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ORIGINAL ARTICLE
Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 397-399

Psychiatric sequelae of traumatic brain injury: Retrospective analysis of 75 subjects from Kaduna, Nigeria


1 Department of Clinical Services, Federal Neuropsychiatric Hospital, Barnawa, Kaduna, Nigeria
2 Department of Psychiatry, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria

Date of Acceptance23-Dec-2011
Date of Web Publication12-Dec-2012

Correspondence Address:
F T Nuhu
Federal Neuropsychiatric Hospital, Barnawa, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.104510

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   Abstract 

Objective: Traumatic brain injury (TBI) is a public health problem and is associated with many complications. However little is known about the psychiatric sequelae of TBI in Nigeria. This study described the pattern and determinants of psychiatric sequelae among subjects with TBI.
Materials and Methods: The study is a retrospective review of cases of subjects referred to Federal Neuropsychiatric Hospital, Kaduna on account of TBI or its complications from 2001 to 2008. Information obtained included the socio-demographic characteristics, type of injury, durations of unconsciousness (LOC) and posttraumatic amnesia (PTA), psychiatric and psychoactive substance use history. Psychiatric diagnosis was based on the criteria of the 10th edition of the International Classification of Diseases (ICD-10)
Results: Mean age of the subjects was 32.2 ± 35.8 years, mean duration of unconsciousness was 6.88 ± 9.40 days, mean duration of PTA was 5.45 ± 8.78 days, 90.7% were males, 69.3% had road traffic accident (RTA), 28.0% had psychosis, 25.3% had cognitive impairment while 17.3%, 8.0%, and 6.7% had epilepsy, personality change and depression respectively. About 15% had no complications yet. Only 30.7% did cranial CT scan. Long duration of LOC and PTA were significantly associated with psychiatric complications (P value <0.05).
Conclusions: Psychiatric sequelae are common after TBI. Long periods of LOC and PTA are predictive of such sequelae. Efforts should be made to prevent RTA, communal clashes and other activities that can lead to TBI.

Keywords: Brain, Nigeria, psychiatric, sequelae, trauma


How to cite this article:
Nuhu F T, Yusuf A J. Psychiatric sequelae of traumatic brain injury: Retrospective analysis of 75 subjects from Kaduna, Nigeria. Niger J Clin Pract 2012;15:397-9

How to cite this URL:
Nuhu F T, Yusuf A J. Psychiatric sequelae of traumatic brain injury: Retrospective analysis of 75 subjects from Kaduna, Nigeria. Niger J Clin Pract [serial online] 2012 [cited 2018 Dec 9];15:397-9. Available from: http://www.njcponline.com/text.asp?2012/15/4/397/104510


   Introduction Top


Traumatic brain injury (TBI) is a significant public health concern. [1] It can result from physical trauma to the head, and its outcome is fairly dependent on the severity of the injury, especially for the moderate and severe categories. Thus, a subject with TBI may present with subtle deficit or severe intellectual and emotional disturbances. [2]

The neuropsychiatric complications of TBI may include psychosis, [3] mood disorder-depression, mania or bipolar, [4] and other neuropsychiatric disorders such as personality changes, seizure disorder, cognitive impairment, and substance use disorders. [5],[6],[7]

Studies conducted among survivors of TBI have identified several risk factors for psychiatric complications. These include increasing age, prolonged period of unconsciousness (LOC), [8] long posttraumatic amnesia (PTA), [9] abnormal premorbid personality, alcoholism, poor social support, financial difficulties, previous history of mental illness, and family history of mental illness. [6],[10]

In Nigeria, previous studies conducted among patients with TBI [1],[11],[12],[13] have focused on the mortality and physical morbidity, and as such, there is paucity of information as regards the psychiatric sequelae of TBI in the country.

The aim of this study, therefore, was to describe the pattern and predictors of psychiatric complications in patients with TBI seen in our center.


   Materials and Methods Top


This retrospective study was conducted at the Federal Neuropsychiatric Hospital, Kaduna, in the Northwestern part of Nigeria, a tertiary health institution that receives referral, mostly psychiatric and sometimes neurological, from virtually all the northern states of the country.

We retrieved the case files of all the patients referred to the hospital on account of head injury or its complications between 2001 and 2008. We obtained the socio-demographic characteristics of the subjects, types of accident, duration of unconsciousness, duration of PTA, previous and family history of mental illness, use of psychoactive substances, and premorbid personality from the case files. The psychiatric diagnosis was based on the criteria of ICD-10 and DSM-IV.

The research and ethics committee of Federal Neuropsychiatric Hospital, Kaduna, gave approval

The data obtained were analyzed using the 15 th edition of the Statistical Package for Social Sciences, setting the significance level at P value <0.05


   Results Top


The mean age of the patients was 32.2 ± 35.8 years, the mean LOC was 6.88 ± 9.4 days, and the mean duration of PTA was 5.45 ± 8.78 days. Majority of the injuries resulted from road traffic accident (RTA). [Table 1] shows the details of the socio-demographic and clinical characteristics of the patients.
Table 1: Sociodemographic/clinical characteristics of the patients

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Approximately 85% of the patients have developed one form of psychiatric disorder or the other. The commonest psychiatric sequel was psychosis.

Further analysis revealed that long LOC (X 2 9.062, P=0.011) and PTA (X 2 7.017, P=0.030) were significantly associated with psychiatric complications while the socio-demographic and other clinical characteristics were not (P>0.05). Multiple regression analysis confirmed that these two clinical variables are predictors of psychiatric complications in patients with TBI (OR 0.1142, P=0.08, 95% CI 0.034-0.598 and OR 0.159, P=0.017, 95% CI 0.035-0.721 for LOC and PTA, respectively)


   Discussion Top


The results of this study show that more than 90% of the patients are males. Previous reports have indicated that more men than women sustained TBI. [1],[2] One possibility is that men are more adventurous and they take a lot of risks. In addition, psychoactive substance abuse could have contributed to the accidents in some of the subjects, although use of alcohol and cannabis was recorded in only 8% of the patients. The possibility of underreporting should be considered. It is a well-known fact that men use psychoactive substances more than women. [14]

Majority of the subjects (58.6%) were within the age range "20-39" years. In some earlier studies from Lagos, Nigeria, [11] and Blantyre, Malawi, [15] similar observations were made among patients with head injuries. It appears, therefore, that most of the subjects with TBI were in their productive years when the injuries occurred. This may have some economic implications. This is more so when we consider that after the accidents more than half of our patients became socially and occupationally impaired even after they seemed to have recovered from the immediate effects of the injury.

The commonest cause of TBI in this study was RTA, and this is similar to the findings from earlier studies. [1],[2] Most patients received initial treatment from hospital. However, neuro-imaging (CT scan) was done by only a third of them. Similar observation was made by Adeleye et al. [1] This is an essential investigation, which will guide the clinician in making a treatment decision that may be lifesaving and may prevent future complications, both physical and psychiatric. The common psychiatric sequelae of TBI identified from this study are psychosis, cognitive impairment, and seizure disorder. Three of those who had psychosis met diagnostic criteria for manic episode while the rest had schizophrenia/schizophrenia-like disorders. Few patients had more than one complication. All the above disorders have been described by previous researchers. [3],[4],[5],[6],[7] However, it remains to be determined whether these disorders were caused by the injury or TBI just precipitated the symptoms in people who were already predisposed. A review of the literature by Davison and Bagley [16] revealed that most of the patients with post-TBI schizophrenia-like psychosis do not have a family history of schizophrenia. It has also been concluded that TBI seems to make patients particularly susceptible to some psychiatric disorders, and these may develop even decades after the injury. [17] In view of the above, it could not be concluded whether those 11 subjects who had no complication at the time of review will remain without symptoms forever.

The absence of association between previous and family history of mental illness and psychiatric sequelae, and use of psychoactive substances and psychiatric sequelae, may have been due to the small numbers of subjects in those categories.

The results of our study confirmed that the duration of LOC and PTA are important factors in the development of psychiatric sequelae following TBI. These parameters have been described as indicators of severity of the injury, and the longer they are, the more severe the injury and the more likely that the patient will develop a complication. [2]

Limitations

This is a retrospective study, and as such, some data were missing, which may have some effects on the outcome of the study. The sample size is also relatively small. In addition, previous and family history of mental illness and use of psychoactive substance were recorded only in a few patients, making it difficult to test for possible association of these variables with psychiatric sequelae of TBI.


   Conclusion and Recommendations Top


In spite of the above limitations, the result of this study confirmed that psychiatric complications are common among people who have suffered trauma to the brain and that the durations of unconsciousness and PTA are important predictors of sequelae. In view of the above, a prospective study of patients with TBI should be a focus of future research in Nigeria where data on this subject are limited. We also recommend that all efforts should be made by all stakeholders to prevent accident and trauma to the brain.

 
   References Top

1.Adeleye AO, Olowookere KG, Olayemi OO. Clinicoepidemiological profiles and outcome during first hospital admission of head injury patients in Ikeja, Nigeria. A prospective cohort study. Neuroepidemiology 2009;32:136-41.  Back to cited text no. 1
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2.Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury. Psychosomatics 2000;41:95-103.  Back to cited text no. 2
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3.Jorge R, Robinson RG. Mood disorders following traumatic brain injury. Int Rev Psychiatry 2003;15:317-27.  Back to cited text no. 3
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4.Oquendo MA, Friedman JH, Grunebaum MF, Burke A, Silver JM, Mann JJ. Suicidal behaviour and mild traumatic brain injury in major depression. J Nerv Ment Dis 2004;192:430-4.  Back to cited text no. 4
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5.Sudarsanan S, Chaudharg S, Pawar AA, Srivastava K. Psychiatric effects of traumatic brain injury. Medical Journal Armed Forces India 2006;62:259-63.  Back to cited text no. 5
    
6.Zhang Q, Sachdev PS. Psychotic disorder and traumatic brain injury. Curr Psychiatry Rep 2003;5:197-201.  Back to cited text no. 6
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7.Fleminger S. Long term psychiatric disorders after traumatic brain injury. Eur J Anaesthesiol Suppl 2008;42:123-30.  Back to cited text no. 7
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8.Kim E, Lauterbach EC, Reeve A, Arciniegas DB, Coburn KL, Mendes MF, et al. Neuropsychiatric complications of traumatic brain injury: a critical review of literature (a report by the ANPA Committee on Research). J Neuropsychiatry Clin Neurosci 2007;19:106-27.  Back to cited text no. 8
    
9.Shukla S, Cook BL, Mukherjee S, Godwin C, Miller MG. Mania following head trauma. Am J Psychiatry 1987;144:93-6.  Back to cited text no. 9
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10.Fujii DE, Ahmed I. Risk factors in psychosis secondary to traumatic brain injury. J Neuropsychiatry Clin Neurosci 2001;13:61-9.  Back to cited text no. 10
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11.Elesha SO, Daramola AO. Fatal head injuries: the Lagos University Teaching Hospital experience (1993-1997). Niger Postgrad Med J 2002;9:38-42.  Back to cited text no. 11
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12.Adeloye A, Obiang HM, Olumide AA. Pattern of acute head injuries in Ibadan. Int Surg 1976;61:478-80.  Back to cited text no. 12
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13.Ohaegbulam SC. Analysis of 1089 cases of head injury. Afr J Med Med Sci 1978;7:23-7.  Back to cited text no. 13
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14.Cheng AT, Gau S, Chen TH, Chang T, Chang YT. A 4-year longitudinal study on risk factors for alcoholism. Arch Gen Psychiatry 2004;61:184-91.  Back to cited text no. 14
    
15.Adeloye A, Ssembatya-Luleg GC. Aetiological and epidemiological aspects of acute head injury in Malawi. East Afr Med J 1997;74:822-8.  Back to cited text no. 15
    
16.Davison K, Bagley CK. Schizophrenia-like psychosis associated with organic disorder of the CNS. Br J Psychiatry 1969;4(suppl):113-84.  Back to cited text no. 16
    
17.Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Heinonen H, et al. Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study. Am J Psychiatry 2002;159:1315-21.  Back to cited text no. 17
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