Improving Emotion Regulation Following Web-Based Group Intervention for Individuals With Traumatic Brain Injury

Association Between Traumatic Brain Injury and Psychopathic Traits Among Justice-Involved Adolescents

Traumatic brain injury (TBI) is a global public health problem and is highly prevalent among justice-involved populations. Pediatric TBI is linked with long-term negative outcomes and is correlated with substance use, criminal behavior, psychiatric disorders, and disruptions in neurocognition. These same TBI correlates are evident among youth with psychopathic traits. Given ongoing neurobiological and social development in adolescence, understanding the link between psychopathic traits and TBI in justice-involved youth is critical. A sample of 263 male adolescents were recruited from a maximum-security juvenile justice facility. Using a structural equation modeling (SEM) framework, measurement invariance of psychopathic traits (TBI ±) was tested, and psychopathy scores were accounted for in terms of TBI variables (severity, age of first TBI, total number), participant's age, IQ, substance use, and internalizing psychopathology. There was evidence of strong invariance across TBI status and those with TBI had higher affective and impulsive lifestyle psychopathic traits than adolescents without TBI. The SEM indicated that TBI severity was associated with lower IQ scores, which in turn were associated with increased lifestyle/antisocial (Factor 2) psychopathic traits. Total number of TBIs was associated with higher substance use, which was associated with both increased interpersonal/affective (Factor 1) and Factor 2 psychopathic traits. These TBI variables also had indirect associations with psychopathic traits through IQ and substance use. The findings indicate that TBI is associated with psychopathic traits and suggest that disturbances in cognition and substance use may be treatment targets for youth with TBI and psychopathic traits.

"Online, the counselor can't see me cry": a systematic literature review on emotion and computer-mediated care

Introduction

Computer-mediated care is becoming increasingly popular, but little research has been done on it and its effects on emotion-related outcomes. This systematic literature review aims to create an overview that addresses the research question: "Is there a relationship between computer-mediated care and emotional expression, perception, and emotional and (long-term) emotion outcomes?"

Method

This systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used five eligibility criteria, namely, (1) participants: adults seeking support; (2) intervention: eHealth; (3) diagnostic criteria: transdiagnostic concept of difficulty identifying, expressing, and/or regulating emotions (e.g., alexithymia); (4) comparator: either face-to-face care or no comparator; and (5) study design: quantitative studies or qualitative studies. Quality was assessed using the QualSyst tool.

Results

The analysis includes 25 research papers. Self-paced interventions appear to have a positive effect on emotion regulation. Videoconferencing interventions improved emotion regulation from before to after treatment but worsened emotion regulation compared with face-to-face treatment.

Discussion

The lack of variation in the modalities studied and the emotion measurements used make it difficult to draw responsible conclusions. Future research should examine how different modalities affect the real-time communication of emotions and how non-verbal cues influence this.

Traumatic Brain Injury and Psychopathic Traits in Justice-Involved Adult Women

Studies have documented associations between traumatic brain injury (TBI) and mental disorders. The relationship between psychopathic personality and TBI remains poorly understood, though both are associated with similar characteristics (e.g., low empathy, aggression, disturbances in social/moral behavior). Yet, it is not clear whether assessment of psychopathic features is influenced by presence versus absence of TBI, and which aspects of TBI may be associated with psychopathic traits. This study examined the psychopathy-TBI association in justice-involved women (N = 341) with structural equation modeling. We tested if measurement invariance of psychopathic traits was evident among those with versus without TBI and which TBI variables (number, severity, age at first TBI) predicted psychopathic features in conjunction with symptoms of psychopathology, IQ, and age. Results provided evidence of measurement invariance, and more women with TBI, compared to those without, met criteria for psychopathy. Younger age of TBI and TBI severity predicted interpersonal-affective psychopathic features.

Feasibility of Using a Mobile App Supported Executive Function Intervention in Military Service Members and Veterans with mTBI and Co-Occurring Psychological Conditions

This pilot study assessed the feasibility of using SwapMyMood, a smartphone application supporting evidence-based strategies for emotion regulation and problem-solving as a supplement to conventional care for military service members and veterans (SM/Vs) experiencing chronic symptoms of mild traumatic brain injury (mTBI) and co-occurring psychological conditions. Eight military SM/Vs were recruited from an intensive outpatient program. Participants were block randomized to an experimental group (conventional care plus use of the SwapMyMood app) or a conventional care only group for six weeks. Conventional care included instruction on problem-solving and emotion regulation strategies using traditional paper manuals and protocols. Effects on the knowledge and use of strategies and related goal attainment were measured. Patient-reported outcomes were measured via several validated problem-solving and emotion regulation scales. No differences were found between groups in goal attainment, global executive function, problem-solving, emotion regulation, and knowledge of how to use the problem-solving and emotion regulation strategies targeted. Experimental group participants rated the application positively, demonstrating feasibility of integration of the app into clinical care. The implementation of SwapMyMood is feasible in a clinical setting. SwapMyMood may be a clinically effective supplemental tool for supporting executive function in SM/Vs with mTBI and co-occurring psychological conditions.

Dynamic cognitive inhibition in the context of frustration: Increasing racial representation of adolescent athletes using mobile community-engaged EEG methods

Introduction

Concussive events and other brain injuries are known to reduce cognitive inhibition, a key aspect of cognition that supports ones' behaviors and impacts regulation of mood or affect. Our primary objective is to investigate how induction of negative affect (such as frustration) impacts cognitive inhibition and the dynamic process by which youth athletes modulate responses. Secondary objective is to address the lack of Black representation in the scientific literature that promotes brain health and investigates pediatric sports-related brain injury. In particular, neuroscience studies predominantly include White participants despite broad racial representation in sport, in part due to technological hurdles and other obstacles that challenge research access for Black participants.

Methods

Using electroencephalography (EEG), we evaluate the dynamic brain processes associated with cognitive inhibition in the context of frustration induction in adolescent athletes during pre-season conditioning (i.e., prior to contact; N = 23) and a subset during post-season (n = 17).

Results

The N2 component was sensitive to frustration induction (decreased N2 amplitude, slower N2 latency), although effects were less robust at postseason. Trial-by-trial changes indicated a steady decrease of the N2 amplitude during the frustration block during the preseason visit, suggesting that affective interference had a dynamic effect on cognitive inhibition. Lastly, exploratory analyses provide preliminary evidence that frustration induction was less effective for athletes with a previous history of concussion or migraines (trending result) yet more effective for athletes endorsing a history with mental health disorders.

Discussion

We emphasize the urgent need to improve representation in cognitive neuroscience, particularly as it pertains to brain health. Importantly, we provide detailed guides to our methodological framework and practical suggestions to improve representative participation in studies utilizing high-density mobile EEG.

Effectiveness of Mental Health Apps for Distress During COVID-19 in US Unemployed and Essential Workers: Remote Pragmatic Randomized Clinical Trial

BACKGROUND

During the COVID-19 pandemic, the general public was concerned about the mental health impacts of unemployment due to COVID-19 and the stress essential workers experienced during this time. Several reports indicated that people in distress were turning to digital technology, but there was little evidence about the impact of these tools on mitigating distress.

OBJECTIVE

This study seeks to determine the acceptability, feasibility, usability, and effectiveness of mobile mental health apps for decreasing mental health symptoms in essential workers and unemployed individuals with suicide risk.

METHODS

We recruited participants who indicated that they were unemployed because of COVID-19 or were COVID-19-designated essential workers. Participants were randomized to 1 of 4 free commercial mobile apps for managing distress that were (1) highly rated by PsyberGuide and (2) met the criteria for intervention features these participants indicated were desirable in a previous survey. Participants used the apps for 4 weeks and completed baseline and 4-week self-assessments of depression, anxiety emotional regulation, and suicide risk.

RESULTS

We found no differences between the apps in any outcome but did find significant changes in depression and anxiety over time (Patient Health Questionnaire [PHQ]-9: estimate=-1.5, SE 0.2, 95% CI -1.1 to -1.8, P<.001; Generalized Anxiety Disorder Scale [GAD]-7: estimate=-1.3, SE 0.2, 95% CI -1.0 to -1.6, P<.001). We found no significant changes in suicidal behavior (Suicide Behaviors Questionnaire-Revised [SBQ-R]) or emotional regulation (Difficulties in Emotion Regulation Scale - Short Form [DERS-SF]) for the 4 weeks. We did find a significant dose-response pattern for changes in depression and anxiety. Using the app at least once a week resulted in greater improvements in treatment conditions over time on depression (estimate=-0.6, SE 0.2, 95% CI 1.0-0.2, P=.003) and anxiety (estimate=0.1, SE 0.2, 95% CI 0.4-0.6, P=.78). There was no association between app frequency and changes in suicidal behavior (SBQ-R) or emotional regulation (DERS-SF). We further found a significant difference between the conditions with regard to app usability, with the control app being the most usable (mean_{Beautiful Mood} 72.9, SD 16.7; mean_{COVID Coach} 71.2, SD 15.4; mean_Calm 66.8, SD 17.3; mean_{7 Cups} 65.2, SD 17.7). We found no significant differences for app acceptability or appropriateness.

CONCLUSIONS

Few studies have evaluated prospectively the utility and usability of commercial apps for mood. This study found that free, self-guided commercial mobile mental health apps are seen as usable, but no one app is superior to the other. Although we found that regular use is indicated for effects on depression and anxiety to occur in those who are more symptomatic, regression to the mean cannot be ruled out.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04536935; https://tinyurl.com/mr36zx3s.

Implementation of Web-Based Psychosocial Interventions for Adults With Acquired Brain Injury and Their Caregivers: Systematic Review

BACKGROUND

More than 135 million people worldwide live with acquired brain injury (ABI) and its many psychosocial sequelae. This growing global burden necessitates scalable rehabilitation services. Despite demonstrated potential to increase the accessibility and scalability of psychosocial supports, digital health interventions are challenging to implement and sustain. The Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework can offer developers and researchers a comprehensive overview of considerations to implement, scale, and sustain digital health interventions.

OBJECTIVE

This systematic review identified published, peer-reviewed primary evidence of implementation outcomes, strategies, and factors for web-based psychosocial interventions targeting either adults with ABI or their formal or informal caregivers; evaluated and summarized this evidence; synthesized qualitative and quantitative implementation data according to the NASSS framework; and provided recommendations for future implementation. Results were compared with 3 hypotheses which state that complexity (dynamic, unpredictable, and poorly characterized factors) in most or all NASSS domains increases likelihood of implementation failure; success is achievable, but difficult with many complicated domains (containing multiple interacting factors); and simplicity (straightforward, predictable, and few factors) in most or all domains increases the likelihood of success.

METHODS

From a comprehensive search of MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, speechBITE, and neuroBITE, we reviewed primary implementation evidence from January 2008 to June 2020. For web-based psychosocial interventions delivered via standard desktop computer, mobile phone, tablet, television, and virtual reality devices to adults with ABI or their formal or informal caregivers, we extracted intervention characteristics, stakeholder involvement, implementation scope and outcomes, study design and quality, and implementation data. Implementation data were both narratively synthesized and descriptively quantified across all 7 domains (condition, technology, value proposition, adopters, organization, wider system, and their interaction over time) and all subdomains of the NASSS framework. Study quality and risk of bias were assessed using the 2018 Mixed Methods Appraisal Tool.

RESULTS

We identified 60 peer-reviewed studies from 12 countries, including 5723 adults with ABI, 1920 carers, and 50 health care staff. The findings aligned with all 3 hypotheses.

CONCLUSIONS

Although studies were of low methodological quality and insufficient number to statistically test relationships, the results appeared consistent with recommendations to reduce complexity as much as possible to facilitate implementation. Although studies excluded individuals with a range of comorbidities and sociocultural challenges, such simplification of NASSS domain 1 may have been necessary to advance intervention value propositions (domain 3). However, to create equitable digital health solutions that can be successfully implemented in real-world settings, it is recommended that developers involve people with ABI, their close others, and health care staff in addressing complexities in domains 2 to 7 from the earliest intervention design stages.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020186387; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186387.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1177/20552076211035988.

Efficacy of digital technologies aimed at enhancing emotion regulation skills: Literature review

BACKGROUND

The impact of emotion regulation (ER) interventions on mental health and wellbeing has been extensively documented in the literature, although only recently have digital technologies been incorporated in intervention design. The aim of this review is to explore available published literature relating to the efficacy, barriers and facilitators of digital technologies in enhancing emotion/mood regulation skills.

METHODS

A review of the literature was performed to explore the effectiveness of digital technology in enhancing ER skills. MEDLINE, CINAHL, PsycINFO and Web of Science databases were searched from inception to 31st August 2020. In addition, the first 10 pages of Google Scholar were examined for relevant articles. The following MeSH term and key words were used to identify relevant articles: "emotion regulation OR mood regulation" AND "intervention OR treatment OR program$ OR therap$" AND "digital technologies OR web-based OR mobile application OR App." Reference lists of retrieved papers were hand searched to identify additional publications. Findings were summarized narratively.

RESULTS

Titles and abstracts were reviewed by one reviewer in two phases, and confirmed by a second reviewer; discrepancies were resolved through discussion. First, the retrieved titles and abstracts were reviewed to identify relevant studies. Full texts of retrieved studies were then read to determine eligibility. The search resulted in 209 studies of which 191 citations were identified as potentially meeting the inclusion criteria. After reviewing the title and abstract of the 191 papers, 33 studies were identified as potentially meeting the inclusion criteria. Following full-text review, 10 studies met the inclusion criteria. Findings indicated the potential effectiveness of online, text-messaging, and smartphone interventions for enhancing ER skills.

CONCLUSION

There is encouraging evidence that digital technologies may be beneficial for enhancing ER skills and providing personalized care remotely. Digital technologies, particularly the use of smartphones, were instrumental in facilitating assessments and delivering online self-help interventions such as cognitive behavioral therapy. Continued research is required to rigorously evaluate the effectiveness of digital technologies in ER skills and carefully consider risks/benefits while determining how emerging technologies might support the scale-up of ER skills and mental health treatment.

Factors Affecting the Delivery and Acceptability of the ROWTATE Telehealth Vocational Rehabilitation Intervention for Traumatic Injury Survivors: A Mixed-Methods Study

Background: Returning to work after traumatic injury can be problematic. We developed a vocational telerehabilitation (VR) intervention for trauma survivors, delivered by trained occupational therapists (OTs) and clinical psychologists (CPs), and explored factors affecting delivery and acceptability in a feasibility study. Methods: Surveys pre- (5 OTs, 2 CPs) and post-training (3 OTs, 1 CP); interviews pre- (5 OTs, 2 CPs) and post-intervention (4 trauma survivors, 4 OTs, 2 CPs). Mean survey scores for 14 theoretical domains identified telerehabilitation barriers (score ≤ 3.5) and facilitators (score ≥ 5). Interviews were transcribed and thematically analysed. Results: Surveys: pre-training, the only barrier was therapists’ intentions to use telerehabilitation (mean = 3.40 ± 0.23), post-training, 13/14 domains were facilitators. Interviews: barriers/facilitators included environmental context/resources (e.g., technology, patient engagement, privacy/disruptions, travel and access); beliefs about capabilities (e.g., building rapport, complex assessments, knowledge/confidence, third-party feedback and communication style); optimism (e.g., impossible assessments, novel working methods, perceived importance and patient/therapist reluctance) and social/professional role/identity (e.g., therapeutic methods). Training and experience of intervention delivery addressed some barriers and increased facilitators. The intervention was acceptable to trauma survivors and therapists. Conclusion: Despite training and experience in intervention delivery, some barriers remained. Providing some face-to-face delivery where necessary may address certain barriers, but strategies are required to address other barriers.

Telehealth in trauma: A scoping review

BACKGROUND

The purpose of this scoping review was to ascertain how 'telehealth' is utilised within health care, from pre hospital to admission, discharge and post discharge, with patients who have suffered major trauma.

METHODS

A scoping review of the literature published in English since 1980 was conducted using MEDLINE, Ovid EMBASE, PsychINFO, CINAHL, Austhealth, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane library) and Web of Science MEDLINE and MEBASE to identify relevant studies.

RESULTS

We included 77 eligible studies with both randomised controlled trial and cohort design methodology. A variety of trauma was included such as traumatic brain injuries (n = 52; 67.5%), spinal cord injury (n = 14; 18.2%) and multi-trauma (n = 9; 11.7%) to both adult (n = 38) and paediatric (n = 32) participants. Telehealth is used in pre-hospital and acute-care settings (n = 11; 14.3%) to facilitate assessment, and in rehabilitation and follow-up (n = 61; 79.2%) to deliver therapy. Effects on health were reported the most (n = 46), with no negative outcomes. The feasibility of telehealth as a delivery mode was established, but coordination and technical issues are barriers to use. Overall, both patients and clinicians were satisfied using this mode of delivery.

CONCLUSION

This review demonstrates how telehealth is utilised across a spectrum of patients with traumatic injuries and to facilitate delivery of therapy, specialist consultations and assessments, with many studies reporting improvements to health. There is a paucity of high-quality rigorous research, which makes replication of findings and uptake of the intervention problematic. Future telehealth and trauma research should focus on the quality and reproducibility of telehealth interventions and the economic feasibility of using this platform to deliver trauma care.

Lifetime history of traumatic brain injury is associated with increased loneliness in adults: A US nationally representative study

BACKGROUND/OBJECTIVES

An estimated 55 million individuals worldwide live with chronic disability associated with traumatic brain injury (TBI), which may include cognitive, behavioral, and social impairments. Reduced participation in social activities is common after TBI; however, few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness and to identify mediators of this association.

METHODS/DESIGN

Retrospective cohort study. Nationally representative sample of N = 724 adults over age 50 years (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised University of California Los Angeles (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, and education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index.

RESULTS

History of TBI was associated with a 1.28-point (95% CI, 0.46-2.11; P < .05; Cohen's D = 0.284) increase in R-UCLA Loneliness Scale scores after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms partially mediated the relationship between TBI and loneliness. All models were adjusted for US population sampling weights.

CONCLUSIONS

History of TBI was associated with greater loneliness compared with individuals without TBI in a representative sample of US adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers

PURPOSE

To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program.

MATERIALS AND METHODS

People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement.

RESULTS

1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health.

CONCLUSIONS

LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Psychological Intervention in Traumatic Brain Injury Patients

Objective

To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury.

Methods

A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables.

Results

The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%).

Conclusions

CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.