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Accelerated death rate in population-based cohort of persons with traumatic brain injury. J Head Trauma Rehabil 2015; 29:E8-E19. [PMID: 23835874 DOI: 10.1097/htr.0b013e3182976ad3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the influence of preexisting heart, liver, kidney, cancer, stroke, and mental health problems and examine the influence of low socioeconomic status on mortality after discharge from acute care facilities for individuals with traumatic brain injury. PARTICIPANTS Population-based retrospective cohort study of 33695 persons discharged from acute care hospital with traumatic brain injury in South Carolina, 1999-2010. MAIN MEASURES Days elapsing from the dates of injury to death established the survival time (T). Data were censored at the 145th month. Multivariable Cox regression was used to examine the independent effect of the variables on death. Age-adjusted cumulative probability of death for each chronic disease of interest was plotted. RESULTS By the 70th month of follow-up, rate of death was accelerated from 10-fold for heart diseases to 2.5-fold for mental health problems. Adjusted hazard ratios for diseases of the heart (2.13), liver-renal (3.25), cancer (2.64), neurological diseases and stroke (2.07), diabetes (1.89), hypertension (1.43), and mental health problems (1.59) were highly significant (each with P < .001). Compared with persons with private insurance, the hazard ratio was significantly elevated with Medicaid (1.67), Medicare (1.54), and uninsured (1.27) (each with P < .001). CONCLUSION Specific chronic diseases strongly influenced postdischarge mortality after traumatic brain injury. Low socioeconomic status as measured by the type of insurance elevated the risk of death.
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Motzkin JC, Koenigs MR. Post-traumatic stress disorder and traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 128:633-648. [PMID: 25701911 DOI: 10.1016/b978-0-444-63521-1.00039-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Disentangling the effects of "organic" neurologic damage and psychological distress after a traumatic brain injury poses a significant challenge to researchers and clinicians. Establishing a link between traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) has been particularly contentious, reflecting difficulties in establishing a unique diagnosis for conditions with overlapping and sometimes contradictory symptom profiles. However, each disorder is linked to a variety of adverse health outcomes, underscoring the need to better understand how neurologic and psychiatric risk factors interact following trauma. Here, we present data showing that individuals with a TBI are more likely to develop PTSD, and that individuals with PTSD are more likely to develop persistent cognitive sequelae related to TBI. Further, we describe neurobiological models of PTSD, highlighting how patterns of neurologic damage typical in TBI may promote or protect against the development of PTSD in brain-injured populations. These data highlight the unique course of PTSD following a TBI and have important diagnostic, prognostic, and treatment implications for individuals with a dual diagnosis.
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Affiliation(s)
- Julian C Motzkin
- Neuroscience Training Program, University of Wisconsin - Madison, Madison, WI, USA; Medical Scientist Training Program, University of Wisconsin - Madison, Madison, WI, USA
| | - Michael R Koenigs
- Department of Psychiatry, University of Wisconsin - Madison, Madison, WI, USA.
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Mansour A, Lajiness-O’Neill R. Call for an Integrative and Multi-Disciplinary Approach to Traumatic Brain Injury (TBI). ACTA ACUST UNITED AC 2015. [DOI: 10.4236/psych.2015.64033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Holloway M. How is ABI assessed and responded to in non-specialist settings? Is specialist education required for all social care professionals? ACTA ACUST UNITED AC 2014. [DOI: 10.1108/scn-12-2013-0043] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to examine the research into prevalence of acquired brain injury in non-ABI specialist services, the impact of the invisible aspects of executive impairment and loss of insight upon functioning and to question how this is assessed and managed by generalist services.
Design/methodology/approach
– A literature search was undertaken to identify where people with an ABI may come in to contact with services that are not specifically designed to meet their needs.
Findings
– ABI is prevalent amongst users of a variety of community, inpatient and criminal justice services. The common albeit invisible consequences of ABI complicate assessment, service use and or treatment particularly in the context of a lack of under pinning knowledge and experience amongst the staff in non-specialist ABI services. As a consequence risks to children and adults are increased, opportunities for rehabilitation and growth are lost and human potential squandered. Addressing the first stage in this process, developing knowledge of the consequences of ABI and how to assess need, is a pre-requisite for change.
Practical implications
– An absence of basic underlying knowledge of the consequences of ABI impacts upon assessment and so limits the effectiveness of services. A consequence of this is manifest in the over-representation of people with an ABI to be found in non-specialist settings.
Originality/value
–Little research is undertaken from a social and community perspective into the impact of ABI over the longer term for those who have no contact with specialist services and yet, quite clearly by their use of other services, have unidentified, unrecognised and un-responded to needs.
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Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment. Brain Inj 2014; 29:238-48. [DOI: 10.3109/02699052.2014.965207] [Citation(s) in RCA: 194] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Juengst SB, Kumar RG, Arenth PM, Wagner AK. Exploratory associations with tumor necrosis factor-α, disinhibition and suicidal endorsement after traumatic brain injury. Brain Behav Immun 2014; 41:134-43. [PMID: 24928066 DOI: 10.1016/j.bbi.2014.05.020] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To examine the relationship of Tumor Necrosis Factor (TNF)-α to disinhibition and suicidal endorsement after traumatic brain injury (TBI). PARTICIPANTS Adults with moderate to severe TBI (acute serum levels: n=48, n=543 samples; acute CSF levels: n=37, n=389 samples; chronic serum levels: n=48, n=326 samples). MAIN MEASURES TNFα levels (CSF, Serum) from time of injury to 12 months post-injury; Frontal Systems Behavior Scale - Disinhibition Subscale at 6 and 12 months post-injury; Patient Health Questionnaire at 6 and 12 months post-injury. RESULTS Participants with TBI had significantly higher CSF and serum TNFα levels than healthy controls (p<0.05). Acute and chronic serum TNFα was significantly associated with disinhibition at 6 months post-injury (p=0.009, p=0.029 respectively), and 6 month disinhibition was associated with suicidal endorsement at both 6 and 12 months (p=0.045, p=0.033 respectively) and disinhibition at 12 months post-injury (p<0.001). CONCLUSION These preliminary data suggest a biological to behavioral pathway of suicidality after TBI, from TNFα to disinhibition to suicidal endorsement. Future investigation is warranted to validate these findings and clarify what biological mechanisms might underlie these relationships.
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Affiliation(s)
- S B Juengst
- Dept. Physical Medicine and Rehabilitation, University of Pittsburgh, United States
| | - R G Kumar
- Dept. Physical Medicine and Rehabilitation, University of Pittsburgh, United States
| | - P M Arenth
- Dept. Physical Medicine and Rehabilitation, University of Pittsburgh, United States
| | - A K Wagner
- Dept. Physical Medicine and Rehabilitation, University of Pittsburgh, United States; Center for Neuroscience, University of Pittsburgh, United States; Safar Center for Resuscitation Research, University of Pittsburgh, United States.
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Nowrangi MA, Kortte KB, Rao VA. A Perspectives Approach to Suicide After Traumatic Brain Injury: Case and Review. PSYCHOSOMATICS 2014; 55:430-7. [DOI: 10.1016/j.psym.2013.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/19/2013] [Accepted: 11/21/2013] [Indexed: 10/26/2022]
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Mackelprang JL, Bombardier CH, Fann JR, Temkin NR, Barber JK, Dikmen SS. Rates and predictors of suicidal ideation during the first year after traumatic brain injury. Am J Public Health 2014; 104:e100-7. [PMID: 24832143 DOI: 10.2105/ajph.2013.301794] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined rates of suicidal ideation (SI) after traumatic brain injury (TBI) and investigated whether demographic characteristics, preinjury psychiatric history, or injury-related factors predicted SI during the first year after injury. METHODS We followed a cohort of 559 adult patients who were admitted to Harborview Medical Center in Seattle, Washington, with a complicated mild to severe TBI between June 2001 and March 2005. Participants completed structured telephone interviews during months 1 through 6, 8, 10, and 12 after injury. We assessed SI using item 9 of the Patient Health Questionnaire (PHQ-9). RESULTS Twenty-five percent of the sample reported SI during 1 or more assessment points. The strongest predictor of SI was the first PHQ-8 score (i.e., PHQ-9 with item 9 excluded) after injury. Other significant multivariate predictors included a history of a prior suicide attempt, a history of bipolar disorder, and having less than a high school education. CONCLUSIONS Rates of SI among individuals who have sustained a TBI exceed those found among the general population. Increased knowledge of risk factors for SI may assist health care providers in identifying patients who may be vulnerable to SI after TBI.
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Affiliation(s)
- Jessica L Mackelprang
- Jessica L. Mackelprang is with the Harborview Injury Prevention and Research Center, Charles H. Bombardier and Sureyya S. Dikmen are with the Department of Rehabilitation Medicine, Jesse R. Fann is with the Department of Psychiatry and Behavioral Sciences, and Nancy R. Temkin and Jason K. Barber are with the Department of Neurologic Surgery, University of Washington School of Medicine, Seattle
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Challenging Behaviours, Co-morbidities, Service Utilisation and Service Access among Community-dwelling Adults with Severe Traumatic Brain Injury: A Multicentre Study. BRAIN IMPAIR 2014. [DOI: 10.1017/brimp.2014.7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To examine patterns, predictors and unmet needs of service utilisation and access to mental health and/or drug and alcohol services among community-dwelling adults with severe traumatic brain injury, and compare those who displayed challenging behaviours with those not displaying challenging behaviour.Design: Retrospective multicentre study.Subjects: All active clients (n= 507) of the New South Wales (NSW) Brain Injury Rehabilitation Program (BIRP) community rehabilitation teams.Methods: Clinician-rated data were collected on client challenging behaviours, mental health and functional status, service utilisation and unmet needs. Between-groups analyses (challenging behaviour versus no challenging behaviours) were conducted to examine patterns of service utilisation and unmet needs. Predictors for service utilisation were tested by multiple linear regression.Results: Challenging behaviours were associated with higher use of BIRP and non-BIRP services and greater levels of unmet needs. Challenging behaviour was an independent predictor of higher levels of service utilisation, in conjunction with pre- and post-injury mental health and drug and alcohol co-morbidities and geographic location. Only 15.3% of the 111 clients with challenging behaviours and co-morbid drug and alcohol problems accessed a drug and alcohol service, while another 32.4% had unmet needs for such services.Conclusion: Challenging behaviours make an independent contribution to increased levels of service utilisation after severe traumatic brain injury.
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Chronic traumatic encephalopathy and suicide: a systematic review. BIOMED RESEARCH INTERNATIONAL 2013; 2013:424280. [PMID: 24328030 PMCID: PMC3847964 DOI: 10.1155/2013/424280] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 10/06/2013] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a global health concern, and the recent literature
reports that a single mild TBI can result in chronic traumatic encephalopathy (CTE).
It has been suggested that CTE may lead to death by suicide, raising important prevention,
treatment, and policy implications. Thus, we conducted a systematic review of the
medical literature to answer the key question: What is the existing evidence
in support of a relationship between CTE and suicide? Systematic
searches of CTE and suicide yielded 85 unique abstracts. Seven articles were
identified for full text review. Only two case series met inclusion criteria and included
autopsies from 17 unique cases, 5 of whom died by suicide. Neither studies used blinding,
control cases, or systematic data collection regarding TBI exposure and/or
medical/neuropsychiatric history. The identified CTE literature revealed divergent
opinions regarding neuropathological elements of CTE and heterogeneity regarding
clinical manifestations. Overall quality of evidence regarding a relationship between
CTE and suicide was rated as very low using Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) criteria. Further studies of
higher quality and methodological rigor are needed to determine the existence and
nature of any relationship between CTE and suicide.
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Interventions for Mood-Related Issues Post Traumatic Brain Injury: Novel Treatments and Ongoing Limitations of Current Research. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Zhang J, Groff RF, Dayawansa S. Imipramine treatment increases cell proliferation following fluid percussion brain injury in rats. Neurol Res 2013; 35:247-54. [PMID: 23485052 DOI: 10.1179/1743132813y.0000000164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Researchers have observed unsustainable neurogenesis of the dentate gyrus of the hippocampus, as well as cognitive improvements in short-term imipramine-treated mice following a controlled cortical impact (CCI) model of traumatic brain injury (TBI). But they have yet to investigate the effects of a longer-duration imipramine treatment. In this study, we investigated the effects of a longer treatment regimen on rats following a fluid percussion injury (FPI) model, which creates a brain injury that more closely resembles those incurred by human patients. METHODS We administered imipramine to rats for 8 weeks following FPI. Brain histology was performed to measure neurogenesis and cognitive recovery was evaluated using the Morris water maze (MWM). RESULTS The Injury+imipramine group demonstrated 172% neurogenesis relative to the injury alone group at 9+ weeks in the dentate gyrus of the hippocampus. Neurogenesis observed here involved both the injured and the uninjured sides of the brain. All four groups (FPI+imipramine, FPI, sham, sham+imipramine) showed a similar performance in the MWM task. DISCUSSION Longer duration of treatment with imipramine promotes sustained increase in hippocampal cell proliferation and survival. Global neurogenesis corresponds to the diffuse nature of FPI injury. Cognitive outcome can be due to a delay in our behavior testing as much as an absence of cognitive benefit of imipramine at this stage of neurogenesis. Nevertheless, exploring the potential benefits of prophylactic antidepressant treatment in human TBI patients is worthwhile.
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Affiliation(s)
- J Zhang
- Department of Neurosurgery, PLA General Hospital, Beijing, China
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Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil 2013; 28:13-20. [PMID: 23076097 DOI: 10.1097/htr.0b013e31826c73cc] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. SETTING Outpatient TBI clinic on a US military base in Iraq. PARTICIPANTS Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. MAIN MEASURES Suicidal Behaviors Questionnaire-Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. RESULTS Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. CONCLUSION Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.
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Affiliation(s)
- Craig J Bryan
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT 84112, USA.
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Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care. J Clin Psychol Med Settings 2013. [PMID: 23184276 DOI: 10.1007/s10880-012-9345-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Abstract
Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.
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Abstract
OBJECTIVE Suicidal ideation and behavior have been associated with a variety of neurological illnesses. Studies are ongoing in combat veterans and other groups to examine possible mechanisms and pathways that account for such associations. METHOD This article provides a review of the literature on suicide ideation and suicidal behavior in patients with neurological illnesses including publications on veteran's health and military medicine. Studies of suicide attempts and deaths in people with neurological illnesses are also reviewed. RESULTS The studies summarized in this review indicate that there are important linkages between suicidal ideation and behavior and neurological conditions, including epilepsy, multiple sclerosis, and amyotrophic lateral sclerosis. CONCLUSION Additional studies are needed to further clarify why suicide ideation and suicidal behavior are associated with neurological diseases, in order to improve quality of life, alleviate patient distress, and prevent nonfatal and fatal suicide attempts in veteran and non-veteran populations.
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Affiliation(s)
- Steven S Coughlin
- Post-Deployment Health Epidemiology Program, Office of Public Health, Department of Veterans Affairs, Washington, DC, USA
| | - Leo Sher
- James J. Peters Veterans’ Affairs Medical Center, New York, USA
- Mount Sinai School of Medicine, New York, USA
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March E, Salzberg M, Hopwood M. Acquired brain injury needs to be acknowledged at the national mental health policy level. Aust N Z J Psychiatry 2013; 47:212-6. [PMID: 23463080 DOI: 10.1177/0004867412452943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Evrim March
- St Vincent's Mental Health, Melbourne, Australia.
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Psychiatric Diagnoses, Mental Health Utilization, High-Risk Behaviors, and Self-Directed Violence Among Veterans With Comorbid History of Traumatic Brain Injury and Substance Use Disorders. J Head Trauma Rehabil 2012; 27:370-8. [DOI: 10.1097/htr.0b013e318268d496] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Olson-Madden JH, Brenner LA, Corrigan JD, Emrick CD, Britton PC. Substance use and mild traumatic brain injury risk reduction and prevention: a novel model for treatment. Rehabil Res Pract 2012; 2012:174579. [PMID: 22685663 PMCID: PMC3363008 DOI: 10.1155/2012/174579] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 02/15/2012] [Accepted: 02/21/2012] [Indexed: 11/17/2022] Open
Abstract
Traumatic brain injury (TBI) and substance use disorders (SUDs) frequently co-occur. Individuals with histories of alcohol or other drug use are at greater risk for sustaining TBI, and individuals with TBI frequently misuse substances before and after injury. Further, a growing body of literature supports the relationship between comorbid histories of mild TBI (mTBI) and SUDs and negative outcomes. Alcohol and other drug use are strongly associated with risk taking. Disinhibition, impaired executive function, and/or impulsivity as a result of mTBI also contribute to an individual's proclivity towards risk-taking. Risk-taking behavior may therefore, be a direct result of SUD and/or history of mTBI, and risky behaviors may predispose individuals for subsequent injury or continued use of substances. Based on these findings, evaluation of risk-taking behavior associated with the co-occurrence of SUD and mTBI should be a standard clinical practice. Interventions aimed at reducing risky behavior among members of this population may assist in decreasing negative outcomes. A novel intervention (Substance Use and Traumatic Brain Injury Risk Reduction and Prevention (STRRP)) for reducing and preventing risky behaviors among individuals with co-occurring mTBI and SUD is presented. Areas for further research are discussed.
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Affiliation(s)
- Jennifer H. Olson-Madden
- Mental Illness Research, Education, and Clinical Center (MIRECC), Eastern Colorado Health Care System (ECHCS) Veterans Affairs Medical Center, Denver, CO 80220, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80111, USA
| | - Lisa A. Brenner
- Mental Illness Research, Education, and Clinical Center (MIRECC), Eastern Colorado Health Care System (ECHCS) Veterans Affairs Medical Center, Denver, CO 80220, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80111, USA
- Departments of Neurology and Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Denver, Aurora, CO 80111, USA
| | - John D. Corrigan
- Department of Physical Medicine and Rehabilitation, Wexner Medical Center at The Ohio State University, Columbus, OH 43210, USA
| | - Chad D. Emrick
- Outpatient Substance Abuse Treatment Program, Eastern Colorado Health Care System (ECHCS) Veterans Affairs Medical Center, Denver, CO 80220, USA
| | - Peter C. Britton
- Center of Excellence, Canandaigua Veterans Affairs Medical Center, Canandaigua, NY 14424, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY 14642, USA
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Reeves RR, Laizer JT. Traumatic Brain Injury and Suicide. J Psychosoc Nurs Ment Health Serv 2012; 50:32-8. [DOI: 10.3928/02793695-20120207-02] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 01/12/2012] [Indexed: 11/20/2022]
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Adams RS, Corrigan JD, Larson MJ. Alcohol Use after Combat-Acquired Traumatic Brain Injury: What We Know and Don't Know. JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 2012; 12:28-51. [PMID: 22485074 PMCID: PMC3319372 DOI: 10.1080/1533256x.2012.647580] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Military personnel engage in unhealthy alcohol use at rates higher than their same age, civilian peers, resulting in negative consequences for the individual and jeopardized force readiness for the armed services. Among those returning from combat deployment, unhealthy drinking may be exacerbated by acute stress reactions and injury, including traumatic brain injury (TBI). Combat-acquired TBI is common among personnel in the current conflicts. Although research suggests that impairments due to TBI leads to an increased risk for unhealthy drinking and consequences among civilians, there has been little research to examine whether TBI influences drinking behaviors among military personnel. This article examines TBI and drinking in both civilian and military populations and discusses implications for clinical care and policy.
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Affiliation(s)
- Rachel Sayko Adams
- Brandeis University, Heller School, Institute for Behavioral Health, Waltham, MA, USA
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Powell T, Gilson R, Collin C. TBI 13 years on: factors associated with post-traumatic growth. Disabil Rehabil 2012; 34:1461-7. [DOI: 10.3109/09638288.2011.644384] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Larney S, Topp L, Indig D, O'Driscoll C, Greenberg D. A cross-sectional survey of prevalence and correlates of suicidal ideation and suicide attempts among prisoners in New South Wales, Australia. BMC Public Health 2012; 12:14. [PMID: 22225627 PMCID: PMC3276432 DOI: 10.1186/1471-2458-12-14] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/06/2012] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to estimate the prevalence of suicidal ideation and suicide attempt among prisoners in New South Wales, Australia; and, among prisoners reporting suicidal ideation, to identify factors associated with suicide attempt. Methods A cross-sectional design was used. Participants were a random, stratified sample of 996 inmates who completed a telephone survey. The estimated population prevalence of suicidal ideation and suicide attempt were calculated and differences by sex and Aboriginality were tested using χ2 tests. Correlates of suicidal ideation and suicide attempt were tested using logistic regression. Results One-third of inmates reported lifetime suicidal ideation and one-fifth had attempted suicide. Women and Aboriginal participants were significantly more likely than men and non-Aboriginal participants, respectively, to report attempting suicide. Correlates of suicidal ideation included violent offending, traumatic brain injury, depression, self-harm, and psychiatric hospitalisation. Univariate correlates of suicide attempt among ideators were childhood out-of-home care, parental incarceration and psychiatric hospitalization; however, none of these remained significant in a multivariate model. Conclusions Suicidal ideation and attempts are highly prevalent among prisoners compared to the general community. Assessment of suicide risk is a critical task for mental health clinicians in prisons. Attention should be given to ensuring assessments are gender- and culturally sensitive. Indicators of mental illness may not be accurate predictors of suicide attempt. Indicators of childhood trauma appear to be particularly relevant to risk of suicide attempt among prisoners and should be given attention as part of risk assessments.
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Affiliation(s)
- Sarah Larney
- Centre for Health Research in Criminal Justice, Justice Health and Forensic Mental Health Network, Sydney, Australia.
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A Preliminary Examination of Prolonged Exposure Therapy With Iraq and Afghanistan Veterans With a Diagnosis of Posttraumatic Stress Disorder and Mild to Moderate Traumatic Brain Injury. J Head Trauma Rehabil 2012; 27:26-32. [DOI: 10.1097/htr.0b013e31823cd01f] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Caro D. Towards sustainable traumatic brain injury care systems: healthcare leadership imperatives in Canada. Healthc Manage Forum 2011; 24:25-30. [PMID: 21630624 DOI: 10.1016/j.hcmf.2010.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic brain injuries pose strategic population health challenges in the face of burgeoning clinical demands that continue to tax capital, financial, and social resource capacities. The sustainability of traumatic brain injury care systems depends on paradigmatic shifts in healthcare leadership thinking. In quest for high-performance care and sustained quality of life for traumatic brain injury patients, this article presents a unique paradigm of seven care performance layers and seven health leadership imperatives that together form the paradigm for the systemic sustainability of TBI care systems of the future.
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Affiliation(s)
- Denis Caro
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada.
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77
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A Guide for the Assessment and Treatment of Suicidal Patients With Traumatic Brain Injuries. J Head Trauma Rehabil 2011; 26:244-56. [DOI: 10.1097/htr.0b013e3182225528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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78
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Prevalence, correlates, and symptom profiles of depression among men with a history of military service. Soc Psychiatry Psychiatr Epidemiol 2011; 46:607-14. [PMID: 20652680 PMCID: PMC5064430 DOI: 10.1007/s00127-010-0226-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 04/09/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to examine the prevalence, correlates, and symptom profiles of depressive disorders in men with a history of military service. METHODS Data were obtained from the 2006 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regressions were used to identify correlates of lifetime and current depression. Regularly occurring symptom profiles were identified via cluster analysis. RESULTS Prevalence of lifetime and current depression was similar in men with and without a history of military service. Younger age was positively, and black minority status, being in a relationship and self-reported good health were negatively associated with a lifetime diagnosis of depression. Other minority status (non-Hispanic, non-black) was positively, and older age, some college, being in a relationship, and self-reported good health were negatively associated with current depression. A cluster of younger men who experience significant depressive symptoms but may not report depressed mood or anhedonia was identified. CONCLUSIONS Depression is as prevalent in men with a history of military service as it is in men without a history. Research should focus on subpopulations of men with a history of military service in which depression may be more prevalent or burdensome. Younger men with significant depressive symptoms may be missed by standard depression screens and still be at elevated risk for negative outcomes associated with depression.
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80
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Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services. J Head Trauma Rehabil 2011; 26:257-64. [DOI: 10.1097/htr.0b013e31821fdb6e] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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81
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Roscigno CI, Swanson KM, Vavilala MS, Solchany J. Children's longing for everydayness: life following traumatic brain injury in the USA. Brain Inj 2011; 25:882-94. [PMID: 21631183 DOI: 10.3109/02699052.2011.581638] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE Little is known about life after traumatic brain injury (TBI) from the child's perspective. RESEARCH DESIGN This descriptive phenomenological investigation explored themes of children's experiences following moderate-to-severe TBI. METHODS AND PROCEDURES INCLUSION CRITERIA (1) 6-18 years of age at injury; (2) moderate-to-severe TBI; (3) ≤3 years since injury; and (4) English speaking and could participate in an interview. Children participated (n = 39) in two interviews at least 1 year apart. A preliminary model was developed and shared for participants' input. MAIN OUTCOMES AND RESULTS Six themes emerged: (1) it is like waking up in a bad dream; (2) I thought going home would get me back to my old life, but it did not; (3) everything is such hard work; (4) you feel like you will never be like the person you were before; (5) it is not all bad; and (6) some people get it, but many people do not. CONCLUSIONS Social support was important to how children adjusted to changes or losses. Most children did adjust to functional changes by second interviews. Children had a more difficult time adjusting to how others defined them and limited their possibilities for a meaningful life.
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Affiliation(s)
- Cecelia I Roscigno
- College of Nursing, University of Illinois at Chicago, 845 South Damen Avenue MC 802, Chicago, IL 60612, USA.
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Abstract
The neurobehavioral sequelae of TBI consist of a spectrum of somatic, neurologic, and psychiatric symptoms. The challenge for clinicians lies in understanding the interface of the various symptoms and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from preexisting or de novo psychiatric, neurologic, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.
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Affiliation(s)
- Silvana Riggio
- Departments of Psychiatry and Neurology, Mount Sinai School of Medicine, One Gustave L Levy Place, Box 1230, New York, NY 10029, USA.
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83
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Predictors of performance monitoring abilities following traumatic brain injury: the influence of negative affect and cognitive sequelae. Int J Psychophysiol 2011; 82:61-8. [PMID: 21315777 DOI: 10.1016/j.ijpsycho.2011.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 11/22/2022]
Abstract
Performance monitoring is a cognitive control process modulated by both cognitive and affective variables. This study examined the relative contributions of negative affect (NA) and cognitive sequelae to performance monitoring dysfunction following severe traumatic brain injury (TBI). We used the error-related negativity (ERN) and post-error positivity (Pe) components of the event-related potential (ERP) to test the hypothesis that NA and cognitive sequelae would predict performance monitoring dysfunction beyond time since injury, and injury severity. Nineteen survivors of severe TBI completed neuropsychological tests, measures of NA, and a computerized Stroop task. Scores on NA and neuropsychological measures were standardized to form magnitude of cognitive sequelae and negative affect composite scores. Separate hierarchical regression analyses with ERN and Pe amplitudes as dependent variables and injury severity, time since injury, magnitude of cognitive sequelae, and NA as independent variables indicated that NA and cognitive sequelae significantly predicted ERN amplitude, with a larger relative contribution of NA than cognitive sequelae. Increased levels of NA were associated with decreased amplitude ERN. Cognitive sequelae, but not NA, predicted Pe amplitude. Injury severity and time since injury were not significant predictors. Results suggest that both NA and cognitive sequelae play critical roles in performance monitoring decrements following TBI and indicate a possible dissociation between the ERN and Pe, with the ERN more related to affective processes and the Pe to cognitive processes.
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Abstract
Cognitive rehabilitation interventions are theoretically based and empirically validated treatments designed to ameliorate the cognitive, behavioral, and emotional impairments commonly experienced by individuals with traumatic brain injury (TBI). Cognitive rehabilitation can play many roles in facilitating recovery after TBI, such as improving impaired cognitive functions, increasing awareness of injury-related deficits, improving mood, facilitating vocational and community involvement, and reducing the probability of secondary disability. The considerable evidence documenting the impact of cognitive rehabilitation on improving the day-to-day function of individuals with TBI is described.
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Affiliation(s)
- Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1240, New York, NY 10029-6574, USA. Kristen.dams-o'
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Caro DHJ. Towards systemic sustainable performance of TBI care systems: emergency leadership frontiers. Int J Emerg Med 2010; 3:357-65. [PMID: 21373305 PMCID: PMC3047861 DOI: 10.1007/s12245-010-0252-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 10/20/2010] [Indexed: 11/25/2022] Open
Abstract
Background Traumatic brain injuries (TBIs) continue as a twenty-first century subterranean and almost invisible scourge internationally. TBI care systems provide a safety net for survival, recovery, and reintegration into social communities from this scourge, particularly in Canada, the European Union, and the USA. Aims This paper examines the underlying issues of systemic performance and sustainability of TBI care systems, in the light of decreasing care resources and increasing demands for services. Methods This paper reviews the extant literature on TBI care systems, systems reengineering, and emergency leadership literature. Results This paper presents a seven care layer paradigm, which forms the essence of systemic performance in the care of patients with TBIs. It also identifies five key strategic drivers that hold promise for the future systemic sustainability of TBI care systems. Conclusions Transformational leadership and engagement from the international emergency medical community is the key to generating positive change. The sustainability/performance care framework is relevant and pertinent for consideration internationally and in the context of other emergency medical populations.
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Affiliation(s)
- Denis H. J. Caro
- Telfer School of Management/École de Gestion Telfer, University of Ottawa/Université d’Ottawa, 5141 Desmarais Building, 55 Laurier East, Ottawa, ON K1N 6N5 Canada
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Abstract
The neurobehavioral sequelae (NBS) of traumatic brain injury (TBI) consist of a spectrum of somatic, neurological, and psychiatric symptoms. The challenge for clinicians lies in understanding the interface of the various symptoms and how they interrelate with other entities. Specifically, the challenge is differentiating post-TBI-related symptoms from pre-existing or de novo psychiatric, neurological, and/or systemic disorders. A comprehensive evaluation and a multidisciplinary approach to evaluating patients are essential to be able to develop the differential diagnosis needed to design a management plan that maximizes recovery.
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87
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Olson-Madden JH, Brenner L, Harwood JE, Emrick CD, Corrigan JD, Thompson C. Traumatic Brain Injury and Psychiatric Diagnoses in Veterans Seeking Outpatient Substance Abuse Treatment. J Head Trauma Rehabil 2010; 25:470-9. [DOI: 10.1097/htr.0b013e3181d717a7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sen AN, Campbell PG, Yadla S, Jallo J, Sharan AD. Deep brain stimulation in the management of disorders of consciousness: a review of physiology, previous reports, and ethical considerations. Neurosurg Focus 2010; 29:E14. [DOI: 10.3171/2010.4.focus1096] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients suffering from disorders of consciousness constitute a population that exists largely outside of the daily practice patterns of neurosurgeons. Historically, treatment has focused on nursing and custodial issues with limited neurosurgical intervention. Recently, however, deep brain stimulation has been explored to restore cognitive and physical function to patients in minimally conscious states. In this article, the authors characterize the physiological mechanisms for the use of deep brain stimulation in persistently vegetative and minimally conscious patients, review published cases and associated ethical concerns, and discuss future directions of this technology.
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Affiliation(s)
- Anish N. Sen
- 1Jefferson Medical College, Thomas Jefferson University, and
| | - Peter G. Campbell
- 2Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Sanjay Yadla
- 2Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jack Jallo
- 2Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ashwini D. Sharan
- 2Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Brenner LA, Carlson NE, Harrison-Felix C, Ashman T, Hammond FM, Hirschberg RE. Self-inflicted traumatic brain injury: Characteristics and outcomes. Brain Inj 2010; 23:991-8. [PMID: 19891537 DOI: 10.3109/02699050903379362] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To characterize the population of those receiving inpatient rehabilitation who sustained a traumatic brain injury (TBI) secondary to a suicide attempt and identify differences between such individuals and a demographically-matched control group (n = 230) of those whose TBIs were of an unintentional aetiology. METHOD Analysed cases were identified from the TBI Model Systems National Database. Based on ICD-9-CM external cause-of-injury codes, 79 participants incurred a TBI secondary to a suicide attempt. An approximate 1 : 3 matched case-control (age, gender, race, injury year) design was chosen to make statistical comparisons. RESULTS Those who sustained a TBI secondary to a suicide attempt had greater pre-existing psychiatric and psychosocial problems (substance use problems (p = 0.01) prior suicide attempt (p < 0.0001), psychiatric hospitalization (p = 0.014) and non-productive activity (p = 0.014)), required more resources during acute and rehabilitative hospitalizations (i.e. charges per day; p = 0.024, p = 0.047) and had greater disability at the time of discharge, even after controlling for injury severity (p = 0.022). CONCLUSION Individuals who sustained TBIs secondary to a suicide attempt had increased pre-injury psychiatric and psychosocial problems and poorer outcomes at discharge than those who incurred unintentional injuries. For these individuals, acute and rehabilitation charges per day were higher and could not be accounted for by injury severity.
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Affiliation(s)
- Lisa A Brenner
- VA VISN Mental Illness Research Education and Clinical Center, Denver, Colorado 80223, USA.
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Clinical Considerations for the Diagnosis of Major Depression After Moderate to Severe TBI. J Head Trauma Rehabil 2010; 25:99-112. [DOI: 10.1097/htr.0b013e3181ce3966] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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91
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Treatment of a patient with traumatic brain injury-related severe self-injurious behavior. J Head Trauma Rehabil 2009; 24:292-6. [PMID: 19625868 DOI: 10.1097/htr.0b013e3181a8e11a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Report a case of severe self-injurious behavior (SIB), paying special attention to treatment. DESIGN Case report. PARTICIPANT A 26-year-old woman (H.S.) 8 years post-traumatic brain injury with a history of severe SIB. METHODS H.S. was treated over a 22-week period with combined behavioral and psychopharmacological interventions. RESULTS Marked reduction in SIB was noted after the interventions were initiated. CONCLUSION Behavioral treatment and medications may be useful tools in the treatment of SIB after traumatic brain injury.
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92
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Abstract
The neurobehavioral sequelae of traumatic brain injury consist of a spectrum of somatic and neuropsychiatric symptoms. The neuropsychiatric symptoms are divided into cognitive and behavioral presentations. In the literature, these neurobehavioral sequelae have been called postconcussive symptoms, postconcussive syndrome, and postconcussive disorder; however, the authors of this review do not use this terminology because the symptoms are not restricted to patients with concussion but instead can be found in all traumatic brain injury patients of all injury severities. The development of neurobehavioral sequelae after traumatic brain injury is a multifactorial process. The patient evaluation requires a multidisciplinary approach in order to delineate physiologic dysfunction and place deficits in the context of the patient's preinjury and postinjury psychiatric status. Consequently, the evaluation of the posttraumatic brain injury patient with neurobehavioral sequelae requires a carefully structured history and physical examination with an emphasis on neurological and psychiatric function. Adjunctive evaluations must be tailored to the patient with neuroimaging, neurophysiological, and neuropsychiatric testing. Maximized outcomes may be achieved by the performance of a careful and detailed assessment that places complaints within the context of the individual.
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Affiliation(s)
- Silvana Riggio
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA.
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Gutierrez PM, Brenner LA, Huggins JA. A preliminary investigation of suicidality in psychiatrically hospitalized veterans with traumatic brain injury. Arch Suicide Res 2008; 12:336-43. [PMID: 18828036 DOI: 10.1080/13811110802324961] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this study was to explore suicidal behaviors documented at time of discharge from acute psychiatric hospitalization. Data from 114 acute psychiatric admissions were reviewed for 22 veterans with a history of traumatic brain injury (TBI). Information extracted included presence of suicidal ideation, nature of suicide attempts, and TBI characteristics. The Lethality of Suicide Attempt Rating Scale was used to classify veterans' non-lethal self-harm behavior. Post-TBI, 6 patients (27.3%) made a total of 14 suicide attempts. Half of those attempts required wounds being sutured, stomach lavage, or other medical attention. Clinicians and researchers are strongly encouraged to focus increased attention on suicide prevention in those with a history of TBI.
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Affiliation(s)
- Peter M Gutierrez
- Department of Psychiatry, VA VISN 19 Mental Illness Research, Education, and Clinical Center, University of Colorado Denver, School of Medicine, Denver, CO 80220, USA.
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