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Original Investigation
January 30, 2019

Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study

Author Affiliations
  • 1Department of Psychiatry, University of California San Diego, La Jolla
  • 2Department of Family Medicine & Public Health, University of California San Diego, La Jolla
  • 3VA San Diego Healthcare System, San Diego, California
  • 4Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
  • 5Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
  • 6Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
  • 7Department of Rehabilitation Medicine, University of Washington, Seattle
  • 8Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
  • 9Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
  • 10Department of Neurological Surgery, University of California, San Francisco
  • 11Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 12Department of Neurology, University of Pennsylvania, Philadelphia
  • 13Department of Radiology & Biomedical Imaging, University of California, San Francisco
  • 14Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco
  • 15Department of Neurological Surgery, University of Washington, Seattle
  • 16Department of Biostatistics, University of Washington, Seattle
JAMA Psychiatry. 2019;76(3):249-258. doi:10.1001/jamapsychiatry.2018.4288
Key Points

Question  Who is at greatest risk for developing mental health problems such as posttraumatic stress disorder (PTSD) or major depression after sustaining a mild traumatic brain injury (mTBI)?

Findings  In this cohort study of 1155 patients with mTBI and 230 patients with orthopedic injuries not involving the head, patients with mTBI were more likely to report PTSD and/or major depressive symptoms 3 and 6 months after injury. Among patients with mTBI, a number of preinjury (eg, prior mental health problems) and injury-related (eg, assault or other violent cause of injury in the case of PTSD) characteristics were associated with increased risk of mental health problems.

Meaning  Injury to the brain is associated with new onset or exacerbation of preexisting mental health problems in a substantial minority of patients; knowledge of risk factors can inform efforts at prevention, screening, diagnosis, and improved treatment.


Importance  Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.

Objective  To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI).

Design, Setting, and Participants  Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study.

Main Outcomes and Measures  Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury.

Results  Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk.

Conclusions and Relevance  After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.