Managing Behavioral Health Needs of Veterans with Traumatic brain injury (TBI) in Primary Care
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- King, P.R. & Wray, L.O. J Clin Psychol Med Settings (2012) 19: 376. doi:10.1007/s10880-012-9345-9
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Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.
KeywordsTraumatic brain injury (TBI)Integrated primary careVeterans
Reports of traumatic brain injury (TBI) are common in the veteran population. Recent accounts have estimated TBI incidence rates in US veterans who served in Afghanistan or Iraq as high as 20 % (Tanielian & Jaycox, 2008). Many of these veterans also experience a wide range of co-morbid medical and behavioral health concerns, including affective disturbance, impaired sleep, chronic pain, and substance abuse, which may prompt their primary care providers (PCPs) to consult with or initiate referral to behavioral health specialists working in primary care settings.
Veterans, including personnel still serving in the reserves or National Guard, may be prone to face multiple deployments or training situations that could place them at risk for TBI multiple times over. Informed behavioral health specialists working in primary care are uniquely positioned to provide timely assessment, psychoeducation, and brief symptom management interventions to veterans with TBI. Further, they may facilitate in routing patients toward specialty medical and mental health services as necessary, promote multidisciplinary, patient-centered care, and support and educate other allied health professionals. This paper serves as a review of behavioral health concerns that often co-occur with TBI in veterans, and suggests areas of clinical concern in which behavioral health specialists may effectively assess, intervene, and help to facilitate holistic patient care beyond the acute injury phase. The focus is primarily on sequelae common to mild and moderate TBI which may more readily present in primary care clinics. Management of severe TBI is beyond the scope of this paper, and may require more intense follow-up care than can be provided by behavioral health specialists working in primary care settings.
In conducting this review, we searched for peer-reviewed articles published between 2000 and 2012, or in press as of the time of manuscript submission. Search parameters were defined by using derivatives of keywords such as “traumatic brain injury”, “TBI”, “brain injury”, “head injury”, “head trauma”, and “concussion” in conjunction with terms pertaining to “primary care”, “veterans”, and common co-occurring disorders, including “post-traumatic stress disorder”, “depression”, “anxiety”, “alcohol abuse”, “substance abuse”, “suicide”, and “self-harm”. In limited cases, we included older articles only if they were seminal to the field or provided unique scholarly insights. We also included reports published by the Department of Veterans Affairs (VA), Department of Defense (DOD), and Centers for Disease Control and Prevention (CDC), industry reports, and reports from recent conference proceedings if relevant. Search procedures yielded over 1,800 results, of which over 1,100 remained after removing duplicates. From these, 500 of the most relevant works were selected for close review by the first author, and of these 158 were selected for inclusion in the manuscript, in addition to pertinent diagnostic references and test manuals.
TBI and Severity Levels
TBI is caused by forceful trauma to the head that results in a disturbance in brain function, and is among the most frequent causes of disability and death in the United States (CDC, 2010; Faul, Xu, Wald, & Coronado, 2010). Examples of common TBI-inducing events include strikes to the head or the head striking an object, penetrative or skull-fracturing injuries, rapid acceleration or deceleration events (e.g., thrust and whiplash in motor vehicle accidents), and exposure to concussive force such as in the case of blast exposure during combat (CDC, 2010; Faul et al., 2010; Howe, 2009). Individuals exposed to blast may endure more than one of these events, for example concussive force from an explosion may cause a soldier in a vehicle to strike his or her head on a solid object.
A CDC report from 2010 showed that rates of emergency room visits and inpatient hospitalization due to TBI have been on the rise since 2002. Falls and motor vehicle accidents account for the majority of TBIs in the general population, and young adult males and adults over age 65 are particularly at risk for sustaining these types of injuries; adults age 75 and older showed the overall highest rates of civilian death and hospitalization from TBI (CDC, 2010). The prevalence of TBI in service members and veterans has prompted the publication of general practice guidelines for persons served in VA and DOD settings (e.g., Cifu et al., 2009). In fact, VA directives mandate that all veterans of Operations Enduring and Iraqi Freedom be screened for TBI (Department of Veterans Affairs, 2007). Those unique service members and veterans exposed to blast have been given particular attention in numerous VA and DOD publications as well (e.g., French, 2010; Hampton, 2011; Hoge et al., 2008; McCrea et al., 2008; Terrio, Nelson, Betthauser, Harwood, & Brenner, 2011). Current estimates suggest that blast exposure accounts for 70–85 % of all recent combat injuries (French et al., 2012; Owens et al., 2008) and that veterans with history of blast exposure are at significantly higher risk for TBI (McCrea et al., 2008).
TBI classification is based on the severity and duration of symptoms acutely after injury (Alexander, 1995; Howe, 2009). Diagnostic ratings range from mild to severe, though in the general population more than 75 % of all TBIs are mild in nature (Faul et al., 2010; Ruff et al., 2009). A number of different operational definitions exist for mild TBI (mTBI), also commonly referred to as concussion. Among the most common is the American Congress of Rehabilitation Medicine’s definition, which describes symptoms such as altered mental status, post-traumatic amnesia (PTA), focal neurological impairment, and/or brief loss of consciousness (LOC) for up to 30 min (Kay et al., 1993), though other diagnostic guidelines per the CDC, the World Health Organization (WHO), and Defense and Veterans Brain Injury Center exist (DVBIC; see McCrea et al., 2008, for a review), as does a grading hierarchy within the mTBI category itself (American Academy of Neurology, 1997). Moderate TBI is evidenced by LOC ranging from 30 min to 24 h and up to 1 week of PTA, and severe TBI includes LOC greater than 1 day with a Glasgow Coma Scale rating less than eight. Permanent neurological damage can occur in severe TBI (Lippert-Gruner, Kuchta, Hellmich, & Klug, 2006). Multiple TBIs (including mTBI) have been linked to poorer prognosis, an increased likelihood of persistent symptoms in the future, and “second-impact syndrome” (Cobb & Battin, 2004; Corrigan & Deutschle, Jr., 2008). Second-impact syndrome can include lasting cognitive effects and in some cases may prove fatal; younger persons and athletes are particularly susceptible to these risks (Cobb & Battin, 2004).
Cognitive Disturbance and Persistent Post-concussion Symptoms
Patient reports of post-concussion symptoms are frequent after mTBI, and may include a host of physical, emotional, cognitive, and sensory complaints such as dizziness, irritability, poor concentration, and sensitivity to light and noise, among others, with post-traumatic headache among the most common complaints in as many as 90 % of patients (Bazarian, Wong, & Harris, 1999; Formisano, Bivona, Catani, D’Ippolito, & Buzzi, 2009; Ryan & Warden, 2003). Cognitive disturbance is most common in the acute phase of concussion, usually identified as a period of up to 1 week after injury. Typical complaints involve short-term deficits in orientation, attention, memory, and processing speed, and these complaints may be exacerbated when LOC occurs. Sleep disturbance is also common and may be present in as many as 70 % of patients (Castriotta & Murthy, 2011; Rao et al., 2008). Such symptoms tend to peak and resolve quickly, often within a week, with the majority of patients seeing full resolution within 3 months of injury (Iverson, 2005; McCrea et al., 2009).
A noteworthy minority of mTBI patients (5–38 %) report lasting symptoms (Iverson, 2005; Meares et al., 2011). Post-concussion syndrome (PCS) may be diagnosed when the symptoms described above persist well beyond expected recovery windows. It should be noted that ICD-10 criteria for Post-concussional syndrome and DSM-IV-proposed diagnostic criteria for Postconcussional disorder differ. In sum, ICD-10 criteria require a history of LOC plus the presence of three symptom categories which last at least 1 month after the injury (wherein each symptom category may include multiple complaints), and DSM-IV criteria require the presence of a quantifiable deficit in attention or memory plus a minimum of three other symptoms that are present for at least 3 months after injury (American Psychiatric Association, 1994; WHO, 1992). The classification of neurocognitive disorder due to TBI currently appears as a proposed revision to DSM-5, and consists of cognitive symptoms that last for at least 1 week after TBI (or resumption of consciousness if LOC was present; American Psychiatric Association, 2012).
Fortunately, the majority of symptoms resolve quickly and there is little reason to prognosticate longstanding functional deficits (Iverson, 2005). In rare cases though, PCS symptom reports have been documented to persist over many years (e.g., Binder, 1986). Community-based studies suggest that female patients, patients injured by motor vehicle accident, and patients hospitalized after mTBI are more likely to report PCS than other patients (Meares et al., 2011).
Although current literature substantiates a wide variety of common post-concussion complaints, there is no clear or single explanation of their nature or etiology (Iverson, 2005). PCS symptom reports are known to be highly subjective and in fact are not specific to TBI. A number of published studies show that both healthy controls and non-head-injured medical samples report a substantial number of typical PCS symptoms, and there is marked overlap among common PCS symptoms and anxiety and mood disorders (e.g., Benge, Pastorek, & Thornton, 2009; Dean, O’Neill, & Sterr, 2012; Iverson & Lange, 2003; King et al., 2012; Mickeviciene et al., 2004). Some literature suggests no significant link between PCS symptom reports and TBI history. Instead, symptom misattribution, expectation of continued complications, affective disturbance, and levels of social support independent of mTBI may predict PCS reports more accurately than an actual history of head injury, particularly in cases of longstanding symptom reports (Howe, 2009; Iverson, 2005; King et al., 2011; Luis, Vanderploeg, & Curtiss, 2003; McCauley, Boake, Levin, Contant, & Song, 2001; Meares et al., 2008, 2011). Further diagnostic complications arise with reports of co-morbid physical injury, chronic pain, and/or polytrauma, as these issues can serve as sources of additional symptoms and exacerbate other complaints (Iverson & McCracken, 1997; Lew et al., 2009; Meares et al., 2011).
Common Assessment, Treatment, and Management Strategies
PCS patients are often treated in the primary care setting. Common medical interventions include non-steroidal analgesics such as acetaminophen or ibuprofen, SSRI-class antidepressants, muscle-relaxants, and other agents used “off-label” (e.g., Arciniegas, Frey, Newmn, & Wortzel, 2010; Evans, Evans, & Sharp, 1994; Mittenberg, Canyock, Condit, & Patton, 2001; Willer & Leddy, 2006). Many treatment recommendations include a gradual return to normal activity, and some studies have shown that graded exercise interventions may be helpful in symptom resolution (Leddy, Baker, Kozlowski, Bisson, & Willer, 2011; Mittenberg et al., 2001; Willer & Leddy, 2006).
Studies suggest that a substantial proportion of PCS patients (approximately 40 %) are referred to behavioral health providers for intervention (Mittenberg et al., 2001). Behavioral health treatment should reinforce the likelihood of a complete return to baseline early in the process, and focus upon the most pressing concerns identified by the patient. Brief interventions targeted at psychoeducation and symptom assessment have been implemented in as little as one session, with sustained improvement demonstrated at 6 months in comparison to control samples (Miller & Mittenberg, 1998; Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996; Mittenberg, Zielinski, & Fichera, 1993; Rona et al., 2012). Psychoeducation is most often aimed at creating realistic recovery expectancies, increasing patient knowledge of diagnostic criteria for PCS, other possible or more likely explanations of symptoms (such as affective disturbance), typical windows of symptom resolution, awareness of pre- versus post-injury symptoms, and options for behavioral intervention (Mittenberg et al., 1993, 2001). Other targeted behavioral health interventions may involve sleep hygiene, relaxation skills, cognitive restructuring, and symptom tracking (Mittenberg et al., 2001).
A number of brief self-report measures are commercially available to track symptom complaints (Alla, Sullivan, Hale, & McCrory, 2009, provide a robust review). The 22-item Neurobehavioral Symptom Inventory (Cicerone & Kalmar, 1995), used in the VA’s Comprehensive TBI Evaluation, is available to VA providers who evaluate and treat veterans with TBI. Self-report measures such as this are simple to administer, time efficient, and can both identify subjective problem areas (i.e., irritability, sleep difficulty) and track changes in a wide variety of symptom complaints over time. Basic compensatory strategies may include writing things down, avoiding multitasking, and moving at a slower pace.
Neuropsychological referrals may be warranted to clarify diagnosis, to quantify cognitive deficits that persist for an extended period of time, or to guide treatment. Diagnostic clarification may identify or rule out neurological causes of symptoms, for example differentiating between a focal neurological deficit and the cognitive effects of depression. Formal cognitive assessments can also help to distinguish between subjective and objective deficits; some patients may at times perceive difficulties that do not manifest under controlled conditions. Further, alterations in treatment might include a recommendation for cognitive rehabilitation, specific behavioral changes to promote optimal patient functioning, other specialty consultation (e.g., psychiatry, neurology), or future re-evaluation. Providers who do seek neuropsychological consultation should identify a clear referral question and consider whether or how results might alter patient treatment from usual care. DOD recently initiated neurocognitive testing for deploying active duty military personnel, and where available, these baseline assessments will likely be helpful metrics for comparison (Jaffee & Meyer, 2009). VA and DOD clinical practice guidelines (Cifu et al., 2009) suggest that neuropsychological referrals take place at least one month after injury to allow for a typical recovery course. In the presence of substantial cognitive deficits, cognitive rehabilitation may be employed to build compensatory strategies for memory and personal organization. Beyond PCS-specific interventions, many studies suggest that first targeting affective disturbances such as post-traumatic stress disorder (PTSD), depression, and generalized anxiety may be indicated when noteworthy symptoms are concurrent or were present prior to injury (e.g., Meares et al., 2011). Neuropsychology referrals are contraindicated during periods of acute medical or emotional distress given the likely impact on test validity.
Literature has long substantiated links between TBI and affective disturbance. Irritability and minor anxiety are considered common sequelae to mTBI, particularly in the acute phase of recovery, but tend to resolve rapidly. However, there is also a body of literature that documents a more enduring relationship between mTBI and ongoing emotional distress. Using a VA administrative database, Carlson et al. (2010) showed that as many as 85 % of veterans with varying levels TBI had at least one formal psychiatric diagnosis, and 64 % had at least two. Some have postulated that psychiatric complications may be due to physical or neurochemical changes resulting from injury (e.g., Hoffman & Harrison, 2009; Jorge & Robinson, 2003). In contrast, others reinforce the importance of weighing the psychosocial and environmental context of the injury (e.g., Carlson et al., 2010; Lew et al., 2008).
In civilian samples, depression has been identified as the single most common affective co-morbidity of any TBI, with anxiety a distant second (Bombardier et al., 2010; Levin et al., 2001; Moore, Terryberry-Spohr, & Hope, 2006; Seel, Macciocchi, & Kreutzer, 2010; Whelan-Goodinson, Ponsford, Johnston, & Grant, 2009). Though reports have varied widely, post-injury depression rates at times have approached 80 % (see Seel et al., 2010, for a review). Some studies have correlated pre-injury affective symptoms with post-injury psychiatric outcomes (e.g., Gould, Ponsford, Johnston, & Schonberger, 2011), but others have demonstrated increased risk for psychiatric complications after injury. In a study of civilian hospital patients with varying TBI severity, Whelan-Goodinson et al. (2009) identified a 13 % increase in new psychiatric diagnoses from the pre- to post-injury period. Depression and general anxiety comprised the majority of new diagnoses in this sample, and symptoms did not tend to diminish over time. In fact, many patients still met diagnostic criteria for more than 5 years after injury. An important consideration in this area involves the potential for affective factors to pose as a long-term influence on functional ability and quality of life in any patient with TBI (e.g., Hudak, Hynan, Harper, & Diaz-Arrastia, 2012).
Perhaps no single psychiatric co-morbidity has received more attention than PTSD in military and veteran populations. A vast research base over more than a decade has explored the co-occurrence of blast injury (including TBI), persistent PCS reports, and PTSD (e.g., Brenner et al., 2010; Carlson et al., 2011; Morisette et al., 2011; Tanielian & Jaycox, 2008), and there is ample reason to believe that the experience of wartime trauma and brain injury to a degree separates military and veteran samples from trends observed in civilian-based studies. Many authors (e.g., Summerall & McAllister, 2010) cite difficulties in estimating rates of TBI, PCS, and PTSD co-occurrence due to notable overlap in diagnostic criteria symptom reports as well as the fact that onset of PTSD symptoms may predate, coincide, or develop after TBI, or develop from entirely separate traumatic experiences. However, an often-cited calculation from a study by Hoge et al. (2008) indicated that nearly 44 % of a sample of soldiers with mTBI with LOC met diagnostic guidelines for PTSD as well. This figure dwarfs estimates from some civilian samples where far lower rates have been reported (consider 13 % of TBI patients in Levin et al.’s (2001) sample). Even in the absence of evidence of causality, the presence of PTSD among veterans with any TBI has been shown to mediate multiple health and functional outcomes (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009).
Common Assessment, Treatment, and Management Strategies
Screening and assessment for mood and anxiety disorders are commonplace practices for behavioral health specialists in primary care settings. A potentially unique consideration involves the importance of screening TBI patients acutely after injury for both the presence of pre-injury psychiatric disorders and new symptoms to promote early detection and facilitate adequate follow-up behavioral health care (Gould et al., 2011). As is seen in Seel et al.’s (2010) review, certain depressive features, such as irritability, hostility, anhedonia, rumination, guilt, and loss of appetite should be considered especially notable in TBI patients. Care should be exercised in differential diagnosis, given that some short-lived symptoms are common after injury and are not necessarily representative of Axis I pathology (Seel et al., 2010). Brief self-reports may be employed to inform diagnosis and measure symptom reports over time. In any case, clinicians should be mindful of the potential to misattribute symptoms; any of these measures may be sensitive to symptoms but not entirely specific due to shared diagnostic features (Bryant, 2001; Summerall & McAllister, 2010).
Brief interventions for depression and general anxiety are also routine practices for behavioral health providers in primary care. In contrast, while well-supported evidence-based interventions exist for PTSD (for example, exposure-based interventions and cognitive processing therapy), such interventions are typically delivered within specialty mental health settings. Although safe (e.g., Shemesh et al., 2011), no interventions have demonstrated consistent effect in the primary care setting (Possemato, 2011; Schnurr et al., 2012). Early pilot work by Cigrang et al. (2011) that blended elements of prolonged exposure and cognitive processing showed promise in reducing PTSD symptoms in a small sample (n = 15) of active duty service members. As seen in some other areas reviewed in this paper, there are few empirically-based treatments for co-occurring affective disorders and TBI, and a specific review on TBI and PTSD conducted by VA investigators found little to no evidence on combined interventions in this group (Carlson et al., 2009). A small but recent study by Wolf, Strom, Kehle, and Eftekhari (2012) showed good effect of a modified prolonged exposure therapy protocol in a sample of 10 veterans with co-occurring chronic PTSD and mild to moderate TBI. One related study (Bryant, Moulds, Guthrie, & Nixon, 2003) used cognitive-behavioral techniques such as psychoeducation, progressive muscle relaxation, exposure therapy, and cognitive restructuring with good effect in TBI patients with acute stress disorder. However treatment protocols in Wolf et al. and Bryant et al. required 5–18, 90–120 min sessions, parameters which are far outside of a typical primary care-mental health visit.
Substantial evidence is available in the literature regarding suicidal ideation and risk for self-harm in persons with brain injury history (including mild injuries). Tsaosides, Cantor, and Gordon (2011) reported rates of suicidal ideation in over a quarter of all TBI patients. In other recent studies, researchers have showed that veterans with TBI history are 1.5 or more times as likely to complete suicide than those without, and previously brain-injured veterans with co-morbid diagnoses of depression or PTSD both attempt and complete suicide at significantly higher rates than those with TBI history only (e.g., Brenner, Betthauser et al., 2011; Brenner, Ignacio, & Blow, 2011; Gutierrez, Brenner, & Huggins, 2008). Veterans with more severe injuries may be up to four-times more likely to suicide (Brenner, Carlson et al., 2009; Brenner, Homaifar, Adler, Wolfman, & Kemp, 2009). Multiple other studies reflect significant involvement of substance abuse in TBI patients’ risk for suicidality (Brenner, Carlson et al., 2009; Mainio et al., 2007; Wasserman et al., 2008).
Common Assessment, Treatment, and Management Strategies
Clinicians should be aware of the increased risk for self-harm in patients with TBI history and should routinely assess and document any concerns related to lethality (Wasserman et al., 2008; see Bryan, Corso, Neal-Warden, and Rudd (2009) for a listing of general guidelines on managing lethality risk in primary care settings). Even without presence of intent or plan to suicide, suicidal ideation alone is a significant indication of personal distress, and as Simpson and Tate (2007) reported, there is no known risk window for individuals with TBI to act on thoughts of self-harm.
Brenner, Homaifar et al. (2009) recommended several potential interventions. Target areas are most germane to serious head injuries, and include the development and promotion of compensatory cognitive strategies and emotional coping skills, enhancing access to and use of substance abuse services and general behavioral healthcare, increasing patient insight into symptoms and personal limitations, teaching patients to separate themselves from specific problems that may be due to TBI (impaired memory, for example), addressing feelings of burdensomeness, and reinforcing protective supports, such as spirituality, family, and a sense of personal meaning. As in other populations, explicit safety planning is recommended according to risk level and individuals at acute risk may warrant inpatient hospitalization for psychiatric stabilization (Bryan et al., 2009). Particular warning signs in the TBI population include cognitive dysfunction, affective disturbance, and feeling a loss of sense of self (Brenner, Homaifar et al., 2009).
Aggression, Impulsivity, and Other Safety Concerns
Evidence links TBI, impulsivity, and aggression (e.g., Diaz, 1995; Greve et al., 2001; Kerr, Oram, Tinson, & Schum, 2011; McKinlay, Brooks, Bond, Martinage, & Marshall, 1981; Rochat et al., 2010), and patients with impulsive behavioral tendencies may be at increased risk for altercations with others, accidents, and re-injury (Loeher Votruba et al., 2008). Much of this evidence pertains to individuals who have experienced moderate to severe TBI, who are hospitalized, and/or who have prior histories of violence. Far fewer studies examine the association between these behavioral features and generally healthy persons with history of mTBI. In mTBI, verbal aggression is far more likely expressed than physical (Rao et al., 2009). Only a small collection of studies report increased risk for physical aggression in mTBI patients independent of other personality pathology (e.g., Ferguson & Coccaro, 2009), and it is more often the case that post-injury depression, decreased psychosocial functioning, and other functional deficits are better predictors of aggression than mTBI is itself (e.g., Rao et al., 2009).
Common Assessment, Treatment, and Management Strategies
Similar to clinical practices for assessing lethality, clinicians should routinely monitor and intervene for aggression, impulsivity, or other safety issues. General feelings of anger and irritability may be targeted for therapeutic intervention via implementation of brief anger management protocols. For example, Hart, Vaccaro, Hays, and Maiuro (2012) demonstrated good effect with a low dropout rate using an eight-session anger management training protocol with patients with moderate to severe brain injuries, and others have suggested benefit from utilizing modified dialectical behavior therapy (DBT) principles to improve self-regulation (e.g., Allen, 2011). However it should be noted that the efficacy of formal anger management or DBT protocols has yet to be demonstrated with less severe injuries. It is also important to reinforce safety and secondary injury prevention strategies through seat belt use and other safety equipment, and educating patients on the possible increased risks for re-injury when alcohol or other substances are involved (CDC, 2010). Behavioral health interventions in these areas are all ultimately aimed at mitigating risk and enhancing overall coping skills.
Numerous studies document the strong association between TBI incidence and pre-injury substance use and abuse, and several papers have been published reviewing this topic (e.g., Bjork & Grant, 2009; Corrigan, 1995; Opreanu, Kuhn, & Basson, 2010; Parry-Jones, Vaughan, & Cox, 2006; Taylor, Kreutzer, Demm, & Meade, 2003). As many of 50 % of hospitalized TBI patients are intoxicated at the time of admission, and rates of pre-injury substance use reach as high as 79 % in this population (Taylor et al., 2003). Alcohol is consistently cited as the most common substance impacting TBI onset, and risk for subsequent TBIs significantly increases when the initial injury is alcohol-related (Drubach, Kelly, Winslow, & Flynn, 1993; Taylor et al., 2003; Winqvist et al., 2008).
The majority of new TBI cases identified in community samples involve males under age 25, and patients with earlier onset of substance use have demonstrated a propensity toward multiple injuries (Corrigan & Deutschle, Jr., 2008). Cases with more severe pre-injury substance abuse have often sustained higher-risk TBI events such as motor vehicle accidents and criminal victimization, and suffer worse psychosocial, cognitive, and vocational outcomes (Andelic et al., 2010; Corrigan, 1995; Drubach et al., 1993; Kelly, Johnson, Knoller, Drubach, & Winslow, 1997; Ponsford, Whelan, & Bahar-Fuchs, 2007; Taylor et al., 2003; Wehman, Targett, Yasuda, & Brown, 2000). Intoxication at the time of injury, separate from a longstanding substance abuse history, has not been shown to directly impact post-injury cognitive functioning (DeGuise et al., 2009; Schutte & Hanks, 2010).
Data on post-TBI substance abuse are less suggestive of a causal link. One potential exception might be a case where personality change occurs post-TBI (Bjork & Grant, 2009). However no substantial evidence exists to suggest that this is a common occurrence after mTBI, which accounts for the vast majority of all head injuries. Many early studies actually showed a reduction in substance use immediately following head injury (e.g., Kreutzer, Doherty, Harris, & Zasler, 1990). More recent work by both Kolakowsky-Hayner et al. (2002) and Ponsford et al. (2007) suggested that many patients return to pre-injury substance use patterns within 1–2 years after injury. It is well documented that both civilians and veterans who present for substance abuse treatment often endorse TBI history, and across studies, it has become clear that post-injury substance abuse has the potential to dampen treatment effects, lead to further medical and psychosocial complications, and increase risk for subsequent injuries (Corrigan and Deutschle, 2008; Kolakowsky-Hayner et al., 2002; Murrey, Dallas, & Maki, 2007; Olson-Madden et al., 2010).
A realistic limitation of much of the extant evidence on TBI and substance abuse is its primary base in civilian or community samples. Compared to the civilian literature, far fewer data are available on outcomes pertaining to TBI and substance abuse in combat veterans. Service members have reported consistently high rates of alcohol abuse since the 1980s, with notable increases from 1998 to 2008, and a rising concern pertains to prescription drug abuse as well (Bray et al., 2009). Of studies that have been published with military samples, some evidence exists to support the claim that military personnel with mTBI are at increased risk for disciplinary action due to substance abuse when compared to controls or others with more severe injuries (Ommaya et al., 1996), but a recent study of combat veterans suggested no notable links between TBI and post-injury alcohol abuse (Heltemes, Dougherty, MacGregor, & Galarneau, 2011). Although intoxication is common at the time of injury in civilian samples, this is not likely the case with military personnel injured during combat operations (Heltemes et al., 2011; Rona et al., 2012). But as with other domains reviewed in this paper, complicating factors with combat veterans involve the interplay of already high base rates of alcohol use and abuse (Bray et al., 2009), postdeployment health and adjustment (Walker, Clark, & Sanders, 2010), self-management of pain symptoms (Nampiaparampil, 2008), and affective and/or cognitive disturbance (Bjork & Grant, 2009; Graham & Cardon, 2008).
Common Assessment, Treatment, and Management Strategies
Relatively little unique information is available on screening and treatment of substance use in patients with TBI. Screening for substance use and abuse is a typical component of behavioral health encounters, and a number of assessment tools are readily available to clinicians working in integrated primary care settings. In two of the few studies to look at substance use assessment in the TBI patient population, the CAGE (Ewing, 1984) effectively identified alcohol dependence (Ashman, Schwartz, Cantor, Hibbard, & Gordon, 2004; Fuller, Fishman, Taylor, & Wood, 1994), however VA and DOD guidelines advise against using it as an independent measure as it fails to specify recent substance-using behaviors (Kivlahan, Liberto, & Haning, 2009). A number of effective substance use interventions are available for use in the primary care setting, and these interventions may be implemented in as little as five minutes. Referral for specialty substance treatment is indicated in cases where patients do not respond to brief interventions, have been unable to change their behaviors independently, require more intensive follow-up, or have previously been diagnosed or treated for alcohol or substance use disorders.
Physical Injury, Chronic Pain, and Quality of Life Variables
Physical injuries, pain, and discomfort have been frequent complaints among veterans of all eras, with half or more of recent combat veterans reporting lasting pain conditions (Haskell, Heapy, Reid, Papas, & Kerns, 2006; Kerns, Otis, Rosenberg, & Reid, 2003; Lin, Kirk, Murphy, McHale, & Doukas, 2004). Many injuries sustained in modern combat operations are due to the direct and indirect effects of explosive devices, which include exposure to pressure waves and blast wind, burns, projectiles, and force trauma (DePalma, Burris, Champion, & Hodgson, 2005; Okie, 2005; Warden, 2006). Some injuries, especially those which are polytraumatic in nature, require long term rehabilitation, are associated with chronic pain reports, and can lead to permanent disabling conditions (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007).
Recent reviews evidence notable links between chronic pain and TBI (e.g., Dobscha et al., 2009; Nampiaparampil, 2008). Estimates of pain prevalence vary widely within mTBI patient samples, but some studies suggest that as many as 95 % of patients experience chronic pain subsequent to injury (Uomoto & Esselman, 1993). Patient complaints most frequently pertain to headache, but musculoskeletal pain (e.g., neck and/or lower back strain) and fatigue are also prevalent (Brown, Hawker, Beaton, & Colantonio, 2011; Englander, Bushnik, Oggins, & Katznelson, 2010; Walker, Clark, Nampiaparampil et al., 2010). In stark contrast, prevalence estimates of pain in persons with moderate or severe TBI are significantly lower, hovering near 20 % (Uomoto & Esselman, 1993).
Empirical explorations of chronic pain issues in modern combat veterans have increased tremendously over the past decade. Affective factors have long been thought to mediate the experience of pain, and many chronic pain patients in the VA are also diagnosed with comorbid PTSD, which itself has been linked to higher reports of pain and headache (Afari et al., 2009; Bryant, Marosszkey, Crooks, Bagueley, & Gurka, 1999; Otis, McGlincehy, Vasterling, & Kerns, 2011; Schreiber & Galai, 1993). In Lew et al.’s (2009) sample, over 42 % of OEF/OIF veteran patients presenting to a polytrauma clinic reported co-morbid chronic pain, persistent PCS, and PTSD (compared to the 3–10 % who reported just one of these conditions). This symptom cluster has been referred to as the polytrauma clinical triad (or P3). Others (e.g., Walker, Clark, & Sanders, 2010) have opined that these same symptoms warrant a unique diagnostic classification (“postdeployment multi-symptom disorder”, p. 138) and specially designed multidisciplinary treatment protocol.
Despite the volumes of work published on long-term outcomes post-TBI, little is known regarding post-acute trajectories of polytraumatic injury (Gironda et al., 2009). Although quality of life has been identified by the VA as a standard pain treatment outcome measure (Department of Veterans Affairs, 2009), empirical inquiry into quality of life variables in veterans with TBI and polytrauma remains in its infancy (see Daggett, Bakas, & Habermann, 2009). A variety of potential quality of life determinants such as perceived symptom severity, self-efficacy, fatigue, functional state/productivity, and other individual and environmental factors exist (Branca & Lake, 2004; Bullinger & The TBI Consensus Group, 2002; Cantor et al., 2008; Cicerone & Azulay, 2006; Daggett et al., 2009). Current evidence suggests that quality of life may be affected as many as 10 or more years after injury (e.g., Zumstein et al., 2011).
Common Assessment, Treatment, and Management Strategies
Little unique information is available on managing pain complaints in the TBI population. General practice parameters include routine screening for pain and quality of life, patient education, enhancing self-management strategies, family education and intervention, and activating community support systems (Department of Veterans Affairs, 2009). Behavioral health providers in primary care who maintain an ongoing dialogue with PCPs and facilitate referrals for specialty mental health care, behavioral medicine services, or specialty pain clinics may help to promote optimal treatment outcome for patients with mTBI.
Family Member and Caregiver Needs
According to one survey, as many as 29 % of veterans’ caregivers reported caring for a patient with a serious TBI (National Alliance for Caregiving, 2010). Evidence suggests that caregivers of veterans in general face increased care demands compared to other populations, and that family members of patients hospitalized for moderate to severe TBI are at marked increased risk for depression and anxiety (National Alliance for Caregiving, 2010; Turner et al., 2010). Caregiver affect and perception of burden may be significantly influenced by patients’ manifest symptoms, the nature and severity of impairment, and the family’s general coping ability and functional state (e.g., Curtiss, Klemz, & Vanderploeg, 2000; Marsh, Kersel, Havill, & Sleigh, 1998, 2002; Schonberger, Ponsford, Olver, & Ponsford, 2010; Turner et al., 2010). Noteworthy similarities exist between the experiences of caregivers of patients with severe TBI and caregivers of patients with dementia. For example, both conditions can necessitate adaptation to emotional and behavioral changes in the patient, and personality changes may result in large differences in the interpersonal relationship between the patient and his or her family member. Additional stressors may develop as a result of caregivers and high-need-patients cohabitating for an extended period of time (Jackson, Turner-Stokes, Murray, Leese, & McPherson, 2009).
Family strain among caregivers for polytrauma patients is a relatively new area of research. In a large study of caregiver experiences, Griffin et al. (2012) detailed the struggles that family members faced in managing TBI in the context of moderate to severe polytrauma survivors’ needs. In their sample, caregivers were most often female, parent to the patient (62 % vs. 32 % who were spouses), and earned less than $40,000 per annum. Twenty-two percent of patients in this study required assistance with activities of daily living more than 4 years post-injury. Among seriously-injured patients who required daily care, family caregivers were often solely responsible for attending to their needs, and nearly half did so for more than 80 h per week with burden of care not typically lessening over time.
Common Assessment and Management Strategies
Most persons who sustain mild to moderate TBI do not face persistent PCS symptoms or require long-term care. However, patients and their families may require additional support and guidance in cases where focal neurological deficits remain, PCS persists, or multiple co-morbid conditions are present as in the case of polytrauma. Caregivers of persons with moderate to severe TBI often cite a need for information and communication with providers (e.g., Gagnon, Swaine, Champagne, & Lefebvre, 2008). As such, inviting family members to join in an appointment for education and personally-tailored feedback can be an important first step for clinicians. Research in dementia care suggests that family members may benefit from interventions to promote their own psychosocial support and adaptation to any relevant emotional, behavioral, and/or functional changes in their loved ones (Barton, 2011; Griffin et al., 2012; Jackson et al., 2009). Behavioral health specialists working in primary care settings may in some cases be the primary source of information or referral options for caregivers, such as a TBI-specific support groups, and therefore should be informed as to local and community referral options. Novel but effective approaches in addressing family and caregiver needs have been reported in the literature, and include use of group problem-solving meetings (Perlick et al., 2011), education and skills-building groups (Kreutzer, Stejskal, Godwin, Powell, & Arango-Lasprilla, 2010), and family-focused therapy (Dausch & Saliman, 2009). If co-morbid psychiatric concerns are present, a referral for a VA Support and Family Education group (Sherman, 2003, 2008) may be beneficial if available.
Clinical Recommendations and General Guidelines
TBI is common among modern combat veterans and has the potential to impact multiple areas of patients’ lives. Furthermore, clinical management of the variety of effects of TBI and associated concerns observed in the veteran population can be challenging for clinicians working in busy primary care settings. This manuscript provided a definition of TBI, an overview of injury classification, and reviewed important considerations regarding many common symptom complaints and trajectories. Further, we detailed the potential impact of co-morbid behavioral health conditions and substance use patterns and reviewed literature on safety concerns, all in hope of assisting behavioral health specialists to more effectively consult with primary care medical providers, and to provide “TBI-aware mental health services” to veterans (Brenner, Homaifar et al., 2009, p. 396).
Summary of specific clinical recommendations
Aim of behavioral health assessment
Sample measurement tools
Potential follow-up actions
Traumatic brain injury
Establish history, number, and severity of injury/injuries
VA Clinical Reminder/Traumatic Brain Injury Screening Tool
2. Screen for co-occurring concerns
3. Consider referral indicators and options
Cognitive disturbance or persistent post-concussion symptoms
Establish onset and duration of symptoms and monitor symptom trajectory
Neurobehavioral Symptom Inventory (Cicerone & Kalmar, 1995)
2. Identify other possible symptom explanations
3. Reinforce recovery expectancy
4. Graded return to activity
5. Symptom tracking
6. Build/reinforce coping skills (e.g., sleep hygiene, relaxation, compensatory strategies)
7. Refer to neuropsychology if symptoms persist for >1 month after injury and are not complicated by acute medical/emotional distress
Identify or rule-out co-occurring depression, anxiety, or post-traumatic stress
Beck Depression Inventory -II (Beck, Steer, & Brown, 1996); Beck Anxiety Inventory (Beck & Steer, 1993); Primary Care PTSD Screen (Prins et al., 2003); Patient Health Questionnaire (Kroenke, Spitzer, & Williams, 2001); PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993)
1. Education, treatment planning
2. Brief interventions to build coping skills
3. Refer to specialty mental health if patient is nonresponsive to treatment or disturbance is severe/outside scope of clinical practice
Routinely monitor medical, psychiatric, and psychosocial risk factors, as well as ideation, intent, and plan to harm self
1. Enhance emotional coping skills
2. Reinforce social supports
3. Promote compensatory strategies
4. Safety plan to reduce risk of self-harm
5. Refer to specialty mental health if patient poses high or continual risk for lethality
Aggression, impulsivity, or other safety concerns
Routinely monitor risk factors and ideation, intent, and plan to harm others, as well as other non-lethal risky behaviors
Brief Anger-Aggression Questionnaire (Maiuro, Vitaliano, & Cahn, 1987)
1. Plan for re-injury prevention and personal risk management strategies
2. Anger management intervention
3. Safety plan to reduce risk of harm to others
4. Refer to specialty mental health if patient poses a high or continual risk for lethality
Regular screening for misuse of alcohol, prescription medications (including medications for pain), or illicit drugs
Alcohol Use Disorders Identification Test (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001); CAGE (Ewing, 1984); Single-Item Alcohol Screening Questions (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009)
2. Brief substance use intervention
3. Refer to specialty substance abuse services if patient does not respond to brief intervention, requires close follow-up, or is diagnosed with substance use disorder
Pain and quality of life
Identify concurrent or untreated pain (acute or chronic, including musculoskeletal pain as well as headache) and/or functional limitation
2. Self-management strategies (e.g., progressive muscle relaxation, meditation)
3. Consult with PCP on possibility of pharmacological intervention and/or referral(s) to polytrauma clinic or physical/occupational therapy
4. Consider referral to behavioral medicine services or specialty pain clinic if pain is chronic, severe, and/or functionally limiting
Family member or caregiver needs
Identify knowledge gaps, unaddressed needs, burden, or other stressors of loved ones/care providers
Zarit Burden Interview (Zarit, Reever, & Bach-Peterson, 1980)
2. Invite loved ones to join in a session
3. Encourage use of psychosocial supports
4. Identify and refer to local/community resources
Screen for TBI Identification of TBI history, recency, and the circumstances under which the veteran was injured are important first steps. Whether the individual was hurt during combat or after abusing a substance can provide useful clinical information. Some injuries may be unreported or undocumented, and providers working in the VA system may administer the TBI Clinical Reminder or VA Traumatic Brain Injury Screening Tool (see Donnelly et al., 2011 for further discussion).
Assess for Current Cognitive, Affective, and Somatic Symptoms Assessment of the presence of current symptoms and tracking these symptoms over time are key practices as well. Many veterans with mild or moderate TBI history will report symptoms at the time of injury and this is consistent with a typical clinical presentation. Though it is possible that distal symptoms may be a direct result of injury, this is not likely the case. It is in fact only a minority of patients who do not recover within prototypical timeframes, and special considerations include affect, pain, pre-morbid functioning, and other psychosocial circumstances.
Educate Patients Clinicians should educate patients and supportive family members on typical symptom trajectories, inform them that a return to pre-injury baseline is the norm, and review other factors such as a concurrent PTSD diagnosis or physical pain conditions which may influence their unique experiences of symptoms. DVBIC’s website (www.DVBIC.org) also provides a number of useful educational handouts for patients and their family members which are available at no cost. All patients should be informed of their rights to have family participate in their care and of options available for continued family support at the clinic or community level.
Validate Patient Concerns Some patients may be confused or overwhelmed by a variety of psychosocial stressors combined with somatosensory, cognitive, or affective symptoms which may or may not be directly related to TBI. VA and DOD clinical practice guidelines emphasize that all provider-patient interactions should demonstrate empathy, expertise, commitment to patient-centered care, and honesty; perceptions that patients are seeking compensation or exaggerating symptoms should never impact the quality of care delivered (Cifu et al., 2009).
Enhance Coping Skills Brief interventions tailored to unique individual experiences (e.g., relaxation, sleep hygiene, and compensatory strategies) may prove helpful. It may be helpful to deliver educational and therapeutic interventions in small, concrete messages to promote patient understanding. For any intervention delivered with TBI patients, clinicians should take into account any persistent cognitive limitations that may impact a patient’s ability to engage in treatment. In the absence of TBI-specific protocols, a 2010 VA Consensus Report indicated that current clinical practice guidelines for PTSD, pain, and TBI should continue to be followed.
Reinforce Safety Behavioral health specialists should emphasize and help plan for safety and re-injury prevention, and given the significantly increased risk for lethality in all veterans with TBI, each clinic visit should incorporate lethality assessment.
Communicate with PCPs Ongoing dialogue with PCPs may facilitate more comprehensive workups or referrals for other specialty services as necessary, such as cognitive rehabilitation, polytrauma, and pain clinics. In some settings, treatment protocols may require direct referrals from physicians.
Refer as Necessary VA and DOD guidelines suggest that referrals for specialty services should be considered when patients experience an atypical recovery trajectory, increased life stress, and/or notable functional difficulties. Neuropsychological referrals may be warranted in the presence of persistent and significant cognitive complaints to identify or rule out other diagnostic considerations, and cognitive rehabilitation may be a resource to further develop patients’ compensatory strategies. Specialty mental health clinic or substance abuse treatment service referrals may be indicated in the presence of severe co-morbid depression, PTSD, or substance abuse. Social work case managers may facilitate care coordination in highly complex cases.
Practice Within Responsible Professional Limits Although VA and DOD Clinical Practice Guidelines for mTBI management (Cifu et al., 2009) offer several indications for referral to “mental health” they do not always distinguish between integrated behavioral health or specialty mental health clinic. Individual providers should of course weigh their own appropriate scopes of practice accordingly. Providers should also continue to regularly update their knowledge of novel treatment and assessment methods. The Defense Centers of Excellence in Psychological Health and TBI (DCOE) partnered with DVBIC to produce a reference to guide PCP’s through VA and DOD clinical recommendations, to include methods to assess, address, and follow-up on symptoms, diagnostic coding, cognitive rehabilitation options, and links to other educational resources for both patients and providers. This handbook (the mTBI Pocket Guide) is available in print and also as a free smart phone application.
Given the prevalence of TBI in the veteran population, it is essential that behavioral health specialists working in primary care settings be aware of TBI-relevant clinical issues, common co-morbidities, and basic management strategies. Though it may be challenging to manage the potentially complex symptom clusters associated with mild and moderate TBI in primary care, the strengths that an integrated primary care team possesses, such as the availability of medical, nursing, behavioral health, and other support services are well-suited to effectively manage TBI-related concerns. A variety of intervention strategies are available, and many of these are amenable to adaptation for the primary care setting.
Several limitations are germane to our review and are worth mention. First, many studies that discuss interventions are not specific to mTBI, and thus their efficacy in this population has yet to be demonstrated. Second, many community-based studies may not generalize to the veteran population, and findings rooted in studies of veterans will not consistently transfer to the general public given unique features of this population, perhaps most notably frequency of combat history and higher base rates of PTSD (Carlson et al., 2009). Further, some studies cited in this paper did not specify the severity of injury, and referred only to a general TBI history. Finally, there is little research that details the predictive ability of pre-mTBI functional and intellectual characteristics on post-injury cognition or long-term cognitive, behavioral, and quality of life outcomes after polytraumatic injury. Future studies may explore these relationships as well as evaluate the efficacy of population-specific interventions, especially those targeted at suicide-risk reduction practices in brain-injured veterans. Researchers and clinicians in a number of settings, particularly those in the VA, DOD, and DVIBC, have begun to tackle some of these questions, and are at the cutting edge in terms of identifying new therapies, exploring co-morbidities, describing the natural disease trajectory of TBIs of all severity levels, and addressing family needs.
The authors wish to thank Emily Pikoff-Mirwis and Borah Kim for their assistance in literature search and reviewing the manuscript. Writing of this manuscript was supported by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Department of Veterans Affairs Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo.
Conflict of interest
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.