SHAUNA HAHN, PMHNP, CBIS THE SILENT EPIDEMIC OF TBI’S: LISTENING FOR DEPRESSION AND SUICIDE
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 of 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.”
THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE “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
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
CLINICAL MANAGEMENT OF TBIS: ASK!!!!!!
THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE IF YOU SUFFER A TBI, YOUR RISK OF HAVING ANOTHER INCREASES BY 3 TIMES! David Hovda, director of the Brain Injury Research Center at the University of California, Los Angeles.
CASE STUDIES DEPRESSION
THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE EPIDEMIOLOGY DEPRESSION TRAUMATIC BRAIN INJURY ‣ 235,000 individuals each year are hospitalized for ‣ Approximately half of the people diagnosed wth non -fatal TBI TBI area also affected with depression within 1 year of their injury ‣ 43.1% of patients discharged from hospitals with ‣ About 2/3 of people are affected with depression TBI diagnosis will develop long-term disability secondary to TBI within 7 years of their injury ‣ 1.1 million total individuals were treated for TBI in ‣ The general population has a rate of depression the ER diagnosis at about 1 of 10 people over a 1 year time ‣ Of those 50,000 ultimately lost their life Fann, J., Hart, T., & University of Washington Model Systems Knowledge Translation Center. (2013). Depression after traumatic bran injury. Archives of Physical Medicine and Rehabilitation, 94(4), 801. Tsaousides, T., Ashman, T. A., & Gordon, W.A. (2013). Diagnosis and Corrigan, J. D., Selassie, A. W., & Orman, J. A. L. (2010). The treatment of depression following traumatic brain injury. Brain epidemiology of traumatic brain injury. The Journal of Head Trauma Impairment, 14(1), 63-76. Rehabilitation, 25(2), 72-80.
THE SILENT EPIDEMIC OF TBIS: LISTENING FOR DEPRESSION & SUICIDE 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)
CASE STUDY DAISY
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!!
CASE STUDY COREY
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 or 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!
CASE STUDY MELAN IE
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