Administration for Community Living 

Behavioral Health Guide: 

Considerations for Best 

Practices for Children, Youth, 

and Adults with TBI 

May 2022

TBI TARC is supported by contract number HHSP233201500119I

from the U.S. Administration for Community Living, 

Department of Health and Human Services, Washington, D.C. 20201
Traumatic Brain Injury Technical Assistance and Resource Center

Contents

Contributors.............................................................................................. 1

Section I: Purpose of the Guide and Overview of Behavioral Health 

and Traumatic Brain Injury....................................................................... 1

Background.................................................................................................................. 1

Purpose........................................................................................................................ 1

Audience................................................................................................................... 2

Note on terminology.................................................................................................. 2

Rationale for focus on behavioral health................................................................... 2

Overview of Behavioral Health and TBI ....................................................................... 3

Systemic issues........................................................................................................ 3

Section II: Partners and Strategies.......................................................... 9

Partners ....................................................................................................................... 9

Nine Principles and Strategies................................................................................... 13

1. Shared vision ................................................................................................... 13

2. Mutual trust and respect................................................................................... 14

3. Shared purpose based on identified needs...................................................... 15

4. Transparent communication............................................................................. 16

5. Flexibility in partnership procedures and structures ......................................... 17

6. Anticipate challenges ....................................................................................... 18

7. Adherence to a code of conduct....................................................................... 19

8. Use of collaborative technology ....................................................................... 20

9. Culturally responsive practices......................................................................... 21

Summary.................................................................................................................... 21

Section III: Training Approaches ...........................................................25

Why Is Training Important?........................................................................................ 25

Which Training Components Should Be Included?.................................................... 26

Basic....................................................................................................................... 27
Traumatic Brain Injury Technical Assistance and Resource Center

Intermediate............................................................................................................ 27

Advanced................................................................................................................ 28

Where Can I Find Existing Materials and Resources?............................................... 28

Where Can I Find Trainers and Existing Training? .................................................... 30

Summary.................................................................................................................... 31

Section IV: Screening for Lifetime History of TBI................................. 32

Why Screen for TBI?.................................................................................................. 32

Lifetime history of TBI is unique.............................................................................. 33

Retrospective self-report of lifetime exposure......................................................... 33

Screening Tools ......................................................................................................... 36

The OSU TBI-ID......................................................................................................... 38

Summary.................................................................................................................... 40

Section V: Modifying Clinical Interventions for TBI .............................51

Introduction ................................................................................................................ 51

Considerations and Best Practices for Diagnostic Procedures .................................. 52

Epidemiology of psychiatric disorders..................................................................... 52

The risk of misdiagnosis ......................................................................................... 53

Causes of distress: Neurological versus psychogenic............................................ 53

Factors to consider when administering diagnostic instruments to people with 

TBI

 

.......................................................................................................................... 54

Selection of diagnostic instruments ........................................................................ 55

Considerations and Best Practices for Clinical Interventions ..................................... 55

Factors to consider when delivering treatment to people with TBI.......................... 56

Modifying existing interventions.............................................................................. 56

Evidence-based Mental Health Treatments for People with TBI................................ 60

Adults...................................................................................................................... 60

Children .................................................................................................................. 60

Couples or Caregivers (adults and children)........................................................... 61

Summary.................................................................................................................... 61

Section VI: Modifying Psychopharmacologic Interventions for TBI ...66
Traumatic Brain Injury Technical Assistance and Resource Center

Introduction ................................................................................................................ 66

General Approach...................................................................................................... 67

Psychiatric Assessment: Modifications for TBI........................................................... 68

Before beginning: Timing of assessment relative to injury...................................... 68

Psychiatric interview ............................................................................................... 69

Medical and Neurological Review of Systems ........................................................... 70

Details of injury ....................................................................................................... 72

Psychiatric and medical history............................................................................... 72

Mental status exam................................................................................................. 73

Further neurological and medical assessment ....................................................... 73

Diagnostic formulation ............................................................................................ 74

Psychopharmacologic Treatment: General Principles in TBI ..................................... 75

Specific Posttraumatic Neuropsychiatric Syndromes................................................. 77

Agitation.................................................................................................................. 77

Sleep dysfunction ................................................................................................... 79

Disorders of affect, mood and anxiety .................................................................... 80

Neurocognitive impairments ................................................................................... 82

Medical contributors................................................................................................ 83

Summary.................................................................................................................... 84

 
1 

Contributors

Section I: Purpose of the Guide and Overview of Behavioral Health and TBI,

Judy Dettmer, BSW, Traumatic Brain Injury Technical Assistance and 

Resource Center (TBI TARC) and the National Association of State Head 

Injury Administrators (NASHIA)

Section II: Partners and Strategies, Thomasine Heitkamp, LCSW, Chester 

Fritz distinguished professor emeritus at the University of North Dakota 

Section III: Training Approaches, Maria Crowley, MA, CRC, TBI TARC and

NASHIA

Section IV: Screening for Lifetime History of TBI, John D. Corrigan, PhD; 

ABPP; professor, Department of Physical Medicine and Rehabilitation; and 

director, Ohio Valley Center for Brain Injury Prevention and Rehabilitation, the 

Ohio State University

Section V: Modifying Clinical Interventions for TBI, Theo Tsaousides, PhD, 

ABPP, clinical assistant professor, and Maria Kajankova, PhD, assistant 

professor, Department of Rehabilitation and Human Performance, Icahn 

School of Medicine at Mount Sinai

Section VI: Modifying Psychopharmacologic Interventions for TBI, Michael 

Chiou, MD, and Lindsey Gurin, MD, NYU Langone Health
1 

Section I: Purpose of the Guide and 

Overview of Behavioral Health and 

Traumatic Brain Injury

Judy Dettmer, BSW, Traumatic Brain Injury Technical Assistance and 

Resource Center (TBI TARC) and the National Association of State Head 

Injury Administrators (NASHIA) 

Background

The development of this resource is funded by the United States Department 

of Health and Human Services’ Administration for Community Living (ACL), 

contract number HHSP233201500119I, for TBI TARC in partnership with the 

Human Services Research Institute and NASHIA. 

Purpose

Brain injury was once referred to as the silent epidemic. There has been a 

significant increase in awareness of brain injury in recent years as a result of 

sports-related concussions and brain injuries incurred in combat in the Iraq 

and Afghanistan conflicts. Even with this increased awareness, there remains 

a significant gap in knowledge about brain injury, its implications for behavioral 

health conditions (e.g., mental illness and substance use disorders) and 

considerations for treatment.1 In addition, there are often state regulations in 

place that can inadvertently restrict access to state-funded behavioral health 

supports for individuals with brain injury. Given the significant prevalence of 

brain injury and co-occurring behavioral health conditions, there is a need for 

guidance to states about how to effectively support these individuals. 

State government-led brain injury programs are in a unique position to affect 

policy, increase training and implement practice changes within the state 

behavioral health system to ensure improved outcomes for this population. 

This guide will provide states with tools for initiating or improving their 

partnerships within state mental health systems. This guide provides: 

▪ An overview of the prevalence and systemic issues that add to the 

complexity of supporting individuals with brain injury and co-occurring 

behavioral health. 
2 

▪ A review of partners and strategies, including a review of the national 

landscape and state behavioral health structure. 

▪ Insight into training approaches that states might implement. 

▪ An overview of screening protocols and methods that behavioral health 

systems can implement. 

▪ Strategies for modifying clinical interventions. 

▪ Guidance for modifying pharmacological interventions that can be 

shared with behavioral health systems and prescribing psychiatrists. 

Audience 

The intended audience for this guide includes directors and staff of state 

government brain injury programs and personnel who serve as grantees for 

the Traumatic Brain Injury (TBI) State Partnership Program. The purpose of 

the TBI State Partnership Program is to create and strengthen personcentered, culturally competent systems of services and supports that 

maximize the independence and overall health and well-being of people with 

TBI across the lifespan and the people who support them.2 Many federal, state 

and local entities share the goals of the TBI State Partnership Program and 

have the capacity to serve as valuable partners. The ability to lead, engage 

and support effective partnerships and collaboration, including behavioral 

health treatment providers, is critical to the success of their effort. 

The intent is to provide them with tools to effect change within their state 

behavioral health systems and ultimately to improve outcomes for individuals 

with brain injury and co-occurring behavioral health conditions. 

Note on terminology

Federal and state systems often have separate funding streams for supporting 

those with mental illness versus those with substance use issues. For the 

purpose of this guide (aside from when it is important to distinguish between 

the two) the term “behavioral health” is used and is meant to be inclusive of 

both mental illness and substance use. 

Rationale for focus on behavioral health

The dictionary definition of behavioral health is: “The healthcare system that 

deals with the diagnosis and treatment of mental health, substance abuse, 

and associated physical disorders. It consists of the integrated delivery of care 

by psychiatrists, primary care physicians, social workers, and other healthcare 
3 

professionals.”3 This, as a result, involves serving people with TBI and 

underscores the need for state government brain injury programs to 

collaborate and partner with administrators and providers of behavioral health 

services. 

Overview of Behavioral Health and TBI

Each year in the United States, TBI results in approximately 2.8 million 

emergency department visits, hospitalizations or deaths.4 Potentially hundreds 

of thousands more individuals sustain TBIs each year but either do not seek 

medical care or are treated in physicians’ offices, urgent care clinics or federal, 

military or Veterans Affairs hospitals, and therefore are not included in data 

sets used to form these estimates.5 In addition, these data are specific to TBI

and do not include estimates of individuals who sustained brain injury as a 

result of a “nontraumatic” mechanism such as anoxia, stroke, aneurysm, etc. 

One-third of individuals with brain injury will experience mental health 

problems six months to one year post-injury.6 People with brain injury of any 

severity have two to four times the risk of attempting or having a death by 

suicide.7 Substance use is a risk factor for sustaining a brain injury. Between 

23% and 51% of adolescents and adults sustaining a TBI were intoxicated 

when the injury occurred,

8,9 and approximately one-quarter of people 

hospitalized for TBI have a history of substance use disorders.10,11

TBI has been demonstrated to be a risk factor for adverse life experiences. 

For example, 25% to 85% of incarcerated individuals report a history of TBI,

12

and a history of brain injury in this population significantly increases the risk of 

assault and violence and decreases the efficacy of treatment for a mental 

health problem.13 In addition, individuals who have experienced domestic 

abuse or assault are more likely to have sustained either a traumatic or 

nontraumatic brain injury, such as anoxia from strangulation.14 Also, people 

experiencing homelessness are more at risk for having a history of TBI before 

becoming homeless, and being homeless increases the risk of injury.15 

Systemic issues

While the need for behavioral health support for individuals with brain injury is 

evident, there are several factors that lead to systemic issues and barriers 

relating to individuals with brain injury accessing and being successful in 

regard to behavioral health treatment and support. As will be discussed in 

section IV, it begins with recognizing the brain injury. 
4 

1. Identifying the brain injury

TBI is often an undiagnosed or misdiagnosed co-occurring condition in 

behavioral health. Those who do report a history of brain injury will also have 

longer and more severe histories of substance use and more co-occurring 

behavioral health issues. For this reason, as many as 75% of the people 

seeking services for concurrent mental health and substance use disorders 

are living with the effects of brain injury.16 Because brain injury is often an 

invisible disability, it is easy to miss and to misunderstand. People with TBI 

seeking services for behavioral health conditions may experience subtle but 

significant changes in memory, attention, problem-solving, sensation, social 

behavior and self-regulation, making it difficult to remember appointments, 

understand expectations, follow through with tasks and participate in group 

settings. Trouble with recognizing social cues and observing social norms may 

make it difficult for the person with TBI to fit into and benefit from some types 

of support. As a result, they often leave treatment prematurely because they 

cannot keep up or become discouraged. It is easy to imagine how frustrating 

this can be for both the client and their care providers. Having the right tools to 

recognize and manage the impact of brain injury can make a big difference in 

outcomes for a significant number of people served in programs addressing 

substance use disorders.17

Section IV will provide recommendations for screening for brain injury within a 

behavioral health setting and strategies for gaining buy-in from the behavioral 

health setting to develop and implement a screening protocol. 

2. Medical paradigm

Brain injury has been trapped in a medical paradigm, which makes sense, 

especially as an individual navigates medical, rehabilitation and post-acute 

rehabilitation following injury. However, as a person navigates the long-term

and chronic consequences and continues to live the rest of their life with brain 

injury, this paradigm needs to shift to a community and behavioral health 

paradigm. Unfortunately, decades of viewing brain injury as a medical 

condition have led to two outcomes that leave states with a battle in terms of 

engaging their state behavioral health systems. First, behavioral health 

providers often feel they are not trained or equipped to treat brain injury 

because they view it as a medical condition. Second, funding streams 

associated with behavioral health are often not inclusive of brain injury, and 

therefore these systems are reluctant to treat brain injury. In fact, there may be 

policies in place that restrict access to behavioral health services for 

individuals with co-occurring brain injury. Because of this, it is critical that state 
5 

brain injury programs focus on demystifying brain injury for behavioral health 

professionals. With this goal in mind, a key message is to assure those in the 

behavioral health system that they are not being asked to treat the brain injury. 

They are being asked to treat the behavioral health condition within the 

context of the person’s brain injury, shifting the thinking about treatment to 

compensating for the effects of brain injury to improve behavioral health 

outcomes. 

Two steps are needed by state brain injury programs to effect change in the 

behavioral health system: 

▪ Step 1 is to review the system’s policies to ensure the language is not 

exclusive of supporting individuals with brain injury. For example, prior 

to a full review of the Colorado practice standards used to guide 

eligibility for Medicaid-funded behavioral health services, countless 

individuals with brain injury were being turned away from services. The 

standards were written in a way that led to clinicians not serving

individuals with co-occurring brain injury and behavioral health

conditions. This was due to confusion: they could not provide treatment 

for brain injury since it is not a covered health diagnosis. After careful 

review, the language was changed to be made clear that they are not 

treating the brain injury, but they are obligated to treat individuals with 

brain injury that have a covered behavioral health diagnosis.

▪ Step 2 is to develop and implement training protocols for the behavioral 

health workforce in each state, which addresses the third systemic 

issue identified.

3. Lack of training for the behavioral health workforce

Section III will provide recommendations and strategies for approaching 

training for the behavioral health workforce. There has historically been a lack 

of training on brain injury for all personnel associated with behavioral health, 

including front office and intake staff, frontline staff, clinicians and 

psychiatrists. Largely, this stems from a lack of recognition of the need for 

training. Once the need is recognized, the next obstacle is that behavioral 

health staff feel like brain injury is a medical condition and therefore out of their 

scope of practice. However, as indicated previously, brain injury can shift from 

a medical event into a community and behavioral health condition. State brain 

injury programs can be instrumental in demystifying brain injury. The key 

message for the behavioral health professionals is for them to understand that 

they are not being asked to treat the brain injury. Rather, it is suggested that 
6 

they treat the behavioral health condition in the context of the person’s brain 

injury. Behavioral health professionals are trained to treat just that, behavioral 

health conditions. In spite of the significant prevalence of co-occurring TBI and 

behavioral health, behavioral health professionals are not trained on brain 

injury. In addition, brain injury is often not a focus of preservice training.

With effective policy, screening and workforce development and training in 

place, state brain injury programs can effectively partner with their behavioral 

health systems to improve outcomes for individuals with co-occurring brain 

injury and behavioral health conditions. This guide will provide states with the 

tools they need to accomplish this goal.

1 Corrigan, J. D. (2019, August). Traumatic brain injury and behavioral health 

treatment. National Association of State Mental Health Program 

Directors. 

https://www.nasmhpd.org/sites/default/files/TAC_Paper_6_508C_1.pdf

2 Traumatic Brain Injury State Partnership Program, HHS-2022-ACL-AODTBSG-0047. 

3 Houghton Mifflin Harcourt Publishing Company. (2016.) Behavioral health. In 

American Heritage® Dictionary of the English Language. 

https://www.thefreedictionary.com/behavioral+health

4 Taylor, C. A., Bell, J. M., Breiding, M.J., & Xu, L. (2017). Traumatic brain 

injury-related emergency department visits, hospitalizations, and deaths 

— United States, 2007 and 2013. MMWR Surveil Summ., 66(9): 1–16.

5 National Center for Injury Prevention and Control. (2010). Traumatic brain 

injury in the United States: Emergency department visits, 

hospitalizations, and deaths, 2002–2006. U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention.

6 Fazel, S., Wolf, A., Pillas, D., Lichtenstein, P., & Långström, N. (2014). 

Suicide, fatal injuries, and other causes of premature mortality in 

patients with traumatic brain injury. JAMA Psychiatry, 71(3), 326. 

https://doi.org/10.1001/jamapsychiatry.2013.3935

7 Dreer, L. E., Tang, X., Nakase-Richardson, R., Pugh, M. J., Cox, M. K., 

Bailey, E. K., Finn, J. A., Zafonte, R., & Brenner, L. A. (2018). Suicide 

and traumatic brain injury: A review by clinical researchers from the 
7 

National Institute for Disability and Independent Living Rehabilitation 

Research (NIDILRR) and Veterans Health Administration Traumatic 

Brain Injury Model Systems. Current Opinion in Psychology, 22, 73–78. 

https://doi.org/10.1016/j.copsyc.2017.08.030

8 Lemsky, C. (2021). Traumatic brain injury and substance use disorders: 

Making the connections (P. Stilen & T. Heitkamp, Eds.). SAMHSA 

Mountain Plains ATTC (HHS Region 8). 

https://www.samhsattcs.org/sites/default/files/2021-11/TBI-SUD-Toolkit11.01.2021-FINAL%20%281%29.pdf

9 Cuthbert, J. P., Harrison-Felix, C., Corrigan, J. D., Kreider, S., Bell, J. M., 

Coronado, V. G., & Whiteneck, G. G. (2015). Epidemiology of adults 

receiving acute inpatient rehabilitation for a primary diagnosis of 

traumatic brain injury in the United States. The Journal of Head Trauma 

Rehabilitation, 30(2), 122–135. 

https://doi.org/10.1097/HTR.0000000000000012

10 Parry-Jones, B. L., Vaughan, F. L., & Miles Cox, W. (2006). Traumatic 

brain injury and substance misuse: A systematic review of prevalence 

and outcomes research (1994–2004). Neuropsychological 

Rehabilitation, 16(5), 537–560. 

https://doi.org/10.1080/09602010500231875

11 Corrigan, J. D., Bogner, J., & Holloman, C. (2012). Lifetime history of 

traumatic brain injury among persons with substance use disorders. 

Brain Injury, 26(2), 139–150.

https://doi.org/10.3109/02699052.2011.648705

12 Farrer, T. J., & Hedges, D. W. (2011). Prevalence of traumatic brain injury 

in incarcerated groups compared to the general population: A metaanalysis. Progress in Neuro-Psychopharmacology & Biological 

Psychiatry, 35(2), 390–394. 

https://doi.org/10.1016/j.pnpbp.2011.01.007

13 Lemsky, C. (2021). Traumatic brain injury and substance use disorders: 

Making the connections (P. Stilen & T. Heitkamp, Eds.). SAMHSA 

Mountain Plains ATTC (HHS Region 8). 

https://www.samhsattcs.org/sites/default/files/2021-11/TBI-SUD-Toolkit11.01.2021-FINAL%20%281%29.pdf
8 

14 St. Ivany, A., & Schminkey, D. (2016). Intimate partner violence and 

traumatic brain injury: State of the science and next steps. Family & 

Community Health, 39(2), 129–137. 

https://doi.org/10.1097/FCH.0000000000000094

15 Hwang, S., Colantonio, A., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., 

Redelmeier, D., & Levinson, W. (2008). The effect of traumatic brain 

injury on the health of homeless people. Canadian Medical Association, 

179(8), 779–784. https://www.cmaj.ca/content/cmaj/179/8/779.full.pdf

16 McHugo, G. J., Krassenbaum, S., Donley, S., Corrigan, J. D., Bogner, J., & 

Drake, R. E. (2017). The prevalence of traumatic brain injury among 

people with co-occurring mental health and substance use disorders. 

The Journal of Head Trauma Rehabilitation, 32(3), E65–E74. 

https://doi.org/10.1097/htr.0000000000000249

17 Lemsky, C. (2021). Traumatic brain injury and substance use disorders: 

Making the connections (P. Stilen & T. Heitkamp, Eds.). SAMHSA 

Mountain Plains ATTC (HHS Region 8). 

https://www.samhsattcs.org/sites/default/files/2021-11/TBI-SUD-Toolkit11.01.2021-FINAL%20%281%29.pdf
9 

Section II: Partners and Strategies

Thomasine Heitkamp, LCSW, Chester Fritz distinguished professor 

emeritus at the University of North Dakota

To effect change and develop infrastructure that effectively supports 

individuals with brain injury and co-occurring behavioral health issues, it is 

important to first understand the behavioral health landscape. This includes 

both national organizations and state behavioral health structures. It is equally 

important to understand best practices related to partnership development. 

The only way to successfully effect change across systems is to ensure that 

the proposed strategies are in line with the system’s mission and are feasible 

to implement. This section will provide an overview of key national 

organizations and a description of the structure of state behavioral health 

systems. Finally, this section provides best practices for developing effective 

partnerships.

Partners

Nationally, there are a few key organizations that provide guidance and 

resources aimed at helping states improve the lives of individuals with 

behavioral health conditions. Some of these organizations also have funding 

that states might consider applying for to assist with system change and 

partnership development efforts. 

Note: At both the federal and state levels, funding streams often separate 

mental health from substance use and addiction. Many national organizations 

focus on one or the other, and grant and funding opportunities are often 

separated. It is important to understand how your state is organized. This will 

be covered later in this section. 

A good place to start is the National Association of State Mental Health 

Program Directors (NASMHPD). NASMHPD is identified as “home to the only 

member organization representing state executives responsible for the public 

mental health service delivery system, serving millions of people annually in all 

50 states, 6 territories and pacific jurisdictions, and the District of Columbia.”1

NASMHPD provides resources that assist treatment providers in engaging in 

best practices. NASHIA has a long-standing partnership with NASMHPD, and 

they work collaboratively to ensure that NASMHPD’s membership is aware of 

brain injury and the significant prevalence of co-occurring behavioral health 

issues. This helps to ensure that each state director of behavioral health has 
10

brain injury on their radar. For example, in a 2018 publication entitled 

Traumatic Brain Injury and Behavioral Health Treatment, NASMHPD provides 

recommendations for behavioral health professionals to advance the needs of 

persons with TBI. Recommendations include the following: 1) behavioral 

health professionals should screen for lifetime exposure to TBI; 2) treatment 

must accommodate neurobehavioral deficits due to TBI; 3) treatment must be 

holistic to address comorbid conditions; and 4) improvement gained by insight 

must be supplanted by other therapeutic supports. 

The National Association of State Alcohol and Drug Abuse Directors

(NASADAD) is a good place to start because it pertains to substance use and 

addictions. NASADAD’s basic purpose is “to foster and support the 

development of effective alcohol and other drug abuse prevention and 

treatment programs throughout every State.”2

The Substance Abuse and Mental Health Services Administration’s

(SAMHSA’s) mission is “to reduce the impact of substance abuse and mental 

illness on America’s communities” and ensure they are critical stakeholders in 

the network of providers of services to people with a TBI.3 Notably, SAMHSA’s 

updated August 2021 publication,4 which provides information specific to a 

behavioral health provider’s response to understanding and addressing the 

needs of persons with a TBI, works toward this mission. An additional product 

developed by SAMHSA grantees in partnership with NASHIA is the Traumatic 

Brain Injury and Substance Use Disorder: Making the Connection toolkit, 

published in November 2021.5 SAMHSA also provides funding to states in the 

form of block grants. Brain injury program directors can benefit from 

understanding what funding is available and if there are ways that brain injury 

can be included in their priorities through the state behavioral health 

organization. 

There are several other organizations that may assist in your systems change 

and partnership efforts, far too many to list. Here are a few key organizations 

to consider: 

National Alliance on Mental Illness (NAMI) “is the nation’s largest grassroots 

mental health organization dedicated to building better lives for the millions of 

Americans affected by mental illness” in the U.S.6 Their collaboration with TBI 

State Partnership Program personnel involves support during March for brain 

injury awareness month and related state activities. NAMI offers easily 

accessible and updated state fact sheets with critical information on a host of 

mental health topics to educate the public about needs: Fact Sheet Library | 
11

NAMI: National Alliance on Mental Illness. This organization exists in all states 

and serves in an advocacy and educational role.

Mental Health America (MHA) is a large, community-based mental health 

organization with numerous locations in cities and towns across America. 

MHA also provides online information and support for mental health. MHA 

provides, among other things, mental health screenings, education about 

mental health and living well, nationwide advocacy and peer support 

programs. 

National Institute on Drug Abuse (NIDA) is housed under the umbrella of the 

National Institutes of Health. NIDA publishes factual and reliable information 

about commonly abused drugs and offers information on effects of drugs on 

adult and adolescent brains. 

Understanding the national landscape can be helpful in terms of gaining 

information and exploring potential funding. To effect change at the state level, 

the state office of behavioral health will be a critical partner. NASMHPD 

provides a directory of state behavioral health organizations that can be found 

at https://www.nasmhpd.org/content/mental-health-links. There is additional 

information on national associations and resources on this website as well. 

NRI, “ the only national organization working with state agencies, the Federal 

Government, and other entities to define, collect, and analyze data on public 

behavioral health systems,” assembled state profiles in the report “State 

Mental Health Agency Organization.”7 This document provides an overview of 

how these agencies are organized, what their responsibilities are and how 

each state is organized. The document can be found at https://www.nriinc.org/media/na0heuv3/nri_2020_profiles_smha_organization_and_structure

_in_state_government-_november_2021.pdf. 

Since each state can be organized differently, it can be helpful to reach out to 

the SAMHSA regional administrator in your area. These administrators are 

knowledgeable about how your state is organized, what initiatives are 

occurring and who to contact to initiate a partnership within your state mental 

health system. To find out more about regional administrators and to obtain 

contact information, visit this link: https://www.samhsa.gov/about-us/who-weare/regional-offices. 

1. Definition and background of partnerships

A working definition of partnerships is: “a collaborative relationship between 

entities to work toward shared objectives through a mutually agreed division of 
12

labor.”8 A myriad of advantages to partnerships exists, including enhancing 

the capacity to better serve clients and the community, sharing best practices, 

collaborating on cross-referrals and increasing knowledge-based resources 

that improve effectiveness. Further, effective partnerships can improve 

organizational capacity, engage new audiences and build organizational 

networks. Noteworthy, however, are the challenges and pitfalls of partnerships 

and the necessity to engage in partnerships effectively.9 The inclusion of 

partnership development as part of this guide is a necessary component to 

ensure successful and lasting systems change. 

2. Partnerships

Effective partnerships occur in a collaborative environment, ensure access to 

information, incentivize workforce productivity, encourage the use of data for 

decision-making, ensure effective communications and are proactive in their 

ability to respond to needs.

10 Nine recommendations for effective partnerships

are provided below, based on information from the authors, which includes the 

following sources: review of the literature,11,12 review of sample TBI partner 

web pages and notice of award information by ACL, review of two sample job 

descriptions for grantees and the authors’ ongoing professional partnerships. 
13

Nine Principles and Strategies

1. Shared vision

A shared vision ensures a culture of people working together with an 

appropriate division of labor based on strengths to ensure success. Ensure the 

process is collaborative and sustainable.13 

Strategy

• Assess the vision of a potential partner agency by conducting a 

comprehensive review of content on their website and social media. 

• Determine capacity to respond to emerging and ongoing needs. A 

document that analyzes key words in the mission, vision and goal 

statements of partners is a critical resource in understanding capacity. 

• Acknowledge perceptions that competition exists in vision and service 

delivery systems and adjust accordingly. 

• If the vision of the partner agency is tangential to the focus of the 

partnership effort or merely for the convenience of securing and 

maintaining grant-funded dollars, little advantage exists in that

partnership. Of note is a focus on consumer-driven partnership that 

assists in addressing needs and commitment among federal funding 

agencies.
14

2. Mutual trust and respect

Mutual trust and respect are the glue that binds the relationship. This step 

requires a laser focus on relationship building with partners through social 

connections and advancing leadership skills, which must include honoring 

your commitment relative to deliverables. 

Strategy

• Acknowledge the success of your partner members both publicly and 

privately and provide rewards for expertise. Encourage partners to 

publicize their successes far and wide. 

• Model respect in meetings by focusing on successes and solutionfocused strategies and engaging the expertise of partners. This 

includes transparent access to information such as helpful web pages 

and public documents. Specifically, follow up after meetings with 

effective notes and tasks. Send gentle reminders if tasks are not 

completed. 

• Acknowledge the work and expertise of your partners in public formats, 

including meetings. To the degree possible, reward advisory board 

members for their expertise with stipends and per diem for travel. 
15

3. Shared purpose based on identified needs

The purpose of the partnerships must be defined and based on serving the 

holistic needs of persons with TBI across their lifespans so they can live as 

productively as possible.

Strategy

• Determine the most effective motivation for engaging in the partnership 

with providers of behavioral health services. Assess the current level of 

service integration that exists, including sharing assessment efforts with 

partner agencies to eliminate the perception that the “wheel is being 

reinvented” needlessly. This provides an opportunity to acknowledge 

the work of partner agencies and their voices in your documents and 

dissemination. A sample model is provided.

14

• Customize your efforts based on the needs of your partnerships with 

the political realities of your organizational structures. Grantee 

employees are assigned to a host of agencies within their state 

structures,15 and this structure can both enhance and limit capacity for 

partnerships. 

• The same principles that apply to strengthen person-centered systems 

of care also apply to engaging in strength-centered partnerships. If the 

purpose of the partnerships is merely a response to a government 

mandate that requires a partnership and the commitment does not 

exist, it has little opportunity for success. Failure in partnership 

development often stems from the tendency for people to be siloed in 

their expertise. Engagement in behavioral health is a two-way street, 

with grantees working to address people with TBI, and vice versa. 
16

4. Transparent communication

The role of the state government’s lead agency on brain injury varies across 

states. However, at the core, these agencies are charged with developing 

infrastructures, programs and policies to improve access to services, supports 

and outcomes for individuals with brain injury. These roles require transparent 

communication and a focus on sharing information about the benefit of the 

partnership. The process and content with which staff and administrators 

communicate, both internally and externally, define the organization. Problems 

or perceived problems with communications are a source of frequent 

consternation in organizations. 

Strategy

• Provide professional, predictable and reliable communication to 

partners. Most importantly, be respectful of staff within each partner 

organization, even if their approach does not always align with yours. 

• Avoid the use of acronyms with partners that do not work in your field 

daily. Do not assume common language exists because, as stated 

earlier, people become siloed in their professional fields. The use of 

non-stigmatizing and person-first language is critical in all written and 

oral communications. Samples of resources that underscore 

appropriate language are available from a host of sources. See the 

following examples from partner behavioral health agencies and the TBI 

network: 

1. The Centers for Disease Control and Prevention (CDC) host a 

national web page with critical information about TBI, including data,

publications and reports, pediatric guidelines and health-provider 

resources to share with partners.16 

2. SAMHSA provides information and links to documents underscoring

the use of language to address the stigma of substance use disorders 

and focus on advancing treatment and recovery.17 
17

 

 

NAMI provides a guide to using non-stigmatizing language to discuss

mental illness.18

3.

Dissemination of resources by partner behavioral health agencies supports 

and advances partnership arrangements. 

5. Flexibility in partnership procedures and 

structures 

Adjusting to the realities of the environment of your partner agencies requires 

flexibility. 

Strategy

• A one-size-fits-all approach will not be effective and does not allow 

partners to honor the various strengths of the partner agency, so 

flexibility is necessary.

• The size of the agency will depend upon its resources and capacity to 

share effort. Turnover in personnel impacts capacity. Being mindful of 

the cost of partnerships, including time for personnel in training and 

collaborative work, travel costs, etc., is critical and identified throughout 

the literature.
18

6. Anticipate challenges 

The work of improving the lives of people with TBI is complicated and requires 

a myriad of complex systems to work collaboratively to address the holistic 

needs of clients. 

Strategy

• A strengths-based approach that focuses on the assets of the 

organization is advised.19

•

•

Recognize that resolving challenges for a person with TBI in a complex 

clinical-delivery system is difficult but critical work. Technical assistance 

that provides a helpful response based on the complexities of the 

system and identified needs is paramount. It is not helpful, for example, 

to develop strategies that are only applicable in urban areas for 

providers in rural communities, or supports that are not culturally 

responsive. 

Engage in partnerships with an understanding and knowledge about 

multiple diagnoses and co-occurring behavioral health and TBI 

disorders.
19

7. Adherence to a code of conduct

Adhering to ethical guidelines of professional practice, which are often guided 

by professional licensing boards and the partner’s professional code of 

conduct, can strengthen partnerships.

20 

Strategy

• Understand partner members’ background and professional licensure to 

ensure the use of their expertise and background, especially in 

assignments to work groups. Ensure appropriate acknowledgment of 

professional credentials and maintain an updated list of partner 

agencies. Again, acknowledge contributions of all who contributed.

• Ensure a clear understanding of the expectations surrounding 

behaviors. Consider the development of a partnership memorandum of 

understanding (MOU) to minimize ambiguity about roles and functions.

Behaviors should focus on expectations and positive outcomes. The 

MOU can be reevaluated as needed, in the spirit of flexibility. The 

benefits must be mutual, with a focus on advancing strong outcomes for 

people with TBI.
20

8. Use of collaborative technology

Use technology effectively to advance the logistical needs of your partners. 

The goal is for partner agencies to view you as a resource for strengthening

their work, and in turn, they will assist you to strengthen your efforts. Find out 

what technology your partner uses and work with it — for example, learn the 

particular program a state mental health system uses for data collection work.

Strategy

• Ensure access to appropriate software for cross-functional collaboration 

and partnerships, including knowledge-management systems. Again, if 

you host a web page, ensure that information is current and accessible. 

A host of program management software exists. The best software is a 

product that people will find valuable and use — see what your partner 

agencies are using to manage their efforts. Understand that some 

entities do not have a choice in the software they use. 

• Adapt technology to expand training and technical assistance that 

advance research-based practices and ensure that information is 

approachable. Forwarding a host of links from web pages without an 

explanation of their value is not helpful. 

• New products should be included on communications and web pages 

as resources. Maintain a spreadsheet of products being shared by 

partner organizations and disseminated in your national and state 

network. Use the federally funded training and technical assistance 

centers to market and share products effectively. 
21

9. Culturally responsive practices

Promote partnership models that ensure culturally and linguistically competent 

care. Partnerships with entities that serve culturally diverse populations are 

essential. Understand the limitations of evidence-based practices on partner 

agencies, including the limitations of evidence-based practices in the 

engagement of racially and ethnically diverse populations. It is critical to

expand the capacity to implement existing culturally appropriate 

interventions.21 The voices of people who represent underserved populations 

are crucial elements in your assessment, planning and intervention. 

Strategy

• Have individuals from specific racial and ethnic groups adapt existing 

EBPs or develop their own interventions based on community-defined 

evidence. 

• Ensure the inclusion of racially and ethnically diverse individuals in 

outcome studies and build the capacity of the behavioral health 

workforce to implement existing culturally appropriate interventions. 

Summary 

In summary, the first step toward effecting change is understanding the 

system you hope to affect. Many ingredients go into creating effective 

partnerships, and the nine outlined above are a sample based on the literature 

and the authors’ experiences. Partnerships require time and due diligence in 

maintaining and supporting relationships. It is critical to praise 

accomplishments publicly and address concerns privately and maintain a 

focus on the objectives and the needs of the population you serve. When 

services are not effective, people suffer needlessly. Do not grandstand with 

partners, do your share of the work, be honest and communicate 

professionally. 
22

1 NASMHPD. (2022). https://www.nasmhpd.org/

2 NASADAD. (n.d.). About us. https://nasadad.org/about-us/

3 SAMHSA. (2022, April 6). About us. https://www.samhsa.gov/about-us

4 SAMHSA. (2021). Treating patients with traumatic brain injury. SAMHSA 

Advisory. 

5 Lemsky, C. (2021). Traumatic brain injury and substance use disorders: 

Making the connections (P. Stilen & T. Heitkamp, Eds.). SAMHSA 

Mountain Plains ATTC (HHS Region 8). 

https://www.samhsattcs.org/sites/default/files/2021-11/TBI-SUD-Toolkit11.01.2021-FINAL%20%281%29.pdf

6 NAMI. (2022.) https://www.nami.org/Home

7 NRI. (n.d.). History of NRI. https://www.nri-inc.org/about-nri/history-of-nri/

8 Donors Forum. (2010). Fair and accountable: Partnership principles for a 

sustainable human services system. 

https://www.wallacefoundation.org/knowledgecenter/Documents/Partnership-Principles-for-a-Sustainable-HumanServices-System.pdf

9 Wake Forest University. (n.d.). The power to transform: Leadership in 

human services organizations. Counseling Blog. 

https://counseling.online.wfu.edu/blog/the-power-to-transformleadership-in-human-services-organizations/

10 Donors Forum. (2010). Fair and accountable: Partnership principles for a 

sustainable human services system. 

https://www.wallacefoundation.org/knowledgecenter/Documents/Partnership-Principles-for-a-Sustainable-HumanServices-System.pdf

11 Centers for Disease Control (CDC). (2013, March). The value of community 

partnerships. https://www.cdc.gov/workplacehealthpromotion/toolsresources/pdfs/issue-brief-no-3-community-partnerships-03062013.pdf

12 Henderson, J., Avagyan, K., Dhanaraj, C., & Perrinjaquet, M. (2014). 

Insights@IMD: Strategic partnerships. International Institute for 
23

Management Development (IMD). 

https://www.imd.org/contentassets/8d81e92f7a5d4931805a0466143ea

8c6/36---strategic-partnerships-final-20.05.14.pdf

13 Evanson, T. A. (n.d.). SUD collaborations that work: Findings from 

providers in region 8. Mountain Plains ATTC (HHS Region 8). Retrieved 

March 10, 2022, from https://attcnetwork.org/sites/default/files/2020-

07/SUD-Service-Report.pdf

14 Roget, N., & Heitkamp, T. (2020). Mountain Plains ATTC advisory board 

discussion: SUD leaders discuss Covid-19 public health emergency - 

September 2020. Mountain Plains ATTC (HHS Region 8). 

https://attcnetwork.org/centers/mountain-plains-attc/advisory-board

15 https://www.nashia.org/state-program-directory 

16 CDC. (2022, March 21). Traumatic brain injury & concussion. 

https://www.cdc.gov/traumaticbraininjury/index.html

17 Massachusetts General Hospital, Recovery Research Institute. (n.d.). The 

power of perceptions and understanding: Changing how we deliver 

treatment & recovery services [Resource guide]. U.S. Department of 

Health and Human Services, Substance Abuse and Mental Health 

Administration. 

https://www.samhsa.gov/sites/default/files/programs_campaigns/02._w

ebcast_1_resources-508.pdf

18 Greenstein, L. (2017, May 1). How you can stop mental illness stigma. 

NAMI: National Alliance on Mental Illness. 

https://www.nami.org/Blogs/NAMI-Blog/May-2017/How-You-Can-StopMental-Illness-Stigma

19 Children’s Bureau. (2008). A closer look: An individualized, strengthsbased approach in public child welfare driven systems of care. U.S. 

Department of Health and Human Services, Administration for Children 

& Families. https://www.childwelfare.gov/pubPDFs/strengthsbased.pdf

20 Bretton Woods Project. (2000, June). Partnerships for development: A new 

World Bank approach. 

https://www.brettonwoodsproject.org/2000/06/art-16310/
24

21 SAMHSA. (2021). Evidence-based and culturally relevant behavioral health 

interventions in practice: Strategies and lessons learned from 

NNEDLearn (2011–2020). NNEDLearn Implementation Analysis. 

https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/

PEP21-05-02-001.pdf
25

Section III: Training Approaches

Maria Crowley, MA, CRC, TBI TARC and NASHIA

Why Is Training Important?

Training is a necessary component to ensuring that behavioral health 

providers at all levels of service are equipped for working with individuals with 

TBI. Everyone within a state mental health system and related community 

providers needs information about brain injury basics in order to best work with 

individuals with TBI. However, everyone within a system does not have to be 

an expert in TBI. For example, physicians and nurses might find it useful to 

have training on current medication recommendations, while psychiatrists, 

psychologists and other counseling staff are concerned with various 

therapeutic interventions and their efficacy. Staff across the system need to 

know what to do for crisis intervention, harm reduction and overall safety.

Many behavioral health professionals will need some level of training to better 

understand brain injury and best practices regarding treatment interventions. 

The goal is to equip providers with necessary knowledge to identify TBI and 

interventions that work best in their particular setting and where to find TBI 

resources in their community for additional expertise.

It is equally important for behavioral health providers to know that they may 

already be working with individuals with TBI but are unaware of it. This 

includes those individuals who:

▪ Do not yet know they have a TBI. 

▪ Do know but are unaware of the extent of the challenges they are 

experiencing related to TBI, how it interacts with their behavior or even 

how to disclose it. 

▪ Do know but have not disclosed it due to concerns about becoming 

ineligible for services. 

Knowing that individuals seeking services have a TBI and how best to provide 

services and how to modify existing modalities will result in better outcomes 

for individuals with TBI (see Section V: Modifying Clinical Interventions for 

TBI). 

The provision of training is often a start to establishing a good partnership with 

a state mental health system. Training can increase awareness of issues and 
26

highlight needs for additional support. Instead of presenting challenges to a 

new mental health partner or provider, training can be a way for a state TBI 

program to open the door, introducing related issues and revealing the 

importance of collaboration and additional specialized resources. Many state 

TBI programs already provide general training to community partners. One 

option is to incorporate practices related to behavioral health into existing 

training on TBI. If possible, imbed TBI training into existing mental health

system training for new staff, as state TBI programs currently do for new TBI 

staff and providers. Approaches could include:

▪ In-person training with TBI staff trainers or subject-matter experts. 

▪ Archived virtual training through a link with TBI staff trainers or subjectmatter experts. 

▪ Core competencies for new staff — these competencies may already 

exist within your system or have been drafted by other state TBI 

programs. One example is the Opioids and Mental Health 

Competencies, created by several ACL TBI State Partnership Grant 

Program grantees. 

▪ Continuing education for existing staff — as new practices or trends 

develop, continuing education can be provided to staff that have 

already been trained in basic approaches by your system. 

Staff turnover is a significant factor in many systems, and behavioral health is 

no different. Providing information that can be accessed later is an effective 

alternative to repeating in-person education. Also, it is important to note that it 

is more effective when providing training to master’s- or doctorate-level staff to 

utilize similar practitioners for training. Clinicians want to learn from peers.

Lastly, just as interventions vary based on age, keep in mind that training will 

vary as well, based on whether information encompasses children and youth 

or adult populations. 

Which Training Components Should Be 

Included?

It might be useful to think of training components in tiers, starting with the most 

basic information and working toward more complex challenges. Each tier 

leads to the next. Basic training applies to all behavioral health staff and can 

be repeated as needed. Intermediate training applies to providers in direct 
27

contact with individuals receiving services. Trainers for both basic and 

intermediate levels should be staff and providers who are well-practiced in 

brain injury causes, sequelae and community resources. Advanced training 

applies only to the clinical staff engaged in therapeutic interventions, and 

trainers should be clinicians who are well-practiced in therapeutic 

interventions.

Basic

Basic training prepares providers to have an overall awareness and 

knowledge of how TBI impacts children, youth and adults, and it supplies basic 

supports and strategies to providers through tutorials, either in-person or 

virtual. Some topics covered in basic training include:

▪ Definitions of brain injury. 

▪ Mechanisms of brain injury. 

▪ Severity of brain injury. 

▪ Prevalence of brain injury. 

▪ Prevalence of brain injury and co-occurring behavioral health issues, 

including mental health, suicide risk and prevention, and opioid and 

substance use disorders. 

▪ Brain development. 

▪ Associated challenges of brain injury. 

▪ Simple compensatory strategies and accommodations. 

▪ Community TBI resources and links. 

▪ National TBI resources and links. 

Intermediate

Intermediate training prepares providers with additional knowledge of 

screening methods and treatment strategies for children, youth and adults 

through tutorial and interactive sessions, either in-person or virtual. Some 

topics covered in intermediate training include:

▪ Screening-tools needs, overview and practice. 
28

▪ Identification of challenges and application of compensatory-strategies

case studies and practice. 

▪ Introduction to effective intervention modalities. 

▪ Detailed review of TBI community-based resources and information. 

▪ Referral protocols to community TBI providers. 

▪ Systemic safety strategies. 

Advanced

Advanced training prepares clinical providers with tools for treatment within 

existing mental health settings by clinical subject-matter experts who are well

versed in TBI and mental health challenges for children, youth and adults

through in-person tutorials and interactive sessions. Some topics covered in 

advanced training include:

▪ In-depth review of behavioral and addiction treatment approaches and 

intervention. 

▪ Medication management and review. 

▪ Treatment modeling, supervision and shadowing. 

▪ Systemic crisis intervention and harm reduction strategies. 

Where Can I Find Existing Materials 

and Resources?

There are several state TBI programs currently providing training to state 

mental health systems. It is important, however, to customize data and 

resources for your own state when providing training. Some national and state 

resources that will be useful are listed here:

▪ Substance Use/Brain Injury Bridging Project. (2021). Client workbook: 

Substance use and brain injury (2nd ed.)

https://static1.squarespace.com/static/5eb2bae2bb8af12ca7ab9f12/t/61

c216a89268ca613d4bd917/1640109740567/SUBI+2+FINAL+508+acce

ssible+12_16_21.pdf.
29

▪ Lemsky, C. (2021, November). Traumatic brain injury and substance 

use disorders: Making the connections (P. Stilen & T. Heitkamp, Eds.). 

SAMHSA Mountain Plains ATTC (HHS Region 8).

https://static1.squarespace.com/static/5eb2bae2bb8af12ca7ab9f12/t/61

9c0a83e44ee504cef1ff47/1637616273263/TBI++SUD+Toolkit+FINAL+

11.05.2021.pdf.

▪ SAMHSA. (2021). Treating patients with traumatic brain injury. 

SAMHSA Advisory.

https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/

PEP21-05-03-001.pdf.

▪ Corrigan, J. (2019, August). Traumatic brain injury and behavioral 

health treatment. NASMHPD. 

https://static1.squarespace.com/static/5eb2bae2bb8af12ca7ab9f12/t/5f

c6a8ccf3de5e49b551047c/1606854863809/TBI+and+BH+TX+Dr+Corri

gan+NASMHPD.pdf

▪ Institute for Behavioral Health, The Heller School for Social Policy and 

Management, Brandeis University. (2022). INROADS.

https://heller.brandeis.edu/ibh/projects/inroads/.

▪ TBI Model Systems. (2011). Emotional problems after traumatic brain 

injury. Model Systems Knowledge Translation Center. 

https://msktc.org/sites/default/files/TBI_Emotional%20Problems%20and

%20TBI.pdf.

▪ The Traumatic Brain Injury Model System Program. (2011, January).

Alcohol use after traumatic brain injury. Model Systems Knowledge 

Translation Center. https://msktc.org/sites/default/files/MSKTC-TBIAlcohol-Use-508_0.pdf.

▪ American Congress of Rehabilitation Medicine. (2021, December 15). 

Mental health pocket card for management of patients with 

posttraumatic stress disorder and mild traumatic brain injury. Archives 

of Physical Medicine and Rehabilitation, 103(3), 611–615. 

https://doi.org/10.1016/j.apmr.2021.10.013 

▪ Alabama TBI.org. (n.d.). Traumatic brain injury: The silent epidemic & 

behavioral health. ADRS Traumatic Brain Injury Program. 

http://www.alabamatbi.org/mental-health.html.
30

▪ Ohio Valley Center for Brain Injury Prevention and Rehabilitation. 

(2013). Accommodating the symptoms of TBI.

https://wexnermedical.osu.edu/-/media/files/wexnermedical/patientcare/healthcare-services/neurological-institute/departments-andcenters/research-centers/ohio-valley/for-professionals/accommodatingsymptoms/accommodating-tbi-booklet-1-

14.pdf?la=en&hash=175F7559BA27362695DDBC8121A89C85F794F4

D0

▪ NSW Agency for Clinical Innovation. (n.d.). Working with people with 

traumatic brain injury. 

http://www.tbistafftraining.info/SelfStudy/Module_10/10.4.htm 

▪ Mountain Plains Mental Health Technology Transfer Center Network. 

(2020, August 4). Traumatic brain injury and mental health: Intensive 

workshops. https://mhttcnetwork.org/centers/mountain-plainsmhttc/product/traumatic-brain-injury-and-mental-health-intensiveworkshops.

▪ Improving MI Practices. (2022). Behavioral health professionals and 

BDI. https://www.improvingmipractices.org/focus-areas/courses/braindevelopment-injury.

▪ Association for Behavioral and Cognitive Therapies. (2022). Adult 

traumatic brain injury for mental health professionals.

https://www.abct.org/fact-sheets/adult-traumatic-brain-injury-for-mentalhealth-professionals/.

Where Can I Find Trainers and 

Existing Training?

The level of training should guide the person providing the training. There are 

a number of TBI basics available to share with behavioral health providers, 

both virtual training webinars and supporting written resources. A few of those 

are included in the list above

For advanced training providers, the section on therapeutic approaches might 

be useful. Contacting TBI TARC for subject-matter experts in this area, who

may be specific to children, youth or adults, is also a useful option. 
31

Summary

Training related to TBI is critical for everyone working in behavioral health 

settings. With the right information delivered at the right time, staff can be 

educated about some of the key components and needs related to this unique 

population.
Section IV: Screening for Lifetime 

History of TBI

32

John D. Corrigan, PhD; ABPP; professor, Department of Physical Medicine 

and Rehabilitation; and director, Ohio Valley Center for Brain Injury Prevention 

and Rehabilitation, the Ohio State University

Screening for lifetime history of brain injury is a critical component to ensuring 

that individuals with brain injury and co-occurring behavioral health conditions

receive appropriate psychological and psychiatric support. State brain injury 

programs are positioned to partner with their state behavioral health agencies 

to ensure screening for brain injury is an integral aspect of their work. This 

section provides states with background on why screening is important and 

the rationale for gaining buy-in from state behavioral health agencies to 

implement brain injury screening protocols. 

Research on TBI is dominated by studies in which the injury was determined 

at the time medical attention was received. As such, descriptions of the 

injuries reflect the extent of altered consciousness as observed at time of 

injury (e.g., behavior observed on the sideline) or documented by 

professionals who treated the acute injury (e.g., the first Glasgow Coma Scale 

score in the emergency department). Studies from later in recovery refer to the 

earlier occurrence (e.g., six months post-moderate or post-severe TBI). Even 

epidemiological data is dominated by reports of incident cases, commonly 

identified by the diagnostic code given at the time of treatment. When the 

intent is to identify TBI in nonmedical settings (e.g., people in domestic 

violence shelters, applicants for long-term services and supports, or new 

clients in behavioral health programs), the traditional ways of characterizing 

TBI as a single index injury are no longer as useful. 

Why Screen for TBI?

It is necessary to understand a person’s entire history of exposure to TBI so 

that knowledge of associated effects on affect, cognition and behavior can be 

incorporated into treatment planning and delivery. Being unaware of 

neurological sources of impairment can undermine the effectiveness of 

whatever treatment approach is being employed. The methods required to 

screen for a lifetime history of TBI are very different from those used to 

determine whether an injury just occurred.
33

Lifetime history of TBI is unique

Why not just collect information about past TBIs from previous medical 

records? This is a logical but impractical approach, as it would require 

acquiring medical records from a person’s entire lifetime, then extracting the 

TBI diagnoses. Perhaps at some time in the future there will be access to a 

lifetime of medical records, but for now, it is very unlikely that all of a person’s 

prior injuries could be located. The ability to obtain a lifetime’s worth of medical 

records from physicians’ offices, emergency departments or hospitals is a 

daunting task even without adding those injuries attended to only by a school 

nurse, athletic trainer or emergency medical technician in the field. The 

medical-record approach is further limited by the suspected, significant 

proportion of TBIs that receive no medical attention (which has been estimated 

to range from 30% to 60% of a person’s lifetime injuries1, 2, 3, 4) as well as 

those (usually mild) TBIs that are missed in the emergency department 

(estimated in one study to be 50% of all cases5).

Why not use advanced medical technologies to detect past TBIs? 

Unfortunately, as of this writing, there is no biomarker for past TBIs. Imaging 

techniques and neuropsychological assessments can be used to detect acute 

TBI of sufficient severity or chronic TBI of even greater severity, but none of 

these techniques are sensitive to all TBIs, especially not all TBIs that may 

have occurred in the remote past. These assessment techniques have what is 

called “specificity” (an abnormal finding is highly likely to be a true case) but 

lack “sensitivity” (a normal finding does not mean that no TBI ever occurred). 

Very mild (transient confusion without loss of consciousness) or very old (a 

TBI experienced in childhood) injuries are the most likely to be missed. 

Further, despite exciting work being conducted using biochemical markers, 

eye movement and speech patterns, there is still no definitive biomarker of 

TBIs that did not occur recently. Once again, to establish prevalence of TBI in 

a population or compare those members of a group with and without histories 

of TBI requires different approaches to identification than research on 

incidence or studies of samples collected from treatment settings. 

Retrospective self-report of lifetime exposure

The gold standard for determining lifetime history of TBI is retrospective selfreport as determined via a structured approach. To be clear, not all 

retrospective self-reporting is equally valid. One or two questions in a selfadministered scale or structured telephone survey will miss all but the most 

recent or most severe TBIs. In public health research, the tendency to forget 

past, minor injuries is called “telescoping.”6,7 Diamond and colleagues 

reported that a one-item, self-administered screener used during admission to 
34

prison detected only 19% of the TBIs identified via structured interview.8 Selfreport also varies by the extent to which the respondent must self-diagnose 

whether the injury occurred. Asking people if they have ever had a 

“concussion” or “traumatic brain injury” requires accurate knowledge on the 

part of the respondent about what these conditions are. 

There is no question that retrospective self-report has its weaknesses; 

however, a structured interview conducted by an informed professional or a 

systematic method of presenting questions in a self-administered screening is, 

for now, the gold standard for determining lifetime history of TBI. Research 

over the past 15 years has brought scientific rigor to this task and provided 

evidence of reliability and validity for results that had previously been accepted 

on face value alone. TBI researchers have become aware of the importance of 

stimulating memory for remote injuries and how to ask about neurological 

symptoms that define a TBI rather than expecting a person to self-diagnose. 

This work has also afforded insight into the limits of retrospective self-report 

that can arise from unawareness of past injuries, poor recall or stigma. 

Methods have been developed to capture episodes of multiple mild TBIs for 

which individual injuries are indistinguishable by the respondent (e.g., those 

arising from years of football or resulting from intimate-partner violence). 

Retrospective self-report typically prompts respondents to recall injury events, 

though the type and structure of prompting vary widely. Some methods limit 

their scope to a subset of TBIs (e.g., those that required medical care or those 

resulting in loss of consciousness). Methods also vary by the extent to which 

signs and symptoms characteristic of TBI are used to establish a positive 

case. When they occur immediately upon experiencing an external force 

affecting the head, signs are considered direct evidence of altered 

consciousness (e.g., being dazed or confused, having a gap in memory, being 

knocked unconscious or experiencing coma). Symptoms are conditions that 

often result from TBI (e.g., seizure, headache, dizziness, sensitivity to light or 

sound, poor concentration) but can also occur for other reasons (e.g., trauma, 

cervical strain, metabolic changes).9 Generally, signs are more reliable than 

symptoms for drawing conclusions from self-report.

Retrospective self-report techniques differ in the way elicited information is 

used. Many techniques result in a dichotomous, “yes or no” indication of 

whether a TBI occurred (e.g., during one’s lifetime or during deployment). 

Some techniques elicit other summary indices, like the worst TBI experienced, 

age at first TBI or number of TBIs with loss of consciousness. Our work on the 

Ohio State University TBI Identification Method (OSU TBI-ID) has suggested 

that reliability of different indicators can vary widely. For instance, the worse 
35

the TBI, the better the reliability; the age at injury can vary by several years 

upon retest; and the number of TBIs without loss of consciousness is highly 

unreliable.10,11 As described above, population surveys of all types of injuries 

concur that the less severe the injury and the more remote in time, the more 

likely recall is unreliable.12,13

1. Validity of retrospective self-reports

As state brain injury programs work with their behavioral health partners 

to develop screening protocols, it is important to advocate for the use of 

valid and reliable screening tools. The approach to validating a screening 

technique can vary. Ideally, retrospective self-report would correspond with 

TBIs documented at the time of their occurrence. Such studies are difficult to 

conduct because comprehensive datasets with which to compare self-report 

are rare. 

As discussed above, these datasets may be limited to medically attended 

TBIs. A study of prisoners’ retrospective self-report identified consistent 

shortcomings: 1) events that did not receive medical attention cannot be 

verified; 2) respondents are inconsistent in the recall of the exact year or age 

at the time of injury; and 3) medical records may confirm that an injury 

occurred, but a TBI may not have been documented.14 Thus, this approach to 

validation often finds inaccurate reporting of lifetime TBIs. The extent of 

inaccuracy is reduced significantly when liberal allowances are made for the 

year or age at injury (e.g., plus or minus three years). Furthermore, 

documented injuries that did not include TBI may not be an inaccurate selfreport due to the above-mentioned problems with under-identification of TBIs 

in emergency departments and hospital records.15 When eliciting lifetime 

history of TBI, it is suspected that TBIs that occurred during early childhood 

may be underreported because the respondent was too young to be aware 

that an injury occurred. Some injury events are passed down via family lore 

rather than a firsthand memory, which can still be included in retrospective 

self-report measures.

While validation via testing of the verity of recall is the most straightforward 

approach, it is not the only approach. Validation of the OSU TBI-ID utilized the 

extent to which summary indices of lifetime history (e.g., most severe TBI 

reported or age at first TBI with loss of consciousness) contributed to the 

prediction of current cognitive abilities and neurobehavioral problems.16,17 A 

predictive validity approach is appropriate when the primary purpose of the 

screening is to determine the likelihood that prior exposure to TBI is affecting 

current cognitive abilities and/or emotional functioning. This use of 
36

retrospective self-report also necessitates having indices from screening that 

are more discriminating than a simple “yes or no,” as our studies support the 

clinical principle that not all TBIs have permanent effects. 

Aside from criterion-related validity, construct validity may be supported by 

studies that survey clinical populations (e.g., prisoners, participants in 

substance use disorder treatment, people who are homeless) and find greater 

morbidity in the subpopulation that has a history of TBI. While most studies do 

find that a history of TBI exacerbates comorbidities or is associated with 

greater psychosocial complexity, this directionality is not universal. For 

instance, two studies of TBI history prior to a subsequent TBI found that while 

patients with a positive history had more psychiatric comorbidity, their 

functional status resulting from the new TBI was not as impaired as patients

without a history.18,19 While one study was of patients entering rehabilitation 

and the other of patients identified in the emergency department, both articles 

speculated that psychosocial complexity contributed to the decision to provide 

more intensive medical services. 

One other source of construct validity is the observation of changes in brain 

structure or function that corresponds with results of a screening test. If people 

who self-report a history of TBI are more likely to have a structural abnormality 

of the brain than people who do not self-report such a history, then this 

observation is consistent with the construct (i.e., structural abnormalities do 

result from TBI). The more consistent a structural abnormality is with the 

known mechanism of how a brain is injured, the more construct validity is 

supported. Similar logic can be applied to functional abnormalities like 

disrupted blood oxygenation in positron emission tomography (PET) scans, 

anomalous networks in imaging that test functional connectivity or cognitive 

deficits on neuropsychological tests. If people who self-report histories of TBI 

differ functionally from those who do not, then construct validity is supported. If 

the nature of the functional abnormality is consistent with the known effects of 

TBI, then the conclusion that there is construct validity is strengthened.

Screening Tools

A number of instruments have been developed for assessing lifetime history of 

TBI (see Table 1). Though the information in Table 1 is not comprehensive, it

represents those methods for which systematic research has been conducted 

to establish reliability and validity. 
37

Table 1: Valid and Reliable Screening Tools

Instrument Instrument Information

Boston Assessment of 

Traumatic Brain Injury 

Lifetime (BAT-L)20 

• 15–37 items depending on history of 1, 2 or 

3 TBIs. 

• Length of administration depends on 

number of TBIs and version. 

• Administered by doctoral-level 

neuropsychologists or other comparably 

trained professionals. 

• Developed for military service members with 

adaptations for civilian and domesticviolence uses. 

• Lifetime history of TBI. 

• Free. 

Brain Injury 

Screening Questionnaire 

(BISQ)21 

• 3 sections/173 items. 

• 10–15 minute administration. 

• Self-report or administrated with assistance. 

• Lifetime history of TBI. 

• Pediatric & adult versions/scored, then minireport generated. 

• $10–$15 per administration. 

Defense and Veterans Brain 

Injury Center’s Brief TBI 

Screen (BTBIS)22 

• 3 questions with 6–8 sub-questions each. 

• 3-5 minute administration. 

• For military service members post-combat. 

• TBIs incurred during deployment. 

• Free. 

Ohio State University TBI 

Identification Method 

(OSU TBI-ID)23,24,25,26 

• 3-step interview. 

• 3–5 minute administration. 

• Administered by anyone who completes 

online training. 

• Lifetime history of TBI. 

• Free. 

TBI Questionnaire (TBIQ)27 • 3 sections. 

• 15-minute administration. 

• Administered by clinician. 

• History of common TBIs, symptom severity 

and physical and behavioral symptoms. 

• Free. 

Brain Check Survey28 

(for children and youth)

• 3 sections/173 items. 

• 10–15 minute administration. 

• Parent-/guardian-report measure. 

• History of TBI, other sources of brain 

impairment and physical and behavioral 

symptoms. 

• Intended for children & youth. 

• Free. 
38

The OSU TBI-ID

The remainder of this brief addresses the OSU TBI-ID, which was developed 

by John Corrigan and Jennifer Bogner at the Ohio State University. It has 

been the most widely used instrument, including in behavioral health settings. 

Several states currently use this instrument to partner with state systems to 

identify a history of TBI, which can then yield better intervention strategies and 

subsequent outcomes. The OSU TBI-ID typically requires three to five minutes 

when administered as a structured interview. A self-administered version has 

also been validated.29 The instrument has been incorporated into electronic 

health records, including EPIC and Cerner systems. There are Spanish, 

Chinese, Afrikaans and Finnish translations. Because the development of the 

OSU TBI-ID was supported in part by federal funding, all aspects of its use, 

including access to online training, is available free of charge.

Reliability of the OSU TBI-ID has been demonstrated by both inter-rater and 

test/retest reliability.30,31,32,33 As described above, the validity of the OSU TBIID is based on the ability to use indices derived from the measure to predict 

whether a person is currently experiencing affective, behavioral or cognitive 

effects of their lifetime exposure to TBI.34,35 Most research using the OSU TBIID reduces the results to make a dichotomous present/absent distinction; 

however, there have also been studies looking at specific indicators. The worst 

TBI experienced in one’s lifetime has been studied the most. Having had at 

least one TBI with loss of consciousness increases risk for a multitude of 

negative health consequences; one moderate or severe TBI further increases 

those risks.36,37,38,39

Less research has been conducted on the age at which people had their first 

TBI. One recent study found that a TBI with loss of consciousness before age 

20 was associated with adult binge drinking.40 Earlier studies that used a 

younger age cutoff (i.e., age 15) did not find greater risk associated with age at 

first injury.41,42,43 How recently one had their last TBI is also a summary 

indicator drawn from the OSU TBI-ID. A study using data from the National 

Health and Retirement Survey found that a recent TBI was associated with 

greater loneliness among older adults.44 

Construct validity of the OSU TBI-ID is further supported by studies that have 

found a positive history associated with both structural and functional brain 

changes observed in imaging45,46,47,48,49,50 and proteomic biomarkers.51,52,53

Construct validity is also evident in the results from multiple studies that show 

differences between subgroups of the general and clinical populations with 

and without a history of TBI (e.g., those treated for substance use disorders, 
39

older adults in residential settings, prisoners, veterans, persons with spinal 

cord injuries).54,55,56,57,58,59,60,61,62,63,64 

The OSU TBI-ID has been used to estimate prevalence of a history of TBI in 

the general population as well as clinical populations. Given that the validity of 

the instrument is based on its ability to predict that there are residual effects of 

past TBIs, prevalence determined from the OSU TBI-ID is probably best 

interpreted as the proportion of the population studied with residual effects and 

not the proportion who have ever experienced an injury that meets the criteria 

of a TBI (which can be a very minor injury). Supporting this conclusion were 

studies conducted on the Christchurch Birth Cohort. Results from the OSU 

TBI-ID administered when the cohort was 35 years old were compared to 

medical records that were captured at time of injury from birth to age 15. Most 

of the cohort accurately reported whether or not they had experienced a 

medically attended TBI with loss of consciousness 19 to 35 years previously. 

Less severe TBIs were not recalled as accurately as those involving loss of 

consciousness.

As already described, the OSU TBI-ID was developed based on the 

contribution of specific indices to predicting current functioning. That research 

started with a very extensive interview that elicited almost every aspect of a 

TBI that might be related to its persistent effects (e.g., severity, cumulative 

severity, number of TBIs, age at injury, medical attention required, symptoms 

experienced immediately, symptoms that persisted, etc.). This developmental 

instrument was called the “Research Version.” Once the validation research 

identified a subset of indices of lifetime exposure that were predictive of 

current functioning, the Research Version was shortened to the version 

currently called the OSU TBI-ID. (The authors erroneously created confusion 

by initially calling that version the “Short Version” when it was the version 

resulting from validation.) That version is available at the OSU TBI-ID: 

https://wexnermedical.osu.edu/-/media/files/wexnermedical/patientcare/healthcare-services/neurological-institute/departments-andcenters/research-centers/ohio-valley/osu_tbiform_july2013.pdf . 

In response to requests from the field, the OSU TBI-ID has been adapted for 

use in surveys and shortened for incorporation into clinical protocols. These 

adaptations have retained key components that are fundamental to their

validity. People require prompting of their memories to maximize their recall, 

particularly of less severe or more remote TBIs. Depending on the intentions 

of the users, trade-offs can be made. For instance, if the primary interest is 

only more severe TBIs, then less prompting may be necessary. A second 

tenet in adaptation has been that the respondent is not asked to self-diagnose. 
40

All versions inquire about injuries to the head or neck, not concussions or 

TBIs. A TBI is determined when an injury that resulted from an external force 

is reported to have resulted in an immediate alteration of consciousness. 

Despite the preservation of these principles when adapting or shortening 

versions, the resulting instruments may not have the reliability and validity of 

the original OSU TBI-ID. 

The OSU TBI-ID is the most widely employed instrument for capturing lifetime 

history of TBI. Providers in multiple states are using the OSU TBI-ID for 

screening clinical populations, including clients in behavioral health treatment, 

high-risk adolescents, victims of domestic violence, prisoners, homeless 

individuals and older adults. It is included in the federally funded TBI Model 

Systems65 and TRACK-TBI longitudinal studies.66 It was adapted for use in 

the Chronic Effects of Neurotrauma Consortium (CENC) national database of 

military service members and veterans.67 It is used in the ABCD longitudinal 

study of adolescent health and development.68 It was used in the 2014 

National Health and Retirement Survey,

69 and in several states has been 

adapted for the CDC’s Behavioral Risk Factors Surveillance System.70 It is 

included in the PhenX Toolkit of instruments that were developed to be used in 

conjunction with the Human Genome Project.71 As a result, the tool has been 

used in numerous peer-reviewed scientific publications.

Summary

To effectively support individuals with brain injury and co-occurring behavioral 

health conditions, the behavioral health professional has to know they are 

working with an individual with brain injury. As discussed in this section, often 

people do not come to the behavioral health system with a diagnosis of brain 

injury. Therefore, screening for lifetime history of brain injury using a valid and 

reliable instrument best suited for behavioral health settings is an important 

first step to ensuring successful outcomes for this population.

1 Corrigan, J. D., & Bogner, J. (2007). Initial reliability and validity of the Ohio 

State University TBI identification method. The Journal of Head Trauma 

Rehabilitation, 22(6), 318–329. 

2 Daugherty, J., DePadilla, L., Sarmiento, K., & Breiding, M. J. (2020). Selfreported lifetime concussion among adults: Comparison of 3 different 
41

survey questions. The Journal of Head Trauma Rehabilitation, 35(2), 

E136–E143. https://doi.org/10.1097/HTR.0000000000000534

3 Diamond, P. M., Harzke, A. J., Magaletta, P. R., Cummins, A. G., & 

Frankowski, R. (2007). Screening for traumatic brain injury in an 

offender sample: A first look at the reliability and validity of the traumatic 

brain injury questionnaire. The Journal of Head Trauma Rehabilitation, 

22(6), 330–338. https://doi.org/10.1097/01.HTR.0000300228.05867.5c

4 Setnik, L., & Bazarian, J. J. (2007). The characteristics of patients who do 

not seek medical treatment for traumatic brain injury. Brain Injury, 21(1), 

1–9. https://doi.org/10.1080/02699050601111419

5 Powell, J. M., Ferraro, J. V., Dikmen, S. S., Temkin, N. R., & Bell, K. R. 

(2008). Accuracy of mild traumatic brain injury diagnosis. Archives of 

Physical Medicine and Rehabilitation, 89(8), 1550–1555. 

https://doi.org/10.1016/j.apmr.2007.12.035

6 Warner, M., Barnes, P. M., Fingerhut, L. A., & Centers for Disease Control 

and Prevention/National Center for Health Statistics. (2000). Injury and 

poisoning episodes and conditions: National health interview survey, 

1997. Vital and Health Statistics. Series 10, Data from the National 

Health Survey, (202), 1–38.

7 Warner, M., Schenker, N., Heinen, M. A., & Fingerhut, L. A. (2005). The 

effects of recall on reporting injury and poisoning episodes in the 

national health interview survey. Injury Prevention: Journal of the 

International Society for Child and Adolescent Injury Prevention, 11(5), 

282–287. https://doi.org/10.1136/ip.2004.006965

8 Diamond, P. M., Harzke, A. J., Magaletta, P. R., Cummins, A. G., & 

Frankowski, R. (2007). Screening for traumatic brain injury in an 

offender sample: A first look at the reliability and validity of the traumatic 

brain injury questionnaire. Journal of Head Trauma Rehabilitation, 

22(6), 330–338. https://doi.org/10.1097/01.HTR.0000300228.05867.5c

9 Iverson, G. L., & Lange, R. T. (2003). Examination of "postconcussion-like" 

symptoms in a healthy sample. Applied Neuropsychology, 10(3), 137–

144. https://doi.org/10.1207/S15324826AN1003_02
42

10 Bogner, J., & Corrigan, J. D. (2009). Reliability and predictive validity of the 

Ohio State University TBI identification method with prisoners. Journal 

of Head Trauma Rehabilitation, 24(4), 279–291. 

https://doi.org/10.1097/HTR.0b013e3181a66356

11 Cuthbert, J. P., Whiteneck, G. G., Corrigan, J. D., & Bogner, J. (2016). The 

reliability of a computer-assisted telephone interview version of the 

Ohio State University traumatic brain injury identification method. 

Journal of Head Trauma Rehabilitation, 31(1), E36–E42. 

https://doi.org/10.1097/HTR.0000000000000075

12 Warner, M., Barnes, P. M., Fingerhut, L. A., & Centers for Disease Control 

and Prevention/National Center for Health Statistics. (2000). Injury and 

poisoning episodes and conditions: National health interview survey, 

1997. Vital and Health Statistics. Series 10, Data from the National 

Health Survey, (202), 1–38. 

13 Warner, M., Schenker, N., Heinen, M. A., & Fingerhut, L. A. (2005). The 

effects of recall on reporting injury and poisoning episodes in the 

national health interview survey. Injury Prevention: Journal of the 

International Society for Child and Adolescent Injury Prevention, 11(5), 

282–287. https://doi.org/10.1136/ip.2004.006965

14 Schofield, P., Butler, T., Hollis, S., & D'Este, C. (2011). Are prisoners 

reliable survey respondents? A validation of self-reported traumatic 

brain injury (TBI) against hospital medical records. Brain Injury, 25(1), 

74–82. https://doi.org/10.3109/02699052.2010.531690

15 Powell, J. M., Ferraro, J. V., Dikmen, S. S., Temkin, N. R., & Bell, K. R. 

(2008). Accuracy of mild traumatic brain injury diagnosis. Archives of 

Physical Medicine and Rehabilitation, 89(8), 1550–1555. 

https://doi.org/10.1016/j.apmr.2007.12.035

16 Bogner, J., & Corrigan, J. D. (2009). Reliability and predictive validity of the 

Ohio State University TBI identification method with prisoners. The 

Journal of Head Trauma Rehabilitation, 24(4), 279–291. 

https://doi.org/10.1097/HTR.0b013e3181a66356 

17 Corrigan, J. D., & Bogner, J. (2007). Initial reliability and validity of the Ohio 

State University TBI identification method. The Journal of Head Trauma 
43

Rehabilitation, 22(6), 318–329. 

https://doi.org/10.1097/01.HTR.0000300227.67748.77

18 Corrigan, J. D., Bogner, J., Mellick, D., Bushnik, T., Dams-O’Connor, K., 

Hammond, F. M., Hart, T., & Kolakowsky-Hayner, S. (2013). Prior 

history of traumatic brain injury among persons in the traumatic brain 

injury model systems national database. Archives of Physical Medicine 

and Rehabilitation, 94(10), 1940–1950. 

19 Dams-O'Connor, K., Spielman, L., Singh, A., Gordon, W. A., Lingsma, H. 

F., Maas, A. I., Manley, G.T., Mukherjee, P., Okonkwo, D.O., Puccio, 

A.M., Schnyer, D.M., Valadka, A. B., Yue, J. K., Yuh, E. L. (2013). The 

impact of previous traumatic brain injury on health and functioning: A 

TRACK-TBI study. Journal of Neurotrauma, 30(24), 2014–2020. 

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20 Fortier, C. B., Amick, M. M., Grande, L., McGlynn, S., Kenna, A., Morra, L., 

Clark, A., Milberg, W. P., & McGlinchey, R. E. (2014). The Boston 

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21 Dams-O'Connor, K., Cantor, J. B., Brown, M., Dijkers, M. P., Spielman, L. 

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22 Schwab, K. A., Ivins, B., Cramer, G., Johnson, W., Sluss-Tiller, M., Kiley, 

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23 Bogner, J., & Corrigan, J. D. (2009). Reliability and predictive validity of the 

Ohio state University TBI identification method with prisoners. The 

Journal of Head Trauma Rehabilitation, 24(4), 279–291. 

https://doi.org/10.1097/HTR.0b013e3181a66356
44

24 Bogner, J. A., Whiteneck, G. G., MacDonald, J., Juengst, S. B., Brown, A. 

W., Philippus, A. M., Marwitz, J. H., Lengenfelder, J., Mellick, D., 

Arenth, P., & Corrigan, J. D. (2017). Test-retest reliability of traumatic 

brain injury outcome measures: A traumatic brain injury model systems 

study. The Journal of Head Trauma Rehabilitation, 32(5), E1–E16. 

https://doi.org/10.1097/HTR.0000000000000291

25 Corrigan, J. D., & Bogner, J. (2007). Initial reliability and validity of the Ohio 

State University TBI identification method. The Journal of Head Trauma 

Rehabilitation, 22(6), 318–329. 

26 Cuthbert, J. P., Whiteneck, G. G., Corrigan, J. D., & Bogner, J. (2016). The 

reliability of a computer-assisted telephone interview version of the 

Ohio State University traumatic brain injury identification method. The 

Journal of Head Trauma Rehabilitation, 31(1), E36–E42. 

https://doi.org/10.1097/HTR.0000000000000075

27 Diamond, P. M., Harzke, A. J., Magaletta, P. R., Cummins, A. G., & 

Frankowski, R. (2007). Screening for traumatic brain injury in an 

offender sample: A first look at the reliability and validity of the traumatic 

brain injury questionnaire. The Journal of Head Trauma Rehabilitation, 

22(6), 330-338. https://doi.org/10.1097/01.HTR.0000300228.05867.5c

28 Department of Occupational Therapy, College of Health and Human 

Services, Colorado State University. Life Outcomes After Brain Injury 

Research Program. http://www.lobi.chhs.colostate.edu/index.aspx

29 Lequerica, A. H., Lucca, C., Chiaravalloti, N. D., Ward, I., & Corrigan, J. D. 

(2018). Feasibility and preliminary validation of an online version of the 

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30 Bogner, J., & Corrigan, J. D. (2009). Reliability and predictive validity of the 

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31 Bogner, J. A., Whiteneck, G. G., MacDonald, J., Juengst, S. B., Brown, A. 

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33 Cuthbert, J. P., Whiteneck, G. G., Corrigan, J. D., & Bogner, J. (2016). The 

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34 Bogner, J., & Corrigan, J. D. (2009). Reliability and predictive validity of the 

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35 Corrigan, J. D., & Bogner, J. (2007). Initial reliability and validity of the Ohio 

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36 B Bogner, J., Corrigan, J. D., Yi, H., Singichetti, B., Manchester, K., Huang, 

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51

Section V: Modifying Clinical 

Interventions for TBI

Theo Tsaousides, PhD, ABPP, clinical assistant professor, and Maria 

Kajankova, PhD, assistant professor, Department of Rehabilitation and Human 

Performance, Icahn School of Medicine at Mount Sinai

Introduction

Most individuals with TBI will seek and receive mental health services at some 

point during their recovery. The constellation of physical, cognitive and 

behavioral changes that people with TBI experience is likely to cause high 

levels of distress and interfere with daily functioning. Mental health services 

are an important component of brain injury rehabilitation. Individuals with TBI 

usually receive comprehensive brain injury rehabilitation services, which may 

include mental health treatment. However, people with TBI may still seek out 

mental health services on their own accord when the emotional distress 

becomes unmanageable and disruptive, especially if they are not connected to 

rehabilitation services. Since TBI can be a chronic condition, individuals may 

seek mental health services at different times post-injury. This window can 

vary greatly, ranging from days or weeks post-injury to 10 or more years postinjury. 

The objective for this section is to highlight the importance of understanding 

the unique factors to consider when providing mental health services to people 

with TBI. Understanding these factors will help state brain injury program 

personnel to more effectively partner with their state mental health agencies to 

improve outcomes for people with TBI and co-occurring behavioral health 

conditions. 

Adults with brain injury are often diagnosed with a range of mood and anxiety 

disorders. They may present with increased suicidality, impulsivity or risktaking behavior. They may experience interpersonal conflict and marital 

dissatisfaction. They may have difficulty gaining or maintaining employment. 

Children and adolescents with TBI may be diagnosed with a range of 

childhood psychiatric and learning disorders and could face adjustment 

problems and academic and social difficulties in school.
While existing diagnostic procedures and treatments for these disorders may 

be effective for symptom reduction and functional improvement in other clinical 

populations, their effectiveness with people with TBI depends on how well they 

are modified and implemented to account for the unique factors relevant to this 

population.

52

In this section, we offer recommendations regarding how to approach 

diagnosis and treatment of mental health disorders in people with TBI. Ideally, 

services should be provided by mental health professionals with knowledge 

and/or expertise in brain injury rehabilitation. However, because access to 

specialized providers may not always be an option, it is important for all mental 

health providers to be aware of the unique factors discussed in this section, to 

have access to resources available for providers and to seek consultation, 

when necessary, prior to engaging in treatment with people with TBI.

Considerations and Best Practices for 

Diagnostic Procedures

Epidemiology of psychiatric disorders

People with TBI present with a range of psychiatric disorders and often at a 

higher rate than the general population. Common diagnoses include mood 

disorders (including major depressive, dysthymic and bipolar disorder), anxiety 

disorders (including generalized anxiety, posttraumatic stress, obsessivecompulsive, panic, acute stress disorders, and agoraphobia and social 

phobia), psychotic disorders and substance use disorders. In addition, people 

with TBI may present with personality changes (apathy, affective lability, 

aggression, behavioral disinhibition), impaired self-awareness, suicidality and 

socially inappropriate behavior. 

Similarly, children and adolescents experience many of the same emotional 

and behavioral difficulties post-TBI as adults, with children most commonly 

experiencing depression, anxiety, personality changes (affective instability, 

aggression, disinhibited behavior and apathy), psychosis/paranoia, secondary 

attention-deficit/hyperactivity disorder (ADHD), oppositional defiant 

disorder/conduct disorder, posttraumatic stress disorder and 

mania/hypomania.

It is important to note that the brain injury could either cause or worsen 

preexisting mental health problems. 
53

The risk of misdiagnosis

People with TBI may seek mental health services, either without disclosing 

their TBI status to the provider or without inquiring whether the provider has 

familiarity with the clinical profile of TBI. As a result, they may not be properly 

diagnosed. A proper diagnosis is essential for effective treatment. 

Misdiagnosis can occur because the presenting psychiatric symptoms are not 

considered in the context of TBI but are instead diagnosed in isolation. For 

example, people with TBI may experience emotional lability and behavioral 

dysregulation because of disruption in their executive functions. These 

symptoms, however, may resemble symptoms of bipolar disorder. If a person 

with TBI is diagnosed with bipolar disorder, they may receive inappropriate 

and ineffective treatment, which may also have a negative impact on the 

provider’s prognosis and the patient’s experience with the mental health 

system. 

Causes of distress: Neurological versus psychogenic

The origins of the emotional and behavioral symptoms that people with TBI 

present with may be neurological or psychogenic in origin. Symptoms could be 

caused by the direct impact of the injury on neurological functioning (e.g., 

lesions, axonal damage, infection, neurochemical disruption, cerebrovascular 

changes). For example, depressive symptoms could be associated with 

disruption in serotonergic neural circuits. Symptoms, however, could also be 

psychogenic in nature. In this case, depression may be a reaction to the 

broader losses a person with TBI experienced after the injury: loss of 

autonomy and independence, loss of employment and income or loss of social 

connections and outlets.

While it may not be possible to accurately identify the cause of the emotional 

or behavioral disturbance, it is important that both be explored and addressed. 

Focusing on either the neurological or the psychological while ignoring the 

other may render the treatment ineffective. If, for example, the mental health 

provider attempts to address depressed mood by prescribing the 

recommended dose of an antidepressant while ignoring endocrine dysfunction 

caused by the brain injury, the treatment may fail to lead to the desired 

outcomes. Similarly, if mood dysregulation persists despite appropriate 

pharmacotherapy, the provider may need to explore environmental stressors 

and engage the patient in psychoeducation and coping-skills training relevant 

to a person with TBI. In pediatric TBI, the interaction between brain 

dysfunction and ongoing developmental processes can impact the onset and 

presentation of symptoms and further complicate diagnosis and treatment 

decisions. 
Factors to consider when administering diagnostic 

instruments to people with TBI

54

Diagnostic methods and procedures do not generally differ for patients with 

TBI. Similar to other clinical populations, an in-depth interview with the patient 

and collateral sources, clinical observations, and use of screening and 

assessment tools and measures are ideal in helping providers make accurate 

diagnoses. Mental health providers already use many of the screening and 

assessment tools recommended in assessing mental health difficulties for 

those with TBI (e.g., SCAT-5, BDI-II, BAI, MMPI-2). However, it is important 

for providers to understand the limitations of these measures when used in the 

TBI population. 

First, reduced cognitive functioning after TBI can complicate the diagnostic 

process. Problems with attention, short- and long-term memory, reading 

comprehension or verbal fluency may render a diagnosis incomplete or invalid. 

These cognitive challenges may impact a patient’s ability to provide accurate 

information during a clinical interview and/or their ability to complete 

assessments. 

Below are some general suggestions for conducting psychiatric diagnostic 

assessments with people with TBI. The provider could:

▪ Read the instructions to the patient aloud. 

▪ Ask the patient to repeat the instructions to ensure they understand 

them. 

▪ Read the items of a self-administered measure to the patient and 

record their responses. 

▪ Obtain corroborating information from significant others. 

Moreover, symptom presentation and severity can be influenced by other 

factors such as severity of injury, anosognosia, impaired self-awareness, 

premorbid personality, premorbid psychiatric history, current substance use, 

perceived social support, and reaction and adjustment to injury. In addition, 

pain and sleep disorders, which are common among people with TBI, can 

confound or complicate diagnosis.
55

Selection of diagnostic instruments

Asking the client during the interview if they experience any cognitive 

challenges in daily life, as well as completing a brief cognitive screening 

measure (e.g., the Montreal Cognitive Assessment [MoCA], Mini-Mental 

Status Exam [MMSE]) could help identify any potential cognitive challenges 

and determine if a referral for a more thorough neuropsychological 

assessment would facilitate diagnosis and treatment. If cognitive deficits are 

suspected, referral to a neuropsychologist is recommended. A comprehensive 

neuropsychological evaluation can help providers better understand the 

client’s cognitive challenges and how they might impact psychological 

functioning. If screening measures like the MoCA or the MMSE are to be used, 

the provider is encouraged to receive training in their administration. 

Below are resources that are available to clinicians and researchers to 

facilitate the selection of measures and tools when assessing psychological 

outcomes post-TBI. These resources include adult and pediatric measures to 

help clinicians assess psychiatric disorders in clinical and research settings. 

They also provide information about the validity limitations of the measures in 

the population domains and measures of common data elements. 

▪ The National Institute of Neurological Disorders and Stroke (NINDS) 

Common Data Elements (CDE). (n.d.). Traumatic Brain Injury. 

https://www.commondataelements.ninds.nih.gov/Traumatic%20Brain%

20Injury#pane-89.

▪ Searchable database of instruments for clinicians and researchers for 

various medical conditions, including TBI. Shirley Ryan AbilityLab 

(2022). Rehabilitation measures database. 

https://www.sralab.org/rehabilitation-measures. 

Considerations and Best Practices for 

Clinical Interventions 

In the last two decades, several interventions have been developed to address 

emotional and behavioral challenges in children and adults with TBI. Some of

these interventions were developed by modifying existing evidence-based 

practices in other clinical populations, while others were created within the 

context of brain injury rehabilitation, considering the unique factors that 

influence treatment process and outcomes in people with TBI.
56

We begin this section by reviewing the unique-to-TBI factors that could 

negatively affect the treatment process, and therefore treatment outcomes. 

Subsequently, we provide recommendations for how to modify existing 

interventions when working with people with TBI. Finally, we provide a list of 

evidence-based practices from studies based on people with TBI.

While extremely important for treatment outcomes, in our discussion we omit 

reference to systemic factors that could interfere with treatment (e.g., proximity 

to healthcare settings, cost of services and insurance coverage, availability of 

providers familiar with TBI, transportation challenges) because they are 

beyond the scope of this chapter. 

Factors to consider when delivering treatment to 

people with TBI

1. Cognitive impairments

People with TBI may experience reduced cognitive functioning that ranges in 

duration and severity. While specific cognitive rehabilitation interventions exist 

to target problems in cognitive functions like attention, memory and executive 

functioning, TBI-related cognitive deficits can interfere with the effectiveness of 

mental health services when these services are not combined with cognitive 

rehabilitation. 

2. Impaired self-awareness

People with TBI may present with deficits in self-awareness, which could 

range from anosognosia (lack of awareness that mental functions are impaired 

and disruptive to daily functioning) to poor anticipation of consequences 

(unable to predict that a certain maladaptive behavior will cause further 

problems). It is important for providers to a) assess the level of self-awareness 

through standard measures or collateral interviews with caregivers and/or 

other providers, and b) determine whether self-awareness is the target or a byproduct of treatment. It is not uncommon to expect that as self-awareness 

increases, psychiatric symptoms may be exacerbated as the person becomes 

more aware of the challenges and losses incurred because of the TBI. 

 Modifying existing interventions

In this section, we provide some examples of how different TBI-related 

cognitive deficits can interfere with both the process and outcome of mental 
57

health treatments and recommendations on how to modify the provider’s 

approach to accommodate for the impairment.

Shown in Table 2 are challenges related to brain injury and recommendations 

on how to modify the provider’s approach to accommodate for the impairment. 

Table 2: Challenges Related to Brain Injury and 

Recommendations

Challenges Recommendations

Remembering appointments.

Memory problems may prevent people 

with TBI from remembering scheduled 

appointments. 

Skipping appointments may be disruptive 

for the continuity of care and may also be 

a source of frustration for providers who 

would have to deal with no-show clients 

and rescheduling.

Encourage consistent use of a 

calendar, set up alerts and reminders 

on a smartphone, send reminder 

emails or texts and explore other 

strategies that may reduce forgetting 

(e.g., sticky notes). 

Remembering content of sessions. 

Memory problems may make it difficult to 

remember the content of a session 

between visits. 

People with TBI may fail to apply and 

generalize insights gained and coping skills 

demonstrated during sessions beyond the 

therapeutic context. As a result, the 

presenting problems may persist and 

require extending the duration of services.

Break down important information 

into manageable chunks, summarize 

the highlights of a session, encourage 

the client to keep a journal for 

recording these highlights, help them 

enter the information in the journal 

at the end of the session and review 

the entry at the beginning of the next 

session.

Remembering to do homework. 

Assigning homework is important for skill 

transfer and generalization. 

Memory problems may interfere with the 

completion of homework assignments 

because the client may forget that they 

had to do a homework assignment or 

what the requirements of the assignment 

were.

If homework assignments are used, 

ensure that they are assigned 

consistently, as opposed to 

periodically (e.g., for every session).

Provide clear instructions and ensure 

that the client understands what the 

assignment is. 

Have the client write down the 

instructions somewhere that 

increases the probability that they 

will locate the information between 

sessions (e.g., the session journal, 

their calendar, a to-do list, a 

homework notebook). 

Review the assigned homework 
58

Challenges Recommendations

during the following session to make 

it an integral component of the 

session. 

If possible, send email or text 

reminder ahead of time, checking 

progress on the homework.

Staying focused. 

Challenges with sustained attention may 

make it difficult to stay focused for 

prolonged periods during the session. 

People with TBI may drift in and out of the 

session, may miss important points due to 

inattention or may become mentally 

fatigued more easily. 

Make the sessions shorter, take 

breaks during the session and 

periodically check in with the client to 

ensure they remain focused.

Being easily distracted. 

Clients may be easily distracted by 

extraneous triggers, such as sounds, 

movements or objects in the environment, 

which will interfere with their focus on 

session content.

Hold sessions in a less visually “busy” 

setting (e.g., have the client face wall 

art instead of a busy bookshelf or 

interior window). 

Reduce the amount of ambient noise 

or sounds that can be distracting.

Slow rate of comprehension. 

Reduced processing speed may interfere 

with how quickly a person with a TBI can 

understand a complex concept or learn a 

skill.

Engage in slower and more deliberate 

communication. 

Use multiple modalities to present 

information and repeat concepts and 

instructions.

Slow rate of responding. 

Slow processing speed leads to delays in 

responding because more time is required 

to access information from long-term 

memory, organize thoughts and ideas and 

formulate a response. This may be 

frustrating to the provider and may make 

the client seem more impaired or less 

engaged.

Allow clients ample time to respond 

to a question or to describe an event 

or experience. 

Indicate that there is no pressure to 

provide a response fast.

Difficulty making decisions. 

People with TBI often report feeling 

“stuck” because they have difficulty 

engaging in problem-solving and decisionmaking. 

They may present as overthinking a 

problem or, conversely, avoiding a task or 

abandoning a goal.

Help the client clarify the decision to 

be made. 

Facilitate decision-making by using 

strategies like a “pros and cons” 

analysis. 

Engage the client in an evidencebased problem-solving approach. 

Help the client generate viable 

choices.

Difficulty initiating behavior. Make sessions more structured (e.g.,
59

Challenges Recommendations

People with TBI may have difficulty 

initiating conversations and bringing up 

relevant topics. 

They may fail to follow through with 

homework assignments or to practice 

recommended coping strategies.

set up a Q&A format). 

Ask clients (or family if relevant) to 

keep notes or generate questions 

during the week, which can provide 

content for the session and help 

recall.

Set up motivators that encourage 

clients to complete tasks.

Getting easily overwhelmed. 

People with TBI may feel easily 

overwhelmed and experience cognitive 

“flooding” even in the presence of minimal 

stressors. 

They may have difficulty accomplishing

daily tasks because of the distress.

Focus on a small number of topics 

during a session. 

Encourage the use of to-do lists. 

Recommend against engaging in 

multitasking. 

Teach relaxation and mindfulness 

techniques.

Photosensitivity. 

People with TBI may present with 

sensitivity to bright lights, which may 

prevent them from being able to focus on 

the session.

Adjust the lighting in the room or 

encourage the person to wear 

photoprotective gear, such as 

sunglasses or visors.

Fatigue. 

Both physical and cognitive fatigue can 

interfere with treatment. 

The physical effort of traveling to the 

treatment setting may affect attendance 

and participation. 

The client may only be able to process a 

limited amount of information. 

It is not uncommon for people with TBI to 

feel fatigued for several days after a day of 

strenuous physical or mental activity.

Keep sessions shorter, if necessary. 

Give breaks. 

Help clients manage their activity 

level to prevent the onset of 

debilitating fatigue. 

Schedule manageable treatmentrelated activities between sessions.

Alexithymia. 

The neurological impairment of the brain 

injury may leave a person with TBI unable 

to recognize, process and be aware of 

their own affective responses. 

In addition, they may misread or ignore 

emotional cues in other people.

Be cautious not to interpret lack of 

emotional awareness as a psychiatric 

symptom (e.g., anhedonia) or as an 

attempt of denial. 

Obtain information about the 

person’s emotional state without 

expecting them to accurately label 

their emotions. 

If possible, focus the treatment on 

increasing emotional awareness.
60

Evidence-based Mental Health 

Treatments for People with TBI 

While existing interventions could be modified to be delivered to people with 

TBI, research involving people with TBI has yielded several evidence-based 

practices for a range of psychiatric disorders, some of which are included 

below.

Adults

▪ Cognitive behavioral therapy for post-TBI depression.1,2,3 

▪ Mindfulness-based cognitive therapy for post-TBI depression.4 

▪ Modified cognitive behavioral therapy (CBT plus motivational 

interviewing and/or nondirective counseling) for post-TBI depression 

and anxiety.5 

▪ Cognitive behavioral therapy for post-TBI hopelessness.6 

▪ Acceptance and commitment therapy for post-TBI psychological 

distress.7 

▪ Goal management training (with external cuing and an emotional 

regulation module) improves post-TBI emotion-regulation skills and 

quality of life.8

▪ Emotion-regulation intervention for post-TBI emotion dysregulation.9 

Children 

▪ Prolonged exposure treatment for children with post-TBI post-traumatic

stress disorder (PTSD).10 

▪ Problem-solving treatment program for post-TBI psychosocial 

functioning (adolescent internalizing behavior and depressive 

symptoms).11

▪ Cognitive behavioral therapy for post-TBI psychological adjustment 

(self-management and compliance).12
61

▪ Positive parenting skills program for post-TBI child behavior and 

parenting skills.13 

Couples or Caregivers (adults and children)

▪ Problem-solving family intervention reduces psychological distress for 

caregivers of adolescents with TBI.14

▪ TBI caregiver intervention for improving emotional, instrumental and 

professional support and brain injury knowledge.15 

▪ Family intervention for parental distress following pediatric TBI.16

▪ Online problem-solving program for teens to improve problem-solving 

skills and reduce depressive symptoms for caregivers.17

▪ Problem-solving intervention for improving self-efficacy and depression 

for caregivers of adolescents with TBI.18

▪ Parenting skills program for psychological distress for caregivers of 

children with TBI.19

▪ Parenting intervention for depression for caregivers of children with 

TBI.20 

▪ Therapeutic couples intervention for reducing unmet needs and 

burdens for caregivers following TBI.21

▪ Couples intervention for improving dyadic adjustment and 

communication.22

Summary

While behavioral issues can present a number of significant challenges, there 

are new or adapted strategies and interventions that can help with addressing 

these issues for children and adults with TBI. These approaches are evidencebased and shown to be effective for improving outcomes for returning to 

school, community and work. 

It is important to collaborate with your state mental health system on what 

might work best and for which settings. 
62

1 Ashman, T., Cantor, J. B., Tsaousides, T., Spielman, L., & Gordon, W. 

(2014). Comparison of cognitive behavioral therapy and supportive 

psychotherapy for the treatment of depression following traumatic brain 

injury. Journal of Head Trauma Rehabilitation, 29(6), 467–478. 

https://doi.org/10.1097/htr.0000000000000098 

2 Fann, J. R., Bombardier, C. H., Vannoy, S., Dyer, J., Ludman, E., Dikmen, 

S., Marshall, K., Barber, J., & Temkin, N. (2015). Telephone and inperson cognitive behavioral therapy for major depression after 

traumatic brain injury: A randomized controlled trial. Journal of 

Neurotrauma, 32(1), 45–57. https://doi.org/10.1089/neu.2014.3423 

3 Topolovec-Vranic, J., Cullen, N., Michalak, A., Ouchterlony, D., Bhalerao, S., 

Masanic, C., & Cusimano, M. D. (2010). Evaluation of an online 

cognitive behavioural therapy program by patients with traumatic brain 

injury and depression. Brain Injury, 24(5), 762–772. 

https://doi.org/10.3109/02699051003709599 

4 Bédard, M., Felteau, M., Marshall, S., Cullen, N., Gibbons, C., Dubois, S., 

Maxwell, H., Mazmanian, D., Weaver, B., Rees, L., Gainer, R., Klein, 

R., & Moustgaard, A. (2014). Mindfulness-based cognitive therapy 

reduces symptoms of depression in people with a traumatic brain injury. 

Journal of Head Trauma Rehabilitation, 29(4). 

https://doi.org/10.1097/htr.0b013e3182a615a0 

5 Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Alway, Y., 

Downing, M., Furtado, C., & O’Donnell, M. L. (2015). Efficacy of 

motivational interviewing and cognitive behavioral therapy for anxiety 

and depression symptoms following traumatic brain injury. 

Psychological Medicine, 46(5), 1079–1090. 

https://doi.org/10.1017/s0033291715002640 

6 Simpson, G. K., Tate, R. L., Whiting, D. L., & Cotter, R. E. (2011). Suicide 

prevention after traumatic brain injury. Journal of Head Trauma 

Rehabilitation, 26(4), 290–300. 

https://doi.org/10.1097/htr.0b013e3182225250

7 Sander, A. M., Clark, A. N., Arciniegas, D. B., Tran, K., Leon-Novelo, L., 

Ngan, E., Bogaards, J., Sherer, M., & Walser, R. (2020). A randomized 

controlled trial of acceptance and commitment therapy for psychological 

distress among persons with traumatic brain injury. Neuropsychological 
63

Rehabilitation, 31(7), 1105–1129. 

https://doi.org/10.1080/09602011.2020.1762670 

8 Tornås, S., Løvstad, M., Solbakk, A.-K., Schanke, A.-K., & Stubberud, J. 

(2016). Goal management training combined with external cuing as a 

means to improve emotional regulation, psychological functioning, and 

quality of life in patients with acquired brain injury: A randomized 

controlled trial. Archives of Physical Medicine and Rehabilitation, 

97(11). https://doi.org/10.1016/j.apmr.2016.06.014 

9 Tsaousides, T., Spielman, L., Kajankova, M., Guetta, G., Gordon, W., & 

Dams-O’Connor, K. (2017). Improving emotion regulation following 

web-based group intervention for individuals with Traumatic Brain 

Injury. Journal of Head Trauma Rehabilitation, 32(5), 354–365. 

https://doi.org/10.1097/htr.0000000000000345 

10 Shorer, M., Segev, S., Rassovsky, Y., Fennig, S., Apter, A., & Peleg, T. P. 

(2020). Efficacy of psychological intervention for children with 

concurrent posttraumatic stress disorder and mild traumatic brain injury. 

Journal of Traumatic Stress, 33(3), 330–337. 

https://doi.org/10.1002/jts.22512 

11 Wade, S. L., Walz, N. C., Carey, J. A. C., & Williams, K. M. (2008). 

Preliminary efficacy of a web-based family problem-solving treatment 

program for adolescents with traumatic brain injury. Journal of Head 

Trauma Rehabilitation, 23(6), 369–377. 

https://doi.org/10.1097/01.htr.0000341432.67251.48 

12 Wade, S. L., Carey, J., & Wolfe, C. R. (2006). An online family intervention 

to reduce parental distress following pediatric brain injury. Journal of 

Consulting and Clinical Psychology, 74(3), 445–454. 

https://doi.org/10.1037/0022-006x.74.3.445 

13 Antonini, T. N., Raj, S. P., Oberjohn, K. S., Cassedy, A., Makoroff, K. L., 

Fouladi, M., & Wade, S. L. (2014). A pilot randomized trial of an online 

parenting skills program for pediatric traumatic brain injury: 

Improvements in parenting and child behavior. Behavior Therapy, 

45(4), 455–468. https://doi.org/10.1016/j.beth.2014.02.003 

14 Petranovich, C. L., Wade, S. L., Taylor, H. G., Cassedy, A., Stancin, T., 

Kirkwood, M. W., & Maines Brown, T. (2015). Long-term caregiver 
64

mental health outcomes following a predominately online intervention 

for adolescents with complicated mild to severe traumatic brain injury. 

Journal of Pediatric Psychology, 40(7), 680–688. 

https://doi.org/10.1093/jpepsy/jsv001 

15 Niemeier, J. P., Kreutzer, J. S., Marwitz, J. H., & Sima, A. P. (2019). A 

randomized controlled pilot study of a manualized intervention for 

caregivers of patients with traumatic brain injury in inpatient 

rehabilitation. Archives of Physical Medicine and Rehabilitation, 100(4). 

https://doi.org/10.1016/j.apmr.2018.07.422 

16 Wade, S. L., Carey, J., & Wolfe, C. R. (2006). An online family intervention 

to reduce parental distress following pediatric brain injury. Journal of 

Consulting and Clinical Psychology, 74(3), 445–454. 

https://doi.org/10.1037/0022-006x.74.3.445

17 Wade, S. L., Walz, N. C., Carey, J. A., McMullen, K. M., Cass, J., Mark, E., 

& Yeates, K. O. (2012). A randomized trial of teen online problem 

solving: Efficacy in improving caregiver outcomes after brain injury. 

Health Psychology, 31(6), 767–776. https://doi.org/10.1037/a0028440 

18 Wade, S. L., Karver, C. L., Taylor, H. G., Cassedy, A., Stancin, T., 

Kirkwood, M. W., & Brown, T. M. (2014). Counselor-assisted problem 

solving improves caregiver efficacy following adolescent brain injury. 

Rehabilitation Psychology, 59(1), 1–9. https://doi.org/10.1037/a0034911

19 Raj, S. P., Antonini, T. N., Oberjohn, K. S., Cassedy, A., Makoroff, K. L., & 

Wade, S. L. (2015). Web-based parenting skills program for pediatric 

traumatic brain injury reduces psychological distress among lowerincome parents. Journal of Head Trauma Rehabilitation, 30(5), 347–

356. https://doi.org/10.1097/htr.0000000000000052 

20 Raj, S. P., Shultz, E. L., Zang, H., Zhang, N., Kirkwood, M. W., Taylor, H. 

G., Stancin, T., Yeates, K. O., & Wade, S. L. (2018). Effects of Webbased parent training on caregiver functioning following pediatric 

traumatic brain injury: A randomized control trial. Journal of Head 

Trauma Rehabilitation, 33(6). 

https://doi.org/10.1097/htr.0000000000000388 

21 Graham, K. M., Kreutzer, J. S., Marwitz, J. H., Sima, A. P., &; Hsu, N. H. 

(2020). Can a couples’ intervention reduce unmet needs and caregiver 
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burden after brain injury? Rehabilitation Psychology, 65(4), 409–417. 

https://doi.org/10.1037/rep0000300

22 Backhaus, S., Neumann, D., Parrott, D., Hammond, F. M., Brownson, C., 

&; Malec, J. (2019). Investigation of a new couples intervention for 

individuals with brain injury: A randomized controlled trial. Archives of 

Physical Medicine and Rehabilitation, 100(2). 

https://doi.org/10.1016/j.apmr.2018.08.174
66

Section VI: Modifying 

Psychopharmacologic Interventions 

for TBI

Michael Chiou, MD, and Lindsey Gurin, MD, NYU Langone Health

Introduction

Alterations of mood, cognition and behavior are common after TBI. These 

posttraumatic neuropsychiatric symptoms are best understood in the context 

of a biopsychosocial model in which structural and/or functional disruption of 

key brain circuitry; pre-injury personality traits; and family, sociocultural, 

economic and other medical factors may each play variable roles in 

determining an injured individual’s unique symptoms burden. Ideal treatment 

of posttraumatic neuropsychiatric symptoms thus involves a comprehensive, 

multipronged treatment approach tailored to the individual’s specific cognitive, 

emotional and social needs. Psychopharmacologic treatment, often a crucial 

component of this treatment paradigm, is most effective when delivered in 

tandem with non-pharmacologic supportive strategies. 

As Sir Charles Symonds famously put it in 1937, to understand psychiatric 

symptoms after head injury, “it is not only the kind of injury that matters, but 

the kind of head.”1 In TBI, traumatic alterations of key neural circuitry are only 

one part of the overall picture; these changes must be understood within the 

context of a whole person whose unique personality structure, preexisting 

psychiatric vulnerabilities and life experience will influence the expression of 

posttraumatic psychiatric symptoms. Appreciation for these multifaceted 

biopsychosocial influences on psychiatric symptomatology is a fundamental 

aspect of psychiatric care in any population. While some of the details of 

pharmacotherapy in TBI may differ from those of general psychiatric practice, 

the broad framework is the same. 

The goal of this section is to provide state brain injury personnel with the 

necessary background and information to effectively communicate with their 

behavioral health partners and provide them with an array of accessible 

approaches for modifying psychopharmacologic interventions for TBI.
67

General Approach

Effective pharmacologic treatment of any psychiatric issue begins with a 

psychiatric assessment in which specific target symptoms are identified. From 

this, a working diagnosis is developed and rational pharmacotherapy is 

initiated, drawing on the available evidence base to address target symptoms 

within the context of the working diagnosis. Ongoing monitoring for treatment 

response and emergence of adverse effects provide feedback that can be 

used to revise the diagnosis and treatment plan as needed. 

Pharmacologic treatment of psychiatric symptoms after TBI follows this same 

basic process, albeit with several unique clinical challenges. Posttraumatic 

cognitive impairment, neurologic sequelae and medical complications can 

interact with psychiatric symptoms to produce complex symptom 

constellations that are anything but straightforward to interpret. Even once a 

diagnostic framework is established, the evidence base for treatment is limited 

by a relative dearth of randomized controlled trials and substantial 

methodological variability across the studies that do exist.2 Medications 

developed for primary psychiatric disorders may not always translate 

effectively to psychiatric symptoms in TBI, and individuals with TBI are at 

increased risk of adverse effects with any psychotropic medication trial. 

All of this being said, pharmacotherapy can be a crucial and often highly 

effective component of treatment for posttraumatic neuropsychiatric 

disturbances. Adherence to a systematic approach that emphasizes 

identification of specific psychiatric, cognitive and behavioral target symptoms 

is key. Depending on the clinical scenario, rational prescribing for 

posttraumatic neuropsychiatric symptoms may be extrapolated from data 

related to the primary psychiatric disorder they most resemble; informed by 

studies specific to TBI, if available; or driven by a hypothesis of the 

neurotransmitter disturbances involved based on the extent and location of 

structural brain injury. 

Psychiatrists already possess the fundamental clinical evaluation skills and 

familiarity with basic neurochemistry and psychopharmacology needed to 

evaluate and treat posttraumatic neuropsychiatric symptoms effectively. In the 

following sections, we discuss modifications to the standard psychiatric 

evaluation that can improve diagnostic clarity in TBI and provide an overview 

of key principles of TBI psychopharmacology. The key is to empower 

psychiatrists to adapt their existing skill sets to meet the complex — but often 

highly treatment-responsive — psychopharmacologic needs of this deeply 

underserved population.
68

Psychiatric Assessment: Modifications 

for TBI

Assessment of neuropsychiatric symptoms in TBI begins with the standard 

initial psychiatric evaluation familiar to all psychiatrists. This is supplemented 

with additional history and examination geared toward identifying common 

neurocognitive and neurobehavioral sequelae of TBI that may confound 

psychiatric diagnosis and/or represent independently treatable target 

symptoms.

Before beginning: Timing of assessment relative to 

injury

TBI is a dynamic process in which primary mechanical injury triggers a 

secondary cascade of damaging neurochemical events that may extend well 

beyond the primary injury in both time and space. At the same time, focal brain 

injury may trigger a transient increase in the brain’s capacity for reorganization 

(i.e., neuroplasticity). The combined impact of these interacting processes 

promoting injury and recovery, respectively, creates a situation in which 

dramatic neurobehavioral changes are expected in the first days, weeks and 

months following TBI, independent of any psychopharmacologic intervention.

Acute recovery from a TBI follows a generally predictable trajectory in which 

initial loss of consciousness is followed by emergence into an acute 

confusional state, most commonly referred to as posttraumatic amnesia 

(PTA).3 The core feature of PTA is impaired memory consolidation, and 

additional features of delirium (e.g., sleep-wake disturbances, hallucinations) 

are variably present. Return of continuous memory consolidation marks the 

end of PTA. Injured individuals are invariably amnestic for this period of time 

(and may report it retrospectively as time spent unconscious). The length of 

time spent in PTA correlates closely with injury severity and is a strong 

predictor of a wide range of functional outcomes after TBI. Residual cognitive 

impairment, especially with regard to executive function, is common after 

emergence from PTA; further recovery varies by individual and may continue 

for months or years after injury.

Having a general sense of the length of time from injury thus provides 

important background context for psychiatric assessment with TBI. The more 

recent the injury, the more plausible it is that an individual may still be making 

his or her way along this continuum. For these individuals, frequent 

reassessments are especially important to ensure that the 
69

psychopharmacologic regimen is keeping pace with the neurobehavioral 

changes that are expected to occur during natural recovery.

Psychiatric interview 

As in routine psychiatric practice, a history of the present illness (HPI) is 

obtained via a combination of open-ended questioning and screening via the 

psychiatric review of systems (ROS). It is worth bearing in mind that cognitive 

impairments, especially in the areas of self-awareness and verbal 

communication, may make it difficult for individuals with TBI to appreciate and 

report symptoms accurately. In light of this, collateral information from a 

reliable family member or other caregiver is crucial, especially for those with 

more severe injuries. 

In addition to the inquiries about mood, anxiety, psychosis and other 

psychiatric target symptoms that comprise the standard psychiatric HPI and 

ROS, several neuropsychiatric symptom domains warrant special attention in 

TBI: 

1. Disorders of sleep and wakefulness are extremely common after TBI 

and should be assessed even if these are not part of the presenting 

complaint, as poor sleep and/or impaired daytime wakefulness can 

substantially exacerbate existing cognitive and psychiatric symptoms 

and can reduce the injured person’s capacity to cope with various 

stressors. Insomnia, fatigue and reduced daytime arousal or excessive 

daytime sleepiness each represent independent target symptoms that 

are potentially amenable to pharmacotherapy. 

2. Emotional and behavioral dyscontrol are common after TBI.4 These 

problems typically resolve in the post-acute period after mild TBI but 

may persist in more severely injured individuals. Emotional dyscontrol 

may manifest as irritability, affective lability, or pathologic laughing and 

crying (also known as pseudobulbar affect). Behavioral dyscontrol may 

manifest as disinhibition or aggression. While these symptoms 

commonly co-occur with other posttraumatic neuropsychiatric 

disturbances, they are target symptoms in their own right. 

3. Disorders of diminished motivation are common in TBI and occur along 

a spectrum from apathy, at the mild end, to akinetic mutism at its most 

severe. Apathy often co-occurs with depression, though it can present 

in isolation and is a potential target symptom.

5 
70

4. Agitation is a nonspecific term that may refer to a wide range of 

problematic behaviors including, among others, motor restlessness 

(akathisia), impulsivity or explosive behaviors.6 Agitation is often 

multifactorial in etiology and may be driven by the combined effect of 

other neuropsychiatric symptoms, physical discomfort, cognitivecommunication limitations and environmental stressors, among others. 

When agitation is reported by collateral informants, it is essential to 

elicit detailed descriptions of specific problematic behaviors and probe 

for possible underlying triggers. Given its broad range of manifestations 

and etiologies, agitation is not itself a specific target symptom; rather, it 

is usually driven by one or more target symptoms that themselves may 

warrant intervention. 

5. Neurocognitive symptoms are a major contributor to functional and 

behavioral impairments in TBI of all severities, especially in moderate 

and severe injuries, and their assessment is crucial. Cognitive problems 

may be reported subjectively by the individual or observed by a 

collateral informant. The cognitive domains most often affected by TBI 

are attention, processing speed, memory and executive function.7

Neurocognitive symptoms are important potential targets of 

pharmacotherapy in individuals with TBI. Effective treatment of these 

symptoms can produce helpful downstream effects for other psychiatric 

symptoms as well as for overall level of functioning. 

Medical and Neurological Review of 

Systems

Psychiatrists are well aware of the crucial role they play in the care of 

individuals with co-occurring psychiatric and medical problems. Psychiatric 

illness can make it difficult for individuals to appreciate somatic symptoms and 

report them in a way that is readily interpreted by medical providers. Even 

when symptoms are reported accurately, the persistence of widespread 

stigma associated with mental health diagnoses can produce unconscious 

bias on the part of medical providers that may confound diagnostic 

assessment. 

These issues are especially relevant in TBI. Medical complications of TBI can 

contribute to neuropsychiatric symptoms, and the presence of 

neuropsychiatric symptoms may interfere with the injured individual’s ability to 

seek out and participate appropriately in necessary medical care. Armed with 

a combination of medical training and experience navigating challenging 
71

behaviors and communication styles that make them unique within the 

healthcare system, psychiatrists can add tremendous value by cutting through 

the “noise” of complex neuropsychiatric presentations in TBI to identify 

potentially relevant underlying medical issues and facilitate further care with 

appropriate specialists. 

In light of the time constraints associated with assessment in the outpatient 

psychiatry setting, we suggest a focused medical ROS covering the most 

common medical sequelae of TBI affecting the neurological, endocrine, 

gastrointestinal, genitourinary and musculoskeletal systems. 

Neurological symptoms are of particular importance. Common issues include, 

but are not limited to:

▪ Headaches. 

▪ Visual disturbances (e.g., loss of acuity, eye movement abnormalities). 

▪ Vestibular system dysfunction (e.g., vertigo, imbalance). 

▪ Seizures. 

▪ Dysautonomia (e.g., postural orthostatic tachycardia syndrome [POTS] 

in milder injuries; paroxysmal sympathetic hyperactivity [PSH], often 

described as autonomic “storming,” in more severe injuries). 

▪ Spasticity. 

▪ Chronic pain. 

Eye movement abnormalities, especially convergence insufficiency, are 

especially relevant in mild TBI, where they may be the sole, subtle, objective 

manifestation of central nervous system dysfunction. In addition to contributing 

to visual strain that can exacerbate headaches, oculomotor dysfunction can 

interfere with the performance of visually mediated cognitive tasks (reading, 

for example) and cause substantial psychological distress. Dysautonomia, 

increasingly recognized as a common complication of even mild TBI, can 

manifest as exercise intolerance or as episodic tachycardia, triggering anxiety 

or panic. Posttraumatic seizures can begin at any time after TBI, even years 

later, and may present subtly as attentional lapses or stereotyped behavioral 

changes in the absence of overt abnormal movements; abrupt onset or 

paroxysmal fluctuations of neuropsychiatric symptoms may raise concern 

about underlying seizure activity.
72

The pituitary gland is vulnerable to injury in TBI. Individuals with TBI may 

develop neuroendocrine dysfunction immediately post-injury or after a delay of 

months or years. Symptoms such as severe fatigue, excessive thirst or 

hunger, menstrual irregularities or erectile dysfunction may reflect 

posttraumatic hypopituitarism.

Nausea and vomiting are common after TBI. When present immediately postinjury, especially after moderate to severe TBI, intractable nausea and 

vomiting typically prompt investigation of structural causes of increased 

intracranial pressure. In the post-acute and chronic phases of recovery, 

considerations include migraine, vestibular dysfunction, or neurogenic 

gastroparesis due to TBI, among others.

Bowel and bladder dysfunction are common after TBI and can be a source of 

significant distress for injured individuals and caregivers. Incontinence may be 

related to altered sphincter control, impaired recognition of somatic voiding 

cues, or both. Constipation and urinary retention can be caused by TBI or may 

be caused or exacerbated by medications, including many psychotropics.

Musculoskeletal pain may be related directly to orthopedic injuries or to 

heterotopic ossification (HO), a process of aberrant bone formation in soft 

tissue triggered by central nervous system trauma that can cause substantial 

pain, immobility and joint deformity.

Details of injury 

Details of the TBI itself should be obtained to the fullest extent possible. An 

understanding of the injury severity and, ideally, extent and location of focal 

brain injury (if any) can provide helpful context for psychiatric symptoms, direct 

attention to specific potential cognitive symptoms and guide pharmacologic 

treatment. If medical records are not available, a rough approximation of injury 

severity may be elicited via questioning about presence and length of acute 

loss of consciousness, length of time spent in PTA, length of hospitalization, 

neurosurgical procedures and post-discharge utilization of inpatient and/or 

outpatient rehabilitation services.

Psychiatric and medical history

Personal and family psychiatric history, substance use history, medical history 

and social and occupational history should also be elicited. A thorough 

exploration of pre-injury psychiatric and psychosocial functioning can provide 

essential background context for understanding posttraumatic 

neuropsychiatric symptoms. Premorbid substance use disorders in particular 
73

may increase risk of TBI, and their presence or persistence after TBI can 

exacerbate other posttraumatic cognitive and neuropsychiatric symptoms. 

Similarly, ADHD has a bidirectional relationship with TBI in which ADHD 

increases risk of TBI, and TBI can exacerbate the cognitive and 

neuropsychiatric disturbances of ADHD. For individuals with cognitive 

dysfunction, taking a developmental history that includes any birth 

complications, developmental delays (milestones, need for early intervention 

services or therapies in early childhood) and educational accomplishment can 

provide helpful context. 

The medical history should include a neurologic history attuned to common 

posttraumatic complications. A history of posttraumatic hydrocephalus and any 

associated cerebrospinal fluid shunting procedures may be relevant for 

individuals presenting with progressive neurocognitive or behavioral 

disturbances. Seizures are important to inquire about, as the presence of 

epilepsy may affect psychotropic medication choice, and antiseizure 

medications may have a wide range of adverse neuropsychiatric effects. In 

general, the medication list should be reviewed for potential contributors to 

cognitive impairment, sedation, akathisia or psychiatric disturbances.

Mental status exam

The mental status exam (MSE) for TBI includes the standard psychiatric MSE 

plus some degree of objective cognitive assessment. While the initial 

psychiatric interview may yield relevant observations about gross cognitive 

function, brief in-office screening instruments can provide a measure of basic 

cognitive function across multiple domains. The most commonly used 

instruments are the MMSE; MoCA; and the Saint Louis University Mental 

Status (SLUMS) Examination.

8 These instruments are not TBI-specific, but 

they can nonetheless provide a rapid general overview of multi-domain 

cognitive function. The MoCA and SLUMS are preferred for their broader 

assessment of multiple cognitive domains; the MMSE covers fewer domains, 

though it is a quicker assessment that may be more practical for individuals 

who cannot tolerate longer testing. In our experience, such screening tools 

can be useful even for persons without overt cognitive complaints, as cognitive 

dysfunction is common after TBI of all severities and even subtle cognitive 

deficits may influence neuropsychiatric symptoms. 

Further neurological and medical assessment

Depending on the circumstances, a focused neurological exam, serum 

laboratory studies, neuroimaging and electroencephalography (EEG) can be 

useful adjuncts to the psychiatric assessment in providing additional data 
74

about the extent, severity and location of focal brain injury. In addition to the 

serum studies typically obtained by psychiatrists as part of a comprehensive 

initial evaluation, we suggest lowering the threshold for obtaining pituitary 

hormone screenings, especially in patients presenting with neurovegetative 

symptoms, menstrual irregularities or sexual dysfunction. 

Neuroimaging, preferably brain magnetic resonance imaging (MRI), should be 

obtained (or previous imaging reviewed) at least once for all individuals with 

TBI seeking psychiatric care, especially those with moderate or severe 

injuries. The presence of overt structural damage to key neurobehavioral 

circuitry — for example, the inferior frontal and anterior temporal cortices, 

which are commonly injured in TBI — can help to clarify the etiology of some 

symptoms and potentially influence treatment. 

It is important to note here, however, that while evidence of focal brain injury 

as demonstrated by neurological exam or ancillary testing can support a 

history of TBI and provide useful information for treatment planning, absence 

of such evidence does not mean that a TBI did not occur, nor does it mean 

that lasting posttraumatic impairments are not possible. By definition, mild TBI 

is associated with normal structural imaging, and individuals with more severe 

injuries can also experience neurobehavioral impairments that appear 

disproportionate to the extent of injury visible on imaging. Diffuse axonal injury 

(DAI), which occurs in TBI as a result of shearing forces applied to the graywhite matter junction and brainstem, can cause devastating neurologic 

impairment despite relatively normal brain computed tomography (CT) imaging 

or only subtle abnormalities on brain MRI. If a new MRI is obtained, especially 

in an individual with reportedly normal prior imaging, it can be helpful to alert 

the reading radiologist to the suspected TBI history so that particular attention 

can be paid to the sequences most likely to reveal evidence of prior DAI 

(typically, susceptibility-weighted imaging [SWI] or gradient echo [GRE]). 

Diagnostic formulation

Psychiatric diagnosis is challenging in TBI; underlying central nervous system 

pathology can alter the expression of psychiatric illness and vice versa, 

leading to atypical presentations of both. Posttraumatic psychiatric symptom 

constellations frequently do not fit neatly into standard diagnostic categories. 

Rather than seeking a unifying psychiatric diagnosis, it may be more feasible 

to apply one or more “best fit” diagnoses to individual symptoms and symptom 

clusters. If a symptom cluster resembles a primary psychiatric disorder, even if 

formal criteria are not met, it is reasonable to conceptualize and treat along 

these lines. Alternatively, some symptoms may be better explained in isolation 
75

as direct neurobehavioral sequelae of TBI. If a preexisting psychiatric illness 

was present, consider the possibility that some symptoms may represent a 

continuation or exacerbation of this illness, now manifesting atypically due to 

TBI.

Posttraumatic cognitive impairments may mimic features of psychiatric illness, 

especially when they occur in combination. The combination of slowed 

processing speed and impaired behavioral initiation may look like depression. 

Poor sustained attention coupled with impaired behavioral response inhibition 

can produce a restless, irritable hyperactivity similar to that of hypomania. The 

behavioral perseveration, impaired social cognition and pleasure-seeking 

behavior with limited capacity for deferred gratification that commonly occur 

after inferior frontal lobe injury can be mistaken for a willful disregard for 

instructions, lack of empathy and profound egocentricity, as might be seen in 

antisocial personality disorder. 

In many cases, the etiology of a given symptom is not immediately clear on 

initial evaluation. In these cases, empiric treatment of a target symptom can be 

clarifying. In practice, the ultimate goal of psychiatric evaluation in TBI is to 

distill a complex, multifaceted presentation into a set of target symptoms that 

can be addressed via rational pharmacotherapy.

Psychopharmacologic Treatment: 

General Principles in TBI 

“Without a map, you cannot get to your destination”:9 know your target 

symptoms. 

While identification of clear target symptoms is essential to good 

psychopharmacologic practice in any population, it is of the utmost importance 

in TBI, where the organizational structure provided by a diagnosis may not be 

readily available. Absence of a clear, definitive psychiatric diagnosis need not 

preclude attempts at pharmacologic treatment as long as there is a solid 

rationale linking medication choice with target symptoms. 
76

Table 3: General Psychopharmacological Treatment 

Principles

Medication lists in TBI can be long and may include agents that interact poorly with 

each other or with the injured person’s neuropsychiatric substrate. 

Whenever Possible, Add by Subtraction First

Before adding a new medication, consider whether reduction or removal of any 

medications might benefit target symptoms. In addition to the common offenders

— antiseizure medications, sedative-analgesics, medications with significant 

anticholinergic burden — consider whether agents previously added to target 

neuropsychiatric symptoms could be producing paradoxical or otherwise 

unwanted effects — for example, increased anxiety and insomnia due to selective 

serotonin reuptake inhibitors (SSRIs) or stimulants; akathisia due to antipsychotics; 

urinary retention or constipation due to anticholinergic impact of amantadine, 

paroxetine, tricyclic antidepressants or atypical antipsychotics.

“Start Low, Go Slow — but Go.” 

This well-known guiding principle of geriatric psychopharmacology applies equally 

to medication management in TBI. Individuals with TBI are sensitive to adverse 

effects of psychotropic medications. Initiation of any pharmacotherapy should 

begin with a low starting dose and be titrated gradually. Nonetheless, standard 

doses may be necessary to achieve therapeutic benefit. 

In the absence of significant adverse effects, prescribers should avoid abandoning 

medication trials prematurely and should not be afraid to increase doses to 

therapeutic range, especially if lower doses are producing a partial treatment 

response.

Reassess Frequently and Adjust as Needed

Even once accurately assessed, neuropsychiatric symptoms in TBI are something of 

a moving target. Symptom evolution is expected as the individual recovers, ages or 

encounters new physiologic or psychosocial stressors. The target symptoms, 

treatment response and presence of side effects must be reassessed frequently, 

with therapy adjusted accordingly. 

Avoid Polypharmacy — Most of the Time

Polypharmacy is a constant concern in TBI. Persons with TBI frequently need 

multiple medications to manage various medical comorbidities and simultaneously 

may be at increased risk of making medication errors due to cognitive impairment. 

All efforts should be made to streamline medication regimens. 

This being said, in some cases where side effects have limited an otherwise 

successful or partially successful psychopharmacologic trial, dose reduction in 

conjunction with addition of a low dose of a second synergistic agent may provide 

a workaround that allows for improved symptom benefit while avoiding the side 

effects encountered at higher doses. 
Specific Posttraumatic 

Neuropsychiatric Syndromes 

Agitation 

Agitation is a nonspecific term for a number of problematic behaviors that can 

occur after acquired brain injury, including disinhibition, aggression, 

restlessness, akathisia and inappropriate verbalization.10 The causes of 

agitation are typically multifactorial and related to a combination of focal 

cerebral dysfunction (e.g., primary lesion to the frontal lobe, temporal lobe, 

prefrontal cortex, thalamus and/or limbic system), neurotransmitter 

dysregulation and impaired cognitive capacity to cope with and communicate 

about stressors. Agitation frequently manifests as an excess of motor and 

verbal behaviors that interfere with care or pose a risk to self or others. 

Predictors of agitation include PTA, impaired cognition and lower functional 

status. Exacerbating factors include more severe injury, premorbid history of 

substance abuse and presence of infection. Agitation has been associated 

with longer lengths of stay in both hospital and acute rehabilitation settings. 

Management is essential to permit effectiveness of therapies; assist 

community integration; and ensure the safety of the patient, caregivers and 

staff. 

Agitation is a diagnosis of exclusion.11 As such, other medical conditions (e.g., 

pain, infection, medication side effects), neurological causes (e.g., 

hydrocephalus, seizures, intracranial mass lesions) and psychiatric causes 

(e.g., underlying personality or mood disorders, sundowning, substance use) 

should first be ruled out with a complete blood count, complete metabolic 

panel, thyroid function tests, urinalysis or urine culture, urine toxicology, 

cerebrospinal fluid analysis, X-ray, CT, MRI; and/or electroencephalogram. 

Diagnosis may be aided by the Agitated Behavior Scale (ABS) and the Overt 

Aggression Scale (OAS).12 The ABS is a measure of agitation specifically 

created for the brain injury population and is helpful for monitoring both patient 

recovery and mediation effectiveness. It is scored 1–4 in 14 domains, 

including distractibility, impulsivity, cooperativeness, verbal and nonverbal 

behavior, aggression, wandering, restlessness and mood. A total score of < 21 

is normal and > 35 indicates severe agitation. The OAS is an observational 

scale that allows recording of type, severity and frequency of various 

aggressive verbal and physical behaviors. 

Shown below are the first-line management of agitation, which includes 

environmental and behavior modifications. 

77 
78

A. First-line Management of Agitation 

• Reduce external stimuli by minimizing light, noise and other distractions. 

• Minimize use of restraints, tubes and lines. 

• Staff and patient family members should frequently reorient the patient. 

• Encourage proper sleep hygiene and sleep quality with a sleep schedule and 

bedtime routine and minimize use of electronics 30–60 minutes before 

bedtime. 

• For restless patients, supervised ambulation may be helpful. 

• Patients with aggression or behavioral issues should be managed by staff 

trained in de-escalation techniques.

Shown below are the pharmacological management strategies for agitation. 

B. Pharmacological Management of Agitation 

• Use of beta blockers (propranolol), antiepileptic drugs (carbamazepine, 

valproic acid), antidepressants (SSRIs, tricyclic antidepressants, trazodone, 

lithium), antipsychotics (typical and atypical), neurostimulants (amantadine, 

methylphenidate) and anxiolytics (buspirone, benzodiazepines).13, 14

• Medications should be trialed one at a time, in the lowest starting dose 

available and with slow increases, while monitoring for medication 

effectiveness and side effects. Frequent reassessment is critical. 

• Be mindful that the effective dose for medications commonly used in the 

general population may be lower in the brain injury population due to the 

sensitivity of the brain after injury (although traditional therapeutic doses may 

ultimately be necessary). Furthermore, the need for medication and 

medication dosing may change during the course of brain injury recovery.

• Propranolol has the best evidence for efficacy in treating agitation in the brain 

injury population with no adverse effect on motor or cognitive recovery. It has 

been shown to improve restlessness, disinhibition, anxiety and tremor. 

Consider a starting dose of 10 mg given three to four times a day with a 

maximum dose of 240 mg/day. Side effects include hypotension, bradycardia 

and lethargy. Propranolol should be considered a maintenance medication, to 

be given around the clock, and not on an as-needed basis for periods of acute 

agitation. 

• For acute agitation, consider atypical antipsychotics such as quetiapine, 

ziprasidone, and olanzapine, again with low starting doses and given as 

needed. Side effects include sedation, extrapyramidal symptoms and dizziness. 

It is recommended to avoid use of typical antipsychotics (haloperidol) and 

benzodiazepines as they may hinder long-term motor and cognitive recovery, 

prolonged posttraumatic amnesia, and have risk of dependence and addiction.
79

Sleep dysfunction

Sleep dysfunction after a traumatic or nontraumatic brain injury is a major 

contributor to daytime fatigue. As such, proper diagnosis and treatment permit 

effectiveness of therapies and aid long-term recovery. Sleep dysfunction is 

common after a brain injury, with a reported incidence of up to three times that 

of the general population.15,16 Brain injury patients have been shown to have 

poorer sleep efficacy, shorter total sleep duration and greater wake after sleep 

onset time. Brain injury patients spend less time in Rapid eye movement 

(REM) sleep and have greater subjective sleepiness and poorer perceived 

sleep quality. This may be due to biochemical changes in the brain after injury 

and/or damage to the hypothalamus, brainstem, reticular activating system 

and basal forebrain. Evaluation of sleep disorders includes recording a sleep 

log and polysomnography. Technological advancements have permitted 

increased use of actigraphy (e.g., wearable watches to monitor sleep).

Prior to pharmacological intervention, consider other factors that may cause 

insomnia, including medications (SSRIs, neurostimulant use), pain, PTSD, 

anxiety, depression and external environmental factors or poor sleep hygiene. 

Those factors should be addressed first.

Shown below are the first-line pharmacological interventions for sleep 

dysfunction. 

A. First-line Pharmacological Interventions for Sleep 

Dysfunction 

• Use of melatonin and melatonin agonists (ramelteon), trazodone and 

mirtazapine. 

• Medications should be trialed one at a time, in the lowest starting dose 

available, with slow increases, while monitoring for medication effectiveness 

and side effects. Frequent reassessment is critical. 

• Use caution in older adults with all sedating medications, which may increase 

risk of nighttime falls. 

• Other options that have been tried include tricyclic antidepressants (which may 

concurrently treat neuropathic pain and insomnia) and hypnotics (e.g., 

zolpidem, zopiclone, eszopiclone, zaleplon). 

• Neurostimulant use for daytime arousal may facilitate nighttime sleepiness and 

improve sleep dysfunction. Stimulants for daytime wakefulness should typically 

be trialed only after attempts have been made to consolidate nighttime sleep. 

Modafinil, a wakefulness-promoting agent approved for the treatment of 
80

narcolepsy and excessive daytime sleepiness due to obstructive sleep apnea, 

may be of use. 

• Non-pharmacologic interventions may also be beneficial, including bright light 

therapy, cognitive behavioral therapy, stimulus control and cognitive 

restructuring.

Disorders of affect, mood and anxiety

Affective dysregulation after a traumatic or nontraumatic brain injury occurs on 

a spectrum ranging from inappropriately flat affect to irritability, lability and 

pathologic laughing and crying. Individuals with TBI may have a diminished or 

absent ability to voluntarily control and regulate emotion. Both dysregulated 

emotion and the diminished ability to express emotion leads to increased 

burden for patients and caregivers.

Care should be taken to distinguish disturbances of affect from mood 

disorders wherever possible. Irritability, affective lability and pathologic 

laughing and crying can occur in the absence of associated mood 

disturbances. Individuals may report feeling that their outward expression of 

affect is disproportionate to, or altogether discordant with, subjective mood; 

that they have difficulty controlling emotional responses; or that family and 

friends misunderstand their emotional reactions. 

Shown below are the first-line pharmacological interventions for posttraumatic 

affective dysregulation. 

A. First-line Pharmacological Interventions for 

Posttraumatic Affective Dysregulation

• SSRIs are the first-line treatment for posttraumatic affective dysregulation and 

can be highly effective for this problem, typically at lower doses than are 

required for treatment of depression and with therapeutic benefit often seen 

within days of drug initiation. 

• Tricyclic antidepressants (TCAs) can also be useful, though their greater sideeffect profile warrants some additional caution. 

• Nuedexta, a combination drug comprised of dextromethorphan and quinidine, 

is approved for the treatment of pseudobulbar affect (pathologic laughing and 

crying) and can be tried if SSRIs and TCAs are unsuccessful or contraindicated.
81

Apathy is similarly important to distinguish from depression, though these two 

disorders co-occur commonly. Neurostimulants (see below) may be beneficial 

for apathy in some individuals with TBI.

The two most common psychiatric disorders after TBI are posttraumatic 

depression and general anxiety disorder, often due to biochemical and organic 

changes after TBI (e.g., frontal lobe injury). Pre-injury anxiety, depression and 

substance abuse are leading risk factors for post-injury depression and anxiety 

disorder.17 Diagnosing posttraumatic depression involves experiencing five or 

more of the following symptoms during a two-week period: depressed mood, 

decreased interest or pleasure, weight or appetite change, sleep disturbance, 

psychomotor slowing or agitation, fatigue, feeling of worthlessness, diminished 

concentration or cognition, and/or recurrent thoughts of death or suicidal 

ideation, and at least one of the symptoms should be either depressed mood 

or decreased interest or pleasure. Diagnosing general anxiety disorder 

involves experiencing excessive anxiety or worry, difficulty controlling worrying 

and at least three or more of the following symptoms: restlessness, easily 

fatigued, difficulty concentrating, irritability, muscle tension and/or sleep 

disturbance.

Posttraumatic depression and general anxiety disorder are often 

underdiagnosed (and undertreated). The gold standard for diagnosis is the 

Structured Clinical Interview for DSM-5 (SCID-5), which is a structured 

interview guide administered by clinicians or trained mental health 

professionals. Structured diagnostic interviews are superior to self-report 

measures — such as the Patient Health Questionnaire-9 (PHQ-9), Beck 

Depression Inventory-II (BDI-II) and Neurobehavioral Functioning Inventory 

(NFI) Depression Scale — but self-report measures may provide benefits in 

the domains of screening and symptom monitoring.

Shown below are the first-line pharmacological interventions for posttraumatic 

depression. 

A. First-line Pharmacological Interventions for 

Posttraumatic Depression

• SSRIs such as sertraline and fluoxetine.18

Shown below are the second-line interventions for posttraumatic depression. 
82

B. Second-line Interventions for Posttraumatic Depression

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) and TCAs. 

• Because these medications are also effective for pain, SNRIs and TCAs may be

of particular utility when there are co-occurring headaches or other pain 

syndromes. Medications should be trialed one at a time, in the lowest starting 

dose available, with slow increases while monitoring for medication 

effectiveness and side effects. 

• Cognitive behavioral therapy, problem-solving therapy and behavioral 

activation training have shown favorable outcomes for treating depression in 

the brain injury population.

Neurocognitive impairments

There is growing evidence supporting the use of pharmacotherapy to improve 

cognitive function after traumatic and nontraumatic brain injury. Most 

approaches seek to enhance cerebral catecholaminergic or acetylcholinergic 

function.19 

Table 10 shows the first-line pharmacological interventions for posttraumatic 

neurocognitive impairments. 

Table 4: First-line Pharmacological Interventions for 

Posttraumatic Neurocognitive Impairments

• The most commonly used medications are amantadine, a glutamate antagonist 

with dopamine-modulating properties approved for treatment of Parkinson’s 

disease and drug-induced parkinsonism; methylphenidate, a stimulant 

approved for treatment of ADHD; and donepezil, an acetylcholinesterase 

inhibitor approved for treatment of Alzheimer’s disease.

Amantadine is most often used for hypoarousal based on evidence for its 

benefit in patients with posttraumatic disorders of consciousness (e.g.,

minimally conscious or vegetative state),20 though it can also be beneficial for 

attention and executive function in less severely impaired patients and may 

improve agitation and irritability in some. Amantadine dosing typically begins 

at 100mg/day in the morning and can be titrated as tolerated to a maximum of 

400mg/day, divided into two doses (usually morning and midday to avoid 

sleep disruption). The most common side effects are orthostatic hypotension 

and nausea; psychosis is rare but can occur at high doses. Constipation and 

urinary retention are possible as a result of amantadine’s mild anticholinergic 
83

impact, and reduction of seizure threshold is a concern in individuals with 

tenuously controlled epilepsy. A dose reduction is required for renal 

insufficiency. 

Methylphenidate has been shown to benefit attention, behavioral initiation and

wakefulness in individuals with TBI. Dosing typically begins at 5mg twice daily, 

given in the morning and at midday. Common side effects include anxiety, 

irritability and insomnia; tachycardia is a consideration and may be a limiting 

factor, especially in individuals with dysautonomia. Methylphenidate has not 

been shown to reduce seizure threshold in TBI and is considered safe to use 

in patients with epilepsy.

Donepezil has been shown to benefit posttraumatic memory and attention 

impairments. Standard dosing is 5 to 10mg/day. Common side effects include 

headache, nausea, diarrhea and anorexia. These side effects may be 

minimized with nighttime administration, though dosing at night can be 

associated with vivid dreams.

While stimulants may appear to be a counterintuitive choice in cases in which 

there is significant irritability, motor restlessness or disinhibition, it is worth 

keeping in mind the possibility that these features may be driven by underlying 

difficulties with sustained attention or executive function that may be stimulant

responsive. Psychiatrists will recognize this reasoning as analogous to the use 

of stimulants to treat hyperactivity in ADHD. In many instances, supporting 

sustained attention and executive function with judicious use of stimulants can 

substantially improve the injured individual’s ability to participate meaningfully 

and appropriately in a wide variety of cognitive and social activities.

Medical contributors

Recommendations for comprehensive management of posttraumatic medical 

and neurologic sequelae are beyond the scope of the present discussion. 

Awareness of these issues, however, may influence psychiatric management. 

When depressed mood or anxiety is accompanied by headaches or chronic 

pain, SNRIs or TCAs may be beneficial. SSRIs can improve chronic subjective 

dizziness. Levetiracetam, used commonly for treatment of posttraumatic 

epilepsy, can contribute to depressed mood and irritability. When this is a 

consideration, individuals may benefit from switching (with guidance from

neurology) to mood-stabilizing antiseizure medications such as valproic acid or 

oxcarbazepine, keeping in mind that while these agents may be preferable for 

mood, they are more likely than levetiracetam to contribute to sedation and 

ataxia. In general, whenever possible, we suggest close communication with 
84

an individual’s medical providers so that pharmacotherapy may be tailored to 

address psychiatric and nonpsychiatric issues in the most streamlined way 

possible.

Summary

Having a foundational understanding of psychiatric issues and general 

principles of psychiatric and pharmacological interventions related to brain 

injury will allow the state brain injury program to engage their behavioral health 

partners more effectively. In addition, the modification tips can easily be 

passed onto psychiatrists in the field to assist them in achieving better 

outcomes for individuals with brain injury and co-occurring behavioral health 

concerns. 

1 Lombard, L. A., & Zafonte, R. D. (2005, October). Agitation after traumatic 

brain injury: Considerations and treatment options. American Journal of 

Physical Medicine & Rehabilitation, 84(10), 797–812. 

https://doi.org/10.1097/01.phm.0000179438.22235.08

2 Luaute, J., Plantier, D., Wiart, L., & SOFMER group. (2016, February). Care 

management of the agitation or aggressiveness crisis in patients with 

TBI. Systematic review of the literature and practice recommendations. 

Annals of Physical and Rehabilitation Medicine, 59(1), 58–67. 

https://doi.org/10.1016/j.rehab.2015.11.001

3 Ponsford, J., Carrier, C., Hicks, A., & McKay, A. (2021, April 15). 

Assessment and management of patients in the acute stages of 

recovery after traumatic brain injury in adults: A worldwide survey. 

Journal of Neurotrauma, 38(8): 1060-1067. 

https://doi.org/10.1089/neu.2020.7299

4 Castano Monsalve, B., Laxe, S., Bernabeu Guitart, M., Vilarrasa, A. B., & 

Quemada, J. I. (2014). Behavioral scales used in severe and moderate 

traumatic brain injury. NeuroRehabilitation, 35(1),67–76. 

https://doi.org/10.3233/NRE-141103

5 Bhatnagar, S., Iaccarino, M.A., & Zafonte, R. (2016, June 1). 

Pharmacotherapy in rehabilitation of post-acute traumatic brain injury. 

Brain Research,1640(Pt A),164–179. 

https://doi.org/10.1016/j.brainres.2016.01.021
85

6 Castano Monsalve, B., Laxe, S., Bernabeu Guitart, M., Vilarrasa, A. B., & 

Quemada, J. I. (2014). Behavioral scales used in severe and moderate 

traumatic brain injury. NeuroRehabilitation, 35(1),67–76. 

https://doi.org/10.3233/NRE-141103

7 Theadom, A., Cropley, M., Parmar, P., Barker-Collo, S., Starkey, N., Jones, 

K., Feigin, V. L., & BIONIC Research Group. (2015, August). Sleep 

difficulties one year following mild traumatic brain injury in a populationbased study. Sleep Medicine, 16(8), 926–932. 

https://doi.org/10.1016/j.sleep.2015.04.013

8 Nakase-Richardson, R., Sherer, M., Barnett, S. D., Yablon, S. A., Evans, C. 

C., Kretzmer, T., Schwartz, D. J., & Modarres, M. (2013, May). 

Prospective evaluation of the nature, course, and impact of acute sleep 

abnormality after traumatic brain injury. Arch Phys Med Rehabil, 

94(5),875–882. https://doi.org/10.1016/j.apmr.2013.01.001

9 Fann, J. R., Burlington, B., Leonetti, A., Jaffe, K., Katon, W. J., & Thompson, 

R.S. (2004, January). Psychiatric illness following traumatic brain injury 

in an adult health maintenance organization population. Arch Gen 

Psychiatry, 61(1), 53–61. https://doi.org/10.1001/archpsyc.61.1.53

10 Lombard, L. A., & Zafonte, R. D. (2005, October). Agitation after traumatic 

brain injury: Considerations and treatment options. Am J Phys Med 

Rehabil, 84(10), 797–812. 

https://doi.org/10.1097/01.phm.0000179438.22235.08

11 Luaute, J., Plantier, D., Wiart, L., & SOFMER group. (2016, February). 

Care management of the agitation or aggressiveness crisis in patients 

with TBI. Systematic review of the literature and practice 

recommendations. Ann Phys Rehabil Med, 59(1), 58–67. 

https://doi.org/10.1016/j.rehab.2015.11.001

12 Castano Monsalve, B., Laxe, S., Bernabeu Guitart, M., Vilarrasa, A. B., & 

Quemada, J. I. (2014). Behavioral scales used in severe and moderate 

traumatic brain injury. NeuroRehabilitation, 35(1),67–76. 

https://doi.org/10.3233/NRE-141103

13 Luaue, J., Plantier, D., Wiart, L., Tell, L., SOFMER group. (2016, February) 

Care management of the agitation or aggressiveness crisis in patients 

with TBI. Systematic review of the literature and practice 
86

recommendations. Ann Phys Rehabil Med, 59(1), 58-67. 

https://doi.org/10.1016/j.rehab.2015.11.001

14 Bhatnagar, S., Iaccarino, M.A., & Zafonte, R. (2016, June). 

Pharmacotherapy in rehabilitation of post-acute traumatic brain injury. 

Brain Research, 1640(Part A),164-179. 

https://doi.org/10.1016/j.brainres.2016.01.021

15 Theadom, A., Cropley, M., Parmar, P., Barker-Collo, S., Starkey, N., Jones, 

K., Feigin, V. L., & BIONIC Research Group. (2015, August). Sleep 

difficulties one year following mild traumatic brain injury in a populationbased study. Sleep Medicine, 16(8), 926–932. 

https://doi.org/10.1016/j.sleep.2015.04.013

16 Nakase-Richardson, R., Sherer, M., Barnett, S. D., Yablon, S. A., Evans, C. 

C., Kretzmer, T., Schwartz, D. J., & Modarres, M. (2013, May). 

Prospective evaluation of the nature, course, and impact of acute sleep 

abnormality after traumatic brain injury. Arch Phys Med Rehabil, 

94(5),875–882. https://doi.org/10.1016/j.apmr.2013.01.001

17 Fann, J. R., Burlington, B., Leonetti, A., Jaffe, K., Katon, W. J., & 

Thompson, R.S. (2004, January). Psychiatric illness following traumatic 

brain injury in an adult health maintenance organization population. 

Arch Gen Psychiatry, 61(1), 53–61. 

https://doi.org/10.1001/archpsyc.61.1.53

18 Fann, J.R., Hart, T., & Schomer, K.G. (2009, December). Treatment for 

depression after traumatic brain injury: a systematic review. Journal of

Neurotrauma, 26(12), 2383-402. https://doi.org/10.1089/neu.2009.1091

19 Lombard, L. A., & Zafonte, R. D. (2005, October). Agitation after traumatic 

brain injury: Considerations and treatment options. Am J Phys Med 

Rehabil, 84(10), 797–812. 

https://doi.org/10.1097/01.phm.0000179438.22235.08

20 Giacino, J. T., Whyte, J., Bagiella, E., Kalmar, K., Childs, N., Khademi, A., 

Eifert, B., Long, D., Katz, D., Cho, S., Yablon, S., Luther, M., 

Hammond, F. M., Nordenbo, A., Novak, P., Mercer, W., MaurerKarattup, P., Nat., R., & Sherer, M. (2012, March 1). Placebo-controlled 

trial of amantadine for severe traumatic brain injury. The New England 
87

Journal of Medicine, 366(9), 819–826. 

https://doi.org/10.1056/NEJMoa1102609