Management of TBI Rehabilitation/Co‐Occurring Me

Issues: Depression, Pain, & Substance Use Diso

Alison N. Cernich, Ph.D., ABPP‐Cn

Acting Senior Liaison, TBI

Office of Rehabilitation Services

Department Department of Veterans Veterans Affairs Affairs
Frequency of Possible Diagnoses among 

OEF and OIF Veterans * Data cited from VA Health Care Utilization by Recent Veterans, Epidemiology Program, Office of Public Health, * These are cumulative data since Oct 1 2002, with data on hospitalizations and outpatient visits as of June 30, 20

have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnosti

counted in multiple categories, so the above numbers add up to greater than 834,463; percentages add up to grea

same reason. 

† P t t d i t d t di 

VETERANS HEALTH ADMINISTRATION 

Percentages reporte

d are approximate 

due to rounding. 
t

mTBI and Co-Occurring Disorders 

• The vast majority of patients who

present to the clinic with a diagnosis ofmild Traumatic Brain Injury (mTBI) do mild Traumatic Brain Injury (mTBI) do 

not often present with mTBI alone. 

• Veterans with positive TBI screens are 

more lik l h di i f likely to have a diagnosis of 

PTSD, depression, and substance abuse disorder. 

• Both civilian and military literature 

provide evidence that the greater theburden of co burden of co -occurring disorders, the occurring disorders, the 

higher the likelihood that symptoms will persist following mTBI. 

VETERANS HEALTH ADMINISTRATION 
Depression & TBI 

• Depression is frequently noted in individuals with 

chronic p ost-concussion sy ( ndrome (Hesdorffer et al, 

2009). 

• Individuals with mTBI who experience depression 

p ost-inj y p y p ury report more symptoms and more severesymptoms than those mTBI patients without depression (Lange et al., 2010). 

• This can extend to the perception of other problems, including co

This can extend to the perception of other problems, including co

in individuals with mTBI, with individuals with depression, anxiety reporting more problems with cognitive function than other groups 2010).

• Depression after mTBI is linked to abnormal imaging results, olde

injury, and higher levels of depressive symptoms in the week follo2009). 

VETERANS HEALTH ADMINISTRATION 

) 
Pain & TBI 

• A recent meta-analysis that considered veteran populat

separately found a 43.1% pain prevalence rate (95% CI

46 3%; Nampiaparampil 2008) 46.3%; Nampiaparampil, 2008). 

• Though that study found that brain injury has an indepe

relationship with chronic pain, over and above other dia

PTSD or depression), other reports have demonstrated contribution of PTSD, insomnia, fatigue, and depression p y ain severity ( , Dobschka et al., 2008) .

• In addition, many veterans from the OEF/OIF/OND conf

with other injuries, such as amputations, orthopedic inju

chronic use injuries that may have occurred separately chronic use injuries that may have occurred separately 

mTBI. In a multiply injured population, the prevalence of is generally higher and the pain is rated as more severe 

t di (M di t l 2004) 

VETERANS HEALTH ADMINISTRATION 

studies (Meerding et al., 2004). 
Headache & TBI 

• Headache is the most frequently cited persistent symptom follo

often the most disruptive to the individual’s functional ability. 

• Approximately 90% of individuals experience headache followin

(Lew et al., 2006) and they generally develop within 7 days of tthird to one-half of individuals with mTBI report headache five y(Dobscha et al., 2008). 

• Headache origin does not follow only from impact to the head b

trauma to the head or neck including: cervical spinal column, spmusculature (International Headache Society, 2004) . 

• Early symptoms of headaches, d

nausea in the immediate period (Emergency Department) after mTassociated with sustained post-cosymptoms months after injury (ChFeinstein, 2004; de Kruijk et al., 2

VETERANS HEALTH ADMINISTRATION 
analysis, the relationship was not a

et al., 2011).

• In civilian brain injury studies, there is an increased risk for increased alc

use in the presence of a co-occurring mood disorder (Jorge et al 2005)

Substance Use Disorders & TBI 

• In general, alcohol and substance 

following brain injury. For exampleat a Level I trauma center, the prev

sub t di d t f 

b

stance use disor

ders went from 

21% post-injury (Whelan-Goodinso

• In a recently published study of ac

with mTBI there was a slightly higwith mTBI, there was a slightly hig

abuse in individuals with a comorbcompared to other injuries (6.9% v when other factors were controlled 

use in the presence of a co occurring mood disorder (Jorge et al., 2005)

• What places an individual with mTBI at potential risk for the developmen

problems are the cognitive and emotional deficits following the injury, in cthe 

presence of 

poor 

p

s

ychosocial adjustment and co

pin

g skills (Graham 

VETERANS HEALTH ADMINISTRATION 

p p p y j p g ( 
Treatment Guidance for mild TBI Treatment Guidance for mild TBI 

• Guideline process was

initiated in 2007

• Litera

ture review spanne

d

2002

‐2008 and also included

data from the WHO review

from 1980

‐2002

• Includes mana

gement

algorithms for initial

concussion

• Does support paucity of Class

A evidence for mTBI care

VETERANS HEALTH ADMINISTRATION 
Depression 

• Non‐pharmacologic treatment

– Reassurance related to recovery

– Reduce activity restriction– Sleep hygiene education– Sleep study, if indicated

– Regular aerobic exercise

• Pharmacotherapy recommended

– Anti‐epileptics– SSRI (single RCT for sertraline showed non‐significant improvements

• AHRQ evidence synthesis reflected a paucity of evidence for treatment o

following TBI

• Recent meta‐analysis documents effectiveness of cognitive‐behavioral th

average effect size 1 15 . in popul i at ons wi ht b i ra n i j n ury (Waldron et al., 2

• A small study explored mindfulness‐based cognitive therapy and demons

symptoms of depression in 20 patients (Bedard et al., 2012

VETERANS HEALTH ADMINISTRATION 
Pain 

• Thorough evaluation with consideration of individual factors and

symptom presentation should be emphasized

• Treatment depends on the eti l o ogy of the pain

– Guidelines for TBI and pain suggest maximization of non‐

pharmacological interventions before medications are initiated

• H t ea• Ultrasound• Cryotherapy• Transcutaneous nerve stimulation

• Relaxation or CBT may require modification for individuals

with TBI but can be effective

• Focus on interventions interventions that minimize minimize side effects effects notable notable in TBI

– Analgesic balms, acetaminophen, and NSAIDS are first line

treatment for most types of pain

• Minimize medications that have the potential for abuseVETERANS HEALTH ADMINISTRATION • Minimize medications that have the potential for abuse
mTBI: Headache Management : Headache Management 

• Headache

– Management is similar to conven

headache management

– Medication treatment should be 

prescribed to avoid sedation

– Other contributors to headache r

• Associated neck or upper back injury• Medication use• Significant caffeine use• Sleep/fatigue

– Pharmacotherapy Pharmacotherapy can include include NSA

and prophylactic headache treatm

VETERANS HEALTH ADMINISTRATION 
Substance Use Disorders 

• Little specific literature exists for the mild TBI

population for treatment of SUDs

• 

Recent ran

domize

d controll

e

d tri l a

s

have exami d ne

d

t

h

e

effect of brief interventions to reduce alcohol use in

individuals with moderate to severe TBI with little to no

effect (Sander (Sander et al., 2012; Ponsford Ponsford et al., 2012;

Tweedy et al., 2012).

– Trials were limited by small sample size

– Interventions Interventions varied with respect respect to time since

injury to implementation

• Specialty referral to

a SUDs clinic with collaborative

work on modification of treatments for individuals with

brain injury is

a general clinical recommendation.

– No clear evidence supports this approach.

VETERANS HEALTH ADMINISTRATION 
Thank You 

VETERANS HEALTH ADMINISTRATION 
TBI and PTSD Comorbid

Returning Veterans

Jennifer J. Vasterling, Ph.D.

VA Boston Healthcare System

VA National Center for PTSD

HSR & D C

ybersemina

r

November, 2012
Overview

 Epidemiology  Mechanisms leading to comor Clinical Implications 
Epidemiology

%

Hoge et al. (2008; et al. (2008; N Eng J M

N Eng J M

50% 

PTSD 30% 

40% 20% 10% 

0% 

TBI +LOC TBI/LOC - I j n ury 

Other No Injury 

N = 2525 Army infa

2525 Army infa
t

TBI Severity and PTSD

Ztika z c et al (2010 A h G P h) l. (2010; Arch Gen Psych) 

N = 3047 civilians 

 Only moderate and severe TBI decreased risk of PTSD

other injury controls 

PTSD

24% 23% 

19% 20% 

none Mild Mod Severe 

TBI Severity

 PTSD assoc. with functional impairment, cognitive symp
Mechanisms
TBI/PCS Stress

PTSD 
------------------------------------------------------------------------------------------------

PTSD  TBI Recovery Recovery 

 Most post-concussive symptoms in OEF/OIF s

can be accounted for by PTSD (Hoge et al, N Eng J Med

 Psychiatric symptoms reduce resilience and coTBI  Somatic pre-occupation (especially for anxiety disorders) 
TBI  PTSD: Mechanism

TSD: Mechanism

 TBI and associated complications can 

TBI and associated complications can 

stressful 

 Cumulative effects of brain (and cogni

dysfunction 

Dorsolateral Frontal Cortex 

Orbital Frontal Cortex Hippoc
ob a 9 3 3

Longitudinal Prediction of Psychiatric Status 

TBI 

 Bryant et al. (2010; Am J Psych) Bryant et al. (2010; Am J Psych)

n = 1084 civilians with traumatic in

At 12 mos., mild TBI patients ~2x more likely to d

Adj OR CI 

PTSD 1.92 1.08, 3.4

Pian c 2 10 . 1 03 . ,4 1

.

Social Phobia 2.07 1.03, 4.1Ago ap r hobia 1.94 1.13, 3.3

Functional impairment related to psychiatric s
Clinical Consideratio
Overlapping Associated Sym

PTSD 

PersistenConc ssConc

uss

Syndrom

++ 

De

pression & Anxiety 

Re-experiencing Shame G ilt 

HeadSensi

p y 

Insomnia Irritability/Anger Poor Concentration 

G

uilt Dizzin

Poor Concentration Fatigue Hyperarousal Avoidance Avoidance Memory deficits 

Adapted from: Stein & McAllister (2009). Am J Psychiatry: 166, 768
Vasterling et al. (2012). British Journal of Psychiatry
Clinical Assessment Implicati

Clinical Assessment Implicati

 Potentially difficult to differentiate etiologicbased on symptoms and neuropsychologicabased on symptoms and neuropsychologica Determining course of symptoms might b

Determining course of symptoms might b

informative 



Assessments might be better used to help 

symptoms that require clinical attention 
Co-morbid TBI: Can I Treat PTS

U l? sua 

 Does TBI contraindicate PTSD treatment? 

Probably not except under special

circumstances, but little data on this

(Chard et al., 2011, J Trauma Stress; Wolf et al., 2012, J Head Trauma Rehab) 

 Does TBI influence TBI influence treatment response treatment response

? 

Unknown, but possibly if there is cognitive 

impairment impairment 

(Wild & Gur, 2008; Br J Psychiatry) 
T B reat t t t tmen

t: 

Bryan

t e

t a

l. (2003

 Randomized Controlled Trial  Cognitive Behavioral Therapy (CBT) for 

stress disorder after mild TBI 

 CBT was associated with reduced PTSD 

months late

r
Treatment Recommendation

Treatment Recommendation

 Address cognitive deficits causing functionimpairment: don’t worry about etiology.  No evidence that PTSD treatment is conin mild TBI in mild TBI. 

 If mild TBI, treat PTSD as usual but allow 

attenuated response. 

 Proceed more cautiously with standard Ptreatment if more severe TBI. 
 

Suicide and Traumatic Brain Injury: 

US Military and Department of VA
 

Lisa Brenner, PhD, ABPP
 

VISN 19 MIRECC
 

Departments of Psychiatry, 

Neurology, and Physical Medicine and Rehabilitation
 

University of Colorado School of Medicine
 
Disclosure 

This presentation is based on work supported, in part, by 

the Department of Veterans Affairs, but does not 

necessarily represent the views of the Department of 

Veterans Affairs or the United States Government. 
 

 

“I think it took awhile before I realized and then 

when I started thinking about things and realizing 

that I was going to be like this for the rest of my life, 

it gives me a really down feeling and it makes me
 

think like—why should I be around like this for the 

rest of my life?͟
	

- VA Patient/TBI Survivor
 
 

Individuals who received care 

between FY 01 and 06 

Analyses included all patients 

with a history of TBI (n = 49, 

626) plus a 5% random sample 

of patients without TBI 

(n = 389,053) 

Suicide - National Death Index 

(NDI) compiles death record 

data for all US residents from 

state vital statistics offices 

TBI diagnoses of interest were 

similar to those used by 

Teasdale and Engberg 
Suicide by TBI Severity – 
 

VHA Users FY 01-06
 

•	 12,159 with concussion or cranial fracture, of 

which 33 died by suicide 

•	 39,545 with cerebral contusion/traumatic 

intracranial hemorrhage of which 78 died by 

suicide 

•	 Of those with a history of TBI, 105 died by 

suicide 

Challenges associated with this type of research 

and need for collaboration 

(~8 million records reviewed)
 
 

 

 

 

 

 

 

 

ICD-9 codes: 

1) concussion (850), 

cranial fracture—fracture

of vault of skull (800), 

fracture of base of skull

(801), and other and

unqualified skull fractures 

(803) 

(2) cerebral laceration

and contusion (851); 

subarachnoid,

subdural, and extradural

hemorrhage after injury

(852); other and

unspecified intracranial 

hemorrhage after injury

(853); and intracranial 

injury of other and

unspecified

nature (854).

Cox proportional hazards survival models for time to suicide, 

with time-dependent covariates, were utilized.
 

Covariance sandwich estimators were used to
 

adjust for the clustered nature of the data, with patients 

nested within VHA facilities. 
ICD-9 
 

 

“Although findings suggested that

increased risk for death by suicide 

was present for those across the 

injury severity continuum,

further work is required to clarify

whether those with 

concussion/cranial fracture versus

cerebral contusion/

traumatic intracranial hemorrhage 

are unique populations. 

It is likely that factors associated 

with increased

risk vary depending on the 

severity of injury sustained. It may

also be that preexisting factors

contribute to a

greater degree for a subset of the 

population (eg, those

with concussion).”


“The different findings regarding the relationship

between mild TBI and suicide risk may reflect important differences 

between the underlying populations and settings
 

of the studies. For example, within civilian populations, TBIs, in general, 

appear to be associated with high risk behaviors
 

(e.g., fighting, alcohol abuse) and psychopathology.
 

25-27 However, within military populations, TBIs may more commonly
 

be associated with injuries that occur during training exercises or 

exposures to combat. This distinction may have meaningful
 

implications. Among civilians, an association between mild TBI and
 

suicide might be attributable to pre-existing personality
 

characteristics and psychopathology that increase or mediate suicide 

risk.”
 

Suicide Attempts Prevalence
 Suicide 

attempts 

Prevalence Sample Injury 

Severity 

Timeframe Country 

Brooks in 

Eames et al. 

1990 

15% 45 Unknown 5 years UK 

Silver et al 

2001 

8.1% 361 Unknown Lifetime United 

States 

Shavelle et 

al 2001 

3% 2,320 Unknown 5 years United 

States 

Simpson & 

Tate 2002 

18% 172 Severe Post-injury Australia 

25% 172 Severe Lifetime Australia 

Anstey et al 

2004 

1.6% 428 Unknown Previous 12 

months 

Australia 

Grahame Simpson
 
• 22 Subjects 

• Total Number of 

Admissions: 114
 

• Median Number 

of Admissions: 3
 

• Range of 

Admissions: 1-20
 
Are 

individuals 

with 

moderate 

to severe 

TBI seeking 

traditional 

psychiatric 

services? 

 

 

Number of Admissions Secondary to a Suicide Attempt
 

͞Half of the patients in the 

current study made suicide 

attempts by overdose, the 

majority using medications 

that were listed as being 

prescribed at time of 

discharge.͟ 

11% of total admissions
 

Number of attempts 1-5 

Median - 2 
Risk Factors
 
 

 

 

 

 

 

 

Suicide Risk Factors
 

Outcome Domain Adjusted Risk 95% CI 

Suicide 

Attempt 

Post-injury psychopathology 

High suicide ideation (BSS≥9) 

versus low/ no suicide ideation 

People with post-injury 

Psychiatric H’x/ Emotional 

distress versus none 

4.9 

7.8 

1.79 – 13.17 

2.11 – 29.04 

Suicide ideation 

Post-injury psychopathology 

Moderate/high levels of 

hopelessness 

(BHS≥9) versus minimal/no 

hopelessness 

People with post-injury 

Psychiatric H’x/ Emotional 

distress versus none 

Worthlessness versus no 

worthlessness 

8.7 

5.5 

1.9 

3.48 – 21.72 

1.95 – 15.77 

NR 

• Hopelessness was found to be a strong independent predictor of suicidal ideation 

•	 Suicidal ideation was a strong predictor of post-injury suicide attempts 

(Simpson & Tate, 2002) 
Hopelessness After TBI
 

• Hopelessness common after severe TBI 

• 35% rate of moderate to severe hopelessness was observed 

among people with TBI between 1 and 10 years post-injury 

(Simpson & Tate, 2002) 
Participants: Sample 

of 13 Veterans with 

a history of TBI, and 

a history of clinically 

significant 

suicidal ideation or 

behavior. 

Method: In-person 

interviews were 

conducted and data 

were analyzed 

using a hermeneutic 

approach 
Cognitive Impairment and Suicidality 

•	 “I knew what I wanted to say although I'd get into a thought 

about half-way though and it would just dissolve into my 

brain. I wouldn't know where it was, what it was and five 

minutes later I couldn't even remember that I had a thought. 

!nd that added to a lot of frustration going on./and you 

know because of the condition a couple of days later you can't 

even remember that you were frustrated.” 

•	 “I get to the point where I fight with my memory and other 

things/and it’s not worth it.”
Emotional and Psychiatric 

Disturbances and Suicidality
 

•	 I got depressed about a lot of things and 

figured my wife could use a $400,000 tax-free 

life insurance plan a lot better than/.I went 

jogging one morning, and was feeling this bad, 

and I said "well, it's going to be easy for me to 

slip and fall in front of this next truck that goes 

by/(
 

Loss of Sense of Self and Suicidality 

•	 Veterans spoke about a shift in their selfconcepts post-injury, which was frequently 

associated with a sense of loss 

– (/when you have a brain trauma/it's kind of like 

two different people that split/it’s kind of like a
 

split personality. You have the person that’s still 

walking around but then you have the other 

person who’s the brain trauma.( 
͞The odds of a suicide 

attempt for those with 

both PTSD and TBI was 3.3 

times the odds of an 

attempt for those with TBI 

alone.” 

Cases (N = 81) and 2:1 

matched controls (N = 160) 

were randomly 

selected from a VAMC 

clinical database 

PTSD history was 

associated with an 

increased risk for a suicide 

attempt (OR = 2.8; 95% CI: 

1.5, 5.1) 

This increased risk was 

present for those with and 

without a history of 

TBI 
 

 

 

 

 

Primary outcome measure: Hopelessness 

Secondary outcome measures: Suicidal ideation and depression 

Hope, self-esteem, problem solving 

Participants who completed the WtoH program would report a significant reduction in their 

levels of hopelessness compared to waitlist controls 

Treatment group would demonstrate significant reductions in suicidal ideation and 

depression, and increased social problem-solving, self-esteem and hopefulness in 

comparison to the waitlist controls 
Hopelessness
 

F(1,15)=13.20, p=0.002
 
 

 

 

 

VA Window to Hope Team
 

Lisa A. Brenner, PhD, ABPP, Grahame K. Simpson, PhD,, 

Bridget Matarazzo, PsyD, Gina Signoracci, PhD, 

Tracy Clemans, PsyD, and Adam Hoffberg, MHS.
 

Liverpool Brain Injury Rehabilitation Unit- Liverpool Health Service, VA VISN 19 Mental Illness Research, 

Education and Clinical Center (MIRECC), Department of Psychiatry, University of Colorado Denver, School of 

Medicine, Department of Physical Medicine and Rehabilitation, Department of Neurology, University of 

Colorado Denver, School of Medicine.
 

Funding provided by the Military Suicide Research 

Consortium through the Department of Defense
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Window of Hope
 

Positive Lifestyle – EASE 

Behavioral Activation 

Eating 

Activity 

Sleep 

Exercise 

Take Another Look 

Cognitive Restructuring 

Stop 

Drop 

Roll 

How to be a STAR 

Problem Solving 

Spot the problem 

Think of options 

Act on best option 

Review how it went 

Building Hope 

Post Traumatic Growth 

Self-esteem/ value 

Finding connection 

Sense of purpose 

Expect good things 
͞/talk to a professional. That's why you guys 

are here professionally trained to deal with
 

people with my problem or problems like I 

have, you know/Left to myself, I'd probably 

kill myself. But that didn't feel right so I turned 

to professionals, you guys. ͞ 

- VA Patient/TBI Survivor
QUESTIONS?