Allison N. Clark

Major and Minor Depression After Traumatic Brain Injury

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.

What Is Community Integration Anyway?: Defining Meaning Following Traumatic Brain Injury

Full community integration, or participation in society, is the ultimate goal of rehabilitation and of research conducted in the field of rehabilitation for persons with traumatic brain injury (TBI). Community integration has been traditionally defined by 3 main areas: employment or other productive activity, independent living, and social activity. However, these have not always received equal weighting and attention in clinical or research efforts. Significant gaps remain in our understanding of factors that impact community integration and in our ability to intervene to improve participation for persons with TBI. This article describes 3 main challenges for researchers and rehabilitation professionals. First, a comprehensive meaning of community integration is needed, which includes the viewpoints and preferences of persons with TBI. Second, cultural competence in measurement and intervention is needed. Third, a thorough assessment of environmental factors impacting participation is needed and should be incorporated into research and treatment planning.

Making connections after brain injury: development and evaluation of a social peer-mentoring program for persons with traumatic brain injury.

Objective:To describe the development and implementation of a social peer-mentoring program for persons with traumaticbrain injury (TBI) and to explore whether this program yielded increased social functioning outcomes compared with wait-list (WL)controls. Design:Pilot randomized controlled study. Participants:Community-dwelling individuals with TBI(12 matched with social peer mentors and 18 completing the WL condition). Intervention:Trained social peer mentors (SPMs)were matched to partners with TBI (peer partners (PP)) to foster skill-building in planning of social activities and improvingsocial communication abilities through phone contacts and joint participation in social events within the community over a 3-monthperiod. Measures:Social Activity Interview, Center for Epidemiological Studies Depression Scale, UCLA Loneliness Scale, Satisfaction with Life Scale, 6-Item Interpersonal Support Evaluation List (baseline and postmentoring); weekly social activity data(1-month baseline, continuously collected during 3-month mentoring or WL period); satisfaction survey. Results:Both SPMand PP participants reported high satisfaction with the mentoring program. Statistically significant improvements in perceived socialsupport after mentoring were observed for the mentored group than for WL participants; however, an increase in depressive symptoms wasalso observed. While significant improvements in social activity level and social network size were not found, a trend toward increasedsatisfaction with social life was present for mentored participants. Conclusions:Satisfaction ratings for the SPM programwere uniformly high and selected positive findings encourage further investigation of social mentoring as an intervention to effectimprovements in social integration. Small sample size and reduced “dosage” of mentor interactions were limitations of thispilot study. Benefits of and challenges to implementation of an SPM program are outlined.

Relationship of race/ethnicity and income to community integration following traumatic brain injury: investigation in a non-rehabilitation trauma sample.

The purpose of the current study was to determine the contribution of race/ethnicity and income to community integration at approximately 6 months following traumatic brain injury (TBI). Participants were 151 persons with mild to severe TBI (38% Black; 38% Hispanic; 24% White) recruited from consecutive admissions to the Neurosurgery service of a county Level I trauma center. A large number of participants had low income and low education. Community integration was assessed using the Community Integration Questionnaire (CIQ), Craig Handicap Assessment and Reporting Technique - Short Form (CHART-SF), and Community Integration Measure (CIM). Results of analysis of covariance (ANCOVA) indicated that, after accounting for injury severity, age, education, and income, race/ethnicity contributed significantly to the variance in CIQ Total score, Home Integration Scale, and Productive Activity Scale scores. Blacks had lower CIQ Total scores compared to Whites. Black and Hispanic participants had lower scores than Whites on the Home Integration Scale, and Blacks had lower scores than Whites and Hispanics on the CIQ Productive Activity Scale. Low income ( < or =

Perceptions of communication abilities for persons with traumatic brain injury: Validity of the La Trobe Communication Questionnaire

20,000) was related to lower scores on the CIQ and CHART-SF Social Integration Scales, and scores on the CIM Total, Belonging, and Independent Participation scales. These results indicate that racial/ethnic differences in community integration exist, even after accounting for income. However, income was more predictive than race/ethnicity for certain aspects of community integration, indicating that it should be accounted for in all studies investigating racial/ethnic differences in outcomes.

Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury

Primary objective: To further evaluate the construct validity of the La Trobe Communication Questionnaire (LCQ) and to investigate the extent to which self-ratings of adults with traumatic brain injury compared to ratings made by close others and self-ratings made by non-injured matched controls. Research design: Prospective cohort study. Methods and procedures: Two hundred and seventy-six adults with TBI (121 of which are >1-year post-injury and previously enrolled in TBI Model Systems and 155 of which were consecutively admitted to a Level 1 trauma centre and were at least 6-months post-injury) completed the La Trobe Communication Questionnaire. In addition, for the TBI Model systems sample, 88 friends/family members and 80 non-injured matched controls participated. Main outcomes and results: Principle components analysis with varimax rotation yielded four factors: Initiation/Conversational Flow, Disinhibition/Impulsivity, Conversational Effectiveness and Partner Sensitivity, which were found to have adequate internal consistency. Adequate discriminative validity was obtained in comparing adults with TBI to non-injured matched controls, while no significant differences were found between self-ratings of communication abilities by adults with TBI and those made by close others. Conclusions: Additional support for the LCQ as a useful measure of perceived social communication abilities was obtained. Confirmatory factor analysis with a larger sample of adults with TBI will be a useful step in further development of this tool.

Predictive ability of preinjury stressful life events and post-traumatic stress symptoms for outcomes following mild traumatic brain injury: analysis in a prospective emergency room sample

OBJECTIVE To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI). DESIGN Inception cohort. SETTING Three TBI Model Systems inpatient rehabilitation facilities. PARTICIPANTS Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique. RESULTS There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration. CONCLUSIONS Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes.

Preinjury coping, emotional functioning, and quality of life following uncomplicated and complicated mild traumatic brain injury

Background A subset of persons with mild traumatic brain injury (mTBI) experience long-term difficulties. Preinjury stress has been hypothesised to play a role in long-term maintenance of symptoms. Objective To investigate the predictive ability of preinjury stressful life events and post-traumatic stress symptoms to health-related quality of life and emotional distress after mTBI. Methods Within 2 weeks of injury, 186 participants with mTBI who were admitted to an emergency centre completed an interview and questionnaires regarding preinjury functioning, including the Stressful Life Events Questionnaire and the Post-Traumatic Stress Disorder Checklist. Outcomes were assessed at 3 months after injury and included the depression and anxiety subscales of the Brief Symptom Inventory, and the physical and mental component scores of the 36-item Short-Form Health Survey (SF-36). The incidence and type of stressful life events were reported. Hierarchical regression analyses were used to determine the predictive utility of Stressful Life Events Questionnaire and Post-Traumatic Stress Disorder Checklist after controlling for age, injury severity (complicated versus uncomplicated mild) and preinjury depression. Results Several potentially life-altering stressful events were endorsed by at least 25% of participants as having been experienced prior to injury. The incidence of stressful life events was a significant predictor of all four outcome variables. History of post-traumatic stress symptoms was predictive of scores on the SF-36 mental health component. Conclusions A history of stressful events may predispose persons with mTBI to have poor outcomes. History of stress should be assessed during the early stages after mTBI to help identify those who could benefit from therapies to assist with adjustment and maximise recovery.

Prognostic Importance of Self-Reported Traits/Problems/Strengths and Environmental Barriers/Facilitators for Predicting Participation Outcomes in Persons With Traumatic Brain Injury: A Systematic Review

Objective:To identify preinjury coping profiles among adults with uncomplicated mild traumatic brain injury (mTBI) and complicated mTBI and to determine whether preinjury coping profiles contribute to the prediction of emotional functioning and quality of life (QOL) 3 months post-mTBI. Participants:One hundred eighty-seven persons with medically documented mTBI (uncomplicated mTBI, n = 89; complicated mTBI, n = 98) were recruited from the emergency center of a level I trauma center and followed in community 3 months post-mTBI. Measures:The Ways of Coping Questionnaire was administered within 2 weeks of injury. Cluster analysis was used to group participants on basis of their preinjury use of problem-focused and avoidant coping strategies. The Brief Symptom Inventory and the 36-item Short-Form Health Survey were administered 3 months postinjury. Results:Cluster analysis distinguished 3 distinct preinjury coping profiles that were differentially associated with outcomes. Participants who used avoidant coping showed the worse emotional functioning and QOL outcomes, although this cluster also reported high usage of problem-focused strategies. Preinjury coping profiles explained a significant proportion of the variance in depression, anxiety, and mental health QOL at 3 months postinjury beyond that accounted for by demographic characteristics and mTBI severity. Conclusions:Cluster analysis holds practical value in illustrating the pattern of coping strategies used by person with uncomplicated and complicated mTBI. It appears worthwhile to address coping in future trials of interventions that are aimed at improving emotional functioning after mTBI.

Sex-Based Differences in Perceived Pragmatic Communication Ability of Adults With Traumatic Brain Injury

OBJECTIVE To conduct a systematic review of the prognostic value of self-reported traits/problems/strengths and environmental barriers/facilitators for participation outcomes in persons with traumatic brain injury (TBI). DATA SOURCES Articles published through August 15, 2013, obtained by conducting electronic searches of PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature databases and a review of reference lists of reviewed articles. STUDY SELECTION Reviewed articles were written in English and presented findings on adult humans with TBI, participation outcomes, and ≥ 1 self-reported trait/problem/strength (eg, depression, pain, coping style) and/or ≥ 1 environment barrier/facilitator (eg, social support, family functioning, access to services). DATA EXTRACTION Each of the 996 abstracts was examined by 2 reviewers, and those failing to meet all inclusion criteria were excluded. Data were extracted from the 63 retained articles by 2 independent reviewers, who met to resolve any differences in study quality rating or evidence recorded. Study quality was determined using American Academy of Neurology (AAN) criteria. DATA SYNTHESIS Conclusions regarding prognostic importance of self-report and environmental barrier/facilitator variables were made using AAN criteria. Conclusions regarding barrier/facilitator variables indicated that access to transportation, access to services, and participation in social interaction were possibly predictive of employment outcome, whereas living arrangements and social support were possibly not predictive of employment outcome. Conclusions regarding self-report variables indicated that the number of postconcussive symptoms, fatigue, and physical competence were probably predictive of employment and need for supervision, whereas self-efficacy was probably not predictive of employment. Subjective well-being, pain, and social interaction were possibly predictive of employment, whereas coping style was possibly not predictive. CONCLUSIONS Although additional investigation is needed, self-report variables are likely to make important contributions to predicting participation outcomes. Future research should be guided by coherent conceptual models and use a consistent set of assessment instruments to facilitate comparisons between studies.