| | Self-Reported Psychosocial Health Among Adults With Traumatic Brain InjuryAbstract McCarthy ML, Dikmen SS, Langlois JA, Selassie AW, Gu JK, Horner MD. Self-reported psychosocial health among adults with traumatic brain injury. ObjectiveTo measure the subjective psychosocial health of a population-based sample of adults with traumatic brain injury (TBI). DesignRetrospective, cohort study involving a 1-year postinjury interview. SettingSixty-two acute care, nonfederal hospitals in South Carolina. ParticipantsPersons (≥15y) hospitalized with TBI. InterventionsNot applicable. Main Outcome MeasureThe psychosocial health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey. ResultsOf the 7612 participants, 29% reported poor psychosocial health. Factors associated with poor psychosocial well-being included younger age, female sex, Medicaid coverage, no health insurance, inadequate or moderate social support, comorbidities (eg, a preinjury substance abuse problem), cognitive complaints, and some or a lot of limitation with activities of daily living. Only 36% of participants who reported poor psychosocial health reported receiving any mental health services. ConclusionsA substantial proportion of persons hospitalized with TBI reported poor psychosocial health at 1 year postinjury. To optimize recovery, clinicians need to ensure that patients’ psychosocial health needs are addressed during the postacute period.
OF ALL INJURIES, traumatic brain injury (TBI) most frequently affects every domain of a person’s health. While cognitive impairments are characteristic of TBI, physical and psychosocial limitations are also common. Numerous studies have documented the neuropsychologic and physical impairments after TBI in adults1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12; fewer have focused on psychosocial well-being. Psychosocial health encompasses emotional and social well-being. Common psychosocial health problems following TBI include depression, anxiety, anergia, decreased social contact, and lack of social integration.13, 14, 15 Studies that have focused on the psychosocial health of people after TBI have consistently demonstrated that persons with TBI commonly experience long-term psychosocial problems.12, 14, 15, 16, 17, 18, 19, 20, 21, 22 For example, Dikmen et al12, 15, 21 compared the psychosocial outcomes of adults with TBI with those who sustained other types of traumatic injuries as well as with the outcomes of noninjured friends of the TBI subjects and found that the adults with TBI reported poorer psychosocial health at 1 and 2 years postinjury compared to either comparison group.
The literature has been less consistent regarding the risk factors associated with poor psychosocial health. Hibbard et al16 did not find a relation between pre-TBI psychiatric disorders and the incidence of post-TBI depression and poor psychosocial functioning at 2 to 3 years postinjury in a community sample of 188 subjects with TBI. In contrast, Deb et al23 found that among 164 adults hospitalized for a TBI, one of the most influential predictors of psychiatric illness 1 year after injury was a history of psychiatric illness prior to TBI. They also found that fewer years of formal education was associated with an increased risk of psychiatric illness 1 year post-TBI. However, this has not been substantiated by other studies.
Although past studies have provided valuable information regarding the psychosocial problems adults experience after TBI, these studies have been based on small clinical samples or patients enrolled at 1 institution, limiting their generalizability and power to identify risk factors for poor psychosocial outcome. The only 2 population-based studies conducted to date have focused specifically on the development of psychiatric conditions after TBI; they have not examined psychosocial functioning more broadly. Fann et al24 determined the incidence of psychiatric illness among a population-based sample of adults enrolled in a large health maintenance organization and found that subjects who sustained a TBI were significantly more likely to experience a psychiatric illness during the 3-year follow-up period compared with subjects who did not sustain a TBI. Similarly, Holsinger et al25 found that the lifetime risk of depression was higher (18.5%) among a population-based sample of World War II veterans who had sustained a TBI during their military service compared to a group of veterans who did not (13.4%) (P<.05).
The South Carolina Traumatic Brain Injury Follow-Up Registry (SCTBIFR) study is a population-based study of adults, aged 15 and older, who were hospitalized with a TBI in South Carolina. The purpose of the SCTBIFR is to document the health and service needs of a large, representative sample of persons at 1, 2, and 3 years post TBI. This article focuses specifically on the subjective, psychosocial health reported by the TBI cohort at 1 year postinjury. Psychosocial health is measured by the psychosocial health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).26 The validity of the SF-36 psychosocial health scales for measuring subjective well-being among persons with TBI has been previously demonstrated.27, 28
Methods  Study Population This study was approved by the institutional review boards of the Medical University of South Carolina, the Centers for Disease Control and Prevention (CDC), and the Johns Hopkins University. All persons, aged 15 years and older at the time of injury, who were hospitalized with a TBI between January 1, 1999, and July 31, 2003, at any of 62 nonfederal, acute care hospitals in South Carolina were eligible for the SCTBIFR. Eligible participants included those with at least 1 TBI discharge diagnosis code in the statewide hospital discharge dataset that was verified through medical record review. The SCTBIFR relied on the CDC’s case definition of a TBI for administrative data.29 A TBI was defined as any hospital discharge record that included one of the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)30 diagnosis codes: (1) 800.0 to 801.9 (fracture of the vault or base of the skull); (2) 803.0 to 804.9 (other and unqualified and multiple fractures of the skull); (3) 850.0 to 854.1 (intracranial injury, including concussion, contusion, laceration, hemorrhage); and (4) 959.01 (head injury not otherwise specified). Following case identification through the hospital discharge dataset, the medical records of potential cases were reviewed by accredited health information specialists to verify the TBI diagnosis. During the study period, 7% of cases were excluded because of lack of documentation in the chart supporting the case definition of a TBI. Data Sources This study relied on data obtained from the South Carolina hospital discharge dataset, medical records, and a telephone survey. The electronic hospital discharge data were used to identify potentially eligible participants and to provide basic demographic data. The statewide hospital discharge database includes up to 10 diagnosis codes, mechanism of injury (E-code), personal identifiers, discharge disposition, and demographic information. In addition to confirming a TBI diagnosis, we reviewed subjects’ medical records to obtain contact information needed for follow-up and to collect additional medical and injury-related information. The health information specialists abstracted more detailed information on the mechanism and circumstances of the injury as well as the presence of pre-existing conditions. Finally, project personnel attempted to complete a telephone interview on all eligible cases about 1 year after the injury (3mo before or after the 1-y anniversary date). The purpose of the interview was to obtain background information on subjects’ health preinjury as well as to assess their health and use of services during the first year postinjury. Procedures Because we did not have the resources to follow up all eligible cases, each year we targeted 1300. A 2-stage stratified random sampling procedure was used to select cases for follow-up based on hospital size and TBI severity.31 To achieve this, hospital size was used to first randomly select 75% of cases. Among those selected based on hospital size, 67% of those with a moderate to severe TBI (Abbreviated Injury Scale [AIS] head region score, ≥3) and 33% with a mild TBI (AIS head region score, 2) were then randomly selected.32 Of the 4519 eligible persons who were selected for follow-up, we excluded 633 (14%) for the following reasons: (1) nonresident of South Carolina (n=135); (2) died prior to follow-up period (n=382); (3) prisoner (n=92); or (4) did not speak English (n=24). An additional 340 (7.5%) were excluded from this particular analysis because a proxy completed the interview (n=340) and this study focuses on self-reported psychosocial well-being. Of the 3546 eligible participants, 1858 (52%) completed the 1-year follow-up interview. Of the 1688 who did not, 875 (52%) could not be located and 813 (48%) refused. An additional 33 were omitted because the data needed to characterize the main outcome—psychosocial health—were missing. Thus, 1825 persons are included in this analysis. The largest differences between those with 1-year follow-up information (n=1825) and those without (n=1721) were by race, insurance, and sex. Fifty-six percent of white participants completed the 1-year interview compared with 42% of the nonwhite participants (P<.001). Slightly more than one third (37%) of uninsured participants completed the follow-up interview, whereas 49% of those with Medicaid and Medicare and 61% of those with commercial insurance completed it (P<.001). Finally, women were more likely to complete the 1-year interview (59%) compared with men (48%) (P<.001). Interview completion rates did not demonstrate large differences by the severity of the TBI (ie, <4% between any 2 AIS categories) or overall injury severity (ie, <2% difference between any Injury Severity Score [ISS] categories). Data collected from the 1825 participants were weighted to represent the total number of TBI-related hospital discharges (N=7612) in South Carolina during the study period. The final sampling weight for each participant was computed as the product of 3 weights: (1) probability of selection weight based on hospital size and TBI severity; (2) postsampling exclusion weight due to ineligibility criteria such as language barrier, died, prisoner, etc; and (3) nonresponse weight that accounts for differences in the response rates by subgroups of the sample. A summary of the weighting methodology and the types of sampling weights used by the SCTBIFR is described in more detail elsewhere.31 Measurement Main outcome We measured psychosocial health during the 1-year follow-up interview using the psychosocial health scales of the SF-36.26, 33, 34, 35 The SF-36 is a generic instrument that measures physical and psychosocial health in a standardized way, from the subject’s perspective, regardless of medical condition or treatment. The SF-36 consists of 36 items that make up 8 scales of physical (ie, physical function, role disability due to physical health problems, bodily pain, general health perceptions) and psychosocial health (ie, vitality, social function, role disability due to emotional problems, mental health). The 8 SF-36 scales have a possible range from 0 (worst health) to 100 (best health). The 8 scales can be aggregated into 2 summary measures known as the physical and mental component summary (MCS) scales.36 All 8 scales are used to construct the 2 summary scales although each scale has a separate weight for the summary scales based on the correlation between the scale and the physical or mental summary factor. The 2 summary scales have been standardized to the U.S. general population for comparison purposes. They have a mean of 50 and a standard deviation (SD) of 10. SF-36 normative data were collected as part of the National Survey of Functional Health Status (NSFHS). The sociodemographic characteristics of the respondents from the NSFHS were similar to those of the U.S. general population which suggests that the SF-36 normative data were derived from a representative sample of the general population.35 For this study, we defined poor psychosocial health as a score of less than 40 (>1 SD below age- and sex-matched population norms) on the MCS scale. Using this criterion, approximately 16% of persons in the general population have poor psychosocial health and 84% fall within the normative range.36 The SF-36 has demonstrated good to excellent reliability and validity when measuring the health of different patient populations, including trauma.26, 28, 33, 34, 35, 36, 37, 38, 39, 40, 41 In our study sample, the internal consistency reliability of the SF-36 scales, measured with the Cronbach α coefficient, ranged from .90 to .91 for all scales. Furthermore, studies have found that the MCS is sensitive to the psychosocial health of different patient populations, including TBI.27, 28, 36, 37 Unmet mental health care needs In addition to measuring participants’ psychosocial health, we asked subjects about their unmet mental health needs postinjury. During the 1-year interview, participants were asked to report whether they felt that they needed but did not receive help improving their mood, managing stress, or emotional upsets since their hospital discharge. Correlates of psychologic health We examined the association between poor psychosocial health and participant and injury characteristics (ie, the severity of the TBI, the presence of a major associated injury and mechanism of injury). We considered sociodemographic traits such as age, sex, race, education, income and health insurance coverage, as well as pre-existing health conditions and social support. During the 1-year interview, we asked participants if they had ever been told by a doctor that they had had a stroke, seizure disorder or epilepsy, depression, mood disorder, or psychiatric disorder, or had been treated for a drug or alcohol problem before their injury. Participants were classified as having a pre-existing condition if they reported one of the above conditions during the telephone interview or if one was documented in their hospital discharge record using a standardized list of 30 comorbidities identified by Elixhauser et al42 for administrative data. Practical assistance, one domain of social support, was measured using 3 questions from the Inventory of Socially Supportive Behaviors.43, 44 The 3 questions asked: how likely was it that a family member or friend would help the person with practical problems such as lending them money, providing a place to stay, or pitching in to help get something done? The 4 response categories are: someone would certainly do this (value, 4), probably do this (value, 3), might do this (value, 2), or no one would do this (value, 1). The responses were summed and a score of 11 or 12 was defined as adequate social support, a score between 7 and 10 was considered moderate social support, and a score less than 7 was defined as inadequate social support. The internal consistency reliability of the practical assistance scale in this TBI sample was good (Cronbach α=.77). To examine the influence of different participant and injury characteristics on psychosocial health postinjury, we controlled for participants’ concurrent health, specifically physical health, cognitive complaints, and the development of selected secondary conditions postinjury. Because all of the 8 SF-36 scale scores are used to derive the MCS score, we used limitations in activities of daily living (ADLs) as an independent measure of physical function. Participants were asked whether they had any difficulty bathing or showering, dressing, eating, transferring to a bed or chair, walking, or using the toilet. Participants who reported they were unable or had a lot of difficulty with at least 1 ADL were categorized as having a lot of limitation with at least 1 ADL. Participants who reported having some difficulty were categorized as having some limitation with at least 1 ADL and subjects who reported no difficulty with any of the 6 activities were classified as having no limitations. The internal consistency reliability of the ADL limitations scale in this TBI cohort was excellent (α=.93). To measure cognitive complaints, participants were administered the Alertness and Behavior Scale (ABS) of the Sickness Impact Profile (SIP) during the follow-up interview.45, 46 The ABS consists of 10 items that measure cognitive complaints such as problems with memory, attention, solving problems, orientation, processing speed, clumsiness, and follow-through. The higher the score, the more cognitive complaints the participant reported. The ABS demonstrated excellent internal consistency reliability in the study sample (α=.91). Finally, we assessed the development of selected conditions postinjury by asking participants if a doctor had told them that they had developed a seizure disorder or epilepsy, a psychiatric disorder, depression, or a mood disorder since the injury. Participants who reported the use of illegal drugs or heavy or binge drinking were categorized as having a substance abuse disorder postinjury.47 To measure the severity of all injuries sustained, ICD/AIS MAP softwarea was used to convert ICD-9-CM diagnosis codes into AIS scores. The AIS is the most widely used anatomic measure of injury severity.32, 48 It classifies each injury according to its associated threat to life on an ordinal scale from 1 (minor) to 6 (fatal). To rate overall injury severity, the ISS was calculated.49 In addition to overall injury severity, we also determined whether a major associated injury was sustained (ie, AIS score ≥2) to body regions other than the head. Data Analysis All analyses were performed on the unweighted and weighted data. Given that the results were similar, only the weighted data are presented. The mean MCS scale and individual psychosocial health scale scores of the SF-36 are reported. The percentage of participants who reported poor psychosocial health (defined as >1 SD below the U.S. population norms) by different participant, preinjury, concurrent health, and injury characteristics are compared using a chi-square test statistic. Multivariable logistic regression was used to model the report of poor psychosocial health as a function of participant, health, and injury characteristics. All variables were initially entered into the model and then sequentially eliminated based on their association with the outcome. Possible interaction terms were considered. The odds ratios (ORs) and 95% confidence limits are presented. Variables were considered significant and retained in the final model if the 95% confidence limits did not include 1. Results Table 1 presents the sociodemographic and injury characteristics of the participants who completed the 1-year interview. The majority of participants were young, men (64%), and white (74%). More than one half (52%) of the sample reported an annual income of less than $20,000 and approximately one third were either uninsured or covered by Medicaid. Thirty-nine percent of the sample sustained a severe TBI (AIS score 4−5). The most common causes of injury were a motor vehicle crash (44%) or a fall (28%). Table 2 displays the items that comprise the 4 psychosocial scales of the SF-36 and the percentage of participants who frequently reported significant psychosocial problems at 1 year postinjury. Participants reported the most problems with vitality and role limitations due to emotional problems. For example, 39% reported that they felt full of pep a little or none of the time. A lower proportion reported anxiety (ie, nervous most or all of the time [19%]) or depressed mood (ie, downhearted and blue most or all of the time [13%]). Figure 1 compares the mean scores of the psychosocial health scales of the TBI study sample to population norms. For all but 1 scale (mental health), the average scores of the sample are at least 10 units lower than the population norms. Twenty-nine percent of the study sample scored greater than 1 SD below the population norms on the MCS scale and 15% scored greater than 2 SDs below (data not shown). There were no significant differences in the SF-36 psychosocial scales or MCS score by TBI severity (data not shown). Figure 2 compares the mean MCS score of the study sample to other samples of patients with different medical conditions.35, 36, 37, 50, 51 The mean MCS score of the TBI sample is 47.3. The psychosocial health of the TBI sample at 1 year postinjury is most similar to patients with diabetes or those following surgery for lung cancer.36, 51 Table 3, Table 4, Table 5 show the percentage of participants who reported poor psychosocial health (ie, >1 SD below the population norms) by participant, concurrent health and injury characteristics. All of the participant and preinjury health characteristics were significantly associated with psychosocial health except sex (see table 3). All of the concurrent health factors were also significantly associated with psychosocial health (see table 4). Although the severity of the TBI was not associated with poor psychosocial health, overall injury severity, the presence of a major associated injury and mechanism of injury were (see table 5). Table 6 displays the variables that remained statistically significant in the multivariable model after controlling for other factors. In the multivariable analysis, none of the injury characteristics were associated with the report of poor psychosocial health. Older age had a protective effect on psychosocial outcome. A 10-year increase in age was associated with a 16% decreased likelihood of reporting poor psychosocial health. Women were 34% more likely to report poor psychosocial health compared with men after controlling for other factors. Participants covered by Medicaid were approximately 2 times (OR=1.84; 95% confidence limits, 1.53−2.21) more likely to report poor psychosocial health compared with participants with commercial insurance. Similarly, participants who were uninsured were also more likely to report poor psychosocial health compared with those with commercial insurance (OR=1.39; 95% confidence limits, 1.16−1.67). Participants with inadequate or moderate social support were also significantly more likely to report poor psychosocial health compared with participants with good social support. Participants who reported a preinjury problem with alcohol or illegal drugs were significantly more likely to report poor psychosocial health (OR=1.70, 95% confidence limits, 1.47−1.98) compared with those who did not report a preinjury substance abuse problem. Concurrent health also significantly influenced the likelihood of reporting poorer psychosocial well-being. Participants who had problems with ADLs reported poorer psychosocial health compared with participants who did not. Each unit increase in cognitive complaints was associated with a 4% increase in the likelihood of reporting poor psychosocial health. Although there was a strong correlation noted between the SIP cognitive complaint score and the SF-36 MCS score (r=−.68) a factor analysis of the 2 scales revealed that the items of the SIP cognitive scale loaded on a different health construct (ie, cognition) from the SF-36 psychosocial scales (ie, psychosocial health) (data not shown). Finally, a significant interaction effect was noted between pre- and postinjury psychiatric conditions. Participants who reported a postinjury psychiatric disorder were 4 times more likely to report poor psychosocial health compared with those who did not. This was attenuated among participants with a preinjury psychiatric condition (OR=3.37; 95% confidence limits, 2.84−4.03). Participants who reported a preinjury psychiatric condition and no postinjury psychiatric condition were 1.58 times more likely to report poor psychosocial health compared with those with no preinjury psychiatric condition. As demonstrated in figure 3, the poorer the psychosocial health reported by participants, the more likely they were to report having received mental health treatment as well as to report unmet need. Among the participants with an MCS score greater than 2 SDs below the population norms (ie, <30), 47% reported unmet need for mental health services, whereas less than 2% of those with good psychosocial health did (ie, 60+). Although the receipt of mental health services increased as psychosocial health worsened, only 36% of the participants with poor psychosocial health (ie, scores of <40) reported receiving any mental health services postinjury. Discussion The purpose of this study was to document the subjective, psychosocial health at 1 year postinjury among a population-based sample of adults who were hospitalized following a TBI. Almost one third (29%) of adults with TBI who completed the 1-year postinjury interview reported poor psychosocial health. The proportion of participants with poor psychosocial health was almost double the rate expected from adults in the general population. The psychosocial well-being of the study sample at 1 year postinjury was most similar to adults with diabetes or lung cancer.36, 51 The most severely impacted domains of psychosocial health were vitality, role limitations at work, school or home due to emotional problems, and social functioning. Among those who reported poor psychosocial health, less than one half reported receiving any mental health services postinjury. The relatively high prevalence of poor subjective psychosocial well-being reported by this study sample, as measured by the psychosocial health scales of the SF-36, is not surprising given that persons who sustain a TBI are at increased risk of developing a psychiatric disorder postinjury.23, 24, 25, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62 Deb et al23 reported that 14% of 196 persons hospitalized with TBI were diagnosed with depression and 9% with a panic disorder at 1 year postinjury compared with general population rates of 2% and less than 1%, respectively. Among a civilian population of persons enrolled in a health maintenance organization, Fann et al24 found that the prevalence of a psychiatric illness was significantly higher during a 3-year follow-up period among 939 persons who sustained a TBI compared with 2817 enrollees who did not. This study did not find an association between any injury characteristics (ie, severity of the TBI, presence or severity of associated injuries or mechanism of injury) and subjective, psychosocial health after controlling for selected participant characteristics. The majority of other studies to date that have examined the relation between TBI severity and psychosocial health have yielded similar results.12, 17, 52, 60 The lack of association is probably due to the subjective nature of psychosocial well-being because other studies have noted a relation between TBI severity and more objective measures of psychosocial health such as return to work or neuropsychologic performance.12, 17, 63 Other dimensions of subjects’ health influenced their psychosocial well-being. Subjects who reported some or a lot of difficulty with at least 1 ADL were significantly more likely to report poor psychosocial health compared to subjects who did not report any functional limitations. It is not clear from these data whether functional limitations negatively affect psychosocial well-being or whether subjects with psychosocial problems perceive their functional abilities as more impaired than they are.59, 64 There was also a strong association noted between cognitive complaints and psychosocial problems. Similarly, it is unclear to what extent subjects’ cognitive complaints were related to their psychosocial problems versus how much of the psychosocial problems were a function of self-perceived cognitive difficulties.52 There was a significant interaction effect noted between the presence of a pre- and postinjury psychiatric disorder on psychosocial health. Participants at highest risk of reporting poor psychosocial well-being were those that developed a psychiatric disorder postinjury and did not have one prior to their injury. It is possible that participants with a pre-existing psychiatric condition are better adjusted to their psychiatric illness or already know how to access mental health services because the highest rates of mental health services received postinjury were among those with a preinjury and postinjury psychiatric disorder. Interestingly, past studies have not consistently found a significant relation between the presence of a pre-existing psychiatric condition and poor psychosocial functioning postinjury.16, 23, 24, 52, 62 Like several other studies, we also found that the presence of a pre-existing substance abuse disorder was associated with poorer psychosocial functioning postinjury.23, 25, 52 Finally, several sociodemographic characteristics were associated with subjective psychosocial well-being at 1 year postinjury. The older the age, the less likely subjects reported poor psychosocial health. While the literature is conflicting regarding the association between age and psychologic problems, several studies with trauma patients have found that younger subjects report poorer psychologic health compared with older subjects.23, 25, 64 Female participants were more likely to report poor psychosocial health compared with male participants in the multivariable regression analysis after adjustment for other factors. Holbrook et al65 also found female sex was a risk factor for poor psychologic outcome among a sample of general trauma patients. These findings are consistent with other studies involving clinical or general population samples: women report more morbidity and symptoms compared with men.66, 67, 68 Participants with Medicaid and those uninsured were significantly more likely to report poorer psychosocial health compared with those commercially insured. Insurance status was highly correlated with income and the highest proportion of participants with a low income were covered by Medicaid, followed by those uninsured. Thus, Medicaid and lack of health insurance are probably acting as proxies for lower socioeconomic status. The literature has consistently shown a strong gradient between socioeconomic status and physical and psychosocial well-being.69, 70, 71 Like other studies, we found a significant association between social support and psychosocial health.64, 72, 73, 74 Almost one third (29%) of the study sample reported poor psychosocial health at 1 year postinjury but less than half of these subjects reported receiving mental health services. A relatively high proportion of participants reported unmet need for mental health services. One of the most prevalent types of unmet need reported by people with TBI is for mental health services (ie, counseling and social services).75, 76, 77, 78 Study Limitations This study had several limitations. First, the generalizability of the study may be limited by the modest 1-year follow-up rate (52%), although the follow-up rate is similar to that of the Colorado Traumatic Brain Injury Registry and Follow-Up System (57%), another large, population-based study with a similar study protocol.77 Nonwhites, men, and persons who were uninsured were less likely to complete the 1-year interview. We attempted to adjust for nonresponse by weighting participants differently according to their differential response rates. Further, the 2 factors associated with nonresponse and poor psychosocial health, sex, and insurance status, most likely impacted the results in different directions. Poor psychosocial health may have been overestimated by a higher response rate by female participants; however, it may have been underestimated by a lower response rate by those uninsured. Second, we did not measure preinjury psychosocial health, so it is not possible to determine what proportion of the psychosocial problems reported by participants postinjury was present prior to the injury. Third, the study design did not include a trauma control group, so it is unclear to what extent the psychosocial problems reported by the participants can be attributed to the TBI itself versus the traumatic event, because studies that have included trauma controls have noted elevated rates of psychosocial problems in both groups.12, 13 Finally, by excluding proxy interviews, we have probably underestimated the prevalence of poor psychosocial health because participants who needed a proxy usually had the worst outcomes in all health domains. Conclusions Despite these limitations, the results of this study suggest that a significant proportion of adults hospitalized with TBI face substantial psychosocial difficulties during the first year postinjury. Psychosocial problems can negatively impact the recovery of persons with TBI. Because less than half of those who reported poor psychosocial health received any mental health services postinjury, it is important that primary care physicians, physiatrists, and other health care providers involved in the postacute treatment of adults with TBI address patients’ psychosocial problems. The earlier the identification and treatment of psychosocial problems, the more likely the person with a TBI will have the possibility of an optimal recovery. Supplier
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a Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD b Department of Rehabilitation Medicine, University of Washington, Seattle, WA c National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA d Department of Biometry and Epidemiology, Medical University of South Carolina, Charleston, SC e Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC f Mental Health Service, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC.  Reprint requests to Melissa L. McCarthy, ScD, Dept of Emergency Medicine, Johns Hopkins University School of Medicine, 5801 Smith Ave, Davis Bldg, Ste 3220, Baltimore, MD, 21209
Supported by the Division of Injury and Disability Outcomes and Programs, National Center for Injury Prevention and Control, and Centers for Disease Control and Prevention (cooperative agreement no. U17/CCU421926). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(06)00285-1 doi:10.1016/j.apmr.2006.03.007 © 2006 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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