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Evaluation of the Neurobehavioral Functioning Inventory as a Depression Screening Tool After Traumatic Brain Injury

Categories: Outcomes

The Question

Is the Neurobehavioral Functioning Inventory (NFI) a useful tool for diagnosing depression?

Past Studies

Past Studies have found that it is common for individuals with traumatic brain injury (TBI) to have psychiatric disturbance as a result of their injury. Review of the literature on diagnosing psychiatric dysfunction showed that TBI frequently caused a number of psychiatric disorders (major depression, bi-polar affective disorder, and anxiety). Major depression is the condition most frequently diagnosed following TBI (26%-77%). There have been limitations in methods used to measure these disorders as research often relied on unstructured outcome assessments, small sample sizes, selection biases, and brief follow-up periods. In addition, individuals who had psychiatric disorders prior to TBI, were not investigated in most of the studies.

Use of structured interviews based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) to assess psychiatric disorders has been a widely accepted tool. DSM-IV utilizes a set of five criteria to accurately diagnose depression; the first including a list of nine symptoms of depression, of which five must be present. Time requirements have made using this tool impractical for use with individuals with TBI. The depression rating scales developed for the general population, as an alternative, have not been recommended for routine use as diagnostic tools for individuals with TBI. The Neurobehavioral Functioning Inventory (NFI), developed specifically for individuals with TBI, has been the assessment tool that includes characteristics suitable to assess depression in patients with TBI. It is a brief self-reporting tool which measures neurobehavioral functioning (nervous system functioning), and has been used, with significant success, in rehabilitation settings. This tool has been well received by patients, family and staff, and requires no special training for administration.

This Study 

This Study attempts to address the issue of whether use of NFI, along with the clinical interview, can be a useful tool in diagnosing major depressive disorder (MDD) in individuals with TBI. The hypothesis for this study includes the supposition that patients will score higher on NFI items if diagnosed with depression than non-depressed individuals, and that these NFI items will “have an acceptable level of specificity and sensitivity in classifying major depression”.(Kennedy et al)

Seventy-eight individuals with TBI were selected for this study. They were three months post-injury, and at least 18 years of age. The average participant was 38 years of age (12.2%), single (77%), white (71%), and male (69%) with a high school education (82%). Most participants had a mild (45%) or severe (43%) injury. The greatest number of participants (33%) had an injury as a result of a motor vehicle accident. The majority of participants were unconscious for an average of 16.4 days. Psychiatric diagnostic interviews, using the Structured Clinical Inventory for DSM-IV Axis I disorders (SCID), showed that 50% of the participants of the study had at least one of the psychiatric disorders in their lifetime: MDD, MDD due to general medical condition, dysthymia, or adjustment disorder with depressed mood. Thirty percent (30%) met the criteria for current MDD with or without a general medical condition. The NFI revealed that certain items related to DSM-IV symptoms of depression were higher in individuals with depression than those without depression. In the depressed and non-depressed groups studied, demographics and severity of injury were variables which showed some differences; however, they were not statistically significant. The NFI instrument was acceptable by staff, individuals with TBI and their families, as has been the case in past studies.

Who May Be Affected By These Findings

Individuals with brain injury, their families, caregivers, health professionals, community providers, researchers.


Limitations of this study were a small sample size, self-reporting by individuals with TBI which may have precluded accurate reporting, diagnosis of depression by counting the number of symptoms without determining the etiology of the depression, and that certain questions on the NFI did not seem necessary for diagnosing depression. Further studies need to address these issues.

Bottom Line

Study findings support the use of NFI as a potentially valuable assessment tool with good predictive value for determining major depression in individuals with TBI. The NFI scores, thought to be indicative of depression, were noticeably higher among individuals with a diagnosis of MDD than those without MDD. NFI was found to be particularly useful in rehabilitation settings for assessment of multiple neurobehavioral functioning areas, including emotional state. The strength of this study was that it was not restricted to using a specific time frame (i.e. years post-injury) to determine results. Staff, individuals with TBI, and their families had a good response to the use of this tool because of its easy administration.

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Find This Study

Kennedy, R.E., Livingston, L. Riddick, A., Marwitz, H.., Kreutzer, J.S., Zasler, N.D. (2005).Evaluation of the Neurobehavioral Functioning Inventory as a Depression Screening Tool After Traumatic Brain Injury. Journal of Head Trauma Rehabilitation, 20 (6); 512-526.