Grahame Simpson

Suicidality in people surviving a traumatic brain injury: Prevalence, risk factors and implications for clinical management

Background: A systematic search was conducted of the literature addressing suicidality after traumatic brain injury (TBI). Results from population-based studies found that people with TBI have an increased risk of death by suicide (3–4 times greater than for the general population), as well as significantly higher levels of suicide attempts and suicide ideation. Clinical studies have also reported high levels of suicide attempts (18%) and clinically significant suicide ideation (21–22%) in TBI samples. Methods and Results: In reviewing risk factors, two prognostic studies using multivariate analysis were identified. Adjusted risk statistics from these studies found an elevated risk of suicide for people with severe TBI in comparison to concussion (hazard ratio 1.4, 95% CI 1.15–1.75) and an elevated risk of suicide attempts among people displaying post-injury suicide ideation (adjusted odds ratio 4.9, 95% CI 1.79–13.17) and psychiatric/emotional distress (adjusted odds ratio 7.8, 95% CI 2.11–29.04). Conclusions: To date, little evidence exists for the role of pre-morbid psychopathology, neuropathology, neuropsychological impairments or post-injury psychosocial factors as major risk factors for post-injury suicidality. Finally, there has been little empirical examination of approaches to suicide prevention. Therefore, current best practice is based on clinical judgement and the untested extrapolation of prevention approaches from other clinical populations.

Suicidality after traumatic brain injury: demographic, injury and clinical correlates

BACKGROUND In spite of the high frequency of emotional distress after traumatic brain injury (TBI), few investigations have examined the extreme of such distress, namely, suicidality, and no large scale surveys have been conducted. The current study examined both the prevalence and demographic, injury, and clinical correlates of hopelessness, suicidal ideation and suicide attempts after TBI. METHODS Out-patients (N = 172) with TBI were screened for suicidal ideation and hopelessness using the Beck Scale for Suicide Ideation and the Beck Hopelessness Scale. Data were also collected on demographic, injury, pre-morbid and post-injury psychosocial variables and included known risk factors for suicide. RESULTS A substantial proportion of participants had clinically significant levels of hopelessness (35%) and suicide ideation (23%), and 18% had made a suicide attempt post-injury. There was a high degree of co-morbidity between suicide attempts and emotional/psychiatric disturbance. Results from regression analyses indicated that a high level of hopelessness was the most significant association of suicide ideation and a high level of suicide ideation, along with occurrence of post-injury emotional/psychiatric disturbance, were the most significant associations of post-injury suicide attempts. Neither injury severity nor the presence of pre-morbid suicide risk factors contributed to elevated levels of suicidality post-injury. CONCLUSIONS Suicidality is a common psychological reaction to TBI among out-patient populations. Management should involve careful history taking of previous post-injury suicidal behaviour, assessment of post-injury adjustment to TBI with particular focus on the degree of emotional/psychiatric disturbance, and close monitoring of those individuals with high levels of hopelessness and suicide ideation.

Cultural variations in the understanding of traumatic brain injury and brain injury rehabilitation.

Little is known about how people from different cultures experience and understand traumatic brain injury (TBI) and the process of brain injury rehabilitation. The Brain Injury Rehabilitation Unit (BIRU) undertook a qualitative project to research cultural variations in the understanding of TBI and the rehabilitation process, interviewing 39 people with TBI and family members from Italian, Lebanese and Vietnamese backgrounds. The focus was on the reporting of sequelae of the TBI; valued qualities of service providers; barriers to effective communication; the role of the families in the rehabilitation process; and the experience of social stigma. Findings suggest there is a universal experience of TBI that transcends individual cultures. Study participants valued attentiveness, friendliness and guidance from rehabilitation staff. Family support was not always available to the person with TBI due to family conflict. Generally, people with TBI and family members valued the assistance of health interpreters facilitating their communication with rehabilitation staff. People with TBI from all three cultures experienced problems of stigma and social isolation. The findings have a number of implications for how brain injury rehabilitation staff can approach service provision to people from diverse cultural backgrounds.Little is known about how people from different cultures experience and understand traumatic brain injury (TBI) and the process of brain injury rehabilitation. The Brain Injury Rehabilitation Unit (BIRU) undertook a qualitative project to research cultural variations in the understanding of TBI and the rehabilitation process, interviewing 39 people with TBI and family members from Italian, Lebanese and Vietnamese backgrounds. The focus was on the reporting of sequelae of the TBI; valued qualities of service providers; barriers to effective communication; the role of the families in the rehabilitation process; and the experience of social stigma. Findings suggest there is a universal experience of TBI that transcends individual cultures. Study participants valued attentiveness, friendliness and guidance from rehabilitation staff. Family support was not always available to the person with TBI due to family conflict. Generally, people with TBI and family members valued the assistance of health interpreters facilitating their communication with rehabilitation staff. People with TBI from all three cultures experienced problems of stigma and social isolation. The findings have a number of implications for how brain injury rehabilitation staff can approach service provision to people from diverse cultural backgrounds.

Influenza vaccine effectiveness against hospitalisation with confirmed influenza in the 2010-11 seasons: a test-negative observational study.

Immunisation programs are designed to reduce serious morbidity and mortality from influenza, but most evidence supporting the effectiveness of this intervention has focused on disease in the community or in primary care settings. We aimed to examine the effectiveness of influenza vaccination against hospitalisation with confirmed influenza. We compared influenza vaccination status in patients hospitalised with PCR-confirmed influenza with patients hospitalised with influenza-negative respiratory infections in an Australian sentinel surveillance system. Vaccine effectiveness was estimated from the odds ratio of vaccination in cases and controls. We performed both simple multivariate regression and a stratified analysis based on propensity score of vaccination. Vaccination status was ascertained in 333 of 598 patients with confirmed influenza and 785 of 1384 test-negative patients. Overall estimated crude vaccine effectiveness was 57% (41%, 68%). After adjusting for age, chronic comorbidities and pregnancy status, the estimated vaccine effectiveness was 37% (95% CI: 12%, 55%). In an analysis accounting for a propensity score for vaccination, the estimated vaccine effectiveness was 48.3% (95% CI: 30.0, 61.8%). Influenza vaccination was moderately protective against hospitalisation with influenza in the 2010 and 2011 seasons.

Early indicators and contributors to psychological distress in relatives during rehabilitation following severe traumatic brain injury: findings from the Brain Injury Outcomes Study.

ObjectivesTo develop a multivariate model of the dynamic interactions among key variables associated with relative distress and disrupted family functioning after traumatic brain injury (TBI). ParticipantsA relative sample (parents, spouses, close others; n = 134) derived from a statewide cohort of people with TBI recruited to the multicenter Brain Injury Outcomes Study. SettingA consecutive series of referrals over a 2-year period to the 11 adult units of the Brain Injury Rehabilitation Program in New South Wales, Australia. Main Outcome MeasuresRelative measures included General Health Questionnaire–28 (psychological distress), Family Assessment Device (family functioning), and BIOS Family Needs Questionnaire (perceived adequacy of support). The degree of impairment and level of participation of the person with TBI were assessed by the Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale, respectively. AnalysisPath analysis examined the varying contribution of impairment, participation, and support variables to both relative distress and disturbances in family functioning. ResultsThe overall model accounted for substantial proportions of the variance in psychological distress and family functioning. Importantly, the distress experienced by relatives was not due to the direct impact of the neurobehavioral impairments, but the effect of these impairments was mediated by the degree of community participation achieved by the person with TBI. ConclusionsThe model highlights the impact on families when the person with TBI experiences restrictions in participation. Clinically, a greater focus on the provision of respite or case management services may assist in reducing relative distress.

Late mortality after severe traumatic brain injury in New South Wales: a multicentre study

Objectives: To determine the long‐term mortality pattern of adults with severe traumatic brain injury (TBI), and to identify the risk factors associated with death in this group.

The overt behaviour scale (OBS): A tool for measuring challenging behaviours following ABI in community settings

Objectives: The Overt Behaviour Scale (OBS) was designed as a comprehensive measure of common challenging behaviours observed after acquired brain injury (ABI) in community settings. The OBS comprises 34 items in nine categories that measure aggression, inappropriate sexual behaviour, perseveration, wandering, inappropriate social behaviour and lack of initiation. The aim of the current study was to determine the reliability, validity and responsiveness of the OBS. Method: Two adult community-based samples of people with ABI were recruited. Sample 1 (n = 30) were concurrently evaluated on the OBS by two raters and again 1 week later to test stability. Other validating scales were also administered. Sample 2 (n = 28) were clients of the ABI Behaviour Consultancy who were treated for challenging behaviours and were administered the OBS before treatment commenced and then again 4 months later. Results: Inter-rater reliability and stability coefficients for the OBS total score was strong (0.97 and 0.77, respectively). Initial evidence of convergent and divergent validity was shown by the differential pattern of correlations with other measures. Moderate-to-strong coefficients (range 0.37–0.66) were observed between the OBS and other measures that had behavioural content (i.e. Mayo-Portland Adaptability Inventory, Current Behaviour Scale, Neurobehavioural Rating Scale–Revised). Divergent validity was shown by the lack of correlation between the OBS and the sub-scales of these tools that do not measure challenging behaviour. Finally, responsiveness was demonstrated with a significant decrease in OBS scores in the expected direction over the 4-month period. This improvement was confirmed by corroborating evidence from key informants. Conclusion: The OBS shows promise as a reliable, valid and responsive measure that can be used for the systematic assessment of challenging behaviours in community settings.

Clinical Features of Suicide Attempts After Traumatic Brain Injury

This study documents demographic, clinical and temporal parameters for suicide attempts after traumatic brain injury (TBI). Clinical interviews and a medical file review were conducted with an outpatient sample (N = 172), identifying 45 clients (26.2%) who had collectively made a lifetime total of 80 suicide attempts. Data were collected on postinjury psychopathology, current hopelessness, and suicide ideation, as well as historical data about the attempts. The sample (N = 43, missing data N = 2) had a lifetime prevalence of 1.86 attempts, with 19 clients (44.2%) making repeat attempts. The majority (70%) of the attempts were made postinjury. Medical attention was provided in 60.7% of attempts. The odds ratio found that respondents with a comorbid postinjury history of psychiatric/emotional disturbance and substance abuse were 21 times more likely to have made an attempt post-TBI compared with respondents with no such history. The findings can inform suicide prevention initiatives among people with TBI.

Prevalence, comorbidities, and correlates of challenging behavior among community-dwelling adults with severe traumatic brain injury: a multicenter study

Objective:Investigate the prevalence, comorbidities, and correlates of challenging behaviors among clients of the New South Wales Brain Injury Rehabilitation Program. Setting:All community-based rehabilitation services of the statewide program. Participants:Five hundred seven active clients with severe traumatic brain injury. Design:Prospective multicenter study. Main Measures:Eighty-eight clinicians from the 11 services rated clients on the Overt Behaviour Scale, Disability Rating Scale, Sydney Psychosocial Reintegration Scale–2, Care and Needs Scale, and Health of the Nation Outcome Scale–Acquired Brain Injury. Results:Overall prevalence rate of challenging behaviors was 54%. Inappropriate social behavior (33.3%), aggression (31.9%), and adynamia (23.1%) were the 3 most common individual behaviors, with 35.5% of the sample displaying more than 1 challenging behavior. Significant associations were found between increasing levels of challenging behavior and longer duration of posttraumatic amnesia, increasing functional disability, greater restrictions in participation, increased support needs, and greater degrees of psychiatric disturbance, respectively (P < 0.004). Multivariate binomial logistic regression found that premorbid alcohol abuse, postinjury restrictions in participation, and higher levels of postinjury psychiatric disturbance were independent predictors of challenging behavior. Conclusions:Challenging behaviors are widespread among community-dwelling adults with severe traumatic brain injury. Services need to deliver integrated anger management, social skills, and motivational treatments.

How important is resilience among family members supporting relatives with traumatic brain injury or spinal cord injury

Objective: To investigate the relationship between resilience and affective state, caregiver burden and caregiving strategies among family members of people with traumatic brain or spinal cord injury. Design: An observational prospective cross-sectional study. Setting: Inpatient and community rehabilitation services. Subjects: Convenience sample of 61 family respondents aged 18 years or older at the time of the study and supporting a relative with severe traumatic brain injury (n = 30) or spinal cord injury (n= 31). Main measures: Resilience Scale, Positive And Negative Affect Schedule, Caregiver Burden Scale, Functional Independence Measure, Carer’s Assessment of Managing Index. Results: Correlational analyses found a significant positive association between family resilience scores and positive affect (rs = 0.67), and a significant negative association with negative affect (rs = −0.47) and caregiver burden scores (rs = −0.47). No association was found between family resilience scores and their relative’s severity of functional impairment. Family members with high resilience scores rated four carer strategies as significantly more helpful than family members with low resilience scores. Between-groups analyses (families supporting relative with traumatic brain injury vs. spinal cord injury) found no significant differences in ratings of the perceived helpfulness of carer strategies once Bonferroni correction for multiple tests was applied. Conclusions: Self-rated resilience correlated positively with positive affect, and negatively with negative affect and caregiver burden. These results are consistent with resilience theories which propose that people with high resilience are more likely to display positive adaptation when faced by significant adversity.