Managing Behavioral Health Needs of Veterans with Traumatic brain injury (TBI) in Primary Care

Abstract

“Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20% among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.”

Implications

For Practice

Traumatic brain injury (TBI) is common among veterans and can be associated with other diseases or illnesses. Some symptoms that frequently occur after a head injury, such as changes in mood and thinking, are also common in many other conditions. After an injury, it is important to screen for pre-existing psychiatric disorders and symptoms, as well as for new onset symptoms. When screening, clinicians should be mindful of the risk of misdiagnosis or overlooking symptoms, and know that the presence of post-traumatic stress disorder (PTSD) in particular has been shown to increase the rate of false positive screens. Additionally, because TBI history has been identified as a suicide risk factor, clinicians should regularly assess and document relevant safety concerns.

Most patients with mild TBI (mTBI, or concussion) gradually return to their normal everyday activities and ultimately experience a full recovery. Education on recovery expectancy and patient reassurance are often identified as treatments of choice for mTBI. Patients may also benefit from building specific skills to compensate for perceived deficits, manage life stress and safety concerns, promote relaxation and to monitor symptoms. Although moderate and severe TBIs are often associated with long-lasting neurological and functional deficits, only a small percentage of mTBI patients are thought to experience persistent post-concussion symptoms. Though these lasting complaints may be associated with mTBI, they may also be strongly influenced by affective disturbances such as depression, PTSD and general anxiety, as well as chronic pain and other medical conditions.

In the event that symptoms persist, both patients and family members might benefit from extra support and guidance. Such interactions may serve to clarify concerns, identify further areas for intervention, or to discuss the possibility of referrals for other services. Clinicians should refer patients to specialty providers when necessary, maintain open communication with the treatment team and remain current on assessment and treatment methods for those with brain injuries.

For Policy

The results of this review highlight that in order to adequately serve individuals with TBI, policies need to be multi-faceted, addressing the needs of both the patient and their family. Thus, policymakers should work with government agencies to continue to provide funding for the development and improvement of interventions for TBI patients and their family members that focus on education and coping with injury. The Department of Veterans Affairs, Department of Defense and the Defense and Veterans Brain Injury Center have dedicated substantial resources in recent years to addressing concerns that veterans with brain injuries face, including co-morbidity, new therapies, the disease trajectory of TBI, and family needs. Although the majority of individuals with mild TBI fully recover, many persons with moderate to severe injuries experience lasting deficits. For those with persistent concerns, policies improving TBI education for family members and expanding treatment patient options would be greatly beneficial.

For Future Research

Despite the wealth of literature on TBI in civilian samples, the authors note that veterans are a unique population with several distinguishing features, such as exposure to combat trauma and elevated rates of PTSD. Although research on the prevalence of TBI in veterans has expanded in recent years, a need exists for further studies on population-specific interventions that detail the efficacy of suicide prevention strategies and other combined interventions for TBIs of all severity levels and co-occurring conditions. Future investigations should also examine the relationship between pre-injury factors and cognition, behaviors and quality of life after TBI (as well as in polytrauma inclusive of TBI), to further generalize knowledge on the natural disease history and psychosocial recovery course after TBI.

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