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Managing depression in brain injury rehabilitation: the use of an integrated care pathway and preliminary report of response to sertraline

Nibras Hassan

Katherine Pierce

Frances Clegg

Regional Rehabilitation Unit, Northwick Park and St Mark's Hospital Trust, Harrow, Middlesex, UK

Aims: To use data generated from an integrated care pathway (ICP) to describe the characteristics of patients presenting with depression in a brain injury rehabilitation programme and to assess their response to treatment with sertraline.

Setting: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16–65) with severe complex disabilities.

Design: Prospective cohort study of 82 patients admitted to the unit during the 15-month period between between 1 September 1999 and 1 December 2000. Response to sertraline was assessed in an open-label, before-andafter study design

Methods and design: All admissions were screened and included in the ICP if there was clinical suspicion of depression, past or present. Anti-depressant medication was prescribed, where appropriate, according to the ICP protocol. Depression was diagnosed on clinical grounds against DSM-IV criteria, and measured where feasible using the Beck Depression Inventory (BDI-II) administered by interview, pretreatment and at 6–8 weeks.

Results: Of 82 admissions 41 (50%) were managed using the ICP and 27 (64%) were either started on or changed to sertraline – 21 for depression ± lability and six for emotional lability only. All of the depressed patients improved clinically at some level and no signi"cant side-effects were observed. The BDI-II was assessable in 17/21 who showed a mean improvement of 14.5 ± 9.7 (con"dence interval (CI) 9.3–19.7, p < 0.001). Eleven patients (52%) had previously failed to respond with a different selective serotonin re-uptake inhibitor (SSRI) agent but still made a signi"cant response when changed to sertraline with a mean reduction in BDI-II of 16.3 ± 10.9 (CI 8.4–24.11, p < 0.001).

Conclusions: The ICP was practical to use and provided systematic data on assessment of depression and response to treatment in ‘real-life’ clinical practice in a brain injury rehabilitation setting. Sertraline appears to be useful and well-tolerated in this context. A full placebo-controlled study is now required.

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