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Mental Health Pocket Card for Management of Patients with Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

    Published:December 15, 2021DOI:https://doi.org/10.1016/j.apmr.2021.10.013
        This pocket card aims to support mental health providers in understanding and using the Departments of Veterans Affairs and Defense Clinical Practice Guideline for assessing and treating posttraumatic stress disorder (PTSD) in those with comorbid mild traumatic brain injury (mTBI) (https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp).

        Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the management of posttrumatic stress disorder and acute stress disorder. Available at: https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp. Accessed October 12, 2021.

        The pocket card (fig 1) is intended to be used as a supplement and guide to the Clinical Practice Guideline but not a replacement to it. Also included is a quick-reference table of public-domain, evidence-based measures to aid diagnosis and treatment (Table 1) .
        Fig 1
        Fig 1Mental health pocket card for management of patients with PTSD and a history of mTBI.
        Table 1Suggested measures available in public domain to use when working with patients with mTBI and mental health comorbidities
        ConstructMeasureScores/Interpretation
        History of TBI

        OSU TBI-ID is the criterion standard in TBI assessment.
        Ohio State University TBI Identification Method (OSU TBI-ID).
        • Corrigan JD
        • Bognar J.
        Initial reliability and validity of the Ohio State University TBI Identification Method.


        https://wexnermedical.osu.edu/neurologic-institute/departments-and-centers/research-centers/ohio-valley-center-for-brain-injury-prevention-and-rehabilitation/osu-tbi-id
        • Worst TBI
        • First TBI
        • Multiple TBIs
        • Recent TBI
        • Other sources
        Postconcussive symptoms

        Symptoms can involve vestibular, somatic, cognitive, and affective domains. These symptoms are nonspecific among patients with TBI and MH conditions.
        Neurobehavioral Symptom Inventory.
        • Silva MA.
        Neurobehavioral Symptom Inventory.
        ,
        • Cicerone KD.
        Persistent post-concussive syndrome: the structure of subjective complaints after mTBI.


        https://www.health.mil/Reference-Center/Forms/2015/04/30/Neurobehavioral-Symptom-Inventory-Form
        • Survey current symptoms to guide symptom-focused treatment
        • Assess for symptom change over time
        • Total score is most reliable
        • Reported RCI is 8 points
        Depression symptomsPHQ-9: Consider total score as well as score on question 9.
        • Fann JR
        • Bombardier CH
        Validity of the Patient Health Questionnaire-9 in assessing depression following traumatic brain injury.


        https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
        • 0-4 None-minimal depression
        • 5-9 Mild
        • 10-14 Moderate
        • 15-19 Moderately severe
        • 20-27 Severe
        • Question 9: Suicidality
        PTSD symptomsPCL-5 for DSM-5.
        • Blevins CA
        • Weathers FW
        • Davis MT
        • Witte TK
        • Domino JL.
        The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.


        https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
        • Scores between 31-33 indicates a positive screen for PTSD
        Alcohol useAlcohol Use Disorders Identification Test.
        • Saunders JB
        • Aasland OG
        • Babor TF
        • de la Fuente JR
        • Grant M.
        Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption II.


        https://auditscreen.org/
        • 0-7 Provide alcohol education
        • 8-15 Give simple advice
        • 16-19 Give simple advice, brief counseling, and continue monitoring
        • 20-40 Give referral to specialist
        Anxiety symptomsGAD-7.
        • Löwe B
        • Decker O
        • Müller S
        • et al.
        Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population.


        https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
        • 0-4 None-minimal anxiety
        • 5-9 Mild
        • 10-14 Moderate
        • 15-21 Severe
        Abbreviations: DSM-5, Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); GAD-7, Generalized Anxiety Disorder Questionnaire 7; MH, mental health; PCL-5, PTSD Checklist; PHQ-9, Patient Health Questionnaire 9; RCI, Reliable Change Index.
        A traumatic brain injury (TBI) is an injury that disrupts the normal function of the brain.

        Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the mangement and rehaibiliation of post-acute mild traumatic brain injury. Available at: https://www.healthquality.va.gov/guidelines/rehab/mtbi/index.asp. Accessed October 12, 2021.

        ,
        • Wortzel HS
        • Arciniegas DB.
        The DSM-5 approach to the evaluation of traumatic brain injury and its neuropsychiatric sequelae.
        It can be caused by a jolt, blow, penetrating object, or blast. The vast majority of TBIs are mild and are also called concussions.

        Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the mangement and rehaibiliation of post-acute mild traumatic brain injury. Available at: https://www.healthquality.va.gov/guidelines/rehab/mtbi/index.asp. Accessed October 12, 2021.

        TBI is a public health concern because it accounts for over 2.5 million emergency department visits each year.

        Centers for Disease Control Prevention. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2014. Atlanta, GA: US Department of Health and Human Servies; 2019.

        Many individuals with mTBI do not seek medical care, so the incidence is likely greater than emergency department records suggest.
        Between 10%-15% of civilians with a history of mTBI also have PTSD.
        • Van Praag DLG
        • Cnossen MC
        • Polinder S
        • Wilson L
        • Maas AIR.
        Post-traumatic stress disorder after civilian traumatic brain injury: a systematic review and meta-analysis of prevalence rates.
        This number more than doubles in military-veteran cohorts.
        • Loignon A
        • Ouellet MC
        • Belleville G.
        A systematic review and meta-analysis on PTSD following TBI among military/veteran and civilian populations.
        Patients with both PTSD and mTBI have higher rates of psychiatric comorbidity, poorer function, and lower quality of life than those with PTSD alone.
        • Bahraini NH
        • Breshears RE
        • Hernandez TD
        • Schneider AL
        • Forster JE
        • Brenner LA.
        Traumatic brain injury and posttraumatic stress disorder.
        ,
        • Stein MB
        • McAllister TW.
        Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury.
        It is important for providers to evaluate lifetime history of TBI at the outset of mental health treatment. If a patient has a history of mTBI, providers should assess for ongoing postconcussive symptoms, which can persist months after the head injury and can include headache, dizziness, fatigue, and sleep disturbances. Postconcussive symptoms can be related to both physical and psychological factors and may warrant adjunctive therapies to optimize the response to PTSD treatments.
        • Avallone KM
        • Smith ER
        • Ma S
        • et al.
        PTSD as a mediator in the relationship between post-concussive symptoms and pain among OEF/OIF/OND veterans.
        For example, referrals for treatment of headaches and vestibular symptoms may be necessary.
        Cognitive complaints are common among individuals with PTSD with and without mTBI.
        • Bolzenius JD
        • Roskos PT
        • Salminen LE
        • Paul RH
        • Bucholz RD.
        Cognitive and self-reported psychological outcomes of blast-induced mild traumatic brain injury in veterans: a preliminary study.
        Regardless of the etiology of the perceived cognitive difficulties (PTSD vs mTBI), it can be beneficial to address these concerns in the therapeutic relationship. First, discuss how the patients view their symptoms of PTSD and mTBI. Use the patients’ own words. Next, provide education about how treatment will be directed at the whole person. Do not attempt to parse out symptom etiology. For example, “What are your concerns about addressing [patients’ words for their symptoms] when you have had a TBI?” Finally, it is essential that providers know and communicate that most evidence-based treatments for PTSD are safe and effective for people with mTBI. For example, “I will offer you treatments that are effective among those who have sustained mTBI.” With that in mind, minor modifications can be used to help patients with mTBI successfully complete PTSD treatment.
        If patients have specific cognitive concerns, below are adaptations to cognitive behavioral therapy
        • Gallagher M
        • McLeod HJ
        • McMillan TM.
        A systematic review of recommended modifications of CBT for people with cognitive impairments following brain injury.
        :
        Tabled 1
        • TBI-specific Information:
          • Education about how TBI affects cognition
          • Give hope because most people with mTBI will return to baseline functioning within a couple months.
        • Attention & Concentration Problems:
          • Use shorter, more frequent sessions
          • Plan breaks during sessions
        • Communication Strategies:
          • Use clear, structured questions
          • Incorporate visual resources when possible
          • Emphasize behavioral techniques
        • Memory Aids:
          • Encourage patient to use a therapy notebook or device to record information
          • Repeat salient points frequently
          • Involve a family member or caregiver
        • Executive Functioning Assistance:
          • Present information slowly to allow for longer processing speed
          • Focus on concrete examples to generate possible solutions
          • Use “say it, show it, do it” approach to model tasks for between sessions

        Authorship

        This page was developed by Catharine H. Johnston-Brooks, PhD, ABPP-CN (e-mail address: [email protected]); Shannon R. Miles, PhD; and Diana P. Brostow, PhD, MPH, RDN.

        Disclaimer

        This information is not meant to replace the advice of a medical professional and should not be interpreted as a clinical practice guideline. Statements or opinions expressed in this document reflect the views of the contributors and do not reflect the official policy of ACRM unless otherwise noted. Always consult your health care provider about your specific health condition. This Information/Education Page may be reproduced for noncommercial use for health care professionals and other service providers to share with their patients or clients. Any other reproduction is subject to approval by the publisher.

        Acknowledgments

        Catharine H. Johnston-Brooks, PhD, ABPP-CN, from the Marcus Institute for Brain Health, University of Colorado Anschutz Medical Campus is a member of the ACRM Military and Veterans Affairs Networking Group and taskforce cochair for Focus on Behavioral Health Issues in Mild TBI. Shannon R. Miles, PhD, from the James A. Haley Veterans’ Hospital and Division of Psychiatry and Behavioral Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, is a member of the ACRM Military and Veterans Affairs Networking Group, and taskforce cochair for Focus on Behavioral Health Issues in Mild TBI. Diana P. Brostow, PhD, MPH, RDN, is from the Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, and the Departments of Physical Medicine and Rehabilitation and Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus.

        References

        1. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the management of posttrumatic stress disorder and acute stress disorder. Available at: https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp. Accessed October 12, 2021.

        2. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the mangement and rehaibiliation of post-acute mild traumatic brain injury. Available at: https://www.healthquality.va.gov/guidelines/rehab/mtbi/index.asp. Accessed October 12, 2021.

          • Wortzel HS
          • Arciniegas DB.
          The DSM-5 approach to the evaluation of traumatic brain injury and its neuropsychiatric sequelae.
          NeuroRehabilitation. 2014; 34: 613-623
        3. Centers for Disease Control Prevention. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2014. Atlanta, GA: US Department of Health and Human Servies; 2019.

          • Van Praag DLG
          • Cnossen MC
          • Polinder S
          • Wilson L
          • Maas AIR.
          Post-traumatic stress disorder after civilian traumatic brain injury: a systematic review and meta-analysis of prevalence rates.
          J Neurotrauma. 2019; 36: 322-332
          • Loignon A
          • Ouellet MC
          • Belleville G.
          A systematic review and meta-analysis on PTSD following TBI among military/veteran and civilian populations.
          J Head Trauma Rehabil. 2020; 35: E21-E35
          • Bahraini NH
          • Breshears RE
          • Hernandez TD
          • Schneider AL
          • Forster JE
          • Brenner LA.
          Traumatic brain injury and posttraumatic stress disorder.
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          Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury.
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          Cognitive and self-reported psychological outcomes of blast-induced mild traumatic brain injury in veterans: a preliminary study.
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          Validity of the Patient Health Questionnaire-9 in assessing depression following traumatic brain injury.
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