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Objective To examine factors related to attrition in a traumatic brain injury (TBI) study sample assessed up to 15 years after injury. Participants One thousand twenty-eight participants with TBI who completed the year 1 follow-up assessment at a TBI Model Systems Center between 1992 and 2018. Method Secondary analysis of data from a prospective longitudinal cohort study considering follow-up data collection completion status at years 1, 2, 5, 10, and 15. Results In univariable analyses, multiple factors were associated with loss to follow-up (LOFU) including being a member of a socially disadvantaged group, substance use history, residence, payor, cause of injury, and results of earlier follow-up attempts. In a multiple logistic regression analysis examining the prediction of follow-up condition at 10 or 15 years post-injury, only payor and race/ethnicity were significant predictors. Hispanic ethnicity was associated with higher odds of LOFU, and these participants often spoke Spanish and were born outside of the United States. Conclusions The findings suggest a need to understand sociodemographic variables and their influence on participant attrition in longitudinal TBI research. With a better understanding of these predictors, procedures can be developed to address retention of participants who are identified as being at increased risk for study drop out.

Introduction Cognitive processes such as perception and reasoning are preceded and dependent on attention. Because of the close overlap between neural circuits of attention and eye movement, attention may be objectively quantified with recording of eye movements during an attention-dependent task. Our previous work demonstrated that performance scores on a circular visual tracking task that requires dynamic synchronization of the gaze with the target motion can be impacted by concussion, sleep deprivation, and attention deficit/hyperactivity disorder. The current study examined the characteristics of performance on a standardized predictive visual tracking task in a large sample from a U.S. Military population to provide military normative data. Materials and Methods The sample consisted of 1,594 active duty military service members of either sex aged 18-29 years old who were stationed at Fort Hood Army Base. The protocol was reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board. Demographic, medical, and military history data were collected using questionnaires, and performance-based data were collected using a circular visual tracking test and Trail Making Test. Differences in visual tracking performance by demographic characteristics were examined with a multivariate analysis of variance, as well as a Kolmogorov-Smirnov test and a rank-sum test. Associations with other measures were examined with a rank-sum test or Spearman correlations. Results Robust sex differences in visual tracking performance were found across the various statistical models, as well as age differences in several isolated comparisons. Accordingly, norms of performance scores, described in terms of percentile standings, were developed adjusting for age and sex. The effects of other measures on visual tracking performance were small or statistically non-significant. An examination of the score distributions of various metrics suggested that strategies preferred by men and women may optimize different aspects of visual tracking performance. Conclusion This large-scale quantification of attention, using dynamic visuomotor synchronization performance, provides rigorously characterized age- and sex-based military population norms. This study establishes analytics for assessing normal and impaired attention and detecting changes within individuals over time. Practical applications for combat readiness and surveillance of attention impairment from sleep insufficiency, concussion, medication, or attention disorders will be enhanced with portable, easily accessible, fast, and reliable dynamic eye-tracking technologies.

Objective: Determine the characteristics of postintensive care syndrome in the cognitive, physical, and psychiatric domains in coronavirus disease 2019 ICU survivors. Design: Single-center descriptive cohort study from April 21, to July 7, 2020. Setting: Critical care recovery clinic at The Mount Sinai Hospital in New York City. Patients: Adults who had critical illness due to coronavirus disease 2019 requiring an ICU stay of 7 days or more and who agreed to a telehealth follow-up in the critical care recovery clinic 1-month post hospital discharge. INTERVENTIONS: None. Measures and Main Results: Patient-reported outcome measures assessing physical and psychiatric domains were collected electronically, a cognitive test was performed by a clinician, and clinical data were obtained through electronic medical records. Outcome measures assessed postintensive care syndrome symptoms in the physical (Modified Rankin Scale, Dalhousie Clinical Frailty Scale, Neuro-Quality of Life Upper Extremity and Lower Extremity Function, Neuro-Quality of Life Fatigue), psychiatric (Insomnia Severity Scale; Patient Health Questionnaire-9; and Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and cognitive (Telephone Montreal Cognitive Assessment) domains. The 3-Level Version of Euro-QoL-5D was used to assess the physical and psychiatric domains. A diagnosis of postintensive care syndrome was made in cases with evidence of impairment in at least one postintensive care syndrome domain. We included 45 patients with a mean (SD) age of 54 (13) years, and 73% were male. Ninety-one percent of coronavirus disease 2019 ICU survivors fit diagnostic criteria for postintensive care syndrome. 86.7 % had impairments in the physical domain, 22 (48%) reported impairments in the psychiatric domain, and four (8%) had impairments on cognitive screening. We found that 58% had some degree of mobility impairment. In the psychiatric domain, 38% exhibited at least mild depression, and 18 % moderate to severe depression. Eighteen percent presented Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores suggestive of posttraumatic stress syndrome diagnosis. In the Telephone Montreal Cognitive Assessment, 9% had impaired cognition. Conclusions: Survivors of critical illness related to coronavirus disease 2019 are at high risk of developing postintensive care syndrome. These findings highlight the importance of planning for appropriate post-ICU care to diagnose and treat this population.

OBJECTIVES To compare characteristics of those who do and do not sustain subsequent traumatic brain injuries (TBIs) following index TBI and to identify reinjury risk factors. DESIGN Secondary data analysis of an ongoing longitudinal cohort study. SETTING TBI Model Systems Centers. PARTICIPANTS In total, 11 353 individuals aged 16+ years. MAIN OUTCOME MEASURES Ohio State University TBI Identification Method. RESULTS In total, 7.9% of individuals reported sustaining a TBI post-index TBI. Twenty percent of reinjuries occurred within a year of the index TBI. Reinjury risk followed an approximate U-shaped distribution such that risk was higher in the first year, declined 2 to 10 years postinjury, and then increased after 10 years. A multivariable Weibull model identified predictors of reinjury: younger (

Research Objectives To test the hypothesis that a history of concussion prior to the collegiate pre-season is associated with risk for re-injury. We also investigate sex differences in cognitive functioning and self-reported concussion symptoms and their associations with new concussion risk. Design Longitudinal cohort study with two consecutive pre-season (P) baseline evaluations (P1 and P2). Setting Urban NCAA Division I University. Participants 212 collegiate athletes (46% female) ≥18 years of age who participated in soccer, baseball/softball, lacrosse, basketball, volleyball, track & field, and/or cheerleading. Interventions Not applicable. Main Outcome Measures The Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) includes self-reported history of diagnosed concussions, computerized cognitive assessment, and Post-Concussion Symptom Scale (PCSS). The Brain Injury Screening Questionnaire (BISQ) characterizes lifetime history of brain injury/concussion. Results Twenty-six percent (n=56) of athletes reported ≥ 1 prior concussion at P1. There were 40 new concussions recorded between P1 and P2, 21 (53%) of which were among athletes who reported a lifetime history of concussion at P1. New concussions occurred in 24% of female athletes (n=23) and 15% of male athletes (n=17). Prior history of concussion and sex were significant predictors of new concussion between P1 and P2; however, in adjusted models, inclusion of P1 poor impulse control and PCSS total symptom scores attenuated the effect of sex on risk for new injury. Conclusions Collegiate athletes with a lifetime history of concussion had a significantly higher risk of sustaining a new concussion. Pre-season symptomology and impulse control may play a role in observed sex differences related to risk of injury. Screening for lifetime history of concussion (including those sustained outside of sports participation) may inform risk tolerance, monitoring, and return-to-play decision-making. Author(s) Disclosures NIH, NIDILRR, DoD, PCORI

BACKGROUND By 2014, all states implemented concussion laws that schools must translate into daily practice; yet, limited knowledge exists regarding implementation of these laws. We examined the extent to which concussion management policies and procedure (P&P) documents of New York State school districts comply with the State's Concussion Awareness and Management Act (the Act). We also aimed to identify barriers to compliance. METHODS Forty-seven school districts provided P&P documents. We examined compliance with the Act and the relationship between compliance and each district's demographics. RESULTS Compliance varied across school districts, with higher overall compliance in large city school districts compared to county districts. However, there was low compliance for several critical items. We found no statistically significant relationship between compliance and demographics. CONCLUSIONS School districts need to increase compliance with concussion legislation to ensure the adequate implementation necessary for the law to impact health and educational outcomes. The results provide important information to individuals charged with the responsibility of implementation and ultimately reducing the negative outcomes associated with brain injuries in schools.

Prospective, single-blinded study. To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. AIR unit. Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52–0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48–0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53–1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47–0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI −0.01 to 0.59, N = 36). Responses of “I don’t know” were excluded from agreement analyses. This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.

Background PTSD, which has been identified in up to 23% of post-9-11 veterans, often results in a chronic, pernicious course. Thus, effective treatments are imperative. The Institute of Medicine (IOM) concluded that the only intervention for PTSD with sufficient evidence to conclude efficacy is exposure therapy. This Phase III trial compares the efficacy of exposure therapy for combat-related PTSD delivered in two different formats- via virtual reality exposure therapy (VRE) or prolonged exposure therapy (PE)- combined with D-Cycloserine (DCS), a cognitive enhancer shown to facilitate the extinction of fear. Methods/design Military personnel of any duty status and civilians deployed to Iraq and Afghanistan were eligible. Participants were randomly assigned to 9 sessions of exposure therapy (VRE or PE) and medication (50 mg DCS or placebo). Participants were treated at three geographically diverse sites. Participants were re-assessed at 3-months post-treatment. The co-primary hypotheses are that (1) DCS will augment response to exposure therapy (both VRE and PE) on PTSD symptoms; (2) VRE will be associated with greater improvement than PE. Genetic and psychophysiological markers will be evaluated as potential moderators and mediators of treatment outcomes as well as secondary outcomes. Discussion This study is the first to compare the relative efficacy of DCS-augmented VRE versus PE on PTSD symptoms. The design has several advantages: participants received an active, effective treatment and predictors of response to treatment included genetic and psychobiological measures. The results may directly influence the future delivery of services, and contribute to the development of a standardized treatment protocol. Trial registration: NCT01352637 .

To characterize sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness in individuals with TBI. Possible relationships between sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness were examined.Forty-four community-dwelling adults with TBI completed the Pittsburgh Sleep Quality Index (PSQI), Multidimensional Assessment of Fatigue (MAF) and Epworth Sleepiness Scale (ESS). They underwent two nights of in-laboratory nocturnal polysomnography (NPSG). Pearson product-moment correlation coefficients and hierarchical linear regression was used to analyse the data.Based on the PSQI cut-off score of ≥ 10, 22 participants were characterized as poor sleepers. Twenty-seven participants met criteria for clinically significant fatigue as measured by the GFI of the MAF. Fourteen participants met criteria for excessive daytime sleepiness as measured by the ESS. Poor sleep quality was associated with poor sleep efficiency, short duration of stage 2 sleep and long duration of rapid eye movement sleep. There was little-to-no association between high levels of fatigue or daytime sleepiness with NPSG sleep parameters.A high proportion of the sample endorsed poor sleep quality, fatigue and daytime sleepiness. Those who reported poorer sleep quality evidenced a shorter proportion of time spent in stage 2 sleep. These findings suggest that disruptions in stage 2 sleep might underlie the symptoms of sleep disturbance experienced following TBI.

Objective Preliminary evaluation of the efficacy of a Web-based group intervention (Online EmReg) to improve emotion regulation (ER) in individuals with traumatic brain injury (TBI). Design Pre-/post-within-subject design with baseline, end-of-treatment, and 12-week follow-up assessments. Participants Ninety-one individuals with TBI and deficits in ER. Intervention Twenty-four sessions of training in ER skills delivered by group videoconference. Measures Difficulties in Emotion Regulation Scale (DERS), Positive Affect Negative Affect Schedule (PANAS), Satisfaction With Life Scale (SWLS), Problem Solving Inventory (PSI), Social Problem Solving Inventory-Revised: Short Form (SPSI-R:S), and Dysexecutive Questionnaire (DEX). Results Significant changes with large effect sizes were found for the DERS at the 12-week follow-up assessment. Significant and moderate changes were found on the SWLS, DEX, PSI, and subscales of the PANAS and SPSI-R:S. Conclusions Online EmReg appears to be a promising method of delivering a group intervention to improve ER following TBI.

Human visual tracking performance is known to be reduced with an increase of the target's speed and oscillation frequency, but changes in brain states following a concussion may alter these frequency responses. The goal of this study was to characterize and compare frequency-dependent smooth pursuit velocity degradation in normal subjects and patients who had chronic postconcussion symptoms, and also examine cases of acutely concussed patients. Eye movements were recorded while subjects tracked a target that moved along a circular trajectory of 10° radius at 0.33, 0.40, or 0.67 Hz. Performance was characterized by the gain of smooth pursuit velocity, with reduced gain indicating reduced performance. The difference between normal and chronic patient groups in the pattern of decrease in the gain of horizontal smooth pursuit velocity as a function of the stimulus frequency reflected patients performing more poorly than normal subjects at 0.4 Hz while both groups performing similarly at 0.33 or 0.67 Hz. The performance of acute patients may represent yet another type of frequency response. The findings suggest that there may be ranges of stimulus frequencies that differentiate the effects of concussion from normal individuals.

Objective To examine the relationship between traumatic brain injury (TBI) and criminal behavior in youth who are incarcerated or on probation in Texas. Setting Seven juvenile justice facilities. Participants Juvenile offenders in state or county correctional facilities or on probation. Design Screening for TBI was conducted among adolescents at 7 juvenile justice centers. Main measures Participants were administered the Brain Injury Screening Questionnaire, and results were linked to participants' offense history and psychiatric diagnoses. Results One in 4 juvenile offenders met criteria for TBI, and the majority of injuries occurred prior to the adolescents' criminal offenses. A history of TBI was related to more violent crimes, as well as more mental health diagnoses and symptoms. Conclusion The high rates of TBI and levels of distress found in juvenile offenders suggest a need for preventive actions, interventions to compensate for challenges related to TBI, and programs to assist individuals' transitions into the community.

Objective To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression. Participants A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy. Measures Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment. Results No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups. Conclusions Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Objective To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI). Setting Diverse community settings. Participants Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396). Design Cross-sectional. Main measure Brain Injury Screening Questionnaire. Results Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms. Conclusion Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

BACKGROUND: Obstructive sleep apnea (OSA) is commonly found in individuals with traumatic brain injury (TBI) and may exacerbate TBI-related symptoms. Nocturnal polysomnography (NPSG) is considered the gold standard for detecting the presence of sleep apnea. However, there is a limitation with its use known as the “first-night effect” (aberrant polysomnography findings on the first night in a sleep lab). OBJECTIVE: The primary objectives were to investigate the night-to-night consistency of diagnosing and classifying obstructive sleep apnea in individuals with TBI, and ascertain if individuals with TBI are prone to a first-night effect. METHODS: 47 community-dwelling adults with self-reported mild-to-severe TBI underwent two nights of in-laboratory NPSG to examine variability between the first and second night with regards to OSA diagnosis and severity as well as sleep architecture. RESULTS: OSA detection and severity were consistent from night-to-night in 89% of participants with TBI. Participants with TBI demonstrated longer REM latency on the first night compared to the second night of sleep study. CONCLUSIONS: These findings indicate that two nights of in-laboratory NPSG are generally consistent in reliably diagnosing OSA in individuals with TBI and that first-night effects are minimal. One night of NPSG has diagnostic utility in the evaluation of sleep disorders in individuals with TBI.

Objective To identify baseline participant variables in the domains of demographics, medical/psychosocial history, injury characteristics, and postinjury functional status associated with longitudinal follow-up completeness in persons with traumatic brain injury (TBI) using the TBI Model Systems (TBIMS) National Database (NDB). Design Exhaustive chi-square automatic interaction detection was used to identify factors that classified participants according to level of follow-up completeness. Setting Retrospective analysis of a multi-center longitudinal database. Participants Individuals (N=8249) enrolled in the TBIMS NDB between 1989 and 2009 who were eligible for at least the first (year 1) follow-up up to the fifth (year 15) follow-up. Interventions None. Main Outcome Measures Follow-up completeness as defined by 6 different longitudinal response patterns (LRPs): completing all follow-ups, wave nonresponse, dropping out, completing no follow-ups without formally withdrawing, formally withdrawing before completing any follow-ups, and formally withdrawing after completing some follow-ups. Results Completing all follow-ups was associated with higher levels of education, living with parents or others, and having acute care payer data entered in the NDB. Subgroups more vulnerable to loss to follow-up (LTFU) included those with less education, racial/ethnic minority backgrounds, those with better motor functioning on rehabilitation discharge, and those for whom baseline data on education, employment, and acute care payer were not collected. No subgroups were found to be more likely to have the LRPs of dropping out or formal withdrawal. Conclusions These data identify subgroups in which retention strategies beyond those most commonly used might reduce LTFU in longitudinal studies of persons with TBI, such as the TBIMS, and suggest future investigations into factors associated with missing baseline data.

Aims: This study aimed to examine the differential treatment effects of cognitive–behavioral therapy (CBT) and supportive psychotherapy (SPT) on self-reported symptoms of depression in individuals with traumatic brain injury (TBI) who sought treatment for major depressive disorder (MDD). Methods: Participants were individuals with a documented TBI meeting criteria for MDD who, as part of a larger randomized controlled trial comparing treatments for MDD after TBI, received CBT (n = 22) or SPT (n = 22). The average age of participants was 48.8 years (standard deviation = 10.2), 57.1% were female, 57.5% were Caucasian, 20% were Hispanic and 15% were African–American. The main outcome measure was the Beck Depression Inventory-‘II (BDI-II). Results: Mean total BDI-‘II score for all participants combined at baseline was 25 (standard deviation = 10.0). There were no significant differences in total BDI-‘II score between treatment groups at either baselineor at the end of treatment. Participants treated with CBT reported significant improvements in sadness, loss of interest and loss of interest in sex, while participants treated with SPT reported significant improvements in symptoms of agitation and irritability. Conclusion: SPT may better target symptoms of behavioral disinhibition (agitation and irritability), while CBT may better target mood symptoms (sadness) and their behavioral manifestations (loss of interest and loss of interest in sex).

The idea that multiple traumatic brain injury (TBI) can have a cumulative detrimental effect on functioning is widely accepted. Most research supporting this idea comes from athlete samples, and it is not known whether remote history of previous TBI affects functioning after subsequent TBI in community-based samples. This study investigates whether a previous history of TBI with loss of consciousness (LOC) is associated with worse health and functioning in a sample of individuals who require emergency department care for current TBI. Twenty-three percent of the 586 individuals with current TBI in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study reported having sustained a previous TBI with LOC. Individuals with previous TBI were more likely to be unemployed ((2)=17.86; p=0.000), report a variety of chronic medical and psychiatric conditions (4.75(2)24.16; p

To aid a clear and unified visual perception while tracking a moving target, both eyes must be coordinated, so the image of the target falls on approximately corresponding areas of the fovea of each eye. The movements of the two eyes are decoupled during sleep, suggesting a role of arousal in regulating binocular coordination. While the absence of visual input during sleep may also contribute to binocular decoupling, sleepiness is a state of reduced arousal that still allows for visual input, providing a context within which the role of arousal in binocular coordination can be studied. We examined the effects of sleep deprivation on binocular coordination using a test paradigm that we previously showed to be sensitive to sleep deprivation. We quantified binocular coordination with the SD of the distance between left and right gaze positions on the screen. We also quantified the stability of conjugate gaze on the target, i.e., gaze-target synchronization, with the SD of the distance between the binocular average gaze and the target. Sleep deprivation degraded the stability of both binocular coordination and gaze-target synchronization, but between these two forms of gaze control the horizontal and vertical components were affected differently, suggesting that disconjugate and conjugate eye movements are under different regulation of attentional arousal. The prominent association found between sleep deprivation and degradation of binocular coordination in the horizontal direction may be used for a fit-for-duty assessment.

OBJECTIVE:: To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes. DESIGN:: Cross-sectional study. SETTING:: Five National Institute of Disability and Rehabilitation Research TBI Model Systems. PARTICIPANTS:: Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012. MAIN OUTCOME RESULTS:: Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals. CONCLUSIONS:: Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF. Language: en

While there has been considerable research on the patterns of pre- and post-substance use among individuals with traumatic brain injury (TBI), little is known about the incidence of co-morbidity between TBI and substance abuse (SA) in individuals whose primary disorder is SA. In the current study, the prevalence of co-occurring TBI in individuals seeking treatment for SA was examined. A total of 845 individuals seeking treatment for SA in New York State were screened via the Brain Injury Screening Questionnaire for the presence of a co-morbid TBI. Results indicate that more than 50% of the sample had results that were positive for a TBI. On average, individuals reported a mean of 6 ± 8 blows to the head, with the number ranging from 0 to 57 and the average age of the first TBI being 14.5 years. Results indicate a high level of co-morbidity between TBI and SA and the need for routine screening for TBI in this population.

Empirical evidence suggests that social and occupational disability plays a significant role in posttraumatic stress disorder (PTSD). The purpose of this study was to assess the role of social/occupational disability and to identify predictors of the development of PTSD in a group of disaster relief workers (DRWs) who had been deployed to the World Trade Center (WTC) following September 11, 2001. Eight hundred forty-two utility workers completed a battery of comprehensive tests measuring PTSD and social occupational functioning. Results indicated a significant association between PTSD symptoms and impaired social/occupational functioning. Symptomatic workers were also more likely to have a history of trauma, panic disorder, and depression. Those with a history of trauma, depression, generalized anxiety disorder or panic reported significantly more disability than those without a psychiatric history. Careful screening of PTSD and social/occupational functioning in DRWs following a disaster is warranted so that early treatment can be undertaken to prevent a chronic and disabling course.

Previous studies that used objective measures of community integration found that in the first year after injury, minority groups with traumatic brain injury (TBI) exhibit lower levels of community integration than White participants. The objective of this study was to determine if this discrepancy persists beyond one year post injury, and if assessing subjective components of community integration helps understand these differences. Participants were 360 community dwelling adults with TBI including 29% from minority backgrounds. Mean time post injury was 8.66 years (SD = 9.94). Main outcome measure utilized was the Participation Objective Participation Subjective (POPS). Multiple regression indicated that minority status predicted levels of transportation use (p0.01), with white participants reporting less use, after controlling for demographic and injury variables. When looking at subjective indicators, minority status predicted levels of dissatisfaction with community, civic, life and leisure participation (p0.01), and total levels of participation (p0.0125), with White participants reporting significantly less dissatisfaction. Findings indicate that differences between minorities and white participants in objective aspects of community integration after one year post-injury are only evident in levels of transportation use. However, when looking at subjective indicators differences between groups are present in other areas. These findings underscore the importance of considering the consumer's subjective experience when providing services to minorities in a rehabilitation setting.

Objectives To quantify posttraumatic brain injury (post-TBI) mental fatigue objectively by documenting changes in performance on neuropsychological tests as a result of sustained mental effort and to examine the relationship between objectively measured mental fatigue and self-reported situational and day-to-day fatigue. Participants The study included 202 community-dwelling individuals with mild-severe TBI and 73 noninjured controls. Measures Measures included Cambridge Neuropsychological Test Automated Battery, Global Fatigue Index, and situational fatigue rating. Method Subjects were administered a 30-minute computerized neuropsychological test battery 3 times. The second and third administrations of the battery were separated by approximately 2 hours of interviews and administration of self-report measures. Results The neuropsychological test scores were factor analyzed, yielding 3 subscales: speed, accuracy, and executive function. Situational fatigue and day-to-day fatigue were significantly higher in individual with TBI group than in individuals without TBI and were associated with speed subscale scores. Individuals with TBI evidenced a significant decline in performance on the accuracy subscale score. These declines in performance related to sustained mental effort were not associated with subjective fatigue in the TBI group. While practice effects on the speed and accuracy scores were observed in non-brain-injured individuals, they were not evidenced in individuals with TBI. Conclusions Findings were largely consistent with previous literature and indicated that while subjective fatigue is associated with poor performance in individuals with TBI, it is not associated with objective decline in performance of mental tasks.

Objective: This preliminary study endeavored to evaluate the use of virtual reality (VR) enhanced exposure therapy for the treatment of posttraumatic stress disorder (PTSD) consequent to the World Trade Center attacks of September 11,2001. Method: Participants were assigned to a VR treatment (N = 13) or a waitlist control (N = 8) group and were mostly middle-aged, male disaster workers. All participants were diagnosed with PTSD according to DSM-IV-TR criteria using the Clinician-Administered PTSD Scale (CAPS). The study was conducted between February 2002 and August 2005 in offices located in outpatient buildings of a hospital campus. Results: Analysis of variance showed a significant interaction of time by group (p

Fox, Greiffenstein, and Lees-Haley (2005) and McCaffrey and Yantz (2005) criticized our 2004 article that reported neuropsychological evidence of cognitive impairment in a sample of individuals exposed to toxic molds who complained of cognitive difficulties (Gordon et al., 2004). They critiqued the study's justification, design, analyses, and conclusions and characterized it as poor epidemiology. This article is a rebuttal to their comments. It documents that both sets of negative comments are based on frequent inaccuracies, mischaracterizations of our findings, and red herrings. Furthermore, they failed to refute the implications of the study's main findings.

This study examined male utility disaster workers' responses to referral for trauma-specific psychotherapy. Among 328 workers offered referral for symptoms related to the World Trade Center (WTC) attacks during psychological screening, approximately 48% chose to accept, 28% chose to consider only, and 24% chose to decline. Analyses examined predisposing factors, i.e., age, race/ethnicity, marital status, education, previous mental health treatment, and previous disorder; as well as illness level; i.e., posttraumatic stress disorder (PTSD), depression, and general psychiatric distress; current treatment; and time of referral as predictors of referral response. PTSD (specifically reexperiencing and hyperarousal symptoms), depressive symptoms, and previous mental health treatment were positively associated with workers' accepting referral. Implications and limitations of these findings are discussed.

The aim of this study was to evaluate the association between coping strategies and reports of with pain and distress in patients with HIV-related peripheral neuropathy. Seventy-eight HIV seropositive subjects completed the Coping Strategies Questionnaire (CSQ), a self-report measure that assesses seven factors, the Brief Pain Inventory (BPI), the Brief Symptom Inventory (BSI) and the Beck Depression Inventory (BDI). Bivariate correlations revealed that younger patients used more Praying-Hoping (r=-.23, p

Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis I disorders. Arch Phys Med Rehabil 2004;85(4 Suppl 2):S36–42. Objective To examine the preinjury rates of Axis I disorders and the prospective rates within the first 6 years after traumatic brain injury (TBI). Design Cross-sectional, longitudinal, and cross-sequential. Setting Community-based research and training center. Participants Persons (N=188) who had sustained TBI within 4 years of enrollment into the project were interviewed at either 2 and 3 assessments. Each assessment was approximately 1 year apart. Several Axis I diagnoses were analyzed to detect cross-sectional differences (by age and time postinjury) and average individual changes over the multiple measurement time points. Interventions Not applicable. Main outcome measure Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Results The odds ratios changed longitudinally within each subject, indicating a decreased probability of having an Axis I diagnosis over time. There were few cross-sectional differences in age; therefore, age at the time of injury had little impact on Axis I diagnoses. Cross-sectional time since injury was not associated with more psychiatric disorders, whereas cross-sectional preinjury history of psychiatric disorders was predictive of postinjury psychiatric disorders. After controlling for cross-sectional effects, the frequencies of Axis I disorders increased in depression, anxiety, and posttraumatic stress disorders in the first assessment postinjury and declined in subsequent assessments. Conclusions Cross-sequential analyses that control for cross-sectional and longitudinal differences produced a more complete description of psychiatric disorders after TBI.

Hibbard MR, Ashman TA, Spielman LA, Chun D, Charatz HJ, Melvin S. Relationship between depression and psychosocial functioning after traumatic brain injury. Arch Phys Med Rehabil 2004;85(4 Suppl 2):S43–53. Objective To examine the relationship between depression and psychosocial functioning up to 5 years after traumatic brain injury (TBI). Design Longitudinal cohort study with 2 assessments completed. Setting Community. Participants Individuals (N=188) with TBI living in the community. Interventions Not applicable. Main outcome measures Structured Clinical Interview for Depression, self-reports of depression severity, functional symptoms, quality of life (QOL), unmet important needs, and psychosocial functioning. Results Based on observed depression patterns at initial and repeat assessment, 4 subgroups were created: no depression, resolved depression, late-onset depression, and chronic depression. Groups were equivalent in terms of demographic and injury-related factors but differed significantly in perceived psychosocial functioning. The no-depression group reported fewer depressive symptoms and higher levels of psychosocial functioning, whereas the chronic-depression group reported the poorest psychosocial functioning, with a further decline in QOL at reassessment. Although the resolved-depression and late-onset-depression groups reported similar psychosocial functioning at initial assessment, psychosocial functioning had improved for the resolved-depression group and declined for the late-onset-depression group at reassessment. Pre- and postpsychiatric diagnoses were common in all groups, with pre-TBI diagnosis of depression not predictive of post-TBI depression. Conclusions Findings highlight the need for broad-based assessments and timely interventions for both mood and psychosocial challenges after TBI.

The feasibility and acceptability of cognitive behavior therapy for HIV-related peripheral neuropathic pain was examined and the potential efficacy of the intervention was compared with that of supportive psychotherapy in reducing pain, pain-related interference with functioning, and distress. Sixty-one patients were randomly assigned to receive six weekly sessions of cognitive behavior therapy or supportive psychotherapy. Thirty-three subjects completed the protocol. Both groups showed significant reductions in pain. The cognitive behavior group improved in most domains of pain-related functional interference and distress; the supportive psychotherapy group showed fewer gains. The high dropout rate suggests that psychotherapeutic treatments for HIV-related pain may have limited feasibility and acceptability.

Social-recreational activities of 62 individuals with spinal cord injury (SCI) living in the community and 219 people with no disability were compared. The relatively small between-group differences that were found in the extent of such activity became statistically insignificant when the groups were "matched" through the use of an analysis of covariance. Age, ethnicity, and one environmental barrier - transportation - comprise the significant predictors of social-recreational activity for the SCI group, with 49% of the variance in activity accounted for.

Objective: The nature of ADHD, especially in adulthood, is not well-understood. Therefore, we explored subcomponents of attention in adult ADHD. Method: Twenty-three adults with ADHD were tested on neurocognitive and visual tracking performance both while on their regular prescription stimulant medication and while abstaining from the medication for 1 day. Pairwise comparisons to 46 two-for-one matched normal controls were made to detect medication-resistant effects of ADHD, and within-participant comparisons were made to detect medication-sensitive effects in patients. Results: Even when on medication, patients performed more poorly than controls on a spatial working memory task, and on visual tracking and simple reaction time tasks immediately following other attention-demanding tasks. Patients’ visual tracking performance degraded while off-medication in a manner consistent with reduced vigilance. Conclusion: There may be persistent cognitive impairments in adult ADHD despite medication. In addition, the benefit of stimulants seems reduced under cognitive fatigue.

The objective was to assess the feasibility of delivering a group treatment to improve emotional regulation via videoconferencing to individuals with traumatic brain injury (TBI). A pre-post feasibility study was undertaken. Seven individuals with TBI were recruited at a brain injury research centre in an urban medical centre. The main measures were therapist assessment of session-by-session progress and feasibility, Difficulties in Emotion Regulation Scale (DERS), Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire (BREQ), Satisfaction with Therapy and Therapist Scale (STTS), and exit interview. Attendance across sessions and participants was over 90%. Adequate skill acquisition and ease of use of the technology were demonstrated. Self-reported satisfaction with treatment was high. Participants noted several benefits in terms of the treatment delivery modality. There was no change is self-reported emotional dysregulation. This is the first study to report the use of videoconferencing for the delivery of group treatment to individuals with TBI. The exceptional compliance and self-reported satisfaction suggest that this treatment delivery option could be a viable alternative for increasing access to healthcare in this population. The findings of the study supported the development of a large clinical trial to assess treatment effectiveness.

This study seeks to determine how panic disorder patients with anxiety and depression comorbidity differ from panic disorder patients without comorbidity at the time of presentation for treatment. One-hundred seventy-one panic disorder patients presenting for their initial assessment and treatment at the Payne Whitney Anxiety Disorders Clinic agreed to participate and completed self-report and diagnostic assessments. Sixty-seven percent of panic disorder subjects were found to have at least one comorbid anxiety or depression diagnosis. Age and gender ratio were not affected by the presence of comorbid diagnoses. Comorbidity significantly contributed to psychological distress and symptom load, overall impairment, and interpersonal impairment.

While anger is an important feature of posttraumatic stress disorder (PTSD) it is unclear whether it is simply concomitant or plays a role in maintaining symptoms. A previous study of disaster workers responding to the terrorist attacks of September 11, 2001 (Evans et al., 2006) indicated that those with PTSD evidenced more severe anger than those without. The purpose of this study was to conduct a one-year follow-up to assess the role of anger in maintaining PTSD. Workers with PTSD continued to report more severe anger than those without; there were statistically significant associations between changes in anger, PTSD severity, depression, and psychiatric distress. Multiple regression analysis indicated initial anger severity to be a significant predictor of PTSD severity at follow-up, which is consistent with the notion that anger maintains PTSD. One implication is that disaster workers with high anger may benefit from early intervention to prevent chronic PTSD.

Objectives: The primary objective was to examine specific aspects of sexual functioning (frequency, desired frequency, importance, and satisfaction) and their relationship to fatigue in individuals with traumatic brain injury (TBI) compared with those without brain injury. The relationship of demographic variables, emotional well-being, and health-related quality of life to sexual functioning was also explored. Participants: 200 community-dwelling adults with self-reported mild-to-severe TBI and 83 individuals without brain injury. Measures: Participation Objective, Participation Subjective, Fatigue Assessment Instrument, Global Fatigue Index, Beck Depression Inventory, and SF-36 Health Survey. Methods: Data were collected through administration of self-report measures and interviews as part of a larger study of post‐TBI fatigue. Results: Several aspects of sexual activity (frequency, desired frequency, and importance) were closely related to specific features of fatigue among individuals with TBI. Women with TBI reported lower frequency and lower importance of sex than men. In individuals without brain injury, the impact of fatigue was limited to the frequency of sexual activity with no sex differences observed. Conclusions: Fatigue plays a different role in the subjective experience of sexual activity for men and women with TBI than for those without brain injuries. Fatigue and sex should be taken into account in future research and interventions focused on sexual function after TBI. Key words: depression, fatigue, sex, health, sexual functioning, traumatic brain injury

INTRODUCTION: Although there has been a decline in the incidence of TBI in the general population, the rate of TBI in older adults has increased. Increased age has been long recognized as a predictor of worse outcomes after TBI. Despite the growing number of TBI in the elderly, our understanding of the long-term consequences of TBI is quite limited. METHODS: Chart review; individuals 55 years and older, who completed inpatient acute rehabilitation during the period 2003-2009 and who died one to four years after injury, were compared to matched patients who did not die. RESULTS: There were a significantly higher proportion of deceased subjects with a diagnosis of Abnormality of Gait (53%), respiratory medications at admission (32%) and discharge (17%). Deceased participants were more likely to be prescribed diabetes medication at discharge (35%) while controls were more likely to be prescribed cholesterol-lowering medications (27%) at admission. Deceased patients were discharged with significantly more medications, CONCLUSIONS: The results suggest the need for medical and lifestyle interventions for selected elderly TBI patients. The factors related to death following TBI in the elderly are in need of more research. Language: en

In an attempt to assess the influence of standardized diagnostic interviews on psychological distress in research volunteers, the Visual Analogue Scale (VAS) was used to measure anxiety and depression during the Structured Clinical Interview for DSM-III-R, Non-patient version (SCID). Subjects were 50 adults with concerns related to the human immunodeficiency virus who were seeking testing and treatment in research trials. Repeated measures analysis of variance showed significant decreases in distress by the end of the interview: 72% of subjects reported diminished anxiety, and 54% reported diminished depression. Thus, the SCID appeared to provide a positive interview experience, a finding that may serve to reassure subjects, their families, and review boards regarding participation in studies that employ structured interviews.

Objective: The authors present preliminary data from two treatment modalities of a randomized clinical trial in which they compared 1 6-week interventions ofinterpersonal psychotherapy to supportive psychotherapy. Method: HIV-positive patients who were not acutely medically ill and had scores of 15 or higher on the Hamilton Depression Rating Scale were randomly assigned to one offour treatment modalities. They were assessed by the Hamilton scale and Beck Depression Inventory at 8 and 1 6 weeks. Most subjects who underwent either interpersonal psychotherapy (N=16) or supportive psychotherapy (N=16) were male, gay or bisexual, white, and college educated. R esults: R esults of last-observation-carried-forward and completer analyses showed that scores on the Hamilton scale and Beck Depression Inventory decreased significantly for both treatments. Differential improvement for interpersonal psychotherapy appeared by midtreatment (week 8) and persisted at termination. � clusions: This is the first controlled study of individual psychotherapies for depressed HIV-positive patients. Results suggest that a specific antidepressant psychotherapy, interpersonal psychotherapy, has advantages over a supportive therapy. (AmJ Psychiatry 1995; 152:1504-1509)