Lisa A. Brenner

Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team.

ObjectivesThe objective of this article is to report the proportion of soldiers in a Brigade Combat Team (BCT) with at least 1 clinician-confirmed deployment-acquired traumatic brain injury (TBI) and to describe the nature of sequelae associated with such injuries. ParticipantsMembers of an Army unit (n = 3973) that served in Iraq were screened for history of TBI. Those reporting an injury (n = 1292) were further evaluated regarding sequelae. Of the injuries suffered, 907 were TBIs and 385 were other types of injury. The majority of TBIs sustained were mild. MethodsPostdeployment, responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT) facilitated clinical interviews regarding injury history and associated somatic (ie, headache, dizziness, balance) and neuropsychiatric symptoms (ie, irritability, memory). Traumatic brain injury diagnosis was based on the American Congress of Rehabilitation Medicine mild TBI criteria, which requires an injury event followed by an alteration in consciousness. ResultsA total of 22.8% of soldiers in a BCT returning from Iraq had clinician-confirmed TBI. Those with TBI were significantly more likely to recall somatic and/or neuropsychiatric symptoms immediately postinjury and endorse symptoms at follow-up than were soldiers without a history of deployment-related TBI. A total of 33.4% of soldiers with TBI reported 3 or more symptoms immediately postinjury compared with 7.5% at postdeployment. For soldiers injured without TBI, rates of 3 or more symptoms postinjury and postdeployment were 2.9% and 2.3%, respectively. In those with TBI, headache and dizziness were most frequently reported postinjury, with irritability and memory problems persisting and presenting over time. ConclusionFollowing deployment to Iraq, a clinician-confirmed TBI history was identified in 22.8% of soldiers from a BCT. Those with TBI were significantly more likely to report postinjury and postdeployment somatic and/or neuropsychiatric symptoms than those without this injury history. Overall, symptom endorsement decreased over time.

Traumatic Brain Injury, Posttraumatic Stress Disorder, and Postconcussive Symptom Reporting Among Troops Returning From Iraq

Objectives:Analyze the contribution of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD) to the endorsement of postconcussive (PC) symptoms during Post Deployment Health Assessment. Determine whether a combination of mTBI and PTSD was more strongly associated with symptoms than either condition alone. Methods:Cross-sectional study design where both the exposure, mTBI and/or PTSD, and the outcomes of interest, PC symptoms, were ascertained after return from deployment. Subjects were injured soldiers (n = 1247) from one Fort Carson Brigade Combat Team (n = 3973). Main Outcome Measures:Positive history of PC symptoms. Results:PTSD and mTBI together were more strongly associated with having PC symptoms (adjusted prevalence ratio 6.27; 95% CI: 4.13–9.43) than either mTBI alone (adjusted prevalence ratio = 4.03; 95% CI: 2.67–6.07) or PTSD alone (adjusted prevalence ratio = 2.74; 95% CI: 1.58–4.74) after adjusting for age, gender, education, rank, and Military Occupational Specialty. Conclusions:In soldiers with histories of physical injury, mTBI and PTSD were independently associated with PC symptom reporting. Those with both conditions were at greater risk for PC symptoms than those with either PTSD, mTBI, or neither. Findings support the importance of continued screening for both conditions with the aim of early identification and intervention.

Assessment and diagnosis of mild traumatic brain injury, posttraumatic stress disorder, and other polytrauma conditions: burden of adversity hypothesis.

OBJECTIVE/METHOD Military personnel returning from Iraq and Afghanistan have been exposed to physical and emotional trauma. Challenges related to assessment and intervention for those with posttraumatic stress disorder (PTSD) and/or history of mild traumatic brain injury (TBI) with sequelae are discussed, with an emphasis on complicating factors if conditions are co-occurring. Existing literature regarding cumulative disadvantage is offered as a means of increasing understanding regarding the complex symptom patterns reported by those with a history of mild TBI with enduring symptoms and PTSD. IMPLICATIONS The importance of early screening for both conditions is highlighted. In addition, the authors suggest that current best practices include treating symptoms regardless of etiology to decrease military personnel and veteran burden of adversity.

Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services.

Objective:To examine associations between history of traumatic brain injury (TBI) diagnosis and death by suicide among individuals receiving care within the Veterans Health Administration (VHA). Method:Individuals who received care between fiscal years 2001 to 2006 were included in analyses. Cox proportional hazards survival models for time to suicide, with time-dependent covariates, were utilized. Covariance sandwich estimators were used to adjust for the clustered nature of the data, with patients nested within VHA facilities. Analyses included all patients with a history of TBI (n = 49626) plus a 5% random sample of patients without TBI (n = 389053). Of those with a history of TBI, 105 died by suicide. Models were adjusted for demographic and psychiatric covariates. Results:Veterans with a history of TBI were 1.55 (95% confidence interval [CI], 1.24–1.92) times more likely to die by suicide than those without a history of TBI. Analyses by TBI severity were also conducted, and they suggested that in comparison to those without an injury history, those with (1) concussion/cranial fracture were 1.98 times more likely (95% CI, 1.39–2.82) to die by suicide and (2) cerebral contusion/traumatic intracranial hemorrhage were 1.34 times more likely (95% CI, 1.09–1.64) to die by suicide. This increased risk was not explained by the presence of psychiatric disorders or demographic factors. Conclusions:Among VHA users, those with a diagnosis of TBI were at greater risk for suicide than those without this diagnosis. Further research is indicated to identify evidence-based means of assessment and treatment for those with TBI and suicidal behavior.

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.

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.

Neuroimaging Correlates of Traumatic Brain Injury and Suicidal Behavior

Introduction:There is an urgent need to define the neurobiological and cognitive underpinnings of suicidal ideation and behavior in veterans with traumatic brain injury (TBI). Separate studies implicate frontal white matter systems in the pathophysiology of TBI, suicidality, and impulsivity. We examined the relationship between the integrity of major frontal white matter (WM) systems on measures of impulsivity and suicidality in veterans with TBI. Methods:Fifteen male veterans with TBI and 17 matched healthy controls (HC) received clinical ratings, measures of impulsivity and MRI scans on a 3T magnet. Diffusion tensor imaging (DTI) data for the genu and cingulum were analyzed using Freesurfer and FSL. Correlations were performed for fractional anisotropy (FA) (DTI) values and measures of suicidality and impulsivity for veterans with TBI. Results:Significantly decreased in FA values in the left cingulum (P = 0.02), and left (P = 0.02) and total genu (P = 0.01) were observed in the TBI group relative to controls. Measures of impulsivity were significantly greater for the TBI group and total and right cingulum FA positively correlated with current suicidal ideation and measures of impulsivity (P <0.03). Conclusion:These data demonstrate a significant reduction in FA in frontal WM tracts in veterans with mild TBI that was associated with both impulsivity and suicidality. These findings may reflect a neurobiological vulnerability to suicidal risk related to white matter microstructure.

An Emergency Department-Based Brief Intervention for Veterans at Risk for Suicide (SAFE VET)

Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.

Reduced amygdala volume is associated with deficits in inhibitory control: a voxel- and surface-based morphometric analysis of comorbid PTSD/mild TBI.

A significant portion of previously deployed combat Veterans from Operation Enduring Freedom and Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) are affected by comorbid posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). Despite this fact, neuroimaging studies investigating the neural correlates of cognitive dysfunction within this population are almost nonexistent, with the exception of research examining the neural correlates of diagnostic PTSD or TBI. The current study used both voxel-based and surface-based morphometry to determine whether comorbid PTSD/mTBI is characterized by altered brain structure in the same regions as observed in singular diagnostic PTSD or TBI. Furthermore, we assessed whether alterations in brain structures in these regions were associated with behavioral measures related to inhibitory control, as assessed by the Go/No-go task, self-reports of impulsivity, and/or PTSD or mTBI symptoms. Results indicate volumetric reductions in the bilateral anterior amygdala in our comorbid PTSD/mTBI sample as compared to a control sample of OEF/OIF Veterans with no history of mTBI and/or PTSD. Moreover, increased volume reduction in the amygdala predicted poorer inhibitory control as measured by performance on the Go/No-go task, increased self-reported impulsivity, and greater symptoms associated with PTSD. These findings suggest that alterations in brain anatomy in OEF/OIF/OND Veterans with comorbid PTSD/mTBI are associated with both cognitive deficits and trauma symptoms related to PTSD.

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.