1. A Study of Risk Factors Linked with Insomnia in Traumatic Brain Injury
Dr Anand Sharma

2. INTRODUCTION Incidence 1,444,000 TBI per year
80% are mild to moderate head injury
Age group years
Insomnia, are very common following traumatic brain injury (TBI)-40 to 80 Percent
Post-TBI insomnia has been associated with numerous negative outcomes
Less is known about the factors associated with insomnia in post TBI patients
Paucity of studies establishing connection between depression and insomnia
Jamie M.,et al Jorge, R, et al 1993

3. AIMS AND OBJECTIVE
To investigate prevalence and risk factors of insomnia in TBI.
This study has also tried to explore the connection between insomnia with neuroanatomical localization of TBI as well as depression.

4. MATERIAL AND METHODOLOGY Inclusion Criteria
204 Participants recruited
Participants had to be 18 years or older,
Have a history of TBI with a documented loss of consciousness or other evidence of a TBI (i.e., pathology on neuroimaging)
Be able to comprehend or answer verbal or written questionnaires

5. MATERIAL AND METHODOLOGY Exclusion Criteria
Other serious medical illness
Have a current substance abuse using DSM-IV criteria,
Have mass brain lesions or other neurologic diagnoses other than TBI,
Have a history of current or past psychosis or mania ,MDD or any other mental disorder except current Insomnia & MDD using DSM-IV criteria
Have a history of clinically significant liver or renal disease.

6. Tools used ISI- For Insomnia
Reliability of 0.91 and a corrected item correlation range of Hindi version of the Insomnia Severity Index is a valid and reliable tool for the measurement of severity of insomnia.
Lahan V et al.2011

7. Tools used PHQ-9 for Depression
kappa=0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%
None (0-4), Mild depression (5-9),Moderate depression(10-14), Moderately severe depression (15-19), Severe depression (20-27)
Kroenke et al :2001
GCS score for Severity of head injury
Severe Head Injury----GCS score of 8 or less
Moderate Head Injury----GCS score of 9 to 12
Mild Head Injury----GCS score of 13 to 15
Graham et al.1974

8. Statistics Data were checked for normality ,outliers and missing data.
No imputation of missing data was performed.
Data were analyzed using SPSS version 20,with a 2 tailed α level of 5 percent.
Statistical analysis were performed by correlation analysis(pearson & spearman),student t test,and chi square test analysis.

9. RESULT Sample size 204 Mean Age : 33.34 Yrs Male (n=161)- 79.3 percent
Female (n=42) percent
Motor Vehicle Accident most common mode of Injury (60%)

10. RESULT
Prevalence of Insomnia

11. RESULT
Sociodemographic and Injury characteristics of study sample (n=204)including insomnia and without Insomnia.
 SEx
Without Insomnia
Insomnia
P value
N=122
Percentage
N=82
Male 98
80.3 64 78
P= .717, r = .026
Female 24
19.7 18 22
Age (years)
18–24 31
25.4 23
28.0
P= .655, r = .031
25–34 43
35.2
29.3
35–44 25
20.5
22.0
45–54 10
8.2 9 11
55–64 7
8.5
65 or older 3
2.5 1
1.2
Type of injury
RTA 60
49.2 48
58.5
P= .416, r = -.057
FFH 16
19.5
Assault 28
23.0 15
18.3
Other injury
3.7
GCS
Mild
80.32
29.26
P= .000, r = .511
Moderate
19.67 58
70.73

12. RESULT
Sociodemographic and Injury characteristics of study sample (n=204)including insomnia and without Insomnia.
 Duration of TBI
Without Insomnia
Insomnia
P value
N=122
Percentage
N=82
Less <3 Month 85
69.67 52
63.41
3-6 Month 18
14.75 24
29.26
P= .014, r =-.843
>6 Month 19
15.57 6
7.31
Monthly income
<50000 69
56.6 60
73.2
P=.07, r =.161 40
32.8
22.0 12
9.8 3
3.7
>200000 1
0.8
1.2
Marital status
P=.395,r=-.060
Married 92
75.4 66
80.5
Unmarried 30
24.6 16
19.5

13. RESULT Correlation Between Insomnia & Severity of TBI
And 29% of patients have some kind of nxiety disorders…..
P= .000, r = .511

14. RESULT Correlation of Insomnia with Duration of TBI
This slide shows severity of depression ……most of patients have mild to moderate depression the form arund 76 % of dpessed patients
P= .014, r =-.843

15. RESULT Distribution of CT finding in insomnia patients
Again this is severity of anxiety disorders ….72% had mild anxiety ,mod and severe anxiety were present in 24 and 4% of cases…..

16. RESULT
Distribution of cerebral contusions in insomnia patients

17. RESULT Correlation between Insomnia & Depression
We have also found that there is statically signifiant correlation between severity of head injury and severity of depression severe the injury there is severe the depression
Chisquare>.396,df1,p>.o5

18. DISCUSSION
study population was implicitly closed to the age and sex distribution of TBI in general adult population
40.2% patients developed insomnia over a period of one year . This rate of insomnia in this study sample is 5.4-times greater than would be expected in the general population (40.2% in our cohort vs 6.7% in the general population).
frequent assessment of the participants at regular follow up upholds the veracity of study
Verma A et al,2007

19. DISCUSSION
two component model of etiology of insomnia in TBI i.e. a general predisposition to developing insomnia and an acute stressor.
Demographic variables do not have significant bearing on insomnia in TBI
Injury characteristics like Severity & Duration of TBI does have significant association with Insomnia.
First three months after TBI imposes maximum risk of insomnia
Roth T et al,2004
McLean A et al,1993
Cohen M et al,1992

20. DISCUSSION
Neuroanatomical localization of injury also suggest a possible role for frontal cortex, temporal lobe, and basal ganglia pathology in post-TBI insomnia
One third of the total study population had depression. However, no association could be established between insomnia and depression
development of post traumatic sleep–wake disorders in TBI patients cannot be explained only on the basis of underlying psychiatric disorders or other ‘functional’ factors.
Jorge RE et al,1993,2004
Baumann CR, et al 2007

21. CONCLUSION
Considering clinical application of the study, knowledge of factors associated with the emergence of insomnia has clinical relevance to treatment providers, since effective intervention requires an accurate differential diagnosis.
Assessment for insomnia in TBI patients should include careful Screening for sleep disorders, depression and/or other psychiatric disturbances.
Insomnia must be considered as the heralding symptom of emotional consequences and its treatment may certainly address the concomitant psychiatric comorbidities as well.

23. REFERENCES
1.Jamie M. Zeitzer, Leah Friedman, Ruth O’Hara. Insomnia in the context of traumatic brain injury.JRRD.2009; 46:
7. Jorge, R., Robinson, R. and Arndt, S. Are there symptoms that are specific for depressed mood in patients with traumatic brain injury. Journal of Nervous & Mental Disease. 1993; 181:
Ref-Sankar SK, Ramamurthi & Tandon's Textbook of Neurosurgery 3rdEditon ,page-318,319
.Lahan V, Gupta R. Translation and validation of the insomnia severity index in hindi language. Indian J Psychol Med .2011;33:172-6
8.Graham Teasdale, Bryan Jennett. Assessment of coma and impaired consciousness: A Practical Scale. The Lancet.1974; 304:81-84
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:
Verma A, Anand V, Verma NP. Sleep disorders in chronic traumatic brain injury. J Clin Sleep Med. 2007; 3:357–62
Roth T, Drake C. Evolution of insomnia: Current status and future direction. Sleep Med. 2004; 5:S23–30.

24. REFERENCES
McLean, A., Dikmen, S. S. and Temkin, N. R. Psychosocial recovery after head injury.
Archives of Physical Medicine and Rehabilitation. 1993;74:
Jorge RE, Robinson RG, Arndt S. Are there symptoms that are specific for depressed mood in patients with traumatic brain injury?. J Nerv Ment Dis. 1993; 181:91–99.
Jorge RE, Robinson RG, Moser D, Tateno A, Crespo-Facorro B, Arndt S. Major insomnia following traumatic brain injury. Arch Gen Psychiatry. 2004; 61:42–50
Baumann CR, Werth E, Stocker R, et al. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain. 2007;130:

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