Brain Injury, September 2009; 23(10): 800–808
Hope, dispositional optimism and severity of depression following
traumatic brain injury
GIL PELEG1, OHR BARAK1,2, YERMI HAREL3,4, JUDITH ROCHBERG3,
& DAN HOOFIEN2,5
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1
The Tel-Aviv-Jaffa Academic College, Tel Aviv, Israel, 2The National Institute for the Rehabilitation of Persons with
Brain Injuries, Tel Aviv, Israel, 3Loewenstein Hospital Rehabilitation Centre, Raanana, Israel, 4Sackler School of
Medicine, Tel-Aviv University, Tel-Aviv, Israel, and 5The Hebrew University of Jerusalem, Jerusalem, Israel
(Received 7 April 2009; revised 8 July 2009; accepted 20 July 2009)
Abstract
Primary objective: To investigate the extent in which two coping variables—hope and dispositional optimism—are related
to depression severity amongst individuals who have sustained traumatic brain injury (TBI).
Methods and procedures: Sixty-five participants were administered the Beck Depression Inventory (BDI), the Adult Hope
Scale (AHS), the Life Orientation Test-Revised (LOT-R) and a demographic and injury-related data questionnaire.
In addition, relevant injury-related data was collected from the medical records.
Main outcomes and results: High levels of depression were experienced in the study sample, while hope and dispositional
optimism were significantly lower in comparison to the general population. The correlation patterns indicate that both hope
and dispositional optimism negatively correlated with participants’ depression levels and that they showed significant
positive correlations with each other. In the case of mild depression, the hope-Pathways sub-scale of the AHS was the only
variable negatively correlated to it, while in moderate-to-severe depression all coping variables were negatively correlated
to it. Regression analysis revealed that the AHS and LOT-R, but not the demographic and injury-related variables,
predicted depression severity.
Conclusions: Clinical implications in referring persons with TBI with mild vs. severe depression to rehabilitation programmes
are discussed.
Keywords: Adult Hope Scale, Beck Depression Inventory, depression, hope, Life Orientation Test Revised, optimism, traumatic
brain injury
Introduction
The functional and psychological repercussions of
traumatic brain injury (TBI) are diverse and can
manifest in profoundly debilitating and wide ranged
disabilities, which may affect the person’s every
aspect of life. Mood disorders are among the
most common post-TBI psychiatric disabilities [1].
Regardless of the severity of injury, individuals
who have sustained TBI are at a high risk for the
development of a mood disorder [2]. The prevalence
of depression following TBI reaches significantly
higher frequencies in comparison to traumatic
injuries of comparable severity, but without involvement of the central nervous system [3], and it is
certainly higher than in the general population [4, 5].
For example, Kreutzer et al. [5] found a 41.9%
prevalence of major depressive disorder evaluated at
an average of 2.5 years post-injury.
Psychological reactions to the injury are the most
probable aetiological derivations of the high
Correspondence: Ohr Barak, Department of Behavioural Sciences, Tel-Aviv-Jaffa Academic College, 14 Rabenu Yerucham Street, Tel Aviv Jaffa 68182, Israel.
E-mail: obar@mta.ac.il
ISSN 0269–9052 print/ISSN 1362–301X online ß 2009 Informa Healthcare Ltd.
DOI: 10.1080/02699050903196696
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Hope, optimism and depression in TBI
depression rates among persons with TBI [3].
The disabilities and deficits following TBI force
the recovering person to face many losses, be it the
cognitive impairments, the functional disabilities
or the loss of previous life fantasies and goals [6].
The coping strategies that were employed prior to
the injury may no longer be available, which may
exacerbate the difficulties [7]. These immediate
and long-term losses are often followed by a period
of mourning. The prolonged process of grief following TBI has been described as ‘partial death’, parts
of the self that have lost their function but continue
to exist as constant reminders of the past, thus
causing a process of mobile mourning in which the grief
continues indefinitely [8].
Many studies have demonstrated an association
between major depression and poor psychosocial
functioning and rehabilitation outcomes following
TBI. For example, participants with prolonged
major depression showed poor psychosocial and
activities of daily living outcomes [9]. Even following
mild TBI, participants with major depression had
poorer outcome on the neurobehavioural rating scale
and the Glasgow Outcome Scale than mild TBI
participants without depression [10]. Despite these
detrimental effects, depression is still inadequately
conceptualized in the TBI population, as it represents a heterogeneous category comprised of multiple aetiologic and clinical implications. The present
study explored the role of two coping variables
that may elucidate aspects in depression severity
following TBI.
Hope is considered as one of the most crucial
theoretical constructs to explicate a person’s way
of coping with life’s challenges. It is described as an
inner feeling that a problem will ultimately be solved
or as the person’s evaluation of self-abilities to
achieve goals [11]. In recent years a more holistic
and integrated concept of hope has emerged [12, 13].
In addition to defining hope as the positive expectation of goal attainment, Snyder et al. [12, 13]
expanded its definition to include two inter-related
cognitive dimensions: agency and pathways. Agency
refers to the person’s perceived inner resources which
are required in order to proceed in a chosen path.
Pathways refers to the possible routes a person is able
to conceive while contemplating a desired destination; a person high in this element is characterized by
the ability to conceive several alternative pathways.
Arnau et al. [14] noted that the two dimensions of
hope commonly, but not always, co-occur, indicating
that both agency and pathways are necessary for the
maintaining of hope.
It was shown in numerous studies that high hope
individuals had higher academic and sports achievements [for example 15, 16]. Hope has been found to
be negatively related to general maladjustment [17]
801
and suicidal ideation [18] and it is also a crucial
factor in dealing with major life stressors and
traumas, such as cancer [19] and old age [20]. The
impact of hope on depression and psychosocial
adjustment was studied in persons with traumatic
spinal cord injuries, where higher hope was associated with less depression and greater overall
psychosocial adjustment, even after controlling for
the time post-injury [21]. In another study, it was
found that hope was negatively correlated with
severity of depressive symptoms and that the relationship was moderated by mature defence styles
[22].
Optimism is another concept that is referred to
often when relating to a person’s way of coping.
As does hope, it refers to the person’s future
orientation, but more in tune with a general expectancy that good rather than bad will happen [23].
Thus, the optimist looks towards the future, attaching positive explanations even to negative outcomes.
Indeed, optimists tend to use more problem-focused
coping strategies than do pessimists. When problemfocused coping is not a possibility, optimists turn to
more adaptive emotion-focused coping strategies
such as acceptance and use of humour. Pessimists
tend to cope through overt denial and by mentally
and behaviourally disengaging from the goals with
which the stressor is interfering [24].
Dispositional optimism was originally conceptualized as a unitary trait representing a single bipolar
continuum, with optimism at one end of the spectrum
and pessimism at the other [23]. Accordingly, Scheier
and Carver’s [24] Life Orientation Test (LOT), one
of the most popular measures for this trait, is typically
considered to be a unidimensional measure of optimism [25]. However, other work suggests that
dispositional optimism may consist of two separate
sub-traits reflecting positively-framed optimism and
negatively-framed pessimism. For example, Dember
et al. [26] proposed a bidimensional model of
optimism, in which people have both a level of
optimism and a level of pessimism. Within this
theoretical perspective, the rejection of pessimism is
not the same as the endorsement of optimism.
Empirical research supports this two-factor model,
although there remains a disagreement as to how
inter-correlated optimism and pessimism are [27].
Optimism plays an important role in the adjustment to stressful life events. Greater optimism
was associated with fewer mood disturbances in
response to a variety of stressors. For example,
participants who were hospitalized for acute myocardial infarction experienced greater satisfaction
with the treatment regime in accordance with higher
scores in dispositional optimism and low depression
scores [28]. Optimism was also found to be an
important moderator of the association between
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hopelessness and suicidal ideation; the study which
encompassed 284 college students showed that
higher dispositional optimism was strongly correlated to lowered degrees of experienced depression
and suicidal ideation [29].
At times, dispositional optimism and hope are
used as interchangeable constructs in popular discourse as in scientific journals. In recent research
[27] it was stated that although the two concepts
have a good correlational relationship they are still
adhering to different theoretical constructs. More
specifically it is argued that hope, as depicted by
Snyder, focuses directly on expectations about
the personal attainment of specific goals, whereas
optimism, as depicted by Carver and Scheier,
focuses on expected quality of future outcomes in
general. Their theoretical point of contact being that
a lack of agency in pursuit of a goal gives rise to the
likelihood of pessimism about reaching that goal;
whereas an absence of pathways towards a goal
but a continued commitment for it (i.e., agency)
does not necessarily promote such pessimism [27].
The present study explored these theoretical correlations among hope-agency, hope-pathways and optimism in the TBI population. The prolonged
process of grief and loss in this population makes it
a suitable test-case for the differential roles of the
coping constructs. In particular, this study examined
whether persons high in one or both coping variables
may show better resilience to post-injury depression;
in addition, whether this resilience is effective for
both mild and severe depression. If so, then hope
and optimism may play a role in better coping and
improved rehabilitation sequel following TBI.
participants were approached by either their therapist or attending psychiatrist in order to obtain
informed consent. Sixty-five participants gave
informed consent and were recruited to the research.
The group comprised of 72.3% males, with a
mean age of 28.8 years (SD9.0, range ¼ 18–55) and
a mean of 12.9 years of education (SD ¼ 1.8,
range ¼ 8–18); 67.7% were single, 27.7% married
and 4.6% divorced; 67.7% of this group was
unemployed, 23.1% employed and 9.2% students.
Injury severity was determined based on Glasgow
Coma Scale (GCS) scores: 31% sustained a mild
injury, 8% a moderate injury and 61% a severe injury
(mean ¼ 8.7, SD ¼ 4.2, range ¼ 3–15). Participants
were on average 2.9 years post-injury (SD ¼ 2.3,
range ¼ 0.5–9.7). In terms of aetiology, 75.4% were
victims of road accidents, 12.3% of war accidents
and 12.3% of falls.
Measures
Beck Depression Inventory (BDI) [30]. The questionnaire includes 21 self-report items in which
the participant is asked to circle the item which
best describes how they had been feeling in the past
week. Subjects rate the severity of each symptom
on a 4-point scale ranging between 0–3. A total score
(range 0–63) is obtained by summing individual
items’ scores. The questionnaire has been found to
have both good reliability ( ¼ 0.87) and validity
in assessing depression following TBI [31]. The
Hebrew version of the BDI has a good internal
reliability as well ( ¼ 0.78) [32]. Internal reliability
in the present group was also good (Cronbach’s
¼ 0.9).
Methods
Participants
The participants were recruited from the National
Institute for the Rehabilitation of Persons with Brain
Injuries and the Loewenstein Hospital Rehabilitation
Centre, two of the largest brain injury rehabilitation
facilities in Israel. Possible candidates for the
research were selected from all consecutive admissions to recruitment institutes over a period of
18 months, based on examination of medical files
for inclusion and exclusion criteria: medically
documented TBI that occurred at least 6 months
prior to the study; between the ages of 18–60 years
old; able to give consent for participation;
cognitively apt to answer the different questionnaires
(as assessed by their therapist); non-psychotic; no
reports of depression prior to TBI onset (pre-morbid
depression was determined by the examiner, using
the detailed anamneses in participants’ medical
files). Following initial file examination, 82 potential
Adult Hope Scale (AHS) [33]. The questionnaire
includes 12 self-report items in which the participant
is asked to circle the degree of agreement he has with
the statement given on a 4-point scale (1–4). A total
score is obtained by summing the items’ scores and
reducing the scores of fillers (items number 3, 5, 7
and 11). The total hope score ranges from 8–32,
with larger scores indicating higher levels of hope.
The agency score is comprised of items 2, 9, 10 and
12 and the pathways score of items 1, 4, 6 and 8; in
each the total score ranges from 4–16. A total score
of 25.64 (SD ¼ 2.93) is the mean hope score in the
healthy population. The mean agency score is 12.83
(SD ¼ 1.69) and the mean pathways score is 12.81
(SD ¼ 1.75) [32]. The AHS was translated to
Hebrew and showed high internal consistency
( ¼ 0.8) [34]. Internal reliability in the present
group was also good (Cronbach’s ¼ 0.8).
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Hope, optimism and depression in TBI
Life Orientation Test Revised (LOT-R) [24]. This
instrument measures dispositional optimism. The
questionnaire includes 10 self-report items in which
the participant is asked to circle his or her degree
of agreement with the statement given on a 5-point
scale (0–4). A total score is obtained by summing the
items’ scores, after reversing negative items (items
number 3, 7 and 9) and reduction of four filler items
(items number 2, 5, 6 and 8). The sum score ranges
from 0–24, with larger scores indicating higher levels
of optimism. A score of 14.33 (SD ¼ 4.28) is the
mean score in the healthy population [24]. The
LOT-R was translated to Hebrew [35] and showed
a fair internal consistency ( ¼ 0.62). Internal reliability in the present group was similar (Cronbach’s
¼ 0.7).
Participants’ demographic and injury related data
questionnaire. This questionnaire included information regarding age, years of formal education,
vocation and marital status. In addition, relevant
injury-related data, including GCS score, aetiology
of injury and time since occurrence of injury, was
collected from the medical records.
Procedure
Participants were administered the questionnaires
individually, in the order presented in the measures
section. Participants who encountered difficulties
in comprehending or filling the questionnaires were
assisted by the examiner (assistance consisted solely
of reading the questions aloud to the participant).
The administration time was 20 minutes and was
carried out at the rehabilitation centres the participants were attending at the time.
Results
Descriptive statistics
Table I illustrates descriptive statistics of the
participants’ scores in the three questionnaires.
Table I. Participants’ depression levels, rates of hope and
dispositional optimism in comparison to healthy adults (n ¼ 65).
Study sample
Mean (SD)
BDI
AHS
AHS agency
AHS pathways
LOT-R
19.32 (11.7)
23.1 (5.0)
11.3 (2.9)
11.9 (2.7)
12.6 (5.2)
Healthy adults
Mean (SD)
6.18
25.64
12.83
12.81
14.33
(6.82)
(2.93)
(1.69)
(1.75)
(4.28)
BDI ¼ Beck Depression Inventory; AHS ¼ Adult Hope Scale;
LOT-R ¼ Life Orientation Test Revised. Healthy adults-see text
for references.
803
The Kolmogorov-Smirnov tests of normality
indicated that the BDI, the AHS and the LOT-R
had normal distributions (d(65) ¼ 0.9, 1.2 and 0.7,
respectively, p > 0.05). Therefore, all further analyses were performed using parametric tests.
The BDI mean score indicates an overall moderate–evere level of depression [30]. Distribution of
depression severity shows that 17 participants
(26.2%) had a non-clinical depression level, 19
participants (29.2%) had a mild depression level,
15 (23.1%) had a moderate depression level and
14 (21.5%) a severe depression level. Using a one
sample t-test, the obtained mean score was significantly higher (t(64) ¼ 9.1, p ¼ 0.000) than mean
BDI scores of healthy adults [36].
The AHS mean score reflects medium–low levels
of hope in the study group. In a one sample t-test,
the obtained mean score was significantly lower
(t(64) ¼ 4.0, p ¼ 0.000) in comparison to the general population norms [33]. The AHS agency and
pathways mean scores were also significantly lower
(t(64) ¼ 4.3, p ¼ 0.000; t(64) ¼ 2.8, p ¼ 0.006,
respectively) in comparison to a sample of the
general population.
The LOT-R mean score was found to be in the
lower regions of the possible range, reflecting
low levels of optimism in the study group. In a one
sample t-test, the obtained mean score was significantly lower (t(64) ¼ 2.7, p ¼ 0.009) in comparison
to the general population norms [24].
Correlation analysis of depression, hope and
dispositional optimism
In order to examine the relations between depression
and the coping variables in the study population,
Pearson correlations were calculated between
depression, hope and dispositional optimism
scores. Results revealed significant negative yet
moderate correlations between AHS and BDI
scores (r ¼ 0.59, p ¼ 0.000), as well as between
LOT-R and BDI scores (r ¼ 0.53, p ¼ 0.000). The
AHS agency and pathways sub-scores also showed
significant negative yet moderate correlations with
the BDI (r ¼ 0.49, p ¼ 0.000 and r ¼ 0.57,
p ¼ 0.000, respectively). Regarding the two coping
variables, AHS and LOT-R scores correlated significantly in a moderate level (r ¼ 0.56, p ¼ 0.000)
and the same pattern was evident between the
LOT-R and the AHS agency and pathways subscores (r ¼ 0.44, p ¼ 0.000 and r ¼ 0.57, p ¼ 0.000,
respectively).
Depression severity and its correlations with hope
and dispositional optimism
In order to examine whether the correlation pattern
found between depression and the coping variables
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is the same across depression severity levels, the
participants were divided to two groups, based on
the original depression severity criteria defined by
Beck et al. [30]: minimal–mild depression (0 < BDI
score < 18); moderate–severe depression (19 < BDI
score < 63). The minimal–mild group included
36 participants and the moderate–severe group
29 participants. In terms of demographic and
injury-related variables, the moderate–severe
group included significantly older participants
(F(1, 64) ¼ 5.4, p < 0.05), a higher frequency of
women (37.9 vs 19.4) and married people (34.5 vs
22.2). There were no statistically significant differences between the groups in severity of GCS, time
since injury, years of education and employment
status. Pearson correlations between depression
and the coping variables were examined for each
depression severity level, as outlined in Table II.
The moderate–severe group’s correlations presented a similar pattern to the overall effect shown
in the whole group, i.e. the BDI score showed
significant negative correlations with the AHS and
the LOT-R total scores. In addition, the BDI score
showed significant negative correlations with the
AHS agency and pathways sub-scores. However,
in the case of the minimal–mild depression group,
the correlation pattern was different. The BDI score
showed a significant negative correlation with the
AHS total score, but not with the LOT-R total score.
This pattern is due to the correlation between BDI
score and the AHS pathways sub-score, but not with
the AHS agency sub-scale score.
Prediction of depression severity—a regression analysis
In order to examine the relative contribution of the
coping, demographic and injury-related variables
of the sample, a stepwise regression analysis was
conducted. The BDI score served as the dependent
variable and the AHS total score, the LOT-R total
score, time since injury, injury severity (GCS score),
employment status and age as predicting variables.
Employment status is a categorical predictor and
it was re-coded into two categories (participants in
the ‘employed’, ‘volunteer’ or ‘student’ categories
were re-assigned into one category, ‘occupied’, while
unemployed participants were kept in a separate
category). As can be seen in Table III, the model
summary included the AHS and LOT-R scores
[F(2, 62) ¼ 21.23, p ¼ 0.000] and accounted for
40.6% of the shared variance. However, it was the
AHS score that contributed the majority of
explained variance. The remaining variables, time
since injury, injury severity, employment status and
age, were excluded from the model.
Discussion
The present study investigated the potential role of
positive coping constructs in depression following
TBI. In replication of previous studies, it was found
that high levels of depression were experienced in
the study sample [3, 37]. Around 45% of the
participants reported depressive symptoms in clinically significant levels, ranging from moderate-tosevere. A substantial number of studies show high
rates of depression in the TBI population. These
were found regardless of the specific tool used to
evaluate depression levels, including the DSM
Symptom Checklist [5], the SCL-90-R [4] and the
BDI-II [38]. The depression scores of this study, as
well as of the aforementioned TBI samples, are
much higher than those reported in studies of
healthy adults [36]. With respect to these high
depression rates and the relative lack of known
mediating factors, the present research explored the
potential role of positive personality assets on postTBI depression.
The degree of hope, as measured by the Adult
Hope Scale, was found to be significantly lower in
this sample as compared to norms reported in the
Table II. Pearson correlation coefficients between depression, hope and dispositional optimism, following
division to two depression severity sub-groups.
AHS
AHS pathways
AHS agency
LOT-R
Minimal-to-mild depression levels (BDI ¼ 0–18), n ¼ 36
BDI
0.35* p < 0.05
0.43* p ¼ 0.01
AHS
0.86* p ¼ 0.000
AHS pathways
AHS agency
0.19
0.88*
0.51*
p > 0.1
p ¼ 0.000
p < 0.005
0.19
0.57*
0.60*
0.40*
Moderate-to-severe depression levels (BDI ¼ 19–64), n ¼ 29
BDI
0.62* p ¼ 0.000
0.62* p ¼ 0.000
AHS
0.88* p ¼ 0.000
AHS pathways
AHS agency
0.50*
0.91*
0.59*
p < 0.01
p ¼ 0.000
p < 0.001
0.43* p < 0.05
0.334 p > 0.05
0.36
p > 0.05
0.25
p > 0.1
p > 0.1
p ¼ 0.000
p ¼ 0.000
p < 0.05
*Statistically significant correlations.
BDI ¼ Beck Depression Inventory; AHS ¼ Adult Hope Scale; LOT-R ¼ Life Orientation Test Revised.
Hope, optimism and depression in TBI
Table III. Stepwise regression-the contribution of coping, demographic and injury severity variables in predicting depression
severity (BDI).
Step 1
Constant
AHS
Step 2
Constant
AHS
LOT-R
B
se B
R2
50.86
1.36
5.59
0.24
0.59*
0.35
50.42
0.98
0.67
5.37
0.27
0.27
0.42*
0.30**
0.41
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AHS ¼ Adult Hope Scale; LOT-R ¼ Life Orientation Test
Revised.
*p < 0.005; **p < 0.05.
general population [33, 39]. In fact, these results are
low even in comparison to other health-challenged
populations, such as women diagnosed with cancer
[19] and traumatic spinal cord injury [21].
Dispositional optimism levels, as measured by the
Life Orientation Test-Revised, were also low when
compared to norms in the general population [24],
as well as to health-challenged populations, including sickle-cell disease [40] and head and neck
cancer [41]. As low levels of hope [14] and optimism
[41] are known predictors of poor psychosocial
outcomes and health quality-of-life, these findings
provide further evidence to the claim prevalent in the
TBI literature, that the effects of head trauma are
often associated with poor long-term psychosocial
outcomes, which decrease the individuals’ qualityof-life [42].
The correlation patterns between hope, dispositional optimism and depression indicate that both
coping measures negatively correlated with participants’ depression levels. These findings accord with
studies performed in the general population for hope
[43]. Similarly, dispositional optimism and depression levels correlated negatively in students [44], as
well as in middle-aged participants [45]. It seems
that, despite the fact the individuals with TBI
express high rates of depression and low coping
abilities, still the correlation patterns are similar
to those in non-injured samples and other healthchallenged populations. This may serve as an indication that similar affective processes are at work,
thus supporting the claim that therapeutic methods
employed with traumas and life changes in people
without brain damage can be applicable for individuals who sustained TBI as well [46].
The correlations between depression and the
coping variables also indicate that hope and optimism are not merely the phenomenological reversal
of depression. Snyder et al. [33] showed that even
when controlling for ‘negative affectivity’ (highly
associated with depression), the hope score still
preserved discriminant predictive power with regard
805
to problem-focused coping. With regard to optimism, in a longitudinal study, young adults with
a ‘pessimistic cognitive style’ were more likely to
develop clinical depression and clinical anxiety, thus
showing optimism’s predictive potency in regard to
these psychopathologies [47].
The two coping constructs showed a positive
moderate correlation with each other. A similar
pattern was described in two large samples of
undergraduate students [27, 33]. There the correlation patterns were used to examine whether hope
and optimism should be conceived as two separate
constructs or as reflections of the same global
underlying trait. Supporting a unitary conceptualization, hope and optimism share a sizeable portion
of their variance and a single global factor provides
a reasonable and parsimonious goodness-of-fit to the
data. Indeed, both constructs share many things in
common. Fundamentally, both stem from an expectancy-value approach to motivation and both were
designed to assess individual differences in what are
thought to be stable characteristics reflecting general
expectations about the future [48]. On the other
hand, Bryant and Cvengros [27] support a distinct
construct approach to hope and optimism, claiming
that separate hope and optimism factors had greater
explanatory power than did a single global ‘super’
factor and that the two constructs showed divergent
patterns of association with coping and self-efficacy.
Their findings accord with the claim that, in comparison to optimism, the hope scales have provided
unique and augmenting variance in predicting outcome [48]. The correlation pattern in the present
study suggests that hope and optimism may contribute distinctively to a person’s coping following a
major life trauma. This despite the fact that the
coping strategies employed by TBI clients prior to
their injury may no longer be available to them.
Next was analysed the relationship between
depression severity and the coping variables. In the
case of participants who exhibited mild depression,
hope-pathways was the factor which contributed to
the negative correlation between hope and depression. Hope-pathways is assumed to reflect a direct,
goal-oriented way of coping with challenges, as it
refers to an individual’s perceived ability to find one
or more effective ways to reach his or her goals, as
well as the perceived ability to formulate alternative
plans when obstacles get in the way of goal attainment [14]. These findings may indicate that, in the
case of mild depression following TBI, the focus
of concern is the difficulty of envisioning ways of
coping with the trauma, rather than a loss in the
internal locus of control. One possible clinical
implication is to refer persons following TBI who
manifest mild depression to therapies directed
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towards
enhancing
explicit
problem-solving
strategies.
In the case of moderate-to-severe depression,
it was found that personality variables (hopeagency and optimism) now play a significant role,
in addition to the goal-oriented coping which was
observed in mild depression. This is in accordance
with previous findings which indicated that hopeagency is a good predictor of severe psychopathology. For example, in a study that examined the
correlations between the agency and pathways subscales and the clinical scales of the Minnesota
Multiphasic Personality Inventory–II, it was found
that the agency sub-scale was a stronger predictor
of psychological maladjustment than the pathways
sub-scale score [17]. In another study, the agency
sub-scale was found to be the strongest predictor of
suicidal ideation in college students [18].
The regression analysis indicates that the two
coping variables, but not the demographic and
injury-related variables, predicted depression severity in the current sample. The lack of impact of the
latter variables on prediction of mood disorders is in
accordance with the TBI literature, where persons
with depression are no different from non-depressed
individuals with respect to age, sex, race, socioeconomic status, marital status, educational level, type
or severity of brain injury, family history of psychiatric disorder or the degree of physical or cognitive
impairment [1, 3, 37].
Of more interest is the finding that of the two
coping variables, hope is the more dominant in
predicting depression severity. Although both hope
and optimism are associated with positive expectations, those associated with hope are specifically
oriented on the perceived ability to sustain action
towards goal attainment. Optimism, on the other
hand, is a more general expectation of positive
events, is not specifically centred on the individual as
the initiator of such events and is not focused on
particular actions that may bring about those positive events [14]. The latter can prove to be a
challenging task for individuals with TBI, dealing
with everyday and chronic difficulties. The relationship between hope and depression was examined
in greater detail by Chang and DeSimone [49]. They
found that hope had both direct and indirect effects
on severity of depressive symptoms, as measured
by the BDI. The indirect effects were mediated via
hope’s effect on coping style and secondary appraisals of control and effectiveness. However, hope still
had a significant direct relationship with depression
after the indirect effects were ruled out. This finding
may account for another conception of hope’s
dominance in accounting for depressive symptoms
in TBI, through its relation to locus of control. It was
shown that in cases of a dominant external locus of
control, depression is more prevalent in participants
post-stroke [50]. Persons with HIV, who attributed
the quality of their health status to externally
controlled variables (e.g. fate), also showed higher
levels of depression [51]. Higher hope levels may
represent a more internal dominant locus of control,
the perception that one has the ability and the ways
to control his or her own goal attainment.
In conclusion, the present results replicate various
findings in the TBI literature concerning the rate and
severity of depression post-injury. In addition, it was
shown that the levels of two coping variables,
hope and dispositional optimism, were low in comparison to healthy adults. It seems that, in the TBI
population, people characterized by worse coping
skills are prone to exhibit higher levels of depression
following the injury. However, this hypothesis
should be further supported in future studies, via
exploration of personal history or with functional
variables such as vocational and educational success.
Clearly, the fact that all of the participants were
active participants in a rehabilitation programme
hampers the ability to generalize from the current
findings. The sample is comprised of persons during
therapy and rehabilitation on average 2.9 years postinjury and thus may represent a biased sample of the
TBI population. One may suspect that these
participants are already in the process of therapeutic
hope-induction or being treated for their depression.
In the future, the authors expect to try and replicate
these findings in a sample of persons with TBI who
are not in the course of rehabilitation.
Acknowledgements
This research was facilitated by a grant from the
Tel-Aviv Jaffa academic college and support from
the research and development funding of the
national institute for the rehabilitation of persons
with brain injuries in Israel.
Declaration of interest: The authors report no
conflict of interest. The authors alone are responsible for the content and writing of the paper.
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