The Temporal Relationship of Mental Health Problems and Functional Limitations following mTBI: A TRACK-TBI and TED Study

Abstract

Mental health problems, such as depression and anxiety, are often associated with functional limitations after traumatic brain injury (TBI), prompting researchers to explore which of these TBI-related sequelae tends to precede the other. Past studies among patients with injuries ranging in severity have predominantly reported that functional impairments predict subsequent psychological concerns, rather than the other way around; however, it remains unclear whether this directionality holds for individuals with mild TBI (mTBI). The present study utilized a cross-lagged panel design within a structural equation modeling analytical framework to explore the longitudinal relationships of symptoms of depression and anxiety to functional status among 717 adult mTBI patients, with assessments occurring at 2 weeks and 3 months post-injury. Symptoms of both depression and anxiety significantly predicted subsequent functional limitations (λs = -0.21 and -0.25), whereas the reverse effects were nonsignificant (λs = -0.05 and -0.03); thus, psychological concerns appeared to function as a precursor to functional impairment. This pattern was particularly pronounced among patients with normal head computed tomography (CT) results; however, results were less clear cut among those subjects whose injuries were accompanied by intracranial abnormalities detected on CT imaging, suggesting the possibility of a more reciprocal relationship in the case of CT-positive mTBI. These results may serve to partially explain the incidence of persistent functional limitations observed among subsets of mTBI patients in past studies. Findings likewise highlight the importance of assessment and treatment for mental health problems after mTBI as an important factor to promote psychological well-being and functional recovery.

Keywords: brain injuries; mental health; patient outcome assessment; traumatic.

FIG. 1.

Participant inclusion STROBE flow diagram. *Note: Participants from one study site were excluded from this report because of concerns specific to that site that the GOSE was not administered according to study procedures. GCS, Glasgow Coma Scale; GOSE, Glasgow Outcome Scale-Extended;

FIG. 2.

Cross-lagged panel analysis model for depression and functional status (model 1). Note: “BSI-dep” = BSI depression subscale. “d” represents the unique error (“disturbance”) term corresponding to its respective dependent variable. Curved lines represent correlations; straight lines represent predictive paths. Correlation and standardized path coefficients are displayed. Statistically significant effects are presented in solid lines; dashed lines indicate nonsignificant effects. Age, sex, computed tomography findings, and psychiatric history were also included in the model as covariates, but, for clarity purposes, are not pictured here. *p < 0.001. BSI, Brief Symptom Inventory.

FIG. 3.

Cross-lagged panel analysis model for anxiety and functional status (model 2). Note: “BSI-anx” = BSI anxiety subscale, “d” represents the unique error (“disturbance”) term corresponding to its respective dependent variable. Curved lines represent correlations; straight lines represent predictive paths. Correlation and standardized path coefficients are displayed. Statistically significant effects are presented in solid lines; dashed lines indicate nonsignificant effects. Age, sex, computed tomography findings, and psychiatric history were also included in the model as covariates, but, for clarity purposes, are not pictured here. *p < 0.001. BSI, Brief Symptom Inventory.