Long-Term Psychological Support Required After Traumatic Brain Injury

Allison Gandey

November 25, 2008

November 25, 2008 — Psychological support services can help alleviate the distress that patients experience after traumatic brain injury and should be offered not only on a short-term basis, report researchers, but for up to 2 years. Investigators also demonstrate that they could predict long-term outcomes as early as 20 days posttrauma using standard testing.

"This has important implications not only for patients, but for their loved ones as well," coauthor Mitra Feyz, from McGill University Health Center, in Montreal, Quebec, told Medscape Neurology & Neurosurgery. "Families want to know first whether their loved one will survive and then what they will be like afterward. This study should help clinicians outline expectations," she said.

The study appears in the September/October issue of the Journal of Head Trauma Rehabilitation.

Elaine deGuise, PhD, led the team in what is known as the McGill Interdisciplinary Prospective Study. The group looked at 46 patients with traumatic brain injury and assessed evaluations at discharge from acute care and at 2 to 5 years of follow-up.

"This study is unique, as it involved a multidisciplinary team," Dr. deGuise noted in a news release. "We could therefore assess the patient from many angles and establish an overall picture."

Could Predict Long-Term Outcomes 20 Days After Injury In Some

Using the Extended Glasgow Outcome Scale, the revised Neurobehavioral Rating Scale, and the Functional Independence Measure at discharge from acute care, investigators found that they could project long-term outcomes.

Researchers observed relatively good physical and functional outcome, but poorer results for cognitive and emotional health.

The mean Extended Glasgow Outcome Scales improved by 25%, with a score of 3.43 at discharge compared with 2.63 at follow-up. Nonparametric tests showed a significant correlation between the scores at discharge and at follow-up (r = .685; P < .01).

This indicates that patients who were more severely impaired at discharge continued to be more impaired at least 2 years postinjury and that those who initially scored better also did so at follow-up.

Table 1. Mean Functional Independence Measures

Variable Score at Discharge Score at Follow-up (2 - 5 years) Improvement (%)
Total score 74.09 100.1 60
Score for physical 55.92 75.67 74
Score for cognitive 18.17 24.48 46

Table 2. Scores on the Revised Neurobehavioral Rating Scale

Variable Score at Discharge Score at Follow-up (2 – 5 years) Improvement (%)
Intentional 2.42 1.78 45
Emotional 1.61 1.64 14
Survival 1.35 1.28 5.3
Arousal 2.36 1.60 59.4
Language 1.87 1.57 33

The results of this study were similar to those found in other investigations, the researchers report, and confirm that long-term prediction of global, functional, and neurobehavioral status can be based on what is observed at discharge from the acute-care setting.

More Than Half of Patients Developed Depressive or Anxiety Disorders

During an interview, Dr. Feyz emphasized that even patients who do not require intervention in a rehabilitation setting on a long-term basis should be considered for psychological support services.

"Cognitive and emotional deficiencies can have major consequences, and most of our patients could not keep the same job after their accidents," she said. "This leads to other psychosocial problems that often result in psychological vulnerability. Out of all the patients observed in this study, 52% presented with depressive or anxiety disorders 2 to 5 years after the trauma."

The investigators point to a number of strengths and weakness of their work. These results were obtained in a Canadian population in the context of a universal healthcare system from emergency treatment to postrehabilitation. All of these patients received the same services based only on their needs and their recovery potential, with no financial considerations.

Cognitive and emotional deficiencies can have major consequences and most of our patients could not keep the same job after their accidents.

It is a representative sample of patients with traumatic brain injury because it included not only those who made sufficient progress to benefit from rehabilitation, but also those who required long-term care placement.

The study was limited, however, by its small sample size. Although the study was prospective, patients were recruited retrospectively, and the choice of validated measures was limited to those used at the time of acute-care admission to compare measures at discharge and at follow-up. Because of this, several objective, physical, and cognitive tests could not be used.

Despite these limitations, researchers suggest that this study will help clinicians, health administrators, insurance companies, and families organize efficient care and plan long-term services for patients with traumatic brain injury.

This study was supported by grants from the McGill University Health Centre, the Montreal General Hospital Foundation, and the Quebec Ministry of Health and Social Services. The researchers have disclosed no relevant financial relationships.

J Head Trauma Rehabil. 2008;23:294-303. Abstract

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