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View: This Study Was Approved by the University of Treatment Volume 53, Number 2, 2016 JRRDJRRD Pages 185–198 Association between mild traumatic brain injury and mental health problems and self-reported cognitive dysfunction in Iraq and Afghanistan Veterans Karen H. Seal, MD, MPH;1–2 Daniel Bertenthal, MPH;1 Kristin Samuelson, PhD;1,3 Shira Maguen, PhD;1–2 Sant Kumar, BA;1 Jennifer J. Vasterling, PhD4 1San Francisco Department of Veterans Affairs (VA) Health Care System, San Francisco, CA; 2University of California, San Francisco, San Francisco, CA; 3California School of Professional Psychology, Alliant International University, San Francisco, CA; 4VA Boston Healthcare System, Boston, MA; and Boston University School of Medicine, Boston, MA Abstract—The Department of Veterans Affairs traumatic brain INTRODUCTION injury (TBI) screening program is intended to detect and expe- dite treatment for TBI and postconcussive symptoms. Between More than 2 million American men and women have April 14, 2007, and May 31, 2012, of 66,089 Iraq and Afghani- served in the conflicts in Iraq and Afghanistan. Due to stan Veterans who screened positive on first-level TBI screening the high incidence of blasts, motor vehicle accidents, and later completed comprehensive TBI evaluation that includes falls, and other combat-related injuries coupled with the Neurobehavioral Symptoms Inventory, 72% reported mod- improved trauma care, traumatic brain injury (TBI) has erate to very severe cognitive impairment (problems with atten- tion, concentration, memory, etc.) that interfered with daily been an unfortunately prevalent injury outcome of the activities. This included 42% who were found not to have sus- current conflicts [1–2]. In published surveys of Iraq and tained combat-related mild TBI (mTBI). In contrast, 70.0% Afghanistan Veterans and Active Duty infantry service- received a posttraumatic stress disorder (PTSD) diagnosis and members, 12 to 23 percent have reported a history of TBI 45.8% received a depression diagnosis. Compared with Veter- [2–3]. Using widely accepted diagnostic criteria, studies ans without mTBI, PTSD, or depression diagnoses, the lowest risk for self-reported cognitive impairment was in Veterans with confirmed mTBI only; a greater risk was found in those with PTSD diagnoses, with the greatest risk in Veterans with PTSD, Abbreviations: ARR = adjusted relative risk, CI = confidence depression, and confirmed mTBI, suggesting only a weakly interval, CTBIE = Comprehensive TBI Screening and Evalua- additive effect of mTBI. These findings suggest that Veterans tion, ICD-9-CM = International Classification of Diseases- with multiple mental health comorbidities, not just those with Ninth Revision-Clinical Modification, mTBI = mild traumatic TBI, report moderate to very severe cognitive impairment. Men- brain injury, NPCD = National Patient Care Database, NSI = tal health treatment for conditions such as PTSD and depression Neurobehavioral Symptoms Inventory, OEF = Operation (with or without TBI) may result in improvements in cognitive Enduring Freedom, OIF = Operation Iraqi Freedom, OND = functioning and/or include assessment and support for Veterans Operation New Dawn, PTSD = posttraumatic stress disorder, experiencing cognitive problems. RR = relative risk, SSN = Social Security number, TBI = trau- matic brain injury, VA = Department of Veterans Affairs. *Address all correspondence to Karen H. Seal, MD, MPH; Key words: cognitive dysfunction, concussion, depression, San Francisco VA Medical Center, 4150 Clement St, Box mental health, mild traumatic brain injury, population-based 111A-1, San Francisco, CA 94121; 415-221-4810, ext 24852; screening, postdeployment, posttraumatic stress disorder, pri- fax: 415-750 6921. Email: [email protected] mary care, recovery expectations, Veterans. http://dx.doi.org/10.1682/JRRD.2014.12.0301 185 186 JRRD, Volume 53, Number 2, 2016 of civilians and Veterans have shown that of all TBI to another clinical entity, such as PTSD) and to develop a cases, 85 percent represent mild TBI (mTBI) [4]. treatment plan depending on diagnosis and presenting Studies of civilian populations have revealed that symptoms. TBI may result in acute postconcussive symptoms, This comprehensive clinical evaluation of TBI is cur- including physical complaints such as headaches; emo- rently considered the “gold standard” for symptomatic tional problems such as irritability; and cognitive con- mTBI diagnosis in the VA healthcare system. The 22- cerns such as impaired attention, concentration, and item Neurobehavioral Symptoms Inventory (NSI) is per- memory [5]. In the majority of civilian cases, particularly formed as part of the comprehensive TBI evaluation and in mTBI, these postconcussive symptoms resolve com- assesses for physical, emotional, and cognitive postcon- pletely in days to months [6–7]. A minority of patients cussive symptoms [19]. Specifically, the NSI includes (approximately 10%–20%) continues to report nonspe- four items that measure different dimensions of Veterans’ cific physical, emotional, and cognitive postconcussive cognitive performance by self-report as well as the self- symptoms months to years after the original injury [6–9]. reported functional effect of the cognitive symptoms on Postconcussive symptoms have been associated with daily activities. poor social and occupational functioning, including This study focuses on one domain of postconcussive underemployment, low income, and marital and family symptoms as measured by the four cognitive functioning problems [10]. items on the NSI and examines the relative association of Military service-related mTBI often occurs in the self-reported moderate to very severe cognitive function- context of other combat-related trauma, and as such, ing with mTBI, PTSD, and depression. While mTBI has mTBI is frequently associated with comorbid mental been shown to have unique effects on health and func- health disorders, especially posttraumatic stress disorder tioning [20–23], we focus on the overlap of mTBI with (PTSD) and depression [11–13]. In particular, postcon- PTSD and depression because these most commonly cussive cognitive symptoms attributed to mTBI, such as present together, and cognitive complaints are important trouble with memory and attention, have long been overlapping features of all three conditions [11–16]. We understood to overlap with symptoms of PTSD and hypothesize that self-reported cognitive symptoms that depression [14–16]. Hoge et al. found that, of Operation adversely affect daily functioning at the level of moder- Iraqi Freedom (OIF) servicemembers who reported ate to very severe are more strongly associated with indi- mTBI with loss of consciousness for <30 min, 44 percent vidual mental health disorders and with mental health met criteria for PTSD and 23 percent met criteria for disorders in conjunction with mTBI than with mTBI depression [2]. Moreover, Hoge et al. found that PTSD alone. Further, we investigate the interactive relation- and depression explained part of the relationship (or sta- ships among these disorders with respect to self-reported tistical variance) between mTBI and memory and con- cognitive functioning and suggest a practical modifica- centration problems [2], a finding that was replicated in a tion of the current VA TBI screening program that may subsequent epidemiologic study [12]. expedite targeted counseling and care for returning com- In April 2007, the Department of Veterans Affairs bat Veterans. (VA) introduced a stepped population-based screening program for mTBI to promote early detection and inter- vention in response to mounting public concern about METHODS TBI [17] As such, on presenting to a VA facility, OIF/ Operation Enduring Freedom (OEF)/Operation New Study Population Dawn (OND) Veterans (who have not already been told This retrospective cohort of OIF/OEF Veterans was that they have a moderate to severe TBI) undergo first- identified using the VA Comprehensive TBI Screening level screening for mTBI, which is typically performed in and Evaluation (CTBIE) database. First-level TBI screen- primary care [18]. If the first-level TBI screen is positive ing is repeated each time a combat Veteran completes a for current symptoms, Veterans are referred for a compre- deployment and returns to a VA healthcare facility; for hensive TBI evaluation by a trained VA TBI specialist, Veterans with multiple deployments, we used the last and typically in a subspecialty clinic, to determine whether most current CTBIE data. In order to screen positive on the current symptoms are due primarily to mTBI (or due the VA first-level TBI screen, Veterans must have 187 SEAL et al. Self-reported cognitive dysfunction in Veterans endorsed all four items: (1) a TBI injury mechanism, positive on the first-level TBI screen and were referred (2) problems that started immediately after the injury, for comprehensive TBI evaluation. Veterans were (3) problems that began or got worse after the injury, and excluded from the analytic cohort if they screened nega- (4) the presence of one or more postconcussive symptoms tive on first-level evaluation (n = 427,504), if they (i.e., memory problems, balance problems or dizziness, screened positive for mTBI but failed to attend the com- sensitivity to bright light, irritability, headaches, and sleep prehensive TBI evaluation at a VA facility, if the results problems) in the 7 d prior to TBI screening [17]. As soon of their comprehensive evaluation were not entered in the as one of the items is not endorsed, the TBI screen termi- CTBIE database (n =
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