Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury.

OBJECTIVE: Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI. SETTING: Nationwide VA-purchased care from 2016 through 2019. PARTICIPANTS: Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144). DESIGN: This was a retrospective, observational study. MAIN MEASURES: Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019. RESULTS: Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use. CONCLUSIONS: Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

Risk of Adverse Outcomes Among Veterans Who Screen Positive for Traumatic Brain Injury in the Veterans Health Administration But Do Not Complete a Comprehensive Evaluation: A LIMBIC-CENC Study.

OBJECTIVE: To examine whether post-9/11 veterans who screened positive for mild traumatic brain injury (mTBI) but did not complete a Comprehensive TBI Evaluation (CTBIE) were at higher risk of subsequent adverse events compared with veterans who screened positive and completed a CTBIE. Upon CTBIE completion, information assessed by a trained TBI clinician indicates whether there is mTBI history (mTBI+) or not (mTBI-). SETTING: Veterans Health Administration (VHA) outpatient services. PARTICIPANTS: A total of 52 700 post-9/11 veterans who screened positive for TBI were included. The follow-up review period was between fiscal years 2008 and 2019. The 3 groups studied based on CTBIE completion and mTBI status were: (1) mTBI+ (48.6%), (2) mTBI- (17.8%), and (3) no CTBIE (33.7%). DESIGN: This was a retrospective cohort study. Log binomial and Poisson regression models adjusting for demographic, military, pre-TBI screening health, and VHA covariates examined risk ratios of incident outcomes based on CTBIE completion and mTBI status. MAIN MEASURES: Incident substance use disorders (SUDs), alcohol use disorder (AUD), opioid use disorder (OUD), overdose, and homelessness documented in VHA administrative records, and mortality as documented in the National Death Index, 3 years post-TBI screen. VHA outpatient utilization was also examined. RESULTS: Compared with the no CTBIE group, the mTBI+ group had 1.28 to 1.31 times the risk of incident SUD, AUD, and overdose, but 0.73 times the risk of death 3 years following TBI screening. The mTBI- group had 0.70 times the risk of OUD compared with the no CTBIE group within the same period. The no CTBIE group also had the lowest VHA utilization. CONCLUSIONS: There were mixed findings on risk of adverse events for the no CTBIE group relative to the mTBI+ and mTBI- groups. Future research is needed to explore the observed differences, including health conditions and healthcare utilization, documented outside VHA among veterans who screen positive for TBI.

Demographic, military, and health comorbidity variables by mild TBI and PTSD status in the LIMBIC-CENC cohort.

OBJECTIVE: To describe associations of demographic, military, and health comorbidity variables between mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD) status in a sample of Former and current military personnel. SETTING: Participants recruited and tested at seven VA sites and one military training facility in the LIMBIC-CENC prospective longitudinal study (PLS), which examines the long-term mental health, neurologic, and cognitive outcomes among previously combat-deployed U.S. Service Members and Veterans (SM/Vs). PARTICIPANTS: A total of 1,540 SM/Vs with a history of combat exposure. Data were collected between 1/1/2015 through 3/31/2019. DESIGN: Cross-sectional analysis using data collected at enrollment into the longitudinal study cohort examining demographic, military, and health comorbidity variables across PTSD and mTBI subgroups. MAIN MEASURES: PTSD Checklist for DSM-5 (PCL-5), mTBI diagnostic status, Patient Health Questionnaire 9-item (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), AUDIT-C, and other self-reported demographic, military, and health comorbidity variables. RESULTS: Ten years following an index date of mTBI exposure or mid-point of military deployment, combat-exposed SM/Vs with both mTBI history and PTSD had the highest rates of depression symptoms, pain, and sleep apnea risk relative to SM/Vs without both of these conditions. SM/Vs with PTSD, irrespective of mTBI history, had high rates of obesity, sleep problems, and pain. CONCLUSION: The long-term symptom reporting and health comorbidities among SM/Vs with mTBI history and PTSD suggest that ongoing monitoring and intervention is critical for addressing symptoms and improving quality of life.

Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder.

Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n = 541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P = 0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P = 0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services.

Associations Among PTSD and Postconcussive Symptoms in the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium Prospective, Longitudinal Study Cohort.

OBJECTIVE: To describe rates of mild traumatic brain injury (mTBI) with and without concurrent posttraumatic stress disorder a sample of former and current military personnel, and to compare the factor structure of the Neurobehavioral Symptom Inventory (NSI) based on whether participants sustained mTBI with and without a positive posttraumatic stress disorder (PTSD) screen. SETTING: Participants recruited and tested at 7 Veterans Affairs (VA) sites and 1 military training facility as part of a national, longitudinal study of mental health, physical, and cognitive outcomes among veterans and service members. Participants: Total of 1540 former and current military personnel with a history of combat exposure. DESIGN: Cross-sectional analysis of observational data, including confirmatory factor analysis. Main Measures: NSI and PTSD Checklist for DSM-5 (PCL-5). RESULTS: Most participants (81.5%) had a history of mTBI and almost half of these screened positive for PTSD (40.5%); only 23.9% of participants without a history of mTBI screened positive for PTSD. Participants with a history of mTBI reported higher elevations of NSI and PCL-5 symptoms compared with those without a history of mTBI. Confirmatory factor analyses of the NSI demonstrated good model fit using a 4-factor structure (somatosensory, affective, cognitive, and vestibular symptoms) among groups of participants both with and without a history of mTBI. CONCLUSION: Symptoms of mTBI and PTSD are strongly associated with each other among veterans and service members with a history of combat exposure. The 4-factor NSI structure is supported among participants with and without a history of mTBI. These findings suggest the potential benefit of a holistic approach to evaluation and treatment of veterans and service members with concurrent and elevated postconcussive and posttraumatic stress symptoms.

Association of Traumatic Brain Injury With Vestibular Dysfunction and Dizziness in Post-9/11 Veterans.

OBJECTIVE: To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. SETTING: Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). PARTICIPANTS: Post-9/11 veterans with at least 3 years of VA care. DESIGN: Cross-sectional, retrospective, observational study. MAIN MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. RESULTS: Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. CONCLUSIONS: There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.

Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities.

BACKGROUND: Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance). PURPOSE: To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services. METHODS: Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26). FINDINGS: Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity. DISCUSSION: Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.

Associations between traumatic brain injury from intimate partner violence and future psychosocial health risks in women.

OBJECTIVE: The effects of traumatic brain injury (TBI) incurred during military service are widely studied; however, less is known about TBI resulting from intimate partner violence ("IPV-related TBI"). Women Veterans are at high risk for IPV, yet no research has examined future psychosocial health risks associated with IPV-related TBI history in this population. METHODS: We examined psychiatric and physical health outcomes, as well as IPV, in a sample of women Veterans who, at Time 1, reported IPV-related TBI with (n = 13) or without (n = 20) persistent symptoms; that is, symptoms such as memory problems, balance problems or dizziness, sensitivity to bright light, irritability, headaches, and sleep problems that began or got worse immediately following the IPV-related TBI and occurred within the past week. These women completed web-based surveys 18 months later (Time 2), which included validated measures of psychiatric and physical health symptoms as well as past-year IPV. We conducted linear regressions to model whether T1 IPV-related TBI with persistent symptoms predicted worse health outcomes at T2, in comparison to T1 IPV-related without persistent symptoms. RESULTS: Controlling for significant covariates (i.e., military sexual trauma; MST), IPV-related TBI with persistent symptoms at Time 1 was associated with significantly worse outcomes at Time 2 across all health outcome domains (sr2 range: 0.12-0.37). After controlling for MST and probable posttraumatic stress disorder (PTSD) at Time 1, IPV-related TBI with persistent symptoms at Time 1 remained significantly associated with worse Time 2 symptoms of insomnia, depression, and physical health (sr2 range: 0.12-0.25). CONCLUSION: Women who experience IPV-related TBI with persistent symptoms are at higher risk for worse psychosocial health outcomes 18 months later. Findings necessitate screening IPV survivors for TBI with persistent symptoms and tailoring TBI and psychosocial interventions to reduce risk for ongoing health sequelae.

Predictors of Employment Status in Male and Female Post-9/11 Veterans Evaluated for Traumatic Brain Injury.

OBJECTIVES: The goal of this study was to investigate predictors of employment status in male and female post-9/11 Veterans evaluated for traumatic brain injury (TBI) in the Veterans Health Administration. Prior research suggests there are gender differences in psychosocial characteristics among this cohort. METHODS: This was a cross-sectional analysis of post-9/11 Veterans who completed a TBI evaluation between July 2009 and September 2013. RESULTS: Women had lower prevalence of deployment-related TBI (65.5%) compared with men (75.3%), but the percentages of those unemployed across the TBI diagnostic categories were similar for men (38%) and women (39%). Adjusted log-binomial regression found that unemployment was significantly associated with age, education, marital status, moderate/severe TBI, suspected posttraumatic stress disorder, depression, and drug abuse/dependence, and neurobehavioral symptom severity for men, whereas for women only more severe affective and cognitive symptoms were associated with unemployment. CONCLUSIONS: Although the unemployment rate was similar across gender, there was a clearer pattern of demographic and health factors, including TBI severity, that was significantly associated with employment status in men. There may be other factors contributing to the female Veteran unemployment rate, underscoring the need to investigate unique contributors to unemployment, as well as how treatment and employment services can be expanded and tailored for post-9/11 Veterans.

Supported Employment for Veterans With Traumatic Brain Injury: Provider Perspectives.

OBJECTIVE: To identify any pilot and nonpilot site differences regarding current (1) provision of supported employment (SE) to veterans with traumatic brain injury (TBI); (2) staffing and communication between the SE and polytrauma/TBI teams; and (3) provider perceptions on facilitators and barriers to providing, and suggestions for improving, SE. DESIGN: Mixed methods cross-sectional survey study. SETTING: Veterans Health Administration SE programs. PARTICIPANTS: Respondents (N=144) included 54 SE supervisors and 90 vocational rehabilitation specialists. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Web-based surveys of forced-choice and open-ended items included questions on SE team characteristics, communication with polytrauma/TBI teams, and experiences with providing SE to veterans with TBI history. RESULTS: SE was provided to veterans with TBI at 100% of pilot and 59.2% of nonpilot sites (P=.09). However, vocational rehabilitation specialists at pilot sites reported that communication with the polytrauma/TBI team about SE referrals was more frequent than at nonpilot sites (P=.003). In open-ended items, suggestions for improving SE were similar across pilot and nonpilot sites, and included increasing staffing for vocational rehabilitation specialists and case management, enhancing communication and education between SE and polytrauma/TBI teams, and expanding the scope of the SE program so that eligibility is based on employment support need, rather than diagnosis. CONCLUSIONS: These findings may contribute to an evidence base that informs SE research and clinical directions on service provision, resource allocation, team integration efforts, and outreach to veterans with TBI who have employment support needs.

Supported Employment for Veterans With Traumatic Brain Injury: Patient Perspectives.

OBJECTIVES: To quantify the need for, and interest in, supported employment (SE) among recent military veterans with traumatic brain injury (TBI); and to examine characteristics associated with veterans' interest in SE. DESIGN: Stratified random sample of Iraq and Afghanistan War veterans confirmed to have TBI through the Veterans Health Administration (VHA) screening and evaluation system. SETTING: Community-based via mailed survey. PARTICIPANTS: We recruited 1800 veterans with clinician-confirmed TBI (mild TBI: n=1080; moderate/severe TBI: n=720) through multiple mailings. Among 1451 surveys that were not returned undeliverable, N=616 (42%) responded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Veterans rated their interest in SE after reading a script describing the program. Additional measures assessed mental health and pain-related comorbidities, employment, financial/housing difficulties, demographics, and military service characteristics. Estimates were weighted to represent the population of veterans with VHA clinician-confirmed TBI. RESULTS: Unemployment was reported by 45% (95% confidence interval [CI], 43-47) of veterans with TBI. Although 42% (95% CI, 40-44) reported they would be interested in using SE if it were offered to them, only 12% had heard of SE (95% CI, 11-14) and <1% had used it. TBI severity and comorbidities were not associated with veterans' interest in SE. However, those who were unemployed, looking for work, experiencing financial strain, or at risk for homelessness were more likely to be interested in SE. CONCLUSIONS: Our research highlights an important gap between veterans' vocational needs and interests and their use of SE. Systematically identifying and referring those with employment and financial/housing difficulties may help close this gap.

Sensory dysfunction and traumatic brain injury severity among deployed post-9/11 veterans: a chronic effects of neurotrauma consortium study.

OBJECTIVES: To describe the prevalence of sensory dysfunction (i.e. auditory, visual, vestibular, chemosensory and multiple sensory problems) and explore associations with traumatic brain injury (TBI) severity and injury mechanism among deployed Post-9/11 Veterans. METHODS: This retrospective cohort analysis used Departments of Defense and Veterans Affairs diagnostic codes and administrative data. RESULTS: Among the 570,248 Veterans in this cohort, almost 23% had at least one diagnosis of sensory dysfunction. In the multinomial regression analysis, the odds of all types of sensory dysfunction were greater among those with any TBI relative to those with no TBI. The odds for auditory or multisensory problems were higher among those that indicated exposure to blast. In particular, exposure to quaternary blast injury (e.g. crush, respiratory and burn injuries) was associated with increased odds for auditory, visual, vestibular and multisensory problems. CONCLUSIONS: Sensory problems affect a substantial number of deployed Post-9/11 Veterans and are more common among those with TBI or with exposure to deployment-related blast exposure. Because sensory problems profoundly impact quality of life, their identification and enhanced education and therapy are vital tools to improve prognosis for these relatively young Veterans.

Understanding the impact of mild traumatic brain injury on veteran service-connected disability: results from Chronic Effects of Neurotrauma Consortium.

OBJECTIVES: Disability evaluation is complex. The association between mild traumatic brain injury (mTBI) history and VA service-connected disability (SCD) ratings can have implications for disability processes in the civilian population. We examined the association of VA SCD ratings with lifetime mTBI exposure in three models: any mTBI, total mTBI number, and blast-related mTBI. METHODS: Participants were 492 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans from four US VA Medical Centers enrolled in the Chronic Effects of Neurotrauma Consortium study between January 2015 and August 2016. Analyses entailed standard covariate-adjusted linear regression models, accounting for demographic, military, and health-related confounders and covariates. RESULTS: Unadjusted and adjusted results indicated lifetime mTBI was significantly associated with increased SCD, with the largest effect observed for blast-related mTBI. Every unit increase in mTBI was associated with an increase in 3.6 points of percent SCD. However, hazardous alcohol use was associated with lower SCD. CONCLUSIONS: mTBI, especially blast related, is associated with higher VA SCD ratings, with each additional mTBI increasing percent SCD. The association of hazardous alcohol use with SCD should be investigated as it may impact veteran health services access and health outcomes. These findings have implications for civilian disability processes.

Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence.

OBJECTIVE: To effectively diagnose and treat women who have experienced intimate partner violence (IPV), it is important to identify the full range of physical and mental health consequences, including hidden wounds such as traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). We aimed to identify the occurrence of IPV-related TBI and associated PTSD symptoms among women veterans who experienced IPV. METHODS: A web-based survey was administered in 2014 to a national sample of U.S. women veterans. Among 411 respondents (75% participation rate), 55% reported IPV during their lives. These participants (N=224) completed screening measures of IPV-related TBI, PTSD, and past-year IPV and comprised the current sample. RESULTS: A total of 28.1% (n=63) met criteria for IPV-related TBI history, and 12.5% (n=28) met criteria for IPV-related TBI with current symptoms. When adjusting for race, income, and past-year IPV, women with IPV-related TBI with current symptoms were 5.9 times more likely to have probable IPV-related PTSD than those with no IPV-related TBI history. Despite symptom overlap between TBI and PTSD, women with IPV-related TBI with current symptoms were significantly more likely to meet criteria for all four DSM-5 PTSD symptom clusters compared to women with an IPV-related TBI history without current symptoms (Cramér's V's=.34-.42). CONCLUSION: Findings suggest there may be clinical utility in screening women who experience lifetime IPV for both TBI and PTSD symptoms in order to help clinicians better target their examinations, treatment, and referrals.

Associations Between Traumatic Brain Injury History and Future Headache Severity in Veterans: A Longitudinal Study.

OBJECTIVE: To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes. DESIGN: Prospective cohort study. SETTING: Department of Veterans Affairs (VA) outpatient clinics. PARTICIPANTS: Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders. RESULTS: Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (ß [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (ß [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (ß [SE]=.66 [.09], P<.001) and longitudinal analyses (ß [SE]=.18 [.09], P=.04). CONCLUSIONS: Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache.

Health services and rehabilitation for active duty service members and veterans with mild TBI.

OBJECTIVE: We review health services and reintegration practices that contribute to the rehabilitation of US active duty service members (ADSMs) and Veterans who experienced traumatic brain injury (TBI), especially mild TBI (mTBI), as discussed at the 2015 Department of Veterans Affairs (VA) TBI State-of-the-Art (SOTA) Conference. METHODOLOGY: We reviewed the state-of-the-art at the time of the previous 2008 TBI SOTA Conference, advances in the field since then, and future directions to address gaps in knowledge. MAIN RESULTS: We reviewed: (1) mTBI and its comorbid conditions documented in ADSMs and Veterans, and recognized the need for additional healthcare utilization, health cost and quality of care studies; (2) VA vocational rehabilitation programmes and the effectiveness of supported employment for helping those with workplace difficulties; (3) the application of technology to assist in TBI rehabilitation, including mobile device applications for self-management, videoconferencing with providers, and virtual reality to help with behavioural and cognitive challenges, and (4) Department of Defense (DoD)-VA partnerships on identification, evaluation and dissemination of TBI best practices. CONCLUSIONS: There have been significant advances in TBI rehabilitation, but multiple areas across the DoD and VA care continuum need further exploration and development to meet the needs of ADSMs and Veterans.

Associations Between Traumatic Brain Injury, Suspected Psychiatric Conditions, and Unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans.

OBJECTIVE: To examine the relations among demographic characteristics, traumatic brain injury (TBI) history, suspected psychiatric conditions, current neurobehavioral health symptoms, and employment status in Veterans evaluated for TBI in the Department of Veterans Affairs. STUDY DESIGN: Retrospective cross-sectional database review of comprehensive TBI evaluations documented between October 2007 and June 2009. PARTICIPANTS: Operation Enduring Freedom/Operation Iraqi Freedom Veterans (n = 11 683) who completed a comprehensive TBI evaluation. MAIN MEASURES: Veterans Affairs clinicians use the comprehensive TBI evaluations to obtain information about TBI-related experiences, current neurobehavioral symptoms, and to identify suspected psychiatric conditions. RESULTS: Approximately one-third of Veterans in this sample were unemployed, and of these, the majority were looking for work. After simultaneously adjusting for health and deployment-related variables, significant factors associated with unemployment included one or more suspected psychiatric conditions (eg, posttraumatic stress disorder, anxiety, depression), neurobehavioral symptom severity (ie, affective, cognitive, vestibular), former active duty status, injury etiology, age, lower education, and marital status. The associations of these factors with employment status varied by deployment-related TBI severity. CONCLUSIONS: Simultaneously addressing health-related, educational, and/or vocational needs may fill a critical gap for helping Veterans readjust to civilian life and achieve their academic and vocational potential.

Traumatic brain injury among women veterans: an invisible wound of intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) is prevalent among women Veterans and is known to increase women's risk for traumatic brain injury (TBI). IPV-related TBI has not been examined in the women Veteran population. OBJECTIVES: To identify the occurrence of IPV-related TBI in a sample of women Veterans and examine the associations of IPV-related TBI with sociodemographic characteristics, health symptoms, health care utilization, and IPV experiences. RESEARCH DESIGN: Cross-sectional mail survey conducted in 2013. SUBJECTS: The sample comprised 176 New England Department of Veterans Affairs (VA) women Veteran patients. MEASURES: Self-reported IPV-related TBI was assessed with a modified VA TBI screening tool. The survey included validated measures of depression (Center for Epidemiologic Studies Depression Scale) and posttraumatic stress disorder (PTSD; Posttraumatic Disorder Checklist) symptoms, as well as overall mental and physical health (SF-12), and IPV (Conflict Tactics Scales-Revised-2). Questions assessed past-year VA and non-VA health care use. RESULTS: A total of 18.8% (n=33) met screening criteria for IPV-related TBI history. Women who experienced IPV-related TBI reported significantly higher depression (mean Center for Epidemiologic Studies Depression Scale scores: 26.6 vs. 20.7, P<0.0001) and PTSD (mean Posttraumatic Disorder Checklist scores: 53.2 vs. 34.1, P<0.0001) symptoms, and poorer perceptions of physical health (mean SF-12 34.6 vs. 42.3, P<0.01) than women who experienced IPV to the head without TBI. IPV-related TBI was also associated with poorer perceptions of mental health, as well as more frequent VA health care utilization and overall IPV. CONCLUSIONS: IPV-related TBI is associated with poorer mental and physical health in women Veterans. This invisible injury is associated with greater VA health care utilization and IPV exposure. Implications for VA practice and policy are discussed.

Cannabis use disorder contributes to cognitive dysfunction in Veterans with traumatic brain injury.

Background: While emerging evidence supports a link between traumatic brain injury (TBI) and progressive cognitive dysfunction in Veterans, there is insufficient information on the impact of cannabis use disorder (CUD) on long-term cognitive disorders. This study aimed to examine the incidences of cognitive disorders in Veterans with TBI and CUD and to evaluate their relationship. Methods: This retrospective cohort study used the US Department of Veterans Affairs and Department of Defense administrative data from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium Phenotype study. Diagnoses suggesting cognitive disorders after a TBI index date were identified using inpatient and outpatient data from 2003 to 2022. We compared the differential cognitive disorders incidence in Veterans who had the following: (1) no CUD or TBI (control group), (2) CUD only, (3) TBI only, and (4) comorbid CUD+TBI. Kaplan-Meier analyses were used to estimate the overall cognitive disorders incidence in the above study groups. The crude and adjusted Cox proportional hazards models were used to estimate crude and adjusted hazard ratios (HRs) for cognitive disorders. Results: A total of 1,560,556 Veterans [82.32% male, median (IQR) age at the time of TBI, 34.51 (11.29) years, and 61.35% white] were evaluated. The cognitive disorder incidence rates were estimated as 0.68 (95% CI, 0.62, 0.75) for CUD only and 1.03 (95% CI, 1.00, 1.06) for TBI only per 10,000 person-months of observations, with the highest estimated cognitive disorder incidence observed in participants with both TBI and CUD [1.83 (95% CI, 1.72, 1.95)]. Relative to the control group, the highest hazard of cognitive disorders was observed in Veterans with CUD+TBI [hazard ratio (HR), 3.26; 95% CI, 2.91, 3.65], followed by those with TBI only (2.32; 95 CI%, 2.13, 2.53) and with CUD (1.79; 95 CI%, 1.60, 2.00). Of note, in the CUD only subgroup, we also observed the highest risk of an early onset cognitive disorder other than Alzheimer's disease and Frontotemporal dementia. Discussion: The results of this analysis suggest that individuals with comorbid TBI and CUD may be at increased risk for early onset cognitive disorders, including dementia.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.

BACKGROUND: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). METHODS: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. RESULTS: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. CONCLUSIONS: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.