Sean M. Barnes

Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD

OBJECTIVE Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. DESIGN The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. RESULTS Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. CONCLUSION This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.

Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive-behavioral treatment for posttraumatic stress disorder (PTSD) and a front-line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy-cognitive therapy only (CPT-C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT-C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT-C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self- and clinician-reported PTSD and self-reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment-wise α correction was applied, this effect did not remain significant.

The influence of comorbid MDD on outcome after residential treatment for veterans with PTSD and a history of TBI

Among military personnel, posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and a history of traumatic brain injury (TBI) are frequently reported, highlighting the need for treatment outcome research with this population. This study examined the influence of the presence or absence of comorbid MDD on the outcome of a residential treatment program at the midpoint and end of the program for 47 male veterans with PTSD and a history of TBI. Results demonstrated significant decreases of self-reported symptoms on the PTSD Checklist-Stressor Specific Version (PCL-S; MDD, d = 1.19; No MDD, d = 1.17) and the Beck Depression Inventory-II (BDI-II; MDD, d = 0.98; No MDD, d = 1.09) following treatment for both groups. There were no differences in the rate of symptom reduction between groups. Individuals who also met criteria for MDD at pretreatment, however, evidenced higher scores on symptom measures at all assessment time points (ds = 0.60-1.25).

Challenges Associated With Screening for Traumatic Brain Injury Among US Veterans Seeking Homeless Services

We identified the prevalence of traumatic brain injury (TBI) among homeless veterans and assessed the TBI-4, a screening tool created to identify TBI history. Between May 2010 and October 2011, 800 US veterans from two hospitals, one eastern (n = 122) and one western (n = 678) completed some or all measures. Findings suggested that 47% of veterans seeking homeless services had a probable history of TBI (data for prevalence obtained only at the western hospital). However, psychometric results from the screening measure suggested that this may be an underestimate and supported comprehensive assessment of TBI in this population.

Facilitating treatment engagement during high-risk transition periods: a potential suicide prevention strategy.

The authors reflect on efforts which several U.S. government departments have made to use treatment engagement during high risk transition periods among military veterans to prevent suicide. They suggest that continued research on treatment engagement and suicide prevention among military veterans is needed. They argue that efforts need to be made to maximize treatment engagement during high-risk transitional periods to enhance clinicians’ ability to care for military veterans.

Characteristics of Traumatic Brain Injuries Sustained Among Veterans Seeking Homeless Services

This hypothesis-generating research describes the characteristics of traumatic brain injuries (TBIs) sustained among 229 Veterans seeking homeless services. Nearly all participants (83%) had sustained at least one TBI prior to their first episode of homelessness. Among participants with a TBI, assaults, transportation-related accidents, and falls were the most common causes of these injuries. Thirty percent of individuals sustained injuries with severity levels that would be expected to be associated with ongoing TBI-related deficits. Forty-three percent of the Veterans sustained at least one brain injury following their first episode of homelessness. Median lifetime number of TBIs was three. The severity of TBIs was similar among Veterans who sustained injuries before or after their first incident of homelessness. Findings suggest that future research should directly examine the potential bi-directional relationship between TBI and homelessness, as well as the impact of TBI-related deficits on Veterans’ ability to benefit from homeless services and/or maintain stable housing.

Problem-Solving Therapy for Suicide Prevention in Veterans With Moderate-to-Severe Traumatic Brain Injury.

Objective: Develop and test the acceptability and feasibility of Problem-Solving Therapy for Suicide Prevention (PST-SP), a group intervention aimed at improving problem solving and preventing suicide, among Veterans with hopelessness and moderate-to-severe traumatic brain injury (TBI). Research Method: Following treatment development, 16 U.S. Veterans with moderate-to-severe TBI and a Beck Hopelessness Scale score ≥4 participated in an acceptability and feasibility pilot study of PST-SP at a Veterans Affairs Medical Center. Participants completed the Client Satisfaction Questionnaire-8 (CSQ-8) and Narrative Evaluation of Intervention Interview (NEII) after participating in PST-SP. Results: PST-SP was developed for Veterans with moderate-to-severe TBI and hopelessness. 75% (n = 12) of participants enrolled in the pilot study attended ≥80% of PST-SP sessions. Participants reported high satisfaction with PST-SP (CSQ-8 M = 27.8 out of 32; SD = 4.78; range 14–32) and described the intervention as valuable, beneficial, and without negative effects (NEII). Conclusions/Implications: Results from measures of acceptability and attendance suggest that PST-SP is an acceptable and feasible intervention for Veterans with hopelessness and moderate-to-severe TBI. Findings support readiness to examine efficacy of the intervention in a Phase II randomized controlled trial.

Suicidal Crises: The Clinical and Research Implications of Overlooking the Role of Suicidal Reactivity

Individuals differ in their likelihood of becoming suicidal in the presence of stressors. This “suicidal reactivity” (i.e. the ease with which suicide-relevant physiological, emotional or cognitive processes are activated by suicide-relevant cues) is explicitly or implicitly included as a component of several extant theories of suicide, but is not consistently emphasized in suicide risk assessment or management. In this chapter, we examine the construct of suicidal reactivity from the perspective of cognitive models of suicidal behaviour. We propose that the failure to adequately assess suicidal reactivity may be a large contributing factor to the lack of progress in suicide risk assessment, and we review assessment measures relevant to suicidal reactivity. We also describe ways in which suicidal reactivity can be treated and illustrate how better understanding, predicting and preparing for reactivity plays a crucial role in suicide risk assessment, management and treatment. Finally, we argue that a lack of attention to the impact of suicidal reactivity on behaviour during research participation likely impedes our ability to draw meaningful conclusions from suicide research. We propose that suicidal reactivity is in need of additional empirical scrutiny and identify avenues for future research.

ACT for Life: Using Acceptance and Commitment Therapy to Understand and Prevent Suicide

Human beings are the only living organisms that consciously and deliberately kill themselves. Moreover, suicide is present in all societies, and internationally nearly one in ten humans will consider suicide at some point during their lives. This has left many of us asking, “What is it about being human that causes so many people to consider killing themselves?” On the surface, the answer is not a simple one. There is not one clear pathway that leads to suicide. Suicide is associated with a broad array of stressors, mental illnesses, and demographic characteristics. Acceptance and Commitment Therapy (ACT) is a transdiagnostic psychosocial treatment approach grounded in a model of psychological (in)flexibility. ACT offers a compelling explanation for why suicide is uniquely human and heterogeneous in etiology, but has been understudied in regard to its applicability to suicide prevention. In the proposed chapter, we delineate the etiology of suicidal thoughts and behaviours according to the ACT model of psychological (in)flexibility. Further, we review and synthesize the extant literature relevant to this etiological model. Topics of focus include inflexible attention, experiential avoidance, cognitive fusion, attachment to a conceptualized self, and disruption of valued living. We discuss implications for suicide risk assessment and key considerations for using ACT to manage suicide risk (e.g. how to promote the acceptance of suicidal ideation, without encouraging suicidal behaviour and ways to identify new valued directions for taking action that strengthen protective factors). Case material is presented to illustrate how ACT can be used with suicidal individuals to help them build a life they deem worth living.

Traumatic brain injury, psychiatric diagnoses, and suicide risk among Veterans seeking services related to homelessness

ABSTRACT Objectives: To explore the differences in negative psychiatric outcomes (i.e. type and number of psychiatric diagnoses, suicide risk) among Veterans with and without a history of traumatic brain injury (TBI) seeking homeless services. Methods: Observational design with data collected at one time-point. Veterans seeking homeless services from two Veteran Affairs (VA) Medical Centres completed study measures (n = 309; 282 with a history of TBI and 27 without a history of TBI). Veterans participated in structured clinical interviews regarding psychiatric and TBI histories. Results: Those with a history of TBI met the criteria for significantly more psychiatric diagnoses (p = 0.0003), and were more likely to be at risk for suicide (p = 0.007) than those without a history of TBI. Conclusions: Even among the high-risk cohort of homeless Veterans, those with a history of TBI were found to be at even greater risk for negative psychiatric outcomes. Further research is required to determine if and how the history of TBI contributes to the inability to maintain stable housing. Moreover, the findings highlight both the importance of assessing for history of TBI among this cohort, and educating providers regarding how to address the needs related to injury sequelae.