Research Letter: Characterizing Lifetime Mild TBI Exposure Among Female and Male Military Service Members and Veterans in the LIMBIC-CENC Study.

OBJECTIVE: To (1) characterize lifetime mild traumatic brain injury (TBI) exposures among male and female US military service members and Veterans (SMVs) and (2) evaluate sex-related differences in mild TBI exposures. SETTING: Clinical research laboratory. PARTICIPANTS: Participants were enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) Prospective Longitudinal Study. DESIGN: Cross-sectional. MAIN MEASURES: Lifetime history of mild TBI was measured via structured interview. All mild TBI characteristics were collected as part of this interview, including total lifetime number; environment (deployment vs. non-deployment); timing of injury (relative to military service and age); and mechanism of injury (blast-related vs. non-blast). RESULTS: Most participants (n = 2323; 87.5% male; 79.6% Veteran) reported ≥1 lifetime mild TBI (n = 1912; 82%), among whom, many reported ≥2 lifetime mild TBIs. Female SMVs reported fewer total lifetime mild TBIs than male participants (P < 0.001), including fewer deployment-related (P < 0.001) and non-deployment (P < 0.001) mild TBIs. There were significant sex differences for total number of mild TBIs sustained before (P = 0.005) and during (P < 0.001) military service but not after separation from military service (P = 0.99). Among participants with a lifetime history of mild TBI, female SMVs were less likely to report ≥2 mTBIs (P = 0.003); however, male SMVs were more likely to report a mild TBI during military service (P = 0.03), including combat-related mild TBI (P < 0.001) and mild TBI involving blast (P < 0.001). CONCLUSIONS: These findings inform clinical and research efforts related to mild TBI in US military SMVs. It may not be sufficient to simply measure the total number of mild TBIs when seeking to compare clinical outcomes related to mild TBI between sexes; rather, it is important to measure and account for the timing, environment, and mechanisms associated with mild TBIs sustained by female and male SMVs.

Symptom validity indices in the Posttraumatic Stress Disorder Checklist for DSM-5.

The use of symptom validity tests (SVTs) is standard practice in psychodiagnostic assessments. Embedded measures are indices within self-report measures. To date, no embedded SVTs have been identified in the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). This research aimed to develop and validate PCL-5 SVTs in two samples of veterans. Participants completed one of two prospective research studies that included cognitive and psychological tests. Participants in Study 1 were veterans (N = 464) who served following the September 11, 2001, terrorist attacks; participants in Study 2 were veterans or service members (N = 338) who had been deployed to Iraq and/or Afghanistan. Both studies included the PCL-5 and the Structured Inventory of Malingered Symptomatology (SIMS), the latter of which served as the criterion for identifying PCL-5 SVTs. For Study 1, two separate SVTs were developed: the PCL-5 Symptom Severity scale (PSS), based on the PCL-5 total score, and the PCL-5 Rare Items scale (PRI), based on PCL-5 items infrequently endorsed at the highest item ratings. At the most conservative SIMS cutoff score, the PSS achieved excellent discrimination for both the Study 1, AUC = .840, and Study 2 samples, AUC = .858, with specific cutoff scores of ≥ 51 and ≥ 56 maximizing sensitivity while maintaining a specificity of .90. The PRI achieved good discrimination, AUCs = .760 and.726, respectively, with a cutoff score of 2 or higher indicated by both studies. The results of these two studies provide provisional support for these two embedded SVTs in the PCL-5.

Contextual Effects of Traumatic Brain Injury on the Connectome: Differential Effects of Deployment- and Non-Deployment-Acquired Injuries.

OBJECTIVE: To identify differential effects of mild traumatic brain injury (TBI) occurring in a deployment or nondeployment setting on the functional brain connectome. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: In total, 181 combat-exposed veterans of the wars in Iraq and Afghanistan ( n = 74 with deployment-related mild TBI, average time since injury = 11.0 years, SD = 4.1). DESIGN: Cross-sectional observational study. MAIN MEASURES: Mid-Atlantic MIRECC (Mid-Atlantic Mental Illness Research, Education, and Clinical Center) Assessment of TBI, Clinician-Administered PTSD Scale, connectome metrics. RESULTS: Linear regression adjusting for relevant covariates demonstrates a significant ( P < .05 corrected) association between deployment mild TBI with reduced global efficiency (nonstandardized ß = -.011) and degree of the K-core (nonstandardized ß = -.79). Nondeployment mild TBI was significantly associated with a reduced number of modules within the connectome (nonstandardized ß = -2.32). Finally, the interaction between deployment and nondeployment mild TBIs was significantly ( P < .05 corrected) associated with increased mean (nonstandardized ß = 9.92) and mode (nonstandardized ß = 14.02) frequency at which connections occur. CONCLUSIONS: These results demonstrate distinct effects of mild TBI on the functional brain connectome when sustained in a deployment versus nondeployment context. This is consistent with findings demonstrating differential effects in other areas such as psychiatric diagnoses and severity, pain, sleep, and cognitive function. Furthermore, participants were an average of 11 years postinjury, suggesting these represent chronic effects of the injury. Overall, these findings add to the growing body of evidence, suggesting the effects of mild TBI acquired during deployment are different and potentially longer lasting than those of mild TBI acquired in a nondeployment context.

Are All Endoscopy-Related Musculoskeletal Injuries Created Equal? Results of a National Gender-Based Survey.

INTRODUCTION: Endoscopy-related injury (ERI) is common in gastroenterologists (GI). The study aim was to assess the prevalence of self-reported ERI, patterns of injury, and endoscopist knowledge of preventative strategies in a nationally representative sample. METHODS: A 38-item electronic survey was sent to 15,868 American College of Gastroenterology physician members. The survey was completed by 1,698 members and was included in analyses. Descriptive, univariate, and multivariate analyses were conducted to evaluate the likelihood of ERI based on workload parameters and gender. RESULTS: ERI was reported by 75% of respondents. ERI was most common in the thumb (63.3%), neck (59%), hand/finger (56.5%), lower back (52.6%), shoulder (47%), and wrist (45%). There was no significant difference in the prevalence of ERI between men and women GI. However, women GI were significantly more likely to report upper extremity ERI while men were more likely to report lower-back pain-related ERI. Significant gender differences were noted in the reported mechanisms attributed to ERI. Most respondents did not discuss ergonomic strategies in their current practice (63%). ERI was less likely to be reported in GI who took breaks during endoscopy (P = 0.002). DISCUSSION: ERI is highly prevalent in GI physicians. Significant gender differences regarding specific sites affected by ERI and the contributing mechanisms were observed. Results strongly support institution of training in ergonomics for all GI as a strategy to prevent its impact on providers of endoscopy.

Research Letter: Blast Exposure and Brain Volume.

OBJECTIVE: To determine whether blast exposure is associated with brain volume beyond posttraumatic stress disorder (PTSD) diagnosis and history of traumatic brain injury (TBI). SETTING: Veterans Affairs Medical Center. PARTICIPANTS: One hundred sixty-three Iraq and Afghanistan combat veterans, 86.5% male, and 68.10% with a history of blast exposure. Individuals with a history of moderate to severe TBI were excluded. MAIN MEASURES: Clinician-Administered PTSD Scale (CAPS-5), Mid-Atlantic MIRECC Assessment of TBI (MMA-TBI), Salisbury Blast Interview (SBI), and magnetic resonance imaging. Maximum blast pressure experienced from a blast event represented blast severity. METHODS: Hierarchical regression analysis evaluated effects of maximum pressure experienced from a blast event on bilateral volume of hippocampus, anterior cingulate cortex, amygdala, orbitofrontal cortex, precuneus, and insula. All analyses adjusted for effects of current and lifetime PTSD diagnosis, and a history of deployment mild TBI. RESULTS: Maximum blast pressure experienced was significantly associated with lower bilateral hippocampal volume (left: ΔR2 = 0.032, P < .001; right: ΔR2 = 0.030, P < .001) beyond PTSD diagnosis and deployment mild TBI history. Other characteristics of blast exposure (time since most recent exposure, distance from closest blast, and frequency of blast events) were not associated with evaluated volumes. CONCLUSION: Exposure to a blast is independently associated with hippocampal volume beyond PTSD and mild TBI; however, these effects are small. These results also demonstrate that blast exposure in and of itself may be less consequential than severity of the exposure as measured by the pressure gradient.

Distress Tolerance and Symptom Severity as Mediators of Symptom Validity Failure in Veterans With PTSD.

OBJECTIVE: Performance validity tests (PVTs) and symptom validity tests (SVTs) are necessary in clinical and research contexts. The extent to which psychiatric distress contributes to failure on these tests is unclear. The authors hypothesized that the relation between posttraumatic stress disorder (PTSD) and validity would be serially mediated by distress tolerance and symptom severity. METHODS: Participants included 306 veterans, 110 of whom met full criteria for current PTSD. PVTs included the Medical Symptom Validity Test (MSVT) and b Test. The Structured Inventory of Malingered Symptomatology (SIMS) was used to measure symptom validity. RESULTS: MSVT failure was significantly and directly associated with PTSD severity (B=0.05, CI=0.01, 0.08) but not distress tolerance or PTSD diagnosis. b Test performance was not significantly related to any variable. SIMS failure was significantly associated with PTSD diagnosis (B=0.71, CI=0.05, 1.37), distress tolerance (B=-0.04, CI=-0.07, -0.01), and symptom severity (B=0.07, CI=0.04, 0.09). The serial mediation model significantly predicted all SIMS subscales. CONCLUSIONS: PTSD severity was associated with failing a memory-based PVT but not an attention-based PVT. Neither PVT was associated with distress tolerance or PTSD diagnosis. SVT failure was associated with PTSD diagnosis, poor distress tolerance, and high symptomatology. For veterans with PTSD, difficulty managing negative emotional states may contribute to symptom overreporting. This may reflect exaggeration or an inability to tolerate stronger negative affect, rather than a "cry for help."

Brain Volume in Veterans: Relationship to Posttraumatic Stress Disorder and Mild Traumatic Brain Injury.

OBJECTIVE: Clarify associations between diagnosis of posttraumatic stress disorder (PTSD) and deployment traumatic brain injury (TBI) on salient regional brain volumes in returning combat veterans. PARTICIPANTS: Iraq and Afghanistan era combat veterans, N = 163, 86.5% male. MAIN MEASURES: Clinician-administered PTSD Scale (CAPS-5), Mid-Atlantic MIRECC Assessment of TBI (MMA-TBI), magnetic resonance imaging. METHODS: Hierarchical regression analyses evaluated associations and interactions between current and lifetime PTSD diagnosis, deployment TBI, and bilateral volume of hippocampus, anterior cingulate cortex, amygdala, orbitofrontal cortex, precuneus, and insula. RESULTS: Deployment TBI was associated with lower bilateral hippocampal volume (P = .007-.032) and right medial orbitofrontal cortex volume (P = .006). Neither current nor lifetime PTSD diagnosis was associated with volumetric outcomes beyond covariates and deployment TBI. CONCLUSION: History of deployment TBI is independently associated with lower volumes in hippocampus and medial orbitofrontal cortex. These results support TBI as a potential contributing factor to consider in reduced cortical volume in PTSD.

Sequelae of Blast Events in Iraq and Afghanistan War Veterans using the Salisbury Blast Interview: A CENC Study.

Objective: To comprehensively characterize blast exposure across the lifespan and relationship to TBI.Participants: Post-deployment veterans and service members (N = 287).Design: Prospective cohort recruitment.Main Measures: Salisbury Blast Interview (SBI).Results: 94.4% of participants reported at least one blast event, 75% reported a pressure gradient during a blast event. Participants reported an average of 337.7 (SD = 984.0) blast events (range 0-4857), 64.8% occurring during combat. Across participants, 19.7% reported experiencing a traumatic brain injury (TBI) during a blast event. Subjective ratings of blast characteristics (wind, debris, ground shaking, pressure, temperature, sound) were significantly higher when TBI was experienced and significantly lower when behind cover. Pressure had the strongest association with resulting TBI (AUC = 0.751). Pressure rating of 3 had the best sensitivity (.54)/specificity (.87) with TBI. Logistic regression demonstrated pressure, temperature and distance were the best predictors of TBI, and pressure was the best predictor of primary blast TBI.Conclusion: Results demonstrate the ubiquitous nature of blast events and provide insight into blast characteristics most associated with resulting TBI (pressure, temperature, distance). The SBI provides comprehensive characterization of blast events across the lifespan including the environment, protective factors, blast characteristics and estimates of distance and munition.

The role of PTSD and TBI in post-deployment sleep outcomes.

The purpose of this study was to evaluate the main and interaction effects of PTSD and TBI on sleep outcomes in veterans. Post-deployment combat veterans (N = 293, 87.37% male) completed clinical interviews to determine diagnosis and severity of PTSD and deployment TBI history, as well as subjective measures of sleep quality, sleep duration, and restedness. Sleep-related medical diagnoses were extracted from electronic medical records for all participants. PTSD and TBI were each associated with poorer ratings of sleep quality, restedness, shorter sleep duration, and greater incidence of clinically diagnosed sleep disorders. Analyses indicated main effects of PTSD on sleep quality (p < .001), but no main effects of TBI. PTSD severity was significantly associated with poorer sleep quality (p < .001), restedness (p = .018), and shorter sleep duration (p = .015). TBI severity was significantly associated with restedness beyond PTSD severity (p = .036). There were no interaction effects between diagnostic or severity variables. PTSD severity is a driving factor for subjective ratings of sleep disturbance beyond PTSD diagnosis as well as TBI diagnosis and severity. Despite this, poor sleep was apparent throughout the sample, which suggests post-deployment service members may globally benefit from routine screening of sleep problems and increased emphasis on sleep hygiene.

RBANS Validity Indices: a Systematic Review and Meta-Analysis.

Neuropsychology practice organizations have highlighted the need for thorough evaluation of performance validity as part of the neuropsychological assessment process. Embedded validity indices are derived from existing measures and expand the scope of validity assessment. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a brief instrument that quickly allows a clinician to assess a variety of cognitive domains. The RBANS also contains multiple embedded validity indicators. The purpose of this study was to synthesize the utility of those indicators to assess performance validity. A systematic search was completed, resulting in 11 studies for synthesis and 10 for meta-analysis. Data were synthesized on four indices and three subtests across samples of civilians, service members, and veterans. Sufficient data for meta-analysis were only available for the Effort Index, and related analyses indicated optimal cutoff scores of ≥1 (AUC = .86) and ≥ 3 (AUC = .85). However, outliers and heterogeneity were present indicating the importance of age and evaluation context. Overall, embedded validity indicators have shown adequate diagnostic accuracy across a variety of populations. Recommendations for interpreting these measures and future studies are provided.

Behavioral and Health Outcomes Associated With Deployment and Nondeployment Acquisition of Traumatic Brain Injury in Iraq and Afghanistan Veterans.

OBJECTIVE: To characterize behavioral and health outcomes in veterans with traumatic brain injury (TBI) acquired in nondeployment and deployment settings. DESIGN: Cross-sectional assessment evaluating TBI acquired during and outside of deployment, mental and behavioral health symptoms, and diagnoses. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Iraq and Afghanistan veterans who were deployed to a warzone (N=1399). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comprehensive lifetime TBI interview, Structured Clinical Interview for DSM-IV Disorders, Combat Exposure Scale, and behavioral and health measures. RESULTS: There was a main effect of deployment TBI on depressive symptoms, posttraumatic stress symptoms, poor sleep quality, substance use, and pain. Veterans with deployment TBI were also more likely to have a diagnosis of bipolar, major depressive, alcohol use, and posttraumatic stress disorders than those who did not have a deployment TBI. CONCLUSIONS: TBIs acquired during deployment are associated with different behavioral and health outcomes than TBI acquired in nondeployment environments. The presence of TBI during deployment is associated with poorer behavioral outcomes, as well as a greater lifetime prevalence of behavioral and health problems in contrast to veterans without deployment TBI. These results indicate that problems may persist chronically after a deployment TBI and should be considered when providing care for veterans. Veterans with deployment TBI may require treatment alterations to improve engagement and outcomes.

Longitudinal changes in neuroimaging and neuropsychiatric status of post-deployment veterans: a CENC pilot study.

PRIMARY OBJECTIVE: The purpose of this study was to evaluate preliminary data on longitudinal changes in psychiatric, neurobehavioural, and neuroimaging findings in Iraq and Afghanistan combat veterans following blast exposure. RESEARCH DESIGN: Longitudinal observational analysis. METHODS AND PROCEDURES: Participants were invited to participate in two research projects approximately 7 years apart. For each project, veterans completed the Structured Clinical Interview for DSM-IV Disorders and/or the Clinician-Administered PTSD Scale, Neurobehavioral Symptom Inventory, and magnetic resonance imaging (MRI). MAIN OUTCOMES AND RESULTS: Chi-squared tests indicated no significant changes in current psychiatric diagnoses, traumatic brain injury (TBI) history, or blast exposure history between assessment visits. Wilcoxon signed-rank tests indicated significant increases in median neurobehavioural symptoms, total number of white matter hyperintensities (WMH), and total WMH volume between assessment visits. Spearman rank correlations indicated no significant associations between change in psychiatric diagnoses, TBI history, blast exposure history, or neurobehavioural symptoms and change in WMH. CONCLUSION: MRI WMH changes were not associated with changes in psychiatric diagnoses or symptom burden, but were associated with severity of blast exposure. Future, larger studies might further evaluate presence and aetiology of long-term neuropsychiatric symptoms and MRI findings in blast-exposed populations.

Neuropsychological Test Administration by Videoconference: A Systematic Review and Meta-Analysis.

The purpose of the current systematic review and meta-analysis was to assess the effect of videoconference administration on adult neurocognitive tests. We investigated whether the scores acquired during a videoconference administration were different from those acquired during on-site administration. Relevant counterbalanced crossover studies were identified according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve studies met criteria for analysis. Included samples consisted of healthy adults as well as those with psychiatric or neurocognitive disorders, with mean ages ranging from 34 to 88 years. Heterogenous data precluded the interpretation of a summary effect for videoconference administration. Studies including particpants with a mean age of 65-75, as well as studies that utilized a high speed network connection, indicated consistent performance across videoconference and on-site conditions, however studies with older participants and slower connections were more variable. Subgroup analyses indicated that videoconference scores for untimed tasks and those allowing for repetition fell 1/10th of a standard deviation below on-site scores. Test specific analyses indicated that verbally-mediated tasks including digit span, verbal fluency, and list learning were not affected by videoconference administration. Scores for the Boston Naming Test fell 1/10th of a standard deviation below on-site scores. Heterogenous data precluded meaningful interpretation of tasks with a motor component. The administration of verbally-mediated tasks by qualified professionals using existing norms was supported, and the use of visually-dependent tasks may also be considered. Variability in previous studies indicates a need for further investigation of motor-dependent tasks. We recommend the development of clinical best practices for conducting neuropsychological assessments via videoconference, and advocate for reimbursement structures that allow consumers to benefit from the increased access, convenience, and cost-savings that remote assessment provides.

Considerations for the assessment of blast exposure in service members and veterans.

Introduction: Blast exposure is an increasingly present occupational hazard for military service members, particularly in modern warfare scenarios. The study of blast exposure in humans is limited by the lack of a consensus definition for blast exposure and considerable variability in measurement. Research has clearly demonstrated a robust and reliable effect of blast exposure on brain structure and function in the absence of other injury mechanisms. However, the exact mechanisms underlying these outcomes remain unclear. Despite clear contributions from preclinical studies, this knowledge has been slow to translate to clinical applications. The present manuscript empirically demonstrates the consequences of variability in measurement and definition across studies through a re-analysis of previously published data from the Chronic Effects of Neurotrauma Study 34. Methods: Definitions of blast exposure used in prior work were examined including Blast TBI, Primary Blast TBI, Pressure Severity, Distance, and Frequency of Exposure. Outcomes included both symptom report and cognitive testing. Results: Results demonstrate significant differences in outcomes based on the definition of blast exposure used. In some cases the same definition was strongly related to one type of outcome, but unrelated to another. Discussion: The implications of these results for the study of blast exposure are discussed and potential actions to address the major limitations in the field are recommended. These include the development of a consensus definition of blast exposure, further refinement of the assessment of blast exposure, continued work to identify relevant mechanisms leading to long-term negative outcomes in humans, and improved education efforts.

Influence of affective instability on suicidal ideation beyond traumatic brain injury and posttraumatic stress disorder in veterans.

OBJECTIVE: Mild traumatic brain injury (TBI) is associated with long-term consequences, including greater risk for posttraumatic stress disorder (PTSD) and suicidal ideation. Affective instability is also independently related to PTSD and suicidality, which may explain why some individuals continue to experience chronic psychiatric complaints following mild TBI. The purpose of the present study was to evaluate affective instability as a key factor for PTSD and suicidal ideation among Veterans with and without TBI. METHOD: Participants (N = 299 Veterans; 86.96% male) completed the Personality Assessment Inventory (PAI) and structured clinical interviews for TBI and psychiatric diagnoses. Hierarchical linear regression was used to evaluate main and interaction effects. RESULTS: There were no significant differences in affective instability (p = 0.140) or suicidal ideation (p = 0.453) between Veterans with or without TBI. Individuals with TBI were more likely to have a PTSD diagnosis (p = 0.001). Analyses evaluating PTSD diagnosis as an outcome indicated a main effect of affective instability (p < 0.001), but not TBI (p = 0.619). Analyses evaluating suicidal ideation as an outcome demonstrated an interaction effect between PTSD and affective instability beyond the effects of TBI (p = 0.034). CONCLUSIONS: Severe Affective instability appears to be a key factor in suicidal ideation among Veterans beyond TBI or PTSD history. PTSD was more strongly associated with suicidality at lower and moderate levels of affective instability. At severe levels of affective instability, however, Veterans with and without PTSD experienced suicidal ideation at similar rates. Findings suggests that high levels of affective instability not better explained by other psychiatric conditions confers similar suicidality risk to that of PTSD in a Veteran population.

Comparing effectiveness of residential versus intensive virtual treatment for veterans with posttraumatic stress disorder.

OBJECTIVE: During the COVID-19 pandemic, restrictions imposed on residential treatment programs necessitated rapid implementation of virtual treatment delivery. Posttraumatic stress disorder (PTSD) Residential Rehabilitation Treatment Programs (P-RRTP) are a key mental health treatment for Veterans with PTSD who require more intensive interventions than outpatient care. During the pandemic, the W. G. (Bill) Hefner VA Healthcare System developed and implemented a Virtual Intensive Outpatient Program for PTSD (VIOPP) to meet the needs of the Veteran population. The purpose of this analysis was to compare the effectiveness of VIOPP to P-RRTP. METHOD: Analyses included N = 370 Veterans, n = 193 who completed P-RRTP between January 2018 to April 2020 and n = 177 who completed VIOPP between June 2020 and November 2022 and provided pre- and posttreatment scores. Pre- and posttreatment scores of the PTSD Checklist for DSM-5 (PCL-5) were available for all patients. Pre- and posttreatment depressive symptom scores from the Nine-item Patient Health Questionnaire (PHQ-9) were available for n = 254 Veterans. Paired and independent samples t tests evaluated differences in change scores overall and by treatment modality (residential vs. virtual). RESULTS: Results indicated a significant decrease in PCL-5 scores regardless of treatment modality, p < .001. Despite beginning VIOPP with significantly higher PCL-5 scores than P-RRTP, there were no significant differences in PCL-5 change scores between virtual (M = -16.94) and residential treatment (M = -17.10), p = .910. PHQ-9 scores also decreased significantly for both treatment groups. CONCLUSION: These analyses suggest that intensive virtual treatment has similar effectiveness to residential treatment for PTSD. This supports the development of intensive virtual interventions as viable alternatives to residential treatments and a valuable component within the continuum of PTSD care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Neuropsychological Profiles of Deployment-Related Mild Traumatic Brain Injury: A LIMBIC-CENC Study.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) is a concern for US service members and veterans (SMV), leading to heterogeneous psychological and cognitive outcomes. We sought to identify neuropsychological profiles of mild TBI (mTBI) and posttraumatic stress disorder (PTSD) among the largest SMV sample to date. METHODS: We analyzed cross-sectional baseline data from SMV with prior combat deployments enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Latent profile analysis identified symptom profiles using 35 indicators, including physical symptoms, depression, quality of life, sleep quality, postconcussive symptoms, and cognitive performance. It is important to note that the profiles were determined independently of mTBI and probable PTSD status. After profile identification, we examined associations between demographic variables, mTBI characteristics, and PTSD symptoms with symptom profile membership. RESULTS: The analytic sample included 1,659 SMV (mean age 41.1 ± 10.0 years; 87% male); among them 29% (n = 480) had a history of non-deployment-related mTBI only, 14% (n = 239) had deployment-related mTBI only, 36% (n = 602) had both non-deployment and deployment-related mTBI, and 30% (n = 497) met criteria for probable PTSD. A 6-profile model had the best fit, with separation on all indicators (p < 0.001). The model revealed distinct neuropsychological profiles, representing a combination of 3 self-reported functioning patterns: high (HS), moderate (MS), and low (LS), and 2 cognitive performance patterns: high (HC) and low (LC). The profiles were (1) HS/HC: n=301, 18.1%; (2) HS/LC: n=294, 17.7%; (3) MS/HC: n=359, 21.6%; (4) MS/LC: n=316, 19.0%; (5) LS/HC: n=228, 13.7%; and (6) LS/LC: n=161, 9.7%. SMV with deployment-related mTBI tended to be grouped into lower functioning profiles and were more likely to meet criteria for probable PTSD. Conversely, SMV with no mTBI exposure or non-deployment-related mTBI were clustered in higher functioning profiles and had a lower likelihood of meeting criteria for probable PTSD. DISCUSSION: Findings suggest varied symptom and functional profiles in SMV, influenced by injury context and probable PTSD comorbidity. Despite diagnostic challenges, comprehensive assessment of functioning and cognition can detect subtle differences related to mTBI and PTSD, revealing distinct neuropsychological profiles. Prioritizing early treatment based on these profiles may improve prognostication and support efficient recovery.

Phenotyping Depression After Mild Traumatic Brain Injury: Evaluating the Impact of Multiple Injury, Gender, and Injury Context.

The chronic mental health consequences of mild traumatic brain injury (TBI) are a leading cause of disability. This is surprising given the expectation of significant recovery after mild TBI, which suggests that other injury-related factors may contribute to long-term adverse outcomes. The objective of this study was to determine how number of prior injuries, gender, and environment/context of injury may contribute to depressive symptoms after mild TBI among deployed United States service members and veterans (SMVs). Data from the Long-term Impact of Military-Relevant Brain Injury Consortium Prospective Longitudinal Study was used to assess TBI injury characteristics and depression scores previously measured on the Patient Health Questionnaire-9 (PHQ-9) among a sample of 1456 deployed SMVs. Clinical diagnosis of mild TBI was defined via a multi-step process centered on a structured face-to-face interview. Logistical and linear regressions stratified by gender and environment of injury were used to model depressive symptoms controlling for sociodemographic and combat deployment covariates. Relative to controls with no history of mild TBI (n = 280), the odds ratios (OR) for moderate/severe depression (PHQ-9 ≥ 10) were higher for SMVs with one mild TBI (n = 358) OR: 1.62 (95% confidence interval [CI] 1.09-2.40, p = 0.016) and two or more mild TBIs (n = 818) OR: 1.84 (95% CI 1.31-2.59, p < 0.001). Risk differences across groups were assessed in stratified linear models, which found that depression symptoms were elevated in those with a history of multiple mild TBIs compared with those who had a single mild TBI (p < 0.001). Combat deployment-related injuries were also associated with higher depression scores than injuries occurring in non-combat or civilian settings (p < 0.001). Increased rates of depression after mild TBI persisted in the absence of post-traumatic stress disorder. Both men and women SMVs separately exhibited significantly increased depressive symptom scores if they had had combat-related mild TBI. These results suggest that contextual information, gender, and prior injury history may influence long-term mental health outcomes among SMVs with mild TBI exposure.

Validation of Military Occupational Specialty as a Proxy for Blast Exposure Using the Salisbury Blast Interview.

Abstract Evaluating large data sets precludes the ability to directly measure individual experiences, instead relying on proxies to infer certain constructs. Blast exposure is a construct of study currently in its infancy, resulting in diverse definitions and measurements across studies. The purpose of the present study was to validate military occupational specialty (MOS) as a proxy for blast exposure in combat veterans. A total of 256 veterans (86.33% male) completed the Salisbury Blast Interview (SBI) and Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) Assessment of Traumatic Brain Injury (MMA-TBI). MOS was collected through record review and categorized into low and high risk for blast exposure. Chi-square analyses and t tests compared SBI metrics between MOS categories. Receiver operating characteristic (ROC) analyses evaluated the diagnostic accuracy of MOS category in determining blast exposure severity. Veterans in high-risk MOS were more likely to have experienced blast and deployment TBI (ps < 0.001) than were those in low-risk MOS. ROC analyses indicated good specificity (81.29-88.00) for blast and deployment TBI outcomes, suggesting that low-risk MOS is generally associated with an absence of blast and deployment TBI outcomes. Sensitivity was low (36.46-51.14), indicating that MOS risk level was not a good predictor of the presence of these outcomes. Results demonstrate that high-risk MOSs will identify individuals with blast exposure and deployment TBI history whereas low-risk MOSs will capture a highly variable group. Accuracy of MOS categorization was not acceptable for diagnostic-level tests; however, results support its use as a screening measure for a history of exposure to blast, use in epidemiological studies, and considerations for military policy.

Subjective cognitive complaints and objective cognitive functioning in combat veterans: Effects of PTSD and deployment mild TBI.

OBJECTIVES: (1) Examine the relationship between subjective cognitive complaints and objective cognitive functioning in combat veterans; and (2) evaluate conditional effects of posttraumatic stress disorder (PTSD) and deployment-related mild traumatic brain injury (TBI) within that relationship. METHOD: Combat veterans (N = 225, 86.22% male) completed a lifetime TBI interview, a structured interview assessing PTSD symptoms, a neuropsychological assessment battery, and a self-report measure of cognitive symptoms. RESULTS: All correlations between subjective cognitive complaints and objective cognitive measures were not statistically significant. Hierarchical linear regression indicated that cognitive performance was not significantly related to cognitive complaints, but both PTSD diagnosis and history of deployment mild TBI explained a significant amount of unique variance in self-reported cognitive symptoms. Interactions between the studied variables were not significant. CONCLUSIONS: PTSD and history of deployment mild TBI were uniquely related to cognitive complaints, but cognitive test performance was not. No confounding effects of PTSD or deployment mild TBI were observed in the relationship between cognitive performance and cognitive complaints. This provides support that symptom distress may be a better explanatory factor for perception of lower cognitive functioning than actual cognitive performance.