To the Editor: In Okie's Perspective article (May 19 issue)1on traumatic brain injury (TBI) from the war in Iraq, she alludesto mood disorders that result from such injuries. Patients withTBI have been described as the "walking wounded"2 owing to theirlingering neuropsychological problems. Lishman studied 670 casesof head injuries from the Second World War and reported that"simple measures of the amount of brain damage . . . were indeedrelated to the amount of psychiatric disability encounteredone to five years later."3 As many as 77 percent of patientswith TBI have been given a diagnosis of depression.4 Mood disordersmay result in the restriction of social contact as well as increasedloneliness and are major barriers to functional and social rehabilitation.5
Technological improvements and better emergency medical carehave reduced the incidence of severe TBI while increasing thenumbers of patients with mild or moderate TBI. Such patientsare more adversely affected by their emotional problems thanby their residual physical disabilities.6 It is important toscreen these patients for depression and to conduct neuropsychologicaltesting soon after head injury in order to facilitate treatmentand reentry into the community, as well as to optimize the long-termoutcome.
Rohit R. Das, M.B., B.S., M.P.H. Boston Medical Center Boston, MA 02118 rohit.das{at}bmc.org
Ranjani N. Moorthi, M.B., B.S., M.P.H. Saint Vincent Hospital Worcester, MA 01608
References
Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352:2043-2047. [Free Full Text]
Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury. Psychosomatics 2000;41:95-103. [Free Full Text]
Lishman WA. The psychiatric sequelae of head injury: a review. Psychol Med 1973;3:304-318. [ISI][Medline]
Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination. Brain Inj 2001;15:563-576. [ISI][Medline]
Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations. Brain Inj 1995;9:81-92. [ISI][Medline]
Satz P, Fourney DL, Zaucha K, et al. Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury. Brain Inj 1998;12:537-553. [CrossRef][ISI][Medline]
To the Editor: Although Okie's article described well many of the issues involved in the current war in Iraq, we wouldlike to clarify our comments, reported in the article, regardingthe classification of mild TBI. We noted that the boundary betweenmild and moderate TBI is one hour of loss of consciousness andthat the cutoff between moderate and severe TBI is one day ofloss of consciousness. However, there is variation in the classificationof mild TBI.
Some authors1 use 30 minutes of loss of consciousness as thecriterion, and others 20 minutes,2 and still others3 define"brief" loss of consciousness as lasting less than 1 hour. Inpractice, we more often use the duration of post-traumatic amnesiato determine the level of severity, since that information isavailable to us more often than are data on loss of consciousness.
Deborah L. Warden, M.D. Louis French, Psy.D. Defense and Veterans Brain Injury Center Washington, DC 20307
References
American Congress of Rehabilitation Medicine. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8:86-87.
Rimel RW, Giordani B, Barth JT, Boll TJ, Jane JA. Disability caused by minor head injury. Neurosurgery 1981;9:221-228. [ISI][Medline]
International classification of diseases, hospital edition, 9th rev., clinical modification: ICD-9-CM. 6th ed. Vol. 1, 2 & 3. Los Angeles: Practice Management Information Corporation, 2002.
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