title: The assessment of low mood, distress and depression in people with severe cognitive and communication impairments following acquired brain injury
Creators: name: Rose, Alexandra Elizabeth
Publisher: name: University of Glasgow
Year: 2024

description: Low mood and depression are thought to be common after brain injury and are traditionally assessed using clinical interviews and self-report mood measures. This is challenging when people have persisting cognitive and receptive communication impairments following severe acquired brain injury. There is limited literature available on mood disorders and how they should be assessed when a person has severe cognitive and receptive communication impairments that impact their self-report and understanding.

This thesis focusses specifically on people with severe cognitive impairments and receptive communication difficulties after brain injury with the objectives to (1) establish whether recommended mood measures have been adequately validated on the population of interest, (2) to explore what the current clinical practice of clinical psychologists and medical professionals is when assessing mood in this population; and (3) to establish whether it is possible to gain consensus among professionals on how mood should be assessed when severe cognitive and receptive communication impairments are present. The methods used included a systematic review, online surveys of clinical psychologists and medical professionals, semi-structured interviews with 23 clinical psychologists and nine medical professionals and five focus groups using the nominal group technique.

The systematic review found that no self-report measures had been adequately validated with people with severe cognitive and receptive communication impairments after brain injury. One study examining the validity of two observer rated measures did not exclude those severe cognitive impairment in their validation study. These observer scales can tentatively be recommended for use in this population, with further research recommended as this validation study was limited by its size and the small number of severely impaired participants included.

Surveys showed that clinicians are adapting the administration of published tools and not using the scores as intended, bringing the validity of their usage into question. The preferred approach of assessment in this population for both groups surveyed was to ask other people about the mood of the person with the brain injury. Thematic analysis of the interviews highlighted issues with the construct of depression after severe brain injury. There was also a view that separate methods are needed when severe cognitive and receptive communication impairment is present, and that the stigma of emotions can be challenging to tolerate which may put pressure on clinical psychologists to contain this and on doctors to prescribe medications.

The results of five focus groups showed overlap in their views of the assessment process that should be followed. This allowed for a consensus model to be proposed based on their views. Further work on establishing wider consensus and acceptability of the proposed model with a broader group of professionals would be beneficial in establishing clinical utility.

This thesis concludes that people that have persisting severe cognitive and receptive communication impairments after brain injury require a different approach to those with less severe impairments when assessing mood. Self-report measures should not be used in this population. The thesis proposes a formulation based model of assessment for this population. New guidelines need to be developed to ensure improved assessment and management of distress, low mood and depression in those with persisting severe cognitive and receptive communication impairments.