Beeta Y. Homaifar

Neuropsychological test performance in soldiers with blast-related mild TBI.

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.

Sensitivity and Specificity of the Beck Depression Inventory-II in Persons With Traumatic Brain Injury

OBJECTIVES Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives. DESIGN This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI. SETTING This study was completed at a Veterans Affairs (VA) Medical Center. PARTICIPANTS Participants were veterans eligible to receive VA health care services. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV). RESULTS We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%). CONCLUSIONS Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.

Prevalence and screening of traumatic brain injury among veterans seeking mental health services.

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.

Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality.

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 patients 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.

A model for therapeutic risk management of the suicidal patient.

While the practice of psychiatry involves many challenges, few scenarios are as clinically and emotionally demanding as managing the patient who is at high risk for suicide. Risk management is a reality of psychiatric practice, and this necessitates practicing and documenting thoughtful suicide risk assessment and management. Therapeutic risk management is based on clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. In this article, the authors present a broad overview of a model for achieving therapeutic risk management of the suicidal patient that involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. These elements are readily accessible to and deployable by mental health clinicians in most disciplines and treatment settings, and they collectively yield a suicide risk assessment and management process (and attendant documentation) that should withstand the scrutiny that often occurs in the wake of a patient suicide or suicide attempt.

Therapeutic risk management of the suicidal patient: safety planning.

This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient.

Description of outpatient utilization and costs in group of veterans with traumatic brain injury

In an attempt to increase understanding regarding the nonacute healthcare needs of veterans with traumatic brain injury (TBI), we examined the outpatient utilization and cost patterns of 72 patients with TBI who were at least 4 years postinjury. We selected participants from a clinical database of veterans receiving care at a western Department of Veterans Affairs (VA) medical center. We extracted data from national utilization databases maintained by the VA and examined data from primary care and internal medicine, psychiatry and substance use, rehabilitation, and other services (e.g., ancillary, diagnostic, prosthetic, dental, nursing home, and home care). We extracted data for fiscal years 2002 to 2007. In addition to descriptive statistics, we modeled visits per year as a function of time since injury. The data show that this sample of patients with TBI consistently used a wide array of outpatient services over time with considerable variation in cost. Further study regarding economic aspects of care for patients with TBI is warranted.

Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments.

This column is the second in a series presenting a model for therapeutic risk management of the suicidal patient. As discussed in the first part of the series, the model involves several elements including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This column explores in more detail how to augment clinical risk assessment with structured instruments. Unstructured clinical interviews have the potential to miss important aspects of suicide risk assessment. By augmenting the free-form clinical interview with structured instruments that demonstrate reliability and validity, a more nuanced and multifaceted approach to suicide risk assessment is achieved. Incorporating structured instruments into practice also serves a medicolegal function, since these instruments may become a living part of the medical record, establishing baseline levels of suicidal thoughts and behaviors and facilitating future clinical determinations regarding safety needs. We describe several instruments used in a multidisciplinary suicide consultation service, each of which has demonstrated relevance to suicide risk assessment and screening, ease of administration, and strong psychometric properties. In addition, we emphasize the importance of viewing suicide risk assessment as an ongoing process rather than as a singular event. Finally, we discuss special considerations in the evolving practice of risk assessment.

Psychiatric hospitalization and veterans with traumatic brain injury: a retrospective study.

ObjectiveTo determine risk factors for psychiatric hospitalization after traumatic brain injury (TBI) in veterans. Subjects and proceduresMedical records of 96 veterans with histories of TBI (17 mild, 33 moderate, and 46 severe) were reviewed for information concerning psychiatric history, including hospitalization and substance misuse. ResultsSubjects with a history of problematic drug and alcohol use had a significantly higher probability of psychiatric hospitalization than those without such a history. Gender, age, problematic alcohol use without problematic drug use, injury severity, time since injury, years of follow-up, and a history of psychiatric symptoms (including those attributed to general medical conditions) were not identified as significant risk factors. Ninety-one veterans (95%) had a history of psychiatric difficulty. In addition, the probability of post-TBI problematic drug and alcohol use, given a pre-TBI history of such use, was significantly higher than the probability given no history. ConclusionsVeterans with problematic drug and alcohol use are at increased risk for psychiatric hospitalization after TBI. In addition, the likelihood of problematic post-TBI drug and alcohol use was significantly greater for those with a preinjury history. Ninety-five percent of veterans in the current sample endorsed lifetime histories of psychiatric difficulty. These findings highlight the need for evidence-based means of psychiatric and/or substance abuse treatment of those with a history of TBI.

Surrogate Endpoints in Suicide Research

Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.