Original research| Volume 98, ISSUE 8, P1636-1645, August 2017

Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions

Published:April 25, 2017DOI:



      To characterize the association between traumatic brain injury (TBI) and chronic pain and pain disability in the context of comorbid conditions, posttraumatic stress disorder (PTSD), and depression to better inform care of combat veterans.


      Retrospective cohort study.


      Medical centers and community clinics.


      Combat veterans (N=116,913) who received Veterans Affairs care between October 1, 2007 and March 31, 2015, completed a Comprehensive Traumatic Brain Injury Evaluation, and received a criterion standard diagnosis of TBI (none, mild, or moderate to severe).


      Not applicable.

      Main Outcome Measures

      Chronic pain defined as ≥2 of the same pain diagnoses ≥90 days apart and pain disability defined as self-reported pain causing moderate to very severe interference with daily functioning.


      Fifty-seven percent received ≥1 chronic pain diagnosis. Compared to those with no TBI, PTSD, or depression, there was an independent risk for chronic pain in veterans with mild TBI, which was higher in veterans with moderate to severe TBI. The risk of chronic pain was additive and highest when all 3 conditions—TBI, depression, and PTSD—were copresent (adjusted relative risk, 1.53 and 1.62 [95% confidence interval, 1.50–1.66] for mild and moderate or severe TBI, respectively, plus other diagnoses). The relation of pain disability to TBI, PTSD, and depression followed a similar additive pattern.


      In combat veterans, chronic pain and pain disability are most commonly associated with TBI in conjunction with PTSD, depression, or both. Integrated models of care that simultaneously address pain in conjunction with TBI, PTSD, and depression will likely be the most clinically effective.


      List of abbreviations:

      ARR (adjusted relative risk), CDW (Corporate Data Warehouse), CI (confidence interval), CTBIE (Comprehensive Traumatic Brain Injury Evaluation), GLM (generalized linear model), OEF (Operation Enduring Freedom), OIF (Operation Iraqi Freedom), OND (Operation New Dawn), PTSD (posttraumatic stress disorder), TBI (traumatic brain injury), VA (Veterans Affairs)
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