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The Veterans Health Administration (VHA) screens veterans who deployed in support of the wars in Afghanistan and Iraq for traumatic brain injury (TBI) and mental health (MH) disorders. Chronic symptoms after mild TBI overlap with MH symptoms, for which there are already established screens within the VHA. It is unclear whether the TBI screen facilitates treatment for appropriate specialty care over and beyond the MH screens. Our primary objective was to determine whether TBI screening is associated with different types (MH, Physical MedicineRehabilitation [PMR], and Neurology) and frequency of specialty services compared with the MH screens. A retrospective cohort design examined veterans receiving VHA care who were screened for both TBI and MH disorders between Fiscal Year (FY) 2007 and FY 2018 (N = 241,136). We calculated service utilization counts in MH, PMR, and Neurology in the six months after the screens. Zero-inflated negative binomial regression models of encounters (counts) were fit separately by specialty care type and for a total count of specialty services. We found that screening positive for TBI resulted in 2.38 times more specialty service encounters than screening negative for TBI. Compared with screening positive for MH only, screening positive for both MH and TBI resulted in 1.78 times more specialty service encounters and 1.33 times more MH encounters. The TBI screen appears to increase use of MH, PMR, and Neurology services for veterans with post-deployment health concerns, even in those also identified as having a possible MH disorder.

Early response after 2 to 4 weeks of antidepressant therapy has been shown to predict remission by 8 to 12 weeks. Most of the work to date on early response has been done using data from randomized controlled trials.This naturalistic study uses archival data from a national tele-mental health company. The positive and negative predictive values as well as sensitivity and specificity were calculated using different drops in baseline Patient Health Questionnaire 9 scores at various periods. Demographic and clinical characteristics were compared between early responders versus those lacking early response. Binary logistic regression analyses determined if early response was predictive of remission, response, and greater than minimal improvement at 14 weeks. For those who do not show early improvement, treatments were investigated using binary logistic regression to see if changes predicted later outcomes.Positive predictive values for all endpoints improved with the strength of early response but did not improve much with the time allowed for that response to occur. In contrast, negative predictive values increased substantially with time. Using a definition of 30% drop in Patient Health Questionnaire 9 score at week 4, 56.5% of patients were early responders. Early responders were ~3.2 times more likely to achieve remission than those lacking early response. Of nonresponders by week 4, those prescribed atypical antipsychotics (+SSRI) had significantly reduced odds of response at week 14, whereas those prescribed a norepinephrine and dopamine reuptake inhibitor had increased odds.Early response may be associated with better outcomes at 14 weeks. In those with lack of response by week 4, patients prescribed a norepinephrine and dopamine reuptake inhibitor may achieve superior outcomes.

OBJECTIVE To examine traumatic brain injury (TBI) characteristics and comorbid medical profiles of Special Operations Forces (SOF) Active Duty Service Member/Veterans (ADSM/Vs) and contrast them with conventional military personnel. SETTING The 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS A subset of participants in the VA TBI Model Systems multicenter longitudinal study with known SOF status. These included 157 participants who identified as SOF personnel (average age = 41.8 years; 96% male, 81% active duty), and 365 who identified as Conventional Forces personnel (average age = 37.4 years; 92% male, 30% active duty). DESIGN Retrospective analysis of prospective cohort, cross-sectional. MAIN MEASURES The Health Comorbidities Interview. RESULTS SOF personnel were more likely to have deployed to a combat zone, had more years of active duty service, and were more likely active duty at time of TBI. SOF personnel were more likely to have had mild TBI (vs moderate/severe) and their TBI caused by violent mechanism. SOF personnel had a higher number of comorbidities, with more diagnoses of chronic pain, osteoarthritis, hyperlipidemia, hip fractures, and obstructive sleep apnea. CONCLUSION SOF personnel are at a higher risk for multimorbidity after TBI. Current rehabilitation practices should incorporate early screening and treatment of common conditions in this population, while future practices may benefit from a focus on prevention.

Introduction Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity. Materials and Methods This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age = 38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses. Results SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms. Conclusions Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF.

While outcome from mild traumatic brain injury (mTBI) is generally favorable, concern remains over potential negative long-term effects, including impaired cognition. This study examined the link between cognitive performance and remote mTBIs within the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter, observational study of Veterans and service members (SMs) with combat exposure.Baseline data of the participants passing all cognitive performance validity tests (Neither of the mTBI positive groups differed from the mTBI negative control group on any of the cognitive domains in multivariable analyses. Findings were also consistently negative across sensitivity analyses (e.g., mTBIs as a continuous variable, number of blast-related mTBIs, or years since the first and last mTBI).Our findings demonstrate that the average veteran or SM who experienced one or more mTBIs does not have postacute objective cognitive deficits due to mTBIs alone. A holistic health care approach including comorbidity assessment is indicated for patients reporting chronic cognitive difficulties after mTBI(s), and strategies for addressing misattribution may be beneficial. Future study is recommended with longitudinal designs to assess within-subjects decline from potential neurodegeneration. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

BackgroundTelemental health platforms may increase access to care for older adults. Historically, older adults have tended to adopt new technologies at a slower rate which creates a perception that they may not be able to benefit from them. The purpose of this study was to determine whether or not older adult patients receiving psychiatric care for depression via a telemental health platform achieve the same outcomes as younger adults.MethodParticipant data utilized in the current investigation were obtained from a national mental health telehealth company (i.e., Brightside) and consisted of 12,908 U.S.-based adult patients receiving psychiatric care for depression between October, 2018 and January, 2022. Propensity matching was used to create an older and younger sample (n = 141 in each) using 23 covariates. These samples were then compared using repeated measures ANOVA on Patient Health Questionnaire-9 (PHQ-9) scores at start of treatment, 6 weeks, 8 weeks, 10 weeks, 12 weeks, 14 weeks, and 16 weeks.ResultsDespite matching, the groups still significantly differed on prior mental health treatment, such that more older adults reported having had prior mental health treatment. There were no other differences between the groups on assessed variables. Both younger and older adults had decreasing scores over time with no significant differences between them.ConclusionOlder adults have similar improvement in depression symptom severity over time following initiation of psychiatric treatment via a telehealth platform. These findings suggest that age is not a barrier to benefitting from telepsychiatric care.

Emerging evidence suggests that repeated blast exposure (RBE) is associated with brain injury in military personnel. United States (U.S.) Special Operations Forces (SOF) personnel experience high rates of blast exposure during training and combat, but the effects of low-level RBE on brain structure and function in SOF have not been comprehensively characterized. Further, the pathophysiological link between RBE-related brain injuries and cognitive, behavioral, and physical symptoms has not been fully elucidated. We present a protocol for an observational pilot study, Long-Term Effects of Repeated Blast Exposure in U.S. SOF Personnel (ReBlast). In this exploratory study, 30 active-duty SOF personnel with RBE will participate in a comprehensive evaluation of: 1) brain network structure and function using Connectome magnetic resonance imaging (MRI) and 7 Tesla MRI; 2) neuroinflammation and tau deposition using positron emission tomography; 3) blood proteomics and metabolomics; 4) behavioral and physical symptoms using self-report measures; and 5) cognition using a battery of conventional and digitized assessments designed to detect subtle deficits in otherwise high-performing individuals. We will identify clinical, neuroimaging, and blood-based phenotypes that are associated with level of RBE, as measured by the Generalized Blast Exposure Value. Candidate biomarkers of RBE-related brain injury will inform the design of a subsequent study that will test a diagnostic assessment battery for detecting RBE-related brain injury. Ultimately, we anticipate that the ReBlast study will facilitate the development of interventions to optimize the brain health, quality of life, and battle readiness of U.S. SOF personnel.

Background Major Depressive Disorder and Generalized Anxiety Disorder are pervasive and debilitating conditions, though treatment is often inaccessible and based on trial-and-error prescribing methods. The present observational study seeks to describe the use of a proprietary precision prescribing algorithm piloted during routine clinical practice as part of Brightside’s telepsychiatry services. The primary aim is to determine the feasibility and acceptability of implementing this intervention. Secondary aims include exploring remission and symptom improvement rates. Methods Participants were adult patients enrolled in Brightside who completed at least 12 weeks of treatment for depression and/or anxiety and received a prescription for at least one psychiatric medication. A prescription recommendation was made by Brightside’s algorithm at treatment onset and was utilized for clinical decision support. Participants received baseline screening surveys of the PHQ-9 and GAD-7, and at weeks 2,4,6,8,10 and 12. Intent-to-treat (ITT) sensitivity analyses were conducted. Feasibility of the implementation was measured by the platform’s ability to enroll and engage participants in timely psychiatric care, as well as offer high touch-point treatment options. Acceptability was measured by patient responses to a 5-star satisfaction rating. Results Brightside accessed and treated 6248 patients from October 2018 to April 2021, treating a majority of patients within 4-days of enrollment. The average plan cost was $115/month. 89% of participants utilized Brightside’s core medication plan at a cost of $95/month. 13.4% of patients in the study rated Brightside’s services as highly satisfactory, averaging a 4.6-star rating. Furthermore, 90% of 6248 patients experienced a MCID in PHQ-9 or GAD-7 score. Remission rates were 75% (final PHQ-9 or GAD-7 score Conclusions Results suggest that the present intervention may be feasible and acceptable within the assessed population. Exploratory analyses suggest that Brightside’s course of treatment, guided by precision recommendations, improved patients’ symptoms of anxiety and depression.

This paper briefly reviews what is unknown about chronic traumatic encephalopathy (CTE), highlights understandable concerns by individuals with a history of mild traumatic brain injuries who present to neuropsychologists with fears about a deteriorating course and eventual dementia due to CTE, and proposes a three-phased model for intervening with such individuals.The proposed model includes three phases - (1) assessment and education, (2) targeted interventions for specific symptoms and comorbidities (e.g., sleep disturbance, headache, depression), and (3) psychotherapy to address mental health issues. While this is generally the order in which they will occur, the approach is not necessarily linear but rather provides a recommended schema.Media attention on concussion has greatly increased in the last several years, as interest in the possible contribution of concussion(s) to CTE grows. This media attention has some adverse effects in that it creates a false perception about the current state of the science and may engender iatrogenic effects. The proposed model is offered as one approach to engage patients within this context.

OBJECTIVE To summarize challenges and best practices relevant to providing care for mental health comorbidities in veterans and service members (V/SM) treated in the Polytrauma System of Care (PSC) and to review themes that emerged during a May 2017 meeting of rehabilitation professionals on this topic. Management of comorbid mental health conditions remains a critical issue within the PSC, given the high rate of these comorbidities and the impact of mental health conditions on treatment planning and outcomes. DESIGN To identify the challenges of concomitantly treating TBI-related symptoms and mental health comorbidities in V/SM treated within the PSC, describe specialty programs within the Veterans Health Administration designed to treat these comorbid conditions, and report on the themes and recommendations identified by rehabilitation professionals at the 2017 meeting. CONCLUSION To further develop mental health treatment within the PSC, the following recommendations were made: (1) continued support for family members as critical members of the rehabilitation team; (2) adding measures and mechanisms to monitor mental health within the PSC; and (3) exploration of modern technologies to enhance care of existing polytrauma clients and to better prepare to serve clients with all types of acquired brain injury.

Objective: Stroke is commonly seen in neuropsychological practice. Individual differences, diffuse damage, and the difficulty inherent in researching stroke create challenges for the clinician trying to synthesize the latest information to educate patients and families on prognosis. The objective of this special issue is to provide an overview of the latest clinical research in stroke - the contributors address assessment and treatment issues that are relevant to practice. Method: We solicited papers from established researchers and issued a general call for papers for the special issue on stroke. Results: We received submissions from several authors, eight of which are included in this issue. These submissions cover both assessment and treatment issues and include two review articles, one on language and one on spatial neglect. Two apparent themes are the utility of early assessment/treatment and the importance of executive functioning in predicting later functioning. Conclusions: The issue highlights the need for clinical neuropsychologists to be aware of the latest research on recovery from stroke and the importance of both assessment and management strategies to reduce impact on daily life.

Objective: Investigate the effectiveness of Concussion Coach, an interactive smartphone application, as a treatment for residual neurobehavioral symptoms and distress in Veterans with a history of mild traumatic brain injury (mild TBI). Methods: Veterans with mild TBI were randomized to Concussion Coach (n = 238) or Treatment-as-Usual (TAU) (n = 241) in a 3-month randomized controlled trial. Primary outcome measures included postconcussive symptom (PCS) severity as measured by the Neurobehavioral Symptom Inventory (NSI), and psychological distress as measured by the Brief Symptom Inventory-18 (BSI-18). Measures of self-efficacy, social support, and comfort with technology were administered as potential moderators and mediators. An intention-to-treat (ITT) analysis was performed (N = 461: Concussion Coach = 231 and TAU = 230) using Bayesian Network (BN)modeling. Results: The probability of decreased PCS severity was significantly greater for those assigned to Concussion Coach, .35 [.32,.37], than for TAU, .29 (.27, .32), with an odds ratio (OR) of 1.29. Also, Concussion Coach showed a significantly greater probability of increased self-efficacy (.36 [.32, .39]) than did TAU (.28 [.25, .30], OR = 1.42). In turn, self-efficacy (increased vs. decreased) showed a significantly greater probability of decreased PCS severity (.51 [.47, .54] vs. .27 [.24, .30], OR = 2.71) and decreased psychological distress (.53 [.49, .56] vs. .32 [.29, .35], OR = 2.35), suggesting that self-efficacy may have mediated Concussion Coach effects. Conclusions: Concussion Coach is effective at reducing PCS severity and psychological distress. Increased self-efficacy/perception of self-management of symptoms may be key to successful treatment of residual symptoms in those with history of concussion.

Objective: The Automated Neuropsychological Assessment Metrics (ANAM) has long been used to assess cognition in military samples before deployment and following injury. The purpose of this study was to explore the effects of various demographic factors on the ANAM4 Military Expanded (ANAM4 ME) performance of Special Operations Forces (SOF) and to provide regression-based normative data for clinicians working with SOF personnel. Method: The sample was a large active duty military sample of SOF and support personnel (n = 24,072) who were tested under a new baseline policy. Results: Performance differences based on demographic variables were generally small. In general, increasing age was associated with significantly worse performance, except on mathematical processing. Higher education level was associated with better performance on most subtests, as expected, but was associated with worse performance on spatial processing. Conclusion: This paper provides regression formulas for calculating adjusted scores based on the most relevant demographic variables, as well as base rates of obtaining one or more clearly above or below average scores across the entire ANAM4 ME battery.

PURPOSE This study aimed to screen the entire genome for genetic markers associated with risk for concussion. METHODS A genome-wide association analyses was performed using data from the Kaiser Permanente Research Bank and the UK Biobank. Concussion cases were identified based on electronic health records from the Kaiser Permanente Research Bank and the UK Biobank from individuals of European ancestry. Genome-wide association analyses from both cohorts were tested for concussion using a logistic regression model adjusting for sex, height, weight, and race/ethnicity using allele counts for single nucleotide polymorphisms. Previously identified genes within the literature were also tested for association with concussion. RESULTS There were a total of 4064 cases of concussion and 291,472 controls within the databases, with two single nucleotide polymorphisms demonstrating a genome-wide significant association with concussion. The first polymorphism, rs144663795 (P = 9.7 × 10-11; OR = 2.91 per allele copy), is located within the intron of SPATA5. Strong, deleterious mutations in SPATA5 cause intellectual disability, hearing loss, and vision loss. The second polymorphism, rs117985931 (P = 3.97 × 10-9; OR = 3.59 per allele copy), is located within PLXNA4. PLXNA4 plays a key role is axon outgrowth during neural development, and DNA variants in PLXNA4 are associated with risk for Alzheimer's disease. Previous investigations have identified five candidate genes that may be associated with concussion, but none showed a significant association in the current model (P < 0.05). CONCLUSION Two genetic markers were identified as potential risk factors for concussion and deserve further validation and investigation of molecular mechanisms.

The contribution of sleep disturbance to persistent cognitive symptoms following a mild traumatic brain injury (mTBI) remains unclear. Obstructive sleep apnea (OSA) is very common, yet its relationship between risk factors for developing OSA and cognitive performance in those with history of mTBI has not been investigated. The current study examined OSA risk levels and its association with cognitive performance in 391 combat-exposed, post-911 veterans and service members (median age = 37 years) enrolled in the Chronic Effects of Neurotrauma Consortium (CENC) prospective multi-center study. Participants included those with and without mTBI (n = 326 and 65, respectively). When using clinical cut-offs, those with history of mTBI were more likely to be categorized as high risk for OSA (mTBI positive = 65% vs. mTBI negative = 51%). After adjustment for TBI status and demographic variables, increased OSA risk was significantly associated with worse performance on measures of complex processing speed and executive functioning (Wechsler Adult Intelligence Scale Fourth Edition Coding, Trail Making Test, part B) and greater symptom burden (Neurobehavioral Symptom Inventory). Thus, OSA, a modifiable behavioral health factor, likely contributes to cognitive performance following mTBI. Accordingly, OSA serves as a potential point of intervention to improve clinical and cognitive outcomes after injury.

The military has a long history with neuropsychology and its precursors. From developing intelligence tests during World War I, to developing early capacity and personality assessments during World War II, to forward deploying for the evaluation and treatment of frequent concussive brain injuries during more recent conflicts, clinical neuropsychology has been at the forefront of military selection, healthcare and research. The objective of this special issue is to provide an overview of the latest clinical research relevant to military neuropsychology-some contributors address assessment and treatment issues that are relevant to current practice and others foretell the future of our field.We solicited papers from established researchers and issued a general call for papers for the special issue on military neuropsychology. Results: We received submissions from several authors, eleven of which are included in this issue. These submissions cover assessment and treatment issues, as well as healthcare utilization and return to duty issues. Two apparent themes are the importance of assessing, treating, and attending to comorbidities following traumatic brain injury (TBI) and future assessment techniques moving beyond traditional cognitive performance assessment.The issue highlights the importance of research in clinical neuropsychology to the practice and advancement of military neuropsychology.

As part of a larger study to test the efficacy of the Concussion Coach cell phone application for patients with post-concussion symptoms, qualitative data were gathered to assess barriers and facilitators for app use and differences in use of the app among those who declined or improved in symptom severity, or were low-use users.Using a prospective descriptive study design, 35 semi-structured qualitative interviews were conducted between 2016-2018. Participants had a history of mild traumatic brain injury and were symptomatic. Interview data were analyzed using qualitative content analysis.Primary facilitators were the app's ease of use, privacy, availability/portability, and increased self-efficacy of the user. Primary barriers were a lack of sufficient app training, stigma, overly "basic" content, and symptom severity. While there were not prominent differences among user groups, users whose symptom severity improved described using more modules of the app than users who declined. Low-users attributed not using the app to content that was too basic or to their forgetting.Interview data suggest that Concussion Coach can benefit Veterans with post-concussive symptoms through increased agency, perceived benefits to emotional well-being, and the availability of non-stigmatized strategies for symptom management.

To identify prevalence and predictors of tobacco smoking among veterans and military service members (V/SM) with traumatic brain injury (TBI) admitted for rehabilitation.Participants were drawn from the VA TBI Model Systems multicentre longitudinal research study. Tobacco smoking was assessed both preinjury and at 1- or 2-year post-TBI follow-up for 336 participants.Smoking prevalence was 32% preinjury and 28% at follow-up. Most participants had a stable smoking pattern but 12% of preinjury non-smokers became smokers at follow-up. Preinjury smoking was the strongest predictor of post-TBI smoking. Higher cognitive function also predicted smoking at follow-up. In univariate analyses, smoking was predicted by lower education, preinjury mental health (MH) history, selected TBI severity metrics, and higher functional status at rehabilitation hospital discharge (Disability Rating Scale [DRS] and motor subscale of the Functional Independence Measure [FIM]).Study findings may help clinicians and administrators recognize who is at high risk for smoking following TBI, to plan for in-hospital and postdischarge screening and interventions.

Population-based post-deployment screening programs within the Departments of Defense and Veterans Affairs have been implemented to assess for mental health conditions and traumatic brain injury. The purpose of this paper is to systematically review the literature on post-deployment screening within this context and evaluate evidence compared to commonly accepted screening implementation criteria. Findings reflected highly variable psychometric properties of the various screens, variable treatment referral rates following screening, low to moderate treatment initiation rates following screening, and no information on treatment completion or long-term outcomes following screening. In sum, the evidence supporting population based post-deployment screening is inconclusive. Implications are discussed.

BACKGROUND Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans’ experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members’ homes and communities to facilitate CR. OBJECTIVE The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal. METHODS This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration. RESULTS Study enrollment and data collection are completed. Data analyses are underway. CONCLUSIONS The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/14170

We sought to further define the epidemiology of the complex, multiple injuries collectively known as polytrauma/blast-related injury (PT/BRI). Using a systems science approach, we performed Bayesian network modeling to find the most accurate representation of the complex system of PT/BRI and identify key variables for understanding the subsequent effects of blast exposure in a sample of Florida National Guard members (1,443 deployed to Operation Enduring Freedom/Operation Iraqi Freedom and 1,655 not deployed) who completed an online survey during the period from 2009 to 2010. We found that postdeployment symptoms reported as present at the time of the survey were largely independent of deployment per se. Blast exposure, not mild traumatic brain injury (TBI), acted as the primary military deployment-related driver of PT/BRI symptoms. Blast exposure was indirectly linked to mild TBI via other deployment-related traumas and was a significant risk for a high level of posttraumatic stress disorder (PTSD) arousal symptoms. PTSD arousal symptoms and tinnitus were directly dependent upon blast exposure, with both acting as bridge symptoms to other postdeployment mental health and physical symptoms, respectively. Neurobehavioral or postconcussion-like symptoms had no significant dependence relationship with mild TBI, but they were synergistic with blast exposure in influencing PTSD arousal symptoms. A replication of this analysis using a larger PT/BRI database is warranted.

Objective: The purpose of this study was to examine the prevalence and stability of symptom reporting in a healthy military sample and to develop reliable change indices for two commonly used self-report measures in the military health care system. Participants and method: Participants were 215 U.S. active duty service members recruited from Fort Bragg, NC as normal controls as part of a larger study. Participants completed the Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Checklist (PCL) twice, separated by approximately 30 days. Results: Depending on the endorsement level used (i.e. ratings of ‘mild’ or greater vs. ratings of ‘moderate’ or greater), approximately 2–15% of this sample met DSM-IV symptom criteria for Postconcussional Disorder across time points, while 1–6% met DSM-IV symptom criteria for Posttraumatic Stress Disorder. Effect sizes for change from Time 1 to Time 2 on individual symptoms were small (Cohen’s d = .01 to .13). The test–retest reliability for the NSI total s...

OBJECTIVE: The authors reviewed the existing literature on the Veterans Health Administration's (VHA's) traumatic brain injury (TBI) screening and evaluation program to provide a qualitative synthesis and critical review of results focusing on the psychometric properties of the screen. METHODS: All studies of the VHA's screening and evaluation process were reviewed, both those involving primary data collection and those relying upon VHA data. Diagnostic statistics were summarized and also recalculated on the basis of a positive screening rate of 20%, the observed rate within the VHA, and an estimated population prevalence of TBI of 15% within the Department of Veterans Affairs (VHA). RESULTS: The TBI screen within the VHA is administered to nearly every eligible patient. The majority of clinical presentations are deemed to be due to mental health and/or a combination of mental health and TBI factors. The screen has good internal consistency, variable test-retest reliability, and questionable validity, with poor agreement between the TBI screen and criterion standards overall. Studies based on nonrepresentative samples reported high sensitivity. Assuming the VHA's TBI screening rate of 20% in a hypothetical sample, sensitivity is poor (the screen misses 30%-60% of TBI cases). However, specificity remains adequate. Studies based on samples with high rates of TBI reported much higher positive predictive values (and slightly lower negative predictive values) than those observed when a hypothetical TBI prevalence of 15% was used. CONCLUSION: Questions remain about the validity of the TBI screen. Future research should address the utility of screening for TBI. Language: en

This study examined whether self-efficacy differentiated treatment responders from non-responders in a trial of cognitive rehabilitation (CR) for postconcussive symptoms. 126 service members with mild TBI seen on average 9.5 months since injury completed one of four cognitive rehabilitation treatments for 6 weeks. The four treatment arms were: (1) Psychoeducation control, (2) Self-administered computerized CR, (3) Interdisciplinary CR, and (4) Interdisciplinary CR integrated with CBT. Outcome was assessed across time (baseline, and 6, 12, and 18 weeks post-treatment) for three domains: psychological (Symptom Checklist-90-Revised; SCL-90-R), cognitive (Paced Auditory Serial Addition Test; PASAT), and functional/behavioural (Key Behaviors Change Inventory; KBCI). Mixed model ANOVAs tested for self-efficacy differences across time in treatment responders versus non-responders, as defined by reliable change indices. A significant interaction was found on the SCL-90 such that responders had increasing self-efficacy with respect to psychological symptoms across four time points, whereas non-responders' self-efficacy did not change. Perceived self-efficacy at the beginning of treatment was associated with treatment engagement within the psychological domain for responders only, suggesting a mediating role in treatment outcome. Overall, results suggest that increasing patients' level of self-efficacy may be important for successful treatment of psychological distress in those with remote concussion.

Purpose/objective Effective treatment for postconcussive symptoms (PCS) immediately following mild traumatic brain injury (mTBI) includes reassurance, support, education about mTBI, and symptom management. However, effective treatments for chronic postconcussive-like symptoms, particularly with mental health comorbidities, remain unclear. Research Method/Design: We conduct a critical review of the treatment literature for chronic PCS, present exemplar studies of two alternative treatment approaches (i.e., cognitive rehabilitation (CR) and psychotherapy with various cognitive-behavioral therapy (CBT) approaches) and compare their relative effectiveness, and examine other literature to compare treatment benefits of one approach over another. Results This review and comparisons found CBT approaches to be 5 to 6 times more potent in reducing chronic PCS than CR. Conclusions/implications Based on these findings we encourage rehabilitation professionals to "re-conceptualize" the factors that likely underlie chronic PCS and the most effective treatment for this condition. We propose that CBT interventions focusing on comorbid and underlying mental health issues should be an essential, not adjunctive, treatment approach for chronic PCS. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective The goal of the Chronic Effects of Neurotrauma Consortium (CENC) study is to explore the effects of concussions among Service Members and Veterans. A factor model was fit to selected neuropsychological measures to identify potentially useful relationships between assessments collected on CENC-enrolled participants. Method 492 post-9/11 participants with combat exposure were enrolled across four VA study sites. Participants completed assessments including concussion history, neurocognitive functioning, and self-report questionnaires. Exploratory factor analyses (EFA) using four different methods with varimax and promax rotations were used to analyse the cognitive variables. Final model selection was based on factor loadings towards simple structure. Results The scree plot suggested the number of factors to be extracted was between 4 and 5. EFA produced a 5-factor MINRES model with promax rotation that resulted in a factor loading with variables loading on only one factor with a predefined threshold (0.40). Variables loaded on five cognition domains: list learning, working memory/executive skills, cognitive control, fluency, and memory. Conclusion These results provide reasonable evidence that data collected from the CENC neuropsychological battery can be reduced to five clinically useful factors. This will enable us to use the factors for further study of the impact of concussion on neurodegeneration.

Disability evaluation is complex. The association between mild traumatic brain injury (mTBI) history and VA service-connected disability (SCD) ratings can have implications for disability processes in the civilian population. We examined the association of VA SCD ratings with lifetime mTBI exposure in three models: any mTBI, total mTBI number, and blast-related mTBI.Participants were 492 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans from four US VA Medical Centers enrolled in the Chronic Effects of Neurotrauma Consortium study between January 2015 and August 2016. Analyses entailed standard covariate-adjusted linear regression models, accounting for demographic, military, and health-related confounders and covariates.Unadjusted and adjusted results indicated lifetime mTBI was significantly associated with increased SCD, with the largest effect observed for blast-related mTBI. Every unit increase in mTBI was associated with an increase in 3.6 points of percent SCD. However, hazardous alcohol use was associated with lower SCD.mTBI, especially blast related, is associated with higher VA SCD ratings, with each additional mTBI increasing percent SCD. The association of hazardous alcohol use with SCD should be investigated as it may impact veteran health services access and health outcomes. These findings have implications for civilian disability processes.

Traumatic brain injury (TBI) is a significant cause of morbidity in military Veterans and Service Members. While most individuals recover fully from mild injuries within weeks, some continue to experience symptoms including headaches, disrupted sleep, and other cognitive, behavioral or physical symptoms. Diffusion magnetic resonance imaging (dMRI) shows promise in identifying areas of structural disruption and predicting outcomes. Although some studies suggest widespread structural disruption after brain injury, dMRI studies of military brain injury have yielded mixed results so far, perhaps due to the subtlety of mild injury, individual differences in injury location, severity and mechanism, and co-morbidity with other disorders such as post-traumatic stress disorder (PTSD), depression, and substance abuse. We present preliminary dMRI results from the ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) military brain injury working group. We found higher fractional anisotropy (FA) in participants with a history of TBI. Understanding the injury and recovery process, along with factors that influence these, will lead to improved diagnosis and treatment.

OBJECTIVE To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD). METHOD Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology. RESULTS No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions. CONCLUSIONS The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.

Objective To evaluate and compare the existing Neurobehavioral Symptom Inventory factor structure models to determine which model provides the best overall fit for postconcussion symptoms and determine which model is useful across different samples (eg, with and without mild traumatic brain injury [TBI] history). Setting N/A. Participants A Florida National Guard sample (N = 3098) and a national Department of Veterans Affairs sample (N = 48,175). Design Retrospective structural equation modeling was used to compare 16 alternative factor structure models. First, these 16 possible models were examined separately in both samples. Then, to determine whether the same factor structures applied across subsamples within these samples, the models were compared for those deployed and those not deployed in the Florida National Guard sample and between those with TBI confirmed on clinical evaluation and those who were determined not to have sustained a TBI within the Department of Veterans Affairs sample. Main measures Neurobehavioral Symptom Inventory. Results A 4-factor model--vestibular, somatic, cognitive, and affective--had the best overall fit, after elimination of 2 items (ie, hearing problems and appetite disturbance), and was most applicable across samples. Conclusions These findings extend the findings of Meterko et al to other samples. Because findings were consistent across sample and subsamples, the current findings are applicable to both Department of Veteran Affairs and Department of Defense postdeployment medical evaluation settings.

Background In recognition of the incidence of traumatic brain injuries (TBIs) in the Iraq and Afghanistan conflicts, the Department of Veterans Affairs (VA) has, since 2007, examined returning U.S. service members for symptoms of TBI, a pre-condition for VA treatment of TBI. This study characterizes "Traumatic Brain Injury screen" service delivery, according to the barrier and facilitator viewpoints of those experiencing the delivery. Methods The purposeful sample comprised both Veteran patient and VA staff participants in the TBI screen program (n = 64), including patients (n = 14), health care providers (n = 38), and key informants (n = 12). Telephone interviews were conducted per standardized, semi-structured interview scripts; respondent narratives recorded and transcribed verbatim; natural emergence of key themes of discourse fostered through conventional content analysis; themes coded by meaning and meaning units organized by nature of influence on service delivery. Results A wide variety of structural, administrative, and communications barriers impede TBI screen service delivery, and certain case management and other functions promote delivery. Conclusions The value of VA TBI screen service delivery is appreciated by its participants, but delivery is perceived as vulnerable to failure; the extent of such failure and short- and long-term effects on patient health and well-being outcomes is incompletely understood and merits investigation. Evaluating VA TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management is suggested.

Traumatic brain injury (TBI), in particular mild TBI (mTBI), is a relatively common injury experienced by service members across both deployed and nondeployed environments. Although many of the principles and practices used by civilian health care providers for identifying and treating this injury apply to military settings, there are unique factors that impact mTBI-related care in service members and Veterans. This article reviews several of these factors, including the epidemiology of TBI in the military/Veteran population, the influence of military culture on this condition, and identification and treatment of mTBI in the war zone.

There is growing concern that military breaching and training and firing artillery and mortars, grenades, and shoulder-fired weapons may have some type of cumulative deleterious effects. There are anecdotal reports of those with repetitive exposure to low-level blast complaining of various symptoms, as well as increasing empirical evidence. The purpose of this report is to provide a systematic review of the literature on repetitive lowlevel blast as it pertains to military and police training protocols. An extensive literature search was conducted, resulting in detailed review of 18 studies. Results suggest few consistent findings, likely due to the heterogeneity of methods, high risk of bias, and lack of reliance on objective blast-exposure data. Adverse effects, when present, dissipated over time. All studies that used blast gauges found significant associations, though only a subset actually reported using the blast-gauge data (to correlate objective exposure with outcomes). When comparing studies within an outcome domain (e.g., cognitive), findings were largely inconsistent. Research with larger sample sizes, followed longitudinally, is needed.

Expectations may play a large role in health-related outcomes, but they may not be fully addressed or considered in medical–legal contexts. Contextual factors can influence a patient’s expectations for recovery following a concussion, including explicit or implicit messages from the media, healthcare providers and systems of care, and the forensic arena. This article discusses these factors as nocebo effects, that is, various inherently “inert” factors may create negative expectancies for recovery and therefore impede a given patient’s progress and recovery. It is argued that the negligence theory upon which the legal system is based tends to compound these nocebo effects. In accident-related concussions, both the accident itself and subsequent nocebo effects including potential healthcare and medical–legal provider negligence can create legal liability.

Background Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans’ experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members’ homes and communities to facilitate CR. Objective The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal. Methods This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration. Results Study enrollment and data collection are completed. Data analyses are underway. Conclusions The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members. International Registered Report Identifier (IRRID) DERR1-10.2196/14170