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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 1Mental health pocket card for management of patients with PTSD and a history of mTBI.
Postconcussive symptoms Symptoms can involve vestibular, somatic, cognitive, and affective domains. These symptoms are nonspecific among patients with TBI and MH conditions.
Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption II.
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.
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.
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.
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.
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
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
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.
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.
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.
Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption II.
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