Lifetime History of Traumatic Brain Injury and Behavioral Health Problems in a Population-Based Sample

Impact of mild traumatic brain injury on health behaviors

Health-related behavioral changes may occur following traumatic brain injury. We focused on understanding the impact of mild traumatic brain injury (TBI) on health-related behaviors and identifying factors associated with such changes. We utilized health check-up records from the Korean National Health Insurance Service database spanning January 1, 2009, to December 31, 2017. The sample included 49,212 patients diagnosed with mild TBI and 1:1 matched controls who participated in national health check-ups in 2009-2010, 2011-2012, and 2016-2017. Multivariable logistic regression analysis was utilized to examine the association between mild TBI and short- and long-term health-related behavioral changes. Mild TBI was significantly associated with an increased risk of insufficient physical activity at the short- [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01 - 1.07] and long-term (OR, 1.06; 95% CI, 1.03 - 1.09) follow-ups. Age ≥ 65 years and female sex were significant effect modifiers for insufficient physical activity (OR, 1.11; 95% CI, 1.02 - 1.21) and smoking (OR, 1.31; 95% CI, 1.14 - 1.51), respectively. Mild TBI may lead to detrimental health-related behavioral changes, varying by age and sex. Thus, age- and sex-specific interventions may be needed to address these changes.

An umbrella review of health outcomes following traumatic brain injury

While numerous reviews have assessed the association between traumatic brain injury (TBI) and various mental and physical health outcomes, a comprehensive evaluation of the scope, validity, and quality of evidence is lacking. Here we present an umbrella review of a wide range of health outcomes following TBI and outline outcome risks across subpopulations. On 17 May 2023, we searched Embase, Medline, Global Health, PsycINFO, and Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. We compared risk ratios across different outcomes for risks compared with people without TBI and examined study quality, including heterogeneity, publication bias, and prediction intervals. The study was registered with PROSPERO (CRD42023432255). We identified 24 systematic reviews and meta-analyses covering 24 health outcomes in 31,397,958 participants. The current evidence base indicates an increased risk of multiple mental and physical health outcomes, including psychotic disorders, attention-deficit/hyperactivity disorder, suicide, and depression. Three outcomes-dementia, violence perpetration, and amyotrophic lateral sclerosis-had meta-analytical evidence of at least moderate quality, which suggest targets for more personalized assessment. Health-care services should review how to prevent adverse long-term outcomes in TBI.

Experience of Intimate Partner Violence-Related Head Trauma and Its Association With Posttraumatic Stress Disorder and Depression Symptoms Among Community Dwelling Women and Men

Individuals who experience intimate partner violence (IPV) often report posttraumatic stress disorder (PTSD) and depressive symptoms and IPV-related head trauma (IPV-HT), which can also affect mental health. We aimed to estimate rates of IPV-HT and examine the unique associations of IPV, HT, and IPV-HT with PTSD and depression symptom severity in a community-based sample of cohabitating couples. A total of 413 participants (216 women, 1 non-binary) self-reported lifetime history of HT and physical IPV. Chi-square analyses and Fisher's exact tests were used to compare the proportion of women and men who reported IPV-HT. Kruskal-Wallis tests with Dunn's post-hoc testing and Bonferroni correction were used to compare symptom severity across five groups: (a) IPV-HT, (b) non-IPV-related HT (Other HT) with exposure to physical IPV (IPV-Other HT), (c) Other HT without exposure to physical IPV (No IPV-Other HT), (d) no exposure to HT with exposure to physical IPV (IPV-No HT), and (e) no exposure to HT without exposure to physical IPV (No IPV-No HT). A greater proportion of women than men reported IPV-HT from a fight or being strangled (fight: 50.0% vs. 3.6%, p < .001; Strangulation: 74.1% vs. 3.8%, p < .001). The IPV-HT and IPV-Other HT groups endorsed greater PTSD and depression symptom severity compared to all individuals with no history of physical IPV, regardless of HT exposure (IPV-No HT and IPV-Other HT groups). No differences in symptom severity between the IPV-HT and the other IPV groups (No HT and Other HT) were found. These results suggest that PTSD and depression symptom severity may be driven by experiencing physical IPV, with some exacerbation due to experiencing HT of any etiology. Future work seeking to examine the effects of IPV-HT on PTSD and depression symptom severity should consider any history of physical IPV and any additional HT exposures.

Barriers to Care After Intimate Partner Violence Acquired Brain Injury: Current Systems Silence Survivors and Providers

OBJECTIVE

A qualitative meta-synthesis was conducted to answer the following question-What barriers are experienced by survivors of intimate partner violence and service providers when seeking or providing resources or care after experiencing brain injury (BI)?

SETTING

This approach was completed through 2 main phases-a systematic search and literature appraisal and reciprocal translation with interpretive triangulation of the extracted data. The databases searched were PubMed, CINAHL, and PsycInfo.

PARTICIPANTS

The initial search yielded 559 articles. The final synthesis included 16 articles for the qualitative meta-synthesis.

DESIGN

After data extraction, a qualitative exploratory design evaluated the experiences of survivors and service providers when connecting with resources.

RESULTS

The findings highlight larger systemic barriers preventing smooth relationships between survivors and providers. Survivor barriers include risk-driven safety mechanisms and a lack of awareness and understanding of BI. Provider barriers are a lack of clarity within providers' scope and training limitations, diagnosis complexity, first responder's initial response to survivors, lack of open discussion, screening limitations, financial barriers, infrastructure barriers, and lack of resources. Systemic barriers include stigmatization, BI symptoms mistaken as other diagnoses like mental health, access and awareness of resources, and navigation of complex systems.

CONCLUSION

This qualitative meta-synthesis demonstrates that survivors and providers face multiple individual and systemic barriers when seeking and providing resources after BI. Future research is needed to understand survivors' help-seeking behaviors and assistance needs and providers' education about BI and organizational relationships and networks. Recommendations are made for future research to understand how to reduce barriers for providers working with survivors, from trauma-informed education and communication to connecting with resources, where to concentrate, and initiatives for collaboration to increase the network of resources yet improve its accessibility.

Traumatic brain injury, working memory-related neural processing, and alcohol experimentation behaviors in youth from the ABCD cohort

Adolescent traumatic brain injury (TBI) has long-term effects on brain functioning and behavior, impacting neural activity under cognitive load, especially in the reward network. Adolescent TBI is also linked to risk-taking behaviors including alcohol misuse. It remains unclear how TBI and neural functioning interact to predict alcohol experimentation during adolescence. Using Adolescent Brain Cognitive Development (ABCD) study data, this project examined if TBI at ages 9-10 predicts increased odds of alcohol sipping at ages 11-13 and if this association is moderated by neural activity during the Emotional EN-Back working memory task at ages 11-13. Logistic regression analyses showed that neural activity in regions of the fronto-basal ganglia network predicted increased odds of sipping alcohol by ages 11-13 (p < .05). TBI and left frontal pole activity interacted to predict alcohol sipping (OR = 0.507, 95% CI [0.303 - 0.846], p = .009) - increased activity predicted decreased odds of alcohol sipping for those with a TBI (OR = 0.516, 95% CI [0.314 - 0.850], p = .009), but not for those without (OR = 0.971, 95% CI [0.931 -1.012], p = .159). These findings suggest that for youth with a TBI, increased BOLD activity in the frontal pole, underlying working memory, may be uniquely protective against the early initiation of alcohol experimentation. Future work will examine TBI and alcohol misuse in the ABCD cohort across more time points and the impact of personality traits such as impulsivity on these associations.

Application of P7C3 Compounds to Investigating and Treating Acute and Chronic Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading worldwide cause of disability, and there are currently no medicines that prevent, reduce, or reverse acute or chronic neurodegeneration in TBI patients. Here, we review the target-agnostic discovery of nicotinamide adenine dinucleotide (NAD+)/NADH-stabilizing P7C3 compounds through a phenotypic screen in mice and describe how P7C3 compounds have been applied to advance understanding of the pathophysiology and potential treatment of TBI. We summarize how P7C3 compounds have been shown across multiple laboratories to mitigate disease progression safely and effectively in a broad range of preclinical models of disease related to impaired NAD+/NADH metabolism, including acute and chronic TBI, and note the reported safety and neuroprotective efficacy of P7C3 compounds in nonhuman primates. We also describe how P7C3 compounds facilitated the recent first demonstration that chronic neurodegeneration 1 year after TBI in mice, the equivalent of many decades in people, can be reversed to restore normal neuropsychiatric function. We additionally review how P7C3 compounds have facilitated discovery of new pathophysiologic mechanisms of neurodegeneration after TBI. This includes the role of rapid TBI-induced tau acetylation that drives axonal degeneration, and the discovery of brain-derived acetylated tau as the first blood-based biomarker of neurodegeneration after TBI that directly correlates with the abundance of a therapeutic target in the brain. We additionally review the identification of TBI-induced tau acetylation as a potential mechanistic link between TBI and increased risk of Alzheimer's disease. Lastly, we summarize historical accounts of other successful phenotypic-based drug discoveries that advanced medical care without prior recognition of the specific molecular target needed to achieve the desired therapeutic effect.

Brain Injury Is Prevalent and Precedes Tobacco Use among Youth and Young Adults Experiencing Homelessness

70%+ of youth and young adults experiencing homelessness (YYEH; 14-24 years old) smoke combustible tobacco. Little is known about the prevalence of acquired brain injury (ABI) among youth and young adult smokers experiencing homelessness (YYSEH) and its impact on tobacco use progression-the aim of our study. Through an interviewer-administered survey, YYSEH were asked about timing of tobacco use; exposure to causes of ABI; including brain oxygen deprivation (BOD; strangulation; accidental; choking games) and blunt force head trauma (BFHT; intentional; shaken violently; accidental); and perpetrators of intentional assault. Participants (n = 96) were on average 22 years old and from populations who experience structural disparities; including those minoritized by race (84.4%) and gender/sexual orientation (26.0%). In total, 87% of participants reported at least one exposure to BFHT and 65% to BOD. Intentional injury was more common than accidental. Furthermore, 60.4% of participants (n = 59) were classified as having ABI using the Brain Injury Severity Assessment. A significant proportion of YYSEH living with ABI were exposed to both BFHT and BOD prior to trying (68.5%, p = 0.002) and to first regular use (82.8%, p < 0.001) of tobacco. Among YYSEH with ABI; injury exposure occurred a median of 1 and 5 years before age of first regular tobacco use, dependent on injury mechanism. ABI from intentional violence is prevalent and precedes tobacco use among YYSEH.

Does Traumatic Brain Injury Cause Risky Substance Use or Substance Use Disorder?

There is a high co-occurrence of risky substance use among adults with traumatic brain injury (TBI), although it is unknown if the neurologic sequelae of TBI can promote this behavior. We propose that to conclude that TBI can cause risky substance use, it must be determined that TBI precedes risky substance use, that confounders with the potential to increase the likelihood of both TBI and risky substance use must be ruled out, and that there must be a plausible mechanism of action. In this review, we address these factors by providing an overview of key clinical and preclinical studies and list plausible mechanisms by which TBI could increase risky substance use. Human and animal studies have identified an association between TBI and risky substance use, although the strength of this association varies. Factors that may limit detection of this relationship include differential variability due to substance, sex, age of injury, and confounders that may influence the likelihood of both TBI and risky substance use. We propose possible mechanisms by which TBI could increase substance use that include damage-associated neuroplasticity, chronic changes in neuroimmune signaling, and TBI-associated alterations in brain networks.

Social Work Care in Traumatic Brain Injury and Substance Use Disorder Treatment: A Capacity-Building Model

Co-occurring traumatic brain injury (TBI) and substance use disorders (SUD) are a major public health concern, yet TBI is often underrecognized within SUD treatment organizations. Social workers in these organizations are well positioned to deliver tailored treatment, but little is known about what social workers are doing to address the needs of these clients. The purpose of this study was to examine current social work practices in providing care to clients with co-occurring TBI and SUD. Using grounded theory methodology, authors conducted semistructured interviews with 17 licensed social workers employed in various SUD treatment settings. Transcript coding was conducted through an iterative process and data were analyzed using NVivo (version 12.0). Results demonstrated that social workers lack basic knowledge on the relationship between TBI and SUD. Additional barriers to providing care included lack of skills to identify history of TBI, lack of community resources, poor agency collaboration, and access-to-care restrictions. Social workers identified their primary roles as advocacy, care coordination, and serving on multidisciplinary teams. These results informed development of a capacity-building model, with recommendations for social work situated in each level of the socioecological framework. This study has important implications for building workforce capacity and collaborative care systems to improve client outcomes.

Traumatic Brain Injury and Treatment of Behavioral Health Conditions

Traumatic brain injury (TBI) is a common neurological condition that results from an external force altering normal brain function, whether temporarily or permanently. A concussion is one type of TBI. TBIs vary greatly in severity, which concomitantly creates tremendous variability in their manifestation. The fingerprint of TBI is damage to the frontal areas of the brain, which, with sufficient magnitude, results in impairment of a person's ability to regulate cognition, emotion, and behavior. These consequences of TBI make recognition in the context of treating behavioral health conditions of utmost importance. TBI not only causes behavioral health problems but also produces associated deficits that can undermine the effectiveness of treatment for a behavioral health condition. This overview delineates key characteristics of TBI and describes its association with behavioral health conditions. Mechanisms underlying the relationship between TBI and behavioral health are presented, and a series of recommendations for professionals are proposed. This article is intended to raise awareness about TBI and simultaneously introduce key concepts for accommodating the effects of TBI in behavioral health care.

Lifetime History of Traumatic Brain Injury With Loss of Consciousness and the Likelihood for Lifetime Depression and Risk Behaviors: 2017 BRFSS North Carolina

OBJECTIVE

Because of the growing concern about the potential effects of traumatic brain injuries (TBIs) on a child's developing brain and the potential impact of lifetime depression and risk behaviors associated with TBI, further exploration is warranted.

SETTING AND PARTICIPANTS

Data (N = 4917) from the 2017 North Carolina Behavioral Risk Factors Surveillance System (BRFSS).

DESIGN

Cross-sectional.

MAIN MEASURES

Examine whether a lifetime history of TBI with loss of consciousness (LOC) or having a history of TBI with LOC prior to 18 years of age was associated with a greater likelihood of lifetime depression, current binge drinking, and current cigarette and e-cigarette smoking.

RESULTS

Respondents with a history of TBI with LOC had 2.1 (95% CI, 1.6-2.8) times higher odds of lifetime depression and 1.7 to 1.8 (95% CI, 1.02-2.97) times higher odds of all risk behaviors than those without a lifetime history of TBI with LOC. There were no statistical differences between age of first TBI with LOC and lifetime depression, binge drinking, cigarette smoking, and e-cigarette use after controlling for key demographics.

CONCLUSION

These findings underscore the importance of increasing awareness among healthcare providers of the prevalence of lifetime depression and risk behaviors among individuals with a history of TBI and the need for improved screening and referrals to evidence-based services.

Traumatic brain injury substantially reduces the conditioned reinforcing effects of environmental cues in rats

Traumatic brain injury affects millions of people each year and is an established risk factor for addiction. Recent animal studies have causally demonstrated that injuries can increase drug self-administration across a variety of substances. One potential behavioral mediator for this finding is an increased responsivity to drug-associated cues. This endophenotype can be identified by profiling non-drug-related behaviors. The current study evaluated several paradigms (conditioned approach, conditioned reinforcement, extinction from variable interval responding, conditioned facilitation) to determine how rats with a frontal TBI differed in their response to Pavlovian conditioning in response to food-paired cues. Surprisingly, rats with a TBI demonstrated increased goal-tracking in a conditioned approach paradigm and exerted less effort for a conditioned reinforcer. Moreover, they had slightly facilitated extinction (as demonstrated by significantly larger interresponse times) in the face of reinforcer-associated cues. Despite these effects, TBI rats still demonstrated conditioned facilitation to an auditory stimulus. Together, these effects suggest a phenotype in the opposite direction of what might be anticipated. Cues still served a strong discriminative function and altered behavior; however, they did not function as strong conditioned reinforcers for TBI animals. One potential reason for this is that substantial changes to the dopamine system after TBI may reduce the conditioned reinforcing effects of cues, but sensitize the brain to potent drugs of abuse. More research will be needed to determine whether this is the case.

Comparison of Diagnostic Sleep Studies in Hospitalized Neurorehabilitation Patients With Moderate to Severe Traumatic Brain Injury

BACKGROUND

OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI.

RESEARCH QUESTION

This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI.

STUDY DESIGN AND METHODS

This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days).

RESULTS

Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764).

INTERPRETATION

Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

Is Pediatric Traumatic Brain Injury Associated with Adult Alcohol Misuse?

Evidence suggests that pediatric traumatic brain injury (TBI) may be causally related to alcohol misuse later in life; however, the nature and extent of the association has not been well described. This study examined the relationship between pediatric TBI and adult alcohol misuse in a population sample ≥20 years of age. We sought to determine (1) whether first self-reported incidence of TBI with loss of consciousness (LOC) before the age of 20 increased the risk for alcohol misuse later in life; and (2) whether sex, injury severity, and age at time of injury modified the association. We found a greater likelihood of binge but not heavy drinking for those whose first self-reported TBI with LOC occurred before the age of 20 when compared with those whose first self-reported TBI with LOC occurred later in life (28.5% vs. 20.4%, p = 0.003). When limited to those with only mild TBI, the relationship to binge drinking remained significant (31.9% vs. 19.3%, p < 0.001) and was evident for both males (38.4% vs. 25.6%, p = 0.016) and females (20.9% vs. 12.4%, p = 0.044). When controlling for sex, age, and race/ethnicity, reporting a first TBI with LOC before age 20 was associated with binge drinking only for those with mild TBI (adjusted odds ratio [AOR] = 1.32; 95% confidence interval [CI] = 1.00-1.74). Results also showed that those with first TBI with LOC occurring between the ages of 10 and 19 years were more likely to binge drink as adults than those first injured earlier in life, regardless of TBI severity. Further research is needed at both the epidemiological and pre-clinical levels to better understand this relationship.

Examining the Efficacy of Communication Partner Training for Improving Communication Interactions and Outcomes for Individuals With Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To describe the evidence regarding communication partner training (CPT) interventions for individuals with traumatic brain injury (TBI) and their conversation partners.

DATA SOURCES

Eleven key databases-PubMed, CINAHL, Cochrane Registry of Controlled Trials, Embase, Linguistic and Language Behavior Abstracts, ProQuest, Scopus, Web of Science, PsycBITE, SpeechBITE, and ERIC-were searched from inception through 2019.

STUDY SELECTION

Selected articles had to be peer reviewed, written in English, experimental or quasiexperimental design, report on TBI communication partners, and describe interventions or strategies targeting communication partners.

DATA EXTRACTION

Of 1088 articles identified, 12 studies were selected for data extraction, critical appraisal, and analysis with considerations of sex and gender. The Oxford Centre for Evidence-Based Medicine's guideline was used to critically appraise Levels of Evidence. Assessment of bias was conducted using the Cochrane Collaboration tools for randomized controlled trials and risk of bias in nonrandomized studies of interventions for nonrandomized controlled trials and the risk of bias in N-of-1 trials scale.

DATA SYNTHESIS

A systematic review with a qualitative meta-analysis of themes and findings across the selected studies identified 3 major categories: (1) benefits of the training for those with TBI, (2) risks of CPT, and (3) suggestions to improve its efficacy.

CONCLUSION

Most of the evidence comes from 1 research group, which may be viewed as a weakness in the current body of literature. However, although the evidence to date is modest, CPT may help to increase accessibility and reduce participation inequities in the community for individuals with TBI.

Traumatic brain injury and risk of dementia at different levels of cognitive ability and education

BACKGROUND AND PURPOSE

The effect of cognitive resources on the risk of dementia following traumatic brain injury (TBI) has hardly been investigated. The aim of this study was to examine the influence of cognitive ability and education in young adulthood on the association between TBI and dementia in men.

METHOD

A cohort of 658 447 Danish men, born between 1939 and 1959, who had been cognitively assessed at conscription were followed in the Danish National Patient Registry and the National Prescription Registry from 1977 through 2016 for incident TBI and dementia. The association between TBI and dementia was analysed using Cox proportional regression.

RESULTS

During follow-up, 29 781(4.5%) men experienced TBI and 10 971(1.7%) developed dementia. TBI was associated with a higher risk of subsequent dementia after adjustment for cognitive ability, education and psychiatric comorbidity. The risk estimate was higher for early-onset dementia (hazard ratio 5.49, 95% confidence interval 4.97-6.06) than for dementia diagnosed after age 60 years (hazard ratio 2.85, 95% confidence interval 2.63-3.10). The association was slightly stronger in men with the highest cognitive scores or education than amongst those at lower levels.

CONCLUSION

Young adult cognitive ability did not explain a relatively strong association between TBI and dementia, and no evidence was found that cognitive ability or education was protective.