Valued living after mild traumatic brain injury: Characteristics and relationship with outcomes.

Psychological factors are strong predictors of mild traumatic brain injury (mTBI) recovery, consequently, psychological interventions can form part of an individual's rehabilitation. This may include enhancing valued living (VL), an approach that is effective in severe and mixed acquired brain injury samples. This study aimed to characterize VL in mTBI and explore its relationship with mTBI and mental health outcomes. 56 participants with a mTBI completed self-report measures before engaging in a psychological intervention. Pre-injury mental health and other demographic and injury-related variables, VL, post-concussion symptoms (PCS), functional disability, and stress, anxiety and depression were measured. A pre-injury mental health condition was significantly associated with VL. VL was uniquely associated with depression after mTBI (ß = -0.08, p = .05), however, there was no relationship with PCS, functional disability, stress or anxiety (p > .05). Following mTBI individuals with a pre-injury mental health condition or who experience heightened depressive symptoms may benefit from a values-based intervention as part of their rehabilitation. Future research, however, is needed to examine the role of VL in mTBI recovery.

Video-consulting to address mental health needs after traumatic brain injury: evaluation of a training workshop to build capacity among psychologists.

BACKGROUND: Traumatic brain injury (TBI) can lead to significant psychological distress, but few psychologists in Australia are trained in working with this complex clinical group. Despite government funding to provide video-consulting (VC) services in Australia, uptake before COVID-19 was limited. OBJECTIVE: This mixed methods study evaluated whether training in eHealth and evidence based TBI psychological therapies increased provider uptake of VC in clinical practice, and delivery of mental health services to individuals with TBI. METHODS: Mental health professionals completed a range of self-report measures before (n = 50), after (n = 48), and four months following (n = 30) a one-day workshop. Participants' TBI knowledge, client-base and levels of access, confidence, motivation and attitudes toward VC were assessed. Knowledge did not increase after training but participants had significant increases in their confidence and motivation to using VC at follow up. Significant reductions in pragmatic barriers to using VC were reported post training and at follow up, all barrier categories indicated significant reductions. There was no significant change in clinical practice of the participants. CONCLUSIONS: Training to increase TBI knowledge requires specific assessment tools and although training appears to reduce barriers to using VC, uptake in clinical practice may require additional supervision and warrants further research.

Can acceptance and commitment therapy facilitate psychological adjustment after a severe traumatic brain injury? A pilot randomized controlled trial.

This study i⁠nvestigated if an Acceptance and Commitment Therapy (ACT) intervention (ACT-Adjust) can facilitate psychological adjustment and reduce psychological distress following severe traumatic brain injury (TBI). The study design comprised a single centre, two-armed, Phase II pilot randomized controlled trial. Nineteen individuals with severe TBI (PTA ≥7 days) who met a clinical threshold for psychological distress (Depression Anxiety Stress Scales-21; DASS > 9) were randomly allocated to either ACT-Adjust (n = 10) or an active control, Befriending Therapy (n = 9), in conjunction with a holistic rehabilitation programme. Primary (psychological flexibility, rehabilitation participation) and secondary (depression, anxiety & stress) outcomes were measured at three-time points (pre, post and follow up). Significant decreases were found for DASS-depression (group by time interaction, F 1,17 = 5.35, p = .03) and DASS-stress (group by time interaction, F 1,17 = 5.69, p = .03) in comparison to the Befriending group, but not for the primary outcome measures. The reduction in stress post-treatment was classed as clinically significant, however interaction differences for stress and depression were not maintained at one month follow up. Preliminary investigations indicate potential for ACT in decreasing psychological distress for individuals with a severe TBI with further sessions required to maintain treatment gains. The pilot results suggest further investigation is warranted in a larger scale clinical trial.

Depression Anxiety Stress Scales (DASS-21): Factor Structure in Traumatic Brain Injury Rehabilitation.

OBJECTIVE: To confirm the construct validity of the Depression Anxiety Stress Scales-21 (DASS-21) by investigating the fit of published factor structures in a sample of adults with moderate to severe traumatic brain injury (posttraumatic amnesia > 24 hours). PARTICIPANTS: Archival data from 504 patient records at the Brain Injury Rehabilitation Unit at Liverpool Hospital, Australia. Participants were aged between 16 and 71 years and were engaged in a specialist rehabilitation program. MAIN MEASURE: The DASS-21. RESULTS: Two of the 6 models had adequate fit using structural equation modeling. The data best fit Henry and Crawford's quadripartite model, which comprised a Depression, Anxiety and Stress factor, as well as a General Distress factor. The data also adequately fit Lovibond and Lovibond's original 3-factor model, and the internal consistencies of each factor were very good (α = 0.82-0.90). CONCLUSION: This study confirms the structure and construct validity of the DASS-21 and provides support for its use as a screening tool in traumatic brain injury rehabilitation.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review.

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

A prospective interrupted time series study of interventions to improve the quality, rating, framing and structure of goal-setting in community-based brain injury rehabilitation.

OBJECTIVE: To investigate whether the introduction of an electronic goals system followed by staff training improved the quality, rating, framing and structure of goals written by a community-based brain injury rehabilitation team. DESIGN: Interrupted time series design. INTERVENTION: Two interventions were introduced six months apart. The first intervention comprised the introduction of an electronic goals system. The second intervention comprised a staff goal training workshop. METHODS: An audit protocol was devised to evaluate the goals. A random selection of goal statements from the 12 months prior to the interventions (Time 1 baseline) were compared with all goal statements written after the introduction of the electronic goals system (Time 2) and staff training (Time 3). All goals were de-identified for client and time-period, and randomly ordered. RESULTS: A total of 745 goals (Time 1 n = 242; Time 2 n = 283; Time 3 n = 220) were evaluated. Compared with baseline, the introduction of the electronic goals system alone significantly increased goal rating, framing and structure (χ(2) tests 144.7, 18.9, 48.1, respectively, p < 0.001). The addition of staff training meant that the improvement in goal quality, which was only a trend at Time 2, was statistically significant at Time 3 (χ(2) 15.0, p ≤ 001). The training also led to a further significant increase in the framing and structuring of goals over the electronic goals system (χ(2) 11.5, 12.5, respectively, p ≤ 0.001). CONCLUSION: An electronic goals system combined with staff training improved the quality, rating, framing and structure of goal statements.

Digital divide among individuals with acquired brain injury: a scoping review protocol.

OBJECTIVE: This scoping review will identify literature pertaining to individuals with an acquired brain injury and digital divide; specifically, examining personal access and use of internet-enabled information and communication technologies. The review will identify the information and communication technologies used by individuals with an acquired brain injury as well as the determinants of technology use. The review will also identify and create a taxonomy of information and communication technologies utilized in relation to cognitive and psychosocial outcomes for individuals with an acquired brain injury in community and outpatient settings. INTRODUCTION: Internet-enabled technologies are increasingly central to all aspects of living, including health care and community participation; however, gaps in the access to and use of information and communication technologies among individuals with an acquired brain injury may limit the utility of a digitalized society. INCLUSION CRITERIA: Studies that focus on access to or use of internet-enabled information and communication technologies among individuals with an acquired brain injury (including stroke, infection, tumor, disease, hypoxia, or traumatic brain injury) will be considered in this review. METHODS: Primary peer-reviewed studies published in English from 2001 onward will be considered for inclusion. Six electronic databases will be searched: Embase, MEDLINE, Web of Science Core Collection, Google Scholar, CINAHL, and APA PsycINFO. Gray literature searches for government and nongovernment organization reports and data, and dissertation theses will be conducted via advanced Google searches. Two reviewers will independently screen titles, abstracts, and full texts of articles based on the "population, concept, context" inclusion criteria. Relevant data will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR).

Suicide prevention after traumatic brain injury: a randomized controlled trial of a program for the psychological treatment of hopelessness.

OBJECTIVE: To evaluate the efficacy of a psychological treatment to reduce moderate to severe hopelessness after severe traumatic brain injury (TBI). METHOD: Randomized controlled trial. Participants were aged between 18 and 65 years, experienced posttraumatic amnesia more than 1day and moderate to severe hopelessness (Beck Hopelessness Scale [BHS]) and/or suicide ideation. Intervention comprised a 20-hour manualized group cognitive behavior therapy program. Participants were randomly allocated using concealed allocation (treatment n = 8; wait-list n = 9); all remained in their allocated group. Outcome variables were collected by assessors blind to group allocation. RESULTS: No between-groups differences were observed on demographic, injury, cognitive, and psychosocial variables at baseline (time 1). A significant group-by-time interaction was found for BHS in the treatment group (F1,15 = 13.20, P = .002), reflecting a reduction in mean BHS scores between time 1 and time 2 (posttreatment) with no main effects for group or time. At 3-month follow-up (time 3), the treatment gains were maintained or improved for 75% (6/8) of participants. Secondary outcome variables (suicide ideation, depression, social problem solving, self-esteem, hopefulness) displayed no significant group-by-time interactions or main effects. CONCLUSIONS: This trial provides initial evidence for the efficacy of a psychological intervention in reducing hopelessness among long-term survivors with severe TBI.

Protocol for a Phase Two, Parallel Three-Armed Non-inferiority Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT-Adjust) Comparing Face-to-Face and Video Conferencing Delivery to Individuals With Traumatic Brain Injury Experiencing Psychological Distress.

Background: People with traumatic brain injury (TBI) face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI. Methods: This paper outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial (RCT) of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales (NSW) and the NSW icare scheme will be randomly allocated to three conditions; (1) video consulting (VC), (2) face-to-face (FtF) and, (3) a waitlist control (WL). Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy (ACT-Adjust) delivered via video consulting for individuals with a moderate to severe TBI. Trial Registration: www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112.

Validating measures of psychological flexibility in a population with acquired brain injury.

This study presents preliminary validation data on both the Acceptance and Action Questionnaire-Acquired Brain Injury (AAQ-ABI) and the Acceptance and Action Questionnaire-II (AAQ-II). Data from 150 participants with ABI was subject to exploratory factor analysis on the AAQ-ABI (15 items). A subset of 75 participants with ABI completed a larger battery of measures to test construct validity for the AAQ-ABI and to undertake a confirmatory factor analysis (CFA) on the AAQ-II (7 items). Three meaningful factors were identified on the AAQ-ABI: Reactive Avoidance, Denial, and Active Acceptance. Reactive Avoidance demonstrated good internal and test-retest consistency (α = .89) and correlated in expected directions with other related measures including the AAQ-II. CFA of the AAQ-II did not provide a good fit but did have similar correlations with measures of psychological distress as found in prior non-ABI samples. The results suggest both measures can be used with individuals following an ABI but they index different facets of psychological flexibility. The AAQ-ABI appears to measure psychological flexibility about the thoughts and feelings relating to the brain injury itself while the AAQ-II measures psychological flexibility around general psychological distress. Future research could explore the additional 2 factors of the AAQ-ABI and use these measures in outcome studies that promote psychological flexibility in individuals with an ABI.

Frequency, clinical correlates, and ratings of behavioral changes in primary brain tumor patients: a preliminary investigation.

PURPOSE: Few studies have addressed the specific behavioral changes associated with primary brain tumor (PBT). This paper will report on the frequency and demographic/clinical correlates of such behaviors, and the reliability of rating such behaviors among people with PBT, family informants, and clinicians. The association of behavioral changes and patient functional status will also be discussed. METHODS: A total of 57 patients with 37 family informants were recruited from two large Australian metropolitan hospitals. Each completed three neuro-behavioral self-report measures; the Emotional and Social Dysfunction Questionnaire, the Frontal Systems Behavior Scale, and the Overt Behavior Scale. Patients also completed a depression symptom measure. Functional status was defined by clinician-rated Karnofsky performance status. RESULTS: Patients were on average 52 years old, a median of 4 months (range 1-82) post-diagnosis, with high grade (39%), low grade (22%), or benign tumors (39%). Patients reported frequency rates of 7-40% across various behavioral domains including anger, inappropriate behavior, apathy, inertia, and executive impairment. The presence of epileptic seizures was associated with significantly higher levels of behavioral changes. Notably, behavior did not correlate with tumor grade or treatment modality. There was moderate agreement between patients and relatives on the presence or absence of behavioral changes, and substantial agreement between relative and clinician ratings. Depressed patients did not generally report more changes than non-depressed patients. Increases in the relative and clinician-rated behavior scores were significantly correlated with decreasing functional status in the patient. CONCLUSION: Behavioral changes were a common sequela of both benign and malignant PBT. Larger scale studies are required to confirm these results. The results suggest the importance of including behavior in brain cancer psychosocial assessments and the need to develop interventions to treat these patients and reduce the burden of care on families.

Development and evaluation of information resources for patients, families, and healthcare providers addressing behavioral and cognitive sequelae among adults with a primary brain tumor.

Behavioral and cognitive changes in patients with primary brain tumor (PBT) are common and may be distressing to patients and their family members. Healthcare professionals report a strong need for information, practical strategies, and training to assist consumers and better address management issues. A literature review by the current project found that 53% of the information resources currently available to consumers and health professionals contained minimal or no information about cognitive/behavioral changes after PBT, and 71% of the resources contained minimal or no information on associated strategies to manage these changes. This project aimed to develop an information resource for patients, carers, and health professionals addressing the behavioral and cognitive sequelae of PBT, including strategies to minimize the disabling impact of such behaviors. In consultation with staff and patient groups, 16 key information topics were identified covering cognitive and communication changes and challenging behaviors including executive impairment, behavioral disturbance, and social/emotional dysfunction. Sixteen fact sheets and 11 additional resource sheets were developed and evaluated according to established consumer communication guidelines. Preliminary data show that these resources have been positively received and well utilized. These sheets are the first of their kind addressing challenging behaviors in the neuro-oncology patient group and are a practical and useful information resource for health professionals working with these patients and their families. The new resource assists in reinforcing interventions provided to individual patients and their relatives who are experiencing difficulties in managing challenging behaviors after PBT.