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Aaronson AL, Smith B, Krese K, Barnhart M, Adamson M, de Wit H, Philip NS, Brenner LA, Bender-Pape T, Herrold AA. Impulsivity and Psychiatric Diagnoses as Mediators of Suicidal Ideation and Suicide Attempts Among Veterans With Traumatic Brain Injury. J Neuropsychiatry Clin Neurosci 2024; 36:125-133. [PMID: 38192217 PMCID: PMC11018458 DOI: 10.1176/appi.neuropsych.20230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a risk factor for suicide, but questions related to mechanisms remain unanswered. Impulsivity is a risk factor for suicide and is a common sequela of TBI. The authors explored the relationships between TBI and both suicidal ideation and suicide attempts and explored whether impulsivity and comorbid psychiatric diagnoses mediate these relationships. METHODS This cross-sectional retrospective chart review study included 164 veterans enrolled in a previous study. Sixty-nine veterans had no TBI history, and 95 had a TBI history (mild, N=44; moderate, N=13; severe, N=12; and unclear severity, N=26). To examine the associations between TBI and suicidal ideation or suicide attempts, as well as potential mediators of these relationships, chi-square tests, t tests, and logistic regression models were used. RESULTS Unadjusted analyses indicated that veterans with TBI were more likely to report suicidal ideation; however, in analyses controlling for mediators, this relationship was no longer significant. Among veterans with TBI, suicidal ideation was related most strongly to high impulsivity (odds ratio=15.35, 95% CI=2.43-96.79), followed by depression (odds ratio=5.73, 95% CI=2.53-12.99) and posttraumatic stress disorder (odds ratio=2.57, 95% CI=1.03-6.42). TBI was not related to suicide attempts, yet suicide attempts were related to high impulsivity (odds ratio=6.95, 95% CI=1.24-38.75) and depression (odds ratio=3.89, 95% CI=1.56-9.40). CONCLUSIONS These findings suggest that impulsivity, followed by psychiatric diagnoses, most strongly mediate the relationships between TBI and both suicidal ideation and suicide attempts. Impulsivity may be mechanistically related to, and serve as a future treatment target for, suicidality among veterans with TBI.
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Affiliation(s)
- Alexandra L Aaronson
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Bridget Smith
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Kelly Krese
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Meghan Barnhart
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Maheen Adamson
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Harriet de Wit
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Noah S Philip
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Lisa A Brenner
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Theresa Bender-Pape
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Amy A Herrold
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
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Krese KA, Donnelly KZ, Etingen B, Bender Pape TL, Chaudhuri S, Aaronson AL, Shah RP, Bhaumik DK, Billups A, Bedo S, Wanicek-Squeo MT, Bobra S, Herrold AA. Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial. JMIR Res Protoc 2022; 11:e37836. [PMID: 35704372 PMCID: PMC9244651 DOI: 10.2196/37836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes. OBJECTIVE The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies. METHODS This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention. RESULTS This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024. CONCLUSIONS We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs. TRIAL REGISTRATION ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37836.
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Affiliation(s)
- Kelly A Krese
- Brain Innovation Center, Shirley Ryan AbilityLab, Chicago, IL, United States
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | | | - Bella Etingen
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Theresa L Bender Pape
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sarmistha Chaudhuri
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Alexandra L Aaronson
- Mental Health Service Line, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, Feinberg School of Medicine, Northwestern University, Hines, IL, United States
| | - Rachana P Shah
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Dulal K Bhaumik
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, United States
| | - Andrea Billups
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sabrina Bedo
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Mary Terese Wanicek-Squeo
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sonia Bobra
- Department of Radiology, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Radiology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Amy A Herrold
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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McDonald SD, Walker WC, Cusack SE, Yoash-Gantz RE, Pickett TC, Cifu DX, Mid-Atlantic Mirecc Workgroup V, Tupler LA. Health symptoms after war zone deployment-related mild traumatic brain injury: contributions of mental disorders and lifetime brain injuries. Brain Inj 2021; 35:1338-1348. [PMID: 34543115 DOI: 10.1080/02699052.2021.1959058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PRIMARY OBJECTIVE To gain a better understanding of the complex relationship between combat deployment-related mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCSs), taking into consideration a wide range of potentially mediating and confounding factors. RESEARCH DESIGN Cross-sectional. METHODS AND PROCEDURES Subjects were 613 U. S. military Veterans and Service Members who served during operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) and completed a structured interview of mental disorders and a battery of questionnaires. Hierarchical binary logistic regression analyses were used to test the hypotheses. MAIN OUTCOMES AND RESULTS After accounting for mental disorders, lifetime mTBIs outside of OEF/OIF/OND deployment, medical conditions, and injury/demographic characteristics, deployment-related mTBI continued to be associated with several PPCSs (headaches, sleep disturbance, and difficulty making decisions). Deployment-related mTBI was also associated with two symptoms not normally associated with mTBI (nausea/upset stomach and numbness/tingling). CONCLUSIONS After adjusting for a wide range of factors, OEF/OIF/OND deployment-related mTBI was still associated with PPCSs on average 10 years after the injury. These findings suggest that mTBI sustained during OEF/OIF/OND deployment may have enduring negative health effects. More studies are needed that prospectively and longitudinally track health and mental health outcomes after TBI.
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Affiliation(s)
- Scott D McDonald
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Psychology, Virginia Commonwealth University, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - William C Walker
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Shannon E Cusack
- Department Of Psychology, Virginia Commonwealth University, Richmond, VA, USA.,Virginia Institute for Psychiatric and Behavioral Genetics (Vipbg), School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ruth E Yoash-Gantz
- Va Mid-Atlantic Mental Illness, Research, And Clinical Center, Durham, NC, USA
| | | | - David X Cifu
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Larry A Tupler
- Va Mid-Atlantic Mental Illness, Research, And Clinical Center, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
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Stika MM, Riordan P, Aaronson A, Herrold AA, Ellison RL, Kletzel S, Drzewiecki M, Evans CT, Mallinson T, High WM, Babcock-Parziale J, Urban A, Pape TLB, Smith B. Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. J Head Trauma Rehabil 2021; 36:44-55. [PMID: 32898030 PMCID: PMC8916049 DOI: 10.1097/htr.0000000000000611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear. METHODS We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings. RESULTS Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms. CONCLUSIONS In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.
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Affiliation(s)
- Monica M Stika
- Department of Veterans Affairs (VA), Edward Hines, Jr. VA Hospital: Spinal Cord Injury/Disorder Service (Dr Stika), Mental Health Service Line: Neuropsychology Service (Drs Riordan, Drzewiecki, and Urban) and Psychiatry Service (Dr Aaronson), Research Service (Drs Bender Pape, Herrold, Kletzel, and Ellison), Center of Innovation for Complex Chronic Healthcare (Drs Bender Pape, Herrold, Kletzel, Smith, and Evans), Hines, Illinois; Departments of Psychiatry & Behavioral Sciences (Drs Aaronson and Herrold), Physical Medicine and Rehabilitation (Dr Pape), and Pediatrics (Dr Smith), and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Dr Evans), Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Clinical Research and Leadership, The George Washington University, Washington, District of Columbia (Dr Mallinson); Department of Veterans Affairs (VA), New Mexico VA Health Care System, Albuquerque (Dr High); Illinois Institute of Technology (IIT), Chicago (Dr Ellison); and Department of Veterans Affairs (VA), Southern AZ VA Health Care System (3-124), Tucson, Arizona (Dr Babcock-Parziale)
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Herrold AA, Kletzel SL, Mallinson T, Pape TLB, Weaver JA, Guernon A, Smith B, Babcock-Parziale J, High WM, Sesso-Osburn F, Vis L. Psychometric measurement properties of the world health organization disability assessment schedule 2.0 (WHODAS) evaluated among veterans with mild traumatic brain injury and behavioral health conditions. Disabil Rehabil 2019; 43:1313-1322. [PMID: 31549869 DOI: 10.1080/09638288.2019.1660914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Examine the psychometric properties of the World Health Organization Disability Assessment Schedule 2.0 among U.S. Iraq/Afghanistan Veterans with a combination of mild traumatic brain injury and behavioral health conditions using Rasch analysis. METHODS 307 Veterans were classified as either combat control (n = 141), or one of three clinical groups: mild traumatic brain injury (n = 10), behavioral health conditions (n = 24), or both (n = 128). Data from the three clinical groups were used to establish step and item calibrations serving as anchors when including the control group. RESULTS Measurement precision was excellent (person separation reliability = 0.93). Ordering of item calibrations formed a logical hierarchy. Test items were off-target (too easy) for the clinical groups. Principal component analysis indicated unidimensionality although 4/36 items misfit the measurement model. No meaningful differential item functioning was detected. There was a moderate effect size (Hedge's g = 1.64) between the control and clinical groups. CONCLUSIONS The World Health Organization Disability Assessment Schedule was suitable for our study sample, distinguishing 4 levels of functional ability. Although items may be easy for some Veterans with mild traumatic brain injury and/or behavioral health conditions, the World Health Organization Disability Assessment Schedule can be used to capture disability information for those with moderate to severe disability.Implications for rehabilitationPersistent functional disability is seen in military and civilian populations with mild traumatic brain injury which often co-occurs with behavioral health conditions.A comprehensive measure of disability is needed to distinguish between levels of disability to inform clinical decisions for individual patients and to detect treatment effects between groups in research.Results of this analysis indicate the World Health Organization Disability Assessment Schedule items are sufficiently unidimensional to evaluate level of disability in the moderate and severe range among persons with mild traumatic brain injury with and without behavioral health conditions.Further examination of the psychometric properties of the World Health Organization.Disability Assessment Schedule is necessary before measurement of disability is recommended for those with less than moderate levels of disability.
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Affiliation(s)
- Amy A Herrold
- Research Service and Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Sandra L Kletzel
- Research Service and Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA
| | - Trudy Mallinson
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Theresa L Bender Pape
- Research Service and Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer A Weaver
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Ann Guernon
- Research Service and Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA.,Department of Research, Marianjoy Rehabilitation Hospital/Northwestern Medicine, Wheaton, IL, USA
| | - Bridget Smith
- Research Service and Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA.,Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | | | - Walter M High
- New Mexico VA Health Care System, Albuquerque, NM, USA
| | | | - Lynnea Vis
- Medical Service Corps, United States Navy
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Herrold AA, Smith B, Aaronson AL, Coleman J, Pape TLB. Relationships and Evidence-Based Theoretical Perspectives on Persisting Symptoms and Functional Impairment Among Mild Traumatic Brain Injury and Behavioral Health Conditions. Mil Med 2019; 184:138-147. [PMID: 30901443 DOI: 10.1093/milmed/usy306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/15/2018] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans.
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Affiliation(s)
- Amy A Herrold
- Research Service & Center for Innovation and Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, 5000 S 5th Ave, MC 151 H, Hines, IL.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Feinberg School of Medicine, 710 N Lakeshore Dr., Chicago, IL
| | - Bridget Smith
- Research Service & Center for Innovation and Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, 5000 S 5th Ave, MC 151 H, Hines, IL.,Department of Pediatrics, Northwestern University, Feinberg School of Medicine, 310 E. Superior St., Morton 4-685, Chicago, IL
| | - Alexandra L Aaronson
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Feinberg School of Medicine, 710 N Lakeshore Dr., Chicago, IL.,Mental Health Service Line, Edward Hines Jr., VA Hospital, 5000 S. 5th Ave, Hines, IL
| | - John Coleman
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX
| | - Theresa L-B Pape
- Research Service & Center for Innovation and Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, 5000 S 5th Ave, MC 151 H, Hines, IL.,Department of Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine, 710 N Lakeshore Dr., Chicago, IL
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Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, Thomas KR, Boyd B, Norman SB, Lang AJ, Keller AV, Schiehser DM, Twamley EW. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2019; 90:333-341. [PMID: 30554135 DOI: 10.1136/jnnp-2018-319315] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/19/2018] [Accepted: 11/18/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To better concurrently address emotional and neuropsychological symptoms common in veterans with comorbid post-traumatic stress disorder (PTSD) and history of traumatic brain injury (TBI), we integrated components of compensatory cognitive training from the Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) programme into cognitive processing therapy (CPT) for PTSD to create a hybrid treatment, SMART-CPT (CogSMART+CPT). This study compared the efficacy of standard CPT with SMART-CPT for treatment of veterans with comorbid PTSD and history of TBI reporting cognitive symptoms. METHODS One hundred veterans with PTSD, a history of mild to moderate TBI and current cognitive complaints were randomised and received individually delivered CPT or SMART-CPT for 12 weeks. Participants underwent psychological, neurobehavioural and neuropsychological assessments at baseline, on completion of treatment and 3 months after treatment. RESULTS Both CPT and SMART-CPT resulted in clinically significant reductions in PTSD and postconcussive symptomatology and improvements in quality of life. SMART-CPT resulted in additional improvements in the neuropsychological domains of attention/working memory, verbal learning/memory and novel problem solving. CONCLUSION SMART-CPT, a mental health intervention for PTSD, combined with compensatory cognitive training strategies, reduces PTSD and neurobehavioural symptoms and also provides added value by improving cognitive functioning.
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Affiliation(s)
- Amy J Jak
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA .,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Sarah Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Laura D Crocker
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | | | - Robin Aupperle
- Laureate Institute for Brain Research, University of Tulsa, Tulsa, Oklahoma, USA
| | | | - Kelsey R Thomas
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Briana Boyd
- Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA.,National Center for PTSD, White River Junction, Vermont, USA
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Amber V Keller
- Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Dawn M Schiehser
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
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Mollayeva T, Stock D, Colantonio A. Physiological and pathological covariates of persistent concussion-related fatigue: results from two regression methodologies. Brain Inj 2019; 33:463-479. [PMID: 30663436 DOI: 10.1080/02699052.2019.1566833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Fatigue severity in persons with mild traumatic brain injury (mTBI) has received little research attention, despite its typically positively skewed nature. Investigation of covariates across a range of fatigue severity may provide insight into important contributors. OBJECTIVE To assess the relative significance of a priori-hypothesized covariates of physiological and pathological (mental and physical) fatigue in persons with mTBI/concussion, applying ordinary least squares (OLS) and quantile regression (QR) approaches. METHODS We conducted a cross-sectional investigation in 80 participants with mTBI/concussion (mean age 45.4 ± 10.1 years, 59% male). The fatigue severity scale (FSS) was used as an outcome measure. Predictors of this outcome, grouped into physiological and pathological models of fatigue were assessed using OLS and QR. RESULTS The mean total FSS score was 46.13 ± 14.59, and the median was 49 (interquartile range 37-57), demonstrating positive skewness. Fatigue severity was associated with variables within the mental, psychological and psychiatric domains at different levels of the fatigue score distribution. CONCLUSION Results highlighted that some covariates had a significant impact on the FSS total score at non-central parts of its distribution, while others exhibited significant impact across the entire distribution. Addressing covariates of fatigue across the severity continuum can enhance research and clinical management.
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Affiliation(s)
- Tatyana Mollayeva
- a Rehabilitation Sciences Institute, Faculty of Medicine , University of Toronto , Canada , Ontario , Canada.,b Toronto Rehab-University Health Network , Research Department , Toronto , Ontario , Canada
| | - David Stock
- c Department of Clinical Health and Epidemiology , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Angela Colantonio
- a Rehabilitation Sciences Institute, Faculty of Medicine , University of Toronto , Canada , Ontario , Canada.,b Toronto Rehab-University Health Network , Research Department , Toronto , Ontario , Canada
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Rehabilitation Trajectories and Outcomes in Individuals With Mild Traumatic Brain Injury and Psychiatric Histories: A TRACK-TBI Pilot Study. J Head Trauma Rehabil 2019; 34:36-44. [DOI: 10.1097/htr.0000000000000399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Pape TLB, Smith B, Babcock-Parziale J, Evans CT, Herrold AA, Phipps Maieritsch K, High WM. Diagnostic Accuracy of the Veteran Affairs' Traumatic Brain Injury Screen. Arch Phys Med Rehabil 2018; 99:1370-1382. [DOI: 10.1016/j.apmr.2017.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 11/02/2017] [Accepted: 11/10/2017] [Indexed: 10/18/2022]
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Long-Term Neurobehavioral Symptoms and Return to Productivity in Operation Enduring Freedom/Operation Iraqi Freedom Veterans With and Without Traumatic Brain Injury. Arch Phys Med Rehabil 2018; 99:S50-S57. [DOI: 10.1016/j.apmr.2016.11.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022]
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Herrold AA, Sander AM, Wilson KV, Scimeca LM, Cobia DJ, Breiter HC. Dual Diagnosis of Traumatic Brain Injury and Alcohol Use Disorder: Characterizing Clinical and Neurobiological Underpinnings. CURRENT ADDICTION REPORTS 2015. [DOI: 10.1007/s40429-015-0078-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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