Twenty-seven studies were included in the review (826 patients, range one to 145).
Pharmacological interventions (13 studies; 301 patients): One study was evidence class I, one was class II, two were class III and nine were class IV. Eleven studies prospectively enrolled depressed patients and examined depression "caseness" post-intervention; two investigated pre-and post-intervention depression scores only. Ten were uncontrolled studies.
No significant difference was found in response rates or decrease in Hamilton rating scale for depression scores for sertraline compared with placebo (one study, evidence class I). Methodological limitations did not allow conclusions to be drawn about the efficacy of tricyclic antidepressants (one study; evidence class III).
Two class III and IV studies of patients treated with amitriptyline showed no improvements in patients with depression and minor traumatic brain injury compared to people with primary depression without traumatic brain injury. MAOI phenelzine was not efficacious in one class III study; MAO-A isoenzyme blocker was effective in one class IV study.
Evidence from seven studies of SSRIs suggested that these drugs were efficacious and well-tolerated in some people with traumatic brain injury. One study of dual action SNRI (milnacipran) suggested it may be efficacious.
Other biological interventions (six studies. 40 patients): One study was class II, one was class III and four were class IV. Three prospectively enrolled depressed patients, one identified patients retrospectively and two reported pre/post depression scores only. There were limited data to support the efficacy and tolerability of ECT, low-intensity magnetic field exposure, biofeedback and acupuncture for treating depression after traumatic brain injury; the authors stressed that the results of these studies were highly preliminary.
Psychotherapeutic and rehabilitation interventions (eight studies, 485 patients): One study was class I, two were class II, one was class III and the others were class IV. None of the studies was designed to evaluate treatments for depression specifically. Seven studies reported pre/post scores only; one study did not report this.
Three of four CBT-based studies (one class II, two class IV) reported positive effects of the treatment on mood. Two studies based on mindfulness-meditation: one (class II) reported no significant difference between treatment and controls; the other reported a marginally significant difference pre- to post-treatment (class IV).
Two studies were of intensive multifaceted treatments delivered by a rehabilitation team: one (class I) reported no significant difference on the proportions of patients that met the criteria for depression; the other (class IV) reported significant improvement in Brain Injury Community Rehabilitation Outcome-39 Scales.