Psychiatric Comorbidity and Psychosocial Problems Among Treatment-Seeking Veterans With a History of Mild Traumatic Brain Injury
Abstract
Mild traumatic brain injuries (MTBIs) are common in sports, military service, and daily life. Limited data are available on the mental health needs of veterans with a history of MTBI who are seeking care in the community. The purpose of this article is to describe the mental health and psychosocial difficulties of a group of treatment-seeking veterans with a history of MTBI. The authors examined psychiatric comorbidities, psychosocial problems, and symptom burden in a cross-sectional sample of 129 treatment-seeking post-9/11 U.S. service members and veterans who reported a history of MTBI during a mental health evaluation at a nonprofit specialty outpatient clinic. The most common clinician-rated comorbid psychiatric diagnoses included posttraumatic stress disorder (N=113; 88%), major depressive disorder (N=57; 44%), alcohol use or abuse (N=56; 43%), and substance use or abuse (N=28; 22%). In addition, these service members and veterans endorsed high rates of anger and aggression, hazardous drinking, bodily pain, sleep difficulties, concentration problems, unemployment, and difficulties with family functioning. These clinical data suggest that post-9/11 service members and veterans who present with a history of MTBI represent a group of people who are highly symptomatic, have multiple comorbid conditions, and are struggling with multiple psychiatric, behavioral, and psychosocial difficulties. Clinical services designed to evaluate and treat these veterans should consider careful integration of mental health screening and services.
Military service members and veterans sustain traumatic brain injuries (TBIs) in accidents, training, combat, and avocational activities. Most TBIs occur from closed head injuries, as the result of acceleration-deceleration forces, blunt trauma, blast exposure, or some combination of these mechanisms. These injuries occur on a broad continuum of severity, from very mild transient injuries to catastrophic injuries resulting in death or severe disability.
By convention, TBIs are typically classified as mild, moderate, or severe, according to Glasgow Coma Scale scores, duration of loss of consciousness, and posttraumatic amnesia. A large majority of TBIs among civilians and military service members are mild in severity. A definition of mild traumatic brain injury (MTBI), provided by the World Health Organization Collaborating Center Task Force on Mild Traumatic Brain Injury, is as follows:
MTBI is an acute brain injury resulting from mechanical energy to the head from external physical forces. Operational criteria for clinical identification include: (i) 1 or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for less than 24 hours, and/or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; (ii) Glasgow Coma Scale score of 13–15 after 30 minutes post-injury or later upon presentation for healthcare. These manifestations of MTBI must not be due to drugs, alcohol, medications, caused by other injuries or treatment for other injuries (e.g. systemic injuries, facial injuries or intubation), caused by other problems (e.g. psychological trauma, language barrier or coexisting medical conditions) or caused by penetrating craniocerebral injury. (1, p. 115)
MTBIs are common among post-9/11 service members and veterans (2–5). Approximately 10%−23% of service members returning from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn meet criteria for having sustained an MTBI (3, 6). On the basis of numerous studies of sport-related concussions among civilians (7), most service members who sustain these injuries might be expected to make a full clinical recovery within days or weeks after injury. However, a substantial portion of civilians recruited from the emergency department (8) or from specialty clinics (9) report persistent symptoms and problems for months or years after injury. Moreover, in a recently published prospective, longitudinal study of active-duty U.S. military service members who sustained in-theater concussive-blast injuries, 72% declined in their overall functioning between one year and five years after injury, and worsening of postconcussion symptoms was common (10). The reasons for the decline were unclear but were related in part to worsening mental health.
An estimated 12%−20% of post-9/11 service members and veterans meet criteria for posttraumatic stress disorder (PTSD) (2–4, 11), and approximately 6%−7% experience both MTBI and PTSD (12). Further complicating this picture is the fact that many post-9/11 veterans struggle with multiple psychiatric and health conditions, including high rates of depression, anxiety disorders other than PTSD, substance misuse, chronic pain, and sleep difficulties (3, 13, 14). The literature examining the impact of comorbidities among post-9/11 veterans with a history of MTBI, however, is currently limited.
Complex Comorbidities and Psychosocial Problems
One study found that having multiple comorbid conditions (i.e., depression, PTSD, and deployment-related MTBI) was associated with more substantial disability among service members and veterans (14). A better understanding of the co-occurrence of different health and psychosocial problems among treatment-seeking post-9/11 service members and veterans with a history of MTBI is important for several reasons. The large overlap in symptoms of PTSD, MTBI, and other psychiatric disorders (15, 16) can often complicate or obscure clinicians’ diagnostic decision making. Furthermore, the potential interactive and cumulative effects of multiple health conditions, psychosocial problems, and psychiatric disorders may affect treatment selection, planning, and outcomes. Finally, examining the potential impact of multiple comorbid conditions, psychosocial problems, and symptom burden can help provide a more complete picture of the challenges that veterans face in reintegrating into civilian and family life and further clarify their treatment needs.
A substantial percentage of post-911 veterans have chosen to access care in the private sector, outside the Veterans Affairs (VA) health care system (17). Therefore, it is important for private-sector health care providers, in addition to VA providers, to better understand the complexities of presentation of those with reported MTBIs, including mental health problems, other health problems, and psychosocial problems. In this article, we describe a sample of treatment-seeking post-9/11 U.S. service members and veterans who reported having a history of MTBI and who were seen outside of the VA health care system, at a nonprofit specialty outpatient clinic. In particular, we present common psychiatric diagnoses and the frequency of comorbid disorders; psychosocial functioning (e.g., employment, social relationships, and family functioning); and the relationship among clinical diagnoses, symptom burden, and quality of life.
Home Base Outpatient Program
Home Base, a Red Sox Foundation and Massachusetts General Hospital program, provides outpatient mental health and TBI services to veterans and families, regardless of ability to pay or discharge status (18). TBI services include comprehensive evaluations by specialists in rehabilitation medicine and neuropsychology. From those evaluations, referrals to other services are made on a case-by-case basis, such as for physical therapy (i.e., multimodal or vestibular), neuroendocrinology, headache specialty evaluation and treatment, or cardioautonomic evaluation.
TBI services are provided alongside mental health and addictions services in an integrated team model that ensures that veterans and their families receive or are connected to uniquely tailored care for both their TBI-related and their mental health needs. In fact, most patients with a history of MTBI who attend our outpatient program receive mental health, substance abuse, social work, and case management services as their primary services. They do not need specialty referrals to other providers. A subgroup of our patients have been identified as needing more intensive medical and rehabilitation services in addition to mental health services.
All patients seen at Home Base are asked to complete a battery of questionnaires during their first clinic visit and undergo a diagnostic evaluation by a licensed psychologist or a licensed psychiatrist. New patients are discussed at multidisciplinary rounds. Primary and secondary diagnoses from the DSM-IV and DSM-5 are reviewed by the clinical team and documented. For this study, we analyzed questionnaire data and clinical diagnoses emerging from these clinical intake assessments for the subset of patients who reported a prior history of MTBI.
The assessment includes diverse patient-reported outcome measures of traumatic stress, depression, anxiety, stress, anger, substance abuse, complicated grief, family functioning, and quality of life. The PTSD Checklist (PCL-C) (19) and the Depression, Anxiety, Stress Scale–21 (DASS-21) (20) were used as primary measures of symptom burden for this sample of patients. Additional measures included the Quality of Life Enjoyment and Satisfaction Questionnaire (21), Brief Anger-Aggression Questionnaire (22), Alcohol Use Identification Test-C (23), Inventory of Complicated Grief, and McMaster Family Assessment Device (24). These measures are described in Box 1.
BOX 1. PATIENT-REPORTED OUTCOME MEASURES
The PTSD Checklist (PCL-C) consists of 17 items that reflect the core domains of reexperiencing, avoidance, and hyperarousal. Total scores range from 17 to 85, with high scores indicating greater traumatic stress symptom severity. The U.S. Department of Veterans Affairs National Center for PTSD recommends a cutoff score of 50 on the PCL-C for a possible diagnosis of PTSD among military and specialty mental health clinic settings.
The Depression, Anxiety, Stress Scale–21 is a 21-item measure that is an abbreviated version of the original 42-item measure. It comprises three 7-item subscales measuring symptoms of depression, anxiety, and stress. Participants are asked to rate the degree to which they endorse each item on a 4-point Likert scale. The recommended cutoff scores for the three scales are as follows: Depression (mild=10–13, moderate=14–20, severe=21–27, and extremely severe=28 or higher), Anxiety (mild=8–9, moderate=10–14, severe=15–19, and extremely severe=20 or higher), and Stress (mild=15–18, moderate=19–25, severe=26–33, and extremely severe=34 or higher).
The Quality of Life Enjoyment and Satisfaction Questionnaire is a 16-item scale that measures satisfaction in multiple life domains, including daily activities and relationships. Item scores range from 1, not at all or never, to 5, frequently or all of the time, with higher scores reflecting better quality of life.
The Brief Anger-Aggression Questionnaire (22) is a six-item measure developed for the rapid screening and identification of anger and aggression levels in violence-prone men. A cutoff score of 9 indicates anger dyscontrol.
The Alcohol Use Identification Test-C (AUDIT-C) (23) is a three-item alcohol screen that is used to help identify persons who are hazardous drinkers or have active alcohol use disorders (23). The AUDIT-C is a modified version of the 10-question AUDIT instrument. A score of 4 or more for men and a score of 3 or more for women (25) is considered indicative of hazardous drinking or active alcohol use disorder.
The Inventory of Complicated Grief is a 19-item self-report measure used to identify individuals with complicated grief (26). Participants rate the frequency of each symptom on a 5-point Likert scale, with total scores ranging from 0 to 76. Individuals with scores of 30 or higher are considered to meet the threshold for complicated grief (27).
The McMaster Family Assessment Device (24) is made of seven scales that measure problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. We collected responses on the General Function subscale only. It includes 12 questions rated on a 4-point Likert scale that assesses the overall health and pathology of the family. The cutoff for this scale is 2.0 (28).
Demographic Characteristics of the Patient Cohort
Between May 2012 and June 2015, 129 post-9/11 U.S. active-duty military service members and veterans with a history of MTBI or moderate TBI sought treatment at Home Base. Of those, 95% (N=123) were men, with a mean±SD age of 32.7±7.9. They indicated that their current or former branch of service was as follows: Army (N=75; 58%), Marines (N=40; 31%), Navy (N=6; 5%), or Air Force (N=5; 4%). Most reported at least one deployment (79%; N=93). A total of 55 (47%) reported that they were in a relationship (missing data; N=13; 10%), and only 15 (13%) indicated that they were employed (missing data; N=13; 10%).
Clinical Characteristics of the Patient Cohort
Clinical characteristics of the cohort are presented in Table 1 and Figure 1. The most common psychiatric diagnoses were PTSD (N=113; 88%), depression (i.e., major depressive disorder, depressive disorder not otherwise specified, mood disorder not otherwise specified; N=57; 44%), alcohol abuse (N=56; 43%), and substance misuse or abuse (N=28; 22%). Multiple diagnoses were common in this sample, with a majority of patients meeting criteria for two or more clinician-rated diagnoses (N=95; 74%), and 36% being diagnosed by their clinician as having three or more conditions. Note that in Figure 1, the percentages reported include results from both clinician-rated diagnoses and patient-reported outcomes (e.g., clinician diagnosis of PTSD or a PCL-C total score of 50 or greater; see Table 1 for more information). The calculations of multiple diagnoses or psychosocial problems are independent of, and do not include, a person’s history of MTBI.
| Characteristic | N | % | Total N |
|---|---|---|---|
| Clinician-rated diagnoses | |||
| PTSD | 113 | 88 | 129 |
| Major depression, depressive disorder NOS, or mood disorder NOS | 57 | 44 | 129 |
| Alcohol abuse | 56 | 43 | 129 |
| Substance abuse | 28 | 22 | 129 |
| Generalized anxiety disorder or anxiety disorder NOS | 11 | 9 | 129 |
| Adjustment disorder NOS | 9 | 7 | 129 |
| Complicated grief | 4 | 3 | 129 |
| ADHD | 4 | 3 | 129 |
| Cognitive disorder NOS | 4 | 3 | 129 |
| Panic disorder | 3 | 2 | 129 |
| Bipolar disorder | 2 | 2 | 129 |
| Obsessive-compulsive disorder | 2 | 2 | 129 |
| Psychosis NOS | 1 | 1 | 129 |
| Specific phobia | 1 | 1 | 129 |
| Social anxiety disorder | 0 | 0 | 129 |
| No. clinician-based diagnoses | |||
| No diagnosed disorderb | 4 | 3 | 129 |
| 1 | 30 | 23 | 129 |
| 2 | 49 | 38 | 129 |
| 3 | 22 | 17 | 129 |
| ≥4 | 24 | 19 | 129 |
| Psychological health and psychosocial problems | |||
| PTSD (PCL-C >50)c | 85 | 72 | 118 |
| Depression (DASS-21 moderate or greater)d | 74 | 62 | 120 |
| Anxiety (DASS-21 moderate or greater)e | 82 | 68 | 120 |
| Life stress (DASS-21 moderate or greater)f | 74 | 62 | 120 |
| Hazardous drinkingg | |||
| Men | 66 | 60 | 111 |
| Women | 1 | 33 | 3 |
| Total sample | 67 | 59 | 114 |
| Anger dysregulation (BAAQ ≥9)h | 69 | 59 | 118 |
| Complicated grief (ICG ≥30)i | 28 | 29 | 96 |
| Family dysfunction (FAD ≤2)j | 38 | 41 | 92 |
| Not employed | 101 | 87 | 116 |
| No. psychological health issues or clinician-based diagnosesk | |||
| 0 | 1 | 1 | 129 |
| 1 | 1 | 1 | 129 |
| 2 | 7 | 5 | 129 |
| 3 | 9 | 7 | 129 |
| 4 | 17 | 13 | 129 |
| 5 | 21 | 16 | 129 |
| 6 | 21 | 16 | 129 |
| ≥7 | 52 | 41 | 129 |
a
PTSD, posttraumatic stress disorder; NOS, not otherwise specified; ADHD, attention-deficit hyperactivity disorder; DASS-21, 21-item Depression, Anxiety, Stress Scale.
b
No additional diagnosis was given, or diagnosis was deferred for further evaluation.
c
The U.S. Department of Veterans Affairs National Center for PTSD recommends a cutoff score of 50 on the PTSD Checklist (PCL-C) for possible diagnosis of PTSD in military and specialty mental health clinic settings.
d
Recommended cutoff scores for depression are mild=10–13, moderate=14–20, severe=21–27, and extremely severe=28 or higher.
e
Recommended cutoff scores for anxiety are mild=8–9, moderate=10–14, severe=15–19, and extremely severe=20 or higher.
f
Recommended cutoff scores for stress are mild=15–18, moderate=19–25, severe=26–33, and extremely severe=34 or higher.
g
On the Alcohol Use Identification Test-C (AUDIT-C), a score of 4 or more for men and a score of 3 or more for women is considered indicative of hazardous drinking or active alcohol use disorder.
h
On the Brief Anger-Aggression Questionnaire (BAAQ), a cut-off score of 9 indicates anger dyscontrol.
i
On the Inventory of Complicated Grief (ICG), those with scores of 30 or more are considered to meet the threshold for complicated grief. Veterans who have not experienced the loss of someone close to them do not complete this scale.
j
The McMaster Family Assessment Device (FAD) General Functioning subscale cutoff score is 2.0. Veterans who are not living with family members do not complete this scale.
k
We calculated the total number of psychological health and clinician-based diagnoses by summing whether a person met criteria for PTSD (clinician based or PCL-C), depression (clinician based or DASS–21), anxiety (clinician based or DASS–21), alcohol misuse (clinician based or AUDIT-C), substance abuse (clinician based), complicated grief (clinician based or ICG), anger dysregulation (BAAQ), life stress (DASS–21), family dysfunction (FAD), or unemployment.
FIGURE 1. Clinical Profile and Characteristics of 129 Patients With a History of Traumatic Brain Injurya
aDiagnoses were based on the following: clinician diagnosis of posttraumatic stress disorder or PTSD Checklist score >50; alcohol misuse, abuse, or dependence diagnosis or Alcohol Use Identification Test–C hazardous drinking; clinician diagnosis of substance use or abuse; clinician diagnosis of major depression, depressive disorder not otherwise specified (NOS), mood disorder (NOS), or a 21-item Depression, Anger, Stress Scale (DASS-21) score of moderate or greater; clinician diagnosis of generalized anxiety disorder or anxiety disorder NOS or an anxiety (DASS-21) score of moderate or greater; life stress (DASS-21) symptoms rated moderate or greater; anger dysregulation on the Brief Anger–Aggression Questionnaire of ≥9; clinician-diagnosed complicated grief or Inventory of Complicated Grief score of ≥30; and family dysfunction (McMaster Family Assessment Device score of ≤2). Life interference due to pain was determined by patients endorsing “very much” on a pain interference question. For several of the questionnaires, the amount of missing data was considerable, so the percentages represented in the figure are based on the number of completed questionnaires. See Table 1 for completion rates.
Table 1 also summarizes the self-reported psychological health and psychosocial problems. These are described based on the number of those who completed each measure. As seen in Table 1, of those who completed the PCL-C, 72% endorsed scores indicative of a possible diagnosis of PTSD (i.e., ≥50) (19). According to recommended cutoff scores from the DASS-21, 62% endorsed moderate or greater symptoms of depression, 68% reported moderate or greater symptoms of anxiety, and 62% reported moderate or greater symptoms of stress. A total of 37% endorsed moderate or greater symptoms on all three scales of the DASS-21.
According to the Alcohol Use Identification Test-C’s suggested cutoff criteria, 59% of men and 33% of women endorsed scores indicative of hazardous drinking or active alcohol use disorders (i.e., cutoff scores of 4 and 3, respectively). Examining individual items on the PCL-C revealed that most patients (89%) reported moderate or greater problems with falling or staying asleep. Cognitive problems were very commonly reported on the PCL-C; 88% endorsed moderate or greater difficulties with concentration in the past 30 days. More than half of the patients (i.e., 59%) endorsed anger and aggression symptoms suggestive of anger dysregulation. The experience of complicated grief was reported by 29%. Of those who completed the General Functioning subscale of the McMaster Family Assessment Device, 41% (N=38) scored below the cutoff, which suggests family dysfunction.
Patients also completed questions regarding pain as part of their evaluation (N=122). Almost all endorsed some degree of pain in the past seven days (i.e., 92%; N=112), and one-third (34%) endorsed experiencing pain as ≥7 on a 10-point scale. A large proportion (i.e., 68%; N=83) indicated that their pain interfered at least somewhat with their day-to-day activities, and 15% indicated that their pain “very much” interfered with their day-to-day activities.
A questionnaire regarding participants’ perceived quality of life was also administered (Quality of Life Enjoyment and Satisfaction Questionnaire; N=110; 85%). Quality of life for these veterans with a history of TBI decreased as the number of psychiatric diagnoses or psychological health problems increased (Spearman r=−.34, p<.001; N=110). As seen in Table 1, 87% of the participants were not employed. Of those who completed the Quality of Life Enjoyment and Satisfaction Questionnaire, 49% (N=54) reported poor satisfaction (i.e., score of 2 or less; “poor” or “very poor” satisfaction) with their work situation, 43% (N=47) endorsed poor satisfaction with their economic status, and 28% (N=23) endorsed poor satisfaction with their current living or housing situation. The aspects of psychosocial functioning that were most frequently endorsed as being poor included leisure time activities (52%, N=57), work (49%, N=54), mood (46%, N=21), sexual drive or interest (43%, N=47), economic status (43%, N=47), household activities (42%, N=46), social relationships (41%, N=45), and family relationships (40%, N=44).
Comparison With Prior Studies
The co-occurrence of TBI with different health, mental health, and psychosocial problems may complicate diagnostic decision making, treatment planning, and outcomes. Previous studies describing the co-occurrence of two or three mental health conditions among service members have suggested that comorbid conditions are common with TBI. In a study of 284 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans from the VA Boston TBI Center for Excellence, 51% met criteria for three or more comorbid conditions (14).
Another study of comorbid mental health conditions among 106,726 U.S. veterans returning from Iraq and Afghanistan seen at VA health care centers found that 29% had two comorbid diagnoses, and one-third had three or more (5). When compared with the general population, rates of comorbid conditions among service members and veterans seem to be higher. The National Comorbidity Survey Replication found that of individuals with a mental health diagnosis (N=3,122), 22% had two diagnoses, and 23% had three or more diagnoses (29).
We examined comorbid conditions in a sample of treatment-seeking veterans with a history of MTBI and found that the vast majority had numerous mental health concerns, with approximately 75% meeting criteria for two or more clinician-rated psychiatric conditions. In this patient cohort, 88% were diagnosed by their clinician as having PTSD. The most common clinician-based psychiatric diagnoses were depression, alcohol use disorders, and substance abuse. The majority either had a clinician diagnosis of depression or screened positive for depression on the DASS-21 (i.e., 71%).
More than half of all patients endorsed hazardous drinking levels on a brief screening measure (59%), and 43% received a clinician diagnosis of an alcohol use disorder. One in five (22%) were diagnosed as having a substance abuse disorder. This illustrates the high rate of alcohol and substance abuse among post-9/11 veterans with a history of MTBI and emphasizes the need for careful evaluation and concurrent treatment. When clinical diagnoses, psychological health, and psychosocial problems were examined together, the vast majority of veterans with a history of MTBI were experiencing five or more problems or conditions (i.e., 73%), and 41% had seven or more (Table 1).
In our sample with a history of TBI, we observed worse quality of life among service members and veterans who endorsed greater symptom burden on measures of PTSD and depression. Poorer quality of life was also associated with a greater number of psychiatric diagnoses and psychosocial problems. The impact of psychological distress and psychosocial problems seemed to affect multiple aspects of quality of life, including occupational, social-relational, and psychological.
Conclusions
This cohort of treatment-seeking post-9/11 veterans with a history of MTBI presented with multiple psychiatric diagnoses, psychological health problems, psychosocial difficulties, and poor quality of life. The description of this cohort of patients adds to and expands the extant literature because most prior studies are conducted within the VA health care system and this study included a much broader clinical assessment than prior studies. Hazardous drinking, anger and aggression, pain, sleep difficulties, concentration problems, complicated grief, unemployment and disability, and relationship distress complicated the clinical presentation of these patients. The majority of patients had five or more major problem areas. It is important to consider these complex, interwoven psychiatric, behavioral, and psychosocial difficulties in the treatment-planning process. It is also necessary to implement and coordinate multidisciplinary treatment to ensure that service members’ and veterans’ diverse health, mental health, and social problems are adequately addressed. Integrated programs that provide multiple levels of care, treatment coordination, and social support can reduce barriers to care and improve outcomes.
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Information & Authors
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Published in print: Fall 2017
Published online: 16 October 2017
Keywords
Authors
Competing Interests
Dr. Zafonte reports owning stock in Oxeia Bioharma Myomo ELminda. Dr. Simon receives funding from Janssen. She reports spousal equity in G1 Therapeutics and Gatekeeper. Dr. Iverson reports acting as consultant for NeuroHealth, LLC, and NeuroHealth Research and Rehabilitation, Inc. Drs. Wojtowicz, Silverberg, and Bui report no financial relationships with commercial interests.
Funding Information
Home Base is funded through contributions from donors, and the philanthropic partnership of the Red Sox Foundation and Massachusetts General Hospital. Home Base is generously supported in part by the Wounded Warrior Project and Welcome Back Veterans, an initiative of the McCormick Foundation and Major League Baseball.
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