The studies reviewed suggest that clinicians cannot assume that standard antidepressant medications will have the same efficacy and tolerability in persons with TBI as in persons without neurologic insult. It is advisable to start with low doses of medications with slow titration toward a therapeutic response while at the same time being cognizant of adverse effects that may be more common in neurologically injured patients such as seizures, sedation, and cognitive dysfunction. On the basis of the 13 studies included in this review, the review authors make the following recommendations:

• Due to their favorable side effect profile, an SSRI is a good first line antidepressant for TBI patients. There is the most evidence supporting the use of sertraline and citalopram. Among the SSRIs, sertraline has the most dopaminergic effect, thus potentially having a positive impact on cognition.
• More data is needed on the efficacy and tolerability of SNRIs (e.g., venlafaxine, milnacipran) in this population. However, data from a small study of milnacipran (which is not available in the United States or the UK) after TBI, and SNRI efficacy data from other populations suggesting higher rates of remission and documenting analgesic effects, suggest that SNRIs may be another reasonable option in this population.
• Evidence of possible reduced efficacy and higher risk of side effects (e.g., seizures) from TCAs may limit the use of this class in this population.
• Traditional MAOIs are not recommended due to lack of efficacy data and potentially serious side effects, particularly when dietary restrictions are not adhered to in a population with a high rate of cognitive difficulties.

Resourses

Treating Depression Following Traumatic Brain Injury: A Summary for Clinicians (PDF). Copyright © 2010 Model Systems Knowledge Translation Center (MSKTC). Based on Fann JR, Hart T, Schomer KG. (2009). Treatment for Depression Following Traumatic Brain Injury: A Systematic Review. J. Neurotrauma.2009 Aug 21. doi:10.1089/neu.2009.1091.

Hart T, Brenner L, Clark AN, Bogner JA, Novack TA, Chervoneva I, Nakase-Richardson R, Arango-Lasprilla JC. Major and minor depression after traumatic brain injury. Arch Phys Med Rehabil. 2011 Aug;92(8):1211-9. doi: 10.1016/j.apmr.2011.03.005