Validating the Traumatic Brain Injury-4 Screening Measure for Veterans Seeking Mental Health Treatment With Psychiatric Inpatient and Outpatient Service Utilization Data

Empirical clustering to identify individuals for whom insomnia is more closely related to suicidal ideation

BACKGROUND

Although the effect sizes are modest, insomnia is consistently associated with suicidal thoughts and behaviors. Subgroup analyses can efficiently identify for whom insomnia is most relevant to suicidal ideation. To improve clinical case identification, the present study sought to identify subclusters of lifetime suicidal ideators for whom insomnia was most closely related to current suicidal ideation.

METHODS

Data on N = 4750 lifetime suicidal ideators were extracted from the Military Suicide Research Consortium's Common Data Elements. Data on sociodemographic characteristics, severity and history of suicidal thoughts and behaviors, and related clinical characteristics were clustered by unsupervised machine learning algorithms. Robust Poisson regression estimated cluster by insomnia associations with current suicidal ideation.

RESULTS

Three clusters were identified: a modest symptom severity cluster (N = 1757, 37.0 %), an elevated severity cluster (N = 1444 30.4 %), and a high severity cluster (N = 1549 32.6 %). In Cluster 1, insomnia was associated with current suicidal ideation (PRR 1.29 [1.13-1.46]) and remained significant after adjusting for sociodemographic and clinical covariates. In Cluster 2, insomnia was associated with current suicidal ideation (PRR 1.14 [1.01-1.30]), but not after adjusting for sociodemographic and clinical covariates. In Cluster 3, insomnia was associated with current suicidal ideation (PRR 1.12 [1.03-1.21]) and remained significant after adjusting for sociodemographic covariates, but not clinical covariates.

LIMITATIONS

Cross-sectional design, lack of diagnostic data, non-representative sample.

CONCLUSION

Insomnia appears more closely related to current suicidal ideation among modest severity individuals than other subgroups. Future work should use prospective designs and more comprehensive risk factor measures to confirm these findings.

Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review

Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.

A systematic review on integrated care for traumatic brain injury, mental health, and substance use

Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU.

Trial registration: Prospero Registration: CRD42018108343.

Shared correlates of prescription drug misuse and severe suicide ideation among clinical patients at risk for suicide

OBJECTIVE

Unintentional drug overdose and suicide have emerged as public health problems. Prescription drug misuse can elevate risk of overdose. Severe suicidal ideation increases risk of suicide. We identified shared correlates of both risk factors to inform cross-cutting prevention efforts.

METHODS

We conducted a cross-sectional study using the Military Suicide Research Consortium's Common Data Elements survey; 2012-2017 baseline data collected from 10 research sites were analyzed. The sample included 3962 clinical patients at risk of suicide. Factors examined in relation to the outcomes, prescription drug misuse and severe suicidal ideation, included demographic characteristics and symptoms of: hopelessness; anxiety; post-traumatic stress disorder; alcohol use; other substance use; prior head/neck injury; insomnia; and belongingness. Poisson regression models with robust estimates provided adjusted prevalence ratios (aPRs) and 97.5% confidence intervals (CIs).

RESULTS

Medium and high (vs. low) levels of insomnia were positively associated with prescription drug misuse (aPRs p < 0.025). Medium (vs. low) level of insomnia was positively associated with severe suicidal ideation (aPR: 1.09; CI: 1.01-1.18). Medium and high (vs. low) levels of perceived belongingness were inversely associated with both outcomes (aPRs p < 0.025).

CONCLUSIONS

Research should evaluate whether addressing sleep problems and improving belongingness can reduce prescription drug misuse and suicidal ideation simultaneously.

Integrated Care: Provider referrer perceptions of occupational therapy services for homeless adults in an integrated primary care setting

BACKGROUND

Occupational therapists have a long history of addressing community performance and participation challenges faced by individuals with complex, chronic conditions, including those with serious mental illnesses (SMI) and cognitive issues that present with a traumatic brain injury (TBI). Healthcare reform has shifted incentives to support practices that promote successful community life for people with complex medical conditions. Community based care models emphasizing integrated primary care, such as Federally Qualified Health Centers (FQHC) are emerging, and a generalist role for occupational therapy is being defined. Those with complex comorbid conditions such as mental illness, substance abuse and traumatic brain injury are at risk for negative health outcomes that are further compounded by homelessness. There is a critical need to understand effective treatment options for this population to reduce the negative effects of chronic health conditions. As occupational therapists further define a role serving traditional clients in less traditional settings, such as the FQHC, it is helpful to explore the perceptions of the utility of OT services on the part of provider referrers.

OBJECTIVE

This study explored provider referrer perceptions of a new occupational therapy service for homeless adults in an FQHC to assist effective allocation of scarce resources.

METHODS

Twelve provider referrers at an FQHC were interviewed regarding their perception of the role and utility of occupational therapy in this setting. Interviews were then coded for themes.

RESULTS

Providers identified the unique value of occupational therapy, emphasizing critical information gleaned from the performance-based assessment of functional cognition, and the positive impact on team interactions and subsequent care decisions.

CONCLUSION

Occupational therapy provides a distinct perspective on client performance in FQHC settings indicating benefit for inclusion of services.

The Relationship between Suicidal Responses and Traumatic Brain Injury and Severe Insomnia in Active Duty, Veteran, and Civilian Populations

This study examined how a positive traumatic brain injury (TBI) screening and insomnia severity relate to suicidal outcomes across active duty, veteran, and civilian samples. Data were used from 3,993 participants from 19 studies. We conducted a series of analyses by group to identify which significantly differed on the variables of interest. TBI and insomnia each had independent relationships with outcomes over and above the impact of the other factor. Veterans presented as clinically worse across the outcomes. However, the relationship between insomnia and suicidal responses was stronger for active duty military compared to veterans. Continued research on TBIs and insomnia severity across groups will improve quality of care for those at risk of suicide.

The development of the Brain Injury Screening Index (BISI): A self-report measure

The aim of this study was to investigate the psychometric properties and screening accuracy of the Brain Injury Screening Index (BISI), a self-report questionnaire designed to identify a history of acquired brain injury. The study was conducted in a closed male prison in the UK. The purposive sample comprised 55 male prisoners who arrived at the establishment during the study. A repeated measures design was used, where the Brain Injury Screening Index (BISI) was administered on three occasions. Inter-rater reliability was poor to moderate, but test retest reliability was moderate to good. Medical records were not available for all participants, but the limited number obtained resulted in a sensitivity of .38 to .71 and specificity of .47 to .70 across the three screening administrations of the BISI. The limitations of the present findings are discussed in the context of the use of the tool in custodial environments. It is argued that these results suggest that, when used as recommended, the BISI has acceptable reliability and validity as an initial screen for identifying individuals who should receive support and a comprehensive neuropsychological assessment, and it merits further investigation and development.

The Military Suicide Research Consortium Common Data Elements: An Examination of Measurement Invariance Across Current Service Members and Veterans

Suicide rates within the U.S. military are elevated, necessitating greater efforts to identify those at increased risk. This study utilized a multigroup confirmatory factor analysis to examine measurement invariance of the Military Suicide Research Consortium Common Data Elements (CDEs) across current service members ( n = 2,015), younger veterans (<35 years; n = 377), and older veterans (≥35 years; n = 1,001). Strong factorial invariance was supported with adequate model fit observed for current service members, younger veterans, and older veterans. The structures of all models were generally comparable with few exceptions. The Military Suicide Research Consortium CDEs demonstrate at least adequate model fit for current military service members and veterans, regardless of age. Thus, the CDEs can be validly used across military and veteran populations. Given similar latent structures, research findings in one group may inform clinical and policy decision making for the other.

The Unique Health Needs of Post-9/11 U.S. Veterans

This article applies a hazard-based approach to the identification of physical, mental, and psychosocial health needs of post-9/11 veterans. The weaponry, survival, and population of servicemen and women by the military have evolved over time, particularly during the post-9/11 era. It is evident that military hazards and potential exposures vary depending on not only the deployment era but also the specific location and role. Many individual factors may affect the development of health problems. Recent evidence-based literature about post-9/11 veterans' long-term complex health issues is summarized, so occupational health nurses can advocate for the provision of veteran-sensitive care.

Comorbid Traumatic Brain Injury and Spinal Cord Injury: Screening Validity and Effect on Outcomes

OBJECTIVES

To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes.

DESIGN

Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI.

SETTING

Inpatient rehabilitation unit.

PARTICIPANTS

From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI.

RESULTS

Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%-93%), a specificity of 51% (95% confidence interval, 39%-64%), and a Youden Index of 0.3 (95% confidence interval, 0.2-0.5). Compared with those without TBI, those with chart review-determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes.

CONCLUSIONS

Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Combat-related Mild Traumatic Brain Injury: Association between Baseline Diffusion-Tensor Imaging Findings and Long-term Outcomes

Purpose To determine whether functional outcomes of veterans who sustained combat-related mild traumatic brain injury (TBI) are associated with scalar metrics derived from diffusion-tensor (DT) imaging at their initial postdeployment evaluation. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. From 2010 to 2013, initial postdeployment evaluation, including clinical assessment and brain magnetic resonance (MR) examination with DT imaging, was performed in combat veterans who sustained mild TBI while deployed. Outcomes from chart review encompassed initial postdeployment clinical assessment as well as later functional status, including evaluation of occupational status and health care utilization. Scalar diffusion metrics from the initial postdeployment evaluation were compared with outcomes by using multivariate analysis. Veterans who did and did not return to work were also compared for differences in clinical variables by using t and χ(2) tests. Results Postdeployment evaluation was performed a mean of 3.8 years after injury (range, 0.5-9 years; standard deviation, 2.5 years). After a mean follow-up of 1.4 years (range, 0.5-2.5 years; standard deviation, 0.8 year), 34 of 57 veterans (60%) had returned to work. Return to work was associated with diffusion metrics in multiple regions of white matter, particularly in the left internal capsule and the left frontal lobe (P = .02-.05). Overall, veterans had a mean of 46 health care visits per year during the follow-up period (range, 3-196 visits per year; standard deviation, 41 visits per year). Cumulative health care visits over time were inversely correlated with diffusion anisotropy of the splenium of the corpus callosum and adjacent parietal white matter (P < .05). Clinical measures obtained during initial postdeployment evaluation were not predictive of later functional status (P = .12-.8). Conclusion Differences in white matter microstructure may partially account for the variance in functional outcomes among veterans who sustained combat-related mild TBI. (©) RSNA, 2016.

Responses to Traumatic Brain Injury Screening Questions and Suicide Attempts among Those Seeking Veterans Health Administration Mental Health Services

BACKGROUND

Psychometrically sound screening tools available to aid in the identification of lifetime history of traumatic brain injury (TBI) are limited. As such, the Traumatic Brain Injury-4 (TBI-4) was developed and implemented in a Veterans Health Administration (VHA) mental health clinic. To provide information regarding both the predictive validity and clinical utility of the TBI-4, the relationship between screening results and future suicide attempts was evaluated.

OBJECTIVE

The aim of this study was to determine whether a positive screen on the TBI-4 was associated with increased risk for suicide attempt within 1-year post screening.

METHODS

The TBI-4 was administered to 1,097 Veterans at the time of mental health intake. Follow-up data regarding suicide attempts for the year post-mental health intake were obtained from suicide behavior reports (SBRs) in Veteran electronic medical records (EMRs). Fisher's exact tests were used to determine the proportion of suicide attempts by TBI-4 status.

RESULTS

In the year post TBI-4 screening, significantly more Veterans who screened positive had a documented suicide attempt as compared to those who screened negative (p = 0.003).

CONCLUSION

Those with a positive TBI screen at mental health intake had a higher proportion of SBRs than those who screened negative for TBI. Findings provided further psychometric support for the TBI-4. Moreover, results suggest the inclusion of this screen could prove to be helpful in identifying those who may be at risk for future suicide attempt within 1-year post screening.