Racial/ethnic disparities in mental health over the first 2 years after traumatic brain injury: a model systems study

Considering the Importance of Personal and Injury Factors Influencing Outcome After Traumatic Brain Injury

OBJECTIVE

Given the high variability in traumatic brain injury (TBI) outcomes and relative lack of examination of the influence of noninjury factors on outcome, this study aimed to examine factors associated with functional outcome at 1 and 2 years after moderate to severe TBI, including both preinjury and injury-related factors.

DESIGN

Observational cohort study.

SETTING

Inpatient hospital recruitment with outpatient follow-up at 1 and 2 years post injury.

PARTICIPANTS

Individuals with moderate to severe TBI were recruited prospectively into a Longitudinal Head Injury Outcome Study. Of the eligible 3253 individuals who were eligible, 1899 participants consented to the study (N=1899).

MAIN OUTCOME MEASURE

Functional outcome was measured using the Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

1476 participants (73.6% males) and 1365 participants (73% males) completed the GOS-E at 1 and 2 years post injury. They had a mean age at injury of 40 years and mean duration of post-traumatic amnesia (PTA) of 26 days. Good recovery, representing return to previous activities on the GOS-E (score 7-8), was present in 31% of participants at 1 year post injury and 33.5% at 2 years post injury. When predictor variables were entered into regression together, good outcome was significantly associated with not being from a culturally and linguistically diverse background and not having preinjury mental health or alcohol treatment, shorter PTA duration, and absence of limb injuries at both 1 and 2 years; higher education was also a significant predictor at 1 year post injury.

CONCLUSIONS

Alongside consideration of injury severity, understanding and addressing preinjury factors is important to maximize outcomes.

Community resource facilitation use by ethnic minority groups with traumatic brain injury in the Midwestern United States

OBJECTIVE

This study surveyed the use of community-based resource facilitation (RF) services by ethnic minority survivors of traumatic brain injury (TBI) living in the Midwestern United States.

METHOD

Past records of RF use by survivors of TBI were reviewed. Demographics and patterns of RF use across 3 ethnic groups were documented. Reported barriers to community integration related to ethnic identity were identified using Chi-square test of independence.

RESULTS

Ethnic minority survivors were less likely to use RF services than white survivors. Caucasian women and men utilized RF services at similar rates, whereas more African American men and Latina women used RF services. Caucasians received information about RF from a greater variety of sources than ethnic minority survivors. Ethnic identity was significantly associated with greater reported needs for TBI awareness.

CONCLUSIONS

A pattern of differential RF use by survivors from ethnic minority groups was noted, suggesting potential socio-cultural influences on help-seeking behavior after TBI. These factors should be considered to develop more accessible and equitable strategies of RF service referral and support. Future investigations of cultural perspectives of TBI and injury-related services may improve understanding of the likelihood and necessity of community-based RF service use by diverse populations.

Developing multidimensional participation profiles after traumatic brain injury: a TBI model systems study

Purpose. To characterize societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions.Materials and Methods. We conducted secondary analyses of a TBI Model Systems sub-study (N = 408). Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1-15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis.Results. A 4-class solution was identified as providing maximal statistical separation between profiles and being clinically meaningful based on profile demographic features. One profile group (48.5% of the sample) exhibited the "best" participation profile (High Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles.Conclusions. Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. The use of participation profiles may promote precision health interventions for community integration.Implications for RehabilitationOur study found unidimensional measures of societal participation in traumatic brain injury (TBI) populations that focus exclusively on frequency indicators may be overly simplistic and miss key subjective components of participationTaking a multidimensional perspective, we documented four meaningfully distinct participation subgroups (including both objective and subjective dimensions of societal participation) within the TBI rehabilitation populationMultidimensional profiles of participation may be used to group individuals with TBI into target groups for intervention (e.g., deeper goal assessment for individuals who do not rate standard participation activities as important, but also do not participate and do not feel enfranchised).

The experience of traumatic brain injury in a culturally and linguistically diverse sample in Australia

PURPOSE

Individuals from culturally and linguistically diverse (CALD) backgrounds experience poorer outcomes following traumatic brain injury (TBI), including poorer quality of life. The reasons for these poorer outcomes are unclear. Therefore, this study aimed to qualitatively investigate the experience of injury, rehabilitation, and recovery amongst individuals from a CALD background following TBI.

MATERIALS AND METHODS

Fifteen semi-structured interviews were conducted, and qualitatively analysed using reflexive thematic analysis.

RESULTS

It was demonstrated that: (a) the cognitive and behavioural consequences of TBI were accompanied by stigma and loss of independence; (b) participants held many beliefs related to their TBI, ranging from bad luck to acceptance. Participants' personal values and beliefs provided strength and resilience, with many viewing the injury as a positive event in their lives; (c) participants were appreciative of the high standard of care they received in hospital and rehabilitation, although communication barriers were experienced; (d) many participants identified with Australian culture, and few believed their cultural background negatively impacted their experience of TBI; (e) external support, particularly from family, was considered central to recovery.

CONCLUSION

These findings offer insight into the challenges CALD individuals face and factors that may facilitate their recovery and improve functional outcomes.

Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020

Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs.

METHODS

Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age.

RESULTS

Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans.

CONCLUSION

Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.

Influence of Foreign Versus US Nativity on the Trajectory of Functional Independence Over the 10 Years After Traumatic Brain Injury: A Model Systems Study

OBJECTIVE

Although racial/ethnic disparities have been documented in numerous outcomes after traumatic brain injury (TBI), research has yet to explore differences in rehabilitation outcomes based upon nativity (foreign-born vs US-born individuals). The purpose of this study was to compare the functional outcomes over the first 10 years after TBI for individuals born in the United States with those who were foreign-born.

SETTING/PARTICIPANTS

A sample of 10 695 individuals in the TBI Model Systems database with a coding for country of birth the United States ( n = 9435) versus other than the United States ( n = 1260) was used.

DESIGN/MAIN MEASURES

Outcome measures at 1, 2, 5, and 10 years after TBI included the Motor and Cognitive subscales of the Functional Independence Measure and the Supervision Rating Scale.

RESULTS

Foreign-born individuals exhibited lower motor functional independence trajectories than those born in the United States, even after controlling for demographic and injury-related covariates. However, foreign-born individuals generally showed a stronger upward quadratic trajectory in motor functional independence with the greatest gains between the 5- and 10-year time points, whereas those born in the United States improved more quickly but then plateaued between the 5- and 10-year time points; these differential effects over time dissipated with the addition of demographic and injury-related covariates. Foreign-born individuals also exhibited lower cognitive functional independence trajectories, as well as greater supervision needs trajectories, than those born in the United States, even after controlling for demographic and injury-related covariates.

CONCLUSION

These findings dovetail with literature suggesting that racially/ethnically diverse groups exhibit reduced functional independence after TBI. The findings may also suggest potential systematic barriers such as healthcare access and language barriers that may influence the frequency, rate, and quality of care received. The results highlight the importance of uncovering cultural distinctions and can aid in facilitating research examining foreign nativity-based disparities following TBI.

An Examination of Racial/Ethnic Differences on the Neurobehavioral Symptom Inventory Among Veterans Completing the Comprehensive Traumatic Brain Injury Evaluation: A Veterans Affairs Million Veteran Program Study

OBJECTIVE

The purpose of this study was to explore racial/ethnic differences in neurobehavioral symptom reporting and symptom validity testing among military veterans with a history of traumatic brain injury (TBI).

METHOD

Participants of this observational cross-sectional study (N = 9,646) were post-deployed Iraq-/Afghanistan-era veterans enrolled in the VA's Million Veteran Program with a clinician-confirmed history of TBI on the Comprehensive TBI Evaluation (CTBIE). Racial/ethnic groups included White, Black, Hispanic, Asian, Multiracial, Another Race, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. Dependent variables included neurobehavioral symptom domains and symptom validity assessed via the Neurobehavioral Symptom Inventory (NSI) and Validity-10, respectively.

RESULTS

Chi-square analyses showed significant racial/ethnic group differences for vestibular, somatic/sensory, and affective symptoms as well as for all Validity-10 cutoff scores examined (≥33, ≥27, ≥26, >22, ≥22, ≥13, and ≥7). Follow-up analyses compared all racial/ethnic groups to one another, adjusting for sociodemographic- and injury-related characteristics. These analyses revealed that the affective symptom domain and the Validity-10 cutoff of ≥13 revealed the greatest number of racial/ethnic differences.

CONCLUSIONS

Results showed significant racial/ethnic group differences on neurobehavioral symptom domains and symptom validity testing among veterans who completed the CTBIE. An enhanced understanding of how symptoms vary by race/ethnicity is vital so that clinical care can be appropriately tailored to the unique needs of all veterans. Results highlight the importance of establishing measurement invariance of the NSI across race/ethnicity and underscore the need for ongoing research to determine the most appropriate Validity-10 cutoff score(s) to use across racially/ethnically diverse veterans.

Post-Burn Psychosocial Outcomes in Pediatric Minority Patients in the United States: An Observational Cohort Burn Model System Study

Racial and ethnic minority burn patients face barriers to longitudinal psychosocial support after injury. Studies utilizing the Burn Model System (BMS) National Database report adult minority patients experience worse psychosocial outcomes in domains such as body image during burn recovery. No study to date has investigated disparities in psychosocial outcomes by racial or ethnic category in the pediatric population using the BMS database. This observational cohort study addresses this gap and examines seven psychosocial outcomes (levels of anger, sadness, depression, anxiety, fatigue, peer relationships, and pain) in pediatric burn patients. The BMS database is a national collection of burn patient outcomes from four centers in the United States. BMS outcomes collected were analyzed using multi-level, linear mixed effects regression modeling to examine associations between race/ethnicity and outcomes at discharge after index hospitalization, and 6- and 12-months post-injury. A total of 275 pediatric patients were included, of which 199 (72.3%) were Hispanic. After burn injury, of which the total body surface area was significantly associated with racial/ethnicity category (p < 0.01), minority patients more often reported higher levels of sadness, fatigue, and pain interference and lower levels of peer relationships compared to Non-Hispanic, White patients, although no significant differences existed. Black patients reported significantly increased sadness at six months (β = 9.31, p = 0.02) compared to discharge. Following burn injury, adult minority patients report significantly worse psychosocial outcomes than non-minority patients. However, these differences are less profound in pediatric populations. Further investigation is needed to understand why this change happens as individuals become adults.

Traumatic brain injury as a chronic disease: insights from the United States Traumatic Brain Injury Model Systems Research Program

Traumatic brain injury (TBI) is a global health priority, associated with substantial burden. Historically conceptualised as an injury event with finite recovery, TBI is now recognised as a chronic condition that can affect multiple domains of health and function, some of which might deteriorate over time. Many people who have had a TBI remain moderately to severely disabled at 5 years, are rehospitalised up to 10 years post-injury, and have a reduced lifespan relative to the general population. Understanding TBI as a chronic disease process can be highly informative for optimising care, which has traditionally focused on acute care. Chronic brain injury care models must be informed by a holistic understanding of long-term outcomes and the factors that can affect how care needs evolve over time. The United States Traumatic Brain Injury Model Systems of Care follows up individuals with moderate-to-severe TBI for over 30 years, allowing characterisation of the chronic (2-30 years or more post injury) functional, cognitive, behavioural, and social sequelae experienced by individuals who have had a moderate-to-severe TBI and the implications for their health and quality of life. Older age, social determinants of health, and lower acute functional status are associated with post-recovery deterioration, while younger age and greater functional independence are associated with risky health behaviours, including substance misuse and re-injury. Systematically collected data on long-term outcomes across multiple domains of health and function are needed worldwide to inform the development of models for chronic disease management, including the proactive surveillance of commonly experienced health and functional challenges.

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A veterans affairs model systems study

BACKGROUND

Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI).

OBJECTIVE

This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five VA TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs).

METHODS

Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89) and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling.

RESULTS

Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories.

CONCLUSION

The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

U.S. vs. Foreign Nativity and 10-Year Trajectories of Mental Health after Traumatic Brain Injury: A Model Systems Study

BACKGROUND

Previous research has found racial and ethnic disparities in life satisfaction, depression, and anxiety after traumatic brain injury (TBI). However, limited studies have examined differences in these variables between U.S.- and foreign-born individuals with TBI. The purpose of this study was to examine whether differences exist in mental health outcomes between U.S.- and foreign-born individuals with TBI at 1, 2, 5, and 10 years after injury, as well as examine whether demographic and injury-related characteristics account for these differences.

METHOD

Participants were 8289 individuals with TBI who identified as U.S.-born and 944 who identified as born outside the U.S. in the TBI Model Systems study. Participants completed measures of mental health outcomes at 1, 2, 5, and 10 years after injury.

RESULTS

Foreign-born individuals with TBI had comparable levels of depression and anxiety trajectories to U.S.-born individuals, yet higher life satisfaction trajectories, even after controlling for demographic and injury-related variables.

CONCLUSION

Rehabilitation professionals should consider in their clinical work the mechanisms that likely influence mental health outcomes among foreign-born individuals, including family-based values that increase resilience, as well as the possible under-reporting of mental health symptoms along the lines of cultural norms.

Factors Associated With High and Low Life Satisfaction 10 Years After Traumatic Brain Injury

OBJECTIVE

To identify correlates of life satisfaction at 10 years after moderate to severe traumatic brain injury (TBI) using an extreme phenotyping approach.

DESIGN

Effect sizes were calculated in this observational cohort study to estimate relationships of 10-year postinjury extremely high, extremely low, and moderate life satisfaction with (1) pre-injury demographics, injury-related factors, and functional characteristics at inpatient rehabilitation admission and discharge; and (2) postinjury demographics and clinical and functional measures at 10 years postinjury.

SETTING

Multicenter longitudinal database study.

PARTICIPANTS

People identified from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Database with life satisfaction data at 10 years post TBI (N=4800).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Satisfaction With Life Scale.

RESULTS

Although few pre-injury factors or clinical and functional factors shortly after injury were associated with 10-year life satisfaction groups, the following 10-year postinjury factors were associated with extremely high vs extremely low life satisfaction group membership: greater independent functioning, less disability, more frequent community participation, being employed, and having fewer depressive and anxiety symptoms. Those with extremely high life satisfaction were distinctly different from those with moderate and extremely low satisfaction. Extremely high life satisfaction was underrepresented among non-Hispanic Black persons relative to non-Hispanic White persons. Relationships between life satisfaction and independent functioning, disability, and participation were attenuated among non-Hispanic Black persons.

CONCLUSIONS

Extreme phenotyping analysis complements existing knowledge regarding life satisfaction after moderate to severe TBI and may inform acute and postacute clinical service delivery by comparing extremely high and extremely low life satisfaction subgroups. Findings suggest little association among personal, clinical, and functional characteristics early post TBI and life satisfaction 10 years later. Contemporaneous correlates of extremely high life satisfaction exist at 10 years post TBI, although the positive relationship of these variables to life satisfaction may be attenuated for non-Hispanic Black persons.

Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury

Objective

The aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI).

Methods

Individuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio.

Results

After adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models.

Conclusion

This exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.

Differences in the prevalence of mental health disorders among Black American adults with sickle cell disease compared to those with non-heritable medical conditions or no medical conditions

Our aim was to determine differences in the prevalence of mental health disorders between Black Americans living with sickle cell disease (SCD) and Black Americans with other, non-heritable medical conditions, or no medical conditions. We examined the prevalence of mental health disorders among a non-institutionalized, community sample of Black adults in the US from the National Survey of American Life. We compared the odds of mental health disorders between Black American adults with SCD and those with other medical conditions, or no medical condition. Among the SCD group, 38·8% reported at least one mental health disorder: 17·6% endorsed a mood disorder, 24·7% an anxiety disorder, 2·4% an eating disorder, and 11·8% a childhood disorder. Compared to those with other medical conditions, Black Americans with SCD had greater poverty, more children in the household, and were less likely to be married/cohabitating (all P < 0·05). Yet, Black Americans with SCD were not at greater odds of having a mental health disorder compared to those with other medical conditions. When compared to the group with no conditions, however, individuals with SCD had 2·57 greater odds of mood disorder (95% confidence interval: 1·43-4·65; P = 0·002). The effect remained when controlling for socioeconomic status, marital status, and perceived physical health. In this study, almost 40% of Black American adults with SCD presented with a mental health disorder. Prevalence of mental health disorders was similar among those with non-heritable medical conditions, but those without a medical condition had a lower prevalence than in SCD. Among Black Americans, there appear to be unmeasured factors, common across medical conditions, that are linked to mental health disorders.

Identifying group-based patterns of suicidal ideation over the first 10 years after moderate-to-severe TBI

OBJECTIVE

To identify group-based patterns in suicidal ideation (SI) over the first 10 years after traumatic brain injury (TBI).

METHODS

Participants included 9539 individuals in the TBI Model Systems National Database who responded to Patient Health Questionnaire-9 Item 9 assessing SI at 1, 2, 5, and/or 10 years post-injury. A k-means cluster analysis was conducted to determine group-based patterns of SI, and pre-injury variables were compared with ANOVAs and chi-square tests.

RESULTS

SI and attempts decreased over time. Four group-based patterns emerged: Low, increasing, moderate, and decreasing SI. The low SI group comprised 89% of the sample, had the highest pre-injury employment, fewer mental health vulnerabilities, least severe injuries, and were oldest. The increasing SI group had the most severe TBIs, were youngest, and disproportionately Black or Asian/Pacific Islander.

CONCLUSION

These findings reinforce the importance of mental health and suicide risk assessment during chronic recovery from TBI.

The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury

BACKGROUND

Many United States veterans and active military with a history of traumatic brain injury (TBI) also experience challenges from comorbid posttraumatic stress disorder (PTSD), yet the additional burden of PTSD is not clear.

PURPOSE

To address this knowledge gap, this study examined the relationship of PTSD to cognitive, social, and physical functioning and depressive symptoms in veterans recently diagnosed with TBI.

METHODS

Veterans were recruited from a VA rehabilitation clinic. The Patient Competency Rating Scale and Center for Epidemiologic Studies Depression Scale measured functioning and depression, respectively. Chart review captured PTSD diagnosis.

FINDINGS

In the sample of 83 veterans, 65% had a current PTSD diagnosis. After controlling for sociodemographic variables and TBI severity, PTSD was a significant predictor of lower cognitive, social, and physical functioning and higher depressive symptomatology.

DISCUSSION

Clinicians should incorporate PTSD assessment in their work with veterans with TBI. Integrated behavioral health and rehabilitation interventions that provide strategies for veterans to manage TBI symptoms and PTSD are critical.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

Cohort Differences in Neurobehavioral Symptoms in Chronic Mild to Severe Traumatic Brain Injury

Our understanding of neurobehavioral symptoms after traumatic brain injury (TBI) largely relies on data gathered in studies conducted at academic medical centers or large clinical centers with research infrastructure. Though this often provides a well-characterized clinical sample, it may also introduce bias based on geographic locations served by these institutions and personal factors associated with patient access to these institutions. We collected neurobehavioral symptoms via the self-reported Behavioral Assessment Screening Tool (BAST) in a National TBI Cohort (n = 263) and a Medical Center TBI Cohort (n = 218) of English-speaking community-dwelling adults with chronic TBI. The primary focus of the present study was to compare demographics and neurobehavioral symptom reporting across the two cohorts and to discuss the implications of any such differences on interpretation of symptom scores. Across all BAST subscales (Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse), participants in the National TBI Cohort reported significantly more frequent symptoms than those in the Medical Center TBI Cohort (p's < 0.001). Participants in the National TBI Cohort were more likely to be non-White and Hispanic compared to the Medical Center TBI Cohort, and those with mild TBI in the National TBI Cohort were more likely to have less than a high school education than those with mild TBI in the Medical Center TBI Cohort. Individuals with TBI recruited through academic and clinical institutions may not be representative of individuals with TBI living across the United States.

Neurobehavioral Symptoms in Community-Dwelling Adults With and Without Chronic Traumatic Brain Injury: Differences by Age, Gender, Education, and Health Condition

Neurobehavioral symptoms after Traumatic Brain Injury (TBI) are prevalent, persist for many years, and negatively affect long-term health, function, and quality of life. Symptoms may differ based on age, gender, education, race, ethnicity, and injury severity. To better understand neurobehavioral functioning after TBI, we need a comprehensive picture of emotional, cognitive, and behavioral symptoms in the context of personal factors that may affect these symptoms. We also need to understand the extent to which these symptoms are specific to TBI, shared across other neurological conditions, or attributable to factors outside of the injury itself. We collected neurobehavioral symptoms via the self-reported Behavioral Assessment Screening Tool (BAST) in a National Cohort of English (n = 2,511) and Spanish speaking (n = 350) community-dwelling adults with and without chronic TBI and other neurological and mental health conditions. The primary focus of the present study was to comprehensively describe neurobehavioral symptoms in adults with and without TBI, broken down by gender and health conditions and then further by age group or educational attainment. As expected, participants with TBI reported more symptoms than Healthy Controls. Regardless of condition, women reported more fatigue, while men reported more substance abuse and impulsivity. Hispanic participants reported more neurobehavioral symptoms than non-Hispanic participants did across health conditions, though primarily Spanish-speakers reported fewer symptoms than English-speakers, suggesting that level of acculturation may contribute to symptom reporting. These data provide a comprehensive characterization of neurobehavioral symptoms in adults with TBI and adults without TBI (healthy controls, adults with other neurological conditions, and adults with mental health conditions).

Racial Disparities in Outpatient Mental Health Service Use Among Children Hospitalized for Traumatic Brain Injury

OBJECTIVE

To examine racial differences in mental health service utilization after hospitalization for traumatic brain injury (TBI) among children with Medicaid insurance.

DESIGN AND MAIN MEASURES

Retrospective analysis of the MarketScan Multi-State Medicaid database from 2007 to 2012 was performed. Outpatient mental health service utilization (psychiatric and psychological individual and group services) was compared at TBI hospitalization, from discharge to 3 months and from 4 to 12 months after discharge, between children of non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and "Other" racial groups. Multivariable mixed-effects Poisson regression models with robust standard errors were utilized.

RESULTS

A total of 5674 children (aged <21 years) were included in the study. There were no differences by race/ethnicity in mental health service utilization during hospitalization. At 3 months postdischarge, NHB children and children in the "Other" racial category were significantly less likely to receive outpatient mental health services than NHW children (NHB relative risk [RR] = 0.84; 95% confidence interval [CI], 0.72-0.98; Other RR = 0.72; 95% CI, 0.57-0.90). At 12 months, all racial minority children were significantly less likely to receive outpatient mental health services than NHW children (NHB RR = 0.84; 95% CI, 0.75-0.94; Hispanic RR = 0.72; 95% CI, 0.55-0.94; Other RR = 0.71; 95% CI, 0.60-0.84).

CONCLUSIONS

Racial disparities in utilization of outpatient mental health services exist for minority children hospitalized for TBI and insured by Medicaid. Future research should focus on improving transitions of care from inpatient to outpatient services for these children.

Trajectories of racial and gender health disparities during later midlife: Connections to personality

OBJECTIVE

We examined race/gender effects on initial levels and trajectories of self-reported physical and mental health, as well as the moderating role of personality. We hypothesized that health disparities would remain stable or decrease over time, and that at-risk personality traits (e.g., neuroticism) would have a more robust negative impact on health for Black participants.

METHOD

Analyses utilized 6 waves of data from a community sample of 1,577 Black and White adults (mean age 60 years), assessed every 6 months for 2.5 years. Using multigroup latent growth curve modeling, we examined initial levels and changes in health among White men, White women, Black men, and Black women.

RESULTS

Black participants reported lower initial physical health than Whites. Women's physical health was stable over time, whereas men's declined. There were no disparities in mental health. Higher agreeableness was associated with higher initial levels of physical health only among Black men and White women. All other personality traits were associated with physical and mental health similarly across race and gender.

CONCLUSIONS

Race and gender influence health trajectories. Most personality- health associations replicated across race and gender, except for agreeableness with physical health. An intersectional framework considering more than one aspect of social identity is crucial for understanding health disparities. Future studies may benefit from including large, diverse samples of participants and further examining the moderating effects of race and gender on personality associations with a variety of health outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study

Cross-sectional approaches to outcome assessment may not adequately capture heterogeneity in recovery after traumatic brain injury (TBI). Using latent class mixed models (LCMM), a data-driven analytic that identifies groups of patients with similar trajectories, we identified distinct 6 month functional recovery trajectories in a large cohort (n = 1046) of adults 18-70 years of age with complicated mild to severe TBI who participated in the Citicoline Brain Injury Treatment Trial (COBRIT). We used multinomial logistic fixed effect models and backward elimination, forward selection, and forward stepwise selection with several stopping rules to explore baseline predictors of functional recovery trajectory. Based on statistical and clinical considerations, the seven-class model was deemed superior. Visualization of these seven functional recovery trajectories revealed that each trajectory class started at one of three recovery levels at 1 month, which, for ease of reference we labeled groups A-C: Group A, good recovery (two classes; A1 and A2); Group B, moderate disability (two classes; B1 and B2); and Group C, severe disability (three classes; C1, C2, and C3). By 6 months, these three groups experienced dramatically divergent trajectories. Group A experienced stable good recovery (A1, n = 115) or dramatic decline (A2, n = 4); Group B experienced rapid complete recovery (B1, n = 71) or gradual recovery (B2, n = 742); Group C experienced dramatic rapid recovery (C1, n = 12), no recovery (C2, n = 91), or death (C3, n = 11). Trajectory class membership was not predicted by citicoline treatment (p = 0.57). The models identified demographic, pre-injury, and injury-related predictors of functional recovery trajectory, including: age, race, education, pre-injury employment, pre-injury diabetes, pre-injury psychiatric disorder, site, Glasgow Coma Scale (GCS) score, post-traumatic amnesia, TBI mechanism, major extracranial injury, hemoglobin, and acute computed tomographic (CT) findings. GCS was the most consistently selected predictor across all models. All models also selected at least one demographic or pre-injury medical predictor. LCMM successfully identified dramatically divergent, clinically meaningful 6 month recovery trajectories with utility to inform clinical trial design.

Psychological distress among persons with upper extremity limb loss

OBJECTIVE

We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL).

DESIGN

A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States.

METHODS

Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects.

RESULTS

Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress.

CONCLUSIONS

These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference's contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample

This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.

Life After: Examining the Relationship Between Sociobehavioral Factors and Mental Health Among African American Ex-Offenders

Mental health problems are 3 times higher among prisoners than the general population. After release, reentry barriers and other factors can exacerbate mental problems. This study of 250 African American ex-offenders examines the relationship between sociobehavioral factors and mental health. Independent variables included self-reported health, alcohol use, employment, and history of mental problems before prison. Covariates included the number of immediate family with mental problems and the number of serious conflicts with family members or friends. Analyses revealed that men who had serious conflicts, used alcohol more often, reported less than excellent health, and not employed were more likely to report being troubled by mental problems. Family mental health history was not statistically significant. The current study adds to the literature by identifying selected factors associated with the mental health of African American male, ex-offenders. Findings from this study can inform interventions to address mental health issues and reduce recidivism.

The impact of cultural background on outcome following traumatic brain injury

Most traumatic brain injury (TBI) outcome studies have been conducted in developed countries involving individuals from the dominant culture. The present study compared outcomes following TBI in individuals from Culturally and Linguistically Diverse (CALD) backgrounds with those from non-CALD backgrounds. 103 CALD and 103 non-CALD participants with predominantly moderate to severe TBI completed a series of questionnaires an average of 22 months post-injury. Groups were comparable in most demographic and injury-related variables, but CALD participants had lower pre-injury employment rates. Individuals in the CALD group were significantly less independent in light domestic duties, shopping, and financial management and reported significantly lower cognitive independence, mobility, and participation in occupational and social activities than non-CALD participants post-injury. They also reported heightened awareness of post-injury deficits, different beliefs regarding injury consequences and factors aiding recovery, more anxiety and depression symptoms, and less problem-focused coping. Higher functional outcome was associated with having a value system that is Australian, younger age at injury, and higher education. Overall, independent of rehabilitation access, individuals from a CALD background showed poorer functional outcome following TBI than those from a non-CALD background. Addressing this discrepancy should be a priority for rehabilitation programmes.

Proof-of-Concept Testing of a Real-Time mHealth Measure to Estimate Postural Control During Walking: A Potential Application for Mild Traumatic Brain Injuries

Background: Most individuals with mild traumatic brain injury (mTBI) experience post-injury deficits in postural control. Currently available measures of postural control are lab-based or supervised, which may hinder timely symptom assessment for individuals with mTBI, including Asian populations, who do not seek initial screening post-injury. In this proof-of-concept testing study, we introduce a real-time mobile health (mHealth) system to measure postural control during walking. The proposed mHealth system can be used for home-based symptom assessment and management of mTBI.

Methods: In our proposed mHealth system, a smartwatch, a smartphone, and a cloud server communicate to measure, collect, and store body balance data in real time. Specifically, we focus on the rotation vector data that have been reported to be the most effective in terms of differentiating balance control during walking across different participants.

Results: Constant motion change in four participants (two females and two males; three healthy participants, and one individual with reduced physical mobility) was collected and analyzed. The results of our data analysis show that, compared to healthy participants, the individual was reduced physical mobility had a wider range of motion between right and left, up and down, and forward and backward while walking. We also found that female participants had narrower ranges of right-to-left and up-and-down motions than their male counterparts.

Conclusions: Our results highlight the potential of the proposed real-time mHealth system for home-based symptom assessment and management of mTBI, which may benefit Asian and other nonwhite racial minority groups that appear to be more reluctant to access post-acute rehabilitation services.

A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges

Depression is one of the most common conditions to emerge after traumatic brain injury (TBI), and despite its potentially serious consequences it remains undertreated. Treatment for post-traumatic depression (PTD) is complicated due to the multifactorial etiology of PTD, ranging from biological pathways to psychosocial adjustment. Identifying the unique, personalized factors contributing to the development of PTD could improve long-term treatment and management for individuals with TBI. The purpose of this narrative literature review was to summarize the prevalence and impact of PTD among those with moderate to severe TBI and to discuss current challenges in its management. Overall, PTD has an estimated point prevalence of 30%, with 50% of individuals with moderate to severe TBI experiencing an episode of PTD in the first year after injury alone. PTD has significant implications for health, leading to more hospitalizations and greater caregiver burden, for participation, reducing rates of return to work and affecting social relationships, and for quality of life. PTD may develop directly or indirectly as a result of biological changes after injury, most notably post-injury inflammation, or through psychological and psychosocial factors, including pre injury personal characteristics and post-injury adjustment to disability. Current evidence for effective treatments is limited, although the strongest evidence supports antidepressants and cognitive behavioral interventions. More personalized approaches to treatment and further research into unique therapy combinations may improve the management of PTD and improve the health, functioning, and quality of life for individuals with TBI.