1. RUNNING HEAD: TRAUMATIC BRAIN INJURY AND DEPRESSION
Traumatic Brain Injury and Depression: Creating and establishing proper mental support
systems for those affected by comorbid diagnoses
Jessica R. Gower
Oakland University

2. TRAUMATIC BRAIN INJURY AND DEPRESSION 2
Traumatic Brain Injury and Depression: Creating and establishing proper mental support
systems for those affected by comorbid diagnoses
Introduction
Traumatic brain injuries affect more people than the common public may realize.
Consistently the public will see headlines on football players and soldiers coming home from the
battlefield being a subject of study for traumatic brain injuries. What one may not realize is what
a traumatic brain injury really is and how it affects daily living. A traumatic brain injury usually
involves a sudden blow or jolt to the head. This blow or jolt to the head can lead to varying
consequences. One could sustain a mild, moderate or severe traumatic brain injury that could
potentially result in death (CDC, 2013). Due to the varying consequences a traumatic brain
injury may result in, there are also varying symptoms used to diagnose a traumatic brain injury
after a person has recovered. Some common symptoms a person will experience no matter the
severity of the head injury include headache, fatigue, memory problems and depression among a
list of other symptoms (BIA, 2012). According to the DSM-IV-TR, five out of nine criteria
symptoms must be present for a minimum of 2 weeks in order to diagnose a person with a
depressive mood disorder (2000). For clarification purposes this paper will not be focusing
specifically on post traumatic stress disorder (classified as a depressive mood disorder according
to the DSM-IV-TR), which many people associate with traumatic brain injury and depression.
The topic of this paper will however, focus specifically on how depression affects someone with
a traumatic brain injury during their journey towards recovery as well as the process of learning a
“new” normal of daily life and what support systems are required that are not currently readily
available and easily accessible to assist in this journey.

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Knowing that each brain injury is unique in itself allows the professional to realize that
each individual affected needs their own unique rehabilitation and treatment program. Not every
traumatic brain injury will result in someone who needs help coping with depression. But, those
that do result in depression will need a program focused on both ways to cope with depression
and their head injury, including other symptoms they may be experiencing. Using an approach
from multiple disciplines is necessary as there is not only a medical problem in such a situation,
but also a social-psychological problem that needs to be addressed the healthcare professional.
Cognitive decentering is defined as “the intellectual capacity to consider a variety of
other perspectives and thus perceive reality more accurately, process information more
systematically, and solve problems more efficiently” (Repko, 2012, p. 55). The problem of
helping one cope with depression resulting from a traumatic brain injury requires an integrative
approach as there is a lot to understand about both the injury itself and the side effect of
depression. As a professional who is trying to help an individual with such an injury, they will
need to be able to understand not only the injury itself, depression itself, but also how depression
affects an individual who has such an injury on top of the matter at hand. In other words, the
professional is required to be able to see things from more than one perspective: the perspective
of a treatment program, as well as a perspective of what is medically and physiologically
occurring with a patient suffering from a brain injury. A professional treating depression will
also need to be able to see the differences of treating a person without a head injury as compared
to treating a person with a head injury. If they do not understand both, there will be little
possibility for true empathy associated with progressive therapy. The ultimate goal is to be able
to understand how the injury and depression relate to each other to form a successful treatment
plan together with the patient of concern.

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The first discipline this paper will focus on is biology. Biology makes up the basis of
medicine and what we understand about the human body. As stated above, one must understand
a traumatic brain injury to its fullest extent before one can try and treat and/or rehabilitate a
person with such an injury. The main goal of the first discipline is to be able to fully describe the
basic ins and outs of a traumatic brain injury. One must understand the normal functions of the
brain and how they can be affected after a blow or jolt to the head. One injury may result from a
car accident, sporting event, an accident at home or work, or even on the battlefield. Ultimately,
however, it is known that traumatic brain injuries often result in death or disability at an alarming
rate (Manley & Mass, 2013). Next, one will need to understand why brain injuries can vary from
person to person, because just as no two people are exactly alike, no two brain injuries are going
to be exactly alike (BIA, 2012).
The discipline of psychology means the “nature of behavior as well as the internal
(psychological) and external (environmental) factors that affect this behavior,” (Repko, 2012, p.
106). The first professional an individual dealing with signs and symptoms of depression (a
nature of behavior) usually seeks help from is their primary care physician. The primary care
physician more often than not will formulate a differential diagnose (or what is otherwise known
as a most likely diagnosis) of depression if the patient meets certain criteria. After forming a
diagnosis they will often then proceed to refer a person dealing with depression to seek
additional help from a professional that specializes in helping people deal with such a concern on
a daily basis. This professional is usually a counselor, psychologist or psychiatrist. Either way,
the professional needs to have an in depth understanding of how psychology works as depression
is a psychological condition that can be debilitating. The professional will also need to
understand the external factors that are affecting the behavior defined, in this case depression.

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The external factors affecting the behavior of depression in this paper will be an instance of a
traumatic brain injury, which may have been incurred in one of many different ways. This
brings us back to the necessity of integrating the two disciplines we have just discussed.
Biology
The first discipline being studied is biology. Biology falls under the overall category of a
natural science. Biology is unique in that it focuses on the living aspect of physical world
whereas the other natural sciences focus on the non-living aspects of the physical world.
“Biology stresses the value of classification of experimental control” (Repko, 2012, p. 114). In
this way a researcher is able to show the conclusions of their research holds true. There is also a
particular assumption specialized to biologists. According to Table 4.10, “Biologists assume that
the hypothetico-deductive approach (i.e., deductive reasoning used to derive explanations or
predictions from laws or theories) based on the principle or falsification (i.e., the doctrine
whereby theories of hypotheses derived from them are disproved because proof is logically
impossible) is superior to description of pattern and inductive reasoning” (Repko, 2012, p121).
In essence, all of this fancy talk means is that an experiment is required to prove a theory true or
false.
It is very important to understand that 235,000 individuals are affected each year by
hospitalizations secondary to non-fatal traumatic brain injuries (Corrigan, Selassie & Orman,
2010). It is estimated from Corrigan, Selassie and Orman’s study that 43.1% of patients
discharged from an acute hospital event will develop a traumatic brain injury long-term
disability. The authors defined a disability as, “broadly and included the inability or substantial
difficulty performing activities of daily living, having post-injury symptoms that prevented the
person from doing things they wanted to do, and poor cognitive mental health scores on standard

6. TRAUMATIC BRAIN INJURY AND DEPRESSION 6
measures based on a previous population study,” (Corrigan, Selassie & Orman, 2010, p. 76).
Out of this study, it was also claimed that 1.1 million people total people were treated in the
emergency department and discharged, and 50,000 people ultimately die from their brain injury.
Knowing this data it is reasonable to conclude that traumatic brain injury is a problem that
requires further research.
When it comes to a traumatic brain injury there are many different ways to diagnosis that
a patient may have one. Most commonly, a patient is diagnosed shortly after an incident that
may have caused it. The event resulting in the injury usually provides the signs and symptoms
needed to diagnose the patient. A head injury resulting from a deep penetrating object would
result in a physician expecting a more severe injury as opposed to a closed head injury that may
have resulted from a hard jolt to the head from something such as a sporting event or car
accident. A person may be experiencing side effects that could be associated with other illnesses
such as headache and depression that will bring them into their primary care physician and may
ultimately result in a diagnosis of a mild traumatic brain injury after assessing a patient’s social
history and events leading up to the symptoms being experienced. As opposed to a major
traumatic brain injury which may have resulted in an initial hospital event and major side effects
such as sensory deficits, motor deficits, personality change, memory loss, amongst other
cognitive symptoms that may be present.
Many physicians will use what is called the Glasgow Coma Score or GCS to diagnose the
severity of an injury (Valente & Fisher, 2011). There is a standardized set of signs and
symptoms that will calculate a person’s initial GCS upon injury and results in a number.
Typically, the lower the more severe the injury is expected to be. The severity of a head injury
may also be determined if a person’s GCS declines from the original score they were given, (for

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example: a patient’s initial GCS if 14 and is rechecked 5 minutes later and they have a score of
9) this would indicate a very severe injury or an injury that is getting worse as time progresses.
As stated earlier, it is also important to remember that every head injury is different. Two people
may share the same mechanism of injury and yet exhibit completely different signs and
symptoms. The signs and symptoms resulting from an injury are dependent upon the pre brain-
injury status (Valente & Fisher, 2011). Ultimately, Valente and Fisher describe the importance
of educating not only oneself as a caregiver, but a patient as well in treatment processes, goals
and what side effects one can expect to have during their recovery process (such as depression
being specifically named).
Another study proposed that many people who visit an Emergency Department never
receive an initial diagnosis of mild traumatic brain injury, but then later receive a diagnosis of
traumatic brain injury after following up with their primary care physician. The purpose of the
study was to see how accurate data was regarding the number of people who visit an Emergency
Department and have a traumatic brain injury resulting from the reason for their visit. The study
proposed a conclusion that patients were not being asked key questions about their injury which
would have better enabled a physician in the Emergency Department to initially diagnosis a
traumatic brain injury. An initial diagnosis in the Emergency Department would ultimately
assist in allowing for better patient care and management of their injury (Powell, et. al, 2008).
The researchers in this study went through the charts of cases where mild traumatic brain injury
was suspected but a true diagnosis was never made. In a legal aspect, if a diagnosis was not
formally written in a patient chart that means the diagnosis was never officially made. The
researchers concluded a diagnosis should have been made by looking at the documented signs
and symptoms. The researchers excluded those patients who were out of the range of 16 to 70

8. TRAUMATIC BRAIN INJURY AND DEPRESSION 8
years of age, and/or arrived to the Emergency Department after 48 hours of their initial injury. If
the signs and symptoms met the criteria set forth by the CDC for diagnosing traumatic brain
injury, they would consider it a missed diagnosis in the Emergency Department. Again, looking
at the overall research and the outcomes, the researchers concluded that in the Emergency
Department the accuracy of diagnosing a mild traumatic brain injury is not all that great of a
success rate. If health care professionals would simply ask key questions that may result in
answers to provide evidence of a traumatic brain injury and/or document more concisely there
would be more accurate data on how many people truly suffer from traumatic brain injury as
well as better patient care outcomes (Powell, et. al, 2008).
Psychology
Psychology is the second discipline being studied. Psychology falls under the overall
category of a social science. Psychology focuses on human behavior and the cognitive
constructs each individual develops to organize their mental processes (Repko, 2012).
Psychologists focus their studies on the nature of human behavior including the internal and
external factors that may affect it. Internal factors would be considered psycho sociological,
while external factors would be considered environmental influences to human behavior.
Psychologists consider it important that their studies are able to be sought out via discussion and
observation which can then be applied towards clinical treatment. There exist assumptions in the
discipline of psychology as well. Psychologists assume “data obtained through systematic
empiricism allow researchers to draw more confident conclusions than they can draw from
casual observation alone.” (Repko, 2012). According to Table 4.11 in Repko’s text, it is also
stated that psychologists assume that group behavior can be reduced to individuals and their
interactions.

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Depression is considered one of the most common psychiatric illnesses diagnosed after a
traumatic brain injury (Tsaousides, Ashman & Gordon, 2013). A study was performed to
highlight the current treatments available for treating an individual diagnosed with depression
after a traumatic brain injury. The study ultimately highlights current recognized treatment
options and where gaps in treatment options exist to help provide further research goals. Some
of the current treatments recognized are pharmacological, including administering drugs
classified as MAOI’s (monoamine oxidase inhibitors), SSRI’s (serotonin reuptake inhibitors), or
TCA,’s (tri-cyclic antidepressants). Another treatment option that was studied to find out
whether it was effective or not was ECT or electroconvulsive therapy. Ultimately, through the
researchers work, they concluded there were not enough subjects available in their study to make
a conclusive decision if ECT would be considered a recognized treatment option. The
researchers also recognized different types of neurocognitive behavior therapies such as
increasing ones physical activity, social groups used for building coping skills together, as well
as comprehensive rehabilitation which includes pharmacological treatment alongside behavior
therapy. It was concluded that in order to establish a proper treatment regimen, there were many
factors to consider due to each brain injury being unique to each individual on top of factoring in
where and how severe a person’s injury was, as well as other injuries they may have incurred,
and how long it has been since the initial injury. Through this conclusion, researchers
established the need for further research on treating individuals dealing with depression after a
traumatic brain injury.
Another article defines what depression is and what signs and symptoms are used to
make a diagnosis. The feeling of being generally sad and “not yourself” for an extended period
of time should be one’s cue to seek help and make sure they have nothing serious that may

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warrant treatment such as depression. If the feeling were to be accompanied by suicidal
thoughts, lack of energy, decreased appetite amongst other symptoms, one should increase their
suspicion that they may in fact be suffering from clinical depression. The article also defines the
prevalence of depression in a population without a preexisting diagnosis of traumatic brain injury
as compared to a population affected with a traumatic brain injury. This gives the reader a
prospective of how common the problem really is in both populations and the need for treatment
options to be available. The causes of depression following a traumatic brain injury are pointed
out to be as follows: physical changes in the brain, emotional responses to the injury and/or
factors unrelated to the injury itself (Fann & Hart, 2013). The possible treatments this article
mentions include medications as well as non-pharmacological approaches. The non-
pharmacological approaches include different forms of behavioral therapy as well as seeking
help from local support groups. Local support groups, as well as where help can be found to
support and treat one’s depression can be found by some links that the authors provided at the
end of their publishment.
A final study in the field of psychology looks at the resources available to diagnose and
treat depression in rural versus non-rural primary care settings. The study uses what is called an
ICD-9 code to identify the prevalence of depression and the specific types of depression
diagnosed in each area (non-rural versus rural). The treatments provided were also reviewed to
see if they agreed with the American Psychiatric Association’s practice guidelines. It was found
that in rural settings a primary care physician was more likely to treat an individual with
depression as opposed to in a non-rural setting a primary care physician would generally refer an
individual to seek treatment from a specialist usually located in a mental health clinic. This
resulted in complications as a primary care physician is not likely to know every type of

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depression that exists and why each type should be treated differently, whereas a specialist in
psychology or psychiatry would have the better knowledge base in that field. The researchers
found that primary care physicians in rural settings were also not likely to establish a diagnosis
using the ICD-9 system that was specific as opposed to specialists being able to find and utilize
what is considered a specific diagnosis according to the ICD-9 system. Jameson and Blank
found that there were a higher percentage of individuals suffering from depression in non-rural
settings that had a better outcome following treatment as they had easier access to a specialty
resource center to seek necessary treatment (2010). The study provides evidence for the
conclusion that primary healthcare providers lack the resources and knowledge needed to
successfully diagnose let alone treat a population with such psychological disorders (Jameson &
Blank, 2010). By not having the resources and knowledge available to the primary healthcare
provider, it puts a stop on any potential treatment.
Integration
As an integrative researcher, one will notice that there are many concepts that quite
obviously overlap in regards to depression and traumatic brain injury as previously discussed.
One way a person could reach past the discrepancies between each discipline (Psychology and
Biology) and create a further understanding of the problem at hand is by redefining the technical
terms each discipline uses into a common vocabulary (Repko, 2012). By creating a common
vocabulary between each discipline, one will ultimately be able to realize what the true problems
are when trying to diagnose and treat traumatic brain injury and depression as comorbid
diagnoses, as well as solve the problem proposed that there is not enough support systems readily
available to those affected.

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Researchers have established both depression and traumatic brain injury (as individual
separate diagnoses) as an epidemic, or a substantial enough problem within society that it is
cause for concern and more research is needed. The lack of treatment resources is also
established by multiple sources in regards to each diagnosis on its own. The research that has
been presented in this paper has established that there is no set and agreed upon course of
treatment according to professionals who see and treat patients affected with either depression or
traumatic brain injury separately. It can be concluded that when diagnosed together it poses
additional problems to the healthcare professional there already lacks treatment resources for
each diagnosis on an individual level. The sources reviewed have established that more research
is needed for both depression and traumatic brain injury not only individually, but also as
comorbid diagnoses. This is because there is no established treatment regimen that has been
agreed upon within the professional organizations that treat either of the problems discussed on
an individual level. This means that finding and establishing a standardized treatment is a cause
for concern when traumatic brain injury and depression are diagnosed together. It can also be
inferred that depression and/or traumatic brain injury can have a negative economic impact as
either condition can result in debility if not treated properly as an individual will not be capable
of being a productive member of society, which is good reason to put forth effort in establishing
treatment and support for patients.
By reviewing the discussed research it is possible to conclude that more funding should
be made available to professionals to accurately diagnose and treat individuals suffering from
traumatic brain injury and depression. By providing more funding, researchers and professionals
will be able to utilize tools they may not have had before to help accurately diagnose individuals
and start the treatment process, because if one is never diagnosed they will never be treated and

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go on with life not knowing they may be suffering from an injury or a mental disorder that could
be affecting their daily life. It was made clear that in rural settings it is more difficult for the
primary healthcare provider to diagnose accurately, let alone treat their patient population in
regards to the diagnoses being discussed. If funding was increased specifically to rural areas that
are affected the most, a great number of people would be reached out to. The patient population
would also be more willing to seek treatment they need as they would not have to travel as far,
causing more social problems in their life such as missed school or work.
Once funding is increased to provide more accurate ways of diagnosing traumatic brain
injury and depression as comorbid, established funding can then be transferred to researching
treatment methods that would be considered effective and agreed upon throughout the
professional community. By finding and establishing an agreed upon treatment regimen,
healthcare professionals will be able to tell if a treatment is being successful for their patient or if
there really is a need to refer a patient to a more expensive specialist. Establishing an agreed
upon treatment regimen at the primary healthcare provider level also decreases cost for the
patient and allows the patient to seek treatment closer to their home. Treatment closer to a
patient’s home also means a patient is more likely to actually follow through, which also
provides a better overall patient outcome.
By establishing a treatment regimen that is agreed upon within the various professional
organizations, a domino effect is essentially created. More sources will become readily available
to those diagnosed with traumatic brain injury and depression. This in turn allows for
individuals affected to receive treatment they need to help them be more successful at coping
with their injuries and depression, ultimately helping them be more productive to society as a
whole. The individual becomes more productive to society at a whole, because they are being

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treated for conditions that could in reality keep them from aspiring to do great things with their
life they thought they could never do because of post injury status, and/or depression keeping
them from striving for goals they could have never imagined after a traumatic brain injury.
Expanding access to proper mental support systems will ultimately help produce a
happier and more productive population affected by either one of or both traumatic brain injury
and depression. These proper mental support systems would be easier to support if at first
professionals are able to effectively diagnose the conditions presented and then formulate best
practices for treatment. When all is said and done, as a reader, one should now be able to
acknowledge that epidemiology, diagnosis, and treatment are extremely important to traumatic
brain injury and depression as individual and comorbid diagnoses in order to develop and
establish proper mental support systems where they are needed most.

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References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th
ed.). Washington, D.C: Author.
BIA. (2012, October 12).Brain injury association of the U.S.A.. Retrieved from
http://www.biausa.org/about-brain-injury.htm
Corrigan, J. D., Selassie, A. W., & Orman, J. A. L. (2010). The epidemiology of traumatic brain
injury. The Journal of Head Trauma Rehabilitation, 25(2), 72-80.
CDC. (2013, August 15). Retrieved from http://www.cdc.gov/traumaticbraininjury/
Fann, J., Hart, T., & University of Washington Model Systems Knowledge Translation Center.
(2013). Depression after traumatic brain injury. Archives of Physical Medicine and
Rehabilitation, 94(4), 801.
Jameson, J. P., & Blank, M. B. (2010). Diagnosis and treatment of depression and anxiety in
rural and nonrural primary care: National survey results. Psychiatric Services
(Washington, D.C.), 61(6), 624.
Manley, G. T., & Maas, A. I. R. (2013). Traumatic brain injury: An international knowledge-
based approach. JAMA : The Journal of the American Medical Association, 310(5), 473.
Powell, J. M., Ferraro, J. V., Dikmen, S. S., Temkin, N. R., & Bell, K. R. (2008). Accuracy of
mild traumatic brain injury diagnosis. Archives of Physical Medicine and Rehabilitation,
89(8), 1550-1555.
Repko, A. F. (2012). Interdisciplinary research process and theory. (2nd ed.). Thousand Oaks,
CA: Sage Publications, Inc.
Tsaousides, T., Ashman, T. A., & Gordon, W. A. (2013). Diagnosis and treatment of depression
following traumatic brain injury. Brain Impairment, 14(1), 63-76.

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Valente, S. M., & Fisher, D. (2011). Traumatic brain injury. Journal for Nurse Practitioners,
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