When a patient is depressed after an accident, it is often difficult to determine what is causing depressive symptoms.

By Lisa Rabasca
Monitor staff

A patient complains of fatigue and sleep disturbance. She tells her psychologist she is easily distracted, has short-term memory problems and feels apathetic.

She never mentions that a month earlier, she was in a car accident that left her feeling dazed, forgetful and listless. Because the physicians at the emergency room said she was fine, she has dismissed the accident and doesn?t talk about it when her psychologist takes her medical history.

But could the patient?s symptoms be related to the accident as a result of a mild traumatic brain injury (MTBI)? Or is she depressed? Or could both diagnoses apply?

Neuropsychologists agree that when a patient is depressed after an accident, it is often difficult to determine what is causing a patient?s depressive symptoms.

A patient may feel blue simply because she has been in an accident. Or she could feel depressed because she recognizes that the accident has somehow impaired her memory and ability to concentrate. Neuropsychologists also caution that it is not uncommon for a patient to believe she has an MTBI despite a history of depression that predates the accident.

Although automobile accidents are the most common cause of MTBI, the condition can result from any sudden motion that causes the brain to bounce against the inside of the skull, including an assault, sports injury, fall or physical abuse. Typical symptoms?which can last from a couple of days to a couple of months or longer?include fatigue, headaches, dizziness, nausea and vomiting, blurred vision, loss of sex drive, short-term memory problems, impaired judgment, irritability, apathy, impatience, anxiety and feelings of helplessness, according to Mitchell Rosenthal, PhD, a professor and associate chair of the department of physical medicine and rehabilitation at Wayne State University in Detroit.

The vast majority of people with MTBI recover fully within days or weeks after injury; however, for those whose symptoms persist, there is no established treatment or time course, Rosenthal says. Patients get better over time as the brain heals.

Misdiagnosis is common

It is easy to misdiagnose or overlook MTBI because the patient often looks, acts and talks as anyone else would, Rosenthal says. 'Their appearance is not different from a client who has not had an MTBI because the symptoms are very subjective,' he says.

In fact, Rosenthal says, it?s only in the past 10 years that psychologists have begun to understand that a patient doesn?t need to hit her head or be unconscious for a long time to suffer an MTBI. In a car accident, for example, 'your head doesn?t even have to make contact with the steering wheel,' he says. 'You just have to be going very fast and come to a very fast stop.'

In 1993, the American Congress of Rehabilitation Medicine Head Injury Interdisciplinary Special Interest Group defined MTBI as experiencing one of the following criteria:

? Loss of consciousness, even if only for seconds or minutes. In some cases, the patient may only experience dazed consciousness.

? Memory loss either immediately before or after the event.

? Shift in mental state at the time of the event. For example, a patient may become unusually belligerent after the event.

Despite these criteria, MTBI continues to be misdiagnosed. 'The major reason for misdiagnosis is people are not trained to recognize it,' says Jeffrey Kreutzer, PhD, professor and director of rehabilitation psychology and neuropsychology at the Medical College of Virginia, Richmond. John Whyte, MD, PhD, director of Moss Rehabilitation Research Institute in Philadelphia, agrees. He says that often medical staff in emergency rooms are not aware of MTBI.

Medical exams typically used to test for brain disorders?MRIs, EEGs and CT scans?will not pick up an MTBI, Kreutzer says. Only an extensive neuropsychological exam that tests for verbal memory, word retrieval, attention span and mental flexibility will determine if the patient has an MTBI, he says. However, Rosenthal says, because the three-hour examination is expensive, physicians are often reluctant to order it for a patient who superficially appears fine.

Setting realistic expectations

Although most people recover from MTBI without treatment, an early diagnosis is essential for the patient?s psychological well-being, say psychologists. The diagnosis will allow patients, families and employers to understand that although there are no visible signs of injury, the lack of concentration and memory lapses associated with MTBI can cause problems in the office and home.

Without a diagnosis, differences between expectations and reality can lead to depression, says Donald Stuss, PhD, director of the Rotman Research Institute in Toronto. If a psychologist treats only the depression and ignores the brain injury, the patient?s depression will worsen because the patient doesn?t understand why it has become difficult to do routine tasks. By diagnosing the MTBI, the doctor will have a more reasonable understanding of how long it will take to recuperate and what can be expected during recovery.

'The patient needs to be told what the problems are, what is to be expected and what the time course is,' Stuss says. Patients with MTBI are vulnerable to

tress, he says, and may not be able to return to work immediately. Patients with demanding occupations, such as air traffic controllers, may never be able to return to their jobs.

'You need to give advice on how the person should pace themselves to return to work,' Stuss says. 'You should help them understand that they may be on one day and off another day in their performance.'

Careful diagnosis is key

While an MTBI might be mistaken for depression, the opposite is also true: Emotional disorders can be misdiagnosed as MTBI, says George Prigatano, PhD, chair of the clinical neuropsychological department at Barrow Neurological Institute in Phoenix.

To be sure, clinicians should evaluate the source of the accident, the pattern of the patient?s symptoms, the pattern of his or her psychological test findings and the patient?s functioning before the accident, says Kreutzer. 'You want to look at the accident report for the speed of the vehicle. If the person was hit from behind at five miles per hour, it is not likely they have MTBI.'

Psychologists should also interview the patient?s family and employer to get a better sense of whether there were problems before the accident, Rosenthal says. Some practitioners get copies of the patient?s school records to see if there is a history of learning disability. When a patient?s test results do not match a self-reported diagnosis of MTBI, Prigatano walks the patient through the results in a frank and clarifying way that doesn?t offend the patient. Sometimes, he says, the diagnosis is depression.

The National Institutes of Health (NIH) sponsored a Consensus Development Conference in October on the Rehabilitation of Persons with Traumatic Brain Injury. To review the consensus statement, log on to the web site at odp.od.nih.gov/consensus.