Diagnostic Accuracy of Mental Health Screening Tools After Mild Traumatic Brain Injury.

Importance: Mental health disorders are common after mild traumatic brain injury (mTBI) and likely exacerbate postconcussive symptoms and disability. Early detection could improve clinical outcomes, but the accuracy of mental health screening tools in this population has not been well established. Objective: To determine the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9), Generalizaed Anxiety Disorder-7 (GAD-7), and Primary Care PTSD (Posttramatic Stress Disorder) Screen for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (PC-PTSD-5) in adults with mTBI. Design, Setting, and Participants: This diagnostic study was performed as a secondary analysis of a cluster randomized clinical trial. Self-report mental health screening tools (PHQ-9, GAD-7, and PC-PTSD-5) were administered online 12 weeks after mTBI and compared against a structured psychodiagnostic interview (Mini-International Neuropsychiatric Interview for DSM-5 (MINI) over videoconference at the same time. Adults with mTBI (N = 537) were recruited from February 1, 2021, to October 25, 2022. Main Outcomes and Measures: Presence of a major depressive episode, anxiety disorders, and PTSD were determined by a blinded assessor with the MINI. Diagnostic accuracy statistics were derived for the PHQ-9, GAD-7, and PC-PTSD-5. Findings were disaggregated for participants with and without persistent postconcussion symptoms (PPCS) by International and Statistical Classification of Diseases, Tenth Revision criteria. Results: Data were available for 499 of 537 trial participants, 278 (55.7%) of whom were female; the mean (SD) age was 38.8 (13.9) years. Each screening questionnaire had strong diagnostic accuracy in the overall sample for optimal cut points (area under the curve [AUC], ≥0.80; sensitivity, 0.55-0.94; specificity, 0.64-0.94). The AUC (difference of 0.01-0.13) and specificity (difference, 5-65 percentage points) were lower in those with PPCS present compared with PPCS absent, but the prevalence of at least 1 mental health disorder was 3 to 5 times higher in patients with PPCS present. The GAD-7 had slightly better performance than the PC-PTSD-5 for detecting PTSD (AUC, 0.85 [95% CI, 0.80-0.89] vs 0.80 [95% CI, 0.72-0.87]). The optimal cutoff on the PHQ-9 was 5 or more symptoms experienced on more than half of days; on the GAD-7, a total score of at least 7. Conclusions and Relevance: The findings of this diagnostic study suggest that the PHQ-9, GAD-7 and PC-PTSD-5 accurately screen for mental health disorders in patients with mTBI. Future research should corroborate optimal test cutoffs for this population.

A scoping review of the effects of mushroom and fungus extracts in rodent models of depression and tests of antidepressant activity.

One of the most important developments in psychopharmacology in the past decade has been the emergence of novel treatments for mood disorders, such as psilocybin for treatment-resistant depression. Psilocybin is most commonly found in different species of mushroom; however, the literature on mushroom and fungus extracts with potential antidepressant activity extends well beyond just psilocybin-containing mushrooms, and includes both psychedelic and non-psychedelic species. In the current review, we systematically review the preclinical literature on mushroom and fungus extracts, and their effects of animal models of depression and tests of antidepressant activity. The PICO structure, PRISMA checklist and the Cochrane Handbook for systematic reviews of intervention were used to guide the search strategy. A scoping search was conducted in electronic databases PubMed, CINAHL, Embase and Web of Science. The literature search identified 50 relevant and suitable published studies. These included 19 different species of mushrooms, as well as seven different species of other fungi. Nearly all studies reported antidepressant-like effects of treatment with extracts. Treatments were most commonly delivered orally, in both acute and chronically administered studies to predominantly male rodents. Multiple animal models of depression were used, the most common being unpredictable chronic mild stress, while the tail suspension test and forced swim test were most frequently used as standalone antidepressant screens. Details on each experiment with mushroom and fungus species are discussed in detail, while an evaluation is provided of the strengths and weaknesses of these studies.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome.

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Differential sensitivity of intraindividual variability dispersion and global cognition in the prediction of functional outcomes and mortality in precariously housed and homeless adults.

OBJECTIVE: To examine cognitive intraindividual variability (IIV) dispersion as a predictor of everyday functioning and mortality in persons who are homeless or precariously housed. METHOD: Participants were 407 community-dwelling adults, followed for up to 13 years. Neurocognition was assessed at baseline and IIV dispersion was derived using a battery of standardized tests. Functional outcomes (social, physical) were obtained at baseline and last follow-up. Mortality was confirmed with Coroner's reports and hospital records (N = 103 deaths). Linear regressions were used to predict current social and physical functioning from IIV dispersion. Repeated measures Analysis of Covariance were used to predict long-term change in functioning. Cox regression models examined the relation between IIV dispersion and mortality. Covariates included global cognition (i.e. mean-level performance), age, education, and physical comorbidities. RESULTS: Higher IIV dispersion predicted poorer current physical functioning (B = -0.46 p = .010), while higher global cognition predicted better current (B = 0.21, p = .015) and change in social functioning over a period of up to 13 years (F = 4.23, p = .040). Global cognition, but not IIV dispersion, predicted mortality in individuals under 55 years old (HR = 0.50, p = .013). CONCLUSIONS: Our findings suggest that indices of neurocognitive functioning (i.e. IIV dispersion and global cognition) may be differentially related to discrete dimensions of functional outcomes in an at-risk population. IIV dispersion may be a complimentary marker of emergent physical health dysfunction in precariously housed adults and may be best used in conjunction with traditional neuropsychological indices.

Predicting Outcomes in Patients with Diffuse Axonal Injury: External Validation of the Widely Used Prognostic Instruments.

AIM: Accurate prognosis of diffuse axonal injury (DAI) is important in directing clinical care, allocating resources appropriately, and communicating with families and surrogate decision-makers. METHODS: A study was conducted on patients with clinical DAI due to closed-head traumatic brain injury treated at a trauma center in Brazil from July 2013 to September 2015.  The objective efficacy of the Glasgow Coma Scale (GCS), Trauma and Injury Severity Scoring system (TRISS), New Trauma and Injury Severity Scoring system (NTRISS), Abbreviated Injury Scale (AIS)/head, Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) models in the prediction of mortality at 14 days and 6-months and unfavorable outcomes at 6 months was tested. RESULTS: Our cohort comprised 95 prospectively recruited adults (85 males, 10 females, mean age 30.3 ± 10.9 years) admitted with DAI. Model efficacy was assessed through discrimination (area under the curve [AUC]), and Cox calibration. The AIS/head, TRISS, NTRISS, CRASH, and IMPACT models were able to discriminate both mortality and unfavorable outcomes (AUC 0.78-0.87). IMPACT models resulted in a statistically perfect calibration for both 6-month outcome variables; mortality and 6-month unfavorable outcome. Calibration also revealed that TRISS, NTRISS, and CRASH systematically overpredicted both outcomes, except for 6-month unfavorable outcome with TRISS. CONCLUSIONS: The results of this study suggest that TRISS, NTRISS, CRASH, and IMPACT models satisfactorily discriminate between mortality and unfavorable outcomes. However, only the TRISS and IMPACT models showed accurate calibration when predicting 6-month unfavorable outcome.

Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial.

INTRODUCTION: Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments. METHODS AND ANALYSIS: We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire). ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov #NCT05365776.

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review.

INTRODUCTION: Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach. ETHICS AND DISSEMINATION: Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

Relationship between drug-induced movement disorders and psychosis in adults living in precarious housing or homelessness.

BACKGROUND: Studies have reported positive associations between drug-induced movement disorders (DIMDs) and symptoms of psychosis in patients with schizophrenia. However, it is not clear which subtypes of symptoms are related to each other, and whether one symptom precedes another. The current report assessed both concurrent and temporal associations between DIMDs and symptoms of psychosis in a community-based sample of homeless individuals. METHODS: Participants were recruited in Vancouver, Canada. Severity of DIMDs and psychosis was rated annually, allowing for the analysis of concurrent associations between DIMDs and Positive and Negative Syndrome Scale (PANSS) five factors. A brief version of the PANSS was rated monthly using five psychotic symptoms, allowing for the analysis of their temporal associations with DIMDs. Mixed-effects linear and logistic regression models were used to assess the associations. RESULTS: 401 participants were included, mean age of 40.7 years (SD = 11.2) and 77.4% male. DIMDs and symptoms of psychosis were differentially associated with each other, in which the presence of parkinsonism was associated with greater negative symptoms, dyskinesia with disorganized symptoms, and akathisia with excited symptoms. The presence of DIMDs of any type was not associated with depressive symptoms. Regarding temporal associations, preceding delusions and unusual thought content were associated with parkinsonism, whereas dyskinesia was associated with subsequent conceptual disorganization. CONCLUSIONS: The current study found significant associations between DIMDs and symptoms of psychosis in individuals living in precarious housing or homelessness. Moreover, there were temporal associations between parkinsonism and psychotic symptoms (delusions or unusual thought content), and the presence of dyskinesia was temporally associated with higher odds of clinically relevant conceptual disorganization.

Factors Associated with Problematic Cannabis Use in a Sample of Medical Cannabis Dispensary Users.

Background: With the recent legalization of cannabis for medical purposes in many countries, there has been an increased number of individuals using such products. While there is considerable evidence indicating that cannabis may have therapeutic effects for a range of different conditions, concerns remain about the risk of developing cannabis use disorders for those at risk, or patients without appropriate clinical guidance. The aim of the present study was to determine the prevalence of problematic cannabis use in a cohort of cannabis users who consumed the drug for medical purposes and to identify potential risk factors. Methods: One hundred individuals who self-identified as using cannabis to improve their mental health were recruited from a community dispensary. Extensive details were collected about subjects' patterns of cannabis use and reasons for use. All subjects completed a structured clinical interview with the Mini-International Neuropsychiatric Interview, while information about perceived stress, depressive symptoms, and somatic symptoms were recorded with the Perceived Stress Scale-10, Beck Depression Inventory, and the Patient Health Questionnaire-15. Results: Rates of problematic cannabis use were high, with 30% meeting the criteria. Only 10% of subjects reported medical cannabis use was recommended by their doctor. Significant risk factors for problematic use included earlier age of cannabis initiation, as well as self-reported use of cannabis products for depression. Conclusions: The prevalence of problematic cannabis use in the community dispensary was higher than expected. Specific risk factors for problematic cannabis use may represent important areas for future intervention to ensure safer consumption for medical purposes.