Neuropsychiatric Syndromes in the Survivors of Traumatic Brain Injury in Oman: An examination of disorder of self-neglect

Abstract

Traumatic Brain Injury (TBI) is one of the most challenging public health problems facing the Sultanate of Oman. Each year between 7,500 and 10,000 Omanis (300-400 per 100,000 of the population), suffer a traumatic brain injury (TBI). Despite this extraordinary incidence, little is known about the psychiatric complications of these injuries. The research described in this thesis, measured the prevalence and nature of the psychiatric complications in Omani TBI patients who attended a national Neurosurgical outpatient clinic. The research also identified the predictors of apathy, which is arguably the most common and debilitating complication of TBI, and as a test of both the efficacy of the agent and the follow-up program for brain injured patients, the outcome of Methylphenidate treatment of apathy was determined for the affected patients. A sample of 103 TBI patients was assessed using various psychiatric assessments that included the Hospital Anxiety and Depression Scale (HADS), the Apathy Evaluation Scale (AES), and various cognitive function tests. Eighty-three patients were male and 75% were aged between 15 and 31 years. All, except one patient, were injured in a road traffic accident (RTA). Based on the Glasgow Coma Scale (GCS), fifty-four patients could be categorized as having had a mild brain injury, twelve were moderately injured, and 37 had a severe brain injury. Forty-six were injured within the previous six months, whereas 46 were injured more than a year beforehand. Forty two percent had apathy and 42% were depressed; 40% had anxiety and 35% had fatigue. This is a significantly higher rate than that reported in the general Omani population. However, in the context of any possible cultural differences, it is similar to the rates of psychiatric complications of TBI cited internationally. Among various clinical and demographic factors, the strongest predictor of apathy was the Buschke Selective Reminding Test (BSRT). Apathy in these patients was not associated with either depression or fatigue; that is, all three problems appeared to exist independently. Additionally, the existence and nature of any apathy did not correlate with the severity of the brain injury. The trial of medicine was disrupted by low levels of recruitment, high rates of non-attendance and poor medication compliance, some of which was attributed to side effects. In the small cohort who took Methylphenidate (20 mg ER tablet) for two weeks, an improvement was not only seen in their level of apathy, but also in respect to their depression and fatigue. The improvement of apathy did not reverse following withdrawal of the drug. The improvement of apathy was not explained in this small group by the improvement in depression. Although a plausibility argument can be made for this medicine and some encouraging clinical results were found, the major finding here is that Oman does not have an adequate rehabilitation program for brain-injured patients. This requires urgent address given the incidence of brain injuries cited above and the predominance of young people who are injured. It is possible that the stigma of having a mental illness affected the number of patients who were willing to participate in the study and such attitudes and their vulnerability to modification warrants further study. Conclusion: Psychiatric complications are common in Omani patients with TBI. Early diagnosis and treatment of these complications will improve the quality of life for these patients and their families. There is an urgent need for an effective rehabilitation system for brain-injured patients and in particular, one that ensures adherence to sustained and regular follow-up.