Durga Roy

Head injury serum markers for assessing response to trauma: Design of the HeadSMART study

ABSTRACT Background: Accurate diagnosis and risk stratification of traumatic brain injury (TBI) at time of presentation remains a clinical challenge. The Head Injury Serum Markers for Assessing Response to Trauma study (HeadSMART) aims to examine blood-based biomarkers for diagnosing and determining prognosis in TBI. Methods: HeadSMART is a 6-month prospective cohort study comparing emergency department patients evaluated for TBI (exposure group) to (1) emergency department patients evaluated for traumatic injury without head trauma and (2) healthy persons. Study methods and characteristics of the first 300 exposure participants are discussed. Results: Of the first 300 participants in the exposure arm, 70% met the American Congress of Rehabilitation Medicine criteria for TBI, with the majority (80.1%) classified as mild TBI. The majority of subjects in the exposure arm had Glasgow Coma Scale scores of 13–15 (98.0%), normal head computed tomography (81.3%) and no prior history of concussion (71.7%). Conclusion: With systematic phenotyping, HeadSMART will facilitate diagnosis and risk-stratification of the heterogeneous group of individuals currently diagnosed with TBI.

Correlates and Prevalence of Aggression at Six Months and One Year After First-Time Traumatic Brain Injury

Few studies have examined clinical correlates of aggression after first-time traumatic brain injury (TBI) within the first year after injury. The authors aimed to identify the rates of aggression at 6 and 12 months post-TBI and establish clinical and demographic correlates. A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for aggression. Post-TBI social functioning and new-onset depression (within 3 months of the TBI) may serve as particularly important predictors for aggression within the first year of TBI, as these factors may afford intervention and subsequent decreased risk of aggression.

Social Media Use in Psychiatric Graduate Medical Education: Where We Are and the Places We Could Go

This commentary discusses the use of social media in psychiatric graduate medical education (GME) based on a systematic search of the literature. The authors conclude that research on social media use in psychiatric GME is in its infancy. For the most part, the few articles that have been published on this topic caution against the use of social media in psychiatric training. However, reports from other specialties, in which social media use in medical education has been more extensively studied, suggest that there may be significant benefits to incorporating social media into medical education. Although additional challenges may exist in implementing these tools in psychiatric education, the authors suggest that this is an emerging field of scholarship that merits further investigation.

Pathological Laughter and Crying and Psychiatric Comorbidity After Traumatic Brain Injury

There are limited data regarding the incidence of pathological laughter and crying (PLC) after traumatic brain injury (TBI). This study aimed to identify the occurrence of PLC in the first year after TBI and to determine whether there is a relationship between PLC and other clinical features or demographics. Subjects who sustained a first-time TBI were recruited from acute trauma units and were assessed at 3, 6, and 12 months after TBI. Rates of PLC at 3, 6, and 12 months after TBI were 21.4%, 17.5%, and 15.5%, respectively. Patients with PLC had higher percentages of psychiatric diagnoses, including personality changes, depressive disorders, and mood disorders secondary to a general medical condition, as well as higher rates of posttraumatic stress disorder. Univariate logistic and linear regression analyses indicated a significant association between PLC and scores on the Clinical Anxiety Scale 3 months after TBI and on the Hamilton Depression Rating Scale 12 months after TBI. Individuals who have PLC during the first year after TBI are more likely to have any psychiatric diagnosis as well as higher rates of mood and anxiety symptoms. In addition, PLC in the early TBI period may serve as a predictor of depression and anxiety symptoms at 12 months after TBI.

Risks, Benefits, and Recommendations for Pastoral Care on Inpatient Psychiatric Units: A Systematic Review.

Objective: A systematic review was conducted of the biomedical literature regarding pastoral care (PaC) providers on inpatient psychiatric units with the aim of answering 3 questions: (1) What are the risks and benefits of PaC providers’ presence on inpatient psychiatric units? (2) What are current recommendations for integration of PaC providers into a psychiatric team? and (3) What gaps exist in the literature? Methods: PubMed, PsycInfo, Embase, CINAHL, and Scopus were searched from the start of each database to July 9, 2014 using terms related to PaC providers and inpatient psychiatry. Two independent reviewers performed full-text reviews of each article identified by independent review of all titles/abstracts from the electronic search and by a hand search of articles included in reference lists. Inclusion criteria were: English-language article, published in a peer-reviewed journal, and focus on a PaC provider working in a psychiatric hospital setting. One author performed data extraction. Results: Forty-nine articles were identified by electronic (84%) and hand search (16%), 18 of which were evaluative studies: 5 qualitative and 13 quantitative. Most of the literature viewed integration of PaC providers in inpatient treatment teams as beneficial. Potential harms were noted and mitigation strategies suggested, including providing training to PaC providers concerning psychiatric illness, clearly defining roles, and enhancing team integration. None of the articles reported outcomes data. Conclusions: Psychiatric inpatients often have unmet spiritual needs. Although the literature suggests potential benefits of PaC providers for psychiatric inpatients, more rigorous studies are needed to establish these benefits as efficacious. The authors of this review recommend the cautious integration of PaC providers into the psychiatric inpatient care team.

Depression after traumatic brain injury: A biopsychosocial cultural perspective

There are several challenges in diagnosing and treating mental illness amongst South Asians. Often times, formulating a patients case presentation cannot adequately be accomplished strictly using a biopsychosocial model. The cultural components play an imperative role in explaining certain psychiatric symptoms and can guide treatment. With the growing population of immigrants coming to the United States, many of which require treatment for mental illness, it is essential that clinicians be cognizant in incorporating cultural perspectives when treating such patients. The authors describe the case of a 24-year old South Asian male who suffered an exacerbation of a depressive syndrome after a traumatic brain injury. Using a biopsychosocial cultural approach, this case highlights how South Asian cultural values can contribute to and incite psychiatric symptoms while simultaneously providing protective drivers for treatment outcomes.

Poor sleep is linked to impeded recovery from traumatic brain injury

Study Objectives While disruptions in sleep are common after mild traumatic brain injury (TBI), the longitudinal relationships between sleep problems and global functioning after injury are poorly understood. Here, we prospectively investigate risk for functional impairment during the first 6 months of TBI recovery based on sleep onset insomnia symptoms and short sleep. Methods Patients presenting to the Emergency Department (ED) at Johns Hopkins Hospital within 24 hours of head injury and evaluated for TBI were eligible for our study. Demographic and injury-related information were collected in the ED. Patients then completed in-person surveys and phone interviews to provide follow-up data on global functioning, sleep, and depressive symptoms at 1, 3, and 6 months post-injury. A total of 238 patients provided sufficient data for analysis, and hypotheses were tested using mixed effects modeling. Results Sleep quality and global functioning improved over the 6 months of TBI recovery, but patients were at increased risk for functional impairment when sleeping poorly (odds ratio [OR] = 7.69, p < .001). Sleep onset insomnia symptoms and short sleep both independently corresponded to poor global functioning. Functional impairment was highest among those with both insomnia and short sleep (43%-79%) compared to good sleepers (15%-25%) and those with short sleep (29%-33%) or insomnia alone (33%-64%). A bidirectional relationship between sleep quality and functioning was observed. Conclusions Functionally impaired patients diagnosed predominantly with mild TBI exhibit high rates of insomnia and short sleep, which may impede TBI recovery. Monitoring sleep after head injury may identify patients with poor prognoses and allow for early intervention to improve functional outcomes.

Influence of study population definition on the effect of age on outcomes after blunt head trauma

ABSTRACT Objectives: The purpose of this study was to assess whether study population definition influences the effect of age on outcomes after blunt head trauma. We hypothesized that examining ‘all comers’ receiving head computerized tomography after blunt head trauma, fewer older individuals would meet Veterans Administration and Department of Defense (VA/DoD) criteria for traumatic brain injury (TBI), and would, therefore, display better outcomes than younger cohorts. However, restricting to participants meeting VA/DoD criteria for TBI, we hypothesized that older individuals would have worse outcomes. Methods: Data from a recently completed prospective cohort study were analysed with age dichotomized at 65 years. Logistic regression modelling, controlled for potential confounders including head trauma severity, was estimated to measure the effect of age on functional recovery, post-concussion symptoms (PCS), and depressive symptoms at 1-month post-TBI. Results: Fewer older than younger individuals met VA/DoD criteria for TBI. Older individuals had better functional, PCS, and depressive outcomes at 1 month. Restricting to those meeting VA/DoD criteria for TBI, older individuals continued to have better functional and PCS outcomes but had outcomes comparable to younger on depressive symptoms. Conclusions: Contrary to our hypothesis, there was a tendency for older adults to have better outcomes than younger, independent of the diagnostic criteria applied.

Program of enhanced psychiatric services for patients with brain injury and neuropsychiatric disturbances: A proposed model of care

Neuropsychiatric disturbances associated with brain injury occur frequently and are a common cause of poor quality of life and caregiver burden. These disturbances can disrupt rehabilitation therapies and contribute to functional impairment if they are not appropriately treated. Although some patients can be treated adequately in an outpatient brain injury clinic or rehabilitation clinic, others need a more specialized structured program. Behavioral problems in particular are challenging and often lead to discharge of patients from traditional rehabilitation programs because their behaviors can be disruptive and/or harmful to themselves and others. These patients are often admitted to inpatient general psychiatric units, where they do not receive the comprehensive care they need. In an effort to prevent unnecessary hospitalizations and to provide comprehensive treatment, a community-based, multidisciplinary program was developed to address the physical, cognitive, and psychiatric needs of patients with brain injury. The program is highlighted with two case presentations: (a) a 31-year-old man with severe traumatic brain injury with subsequent cognitive and behavioral symptoms who had improvement in symptoms and quality of life, and (b) a 38-year-old woman with cognitive and mood symptoms after left temporal lobe resection due to medication-refractory epilepsy who had improved mood symptoms and daily life functioning. Brain injury is commonly associated with a host of neuropsychiatric symptoms that wax and wane. There is an urgent need to develop comprehensive programs that can address the multiple needs of this patient population in a community setting.

Pharmacologic Management of Aggression in Adults with Intellectual Disability

Introduction : Aggression is a common behavioral problem seen in patients with intellectual disabilities (ID). The safety and efficacy of second generation antipsychotics (SGAs), mood stabilizers and antidepressants in the management of aggression in these individuals have minimally been studied. This review aims to 1) summarize the studies conducted using second generation antipsychotics, mood stabilizers and antidepressants in treating aggressive behaviors in patient with ID and 2) determine based on the existing literature, which medications have been examined in the most rigorous study design that might suggest the most efficacy for use in clinical practice. Methods : Literature searches using PUBMED Central, CINAHL Plus, PsychINFO, and Embase databases were conducted using the following terms: intellectual disability/disabilities, mental retardation, developmental disability/disabilities, aggression, agitation, behavior disorder, adult, treatment, management. Studies predominantly including children with ID, and autism/pervasive developmental disabilities spectrum disorders were excluded. Analyses were done by class of medication: SGAs, mood stabilizers and antidepressants. The primary outcome measure was reduction in aggressive or self injurious behaviors as measured by each individual study. Results : The most rigorous study designs found using these agents were randomized controlled trials (RCT). A total of 10 RCTs were found, the majority being with risperidone (3) and lithium (2). Treatment with risperidone showed reduction in aggression when compared to placebo in most RCTs with the exception of one study in which risperidone was not better than placebo. Both lithium studies showed reduction in aggression when compared to placebo. The most abundant literature exists in retrospective chart reviews. The most commonly studied agent was risperidone which showed reduction in aggression in majority of the studies. Conclusions : Limited data exists for treatment of aggression in adults with ID. There are very few studies examining pharmacologic agents using RCTs. Given that risperidone and lithium were the most commonly studied agents in the most rigorous experimental design, it is suggested that these two agents prove efficacious for treatment of aggression in patients with ID. Limitations to most of these studies included concomitant psychotropic administration with variations in types and dosing, severity of ID, and the idea that a wide variety of aggression scales were used to assess outcome. Further research with more scientific rigor is required in this field.