This is a summary of the guidelines developed by a collaborative of The British Society of Rehabilitation Medicine
and The British Geriatrics Society in association with The Royal College of Physicians’
Clinical Effectiveness and Evaluation Unit (London)

According to the terms agreed with the Royal College of Physicians (London), the full guideline will initially be sold by the Royal College of Physicians Publications Department

________________________________________________________________________________________________

Depression is commonly associated with acquired brain injury (ABI) and can interfere with rehabilitation, leading to poorer outcomes.

Management of depression is typically multi-factorial, and mood may well improve either spontaneously or as a result of rehabilitation and regained independence.

In collaboration with the British Society of Rehabilitative Medicine and in association with the Royal College of Physicians (London) Clinical Effectiveness and Evaluation Unit, the BGS has produced a clinical guideline for the use of anti-depressant medication in adults undergoing recovery or rehabilitation following acquired brain injury. T

Minor or moderate depression
The aim of the guidelines is to provide the general physician, GP or other clinician treating patients with ABI with a safe approach to managing minor to moderate depression in the context of brain injury rehabilitation, whether in hospital or in the community, and to identify those individuals who require more specialist advice and referral to mental health services.

Setting the context
Although the guidelines focus on the use of anti-depressant drugs, these are by no means the only way to manage depression following ABI, and it is important in any event to consider other contributing factors and whether they could be rectified, prior to reaching for the prescription pad. Alternative interventions may include simple measures to address environmental or other factors which contribute to low mood (such as missing their home and family, or worries about life outside hospital). Non-pharmacological interventions, such as cognitive behavioural therapy or psychotherapeutic interventions, may also be suitable for patients who have the cognitive and communicative abilities to engage successfully. However, it is accepted that, at the current time, these programmes are rarely available within general medical settings, and tend to be a longer-term intervention. For the purpose of the guidelines therefore, they are considered as a second line intervention which may follow on from specialist referral, rather than as a practical treatment alternative which is currently available to most general doctors in acute treatment settings.

From the viewpoint of a general clinician considering the prescription of anti-depressant medication, the guidelines give practical advice to support safe practice. They highlight issues for the clinician to consider, such as, does the patient have depression which is severe enough to affect their health or to impede their recovery; and is the patient likely to respond to anti-depressant medication or are other interventions more appropriate?

Evidence
The guidelines consider the evidence for use of anti-depressants in people with ABI. While there is little or no formal research-based evidence to date to inform the most appropriate regimen or length of treatment, general conclusions may be drawn, mainly from the literature on treatment of depression following stroke. This indicates that anti-depressants have seemed reasonably acceptable to patients and are shown to bring about significantly greater reduction in depression than either placebo or no treatment. However, the treatment effect is smaller than was initially supposed.

Overall, approximately four patients would need to be treated to produce one recovery from depression which would not have occurred had they been given placebo, and one patient in every ten would drop out because of side-effects. Although change in depressive symptoms is often reported, actual gains in terms of improved function or quality of life are harder to demonstrate. However, isolated studies have reported reduced mortality and improved function in the treated group, compared with controls. Also indicated is the fact that SSRIs appear generally to be about as effective as tricyclics, but have fewer reported side-effects and overall appear to be cost-efficient despite the slightly higher drug costs.

Diagnosis and treatment
The guideline outlines the diagnosis and measurement of depression, including screening and quantification tools. It touches on issues around “consent”, pointing out that many people believe that depression carries a certain stigma. Patients sometimes report that they feel pressurised into taking anti-depressant medication when they do not believe they are depressed, or when they would rather use other methods to combat the symptoms. The guideline stresses that it is important to ensure that patients give their informed consent to treatment, if they have the capacity to do so.

The guideline covers the choice of anti-depressant agent which, in the absence of formal research, is adapted from Royal College of Physicians’ (London) Guide: The Psychological Care of Medical Patients.

Finally, the Guideline states that implementation will require investment to provide improved training in assessment and management of depression for all clinicians working with ABI patients; better information and awareness among the general public with regard to depression and its management in this context; and better monitoring, follow-up and communication between clinicians across the different settings. However, successful implementation could be expected to reduce unnecessary, unwanted, and potentially dangerous use of medication in a vulnerable patient group – with overall cost-effective results.

Prof Lynne Turner-Stokes
Regional Rehabilitation Unit, Northwick Park Hospital
Dr Ron MacWalter
Consultant Physician & Hon Reader in Medicine
Ninewells Hospital & Medical School