A Longitudinal Investigation of Alexithymia as a Predictor of Empathy, Emotional Functioning, Resilience, and Life Satisfaction Two Years after Brain Injury.

OBJECTIVE: To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years post-injury. DESIGN: Multicenter, longitudinal cohort study. SETTING: Data were collected during Year 1 and Year 2 post-injury follow-up interviews across four TBI Model System (TBIMS) centers. PARTICIPANTS: Persons with TBI (N = 175; 134 men and 41 women) who had English fluency and were capable of providing self-report data. MAIN OUTCOME MEASURE: Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist-Civilian, Satisfaction With Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire-9, suicidal ideation, and problematic substance use. RESULTS: Simple adjusted models demonstrated that after controlling for the specific outcome at Year 1, TAS-20 scores significantly predicted Year 2 scores for perspective taking, physical aggression, emotion dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning. CONCLUSIONS: Compared to those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1-year post-injury reported poorer emotional health at 2 years after TBI, even after controlling for Year 1 outcome scores, sociodemographics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process.

Suicide Attempts and Ideation Among Veterans/Service Members and Non-Veterans Over 5 Years Following Traumatic Brain Injury: A Combined NIDILRR and VA TBI Model Systems Study.

OBJECTIVE: This study compared rates of suicide attempt (SA) and suicidal ideation (SI) during the first 5 years after traumatic brain injury (TBI) among veterans and service members (V/SMs) in the Veterans Affairs (VA) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Model Systems National Databases to each other and to non-veterans (non-Vs) in the NIDILRR database. SETTING: Twenty-one NIDILRR and 5 VA TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States. PARTICIPANTS: Participants with TBI were discharged from rehabilitation alive, had a known military status recorded (either non-V or history of military service), and successful 1-, 2-, and/or 5-year follow-up interviews completed between 2009 and 2021. The year 1 cohort included 8737 unique participants (8347 with SA data and 3987 with SI data); the year 2 (7628 participants) and year 5 (4837 participants) cohorts both had similar demographic characteristics to the year 1 cohort. DESIGN: Longitudinal design with data collected across TBIMS centers at 1, 2, and 5 years post-injury. MAIN OUTCOMES AND MEASURES: History of SA in past year and SI in past 2 weeks assessed by the Patient Health Questionnaire-9 (PHQ-9). Patient demographics, injury characteristics, and rehabilitation outcomes were also assessed. RESULTS: Full sample rates of SA were 1.9%, 1.5%, and 1.6%, and rates of SI were 9.6%, 10.1%, and 8.7% (respectively at years 1, 2, and 5). There were significant differences among groups based on demographic, injury-related, mental/behavioral health, and functional outcome variables. Characteristics predicting SA/SI related to mental health history, substance use, younger age, lower functional independence, and greater levels of disability. CONCLUSIONS: Compared with participants with TBI in the NIDILRR system, higher rates of SI among V/SMs with TBI in the VA system appear associated with risk factors observed within this group, including mental/behavioral health characteristics and overall levels of disability.

Caregiver resilience following traumatic brain injury: Findings at six months postinjury.

PURPOSE/OBJECTIVE: Examine contributors to resilience among caregivers of individuals who have sustained a moderate-to-severe traumatic brain injury (TBI), with the goal of identifying important targets for an intervention to improve caregiver resilience as well as outcomes for people with TBI. RESEARCH METHOD/DESIGN: Participants were adult caregivers (n = 176) and individuals with TBI who required inpatient rehabilitation at six TBI Model System sites. Measures included the Connor-Davidson Resilience Scale-10, Family Needs Questionnaire, Zarit Burden Interview, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected between September 2018 and June 2021. RESULTS: Caregivers endorsed levels of personal resilience that were comparable to norms for community samples and slightly higher than groups under stress or with medical illness. Reports of the burden associated with the caregiving role were relatively low, as was reported psychological distress. In a multivariable model, higher proportions of met emotional support needs were associated with increased resilience. CONCLUSIONS/IMPLICATIONS: Resilience may be strengthened by emotional support networks, including friends or family who may not already be directly involved in the provision of care. Supporting engagement with community agencies, peer mentors, or other informal resources within the family system that provide emotional support may bolster resilience outcomes for caregivers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A Veterans Affairs Model Systems study.

BACKGROUND: Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI). OBJECTIVE: This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). METHODS: Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89), and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling. RESULTS: Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories. CONCLUSION: The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI. SETTING: Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition). DESIGN: This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review. MAIN MEASURES: Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported). RESULTS: Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors. CONCLUSIONS: Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

U.S. vs. Foreign Nativity and 10-Year Trajectories of Mental Health after Traumatic Brain Injury: A Model Systems Study.

BACKGROUND: Previous research has found racial and ethnic disparities in life satisfaction, depression, and anxiety after traumatic brain injury (TBI). However, limited studies have examined differences in these variables between U.S.- and foreign-born individuals with TBI. The purpose of this study was to examine whether differences exist in mental health outcomes between U.S.- and foreign-born individuals with TBI at 1, 2, 5, and 10 years after injury, as well as examine whether demographic and injury-related characteristics account for these differences. METHOD: Participants were 8289 individuals with TBI who identified as U.S.-born and 944 who identified as born outside the U.S. in the TBI Model Systems study. Participants completed measures of mental health outcomes at 1, 2, 5, and 10 years after injury. RESULTS: Foreign-born individuals with TBI had comparable levels of depression and anxiety trajectories to U.S.-born individuals, yet higher life satisfaction trajectories, even after controlling for demographic and injury-related variables. CONCLUSION: Rehabilitation professionals should consider in their clinical work the mechanisms that likely influence mental health outcomes among foreign-born individuals, including family-based values that increase resilience, as well as the possible under-reporting of mental health symptoms along the lines of cultural norms.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study.

OBJECTIVE: The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury. PARTICIPANTS: Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC). SETTING: Five VA PRCs. DESIGN: Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study. MAIN MEASURES: PART-O. RESULTS: Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 . CONCLUSION: Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Perceived care partner burden at 1-year post-injury and associations with emotional awareness, functioning, and empathy after TBI: A TBI model systems study.

BACKGROUND: People with traumatic brain injury (TBI) can lack awareness of their own emotions and often have problems with emotion dysregulation, affective disorders, and empathy deficits. These impairments are known to impact psychosocial behaviors and may contribute to the burden experienced by care partners of individuals with TBI. OBJECTIVE: To examine the associations of emotional awareness, emotional functioning, and empathy among participants with TBI with care partner burden. METHOD: This multisite, cross-sectional, observational study used data from 90 dyads (participants with TBI and their care partner) 1-year post-injury. Participants with TBI completed the Difficulty with Emotional Regulation Scale (DERS; Awareness, Clarity, Goals, Impulse, Nonacceptance, and Strategies subscales); PTSD Checklist-Civilian Version; NIH Toolbox Anger-Affect, Hostility and Aggression Subdomains; PHQ-9; GAD-7; and the Interpersonal Reactivity Index (empathic concern and perspective taking subscales). Care partners completed the Zarit Burden Inventory (ZBI) and provided demographic information. RESULTS: Care partners were predominately female (77%), and most were either a spouse/partner (55.2%) or parent (34.4%). In an unadjusted model that included assessments of emotional awareness, emotional functioning, and empathy of the participant with TBI, the DERS-Awareness and NIH-Hostility subscales accounted for a significant amount of variance associated with care partner burden. These findings persisted after adjusting for care partner age, relationship, education, and the functional status of the participant with TBI (ß= 0.493 and ß= 0.328, respectively). CONCLUSION: These findings suggest that high levels of hostility and low emotional self-awareness can significantly affect the burden felt by TBI care partners.

Using Machine Learning to Examine Suicidal Ideation After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems National Database Study.

OBJECTIVE: The aim of the study was to predict suicidal ideation 1 yr after moderate to severe traumatic brain injury. DESIGN: This study used a cross-sectional design with data collected through the prospective, longitudinal Traumatic Brain Injury Model Systems network at hospitalization and 1 yr after injury. Participants who completed the Patient Health Questionnaire-9 suicide item at year 1 follow-up ( N = 4328) were included. RESULTS: A gradient boosting machine algorithm demonstrated the best performance in predicting suicidal ideation 1 yr after traumatic brain injury. Predictors were Patient Health Questionnaire-9 items (except suicidality), Generalized Anxiety Disorder-7 items, and a measure of heavy drinking. Results of the 10-fold cross-validation gradient boosting machine analysis indicated excellent classification performance with an area under the curve of 0.882. Sensitivity was 0.85 and specificity was 0.77. Accuracy was 0.78 (95% confidence interval, 0.77-0.79). Feature importance analyses revealed that depressed mood and guilt were the most important predictors of suicidal ideation, followed by anhedonia, concentration difficulties, and psychomotor disturbance. CONCLUSIONS: Overall, depression symptoms were most predictive of suicidal ideation. Despite the limited clinical impact of the present findings, machine learning has potential to improve prediction of suicidal behavior, leveraging electronic health record data, to identify individuals at greatest risk, thereby facilitating intervention and optimization of long-term outcomes after traumatic brain injury.

Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study.

BACKGROUND: Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls. OBJECTIVE: This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults. METHODS: Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point. RESULTS: Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes. CONCLUSION: These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

Racial/Ethnic Differences in Arrest Probability Trajectories after Traumatic Brain Injury: A Model Systems Study.

Background: Previous literature has documented racial/ethnic differences in traumatic brain injury (TBI) risk, cause, treatment, and rehabilitation. The purpose of the current study was to investigate potential racial/ethnic differences in arrest probability trajectories over the first 10 years after TBI and whether injury and sociodemographic characteristics accounted for these differences. Methods: The current study included 13,195 participants with moderate-to-severe TBI in the TBI Model Systems National Database who had arrest data from at least one follow-up time point (Years 1, 2, 5, and/or 10). A series of hierarchical linear models assessed racial/ethnic differences in trajectories of arrest probability over these 10 years post-injury and then included socio-demographic and injury-related covariates. Results: White individuals with TBI had lower arrest probability trajectories than Black and Native American individuals, and Asian individuals with TBI had lower arrest probability trajectories than White, Black, Latinx, and Native American persons. In many cases, racial/ethnic disparities persisted even when injury and sociodemographic characteristics were covaried. Conclusion: These results suggest that rehabilitation clinicians should assess for post-injury arrest risk factors such as age, sex, education, pre-injury unemployment, arrest history, and substance abuse, particularly in Black, Latinx, and Native American groups, and integrate programming to lessen post-injury arrest probability and improve overall rehabilitation outcomes.

Exploring racial performance disparities with the Modified Mini-Mental State Exam (3MS) in an acute brain injury rehabilitation setting.

PURPOSE/OBJECTIVE: The Modified Mini-Mental State Exam (3MS) is a brief, widely used cognitive screening tool. This study examined differences in 3MS performance between Black and White individuals undergoing acute brain injury rehabilitation. RESEARCH METHOD/DESIGN: Participants were Black (44.1%; n = 78) and White (55.9%; n = 99) individuals admitted over a 2-year period to inpatient rehabilitation for an acute neurological injury or illness at a major, urban mid-Atlantic medical center. An attending psychologist administered the 3MS during assessment at admission, and demographic and injury-related information was extracted from electronic medical records. RESULTS: While there were no significant racial differences in the subsamples' gender, employment status, marital status, years of education, or days on the rehabilitation unit, Black participants were older and had a higher proportion of focal injuries or stroke. There were no significant racial differences in 3MS total scores. At the item level, Black participants scored lower on abstract reasoning, repetition, visuospatial construction, and comprehension. When adjusting for age and type of injury, significant differences remained in repetition and comprehension. The 3MS's internal consistency was adequate and comparable across races, as were item-total correlations, with the exception of White participants having a larger item-total correlation for the basic attention item. CONCLUSIONS/IMPLICATIONS: These findings underscore a point of caution about interpreting the results of a cognitive screening measure like the 3MS without the context of an individual's neurological history and race. Black individuals might be at risk for being inappropriately screened to be cognitively impaired, and some level of racial sensitivity should be taken at the item level for repetition and comprehension constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Caregiver Characteristics of Adults with Acute Traumatic Brain Injury in the United States and Latin America.

Objectives: To compare characteristics of caregivers of adults with acute traumatic brain injury (TBI) in the U.S. and Latin America (Mexico and Colombia). Design: Secondary data analysis of two cohorts. Cohort 1: English-speaking caregivers of adults with TBI in the U.S. (n = 80). Cohort 2: Spanish-speaking caregivers of adults with TBI in Mexico or Colombia (n = 109). Results: Similarities between the U.S. and Latin American caregiver groups, respectively, were: predominantly women (81.3%, 81.7%, respectively); spouses/domestic partners (45%, 31.2%); and motor vehicle accident (41.5%, 48.6%) followed by fall etiologies (40%, 21.1%). Differences between U.S. and Latin American caregivers were: age (49.5 years, 41.5 years, p < 0.001); employment status ((Χ52 = 59.63, p < 0.001), full-time employment (63.7%, 25.7%), homemaker (2.5%, 31.2%), and retired (17.5%, 1.8%)); violence-related etiology (2.5%, 15.6%); and severity of depressive symptoms (M = 7.9, SD = 5.8; M = 5.8, SD = 5.7; p = 0.014). Conclusions: TBI caregivers in the U.S. were older and employed full-time or retired more often than those in Latin America. Violence-related etiology was nearly five times more common in Latin America, raising concerns for potential implications of post-traumatic stress and family adjustment after injury. Although both groups likely could use mental health support, this was particularly true of the U.S. cohort, maybe due to differential demographics, mechanisms of injury, or family and community support.

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.

Network Analysis of Neurobehavioral Symptom Patterns in an International Sample of Spanish-Speakers with a History of COVID-19 and Controls.

(1) Background: Psychometric network analysis provides a novel statistical approach allowing researchers to model clusters of related symptoms as a dynamic system. This study applied network analysis to investigate the patterns of somatic, cognitive, and affective neurobehavioral symptoms in an international sample of Spanish-speaking individuals with a history of COVID-19 positivity and non-COVID controls; (2) methods: the sample (n = 1093) included 650 adults from 26 countries who reported having previously tested positive for COVID-19 (COVID+) through a viral and/or antigen test (average of 147 days since diagnosis). The control group (COVID-) was comprised of 443 adults from 20 countries who had completed the survey prior to the COVID-19 pandemic; (3) results: relative to the COVID- network, the COVID+ network was very well-connected, such that each neurobehavioral symptom was positively connected to the network. The organize-to-headache and dizzy-to-balance connections in the COVID+ network were stronger than in the COVID- network. The hearing, numbness, and tense symptoms were more central to the COVID+ network with the latter connected to the sleep, fatigue, and frustrated symptoms. The COVID- network was largely disjointed, with most of the somatosensory symptoms forming their own cluster with no connections to other symptom groups and fatigue not being connected to any other symptom. The cognitive and affective symptoms in the COVID- network were also largely connected to symptoms from within their own groups; (4) conclusions: These findings suggest that many of the long-term neurobehavioral symptoms of COVID-19 form a discernable network and that headaches, frustration, hearing problems, forgetfulness, and tension are the most central symptoms. Cognitive and behavioral rehabilitation strategies targeting these central symptom network features may hold promise to help fracture the lingering symptom network of COVID-19.

Relations Among Suicidal Ideation, Depressive Symptoms, and Functional Independence During the 10 Years After Traumatic Brain Injury: A Model Systems Study.

OBJECTIVE: To investigate relative causality in relations among suicidal ideation (SI), depressive symptoms, and functional independence over the first 10 years after traumatic brain injury (TBI). DESIGN: Prospective longitudinal design with data collected through the Traumatic Brain Injury Model Systems (TBIMS) network at acute rehabilitation hospitalization as well as 1, 2, 5, and 10 years after injury. SETTING: United States Level I/II trauma centers and inpatient rehabilitation centers with telephone follow-up. PARTICIPANTS: Individuals enrolled into the TBIMS National Database (N=9539) with at least 1 SI score at any follow-up data collection (72.1% male; mean age, 39.39y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient Health Questionnaire-9 and FIM at years 1, 2, 5, and 10 post injury. RESULTS: A cross-lagged panel structural equation model, which is meant to indirectly infer causality through longitudinal correlational data, suggested that SI, depressive symptoms, and functional independence each significantly predicted themselves over time. Within the model, bivariate correlations among variables were all significant within each time point. Between years 1 and 2 and between years 2 and 5, depressive symptoms had a larger effect on SI than SI had on depressive symptoms. Between years 5 and 10, there was reciprocal causality between the 2 variables. Functional independence more strongly predicted depressive symptoms than the reverse between years 1 and 2 as well as years 2 and 5, but its unique effects on SI over time were extremely marginal or absent after controlling for depressive symptoms. CONCLUSIONS: A primary goal for rehabilitation and mental health providers should be to monitor and address elevated symptoms of depression as quickly as possible before they translate into SI, particularly for individuals with TBI who have reduced functional independence. Doing so may be a key to breaking the connection between low functional independence and SI.

Identifying group-based patterns of suicidal ideation over the first 10 years after moderate-to-severe TBI.

OBJECTIVE: To identify group-based patterns in suicidal ideation (SI) over the first 10 years after traumatic brain injury (TBI). METHODS: Participants included 9539 individuals in the TBI Model Systems National Database who responded to Patient Health Questionnaire-9 Item 9 assessing SI at 1, 2, 5, and/or 10 years post-injury. A k-means cluster analysis was conducted to determine group-based patterns of SI, and pre-injury variables were compared with ANOVAs and chi-square tests. RESULTS: SI and attempts decreased over time. Four group-based patterns emerged: Low, increasing, moderate, and decreasing SI. The low SI group comprised 89% of the sample, had the highest pre-injury employment, fewer mental health vulnerabilities, least severe injuries, and were oldest. The increasing SI group had the most severe TBIs, were youngest, and disproportionately Black or Asian/Pacific Islander. CONCLUSION: These findings reinforce the importance of mental health and suicide risk assessment during chronic recovery from TBI.

Network Analysis of Neurobehavioral and Post-Traumatic Stress Disorder Symptoms One Year after Traumatic Brain Injury: A Veterans Affairs Traumatic Brain Injury Model Systems Study.

Traumatic brain injury (TBI) is often experienced under stressful circumstances that can lead to symptoms of post-traumatic stress disorder (PTSD) and neurobehavioral symptoms of brain injury. There is considerable symptom overlap in the behavioral expression of these conditions. Psychometric network analysis is a useful approach to investigate the role of specific symptoms in connecting these two disorders and is well suited to explore their interrelatedness. This study applied network analysis to examine the associations among PTSD and TBI symptoms in a sample of Service Members and Veterans (SM/Vs) with a history of TBI one year after injury. Responses to the Neurobehavioral Symptom Inventory (NSI) and PTSD Checklist-Civilian version (PCL-C) were obtained from participants who completed comprehensive inpatient rehabilitation services across five Veterans Affairs polytrauma rehabilitation centers. Participants (N = 612) were 93.1% male with an average age of 36.98 years at injury. The analysis produced a stable network. Within the NSI symptom groups, the frustration symptom was an important bridge between the affective and cognitive TBI symptoms. The PCL-C nodes formed their own small cluster with hyperarousal yielding connections with the affective, cognitive, and somatic symptom groups. Consistent with this observation, the hyperarousal node had the second strongest bridge centrality in the network. Hyperarousal appears to play a key role in holding together this network of distress and thus represents a prime target for intervention among individuals with elevated symptoms of PTSD and a history of TBI. Network analysis offers an empirical approach to visualizing and quantifying the associations among symptoms. The identification of symptoms that are central to connecting multiple conditions can inform diagnostic precision and treatment selection.

Factor structure of the Modified Mini Mental State (3MS) exam among participants in inpatient neurorehabilitation.

OBJECTIVE: To evaluate the factor structure of the Modified Mini Mental State (3MS) Exam and its suitability as a cognitive screening tool among individuals admitted to an inpatient rehabilitation unit for new-onset neurological injury/illness. METHOD: A retrospective chart review was conducted. Of the 187 individuals meeting the inclusion criteria, 116 had a diffuse pattern of neurological injury/illness; 71 had a focal injury/illness. Confirmatory and exploratory factor analyses (CFA; EFA) were conducted for the whole sample and separately by group. RESULTS: The CFA suggested poor fit indices. The EFA of the total sample suggested a three-factor solution (Orientation/Awareness; Learning/Recall and Executive Functioning; Psychomotor Ability). The EFA of the diffuse subsample suggested a three-factor solution (Attention and Learning/Recall; Psychomotor Ability; Expressive Language). The Orientation/Awareness, Learning/Recall, Executive Functioning, Psychomotor Ability, and Expressive Language four-factor solution observed among the focal subsample was considered invalid. CONCLUSION: The 3MS provides information about the pattern of cognitive performance among individuals in neurorehabilitation; clinicians are advised to interpret total scores with caution. Among individuals with focal injuries/illnesses, clinicians might use the 3MS to compare the pattern of cognitive ability to expectations for performance and to support strengths-based approaches to participation in rehabilitation therapies.

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.