Head injury among drug abusers: an indicator of co-occurring problems

Experiences of offenders with traumatic brain injury

Purpose:

Traumatic brain injury is recognised as a significant and pervasive health issue among offender populations. Despite this, no qualitative research exists exploring the experiences and perceptions of offenders with TBI in prison.

Methods:

Qualitative interviews were conducted with male and female offenders housed in a UK prison. Interviews examined what participants felt led them to offend, experiences of incarceration, and post-release plans. Presence of TBI was assessed via the Brain Injury Screening Index. Data were analysed by means of inductive content analysis.

Findings:

Both male and female prisoners primarily attributed their incarceration to drugs and alcohol use, with males also referencing more issues with aggression, while mental illness and past abuse were more commonly mentioned among females. A lack of recognition for the possible role of TBI was noted, with several males describing themselves as ‘stupid’ or prone to making ‘poor lifestyle choices’. Both groups indicated a desire to return to education or work post-release.

Conclusions:

Despite significant rates of injury, there is a clear lack of understanding and consideration of the role of TBI in the behaviour and presentation of offenders. There is need for improved identification and education around TBI early in the criminal justice process.

Recommendations for Prescribing Opioids for People With Traumatic Brain Injury

Our objective was to make recommendations intended to reduce the rate of opioid misuse and overdose for a particularly high-risk group of people with traumatic brain injury (TBI). A consensus process conducted with TBI researchers and expert practitioners developed practical recommendations to inform prescribing of opioids for people with TBI. After determining key general principles for prescribing opioids for people with TBI, 6 TBI-specific recommendations were developed, 1 for acute pain in the agitated patient with TBI, 3 recommendations to be considered before prescribing an opioid, and 2 for follow-up and use by mental health and substance use disorder providers. While there is much needed research to examine the relationship between opioid misuse and TBI, the present recommendations provide at least some clinical considerations that might serve to prevent further deaths among a high-risk group.

Living with suicidality following traumatic brain injury: a qualitative study

PURPOSE

Numbers of traumatic brain injury (TBI) are increasing, and with suicidality post-injury presenting at 3-4 times higher than in the general population, understanding this is crucial in reducing a devastating outcome. Given the lack of literature, this study investigated the experiences of living with suicidality after TBI.

METHODS

Interview data from nineteen participants with TBI from a Brain Injury Rehabilitation Unit (BIRU) in New South Wales (NSW), Australia were collected and thematically analyzed.

FINDINGS

The participants (predominantly male) sustained extremely severe injuries (median PTA 60 [IQR 81.0] days) and were in the chronic phase post-injury (median 8.0 [IQR 9.0] years). Six main themes were identified; Loss of sense of self, TBI as a hidden disability, Chronic but transient suicidality, Reliance, Protective factors, and Hope. Tentative relationships between themes and subthemes were identified.

CONCLUSION

Chronic suicidality after TBI was demonstrated consistently regardless of receiving long-term support. However, their engagement with protective factors such as social support, spirituality and positive personal qualities was identified. Implementing these as coping strategies during long-term rehabilitation may reduce the levels of suicidal distress. Implications, methodological considerations and future research were discussed, with the aim of improving experiences of individuals with TBI to reduce suicidality.

Association between traumatic brain injury and prison charges: a population-based cohort study

BACKGROUND

Traumatic Brain Injury (TBI) is a serious hidden health issue disproportionately affecting people who experience incarceration.

OBJECTIVE

We examined the association between TBI and serious disciplinary charges among men and women sentenced by the courts to terms of two or more years.

METHODS

The study originated in Ontario, Canada and used linked administrative health and correctional data. The cohort included adults experiencing their first federal sentence between 1998 and 2011 (N = 12,038). We examined disciplinary charges incurred 2 years post-sentence commencement. TBI was defined using the International Classification of Diseases (ICD-9 and ICD-10) diagnostic codes. Robust Poisson regression was conducted to assess the association between TBI and disciplinary charges.

FINDINGS

The prevalence of TBI for the full sample was 13.2%. One-third of adults with a recent TBI had a serious disciplinary charge. The unadjusted risk of incurring a serious charge for those with a history of TBI was 39% higher than those with no history of TBI (CI: 1.29-1.49). The adjusted risk was 1.14 (CI: 1.06-1.22).

CONCLUSIONS

TBI is a serious health concern that makes it difficult for incarcerants to adjust to prison. Additional support/resources are needed to support those with histories of TBI.

Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology

Executive function is an umbrella term that includes cognitive processes such as decision-making, impulse control, attention, behavioral flexibility, and working memory. Each of these processes depends largely upon monoaminergic (dopaminergic, serotonergic, and noradrenergic) neurotransmission in the frontal cortex, striatum, and hippocampus, among other brain areas. Traumatic brain injury (TBI) induces disruptions in monoaminergic signaling along several steps in the neurotransmission process - synthesis, distribution, and breakdown - and in turn, produces long-lasting deficits in several executive function domains. Understanding how TBI alters monoamingeric neurotransmission and executive function will advance basic knowledge of the underlying principles that govern executive function and potentially further treatment of cognitive deficits following such injury. In this review, we examine the influence of TBI on the following measures of executive function - impulsivity, behavioral flexibility, and working memory. We also describe monoaminergic-systems changes following TBI. Given that TBI patients experience alterations in monoaminergic signaling following injury, they may represent a unique population with regard to pharmacotherapy. We conclude this review by discussing some considerations for pharmacotherapy in the field of TBI.

The Building Bridges project: Linking disconnected service networks in acquired brain injury and criminal justice

People with acquired brain injury (ABI) are overrepresented in prison populations across many countries. An effective service response to reduce this trend requires collaboration between the ABI and criminal justice (CJ) sectors. The Building Bridges project piloted a novel professional development model designed to increase cross-sectoral knowledge and collaboration between the ABI and CJ sectors. A total of 178 service providers from Victoria, Australia, participated in six professional development forums that included content about ABI, policing, disability and legal supports, and correctional/post-release services. Participants came from the disability, criminal justice, and health and community service sectors. Using a pre-test-post-test design with 6-month follow-up, data were obtained via a project-specific questionnaire evaluating knowledge and behaviour change among participants. Statistically significant gains in knowledge were shown at post-test and maintained at follow-up. Work-related behaviours addressing ABI/CJ issues had increased significantly within both sectors at follow-up compared to the 6 months prior to the forum. Carefully constructed professional forums improved cross-silo collaboration in the ABI/CJ sectors. This pilot project illustrates effective use of existing service resources, and highlights training as an important part of a raft of initiatives needed to address the overrepresentation of people with ABI in the CJ system.

Head Injury and Substance Use in Young Adults

BACKGROUND

Prior studies suggest a link between head injuries and substance use but do not routinely capture mechanisms connecting the two.

OBJECTIVES

The goal of the study was to explore whether past head injuries predicted current substance use among young adults, taking factors such as stress, self-esteem, temper, and risk-taking into consideration.

METHODS

Data were drawn from a web-based survey conducted in 2014 and 2015 at a public university in the United States (n = 897). Questions were asked about history of head injuries as well as past 12-month binge drinking, marijuana use, and prescription drug misuse. To evaluate the association between head injury and substance use, two logistic regression models were performed for each substance. Head injury was first regressed on the outcome, then related risk factors were entered into the models to determine whether they explained any association between injury and outcome.

RESULTS

A history of multiple head injuries was associated with increased odds of bingeing, marijuana, and prescription drug use. Prior delinquency and risk-taking accounted for the associations with bingeing and marijuana use. Taking all variables into consideration, multiple head injuries were associated with greater odds for prescription drug misuse.

CONCLUSIONS

Results suggest the need to give consideration to a range of concomitant variables when considering behavioral outcomes associated with head injury. Head injuries may be a marker of a constellation of risk-taking behaviors that contributes to substance use. For those with multiple injuries, misuse of prescription drugs may be an attempt to cope with lingering side effects.

History of traumatic brain injury in prison populations: A systematic review

Traumatic brain injury (TBI) can lead to cognitive, behavioural and social impairments. The relationship between criminality and a history of TBI has been addressed on several occasions.

OBJECTIVE

The objective of this review was to present an update on current knowledge concerning the existence of a history of TBI in prison populations.

METHODS

PubMed and PsycINFO databases were searched for relevant papers, using the PRISMA guidelines. We selected papers describing TBI prevalence among incarcerated individuals and some that also discussed the validity of such studies.

RESULTS

Thirty-three papers were selected. The majority of the papers were on prison populations in Australia (3/33), Europe (5/33) and the USA (22/33). The selected studies found prevalence rates of the history of TBI ranging from 9.7% and 100%, with an average of 46% (calculated on a total population of 9342). However, the level of evidence provided by the literature was poor according to the French national health authority scale. The majority of the prisoners were males with an average age of 37. In most of the papers (25/33), prevalence was evaluated using a questionnaire. The influence of TBI severity on criminality could not be analysed because of a lack of data in the majority of papers. Twelve papers mentioned that several comorbidities (mental health problems, use of alcohol…) were frequently found among prisoners with a history of TBI. Two papers established the validity of the use of questionnaires to screen for a history of TBI.

CONCLUSION

These results confirmed the high prevalence of a history of TBI in prison populations. However, they do not allow conclusions to be drawn about a possible link between criminality and TBI. Specific surveys need to be performed to study this issue. The authors suggest ways of improving the screening and healthcare made available to these patients.

Traumatic brain injury among female offenders in a prison population: results of the FleuryTBI study

AIM

The study was designed to estimate the prevalence of traumatic brain injury (TBI) in a French prison population of female offenders, study the variables known to be associated with TBI, and compare our results with those obtained among male offenders as described in a previous paper.

PARTICIPANTS

All female offenders (adults and juveniles) consecutively admitted to Fleury-Mérogis prison over a 3-month period were included in the study.

METHOD

During the admission procedure, female offenders were interviewed by healthcare staff using a self-reported questionnaire.

RESULTS

In all, 100 female offenders were included. The rate of self-reported TBI was high, with a prevalence of 21%. The first cause of TBI was violence related (35%) and a majority of female offenders with a history of TBI reported having sustained more than one TBI. When compared with those who did not report a TBI, epilepsy and use of alcohol were higher among female offenders with a history of TBI. Perceived health was significantly worse for women who reported a TBI.

CONCLUSIONS

This study findings provide additional evidence that TBI among offender populations is serious and that specific actions need to be developed and implemented in correctional settings such as screening for TBI upon arrival.

Traumatic brain injury and co-occurring problems in prison populations: A systematic review

BACKGROUND

A growing body of epidemiological research suggests high rates of traumatic brain injury (TBI) in prisoners. The aim of this review is to systematically explore the literature surrounding the rates of TBI and their co-occurrences in a prison population.

METHODS

Six electronic databases were systematically searched for articles published between 1980-2014. Studies were screened for inclusion based on pre-determined criteria by two researchers who independently performed data extraction. Study quality was appraised based on a modified quality assessment tool.

RESULTS

Twenty-six studies were included in this review. Quality assessment ranged from 20% (poor) to 80% (good), with an overall average of 60%. Twenty-four papers included TBI prevalence rates, which ranged from 5.69-88%. Seventeen studies explored co-occurring factors including rates of aggression (n = 7), substance abuse (n = 9), anxiety and depression (n = 5), neurocognitive deficits (n = 4) and psychiatric conditions (n = 3).

CONCLUSIONS

The high degree of variation in TBI rates may be attributed to the inconsistent way in which TBI was measured, with only seven studies using valid and reliable screening tools. Additionally, gaps in the literature surrounding personality outcomes in prisoners with TBI, female prisoners with TBI and qualitative outcomes were found.

Relationships Between Traumatic Brain Injury and Illicit Drug Use and Their Association With Aggression in Inmates

Extensive interviews of correctional inmates in South Carolina (2009-2010) were conducted under a Center for Disease Control and Prevention (CDC) grant. We evaluated the extent to which early traumatic brain injury (TBI) and subsequent illicit drug abuse may conjointly influence development of aggression, controlling for alcohol use, and whether cognitive or emotional dysregulation mediated this relationship. Early TBI predicted greater severity and earlier onset of drug use, and an earlier age at first use predicted greater aggression regardless of the age of TBI. Emotional dysregulation mediated effects of TBI on aggression. The potential to design more targeted treatments for this susceptible population are discussed.

Prevalence of traumatic brain injury and epilepsy among prisoners in France: Results of the Fleury TBI study

OBJECTIVE

The first aim of this study was to estimate the prevalence of TBI and epilepsy in a French prison population and to study variables known to be associated with TBI. The second aim was to compare prisoners with and without a history of TBI.

PARTICIPANTS

All offenders (females, males and juveniles) admitted consecutively to Fleury-Mérogis prison over a period of 3 months were included in the study.

DESIGN

During the admission procedure, offenders were interviewed by healthcare staff using a self-reported questionnaire.

RESULTS

In all, 1221 prisoners were included. The rates of TBI and epilepsy were high, with a prevalence of 30.6% and 5.9%, respectively. Psychiatric care, anxiolytic and antidepressant treatment, use of alcohol and cannabis were all significantly higher among offenders with a history of TBI. Moreover, the number of times in custody and the total time spent in jail over the preceding 5 years were significantly higher among offenders with a history of TBI.

CONCLUSIONS

These results provide further evidence that specific measures need to be developed such as, first of all, screening for TBI upon arrival in prison.

Does Traumatic Brain Injury Lead to Criminality? A Whole-Population Retrospective Cohort Study Using Linked Data

Background

Traumatic brain injury (TBI) may be a risk factor for criminal behaviour however multiple factors potentially confound the association.

Methods

Record linkage and Cox proportional hazards regression analyses were used to examine the association between hospital-recorded TBI (n = 7,694) and subsequent first criminal conviction in a retrospective cohort matched 1:3 with 22,905 unaffected community controls and full-sibling controls (n = 2,397). Aboriginality, substance abuse, social disadvantage, and mental illness were included in analyses as potential confounders

Results

In multivariable models, relative to general population controls, TBI was associated with any conviction (males: Hazard Ratio (HR) = 1·58 (95% CI 1·46 to 1·72); females: HR = 1·52 (95% CI 1·28 to 1·81)); and similar Hazard Ratios were obtained for the sibling analyses in males (HR = 1.68 (95% CI 1.31-2.18)) and females (HR 1.27 (95% CI 0.71-2.29)). TBI was also associated with violent convictions relative to the general population, (males: HR = 1.65 (95% CI 1.42 to 1.92); females HR = 1.73 (95% CI 1.21 to 2.47)), and in analyses with sibling controls in men (HR = 1.89 (95% CI 1.20-3.00)), but not in women (HR 0.73, 95% CI 0.29-1.81)).

Conclusion

The results support a modest causal link between TBI and criminality after comprehensive adjustment for confounding. Reducing the rate of TBI, a major public health imperative, might have benefits in terms of crime reduction.

Prevalence of traumatic brain injury in cocaine-dependent research volunteers

BACKGROUND

There is a high prevalence of traumatic brain injury (TBI) among those with substance dependence. However, TBI often remains undiagnosed in these individuals, due to lack of routine screening in substance use treatment settings or due to overlap in some of the cognitive sequelae (eg impulsivity, disinhibition) of TBI and cocaine dependence.

METHODS

The prevalence of self-reported mild to moderate TBI in a group of cocaine-dependent (n = 95) and a group of healthy volunteers (n = 75) enrolled at the same facility was assessed. Additionally, the relationship between TBI and clinically relevant correlates, including impulsivity, cocaine use history, and treatment outcome in the cocaine-dependent group was also examined.

RESULTS

A higher proportion of individuals with cocaine dependence (29.5%) reported having suffered a TBI in their lifetime compared to controls (8%) on a Closed Head Injury scale. Among cocaine users, the average age of sustaining TBI was significantly lower than the age of initiating cocaine use. Presence of TBI was not associated with higher impulsivity on the Barratt Impulsiveness Scale-11 or self-reported years of cocaine use. No differences were noted on treatment outcome for cocaine dependence as measured by treatment effectiveness scores (TES) between cocaine users with TBI and their non-TBI counterparts.

CONCLUSIONS

These results are the first to highlight the high prevalence of TBI among individuals with cocaine dependence. This study underscores the possible role of TBI history as a risk factor for onset of cocaine use, however, more research is needed to determine the impact of co-morbid TBI as a complicating factor in the substance abuse treatment setting.

Prevalence of traumatic brain injury among prisoners in South Carolina

OBJECTIVE

To determine lifetime prevalence of traumatic brain injury (TBI) in a statewide sample of prisoners.

DESIGN

Retrospective and cross-sectional cohort study.

PARTICIPANTS

Stratified random sample of prisoners scheduled to be released by release type for each gender (275 men and 267 women with completed sentences and 19 men and 15 women granted parole) and a random sample of prisoners by gender with lifetime or death sentences (26 men and 34 women). PRIMARY MEASURE: Weighted prevalence of TBI. In-person interviews ascertained history of TBI using a customized version of the Ohio State University TBI Identification Method.

RESULTS

Sixty-five percent of male releases and nonreleases, and 72% and 73% of female releases and nonreleases, reported at least 1 TBI with an alteration of consciousness. Forty-two percent of male releases and 50% of nonreleases, and 50% of female releases and 33% of nonreleases, reported at least 1 TBI with loss of consciousness. Thirty-five percent of male releases and 42% of nonreleases, and 55% of female releases and 58% of nonreleases, reported ongoing symptoms from TBI.

CONCLUSIONS

A substantial proportion of prisoners reported having experienced a TBI during their lifetime. The ongoing TBI symptoms reported by prisoners may impact their success on release.

Substance use and mild traumatic brain injury risk reduction and prevention: a novel model for treatment

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.

A population-based study of repetitive traumatic brain injury among persons with traumatic brain injury

PRIMARY OBJECTIVE

The objective was to estimate and compare the hazards of repetitive traumatic brain injury (RTBI) events as a function of the index TBI severity, in a cohort of TBI hospital discharges include in the South Carolina Traumatic Brain Injury Follow-up Registry.

RESEARCH DESIGN

Retrospective cohort.

METHODS AND PROCEDURES

There were 4357 persons with TBI who were followed from the index hospital discharge through 31 December 2005 for RTBI events through the statewide hospital discharge (HD) and emergency department (ED) records. Prentice, Williams, Peterson total time/conditional probability model (PWP-CP) for recurrent events survival analysis was used to assess RTBI as a function of index TBI severity.

MAIN OUTCOMES AND RESULTS

Index TBI severity approached significance in its relationship with RTBI, with persons with a severe index TBI experiencing events at a higher rate than those with a mild/moderate index TBI. Among the other covariates evaluated, epilepsy/seizure disorder, race, gender, payer status, cause of injury and having a prior history of TBI were associated with RTBI.

CONCLUSIONS

While TBI severity approached significance with RTBI, other variables, such as epilepsy/seizure disorder, seem to have a more significant relationship with RTBI.

Pre-existing health conditions and repeat traumatic brain injury

OBJECTIVE

To assess and compare the effect of Pre-existing epilepsy/seizure disorder and drug/alcohol problem on the hazard of repeat traumatic brain injury (TBI) in persons with TBI who participated in a follow-up study.

DESIGN

Retrospective cohort.

SETTING

Acute care hospitals in South Carolina.

PARTICIPANTS

Participants were from the South Carolina Traumatic Brain Injury Follow-up Registry cohort of persons (N=2118) who were discharged from an acute care hospital in South Carolina and who participated in a year-1 follow-up interview.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Repeat TBI was defined by 2 isolated events of TBI in the same person at least 72 hours apart and recorded in hospital discharge or emergency department records from 1999 through 2005.

RESULTS

A Cox proportional hazards model was used to assess the associations of Pre-existing epilepsy/seizure disorder and drug/alcohol problem with time to repeat TBI, controlling for other confounding factors. There were 2099 persons with information on both Pre-existing conditions. There were 147 (7%) persons who sustained repeat TBI after recruitment to the follow-up study, and 82 (3.9%) had a previous TBI before recruitment for which they were seen in the hospital discharge or emergency department since 1996. The hazard of repeat TBI for persons with Pre-existing epilepsy/seizure disorder was 2.3 times the hazard for those without (hazard ratio, 2.3; 95% confidence interval, 1.2-4.4; P=.011). Pre-existing drug/alcohol problem was not associated with repeat TBI. Other variables significantly associated with repeat TBI were having a prior TBI, being insured under Medicaid, and having no insurance.

CONCLUSIONS

Pre-existing epilepsy/seizure disorder predisposes to repeat TBI. Appropriate management of seizure control may be an important strategy to allay the occurrence of repeat TBI.

Reliability and predictive validity of the Ohio State University TBI identification method with prisoners

OBJECTIVES

Evaluate the psychometric properties of indices of lifetime exposure to traumatic brain injury (TBI) among prisoners.

PARTICIPANTS

Convenience samples recruited from male (N = 105) and female (N = 105) state prison facilities.

DESIGN

Assess test/retest reliability and criterion-related validity.

PRIMARY MEASURES

Summary indices of the number, severity, timing, and effects of lifetime exposure to TBI calculated from data elicited via a structured interview.

RESULTS

Test/retest reliability ranged from acceptable to high. Factor analysis showed that indices of lifetime exposure could be characterized by (1) age of onset (especially childhood onset), (2) combinations of number and likely severity of injuries, and (3) number of symptoms and functional effects. Age at injury, number of TBIs with loss of consciousness, and symptoms persisting contributed independently to the prediction of common cognitive and behavioral consequences of TBI.

CONCLUSION

These results provide further support for the reliability and validity of summary indices of lifetime exposure to TBI when elicited via a structured interview.

An update on substance use and treatment following traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity among young adults. Substance abusers constitute a disproportionate percentage of these patients. A history of substance abuse predicts increased disability, poorer prognosis, and delayed recovery. While consensus in the literature indicates that substance-abuse rates decline following injury, conflicting literature shows a significant history of brain injury in addicts. We reviewed the literature on substance abuse after TBI to explore the state of knowledge on TBI as a risk factor for substance abuse. While recent reviews regarding substance abuse in TBI patients concur that substance-abuse rates decline even after mild TBI, an emerging literature suggests mild TBI may cause subtle impairments in cognitive, executive, and decision-making functions that are often poorly recognized in early diagnosis and treatment. When combined with difficulties in psychosocial adjustment and coping skills, these impairments may increase the risk for chronic substance abuse in a subset of TBI patients. Preliminary results from veterans indicate these patterns hold in a combat-related post-traumatic stress disorder population with TBI. This increasingly prevalent combination presents a specific challenge in rehabilitation. While this comorbidity presents a challenge for the successful treatment and rehabilitation of both disorders, there is sparse evidence to recommend any specific treatment strategy for these individuals. Mild TBI and substance abuse are bidirectionally related both for risks and treatment. Further understanding the neuropsychiatric pathology and different effects of different types of injuries will likely improve the implementation of effective treatments for each of these two conditions.

Psychiatric disorders and traumatic brain injury

Psychiatric disorders after traumatic brain injury (TBI) are frequent. Researches in this area are important for the patients' care and they may provide hints for the comprehension of primary psychiatric disorders. Here we approach epidemiology, diagnosis, associated factors and treatment of the main psychiatric disorders after TBI. Finally, the present situation of the knowledge in this field is discussed.

Psychiatric risk factors for traumatic brain injury

OBJECTIVE

To examine the risk of sustaining a traumatic brain injury (TBI) associated with prior psychiatric conditions beyond that of fixed demographic variables.

DESIGN

Retrospective cohort study of non-referred community-dwelling male US veterans.

METHODS

Two-hundred and seventy-one individuals who sustained a TBI with altered consciousness were compared with 630 controls without a history of head injury, selected from a larger sample of 3766.

RESULTS

Hierarchical logistic regression analyses were used to model odds ratios and 95% confidence intervals for the unique association between pre-existing psychiatric disorders and the likelihood of incurring a TBI while adjusting for demographic characteristics and other known predictor variables. Mood (odds ratio 2.48, 95% confidence interval 1.23-5.01), anxiety (OR 1.64, 95% CI 1.01-2.68) and conduct disorders (OR 1.66, 95% CI 1.16-2.38) increased the risk of head injury.

CONCLUSIONS

The pre-existence of psychiatric illness, particularly depression, anxiety and conduct disorder, increased the future risk of incurring a TBI. The implementation of early identification and treatment of psychiatric conditions may potentially lower risk and reduce yearly incidence rates of TBI.

Substance Use and Abuse in Trauma: Implications for Care

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.

A prospective examination of high-cost health services utilization among drug using prisoners reentering the community

The use of health services by prisoners during their incarceration and after their return to the community impacts the U.S. health care system and health care costs associated with this system. These health care costs are expected to increase over the next decade as more prisoners return to their communities. The current study prospectively examines the use of high-cost health care services-emergency room visits and hospitalizations-among 565 male drug-abusing prisoners about 1 year after prison release. A series of structural equation models were used to examine predisposing factors, including health status and drug use, and to estimate the frequency of high-cost health service utilization. As expected, health status was the most robust predictor of high-cost health services. However, the finding that drug abuse had nonsignificant relationships with high-cost health services utilization was not expected. Discussion focuses on health care service issues and health problems as prisoners' transition from prison to the community.

Neuropsychiatric consequences of traumatic brain injury: a review of recent findings

PURPOSE OF REVIEW

Behavioral and psychiatric disturbances are the more frequent consequences of traumatic brain injury and major determinants of the quality of life of patients. This review was designed to familiarize the reader with the more recent work published in this field.

RECENT FINDINGS

We have now a more consistent view of the epidemiology of post-traumatic brain injury psychiatric disorders both in adult and pediatric populations. Mood disorders, anxiety disorders and substance use disorders are the more prevalent psychiatric diagnoses among traumatic brain injury patients. The phenomenological characteristics and clinical correlates of major depression, post-traumatic stress disorder, alcohol use disorders, and post-traumatic brain injury attention deficit hyperactivity disorder have been studied in more detail. Newer structural, metabolic and functional neuroimaging techniques help to clarify the pathogenesis of these disorders. In turn, this knowledge may lead to the implementation of more efficient therapeutic interventions. Unfortunately, controlled treatment studies have been the exception in the field, and treatment decisions usually lack adequate empirical support.

SUMMARY

Recent advances in the basic neuroscience of traumatic brain injury as well as in behavioral genetics, social science and neuroimaging techniques should contribute to a better understanding of the pathophysiology of the psychiatric disorders occurring after the injury. There is a great need for randomized, double-blind, placebo-controlled trials to establish the most effective treatments for these disorders.