This seven-minute program provides information regarding the impact of using drugs and alcohol after a traumatic brain injury (TBI). The video guides the viewer through a discussion about how the brain works before and after a brain injury, and then demonstrates how drugs and alcohol can affect persons with a history of TBI using brain animations and short vignettes. This tool was designed to help providers engage clients in a dialogue about substance use post-injury and was made possible by funding from the Congressionally Directed Medical Research Program. Jennifer Olson-Madden, Ph.D., VISN 19 MIRECC was the project PI. Collaborators included: John Corrigan, Ph.D., Ohio State University, and Lisa Brenner, Ph.D., VISN 19 MIRECC.
Annotated Bibliography - Suicide and Traumatic Brain Injury (TBI) - Updated August 2011
This seven (7) page document provides quick and easy reference to the latest in research on Suicide and TBI. Download the bibliography.
Traumatic Brain Injury and Suicide - A Manual for Clinicians and Care Providers
There is a need for more resources that are specifically targeted toward TBI survivors who may be considering suicide. Based upon this need, researchers at the VA VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC) produced this information and resources guide. The target audience is clinicians and care providers working with TBI survivors. Download the 31 page manual.
Easily reproducible brochure for veterans and the family/caregiver. Individuals with a history of TBI and their family members shared their stories with us and made the following suggestions regarding suicide prevention.
The purpose of this project is to explore the degree to which performance consistency on neuropsychological measures varies in a sample of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) Veterans with a history of mild traumatic brain injury (mTBI) with persistent self-reported symptoms.
The purpose of this retrospective chart review study is to examine differences in post-concussive (PC) symptom endorsement among four groups of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans: those with a history of target, service-related, mild traumatic brain injury (mTBI) and co-occurring posttraumatic stress disorder (PTSD) (Group 1); those with a history of target, service-related, mTBI only (Group 2); those with PTSD only (Group 3); and those with no history of target, service-related, mTBI or PTSD (Group 4).
This project will determine whether methods drawn from basic science can robustly detect the effects of traumatic brain injury (TBI) and/or post traumatic stress disorder (PTSD) on executive functioning. Although TBI often occurs in the context of a traumatic event, very little research has attempted to disentangle the effects of TBI from PTSD, both of which compromise executive functioning.
The purpose of this study is to explore and potentially increase the capacity of the non-VA community mental health system within the state of Colorado to provide a comprehensive and coordinated service delivery system for Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans and their families. The specific population of interest is OEF/OIF Veterans with a history of traumatic brain injury (TBI) and co-occurring behavioral health issues.
Traumatic brain injury is an important medical problem for Veterans. Individuals with traumatic brain injuries are at increased risk for various psychiatric problems, including those associated with suicide. This study seeks to better understand the relationship between these factors.
While there is a dearth of evidence-based treatment for co-occurring PTSD and mTBI, it has been suggested that best practices entail treating presenting symptoms (hyperarousal, hypoarousal, emotional reactivity, irritability, depression, anxiety, concentration problems). Yoga may be particularly well-suited to treating returning servicemen as data suggests that core symptoms that develop with a history of trauma exposure, are physiologically based, somatically experienced and often not amenable to change through talking alone. Research suggests that that moment-to-moment awareness of present experience may decrease emotional reactivity and anxiety, and increase the capacity for self-regulation. Mindfulness skills have also been associated with: building resilience in the midst of stress; allowing one to better cope with physical discomfort; decreasing anxiety and depression; decreasing reactivity. An 8-week, 16-session, hatha yoga intervention will be conducted with Veterans to assess the acceptability and feasibility of an intervention in this population. Veterans will be screened and assessed for mental and physical health prior to enrolling in the intervention. Weekly sessions, out of session practice, and weekly assessments will track possible changes in the Veterans quality of life, mental and physical health.
The National Center on Homelessness among Veterans was established, in part, to assist the Department of Veterans Affairs (VA) in programming efforts to provide care for Veterans who are homeless or at-risk for homelessness. An immediate goal of the Center is to enlist research and clinical expertise to increase understanding regarding traumatic brain injury (TBI) among the homeless Veteran population.
The purpose of this project is to gather pilot data related to risk factors associated with suicide in Veterans with Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) and to develop an educational and interventional tool and instructional guide that can be utilized by local and national providers to increase understanding regarding suicide risk assessment.
This proposed project will be the first to replicate a groundbreaking psychological treatment for suicide prevention among those with moderate or severe traumatic brain injury, Window to Hope (WtoH), developed by PI Simpson and colleagues in Sydney, Australia. WtoH has been successfully evaluated in a Randomized Controlled Trial (RCT), in which treated Australian civilians (n=17) with severe TBI recorded significant decreases in hopelessness. The current project aims to (i) undertake the cross-cultural adaptation of the WtoH program; (ii) establish the acceptability and feasibility of WtoH within the VAMC context; and (iii) conduct a RCT within the VAMC to replicate the results from the original trial (efficacy). Deliverables are expected to include an intervention suitable for a larger trial and broader dissemination.
Bahraini N, Simpson GK, Brenner LA, Hoffberg AS, Schneider AL. (2013) Suicidal Ideation and Behaviours after Traumatic Brain Injury: A Systematic Review. Brain Impairment / FirstView Article, pp 1-21.
Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.
Brenner, L. A., Hoffberg, A. S., Shura, R. D., Bahraini, N., & Wortzel, H. S. (2013). Interventions for mood-related issues post traumatic brain injury: Novel treatments and ongoing limitations of current research. Current Physical Medicine and Rehabilitation Reports, September 2013, Volume 1, Issue 3, pp 143-150
Mood-related issues following traumatic brain injuries (TBI) are highly prevalent and negatively impact psychosocial functioning. Such symptoms are also frequently undertreated. The aim of this publication is to highlight work regarding interventions for the treatment of post-TBI mood issues. Twelve recently published articles were identified (two systematic reviews, one Cochrane protocol, and nine original research studies). Presented manuscripts support both traditional (e.g., psychotherapy) and novel (e.g., exercise) interventions. Despite these scholarly endeavors, definitive findings regarding effective treatments for post-TBI mood disorders remain sparse. Of particular concern was the lack of recent research regarding traditional pharmacological interventions. Further work is required to identify efficacious and effective interventions for members of this high risk population.
OBJECTIVES:: To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury-4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. STUDY DESIGN:: Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. PARTICIPANTS:: The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. MAIN MEASURES:: For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. RESULTS:: The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. CONCLUSIONS:: The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.
Bryan CJ, Clemans TA. (2013). Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel. JAMA Psychiatry. ():1-6.
Importance: Traumatic brain injury (TBI) is believed to be one factor contributing to rising suicide rates among military personnel and veterans. This study investigated the association of cumulative TBIs with suicide risk in a clinical sample of deployed military personnel referred for a TBI evaluation. Objective: To determine whether suicide risk is more frequent and heightened among military personnel with multiple lifetime TBIs than among those with no TBIs or a single TBI. Design: Patients completed standardized self-report measures of depression, posttraumatic stress disorder (PTSD), and suicidal thoughts and behaviors; clinical interview; and physical examination. Group comparisons of symptom scores according to number of lifetime TBIs were made, and generalized regression analyses were used to determine the association of cumulative TBIs with suicide risk. Participants: Patients included 161 military personnel referred for evaluation and treatment of suspected head injury at a military hospital's TBI clinic in Iraq. Main Outcomes and Measures: Behavioral Health Measure depression subscale, PTSD Checklist–Military Version, concussion symptoms, and Suicide Behaviors Questionnaire–Revised. Results: Depression, PTSD, and TBI symptom severity significantly increased with the number of TBIs. An increased incidence of lifetime suicidal thoughts or behaviors was associated with the number of TBIs (no TBIs, 0%; single TBI, 6.9%; and multiple TBIs, 21.7%; P = .009), as was suicidal ideation within the past year (0%, 3.4%, and 12.0%, respectively; P = .04). The number of TBIs was associated with greater suicide risk (β [SE] = .214 [.098]; P = .03) when the effects of depression, PTSD, and TBI symptom severity were controlled for. A significant interaction between depression and cumulative TBIs was also found (β = .580 [.283]; P = .04). Conclusions and Relevance: Suicide risk is higher among military personnel with more lifetime TBIs, even after controlling for clinical symptom severity. Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide.
Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013 Jan;28(1):13-20.
OBJECTIVE: To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. SETTING: Outpatient TBI clinic on a US military base in Iraq. PARTICIPANTS: Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. MAIN MEASURES: Suicidal Behaviors Questionnaire-Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. RESULTS: Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. CONCLUSION: Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.
Olson-Madden JH, Brenner LA, Matarazzo BB, Signoracci GM; Expert Consensus Collaborators. Identification and Treatment of TBI and Co-occurring Psychiatric Symptoms Among OEF/OIF/OND Veterans Seeking Mental Health Services Within the State of Colorado: Establishing Consensus for Best Practices. Community Ment Health J. 2013 Jan 17. [Epub ahead of print]
This paper highlights the results of a consensus meeting regarding best practices for the assessment and treatment of co-occurring traumatic brain injury (TBI) and mental health (MH) problems among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans seeking care in non-Veterans Affairs Colorado community MH settings. Twenty individuals with expertise in TBI screening, assessment, and intervention, as well as the state MH system, convened to establish and review questions and assumptions regarding care for this Veteran population. Unanimous consensus regarding best practices was achieved. Recommendations for improving care for Veterans seeking care in community MH settings are provided.
Wortzel HS, Arciniegas DB: A Forensic Neuropsychiatric Approach to Traumatic Brain Injury, Aggression, and Suicide. Journal of the American Academy of Psychiatry and the Law 41:274-86, 2013
Aggression is a common neuropsychiatric sequela of traumatic brain injury (TBI), one which interferes with rehabilitation efforts, disrupts social support networks, and compromises optimal recovery. Aggressive behavior raises critical safety concerns, potentially placing patients and care providers in harm’s way. Such aggression may be directed outwardly, manifesting as assaultive behavior, or directed inwardly, resulting in suicidal behavior. Given the frequency of TBI and posttraumatic aggression and the potential medicolegal questions surrounding the purported causal relationships between the two, forensic psychiatrists need to understand and recognize posttraumatic aggression. They also must be able to offer cogent formulations about the relative contributions of neurotrauma versus other relevant neuropsychiatric factors versus combinations of both to any specific act of violence. This article reviews the relationships between TBI and aggression and discusses neurobiological and cognitive factors that influence the occurrence and presentation of posttraumatic aggression. Thereafter, a heuristic is offered that may assist forensic psychiatrists attempting to characterize the relationships between TBI and externally or internally directed violent acts.
Barnes, S.M., Walter, K.H., & Chard, K.M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD? Rehabilitation Psychology, 57, 18-26.
Objective: Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. Design: The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. Results: Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. Conclusion: This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.
Betthauser LM, Bahraini N, Krengel MH, Brenner LA. Self-Report Measures to Identify Post Traumatic Stress Disorder and/or Mild Traumatic Brain Injury and Associated Symptoms in Military Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). Neuropsychol Rev. 2012 Feb 19.
Individuals serving in Iraq and Afghanistan sustain injuries associated with physical and psychological trauma. Among such injuries, mild traumatic brain injury (mTBI) and post traumatic stress disorder (PTSD) are common. Self-report measures are frequently used to identify mTBI and/or PTSD and symptoms associated with these conditions. In addition to providing information regarding mTBI and PTSD, the goal of this literature review was to identify and present information on the psychometric properties of measures used to obtain information regarding these common conditions among Veterans who have returned from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). A comprehensive review of studies in which self-report measures were used to evaluate mTBI, PTSD, and associated symptoms among OEF/OIF Veterans is presented. Findings suggest that additional work is needed to identify psychometrically sound and clinically useful self-report measures that assess mTBI and PTSD and associated symptoms among OEF/OIF Veterans.
Brenner L, Bahraini N and Hernández TD (2012). Perspectives on creating clinically relevant blast models for mild traumatic brain injury and post traumatic stress disorder symptoms. Front. Neur. 3:31.
Military personnel are returning from Iraq and Afghanistan and reporting non-specific physical (somatic), behavioral, psychological, and cognitive symptoms. Many of these symptoms are frequently associated with mild traumatic brain injury (mTBI) and/or post traumatic stress disorder (PTSD). Despite significant attention and advances in assessment and intervention for these two conditions, challenges persist. To address this, clinically relevant blast models are essential in the full characterization of this type of injury, as well as in the testing and identification of potential treatment strategies. In this publication, existing diagnostic challenges and current treatment practices for mTBI and/or PTSD will be summarized, along with suggestions regarding how what has been learned from existing models of PTSD and traditional mechanism (e.g., non-blast) TBI can be used to facilitate the development of clinically relevant blast models.
Brenner LA, Braden CA, Bates M, Chase T, Hancock C, Harrison-Felix C, Hawley L, Morey C, Newman J, Pretz C, Staniszewski K. A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial. J Head Trauma Rehabil. 2012 Nov;27(6):E57-68.
OBJECTIVES: To assess the efficacy of a standardized 12-week health and wellness group intervention for those with moderate to severe traumatic brain injury (TBI). STUDY DESIGN: Randomized controlled trial. PARTICIPANTS: Seventy-four individuals with moderate to severe TBI recruited from the outpatient program at a rehabilitation hospital, a Veterans Affairs Medical Center, and the community. METHOD: Eligible participants were randomized to treatment (health and wellness therapy group) or wait-list control (treatment, n = 37; wait-list, n = 37). The primary outcome was the Health Promoting Lifestyle Profile-II. RESULTS: The results of the mixed-model repeated-measures analysis indicated no differences between treatment and control groups engaging in activities to increase their health and well-being. CONCLUSIONS: Findings did not support the efficacy of the intervention. Results may have been impacted by the wide variability of individualized health and wellness goals selected by group members, the structure and/or content of the group, and/or the outcome measures selected.
Hart T, Hoffman JM, Pretz C, Kennedy R, Clark AN, Brenner LA. (2012). A Longitudinal Study of Major and Minor Depression Following Traumatic Brain Injury. Archives of Physical Medicine, 93, 1343-9.
OBJECTIVE: To examine patterns of change and factors associated with change in depression, both major (major depressive disorder [MDD]) and minor, between 1 and 2 years after traumatic brain injury (TBI). DESIGN: Observational prospective longitudinal study. SETTING: Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=1089) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patient Health Questionnaire-9. RESULTS: Among participants not depressed at 1 year, close to three fourths remained so at 2-year follow-up. However, 26% developed MDD or minor depression between the first and second years postinjury. Over half of participants with MDD at year 1 also reported MDD the following year, with another 22% reporting minor depression; thus three fourths of those with MDD at year 1 experienced clinically significant symptoms at year 2. Almost one third of those with minor depression at year 1 traversed to MDD at year 2. Polytomous logistic regression confirmed that worse depression at year 1 was associated with higher odds of depression a year later. For those without depression at year 1, symptom worsening over time was related to year 2 problematic substance use and lower FIM motor and cognitive scores. For those with depression at year 1, worsening was associated with lower cognitive FIM, poor social support, and preinjury mental health issues including substance abuse. CONCLUSIONS: Major and minor depression exist on a continuum along which individuals with TBI may traverse over time. Predictors of change differ according to symptom onset. Results highlight importance of long-term monitoring for depression, treating minor as well as major depression, and developing interventions for comorbid depression and substance abuse.
Homaifar, B. Y., Bahraini, N.H., Silverman, M.M., Brenner, L.A.. (2012). Executive Functioning as a Component of Suicide Risk Assessment: Clarifying its Role in Standard Clinical Applications. Journal of Mental Health Counseling, 34(2), 110-120.
Clinically, because executive dysfunction (e.g., impulsivity, insight, thinking process) is often thought of in the context of those with traumatic brain injuries and other neurologic conditions, its formal assessment has historically been seen as the domain of those who assess and treat patients with neurologic disease. However, mental health counselors (MHCs) could benefit from learning how executive functioning relates to suicide risk assessment and coping strategies. Assessment of executive functions can be incorporated in routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. In fact, during standard clinical assessment, mental health professionals often informally assess components of executive functioning such as impulsivity, insight, and thinking processes. This article highlights aspects of executive functioning with which MHCs may already be familiar and demonstrates their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.
Homaifar BY, Brenner LA, Forster JE, Nagamoto H. Traumatic brain injury, executive functioning, and suicidal behavior: A brief report. Rehabil Psychol. 2012 Nov;57(4):337-41.
Objective: The aim of this pilot study was to explore the relationship between executive dysfunction and suicidal behavior in two groups of participants: (Group 1, n = 18) veterans with traumatic brain injury (TBI) and a history of at least one suicide attempt (SA), and (Group 2, n = 29) veterans with TBI and no history of SA. Controlling for the severity of TBI, it was hypothesized that participants in Group 1 would perform more poorly than those in Group 2 on measures of executive functioning. Design: The primary outcome variable was decision making as assessed by performance on the Iowa Gambling Task (IGT). Secondary outcome variables included laboratory-measured impulsivity as measured by the Immediate and Delayed Memory Test (IMT/DMT), abstract reasoning as measured by the Wisconsin Card Sorting Test (WCST), and aggression as measured by the Lifetime History of Aggression (LHA) scale. Results: Among those in Group 1, time between TBI and first suicide attempt postinjury varied widely (months to nearly 30 years). Only the WCST perseverative errors score differed significantly between individuals with and without histories of one or more suicide attempts (SAs). Conclusion: Suggestions for future study of SA among those with TBI are provided. When working with individuals with TBI, clinicians are encouraged to incorporate suicide risk assessment into their practice. Augmenting this process with a measure of perseveration may be beneficial. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Olson-Madden J, Brenner LA, Corrigan JD, Emrick CD, Britton PC. (2012). "Substance Use and Mild Traumatic Brain Injury Risk Reduction and Prevention: A Novel Model for Treatment," Rehabilitation Research and Practice, vol. 2012, Article ID 174579, 6 pages, 2012. doi:10.1155/2012/174579.
Traumatic brain injury (TBI) and substance use disorders (SUDs) frequently co-occur. Individuals with histories of alcohol or other drug use are at greater risk for sustaining TBI, and individuals with TBI frequently misuse substances before and after injury. Further, a growing body of literature supports the relationship between comorbid histories of mild TBI (mTBI) and SUDs and negative outcomes. Alcohol and other drug use are strongly associated with risk taking. Disinhibition, impaired executive function, and/or impulsivity as a result of mTBI also contribute to an individual’s proclivity towards risk-taking. Risk-taking behavior may therefore, be a direct result of SUD and/or history of mTBI, and risky behaviors may predispose individuals for subsequent injury or continued use of substances. Based on these findings, evaluation of risk-taking behavior associated with the co-occurrence of SUD and mTBI should be a standard clinical practice. Interventions aimed at reducing risky behavior among members of this population may assist in decreasing negative outcomes. A novel intervention (Substance Use and Traumatic Brain Injury Risk Reduction and Prevention (STRRP)) for reducing and preventing risky behaviors among individuals with co-occurring mTBI and SUD is presented. Areas for further research are discussed.
Wortzel HS, Arciniegas DB. Treatment of Post-Traumatic Cognitive Impairments. Curr Treat Options Neurol. 2012 Aug 7. [Epub ahead of print]
OPINION STATEMENT: Cognitive impairment is a common consequence of traumatic brain injury (TBI) and a substantial source of disability. Across all levels of TBI severity, attention, processing speed, episodic memory, and executive function are most commonly affected. The differential diagnosis for post-traumatic cognitive impairments is broad, and includes emotional, behavioral, and physical problems as well as substance use disorders, medical conditions, prescribed and self-administered medications, and symptom elaboration. Thorough neuropsychiatric assessment for such problems is a prerequisite to treatments specifically targeting cognitive impairments. First-line treatments for post-traumatic cognitive impairments are nonpharmacologic, including education, realistic expectation setting, environmental and lifestyle modifications, and cognitive rehabilitation. Pharmacotherapies for post-traumatic cognitive impairments include uncompetitive N-methyl-D-aspartate receptor (NMDA) antagonists, medications that directly or indirectly augment cerebral catecholaminergic or acetylcholinergic function, or agents with combinations of these properties. In the immediate post-injury period, treatment with uncompetitive NMDA receptor antagonists reduces duration of unconsciousness. The mechanism for this effect may involve attenuation of neurotrauma-induced glutamate-mediated excitotoxicity and/or stabilization of glutamate signaling in the injured brain. During the subacute or late post-injury periods, medications that augment cerebral acetylcholinergic function may improve declarative memory. Among responders to this treatment, secondary benefits on attention, processing speed, and executive function impairments as well as neuropsychiatric disturbances may be observed. During these post-injury periods, medications that augment cerebral catecholaminergic function may improve hypoarousal, processing speed, attention, and/or executive function as well as comorbid depression or apathy. When medications are used, a "start-low, go-slow, but go" approach is encouraged, coupled with frequent reassessment of benefits and side effects as well as monitoring for drug-drug interactions. Titration to either beneficial effect or medication intolerance should be completed before discontinuing a treatment or augmenting partial responses with additional medications.
Brenner LA. Neuropsychological and neuroimaging findings in traumatic brain injury and post-traumatic stress disorder. Dialogues Clin Neurosci. 2011;13(3):311-23. Review.
Advances in imaging technology, coupled with military personnel returning home from Iraq and Afghanistan with traumatic brain injury (TBI) and/or post-traumatic stress disorder (PTSD), have increased interest in the neuropsychology and neurobiology of these two conditions. There has been a particular focus on differential diagnosis. This paper provides an overviev of findings regarding the neuropsychological and neurobiological underpinnings of TBI and for PTSD. A specific focus is on assessment using neuropsychological measures and imaging techniques. Challenges associated with the assessment of individuals with one or both conditions are also discussed. Although use of neuropsychological and neuroimaging test results may assist with diagnosis and treatment planning, further work is needed to identify objective biomarkers for each condition. Such advances would be expected to facilitate differential diagnosis and implementation of best treatment practices.
History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.
Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2011). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services. Journal of Head Trauma Rehabilitation, 26(4), 257-264.
This manuscript examines associations between a history of traumatic brain injury (TBI) diagnosis and death by suicide among individuals receiving care within the Veterans Health Administration (VHA). Among VHA users, those with a diagnosis of TBI were at greater risk for suicide than those without this diagnosis. Further research is indicated to identify evidence-based means of assessment and treatment for those with TBI and suicidal behavior.
Hart, T., Brenner, L. A., Clark, A. N., Bogner, J. A., Novack, T. A., Chervoneva, I. et al. (2011). Major and minor depression following traumatic brain injury. Archives of Physical Medicine, 92, 1211-1219.
OBJECTIVE: To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation. DESIGN: Observational prospective study with a 2-wave longitudinal component. SETTING: Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale. RESULTS: Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI. CONCLUSIONS: Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups.
McFadden, K. L., Healy, K.M., Dettmann, M. L., Kaye, J. T., Ito, T. A., & Hernández, TD. (2011). Acupressure as a non-pharmacological intervention for traumatic brain injury (TBI). Journal of Neurotrauma, 28, 21-34.
Acupressure is a complementary and alternative medicine (CAM) treatment using fingertips to stimulate acupoints on the skin. Although suggested to improve cognitive function, acupressure has not been previously investigated with a controlled design in traumatic brain injury (TBI) survivors, who could particularly benefit from a non-pharmacological intervention for cognitive impairment. A randomized, placebo-controlled, single-blind design assessed the effects of acupressure (eight treatments over 4 weeks) on cognitive impairment and state of being following TBI, including assessment of event-related potentials (ERPs) during Stroop and auditory oddball tasks. It was hypothesized that active acupressure treatments would confer greater cognitive improvement than placebo treatments, perhaps because of enhanced relaxation response induction and resulting stress reduction. Significant treatment effects were found comparing pre- to post-treatment change between groups. During the Stroop task, the active-treatment group showed greater reduction in both P300 latency (p=0.010, partial η²=0.26) and amplitude (p=0.011, partial η²=0.26), as well as a reduced Stroop effect on accuracy (p=0.008, partial η²=0.21) than did the placebo group. Additionally, the active-treatment group improved more than did the placebo group on the digit span test (p=0.043, Cohen's d=0.68). Together, these results suggest an enhancement in working memory function associated with active treatments. Because acupressure emphasizes self-care and can be taught to novice individuals, it warrants further study as an adjunct treatment for TBI.
Terrio, H. P., Nelson, L. A., Betthauser, L. M., Harwood, J. E., & Brenner, L.A. (2011). Postdeployment traumatic brain injury screening questions: Sensitivity, specificity, and predictive values in returning soldiers. Rehabilitation Psychology, 56(1), 26-31.
OBJECTIVE: To evaluate the sensitivity, specificity, and predictive values of Post-Deployment Health Assessment traumatic brain injury (TBI) screening questions employed by the Department of Defense (DOD). Participants: Complete data was obtained from 3,072 soldiers upon return from a 15-month deployment to Iraq. METHOD: Comparisons were made between responses to the DOD four-item screener and a brief structured clinical interview for likely deployment-related TBI history. The interview process was facilitated using responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT). RESULTS: The sensitivity and specificity of the DOD screening tool (positive response to all four items) in comparison to the clinician-confirmed diagnosis was 60% and 96%, respectively. The sensitivity increased to 80%, with a slight decrease in specificity to 93%, for positive TBI screening when affirmative responses to questions 1 and 2 only were included. CONCLUSIONS: Affirmative responses to questions 1 and 2 of the DOD TBI screening tool demonstrated higher sensitivity for clinician-diagnosed deployment-related TBI. These two items perform better than positive responses to all four questions; the criteria presently being used for documentation and referral of a deployment-related TBI. These findings support further exploration of TBI screening and assessment procedures.
Wagner PJ, Wortzel HS, Frey KL, Anderson CA, Arciniegas DB. (2011) Clock-Drawing Performance Predicts Inpatient Rehabilitation Outcomes After Traumatic Brain Injury. The Journal of Neuropsychiatry and Clinical Neurosciences 2011; 23:449–453
The authors used clock-drawing performance to assess cognition and predict inpatient rehabilitation outcomes among persons with traumatic brain injury. Clock-drawing performance, as assessed with the Clock Drawing Interpretation Scale, predicts rehabilitation length of stay as well as Functional Independence Measure scores at the time of neurobehavioral assessment and rehabilitation discharge.
Wortzel HS, Kraus MF, Filley CM, Anderson CA, Arciniegas DB. Diffusion tensor imaging in mild traumatic brain injury litigation. J Am Acad Psychiatry Law. 2011;39(4):511-23.
A growing body of literature addresses the application of diffusion tensor imaging (DTI) to traumatic brain injury (TBI). Most TBIs are of mild severity, and their diagnosis and prognosis are often challenging. These challenges may be exacerbated in medicolegal contexts, where plaintiffs seek to present objective evidence that supports a clinical diagnosis of mild (m)TBI. Because DTI permits quantification of white matter integrity and because TBI frequently involves white matter injury, DTI represents a conceptually appealing method of demonstrating white matter pathology attributable to mTBI. However, alterations in white matter integrity are not specific to TBI, and their presence does not necessarily confirm a diagnosis of mTBI. Guided by rules of evidence shaped by Daubert v. Merrell Dow Pharmaceuticals, Inc., we reviewed and analyzed the literature describing DTI findings in mTBI and related neuropsychiatric disorders. Based on this review, we suggest that expert testimony regarding DTI findings will seldom be appropriate in legal proceedings focused on mTBI.
INTRODUCTION: There is an urgent need to define the neurobiological and cognitive underpinnings of suicidal ideation and behavior in veterans with traumatic brain injury (TBI). Separate studies implicate frontal white matter systems in the pathophysiology of TBI, suicidality, and impulsivity. We examined the relationship between the integrity of major frontal white matter (WM) systems on measures of impulsivity and suicidality in veterans with TBI. METHODS: Fifteen male veterans with TBI and 17 matched healthy controls (HC) received clinical ratings, measures of impulsivity and MRI scans on a 3T magnet. Diffusion tensor imaging (DTI) data for the genu and cingulum were analyzed using Freesurfer and FSL. Correlations were performed for fractional anisotropy (FA) (DTI) values and measures of suicidality and impulsivity for veterans with TBI. RESULTS: Significantly decreased in FA values in the left cingulum (P = 0.02), and left (P = 0.02) and total genu (P = 0.01) were observed in the TBI group relative to controls. Measures of impulsivity were significantly greater for the TBI group and total and right cingulum FA positively correlated with current suicidal ideation and measures of impulsivity (P <0.03). CONCLUSION: These data demonstrate a significant reduction in FA in frontal WM tracts in veterans with mild TBI that was associated with both impulsivity and suicidality. These findings may reflect a neurobiological vulnerability to suicidal risk related to white matter microstructure.
Arciniegas, D. B., Frey, K. L., Newman, J., & Wortzel HS (2010). Evaluation and management of posttraumatic cognitive impairments. Psychiatric Annals, 40(11), 540-552.
Psychiatrists are increasingly called upon to care for individuals with cognitive, emotional, and behavioral disturbances after TBI, especially in settings serving military service personnel and Veterans. In both the early and late post-injury periods, cognitive impairments contribute to disability among persons with TBI and are potentially substantial sources of suffering for persons with TBI and their families. In this article, the differential diagnosis, evaluation, and management of posttraumatic cognitive complaints is reviewed. The importance of pre-treatment evaluation as well as consideration of non-cognitive contributors to cognitive problems and functional limitations is emphasized first. The course of recovery after TBI, framed as a progression through posttraumatic encephalopathy, is reviewed next and used to anchor the evaluation and treatment of posttraumatic cognitive impairments in relation to injury severity as well as time post-injury. Finally, pharmacologic and rehabilitative interventions that may facilitate cognitive and functional recovery at each stage of posttraumatic encephalopathy are presented.
This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.
Breshears, R. E., Brenner, L. A., Harwood, J. E. F., & Gutierrez, P. M. (2010). Predicting suicidal behavior in Veterans with traumatic brain injury: The utility of the Personality Assessment Inventory. Journal of Personality Assessment, 92,349-355.
In this study, we investigated the Personality Assessment Inventory's (PAI; Morey, 1991, 2007) Suicide Potential Index (SPI) and Suicide Ideation scale (SUI) as predictors of suicidal behavior (SB) in military Veterans with traumatic brain injury (TBI; N = 154). We analyzed electronic medical records were searched for SB in the 2 years post-PAI administration and data via logistic regressions. We obtained statistical support for the SPI and SUI as predictors of SB. Analyses we performed using receiver operating characteristics suggested an optimal SPI cutoff of > or = 15 for this sample. Findings suggest that SPI and SUI scores may assist in assessing suicide risk in those with TBI, particularly when population-based cutoffs are considered.
Olson-Madden, J., Brenner, L.A., Harwood, J. E., Emrick, C. D., Corrigan, J. D., & Thompson, C. (2010). Traumatic brain injury and psychiatric diagnoses in Veterans seeking outpatient substance abuse treatment. Journal of Head Trauma and Rehabilitation, 25(6), 470-479.
OBJECTIVES: Explore the incidence of traumatic brain injury (TBI) in veterans seeking outpatient substance abuse treatment and the association between TBI and psychiatric diagnoses. MAIN MEASURE: The Ohio State University TBI identification method (OSU TBI-ID) was administered to veterans with positive TBI-4 screens; substance-related and psychiatric diagnoses were extracted from the medical record. PARTICIPANTS: : Over an 18-month period, 247 veterans completed the TBI-4. Of the 136 who screened positive, 70 were administered the OSU TBI-ID. RESULTS: On the basis of the TBI-4, 55% (95% CI: 49%-61%) of veterans screened positive for a history of TBI. The OSU TBI-ID was used to confirm screening results. Those who completed the OSU TBI-ID sustained an average of 3.4 lifetime TBIs. For each additional TBI sustained, after initial injury, there was an estimated 9% increase in the number of psychiatric diagnoses documented (99% CI: 1%-17%). For each additional documented psychiatric diagnosis, there was an estimated increase of 11% in the number of injuries sustained (99% CI: 1%-22%). Also, 54% (38/70) had a positive history of TBI prior to adulthood. CONCLUSION: These results emphasize the need for TBI screening in this vulnerable population, as well as the importance of increasing brain injury awareness among those abusing substances and their care providers. These findings also highlight the need for specialized services for those with TBI and co-occurring substance misuse aimed at decreased future TBIs or negative psychiatric outcomes or both. Further study is needed to clarify best practices.
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