43

Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program

Appendix A: SEARCH STRATEGY 

Our study search coordinator, in consultation with our evidence synthesis team, developed the 

following search strategy. The PubMed and PsycINFO databases were searched for the following 

terms:

TBI – brain injury (and variants of injury); coma; coma, post-head injury; Glasgow Coma Scale; 

head injuries, closed; post-concussion syndrome; brain concussion; post-concussive; and brain 

injury, chronic.

PTSD - combat disorders (and variants of disorder); posttraumatic stress; posttraumatic stress 

disorder (and variants of disorder); post-traumatic stress disorder (and variants of disorder); 

stress disorders, post-traumatic; anxiety; and anxiety disorders. 

The results from the TBI and PTSD searches were merged attempting to identify studies that 

included participants with both TBI and PTSD. The search was limited to English language 

studies of human subjects published between 1980 and 2009.

Sample Search Strategy:

--------------------------------------------------------------------------------

1 brain injur*.mp. or exp Brain Injuries

2 coma.mp. or Coma, Post-Head Injury/ or Coma/ or Glasgow Coma Scale

3 Head Injuries, Closed/ or Post-Concussion Syndrome/ or Brain Concussion/ or postconcussive.mp. or Brain Injury, Chronic

4 combat disord*.mp. or exp Combat Disorders

5 (posttraumatic stress or posttraumatic stress disorder* or post-traumatic stress disorder* or 

ptsd).mp. or exp Stress Disorders, Post-Traumatic

6 anxiety.mp. or exp Anxiety/ or exp Anxiety Disorders

7 or/1-3 

8 or/4-6

9 7 and 8

10 limit 9 to English language

11 limit 10 to yr=”1980 - 2009”

12 limit 11 to human

In addition, the REHABDATA database was searched as follows:

From the advanced search page at www.naric.com/research/rehab/advanced.cfm, 

Used “All the words” field, 

Searched for “brain injuries posttraumatic.”

[Provided by Jessica Chaiken of the National Rehabilitation Information Center (NARIC)]

Results of the database searches were combined and duplicate entries eliminated.
44

Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program

Appendix B: DATA ABSTRACTION FORM
45

Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program
46

Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program
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Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program
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Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program
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Traumatic Brain Injury and Post-Traumatic Stress Disorder Evidence-based Synthesis Program
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raumatic Stress Disorder Evidence-based Synthesis Program

PEER REVIEWER COMMENTS

Authors’ Responses

e, and methods for this review clearly described? 

g “history of TBI” and “sequelae of TBI” or 

possibly associated) with history of TBI.”

Done.

bid and comorbidity – maybe simpler to say that 

with history of TBI or TBI in those who meet criteria 

We have defined and clarified our use of the terms “TBI,” “PTSD,” and “comorbidity” in the background section and throughout the revised report.

onditions and anxiety disorders other than PTSD 

pecified” (PTSD is an anxiety disorder so use of 

orbidities” and “anxiety” can be confusing at first 

Changed statements throughout the revised report to read as recommended.

us on mTBI given the political context in which it 

We have included a brief additional statement regarding the political importance and rationale for focusing on mTBI. 

for including the RAND study given that it is 

t meeting inclusion criteria. Were other reports 

A statement has been inserted. This study was peer reviewed. Though not published in a peer-reviewed journal, it is published by RAND and readily available on the RAND website. Additional rationale were provided in the draft report indicating that this was one of the largest and most nationally representative studies assessing TBI and PTSD in military personnel who had served in Iraq and Afghanistan. Therefore, it provides key evidence in examining TBI/PTSD prevalence. 

is literature search is about people with a history 

diagnosed with PTSD.

We have attempted to clarify this. Our search was broad. We included any study that assessed reported prevalence of individuals with mTBI and PTSD. Authors frequently referred to these individuals as having “comorbid” TBI and PTSD. However, we agree that the more accurate term for mTBI is “history of...” and have clarified this in our revised report. 

 language – use post-concussive symptoms rather 

ptoms that result from TBI; consider including 

ge” or “terminology” at the beginning of the review.

We appreciate this suggestion and have been more clear throughout the report in terms of “TBI history,” “symptoms related to a TBI,” and “comorbidity.” 

f bias in our synthesis of the evidence? 

ort without more justification may give impression 

 pg. 30 that RAND report may provide the most 

sider how study is weighted given that it is not 

ndings should be classified as secondary findings?

We have reworded the referenced statement on pg. 30 and provided further rationale for our inclusion of this report. As noted above, the RAND report includes a statement that it underwent peer review with multiple reviewers. The nature of comments and authors’ responses to these comments are not available. However, in our experience, the extent of peer review and number of reviewers on evidence reports (as witnessed by this VA ESP report) are typically greater than with most manuscripts submitted for publication in refereed journals. The final report is published on the RAND website. Whether it would have been accepted by a traditional paper journal is not known but we suspect condensed versions would have met journal publication criteria. 

uction) of belief that mTBI is associated with 

this is the case in the minority of cases.

We have modified the introduction to include more information on the natural history of mTBI, including evidence that the majority of cases do not have long-term sequelae. 
51

raumatic Stress Disorder Evidence-based Synthesis Program

Authors’ Responses

s a reviewer when he was a contributor with study; 

d reviewer; CH’s research is controversial as noted 

Reviewers frequently have a bias. Often our goal is to seek a selection of reviewers that will ensure a broad range of opinions and comments. Prior publication history does not disqualify a reviewer. In general, we select reviewers without disclosure of the names of other reviewers, including the TAP members.

 the epidemiology, assessment, or treatment of TBI/PTSD that we may have overlooked? 

study (Ref #83) in Exec. Summary (80% TBI subjects 

The referenced study was included under secondary findings because it did not meet the study inclusion criteria (did not include participants with probable or diagnosed PTSD), which were developed a priori in consultation with our TAP. Consistent with previous ESP report formats, we did not include secondary findings in our Executive Summary.The suggested paper did not meet the study inclusion criteria (did not include data on probable or diagnosed PTSD).We have updated our search through June, 2009. The following additional studies met inclusion criteria and were added to the evidence synthesis review: Brenner et al., 2009; Chalton et al., 2009; and Mora et al., 2009.

BI and PTSD is flawed; TBI is acute injury event 

toms and impairment existing for a defined period 

tic event; it would be correct to ask how often a TBI 

the onset of PTSD and whether TBI is a risk factor 

or may not be causal; it also would be correct 

between PTSD and the sequelae or persistent 

sulting from TBI injury event; need accepted and 

quelae attributed to mTBI/concussion; need to 

vidence is for causal association between mTBI/

 symptoms, sequelae, or impairment (see recent 

The questions addressed in this evidence synthesis review were developed with considerable input from the VA ESP and specifically our TAP, with the purpose of addressing key questions of clinical and health policy importance and to inform the work of a VA consensus conference on this topic. We agree with the reviewer that the term “comorbid TBI and PTSD” is problematic especially when referring to mTBI. We had discussed the controversy surrounding this issue in our Introduction, Discussion and Future Research Recommendations sections. We have reviewed and further clarified these issues in the revised report. We strongly believe, and included in both our oral presentation at the consensus conference and in this report, that future research is needed to address the issues described by the reviewer. 

ow PTSD may affect, mediate, or confound the 

ttributed to an mTBI/concussion event (see 2008 

nition for dependent variable under study (e.g., 

We agree and have spoken to this in our Limitations and Future Research Recommendations sections.

 the term prevalence; prevalence cannot be 

ent definitions; technically correct to present the 

dy participant who had a history of TBI (should 

e Figure 3); never correct to present prevalence 

ince TBI definition refers to past injury event (see 

ow prevalence of comorbid PTSD and persistent 

buted to TBI; lack of clarity by not separating mTBI 

e TBI for Question 1; inconsistent with Questions 2 

We have clarified throughout the revised report our intent to examine the prevalence of PTSD in individuals with a history of TBI. Our background clarifies that we addressed TBI with an emphasis on mTBI. For KQ1, we sought to examine prevalence of PTSD in individuals with a history of mTBI versus moderate or severe TBI. As such, our figures denote (when authors provided such information) the prevalence of mTBI history separate from moderate or severe TBI. For KQ2 and KQ3, we sought to assess diagnostic accuracy and treatment effectiveness versus harms for adults specifically with mTBI history who have PTSD. 
52

raumatic Stress Disorder Evidence-based Synthesis Program

Authors’ Responses

wed for the same reasons; the mTBI/concussion 

 (and should not) be the focus of diagnosis and 

diagnosed; questions would only be valid if asked 

sis and treatment of sequelae of mTBI/concussion 

definition of sequelae)

We disagree. 

rate terminology in characterizing the sequelae 

mTBI; “post-concussive symptoms” encompasses 

ysical, neurocognitive, and behavioral symptoms 

mTBI; need agreement on the nature of the 

tional somatic syndromes, or related conditions.

We agree and have clarified our wording throughout the report. 

ns that cannot be answered; questions are ill

dress limitations of current concussion/mTBI 

e definition for sequelae attributed to concussion/

cus beyond PTSD.

We agree that future research is needed to address limitations of current case definitions of mTBI. This has been discussed in the report. As noted above, we disagree that the key questions were ill-conceived. 

on of TBI as an event, diagnosis, sequelae 

 editing, defining of terms, and rephrasing/

dress these concerns.

We thank the reviewer and have edited the report to address these concerns. 

esults section. We attempted to follow a standard VA ESP report format and have not restated key 

questions in the results section of the Executive Summary. However, key questions are restated in the Results section of the main report.

d unclear – need to state rationale (make change 

We have edited the report to reflect our 10% cut-off for children <18 years of age.

OUND

oms associated with mTBI in civilian cases generally 

onths (1st paragraph of intro gives impression that 

d with negative outcomes).

We have edited this section to include evidence on the natural history of mTBI.

raph in background is inaccurate (“making an 

ink what was meant was “determining etiology 

 individuals who have a history of TBI and PTSD”; 

on that symptoms are needed for TBI diagnosis and 

are common in mTBI (suggest reworking).

We appreciate the reviewer’s suggestion and have reworked the referenced paragraph.

 education for mTBI is limited to education within a 

d post-injury.

We have edited the relevant paragraph to address this comment.

difficult to follow. We have clarified this paragraph.

/VA definition of TBI in addition to CDC definition 

07).

Because the operational definitions are similar, we have retained the CDC definition in the report. 

gnosis of mTBI was first followed by PTSD? Does it 

ation starts ... mental health or neurology?

We noted in the report that the reported prevalence of TBI/PTSD was highly dependent on the construction of the cohort, method and timing of ascertainment, and definitions of disease/injury. The current literature is insufficient to determine whether timing of event/diagnosis influences outcomes or if there are clinically important differences according to where the initial evaluation starts. 
53

raumatic Stress Disorder Evidence-based Synthesis Program

Authors’ Responses

 several items are controversial. Unclear comment. We have included the chart as a direct extraction from a published 

article that we reference. We believe it is important for the reader to have a full range of information. We have included in the text some background on the controversies surrounding case definitions. 

tween screening measures and clinician confirmed 

to mention that VA TBI screening is symptomatic 

ce is difficult to ascertain because positive TBI 

uch with or without continued symptoms); VA/

screen as a symptomatic positive patient with 

We thank the reviewer and have included a statement about the VA/DOD screening. 

ing and addressing some of the issues CH raises. We have added further information to the Discussion section. Our Future Research 

Recommendations section had previously discussed these issues. 

nce of PTSD in a particular group of veterans who 

 overall prevalence of comorbid PTSD and TBI in 

We reported the findings according to our key questions where data were available from published evidence. We have included a separate figure presenting data on prevalence of PTSD specifically in veterans with a history of mTBI.

al 5 studies not published? If published, why not 

es/manuscripts?

See our comment above regarding our rationale for including the RAND study. There were 31 unique published studies and the RAND report included in the evidence review. The other 5 publications met inclusion criteria but described the same study population as one of the 31 “unique” studies.

at does “probable TBI/PTSD not included” mean? 

We have clarified this in the diagram. This meant that individuals with a probable history of TBI and/or probable PTSD (as defined in our Methods section) were not included in the study and thus the study did not meet our evidence report inclusion criteria. 

28 included studies earlier, including study design, 

tion studied (perhaps grouped by population 

would be more helpful than current Table 1.

We placed the table in the appendix consistent with the ESP report template. The quality ratings did not directly apply to these studies and we discussed issues regarding applicability. 

scription and summarization of the findings from 

evant studies rather than limited information 

 studies

We have attempted to do this through our emphasis on the RAND report. Relevant to the military and veteran population, this study was the most population-based as investigators attempted to contact a random sample of military veterans across the United States. Additionally, investigators used detailed, previously-established methods for conducting phone interviews. We disagree that providing ranges across studies is not helpful. These help to show the variation in the literature that may result from studies employing different methods for cohort creation, case ascertainment and timing, and definitions of disease/injury. Therefore it is instructive in establishing future research recommendations. 

rather than state that there are none We have edited accordingly.

Active Research – How many e-mails (effort to 

f response from non-VA investigators; portfolio 

A brief statement has been inserted. We acknowledge that our methods likely do not achieve rigorous scientific quality measures. This was an attempt to identify with limited resources high profile active research. The purpose was to guide policy makers, funders, and researchers to ongoing studies and assist in future research planning. 
54

raumatic Stress Disorder Evidence-based Synthesis Program

Authors’ Responses

 31) the need to review “systems issues” and 

t specialties – there is a real need to figure out 

ecialties together to do treatment planning (Batten 

s need).

We appreciate this suggestion and have added this suggestion to our Discussion.

 that researchers come to a consensus as to 

s research so that findings can be pooled/

We agree with this suggestion and have clarified this section in our Discussion. 

nment bias; term “overlapping conditions” is 

nd 1st sentence of last paragraph (p 31).

We have attempted to clarify these parts of the Discussion section. Ascertainment bias refers to problems with how the cases were defined, identified, and enrolled in a given study that could systematically skew the association(s) under investigation. This could occur because of selection of non-representative study populations, non-representative study participants, timing of the case assessment relative to the injury event, or individuals being aware of the purpose of the assessment and potential gains/harms from a certain response. Each of these alone could potentially result in study outcomes that are biased and not truly reflective of the actual prevalence of TBI/PTSD. 

very well written. Thanks for doing this. We thank the reviewers for their guidance and positive feedback.

omprehensive report and I found the figures and 

Thank you. 
55

raumatic Stress Disorder Evidence-based Synthesis Program

EVIDENCE TABLES 

ublished studies evaluated in Key Question 1

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

tional

ns 

ervices 

o TBI 

TSD

N=72; 82% 

(n=59) with 

TBI; 63% with 

PTSD (n=45)

Data for all study subjects Trauma etiology: NRTBI severity: 46% mild; 17% moderate; 36% severe Time of assessment or since trauma: Median = 23 years (1-53) Mean age: 52 (9.7) yearsWomen: 10%Race: Caucasian 65%; Hispanic 19%; African American 10%; Other 4%Education: Less than high school 3%; high school graduate 26%; more than high school 71%Pain: NROther mental health conditions: NR

44% (n=32) of all 

subjects

[89% of subjects 

with mild TBI; 36% 

of subjects with 

moderate TBI; 19% 

of severe TBI] 

Interview and chart review.

Structured Clinical Interview for DSM-IV (SCID-IV).

tional

cruited 

spital 

t head 

inic

N=21; all TBI Data for all study subjects 

Trauma etiology: MVC 43%; fall 29%; assault 24%; work-related accident 5%TBI severity: 19% mild; 19% moderate; 62% severeTime of assessment or since trauma: 3-359 mos (median = 14)Mean age: 42.90 (10.98) Women: 33%Race: NREducation: 12.61 (2.85) yearsPain: NROther mental health conditions: 60% anxious (30% mild; 30% moderate or severe); 35% depressed (15% mild; 15% moderate)

14% (n=3) of all 

subjects

[0% of subjects 

with mild TBI; 50% 

of subjects with 

moderate TBI; 8% 

of subjects with 

severe TBI]

Retrospective assessment of post-traumatic amnesia.

Clinician Administered PTSD Scale (CAPS).
56

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

tional

iew of 

oldiers 

without 

uries 

t the 

tates 

tute of 

search 

nter

n=119

22% with 

PTSD; 18% 

with TBI (all 

but one mTBI)

Data for all study subjects Trauma etiology: Military 100%TBI severity: Mild 95%; severe 5% (n=1)Time of assessment or since trauma: 193.7 (171.9) days for blast injury group; 189.7 (175.2) days for no blast injury groupMean age: 26.3 (6.1) for blast injury group; 25.9 (6.0) for no blast injury groupWomen: 15% blast injury group; 4% no blast injury groupRace: NREducation: NRPain: NROther mental health conditions: NR

6% (n=7) of all 

subjects; 35% of 

mTBI subjects 

(PTSD status for 

1 severe TBI case 

not reported)

Record review, loss of consciousness served as definition for mTBI.

Self report through PCL-M (> 44 required for PTSD diagnosis).

tional

mbers 

ed 

rauma 

istry

n=76,

31 with TBI 

Data for all study subjects Burned veterans, TBI vs. no TBITrauma etiology: Combat (blast and burn) 100%TBI severity: mild 100%Time of assessment or since trauma: NRMean age: 26Women: 4%Race: NREducation: NRPain: NROther mental health conditions: NR

18% (n=14) of all 

subjects; 45% of 

TBI subjects

Medical records and clinical interviews. Glasgow Coma Scale (≥ 13), loss of consciousness (< 30 mins) and/or post-traumatic amnesia (≤ 24 h).

Self-report through PTSD Checklist (PCL-M). Score of 44+ indicative of PTSD.

tional

cts 

d as 

e in VA 

enter

n=126;

all TBI

Data for all study subjects OEF/OIF war veteransTrauma etiology: Combat (blast) 100%TBI severity: mild 100%Time of assessment or since trauma: 30 mos (range 8 mos - 4.5 years)Mean age: NRGender: NRRace: NREducation: NRPain: 63% (headache)Other mental health conditions: NR

66% (n=83) of all 

subjects

Administrative data based on positive Veterans Affairs (VA) 4-item TBI screen, including loss of consciousness (< 30 mins) and/or post-traumatic amnesia (< 24 h) and/or alteration of consciousness (< 24 h).

Self-report through PCL. Score of 50+ indicative of PTSD.
57

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

tional

antry 

rveyed 

duty

n=2525 

819 injured; 

384 with TBI.

1706 not 

injured

Data for all study subjects Iraq war veteransTrauma etiology (subjects with TBI, can have more than one source of injury): Blast/explosion 75%; fall 29%; MVC 22%TBI severity: mild 100%Time of assessment or since trauma: 3-4 mos post-deploymentMean age: NRWomen: 5%Race: NREducation: less than HS 42%; HS grad 58%Pain: 30% (arm, leg, or joint pain; most frequently endorsed pain); 11% (headache)Other mental health conditions: Depression 11%

5% (n=125) of all 

subjects; 

33% of TBI 

subjects

Self-report, a) loss of consciousness (n=124 subjects); and b) altered mental status (dazed, confused loss of memory)(n=260 subjects).

Self-report through PCL. Score of 50+ indicative of PTSD.

rt

eterans 

tnam 

y Study

n=245;

193 with TBI

Data for all study subjects Vietnam veteransTrauma etiology: Combat 100%TBI severity: penetrating 100%Time of assessment or since trauma: NRMean age: NRGender: NRRace: NREducation: NRPain: NROther mental health conditions: NR

25% (n=62) of all 

subjects; 

32% of TBI 

subjects

NR. Structured clinical 

interview (SCID), based on DSM-IV criteria.

tional

 OEF/

rans 

ved 

ctober 

 lived 

aphic 

t area

n=2235;

275 with TBI 

Data for all study subjects OEF/OIF war veteransTrauma etiology (could have more than 1): Combat 34% (blast 74%, non-blast 26%); falls 39%; sports/physical training 28%; MVC 20%TBI severity: mild 100%Time of assessment or since trauma: NRAge groups: 18-25 18%; 26-30 15%; 31-35 16%; 36-40 17%; 41+ 38%Women: 13%Race: NREducation: NRPain: NROther mental health conditions: NR

5% (n=109) of all 

subjects; 

39% of TBI 

subjects

Self report, Brief Traumatic Brain Injury Screen.

Self report through PCL. Score of 50+ indicative of PTSD.
58

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

ntrol, 

non

r

eated 

 PM&R 

n=144; 

38 with TBI

Data for all study subjects Trauma etiology: Terror subgroup - blast 70%, gunshot 30%. Non-terror subgroup – MVC 82%; fall 17%TBI severity: mild 32%; moderate 21%; severe 47%Time of assessment or since trauma: end of rehab stay – terror 218 ± 131days, non-terror 152 ± 114 daysMean age (range): 30 (9-76)Women: 33%Race: NREducation: Less than HS 15%; HS grad 47%; “student” 8%; college grad 29%Pain: NROther mental health conditions: NR

11% (n=16) of all 

subjects;

42% of TBI 

subjects in terror 

subgroup;

42% of TBI 

subjects in nonterror subgroup

[Prevalence not 

reported by TBI 

severity]

Based on Glasgow Coma Scale scores and brain computed tomography (CT).

Semi-structured interview; Revised PTSD Inventory (Solomon et al., 1993). Instrument based on Brief Symptoms Inventory.

rt

cts 

 from 

ospital

n=125; 

all TBI 

Data for all study subjects Trauma etiology: MVC 49%; assault 7%TBI severity: mild 44%; moderate 30%, severe 27%Time of assessment or since trauma: NRMean age: 43Women: 23%Race: white 92%; black 6%Education: HS grad 85%Pain: NROther mental health conditions: 71% of TBI/PTSD subjects had a history of depression or anxiety symptoms unspecified

11% (n=14) of all 

subjects

[9% (n=5) with 

mild TBI; 8% (n=3) 

with moderate TBI; 

18% (n=6) with 

severe TBI]

Medical record, based on Glasgow Coma Scale score.

PCL administered as a structured interview. Score of moderate severity on one intrusive, three avoidant, and two arousal symptoms indicative of PTSD.

rt

cts 

 from 

bases 

harge 

uma 

als 

n=198; 

all TBI 

Data for all study subjects Trauma etiology: MVC 70%; fall 16%, pedestrian injury 6%; other 8%TBI severity: mild 19%; moderate 21%; severe 60%Time of assessment or since trauma: 3 yearsMean age: 35Women: 34%Race: white 74%; black 23%; other 3%Education: Less than HS grad 32%; HS grad 34%; at least some college 34%Pain: NROther mental health conditions: NR

11% (n=22) of all 

subjects at 6 mos 

post-injury; 16% 

at 12 mos postinjury

[Prevalence not 

reported by TBI 

severity]

Received treatment for head injury at hospital.

Self-report through the IES. Score of 35+ indicative of PTSD.
59

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

were 

tive 

s to a 

auma 

al

n=307;

189 with TBI 

Data for all study subjects Trauma etiology: NRTBI severity: mild 100%Time of assessment or since trauma: mean 8 daysMean age: 37Women: 24%Race: NREducation: NRPain: NROther mental health conditions: NR

8% (n=24) of all 

subjects; 15% of 

TBI subjects

Loss of consciousness of ≤ 30 minutes, PTA ≤ 24 hours, and GCS of ≥ 13 30 minutes post-trauma. 

CAPS, amnesia eliminated as a symptom.

tional

 from 

wards 

ment 

BI

n=120;

all TBI 

Data for all study subjects Trauma etiology: MVC 90%TBI severity: mild 100%Time of assessment or since trauma: within 24 h after hospitalization; 7-10 days, 4 weeks, 6 mosMean age: 31.4Women: 42%Race: NREducation: 13 years (mean)Pain: NROther mental health conditions: NR

14% (n=17) of all 

subjects at 6 mos 

post-injury 

Presenting to hospital/ clinic for TBI (all had GCS 13-15).

CAPS.

rt

were 

tive 

s in 

cident 

gency 

ment

n=131; 66 

with TBI

118 at 6 

weeks; 56 with 

TBI

74 at 3 mos; 

58 with TBI

Data for all study subjects Trauma etiology: MVC 100%TBI severity: mild 100%Time of assessment or since trauma: 6 weeks and 3 mosMean age (range): 37 (18-65)Women: 60%Race: NREducation: NRPain: NROther mental health conditions: NR

14% (n=17) of 

all subjects at 6 

weeks;

30% of TBI 

subjects 

14% (n=10) of all 

subjects at 3 mos;

17% of TBI 

subjects

Post-traumatic amnesia (< 24 h), as described by Gronwall and Wrightson (1980).

PTSD Symptom Scale (PSS). Amnesia eliminated as a symptom.

tional

cts 

 from 

nity 

t and 

ation 

 and 

eer 

tions

n=34; 

all TBI 

Data for all study subjects Trauma etiology: MVC 47%; fall 32%; assault 18%; sports injury 3%TBI severity: severe 100%Time of assessment or since trauma: 6 year (0.6-34)Mean age (range): 40 (20-60)Women: 12%Race: NREducation: NRPain: NROther mental health conditions: NR

3% (n=1) of all 

subjects

NR. Subjects with severe TBI recruited from community out-patient and rehabilitation services and voluntary organizations.

CAPS, requiring clinical judgment of symptoms being related to trauma. (compared to 3 other methods of assessment.)
60

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

cts 

 from 

enters, 

ury 

ons, 

per 

bsite 

ments, 

d-of

h

n=188;

all TBI

83 at 24 mos; 

all TBI

Data for all study subjects Trauma etiology: NRTBI severity: mild 29%; moderate-severe 62%; 9% unknown Time of initial assessment or since trauma: 3mos - 4 yearsMean age (range): 40 (18-87)Women: 47%Race: white 72%; black 12%Education: Less than high school 27%; HS/some college 38%; college graduate 25%Pain: NROther mental health conditions at time 1: Depression 35%; Anxiety symptoms unspecified 27%; Substance use disorder (SUD) 14%

30% (n=56) of all 

subjects at time 1 

(initial assessment 

between 3 mos 

and 4 years postinjury)

18% (n=34) of all 

subjects at time 

2 (12 mos after 

initial assessment)

21% (n=17) of all 

subjects at time 

3 (24 mos after 

initial assessment)

[Prevalence not 

reported by TBI 

severity]

Self-reported; severity determined using ACRM loss of consciousness criteria.

SCID, based on DSMIV criteria. 

tional

cts 

hrough 

ury 

es

n=66; 

all TBI 

Data for all study subjects Trauma etiology: MVC 45%; falls 18%; assault 3%TBI severity: severe 100%Time of assessment or since trauma: mean 5.9 years (range 1-26 years)Mean age (range): 38 (17-70)Women: 24%Race: NREducation: mean 12 years (range 9-19 years)Pain: NROther mental health conditions: NR

18% (n=12) of all 

subjects

Self-report, based on loss of consciousness (+6 hrs) and/or posttraumatic amnesia (≥ 1 day).

Self-report through IES, corroborated by relative or caregiver. Score of 26+ indicative of PTSD.

ries

tive 

s to 

oral 

ogy 

single 

sity 

al; 

nts 

d with 

r TBI

n=10; 

all TBI

(all OCD) 

Data for all study subjects Trauma etiology: MVC 100%TBI severity: mild 60%; moderate 20%; severe 20%Time of assessment or since trauma: > 51 mosMean age: 30Women: 60%Race: NREducation: mean 11 yearsPrevious head injury: 0%Pain: NROther mental health conditions: Obsessivecompulsive disorder 100%; depression 90%

70% (n=7) of all 

subjects 

[60% (n=6) 

with mild TBI; 

10% (n=1) with 

moderate TBI; 0% 

with severe TBI]

Glasgow Coma Scale score, determined at hospital admission.

SCID, based on DSMIII-R criteria.
61

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

ants 

arger 

l study 

from a 

opsych 

nter 

ically 

ed TBI 

years 

tudy 

n=76; 

all TBI

Data for all study subjects Trauma etiology: MVC 64%; combat 25%; workrelated 9%TBI severity: severe 100%Time of assessment or since trauma: 14± 5.8 (SD) yearsMean age (range): 25 (17-50) age at injuryWomen: 83%Race: NREducation: NRPain: NROther mental health conditions: Depression 45%

10% (n=7) of 68 

responding to 

PTSD items

Subjects were in a coma for an unspecified long period of time.

Post-Traumatic Stress Disorder Inventory, based on DSM-III criteria. “Probable PTSD” diagnosis assigned to subjects meeting 4 criteria: traumatic event, re-experiencing, numbing, and hyperarousal symptoms.

rt

ants 

 from 

ncy 

 or 

unit of 

evel-1 

enter

n=200;

115 with TBI 

Data for all study subjects Trauma etiology: MVC 69%; assault 15%; other 16%TBI severity: mild 83%; moderate 17% Time of assessment or since trauma: 88 daysMean age: 34Women: 78%Race: Hispanic 52%; black 32%; white 16%Education: mean 11 yearsPain: NROther mental health conditions: Depression 9%

8% (n=15) of all 

subjects; 

13% of TBI 

subjects

[12% (n=11) of 

subjects with mild 

TBI; 15% (n=4) 

of subjects with 

moderate TBI]

Hospital admission logs (“nonpenetrating head injury” based on Glasgow Coma Scale scores 9-15).

SCID, based on DSMIV criteria.

tional

tended 

dent 

gency 

wing a 

event 

idence 

edical 

d

n=53; 

all TBI 

Data for all study subjects Trauma etiology: assault 58%; MVC 30%; fall 11%TBI severity: mild 58%; moderate 21%; severe 17%; none 2 subjectsTime of assessment or since trauma: 5 mosMean age: 35Women: 13%Race: NREducation: NRPain: NROther mental health conditions: NR

17-27% of all 

subjects 

[Prevalence not 

reported by TBI 

severity]

Based on history of post-traumatic amnesia.

Those with IES-R score ≥ 20 administered the CAPS, with amnesia excluded as a symptom. Results reported using the most strict and most lenient cutoffs as recommended by scale authors on the CAPS. 
62

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

tive 

ns to 

major 

y rehab 

n=96; 

all TBI 

Data for all study subjects Trauma etiology: MVC 73%; industrial injury 15%; assault 13%TBI severity: mild 100%Time since trauma: 6 mosMean age: 34Women: 20%Race: NREducation: NRPain: 58% report daily pain; M = 6.90 (2.65) on a 1-10 severity scaleOther mental health conditions: NR

27% (n=26) of all 

subjects

Medical records based on Glasgow Coma Scale score and posttraumatic amnesia (Westmead PTA scale).

Post-traumatic Stress Disorder Interview (PTSD-I; Watson et al., 1991), based on DSM-III-R criteria.

rt

tive 

ns to 

major 

ospital 

 MVC

n=105; 

46 with TBI

Data for all study subjects Trauma etiology: MVC 100%TBI severity: mild 100%Time of assessment or since trauma: 6 mosMean age: 31Women: 40%Race: NREducation: NRPain: Headaches in 100% of subjects with mTBI/PTSDOther mental health conditions: NR

9% (n=9) of all 

subjects;

20% (n=9) of TBI 

subjects

Hospital admissions, posttraumatic amnesia < 24 h, loss of consciousness. 

Composite International Diagnostic Interview (CIDI).

rt

ve MVC 

ated at 

e major 

ospital 

ence 

I

n=79; 

all TBI

Data for all study subjects Trauma etiology: MVC 100%TBI severity: mild 100%Time of assessment or since trauma: mean 7.15 days (range 2-28); PTSD assessed 6 mos and 2 years post-traumaMean age (range): 29 (16-60)Women: 30%Race: NREducation: NRPain: NROther mental health conditions: NR

24% (n=15) of 63 

subjects assessed 

at 6 mos;

22% (n=11) of 50 

subjects assessed 

at 2 years

Hospital admission, posttraumatic amnesia < 24 h. 

Composite International Diagnostic Interview (CIDI).
63

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

tional

ants 

mly 

om 431 

s with 

ed in a 

lity of 

vey

n=100; 

all TBI

Data for all study subjects Trauma etiology: MVC 62%; assault 8%; other 30%TBI severity: NRTime of assessment or since trauma: mean 7.6 yearsMean age: 40Women: 47%Race: white 73%; black 14%; Hispanic 9%Education: HS grad or less 29%; some college/college grad 49%Pain: NROther mental health conditions: Depression 61%; SUD 28%; obsessive-compulsive disorder (OCD) 15%; panic disorder 14% ; phobias 10% ; general anxiety disorder 9%

19% (n=19) of all 

subjects 

Self-reported loss of consciousness.

SCID, based on DSMIV criteria.

tional

were 

n and 

edical 

within 

 MVC 

n=107;

16 with TBI 

Data for all study subjectsTrauma etiology: MVC 100%TBI severity: NRTime since trauma: 1-4 mosMean age: 35.9Women: 69%Race: 9.3% “minorities”Education: NRPain: NROther mental health conditions: NR

8% (n=9) of all 

subjects;

56% of subjects 

with TBI (9 of 16)

Clinical screening – rates of TBI stratified across multiple types of injury that varied in likelihood of producing TBI – only strictest criterion (e.g., loss of consciousness) used in the present review as evidence of TBI.

ClinicianAdministered PTSD Scale (CAPS).

tional

ent 

mbat 

rom a 

tment 

and/

tive 

ers 

ent 

with a 

of PTSD

n=43;

all PTSD

Data for all study subjects Trauma etiology: Combat 100% (27 with a blast concussion and 16 without)TBI severity: mild 60%; moderate 40%Time of assessment or since trauma: NRMean age (range): 52 (26-72)Women: 0%Race: NREducation: NRPain: NROther mental health conditions: SUD 42%; Attention-deficit/hyperactivity disorder (ADHD) 16%

60% (n=25) of 42 

respondents 

[Prevalence not 

reported by TBI 

severity]

Self-report, either a) being in the presence at a detonation of ordnance, often resulting in death or serious injury to others closer to blast, b) experiencing unconsciousness for ≤ 20 mins or dazed for ≥ 1 hour without loss of consciousness, or c) requiring medical attention for concussive episode.

Not described, all subjects were enrolled in a PTSD recovery program and/or addictive disorders treatment program and had a clinical diagnosis of PTSD. 
64

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

tive 

uty 

mbers 

derate 

er Reed 

dical 

er 

n=41; 

all TBI 

Data for all study subjects Trauma etiology: MVC 70%; fall 19%; assault 9%TBI severity: moderate 100%Time of assessment or since trauma: 4-29 mosMean age: 27Women: 2%Race: NREducation: NRPain: NROther mental health conditions: NR

11% (n=3) of 

28 subjects at 8 

weeks post-injury;

20% (n=3) of 15 

subjects at 6 mos 

post-injury; 

n=0 of 18 subjects 

at 12 mos postinjury;

14% (n=1) of 7 

subjects at 24 mos 

post-injury

Based on history of post-traumatic amnesia and Rancho Los Amigos scale.

Present State Examination, additional PTSD questions added to assess full spectrum of PTSD symptoms (e.g., added symptoms about re-experiencing and avoidance). Memory of event not required. Administered by clinicians.

rt

ants 

 from 

 who 

mitted 

vation 

mild/

e TBI

n=35;

all TBI 

Data for all study subjects Trauma etiology: MVC 34%; dom. assault 29%; assault 14%; sport/other 14%; industrial 3%TBI severity: mild 69%; moderate 31%Time of assessment or since trauma: 3 mosMean age: 35Women: 34%Race: NREducation: NRPain: NROther mental health conditions: Depression 9%

34% (n=12) of all 

subjects

[25% of subjects 

with mild TBI; 55% 

of subjects with 

moderate TBI]

Based on Glasgow Coma Scale, subjects admitted to hospital for minor head injury.

Self report through IES (>26 required for a positive screen for PTSD).

tional

ants 

d with 

ussive 

me or 

rior 

dy 

ent; 

ation 

d on 

d or 

n of 

ment

n=70;

28 with TBI, 42 

with PTSD

Data for all study subjects Trauma etiology: MVC 66%; blunt head trauma 14%; fall 10%; other 10%TBI severity: mild 100%Time of assessment or since trauma: TBI 20.8 ± 16.4 mos; PTSD 29.1 ± 32.7 mosMean age: 37Women: 41%Race: NREducation: NRPain: NROther mental health conditions: NR

0 TBI subjects had 

PTSD 

Unstructured interview by first author.

Unstructured interview by first author.
65

raumatic Stress Disorder Evidence-based Synthesis Program

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

rt

tive 

mitted 

pital 

ogy 

nt with 

dence 

I

n=28; 

all TBI

Data for all study subjects Trauma etiology: NRTBI severity: mild 100%Time since trauma: 3 mos & 1 yearMean age: 37Women: 46%Race: NREducation: NRPain: 32% reported headaches at 1 year postTBIOther mental health conditions: NR

0 subjects had 

PTSD; 

11% with “high” 

IES scores (above 

19) 1 year posttrauma

Through neurologic exam (not specified).

Self-report through IES and unspecified symptom checklist. Information regarding how PTSD diagnosis was established not provided.
66

raumatic Stress Disorder Evidence-based Synthesis Program

AND study evaluated in Key Question 1

y

and 

tion

n Characteristics of participants

Prevalence of 

TBI history with 

PTSD

Traumatic brain 

injury definition/

measure

Post-traumatic

stress disorder 

assessment

tional

ervice 

ers 

rans 

ed 

ndom 

ling 

phone 

ges 

sing 24 

c areas 

n=1965;

19.5% with 

TBI (weighted 

percentage) 

Data for all study subjects Trauma etiology: Military 100%TBI severity: NRTime of assessment or since trauma: NR. Time since deployment was 35% 0-17 mos, 33% 18-35 mos, 33% 36 mos or greaterMedian age: 30Women: 12%Race: white 66%; non-white 34%Education: NRPain: NROther mental health conditions: Probable major depression 14% 

6.6% of all 

subjects; 34% 

of TBI subjects 

(weighted 

percentages)

Self report, Brief Traumatic Brain Injury Screen.

Self report through PCL.-M.
67

raumatic Stress Disorder Evidence-based Synthesis Program

ACTIVE RESEARCH FINDINGS

earch: Epidemiology of TBI/PTSD (Key Question #1) 

roject Title/Status Main Objective(s) Study Characteristics

ng OEF/OIF Transition 

DoD to VA

s: Completed, article in 

ration

1. Determine feasibility of DoD-to-VA transfer of PHI on a local level2. Determine rate of transition of Wounded Warriors from Brooke Army Medical Center to VA healthcare system3. Determine use of VA mental healthcareNOTE: TBI diagnosis obtained from medical records

Study Design: Observational cohortPopulation: OEF/OIF deployed personnel treated and discharged from Brooke Army Medical Center (BAMC) FY02-FY07Intervention: NoneComparator: NoneOutcomes: Prevalence of PTSD at BAMC and at VA; delay from discharge at DoD to diagnosis/treatment of PTSD in VA systemTiming: From discharge at DoD to treatment at VASetting: Army Medical Center and VA sites

tive Assessment of 

ans after Traumatic 

Injury

s: In progress

1. Describe war-related cognitive and affective symptoms and patterns of substance abuse in OEF/OIF veterans2. Construct cognitive and affective profiles of OEF/OIF veterans over time3. Describe the temporal relationship between composite stress index and cognitive profiles of OEF/OIF veterans4. Describe the temporal relationships among TBI, cognitive symptoms, patient outcomes, and health services outcomes

Study Design: Prospective cohortPopulation: 500 OEF/OIF veteransIntervention: NoneComparator: NoneOutcomes: TBI identified with structured diagnostic interview; PTSD identified with PTSD checklistTiming: Baseline, 6, 12, and 18 mosSetting: 5 outpatient VA sites (VISN 2)

rstanding and Meeting 

eeds of Informal 

ivers to Improve 

omes for TBI patients 

Polytrauma

s: In progress

Assess the relationship between caregiving and patient, caregiver, and family health outcomes, including the physical, emotional, and financial burden of caregiving and the resources available to caregivers

Study Design: ObservationalPopulation: Family caregivers of all OEF/OIF patients with a TBI discharged from a Polytrauma Rehabilitation Center (PRC)Intervention: NoneComparator: NoneOutcomes: Caregiver-report of patients’ TBI and PTSD diagnosesTiming: At least 3 mos post-discharge from PRCSetting: Surveys administered by mail
68

raumatic Stress Disorder Evidence-based Synthesis Program

roject Title/Status Main Objective(s) Study Characteristics

nal Health Study for 

w Generation of U.S. 

ans 

s: In progress

1. Determine if the health status of OEF/OIF veterans is better, worse, or the same as non-deployed veterans2. Characterize healthcare utilization and VA disability compensation patterns of OEF/OIF veterans3. Describe the natural histories of psychological disorders, mTBI, musculoskeletal problems, and other health conditions over time among veterans4. Obtain prevalence figures for mTBI and PTSD from a population-based sample

Study Design: LongitudinalPopulation: 30,000 deployed OEF/OIF veterans and 30,000 non-deployed OEF/OIF era veterans Intervention: NoneComparator: NoneOutcomes: TBI and PTSD identified with screening instruments used in VAMCs Timing: 10 year follow-up with assessment every 3 yearsSetting: Surveys administered by mail, on-line, and by telephone

TBI/PTSD Comorbidity 

ost-Deployment 

omes in National Guard 

ers

s: Completed, 

scripts in preparation

1. Describe the scope of mTBI/PTSD among returning National Guard OIF veterans2. Identify the extent to which these problems impacted veterans’ psychosocial functioning, physical health, and quality of life over time 3. Examine variation in new OIF veterans’ experiences with VA by mTBI and probable PTSD status

Study Design: Two-wave longitudinal cohortPopulation: OIF National Guard soldiers Intervention: NoneComparator: NoneOutcomes assessed: In-theater: blast exposure, mTBI, PTSD symptoms; Post-deployment: combat exposure, exposure to explosive blasts and injuries sustained, mTBI and post-concussive symptoms, current psychosocial functioning, physical health, access and use of VA healthcare servicesTiming: In-theater screening one-month before returning home; mailed survey at 1 year post-deploymentSetting: In-theater and home

Traumatic Brain Injury 

ession

s: In progress

To identify risk factors for depression among patients with first time TBI (all severity levels)(NOTE: PTSD assessed with full structured interview)

Study Design: Prospective, observationalPopulation: 140 consecutive TBI patients; recruited soon after injury Intervention: NoneComparator: NoneOutcomes: Major depression; also assessing PTSDTiming: Follow-up at 1 year post-injurySetting: Clinical (2 university-affiliated trauma units)

verity and Associated 

ocognitive findings in 

OIF Veterans

s: Data collection 

lete; analysis in 

ess

To examine the epidemiology of TBI in OEF/OIF veterans and the relationship between self-reported severity of TBI and level of PTSD symptomatology and neurocognitive performance(NOTE: results to be analyzed by severity of TBI)

Study Design: Prospective, observationalPopulation: Approximately 850 OEF/OIF veterans; TBI and PTSD status unknown by investigators at time of enrollmentIntervention: NoneComparator: NoneOutcomes: Neurocognitive and psychological test battery (including PTSD Checklist) findings examined in relation to TBI history (chart review or self-report)Timing: Post-deployment; time from TBI assessedSetting: One Polytrauma Rehabilitation Center, three Level III Polytrauma Support Clinic Teams
69

raumatic Stress Disorder Evidence-based Synthesis Program

earch: Assessment of mTBI/PTSD (Key Question #2) 

Project Title/Status Main Objective(s) Study Characteristics

nitive Assessment of 

rans after Traumatic 

n Injury

us: In progress

Describe the psychometric properties of the VA TBI screening tool

Study Design: Prospective cohortPopulation: 500 OEF/OIF veteransIntervention: NoneComparator: NoneOutcomes: Item analysis of the VA TBI screening tool; test-retest reliability and sensitivity/specificity with structured diagnostic interview for TBI probability/ severity as criterionTiming: Baseline, 6, 12, and 18 mosSetting: 5 outpatient VA sites (VISN 2)

kers for the 

tification, Norming, and 

rentiation of TBI and 

D (MIND)

us: Planning stage

1. Clarify differential diagnoses between TBI and PTSD 2. Build objective, consistent, and operator-independent diagnostic criteria

Study Design: Cross-sectionalPopulation: Subset of OEF/OIF veterans from New Generation study with TBI and/or PTSD and a comparison group Intervention: NoneComparator: NoneOutcomes: Advanced diagnostic tests (neuroimaging, sleep studies, neuroendocrine measures)Timing: One-time testing; patients continue enrollment in New Generation studySetting: VA War Related Illness and Injury Study Centers

al and Behavioral 

elae of Blast-Related 

matic Brain Injury

us: In progress

Identify the similarities and potential differences in the neural and behavioral sequelae of blast-related TBI compared to mechanically-induced TBI occurring in civilians

Study Design: Prospective, cross-sectional observationalPopulation: n=120 in 4 groups – military with mild to moderate TBI, military with mild to moderate orthopedic injury (OI), civilian with mTBI, civilian with OIIntervention: NoneComparator: NoneOutcomes: Advanced MRI findings, neuropsychological test results, post-concussion symptoms, PTSD symptoms, depression, pain and fatigue scalesTiming: Assessment at 12-24 mos post-injurySetting: Cleveland and Houston VAMCs; community hospital trauma/rehabilitation centers
70

raumatic Stress Disorder Evidence-based Synthesis Program

Project Title/Status Main Objective(s) Study Characteristics

Severity and Associated 

rocognitive findings in 

/OIF Veterans

us: Data collection 

plete; analysis in 

gress

Examine the relationship between self-reported severity of TBI and level of PTSD symptomatology and neurocognitive performance on a measure of premorbid intellectual functioning and prefrontal verbal abstraction(NOTE: results to be analyzed by severity of TBI)

Study Design: Prospective, observationalPopulation: Approximately 850 OEF/OIF veterans; TBI and PTSD status unknown by investigators at time of enrollment Intervention: NoneComparator: NoneOutcomes: Neurocognitive and psychological test battery (including PTSD checklist) findings examined in relation to TBI history (chart review or self-report)Timing: Post-deploymentSetting: One Polytrauma Rehabilitation Center, three Level III Polytrauma Support Clinic Teams

traumatic Stress 

rder with and 

out Traumatic Brain 

ry: Comorbidity and 

gitudinal Course of 

overy

us: Preparing for data 

ysis

Examine neurocognition in OEF/OIF post-deployed and active-duty personnel with TBI alone, PTSD alone, and comorbid TBI and PTSD compared with combat controls and non-combat controls(NOTE: same population as in study described below)

Study Design: Prospective, observationalPopulation: Approximately 170 OEF/OIF veterans and active-duty personnelIntervention: NoneComparator: NoneOutcomes: Neurocognitive and psychological test battery (including PTSD checklist) findings examined in relation to TBI history (chart review or self-report)Timing: Continuous recruitment since 2006Setting: One Polytrauma Rehabilitation Center, two Level III Polytrauma Support Clinic Teams

Olfaction be used to 

riminate Traumatic Brain 

y from Posttraumatic 

ss Disorder?

us: Preparing for data 

ysis

Examine the utility of the University of Pennsylvania Smell Test (UPSIT) as a means of discriminating TBI from PTSD(NOTE: same population as in study described above)

Study Design: Prospective, observationalPopulation: Approximately 170 OEF/OIF veterans and active-duty personnelIntervention: NoneComparator: NoneOutcomes: UPSIT and PTSD Checklist in relation to TBI history (chart review or self report)Timing: Continuous recruitment since 2006Setting: One Polytrauma Rehabilitation Center, two Level III Polytrauma Support Clinic Teams

Screening Instruments 

Processes for Clinical 

ow-up

us: In progress

Evaluate the reliability and validity of the existing Traumatic Brain Injury (TBI) Clinical Reminder Screen for OEF/OIF Veterans controlling for comorbidities and demographics

Study Design: Diagnostic test evaluationPopulation: OEF/OIF veteransIntervention: NoneComparator: NoneOutcomes: Reliability and validity Timing: Not statedSetting: VA Polytrauma Rehabilitation Centers, Network Sites, and Support Clinic Teams
71

raumatic Stress Disorder Evidence-based Synthesis Program

earch: Treatment of mTBI/PTSD (Key Question #3)

oject Title/Status Main Objective(s) Study Characteristics

litation Strategies to 

e Violence and Anger 

nd PTSD

 Proposal under 

1. Identify risk and protective factors empirically related to violent behavior among veterans who have returned from Iraq and Afghanistan2. Examine the link between specific factors related to violence among veterans from previous conflicts and post-deployment violence risk among Iraq and Afghanistan veterans3. Develop an evidence-based risk assessment instrument to administer to Iraq and Afghanistan veterans in order to identify those most in need of services

Study Design: Prospective cohortPopulation: 300 OEF/OIF veterans and a member of their familyIntervention: NoneComparator: NoneOutcomes: Modality of psychotherapy, dosages and classes of psychiatric medicationsTiming: Interview at baseline and 6 mosSetting: VA, outpatientNOTE: although the direct aim of the study is not to evaluate particular rehabilitation strategies, the investigators believe that information yielded from the study may be useful in sequencing treatment efforts

st of Preference

nsomnia Treatment 

F/OIF Veterans

 Proposal under 

Pilot test a brief, preference-based insomnia intervention augmented by audio files (MP3) and web-based resources

Study Design: One group, pre-postPopulation: 26 OEF/OIF veterans, history of blast exposure or other injury resulting in period of altered consciousness AND insomnia complaint of ≥ 1 mo. duration with daytime impairment, Insomnia Severity Index (ISI) ≥ 10, phone and internet access, ability to listen to audio files on MP3 playerIntervention: Multi-component – relaxation therapy, mindfulness exercise, stimulus control instructions, sleep restriction therapy, and sleep education and hygieneComparator: NoneOutcomes: ISI, Pittsburgh Sleep Quality Index-Addendum for PTSD (PSQI-A), daily sleep diary, treatment feasibilityTiming: 4 week treatment phase, assessed pre-treatment, during treatment, and 2 weeks post-treatment Setting: VA, outpatient

ased Initiative: 

rt (Pilot)

 Completed, report in 

pment

1. Determine the feasibility of implementing volunteer support teams with TBI families2. Identify the obstacles and opportunities in implementation

Study Design: Case seriesPopulation: Family members of 6 Guard/Reserve service members (OEF/OIF veterans) with mild-complicated TBI and co-occurring PTSDIntervention: Project coach for needs assessment, team formation, trainingComparator: NoneOutcomes: Qualitative data on family issues and concernsTiming: Returning to community post-injurySetting: Outpatient (family homes), rural
72

raumatic Stress Disorder Evidence-based Synthesis Program

oject Title/Status Main Objective(s) Study Characteristics

udy of Hyperbaric 

n Therapy (HBOT) 

nic Traumatic Brain 

TBI)/Post-Concussion 

me (PCS) and TBI/

aumatic Stress 

er (PTSD)

 In progress

Determine if one or two 40-treatment courses of low pressure HBOT can improve cognition and brain imaging in subjects with either chronic mild-moderate TBI (also known as PCS), or chronic TBI with PTSD secondary to blast injury

Study Design: Open-label, single group Population: 30 patients (15 with TBI, 16 with TBI and PTSD), 18-45 years old, blast-induced injury resulting in mTBI/concussion with loss of consciousness; able to manage self-careIntervention: 40 (or 80) HBOT sessions; 2 sessions per day for 20 days (4 weeks)Comparator: NoneOutcomes: Psychometric and neuropsychological tests, brain imagingTiming: Injury 1 to 4 years prior to enrollment; baseline assessment, post-treatment assessment, and follow-up at 6 mos and 1 year post-treatmentSetting: Non-VA clinic

ing Sleep: Initial 

ent in OIF/OEF 

ns with Blast-Induced 

BI

 Completed, 

ation in development

Determine if treating impaired sleep would reduce headache frequency and severity

Study Design: Case seriesPopulation: OIF/OEF veterans with headaches associated with mTBI and persisting neurocognitive deficitsIntervention: Education in sleep hygiene and prazosin to reduce nightmares associated with PTSDComparator: Patients who do not complete prazosin protocol or who discontinued prazosin after intervention periodOutcomes: Headache frequency and severity, cognitive assessment, sleep assessmentTiming: Assessment at baseline, after 9 week intervention, 6 mo. follow-upSetting: Outpatients from VAMC