FORCE: QUOTE FROM A SPOUSE

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

WHAT IS NEUROINFLAMMATION?

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

HPA AXIS DYSFUNCTION:

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

GLIAL CELLS

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

• 1. GLIAL CELLS GET RAMIFIED-FROM REST TO

ACTIVATION

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

EXCITOTOXICITY INDUCED CELL DEATH

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

RELEASE OF INOS

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

PRO-INFLAMMATORY CYTOKINES DEGRADE THE BBB

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

DEPRESSION & TBI ARE BOTH NEUROINFLAMMATION

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

NEUROINFLAMMATION & PSYCHIATRIC ILLNESS

ASK!!!!!!

CLINICAL MANAGEMENT OF TBIS:

IF YOU SUFFER A TBI, YOUR RISK OF HAVING ANOTHER INCREASES BY 3 TIMES!

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

David Hovda, director of the Brain Injury Research Center at the University of California, Los Angeles.

DEPRESSION

CASE STUDIES

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

EPIDEMIOLOGY

TRAUMATIC BRAIN INJURY

• 235,000 individuals each year are hospitalized for

non-fatal TBI

• 43.1% of patients discharged from hospitals with

TBI diagnosis will develop long-term disability secondary to TBI

• 1.1 million total individuals were treated for TBI in

the ER

• Of those 50,000 ultimately lost their life

• Approximately half of the people diagnosed wth

TBI area also affected with depression within 1 year of their injury

• About 2/3 of people are affected with depression

within 7 years of their injury

• The general population has a rate of depression

diagnosis at about 1 of 10 people over a 1 year time

• injury. Archives of Physical Medicine and Rehabilitation, 94(4), 801.

DEPRESSION

49% MOD-SEVERE TBI DEVELOPED PSYCHIATRIC ILLNESS 34% MILD TBI 18% CONTROLS

AMONG PEOPLE WITH TBI WITHOUT A HISTORY OF PSYCHIATRIC ILLNESS:

MOD-SEVERE TBI GROUP HAD 4X MORE PSYCHIATRIC ILLNESS THAN THE CONTROL GROUP MILD TBI GROUP HAD 2.8X MORE PSYCHIATRIC ILLNESS

Fann & Collegues

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

100 ADULT WITH TBI, ON AVERAGE 8 YEARS POST-INJURY, 61% MEET DSM CRITERIA FOR MAJOR DEPRESSIVE DISORDER

Hibbard & Collegues

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

722 TBI PATIENTS IN A REGIONAL LEVEL 1 TRAUMA CENTER 42% MET THE PRE-REQUISITE FOR SYMPTOMS OF MAJOR DEPRESSIVE DISORDER

Kreutzer, Seel, and Gourley (2001)

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

DAISY

CASE STUDY

CASE STUDY: DAISY

MEDICAL HISTORY

▸ TBI at age 19; she was hit from behind by a truck late at night

riding on her motorcycle. She was helmeted, but it caved on

• impact. Loss of consciousness. Post-hospitalization sequelae:

slept 22 hours a day x 1 month. Would cry in the dark for her 2 waking hours. She had zero social support.

CASE STUDY: DAISY

PSYCHIATRIC SYMPTOMS

▸ Major Depressive Disorder, Recurrent, Severe: presenting with

depression, suicidal ideation

▸ 41 year old professional ▸ In marital relationship with an emotionally and verbally abusive

partner

CASE STUDY: DAISY

PSYCHIATRIC TREATMENT

▸ Prescribed Viibryd (SSRI, 5-HT1A partial agonist) at treatment dose ▸ Deplin (MTHFR polymorphism) ▸ Specialty supplement products which boost serotonin and decrease inflammation, curcumin-

based

▸ Magnesium ▸ Fish Oil ▸ Ibuprofen 400 mg PO daily ▸ Seeing Mental Health Counselor ▸ Outcome: She has left her husband. Symptom reduction, but not complete remission.

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

THE DANISH STUDY

▸ LARGEST STUDY OF ITS KIND! ▸ NATIONAL REGISTER STUDY BASED ON

ALL DANES BORN BETWEEN 1977 & 2000—TOTAL OF 1.4 MILLION PEOPLE FOLLOWED UNTIL 2010

▸ 113,906 ADMITTED TO HOSPITAL WITH

HEAD INJURIES

▸ 69% MORE LIKELY TO DEVELOP

DEPRESSION!!

COREY

CASE STUDY

CASE STUDY: COREY

MEDICAL HISTORY

▸ Age 48 ▸ Thrown out of a window when he was three years old by his

father

▸ Learning disabled/ illiterate ▸ Co-morbid neck and back pain, chronic headaches, HTN,

hypothyroidism

▸ Social Security income

CASE STUDY: COREY

PSYCHIATRIC SYMPTOMS

▸

Depression “my whole life”

▸

Anxiety “my whole life”

▸

Chronic fatigue

▸

Difficulty with attention and concentration

▸

Poor memory

▸

Social isolation—difficulty tolerating being around others

▸

H/O impulsive behavior—incarcerations, assaults

▸

Chronic suicidal ideation with h/o attempts

CASE STUDY: COREY

PSYCHIATRIC MANAGEMENT

▸ Rx: duloxetine 90 mg, lamotrigine 150 mg, melatonin 3 mg prn

insomnia

▸ Outcomes: Depression (mild to moderate); intermittent SI,

continued sobriety; improved acceptance of TBI and depressive sx

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

SUICIDE

▸ New research from the University of

Toronto published in the Canadian Medical Association Journal indicates that a single concussion triples the long-term risk for suicide.

▸ The risk increases by another third if

the injury occurs on the weekend, suggesting that recreational injuries are riskier.

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

REIDELMEIER ET AL: SUICIDE AFTER TBI

▸ A total of 667 suicide deaths occurred over a median follow up of

9.3 years equivalent to 31 deaths per 100 000 patients annually (3 x population norm)

▸ Each additional concussion was associated with a further increase

in suicide risk

▸ Most had visited a physician in the month before death; PCPs

accounted for a majority of these visits and a psychiatric d/o was the responsible diagnosis for only a minority of the visits!

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

HOW CONCUSSIONS DIFFER FROM OTHER RISK FACTORS FOR SUICIDE:

▸ 1. Concussions are sometimes

PREVENTABLE

▸ 2. Concussions are easily neglected

under a popular belief that neurologic symptoms will have an obvious cause and will resolve quickly

▸ 3. Concussions are rarely deemed

relevant for consideration by psychiatric

• r other providers when eliciting a

patient’s history

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

WHAT DID THE DANISH STUDY SAY?

▸ Almost 35,000 people with TBIs died from suicide ▸ Only 10% sought treatment for brain injury ▸ Risk is greatest in first six months after injury ▸ Even 7 years post-injury patients still faced a 75%

higher risk of suicide compared to peers

▸ Skull fracture w/o TBI doubled risk for suicide ▸ mTBI doubled risk for suicide ▸ In people with severe TBIs, there was 2.5 x risk!

MELAN IE

CASE STUDY

CASE STUDY MELANIE

MEDICAL HISTORY

▸ Age 42 ▸ Employed as a hairdresser, massage therapist ▸ H/O 3 MVCs resulting in cervicogenic disc degeneration ▸ OD on NO in 2015 (“Whip It” Abuse/ Inhalant Use Disorder) => She was using

100 Whip Its per day! Secondary to OD, permanent neuropathies in her hands and feet

▸ Deep suicidal depression with severe self-care deficits ▸ Very limbically fragile—often cries with little provocation and laughs to the

point of crying again, again with little provocation

DIAGNOSIS? PROGNOSIS?

BIPOLAR II D/O VS PSEUDO BULBAR AFFECT?

CASE STUDY MELANIE

THE DANISH STUDY

▸Risk for Bipolar

Disorder is 28% greater for individuals with TBIs!

WHAT IS PSEUDOBULBAR AFFECT? IT IS A NEUROLOGICAL SYNDROME OF EMOTIONAL AFFECT DISINHIBITION, CHARACTERIZED BY UNCONTROLLABLE, EXAGGERATED AND OFTEN INAPPROPRIATE EMOTIONAL OUTBURSTS, WHICH MAY CAUSE SEVERE DISTRESS, EMBARASSMENT, AND SOCIAL DYSFUNCTION.

CASE STUDY MELANIE

CASE STUDY MELANIE

HOW COMMON IS PBA?

▸ Engleman et al. Neuropsychiatric Disorders & Treatment, 2014.

Estimated prevalence of PBAs in those with TBIs is 5.3-48.2%.

▸ Zelig et al. Brain Injury, 1996: Diagnosed the low end—5.3%. ▸ Work et al. Advances in Therapy, 2011. Diagnosed the high end—

48.2%

THE ESTIMATED US POPULATION WITH PBA RANGED FROM 1.8 TO 7.1 MILLION!!

CASE STUDY MELANIE

TREATMENT:

▸ RIDICULOUS POLYPHARMACY!!! Depakote at therapeutic level,

Lithium at therapeutic level, aripiprazole, duloxetine, clonidine, propranolol.

▸ Q 2 Week visits for 5 months until suicidal intent abated and

patient began to stabilize

KEVIN

CASE STUDY

CASE STUDY KEVIN

MEDICAL & PSYCHIATRIC HISTORY:

▸ 65 y.o. ▸ NO medical co-morbidities ▸ Original diagnosis of Schizophrenia (occasional paranoia, incongruous affect,

irritable, anxious, restless)

▸ Alcohol Use Disorder, Mild-Moderate ▸ MVC at age 16—went through the windshield ▸ Severe Impulsve Control problems ▸ Hypochondriasis—unable to attenuate worry

CASE STUDY KEVIN

TREATMENT

▸ Active socially in our drop in center ▸ Olanzapine 10 mg, Fluoxetine 20 mg

CASE STUDY KEVIN

WHAT’S THE CORRECT DIAGNOSIS?

▸ The Danish Study indicated a 65% increase in risk for

Schizophrenia! Is Schizophrenia the correct diagnosis?

▸ Does he have Pseudo Bulbar Affect? ▸ At this juncture, he is diagnosed with Psychosis Secondary to

Organic Medical Condition.

RACHE L

CASE STUDY:

CASE STUDY: RACHEL

MEDICAL HISTORY

▸ 68 y.o. ▸ Fell? Had TIA in June 2017? Woke up a day and half later, unsure as to what had

happened

▸ Necrotizing fasciitis in 2003 ▸ H/O Breast CA (in 2002 and recurrence in 2014) ▸ Ambulates with a wheelchair and requires supplemental oxygen (2/2 tamoxifen) ▸ Obese ▸ Pathologic Nystagmus with dystonia

PROGNOSIS? ?

CASE STUDY: RACHEL

PSYCHIATRIC SYMPTOMS

▸ Depression, ranging from Severe to Mild ▸ Loss of memory—got lost coming to the clinic one day ▸ Loss of problem-solving (can no longer calculate, can no longer do

Sudokus)

▸ Fatigue with sustained mental effort ▸ Balance is Poor ▸ C/O “cognitive fog”

DAVID

CASE STUDY

CASE STUDY: DAVID

MEDICAL HISTORY + PSYCHIATRIC SYMPTOMS

▸ Suffered TBI at age 22 when assaulted with a hammer by a group

• f teenagers. He was hit in the face; loss of consciousness;

temporary loss of vision

▸ Age 36, Engineering Manager ▸ dx Major Depressive Disorder, Recurrent, Moderate ▸ Struggling with rumination, low self-esteem, guilt, intermittent

suicidal ideation following divorce (10 year marriage)

CASE STUDY: DAVID

PSYCHIATRIC TREATMENT:

▸ Resistance to medication ▸ Low-antigen diet (eliminated dairy and gluten) ▸ Therapy (CBT/DBT/Mindfulness) ▸ Treatment with specialty supplement products, which boosted serotonin and which

were anti-inflammatory

▸ Outcome: Very good response to treatment with eventual remission from depression ▸ Intermittent relapses secondary to lapses in adhering to his diet; for about 4-5 days

following a dietary "cheat," he would become very symptomatic again

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

CLINICAL ASSESSMENT

▸ Injury severity ▸ Physical, emotional, and cognitive symptoms ▸ Medical and psychiatric history ▸ Impact on day to day functioning ▸ Awareness of challenges and strengths ▸ Readiness to engage in symptom management

Weyer Jamora, BIAA, 2018

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

WAYS TO ASSESS:

▸ Clinical Interview ▸ Physical Exam ▸ Collateral Information (records and informants) ▸ Self-Report ▸ Objective Testing

Weyer Jamora, BIAA, 2018

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

THE INTERVIEW:

▸ Determine Injury Severity ▸ Ask re: premorbid functioning ▸ Ask re: sleep, energy, headaches, dizziness

Weyer Jamora BIAA 2018

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

HOW TO ASK ABOUT THE INJURY:

▸ Avoid using the word “accident” ▸ Avoid using the word “consciousness.” ▸ Be specific: “Did anybody see you knocked out?” ▸ “What was the last thing you remember before your injury? What

happened next? Then, next?”

Weyer Jamora, BIAA, 2018

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

NEURO EXAM

▸ Saccades vs Nystagmus ▸ Balance & Gait exam

Weyer Jamor, BIAA 2018

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

SCREENING TOOLS:

▸ HELPS

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE

SCREENING TOOLS:

▸ TBI

THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION &SUICIDE

SCREENING TOOLS:

▸ MAX IMPACT App

THE END