Rocky Mountain MIRECC for Veteran Suicide Prevention - MIRECC / CoE
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Rocky Mountain MIRECC for Veteran Suicide Prevention

Rocky Mountain MIRECC for Veteran Suicide Prevention

Updated: 20 May 2019


Lisa A. Brenner PhD ABPPLisa A. Brenner PhD ABPP
Director, VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC)
Accepting Fellowship Applications for 2019-2021 years
Clinical Interest:
Suicide, Traumatic Brain Injury, and Co-morbid Psychiatric Disorders
Year of Licensure: 1999
Accepting fellowship applications for the 2019-2021 years
Lisa A. Brenner. Ph.D. is a Board Certified Rehabilitation Psychologist, and a Professor of Psychiatry, Neurology, and Physical Medicine and Rehabilitation (PM&R) at the University of Colorado, Anschutz School of Medicine, and the Director of the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC). She is the Research Director for the Department of PM&R. Dr. Brenner is also a Fellow of the American Psychological Association, Division 22, Rehabilitation Psychology. Her primary area of research interest is traumatic brain injury, co-morbid psychiatric disorders, and negative psychiatric outcomes including suicide. She serves as the Research Division Director for the American Association of Suicidology, and an Associate Editor of the Journal of Head Trauma Rehabilitation. Dr. Brenner has numerous peer-reviewed publications, participates on national advisory boards, and is currently co-authoring a book regarding neurodisability and suicide.
Examples of grant funded projects include: A Brief Intervention to Reduce Suicide Risk in Military Members and Veterans (U.S. Army Medical Research and Materiel Command Military Operational Medicine Research Program), Window to Hope: Evaluating a Psychology Treatment for Hopelessness Among Veterans with Traumatic Brain Injury (Military Suicide Research Consortium), and Health and Wellness Intervention for Individuals with TBI (National Institute on Disability and Rehabilitation Research).

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Recent Publications

Brostow DP, Gunzburger E, Abbate LM, Brenner LA, Thomas KS. Mental Illness, Not Obesity Status, is Associated with Food Insecurity Among the Elderly in the Health and Retirement Study. J Nutr Gerontol Geriatr. 2019 Feb 22:1-24. doi: 10.1080/21551197.2019.1565901. [Epub ahead of print] PubMed PMID: 30794096.
OBJECTIVES: Food insecurity, limited or uncertain access to adequate nutrition, is an increasingly recognized determinant of health outcomes and is often associated with having obesity. It is unclear, however, if this association persists in elderly populations. METHODS: We conducted a cross-sectional study of 2868 participants' aged 65+ years from the Health and Retirement Study. Multivariate logistic regression was used to assess associations between food insecurity and body mass index, demographic characteristics, psychiatric history, and medical history. RESULTS: Participants with overweight/obesity had a higher prevalence of food insecurity than leaner counterparts, however, weight status was not a significant predictor of food insecurity after multivariate adjustment. Instead, mental illness, current smoking status, and non-White race were all independently associated with food insecurity. DISCUSSION: Beyond financial status, health care providers are encouraged to use these characteristics to identify elderly patients that may be at risk of food insecurity. KEYWORDS: Depression; elderly; food insecurity; mental health; obesity
Brenner LA, Bahraini NH. Concussion and risk of suicide: who, when and under what circumstances? Nat Rev Neurol. 2019 Mar;15(3):132-133. doi: 10.1038/s41582-019-0136-x. PubMed PMID: 30696951.
A new analysis has found that concussion and mild traumatic brain injury (mTBI) are linked to an increased risk of suicidal behaviours and thoughts. However, a host of risk factors might influence this correlation, and careful investigation is required to establish which individuals with mTBI might be most at risk of suicide.
Trajectory of Postconcussive Symptoms 12-Months Post-Deployment in Soldiers with and without Mild Traumatic Brain Injury - Warrior STRONG Study
6 December 2018 - RMIRECC Director Dr. Lisa Brenner worked on this Warrior STRONG study that found, "The prevalence of clinically relevant postconcussive symptoms remained relatively constant over one year of follow-up, whether or not symptoms were associated with concussion. Service members with recent mTBI reported more symptoms than non-mTBI at all time-points." Read more.
A Clinical Evidence-Based Approach to Examine the Effects of mTBI and PTSD Symptoms on ANAM Performance in Recently Deployed Active Duty Soldiers: Results From the Warrior Strong Study
9 March 2018 - Drs. Lisa Betthauser and Lisa Brenner participated in this publication in the Journal of Head Trauma Rehabilitation. The article looks to establish a baseline of how soldiers with mTBI and/or PTSD Symptoms perform a certain standardized test, the ANAM4. The study "results illustrate that a combination of mTBI and PTS is associated with worse ANAM4 performance than either condition alone." Read more
A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers
27 February 2018 - Drs. Brenner and Gutierrez participated in this randomized controlled trial known as "Operation Worth Living" (OWL). The study sought to compare the treatment use of Collaborative Assessment and Management of Suicidality (CAMS) to enhanced care as usual (E-CAU) in the reduction of both suicidal ideation and suicide attempts in US Army Soldiers. From the abstract, "Conclusions: Soldiers receiving CAMS and E-CAU significantly improved post-treatment. Those who received CAMS were less likely to report SI at 3 months; further group differences were not otherwise seen." Read more.
Persistent Symptoms and Objectively Measured Balance Performance Among OEF/OIF Veterans With Remote Mild Traumatic Brain Injury
27 February 2018 - RMIRECC authors Jeri Forster PhD, Kelly Stearns-Yoder MA, and Lisa Brenner PhD participated in writing this paper along with colleagues from the University of Colorado School of Medicine, Physical Medicine and Rehabilitation Department. This study explored the relationships between dizziness, fatigue, and depression and PTSD and balance in Veterans with mTBI. "Findings suggest that dizziness, fatigue, depression and PTSD, and time since most recent mTBI may influence balance performance." Read more
Dorsey Holliman, B., Monteith, L.L., Spitzer, E.G., & Brenner, L.A. (2018). Resiliency, cultural beliefs and practices that mitigate suicide risk among African American female veterans. SAGE Open. Advance online publication. doi:10.1177/2158244017753506
To our knowledge, no studies have examined protective factors for suicide among African American women Veterans. We conducted a qualitative study to identify and describe cultural beliefs and practices that mitigate suicide risk among African American women Veterans. Our sample included 16 African American women Veterans (M age = 53.3) eligible to receive Veterans Health Administration care. The following three themes emerged as being protective against suicide: (a) resilience, (b) social support, and (c) religion. Women described developing resilience from exposure to adversity. Social support primarily entailed informal assistance from family and friends. Finally, religion comprised three subthemes: faith in God, personal practices, and religious beliefs. Results underscore the importance of specific cultural beliefs and practices as being protective against suicide among African American women Veterans. Keywords women Veterans, African American, suicide, culture, resilience, qualitative
Brenner LA, Stearns-Yoder KA, Hoffberg AS, Penzenik ME, Starosta AJ, Hernández TD, Hadidi DA, Lowry CA. Growing literature but limited evidence: A systematic review regarding prebiotic and probiotic interventions for those with traumatic brain injury and/or posttraumatic stress disorder. Brain Behav Immun. 2017 Jun 9. pii: S0889-1591(17)30192-7. doi: 10.1016/j.bbi.2017.06.003.
Traumatic brain injury (TBI) is highly prevalent among a wide range of populations, including civilians, military personnel, and Veterans. TBI sequelae may be further exacerbated by symptoms associated with frequently occurring comorbid psychiatric conditions, including posttraumatic stress disorder (PTSD). This is particularly true among the population of military personnel from recent conflicts in Iraq and Afghanistan, with a history of mild TBI (mTBI) and PTSD. The need for efficacious treatments for TBI and comorbid PTSD is significant, and evidence-based interventions for these frequently co-occurring conditions are limited. Based on findings suggesting that inflammation may be an underlying mechanism of both conditions, anti-inflammatory/immunoregulatory agents, including probiotics, may represent a novel strategy to treat TBI and/or PTSD-related symptoms. The focus of this systematic review was to identify and evaluate existing research regarding prebiotic and probiotic interventions for the populations of individuals with a history of TBI and/or PTSD. Only 4 studies were identified (3 severe TBI, 1 PTSD, 0 co-occurring TBI and PTSD). Although findings suggested some promise, work in this area is nascent and results to date do not support some claims within the extensive coverage of probiotics in the popular press. Published by Elsevier Inc.
KEYWORDS: Bifidobacteria; Lactobacilli; PTSD; Persistent post-concussive symptoms; Posttraumatic stress disorder; Prebiotic; Probiotic; Synbiotic; Systematic review; TBI; Traumatic brain injury
Bahraini, N.H., Monteith, L.L., Gerber, H.R., Forster, J.E., Hostetter, T.A., & Brenner, L.A. (2017). The Association Between Posttraumatic Stress Disorder and Perceptions of Deployment-Related Injury in Veterans With and Without Mild Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. doi: 10.1097/HTR.0000000000000307.
OBJECTIVES: To examine whether the association between posttraumatic stress disorder (PTSD) and injury perceptions (ie, consequences, emotional representations, and coherence) differs for Veterans with mild traumatic brain injury (mTBI) compared with Veterans with non-TBI (ie, orthopedic). PARTICIPANTS: Eighty Veterans injured during post-9/11 deployments. DESIGN: Observational, 2×2 factorial design. MAIN MEASURES: Injury histories ascertained using the Ohio State University TBI-Identification Method and Deployment Injury Questionnaire; Injury Perception Questionnaire-Revised (injury perceptions); Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (PTSD diagnosis); and PTSD Symptom Checklist-Civilian Version (PTSD symptoms). RESULTS: The association between PTSD diagnosis and injury perceptions did not differ between Veterans with mTBI and those with non-TBIs, adjusting for age, subjective pain, and depressive symptoms. PTSD symptom severity was significantly associated with injury consequences (P < .0001) and emotional representations (P < .0001), irrespective of injury type (mTBI vs non-TBI). Only injury coherence was associated with a significant interaction between PTSD symptom severity and mTBI (P = .04). CONCLUSION: PTSD symptom severity influences perceptions about mTBI and non-TBIs sustained during deployment. Altering injury perceptions may be an important treatment target for Veterans with co-occurring PTSD and deployment-related injuries.
Bahraini NH, Breshears RE, Hernández TD, Schneider AL, Forster JE, Brenner LA. Traumatic Brain Injury and Posttraumatic Stress Disorder. Psychiatr Clin North Am. 2014 Mar;37(1):55-75.
Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI. Published by Elsevier Inc.
PubMed Keywords: Brain injury, Evaluation, Imaging, Pathophysiology, Posttraumatic stress, Treatment
Bahraini NH, Devore MD, Monteith LL, Forster JE, Benseng S, Brenner LA. (2013). The role of value importance and success in understanding suicidal ideation among Veterans. Journal of Contextual Behavioral Science. Volume 2, Issues 1–2, 15 April 2013, Pages 31–38
mountainsRecent studies highlight the need for increased understanding of risk and protective factors for suicidal thoughts and behaviors among Veterans. Although personal values have been studied in regard to psychological well-being, the degree to which suicidal ideation relates to difficulties successfully living according to one's values or identifying values that are important has yet to be examined in civilian or Veteran populations. One hundred and twenty-two Veterans at an urban medical center completed the Survey of Life Principles (SLP; Ciarrochi & Bailey, 2008), a measure of personal values across several life domains, and the Beck Scale for Suicidal Ideation (BSS; Beck & Steer, 1993). Electronic medical records were reviewed to obtain medical histories. As hypothesized, both the ability to identify values and engage in behavior consistent with values were associated with decreased odds of reporting suicidal ideation, controlling for past suicidal behavior, history of mental health treatment, and psychiatric co-morbidity. Findings suggest that the role of different value dimensions as potential protective factors for suicidal ideation in the Veteran population may warrant further exploration.
Keywords: Suicide Prevention
Brenner LA, Bahraini N, Homaifar BY, Monteith LL, Nagamoto H, Dorsey-Holliman B, Forster JE. Executive Functioning and Suicidal Behavior Among Veterans With and Without a History of Traumatic Brain Injury. Arch Phys Med Rehabil. 2015 Aug;96(8):1411-8. doi: 10.1016/j.apmr.2015.04.010.
OBJECTIVE: To examine the relationship between executive dysfunction, as a multidimensional construct (ie, decision-making, impulsivity, aggression, concept formation), and suicide attempt (SA) history in a high-risk sample of veterans with moderate to severe traumatic brain injury (TBI). DESIGN: Observational, 2×2 factorial design. To estimate group differences, linear regression was used to model the primary and secondary outcomes of interest as a function of history of SA, TBI, and the interaction between the 2 variables. Additionally, to determine the pattern of performance over the course of the Iowa Gambling Test (IGT), scores were modeled across the 5 IGT blocks by using a varying-coefficient model. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans (N=133; no SA/no TBI, n=48; no SA/yes TBI, n=51; yes SA/no TBI, n=12; yes SA/yes TBI, n=22) completed the study measures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: IGT, Immediate and Delayed Memory Test, State-Trait Anger Expression Inventory-2, Wisconsin Card Sorting Test. RESULTS: All groups demonstrated learning over the course of the IGT, except for veterans with a history of both SA and TBI. No group differences were identified on other measures of executive functioning. CONCLUSIONS: These findings highlight the potential, unique decision-making challenges faced by veterans with a history of TBI and SA. Specialized interventions focused on overall distress reduction and means restriction may be required to prevent future self-directed violence. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Full text is available
Keywords: Brain injuries; Rehabilitation; Suicide; Veterans
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.
Keywords: Traumatic Brain Injury (TBI)
Brenner LA, Homaifar BY, Olson-Madden JH, Nagamoto HT, Huggins J, Schneider AL, Forster JE, Matarazzo B, Corrigan JD. Prevalence and Screening of Traumatic Brain Injury Among Veterans Seeking Mental Health Services. J Head Trauma Rehabil. 2013 Jan;28(1):21-30.
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.
Keywords: Assessment, Suicide Prevention, Traumatic Brain Injury (TBI)
Fogleman ND, Naaz F, Knight LK, Stoica T, Patton SC, Olson-Madden JH, Barnhart MC, Hostetter TA, Forster J, Brenner LA, Banich MT, Depue BE. Reduced lateral prefrontal cortical volume is associated with performance on the modified Iowa Gambling Task: A surface based morphometric analysis of previously deployed veterans. Psychiatry Res. 2017 Jun 28;267:1-8. doi: 10.1016/j.pscychresns.2017.06.014.
Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are two of the most common consequences of combat deployment. Estimates of comorbidity of PTSD and mTBI are as high as 42% in combat exposed Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND) Veterans. Combat deployed Veterans with PTSD and/or mTBI exhibit deficits in classic executive function (EF) tasks. Similarly, the extant neuroimaging literature consistently indicates abnormalities of the ventromedial prefrontal cortex (vmPFC) and amygdala/hippocampal complex in these individuals. While studies examining deficits in classical EF constructs and aberrant neural circuitry have been widely replicated, it is surprising that little research examining reward processing and decision-making has been conducted in these individuals, specifically, because the vmPFC has long been implicated in underlying such processes. Therefore, the current study employed the modified Iowa Gambling Task (mIGT) and structural neuroimaging to assess whether behavioral measures related to reward processing and decision-making were compromised and related to cortical morphometric features of OEF/OIF/OND Veterans with PTSD, mTBI, or co-occurring PTSD/mTBI. Results indicated that gray matter morphometry in the lateral prefrontal cortex (lPFC) predicted performance on the mIGT among all three groups and was significantly reduced, as compared to the control group. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.
KEYWORDS: Anatomy; Magnetic resonance imaging (MRI); Mild traumatic brain injury (mTBI); Modified Iowa Gambling Task (mIGT); Post-traumatic stress disorder (PTSD); Veterans
Gutierrez, P. M., Brenner, L. A., Rings, J. A., Devore, M. D., Kelly, P. J., Staves, P. J., Kelly, C. M., & Kaplan, M. S. (2013). A qualitative description of female veterans’ deployment-related experiences and potential suicide risk factors. Journal of Clinical Psychology, 69, 923-935.
OBJECTIVE: A qualitative study among female Veterans from recent conflicts was conducted to explore the women's experiences and potential suicide risk factors according to the Interpersonal Psychological Theory of Suicide, including burdensomeness, failed belongingness, and acquired ability. METHODS: The presented paper is an extension of published work by Brenner et al. (2008) regarding mostly male combat Veterans. The methodology employed was qualitative descriptive with hermeneutic hues (Sandelowski, 2000). Interviews were conducted with 19 women, aged 24-52 years, all of whom had been deployed to combat zones in Iraq and/or Afghanistan. RESULTS: Transcripts were reviewed and themes emerged regarding women being a minority within their environment and deployment-related stressors. These experiences seemed to influence participants' views of the world and ways of coping. CONCLUSIONS: Among the interviewed female Veterans, preliminary support was provided for Joiner's concepts. Therapeutic strategies for applying themes to clinical practice (e.g., peer support, family therapy, interventions aimed at increasing distress tolerance) are provided. © 2013 Wiley Periodicals, Inc.
Keywords: Gender Specific Care, Suicide Prevention
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Matarazzo, B. B., Clemans, T. A., Silverman, M. M., & Brenner, L. A. (2013). The Self-Directed Violence Classification System and the Columbia Classification Algorithm for Suicide Assessment: A crosswalk. Suicide and Life-Threatening Behavior, 43, 235-249.
The lack of a standardized nomenclature for suicide-related thoughts and behaviors prompted the Centers for Disease Control and Prevention, with the Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center, to create the Self-Directed Violence Classification System (SDVCS). SDVCS has been adopted by the Department of Veterans Affairs and the Department of Defense. Another classification system, the Columbia Classification Algorithm for Suicide Assessment, has been recommended by the Food and Drug Administration. To facilitate the use of both systems, this article provides a "crosswalk" between the two classification systems.
Keywords: Suicide Prevention
Matarazzo BB, Hoffberg AS, Clemans TA, Signoracci GM, Simpson GK, Brenner LA. Cross-cultural adaptation of the Window to Hope: A psychological intervention to reduce hopelessness among US Veterans with traumatic brain injury. Brain Inj. 2014 Jun 19:1-10.
Abstract Primary objective: To conduct a cross-cultural adaptation of Window to Hope (WtoH), a treatment to reduce hopelessness after traumatic brain injury (TBI), from the Australian civilian context to that of US Veterans. Research design: Three-stage mixed-methods approach. Methods: Stage 1: Consensus conference with stakeholders to revise the manual. Stage 2: Pilot study of the revised manual with US Veterans to examine acceptability, feasibility and fidelity. Stage 3: Review of results with consensus conference attendees and further revisions. Results: Stage 1: Conference attendees reached 100% consensus regarding changes made to the manual. Stage 2: Qualitative results yielded themes that suggest that participants benefitted from the intervention and that multiple factors contributed to successful implementation (Narrative Evaluation of Intervention Interview, User Feedback Survey-Modified, Post-Treatment Interviews). Therapists achieved 100% treatment fidelity. Quantitative results from the Client Satisfaction Questionnaire-8 suggest that the intervention was acceptable. Stage 3: The culturally adapted manual was finalized. Conclusions: Results of this study suggest that the revised WtoH manual is acceptable and feasible. US therapists exhibited adherence to the protocol. The three-stage methodology was successfully employed to cross-culturally adapt an intervention that is well-suited for a Phase II randomized controlled trial among US military Veterans.
Pubmed Keywords: Cognitive behaviour therapy; mental health; suicide prevention
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.
Keywords: Assessment, OEF/OIF/OND, Traumatic Brain Injury (TBI)
Olson-Madden JH, Homaifar BY, Hostetter T, Matarazzo BB, Huggins J, Forster JE, Schneider AL, Nagamoto HT, Corrigan JD, Brenner LA. Validating the Traumatic Brain Injury-4 (TBI-4) Screening Measure for Veterans Seeking Mental Health Treatment with Psychiatric Inpatient and Outpatient Service Utilization Data. Arch Phys Med Rehabil. 2014 Jan 27.
OBJECTIVE: To determine whether a positive screen on the Traumatic Brain Injury-4 (TBI-4) can identify Veterans who utilize more inpatient and outpatient mental health services. Two criteria to identify a positive screen were evaluated. DESIGN: Validation cohort. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Individual seeking Veterans Health Administration mental health services (N=1,493). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One year of inpatient and outpatient mental health utilization data following the TBI-4 screen date. RESULTS: In the year post-mental health intake, those who answered positively to any of the four TBI-4 screening questions (Criterion 1) or Question 2 (Criterion 2; ever being "knocked out") had significantly more psychiatric hospitalizations compared to those who met neither criterion. Those who were positive by Criterion 2 also had significantly fewer outpatient mental health contacts. CONCLUSIONS: Veterans screening positive for history of TBI on the TBI-4 had more hospital stays in the year post-mental health intake. Those who reported having been "knocked out", also had fewer outpatient mental health visits. These findings may suggest an overall relationship in this population between greater needs for mental health care and likelihood of prior injury. For those with a history of loss of consciousness, the reduced use of outpatient care may reflect greater problems engaging in treatment or with preventive aspects of the healthcare system, when they are not in crisis. Using a screener such as the TBI-4 could facilitate identification of Veterans who might benefit from targeted and intensive outpatient interventions to avoid frequent inpatient psychiatric hospitalization. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PubMed Keywords: (CDW), (CPT), (TBI), (TBI-4), (TBI-ID), (VAMC), (VHA), Corporate Data Warehouse, Current Procedural Terminology, Traumatic Brian Injury-Identification, Traumatic brain injury, Veterans Administration Medical Center, Veterans Health Administration, hospitalization, mental health, the Traumatic Brain Injury-4, traumatic brain injury, utilization
O'Neil ME, Carlson KF, Storzbach D, Brenner LA, Freeman M, Quiñones AR, Motu'apuaka M, Kansagara D. Factors Associated with Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. J Int Neuropsychol Soc. 2014 Feb 5:1-13.
A history of mild traumatic brain injury (mTBI) is common among military members who served in Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). We completed a systematic review to describe the cognitive, mental health, physical health, functional, social, and cost consequences of mTBI in Veteran and military personnel. Of 2668 reviewed abstracts, the 31 included studies provided very low strength evidence for the questions of interest. Cognitive, physical, and mental health symptoms were commonly reported by Veterans/military members with a history of mTBI. On average, these symptoms were not significantly more common in those with a history of mTBI than in those without, although a lack of significant mean differences does not preclude the possibility that some individuals could experience substantial effects related to mTBI history. Evidence of potential risk or protective factors moderating mTBI outcomes was unclear. Although the overall strength of evidence is very low due to methodological limitations of included studies, our findings are consistent with civilian studies. Appropriate re-integration services are needed to address common comorbid conditions, such as treatment for post-traumatic stress disorder, substance use disorders, headaches, and other difficulties that Veterans and members of the military may experience after deployment regardless of mTBI history. (JINS, 2014, 20, 1-13).
Keywords: Suicide Prevention
Raheja UK, Fuchs D, Giegling I, Brenner LA, Rovner SF, Mohyuddin I, Weghuber D, Mangge H, Rujescu D, Postolache TT. In psychiatrically healthy individuals, overweight women but not men have lower tryptophan levels. Pteridines. 2015 Jun;26(2):79-84.
Gender differences in tryptophan (TRP) breakdown in obese individuals have been previously reported. This could be both contributory to, as well as a consequence of, gender differences in mood changes among obese people. To exclude the potential effect of depression on TRP breakdown and its levels in obesity, we replicated analyses in psychiatrically healthy individuals. In 1000 participants, plasma kynurenine (KYN), TRP, and the KYN/TRP ratio were compared between overweight/obese and normal-weight individuals using analysis of covariance, with adjustment for age and gender. Bivariate post hoc tests were also conducted. There were no significant relationships between KYN, TRP, or the KYN/TRP ratio and overall overweight/obese status. However, a significant gender by weight category interaction was identified for TRP only, with overweight/obese women having lower TRP than overweight/obese men (p = 0.02). No gender differences in TRP were found in non-obese participants. Our study in psychiatrically healthy individuals suggested that lower TRP levels in obese women were not secondary to depression, strengthening the possibility that TRP levels could mediate depression in vulnerable women. Thus experimental manipulations of TRP levels could be used to advance theoretical knowledge, prevention, and clinical control of depression in obese women.
Keywords: gender differences; obesity; tryptophan; women
Russell LM, Devore MD, Barnes SM, Forster JE, Hostetter TA, Montgomery AE, Casey R, Kane V, Brenner LA. Challenges associated with screening for traumatic brain injury among US veterans seeking homeless services. Am J Public Health. 2013 Dec;103 Suppl 2:S211-2. doi: 10.2105/AJPH.2013.301485. Epub 2013 Oct 22.
We identified the prevalence of traumatic brain injury (TBI) among homeless veterans and assessed the TBI-4, a screening tool created to identify TBI history. Between May 2010 and October 2011, 800 US veterans from two hospitals, one eastern (n = 122) and one western (n = 678) completed some or all measures. Findings suggested that 47% of veterans seeking homeless services had a probable history of TBI (data for prevalence obtained only at the western hospital). However, psychometric results from the screening measure suggested that this may be an underestimate and supported comprehensive assessment of TBI in this population.
Keywords: Traumatic Brain Injury (TBI)
Vanderploeg RD, Nazem S, Brenner LA, Belanger HG, Donnell AJ, Scott SG. Suicidal Ideation among Florida National Guard Members: Combat Deployment and Non-Deployment Risk and Protective Factors. Arch Suicide Res. 2014 Dec 17. [Epub ahead of print]
Objectives: This study examined relationships among risk/protective factors and suicidal ideation (SI) in deployed and non-deployed National Guard members, particularly examining for possible differential effects of deployment on SI. Methods: 3,098 Florida National Guard members completed an anonymous online survey that assessed variables associated with SI including demographics, current psychiatric diagnoses, and pre, during, and post-deployment experiences. Results: Those deployed had significantly higher rates of SI (5.5%) than those not deployed (3.0%; p < .001). In multivariate analyses, among those not deployed, SI was significantly associated with major depressive disorder (p <.001), posttraumatic stress disorder (PTSD) (p <.001), prior psychological trauma (p <.01), and heavy/hazardous alcohol consumption (p < .05). In contrast, in the deployed, only PTSD (p <.001) and deployment-related mild traumatic brain injury (p < .05) were independently associated with SI. Conclusions: Risk and protective factors differed by deployment status in National Guard members suggesting the possible need for cohort-specific treatment targets to minimize SI.
Keywords: PTSD; blast injury; deployment; mental disorders; military personnel; suicidal ideation; traumatic brain injury; suicide prevention
Wortzel HS, Brenner LA, Arciniegas DB. Traumatic Brain Injury and Chronic Traumatic Encephalopathy: A Forensic Neuropsychiatric Perspective. Behav Sci Law. 2013 Sep 9.
Recent scientific reports and popular press describing chronic traumatic encephalopathy (CTE) collectively link this condition to a broad array of neuropsychiatric symptoms, including extremely rare and multi-determined behaviors such as murder-suicide. These reports are difficult to reconcile with several decades of research on the science of traumatic brain injury (TBI) and its consequences, especially the natural history and prognosis of mild TBI. This article attempts to reconcile these sources by reviewing the state of the science on CTE, with particular attention to case definitions and neuropathological criteria for this diagnosis. The evidence for links between TBI, CTE, and catastrophic clinical events is explored, and the complexity of attributing rare frequency behavioral events to CTE is highlighted. The clinical and medicolegal implications of the best available evidence are discussed, concluding with a cautionary note against prematurely generalizing current findings on CTE to entire populations of persons with, or at risk for, concussion exposures. Copyright © 2013 John Wiley & Sons, Ltd.
Keywords: Traumatic Brain Injury (TBI)
Wortzel HS, Homaifar B, Matarazzo B, Brenner LA. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014 Jan;20(1):63-7.
This column is the third in a series describing a model for therapeutic risk management of the suicidal patient. In the preceding column, we described augmenting clinical suicide risk assessment with structured instruments. In this column, we describe how clinicians can use the totality of available clinical data to offer a two-dimensional risk stratification that qualifies risk in terms of both severity and temporality. By offering two separate designations that reflect severity for both acute and chronic risk, conceptualizing and communicating a patient's risk for suicide is accomplished in a more nuanced way, providing the level of detail necessary when working with high risk individuals, especially those struggling with chronic suicidal ideation. Formulations reflecting suicide risk need to be accurate and facilitate good clinical decision-making in order to optimally balance the principles of autonomy, non-maleficence, and beneficence. Stratifying risk in terms of both severity and temporality helps identify situations in which involuntary hospitalization is warranted, while also helping to minimize unnecessary admissions. Hence, two-dimensional risk stratification that addresses both acute and chronic risk for suicide is an essential component of therapeutic risk management of the suicidal patient.
Keywords: Suicide Prevention

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