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Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase.An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014.Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue.Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.

Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI.The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices.In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.

Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA).Inpatient TBI rehabilitation ward in Victoria, Australia.A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020.Retrospective cohort study utilizing electronic medical record data.The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS).Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (β = -.14, P.001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (β = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures.This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.

Objective This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. Design Observational prospective study with correlational design. Setting Inpatient rehabilitation hospital for TBI. Participants A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. Measures Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). Results Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. Conclusions Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

Background Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors. Methods Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions. Results Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms. Conclusions This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.

OBJECTIVES: To examine the frequency and nature of postconcussive symptoms (PCSs) and behavioral outcomes in young children following mild traumatic brain injury (mTBI) or concussion. SETTING: Emergency department. PARTICIPANTS: Children aged 2 to 12 years presenting with either a concussion or minor bodily injury (control). OUTCOME MEASUREMENT: Parent ratings of PCS were obtained within 72 hours of injury, at 1 week, and 1, 2, and 3 months postinjury using a comprehensive PCS checklist. Preinjury behavior was examined at baseline using the Clinical Assessment of Behavior, which was readministered 1 and 3 months postinjury. RESULTS: PCS burden following mTBI peaked in the acute phase postinjury but reduced significantly from 1 week to 1 month postinjury. Parents of children with mTBI reported more persistent PCSs up to 3 months postinjury than trauma controls, characterized mostly by behavioral and sleep-related symptoms. Subtle increases in problematic behaviors were observed from baseline (preinjury) to 1 month postinjury and persisted at 3 months postinjury; however, scores were not classified as clinically "at risk." CONCLUSIONS: A significant minority of young children experienced persistent PCS and problematic behavior following mTBI. Care must be taken when assessing PCS in younger children as method of PCS assessment may influence parental reporting.

To examine self-rated, clinician-rated, and self-awareness of on-road driving performance in individuals with traumatic brain injury (TBI) deemed fit and unfit to resume driving and healthy controls, and to explore their associations with demographic, injury, cognitive, and mood variables.Participants included 37 individuals with moderate to severe TBI, and 49 healthy age, sex, and education-matched controls from Australia and Canada. Participants completed an on-road assessment, the Brain Injury Driving Self-Awareness Measure (BIDSAM), and a comprehensive neuropsychological assessment.Awareness scores on the BIDSAM were significantly different between groups, F(2, 83) = 28.44 (P.001; η = 0.41), with post hoc tests indicating TBI participants who failed the on-road assessment had worse scores compared with those who passed and controls. Poor self-awareness was significantly correlated with reduced psychomotor speed (rs = -0.37; P.01) and attentional switching (rs = 0.28; P.01). Worse self-ratings of driving were associated with depression (rs = 0.42; P.01) and anxiety (rs = 0.38; P.01).Individuals with TBI who failed an on-road assessment significantly overestimated their driving ability. Impaired cognitive function was associated with reduced self-awareness of driving. These findings suggest impaired awareness of driving may need to be addressed as part of driver rehabilitation programs.

OBJECTIVE:: To examine the validity of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST)-2 widely recommended rating scales-in a traumatic brain injury (TBI) population at 24 months following injury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders was used as the gold standard criterion. SETTING:: TBI rehabilitation program at Epworth Hospital, Victoria, Australia. PARTICIPANTS:: A total of 113 individuals, 87 males and 26 females, with complicated mild to severe TBI. DESIGN:: Prospective study documenting substance use following TBI. MAIN MEASURES:: AUDIT, DAST, and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. RESULTS:: In individuals with TBI, a cutoff score of 11 on the AUDIT may be the most appropriate indicator of an alcohol use disorder whereas a cutoff score of 6 on the DAST may be the most appropriate indicator of drug use disorder. Both screening measures demonstrated excellent diagnostic accuracy at 24 months following injury. CONCLUSION:: The optimal cutoff score for the AUDIT may need to be elevated for use following TBI. Nevertheless, both the AUDIT and the DAST are suitable measures for assessing substance use following TBI. Given the importance of uniformity in postinjury assessment, the AUDIT and the DAST may serve as future screening standards in TBI research. Language: en

Objective To examine the stability of employment between 1 and 3 years following traumatic brain injury (TBI) and to identify the variables associated with continued employment throughout this time span. Participants This study included 236 individuals with predominantly moderate to very severe TBI, who had received rehabilitation in the context of a no-fault accident compensation system. Participants were eligible for the current study if they were employed before injury and reported their employment status at 1, 2, and 3 years following their injury as part of a longitudinal head injury outcome study. Results Only 44% of participants remained employed at each of the 3 years following TBI. There was also substantial transition into and out of employment across the 3 years. Significantly greater instability in employment was reported by individuals who were machinery operators or laborers before injury, had a longer duration of posttraumatic amnesia, reported more cognitive difficulties, and were less mobile 1 year following their injury. Conclusion A number of important factors determine the likelihood of achieving stability in employment following TBI. Findings from the current study support the continued need to identify ways in which physical as well as cognitive changes contribute to employment following TBI. Further examination is needed to identify possible compensatory strategies or job modifications to maximize the likelihood of job retention.

OBJECTIVE:: To examine self-awareness and injury-related, emotional and demographic factors across acute/subacute (3-12 months), medium-term (24-60 months), and long-term (120-240 months) time periods after traumatic brain injury (TBI), because unawareness of injury-related changes can affect engagement in rehabilitation and functional outcomes. PARTICIPANTS:: A total of 168 individuals with mild to severe TBI and 105 of their close others. MAIN OUTCOMES MEASURES:: Awareness Questionnaire (AQ) and Hospital Anxiety and Depression Scale. DESIGN:: Cross-sectional study. RESULTS:: There were no significant differences in awareness as a function of time postinjury, except for the AQ motor/sensory domain wherein individuals with TBI at longer time periods displayed increased awareness of deficits than those at earlier time periods. Greater patient-other AQ discrepancy scores (interpreted as lower patient awareness) were associated with longer posttraumatic amnesia duration in the individual with TBI and also with increased self-reported depressive symptoms in the close others. Conversely, smaller AQ discrepancy scores (interpreted as better awareness) were associated with increased self-reported depressive symptoms by the individuals with TBI. CONCLUSION:: This study highlights the limitations of using discrepancy scores to measure awareness, as ratings of injury-related changes are influenced by the mood of the individual with TBI and the close other, as well as by injury severity. Language: en

To examine the temporal relation between fatigue, depression, and daytime sleepiness after traumatic brain injury. Fatigue is a frequent and disabling consequence of traumatic brain injury (TBI). However, it is unclear whether fatigue is a primary consequence of the structural brain injury or a secondary consequence of injury-related sequelae such as depression and daytime sleepiness.Eighty-eight adults with complicated mild-severe TBI (69% male).Fatigue Severity Scale; depression subscale of the Hospital Anxiety and Depression Scale; Epworth Sleepiness scale at baseline and 6-month follow-up.A cross-lagged path analysis computed within a structural equation modeling framework revealed that fatigue was predictive of depression (β = .20, P.05) and sleepiness (β = .25, P.05). However, depression and sleepiness did not predict fatigue (P.05).The results support the view of fatigue after TBI as "primary fatigue"-that is, a consequence of the structural brain injury rather than a secondary consequence of depression or daytime sleepiness. A rehabilitation approach that assists individuals with brain injury in learning to cope with their neuropsychological and physical limitations in everyday life might attenuate their experience with fatigue.

Introduction Traumatic brain injury (TBI) results in complex cognitive (and other) sequelae. Impairments in executive function and self-awareness are among the most characteristic neuropsychological sequelae and can exert a profound effect on resuming previous life roles. An international group of researchers and clinicians (known as INCOG) convened to develop recommendations for interventions to improve impairments in executive functioning and self-awareness after TBI. Methods The team reviewed the available literature and ensured the recommendations were current. To promote implementation, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Results Intervention programs incorporating metacognitive strategy instruction for planning, problem-solving, and other cognitive-executive impairments have a solid evidence base. New evidence supports the use of strategies to specifically improve reasoning skills. Substantial support exists for use of direct corrective feedback to improve self-awareness. Conclusions An increasing number of scientifically well-designed studies are available that demonstrate the effectiveness of a variety of interventions for the remediation of impairments in executive function and self-awareness after TBI.

Introduction Traumatic brain injury results in complex cognitive sequelae. Impairments in memory are among the most common sequelae resulting in significant functional problems. An international team of researchers and clinicians (known as INCOG) was formed to develop recommendations for the management of impairments in memory. Methods The experts met to select appropriate recommendations and then reviewed available literature to ensure recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to the best practice recommendations. Results The recommendations for rehabilitation of memory impairments support the integration of internal and external compensatory strategies implemented using appropriate instructional techniques that consider functional relevance and important patient characteristics. Restorative strategies have regained significant popularity, given broader access to computer technology; however, evidence for efficacy of these techniques remains weak and the choice in using these should be guided by special considerations. Conclusion There is good evidence for the integration of internal and external compensatory memory strategies that are implemented using instructional procedures for rehabilitation for memory impairments. The evidence for the efficacy of restorative strategies currently remains weak.

Cognitive-communication disorders are common in individuals with traumatic brain injury (TBI) and can have a major impact on long-term outcome. Guidelines for evidence-informed rehabilitation are needed, thus an international group of researchers and clinicians (known as INCOG) convened to develop recommendations for assessment and intervention.An expert panel met to select appropriate recommendations for assessment and treatment of cognitive-communication disorders based on available literature. To promote implementation, the team developed decision algorithms incorporating the recommendations, based on inclusion and exclusion criteria of published trials, and then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to best practice recommendations.Rehabilitation of individuals with cognitive-communication disorders should consider premorbid communication status; be individualized to the person's needs, goals, and skills; provide training in use of assistive technology where appropriate; include training of communication partners; and occur in context to minimize the need for generalization. Evidence supports treatment of social communication problems in a group format.There is strong evidence for person-centered treatment of cognitive-communication disorders and use of instructional strategies such as errorless learning, metacognitive strategy training, and group treatment. Future studies should include tests of alternative service delivery models and development of participation-level outcome measures.

OBJECTIVE:: To examine the frequency and experience of return to secondary or tertiary study over a 10-year period following traumatic brain injury (TBI). PARTICIPANTS:: A group of 295 students with moderate to severe TBI followed prospectively. SETTING:: Epworth HealthCare TBI outpatient rehabilitation program follow-up clinic 1 to 10 years postinjury. MAIN OUTCOME MEASURES:: Frequency of return to study. Also, for a subset, changes in course enrollment, utilization of additional educational supports, and experience of return to study postinjury. RESULTS:: Of those studying preinjury, 295 attended the follow-up clinic appointments, with 167 (56%) having returned to study. Those who did not return to study had significantly longer posttraumatic amnesia duration. The cross-sectional follow-up revealed that 60.4% were studying at 1 year postinjury, 37.5% at 2 years postinjury, 50.0% at 3 years postinjury, 31.1% at 5 years postinjury, and 2.0% at 10 years postinjury. Many had migrated into employment. A subsample of 95 participants reported on their educational experience. Of those, 28.7% changed their course enrollment from full-time to part-time. While supports such as tuition and special consideration were greatly increased postinjury, students reported the proportion of subjects passed of 79.0%. However, they experienced cognitive difficulties and fatigue and felt less satisfied with their studies. CONCLUSIONS:: Return to study was relatively successful; however, this was associated with the experience of fatigue and need for far greater effort, assistance and reduced study hours, and somewhat less overall satisfaction. Language: en

OBJECTIVE:: To examine the influence of self-reported preinjury coping on postinjury coping, psychosocial functioning, emotional functioning, and quality of life at 1 year following traumatic brain injury (TBI). SETTING:: Inpatient hospital and community. PARTICIPANTS:: One hundred seventy-four participants with TBI. DESIGN:: Prospective, longitudinal design. Participants were assessed at 5 time points: after emerging from posttraumatic amnesia, and at 6, 12, 24, and 36 months postinjury. MAIN MEASURES:: Coping Scale for Adults-Short Version; Quality of Life Inventory; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale. RESULTS:: High preinjury use of nonproductive coping style predicted high use of nonproductive coping, more anxiety, and lower psychosocial functioning at 1 year postinjury. Increased use of nonproductive coping and decreased use of productive coping predicted poorer psychosocial outcome at 1 year post-TBI. Use of both productive and nonproductive coping decreased in the first 6 to 12 months post-TBI relative to preinjury. Unlike productive coping, nonproductive coping reached preinjury levels within 3 years postinjury. CONCLUSION:: The findings support identification of individuals at risk of relying on nonproductive coping and poorer psychosocial outcome following TBI. In addition, the results emphasize the need to implement timely interventions to facilitate productive coping and reduce the use of nonproductive coping in order to maximize favorable long-term psychosocial outcome.

Objective: To investigate variables associated with the frequency and quantity of alcohol consumption following a brief alcohol intervention in individuals with traumatic brain injury. Participants: Initial sample of 60 participants with traumatic brain injury (mean age = 35 years) with preinjury history of alcohol use; of whom, 50 were evaluated at follow-up. Research Design: Randomized controlled trial, stratified for gender, which used a random-effects regression model to examine the association of predictor variables with the frequency and quantity of alcohol use 6 months following a brief alcohol intervention. Main Measures: Alcohol Use Disorders Identification Test; Time Line Follow Back; California Verbal Learning Test‐II; Modified Six Elements Test; Readiness to Change Questionnaire; and Hospital Anxiety and Depression Scale.Interventions:Participants received one of the following treatments: informal discussion; discussion plus information; and brief motivational interview plus information. Results: While both intervention groups showed less drinking, the intervention group membership effect was not significant. Being in the action stage of readiness to change was associated with lower drinking frequency and quantity. Higher education and higher levels of depression were associated with increased drinking. Memory and executive function, and heavy preinjury alcohol use, were not significant predictors. Conclusions: These findings support a focus on readiness to change behavior and treatment of depression in addressing alcohol use issues following traumatic brain injury. Treatment efficacy studies in larger samples are needed. Key words: alcohol, brain injury, intervention study, motivational interviewing, predictors, randomized controlled trial, substance use, treatment outcome

OBJECTIVE: : To investigate the relationship of psychiatric functioning with psychosocial functioning at 1 year following traumatic brain injury (TBI), after controlling for relevant demographic, injury-related, and concurrent factors. DESIGN: : Prospective 1-year longitudinal study. PARTICIPANTS: : Participants were 122 individuals with TBI and 88 proxy informants. SETTING: : Rehabilitation hospital. MAIN MEASURES: : The Structured Clinical Interview for DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision)) Axis I Disorders, Hospital Anxiety and Depression Scale, Sydney Psychosocial Reintegration Scale, and Glasgow Outcome Scale--Extended. RESULTS: : At 1 year post injury, occupational activities were the area of most change after TBI followed by interpersonal relationships and independent living skills, according to the Sydney Psychosocial Reintegration Scale. The majority of participants were rated as having moderate disability on the Glasgow Outcome Scale--Extended. After controlling for relevant background factors, pre-injury, acute post injury, and concurrent psychiatric disorders were significantly related to 1-year psychosocial outcome. Conclusion:Screening in the acute post-injury stage for presence of pre-injury psychiatric history or current distress may help identify individuals who require more intensive rehabilitation and psychiatric support and more active post discharge monitoring. Further research exploring potential causal mechanisms for these findings is required. Language: en

Objective: To investigate predictors of posttraumatic brain injury psychiatric disorders. Design: Retrospective, cross-sectional design with stratified random sampling of groups of patients on average 1 to 5 years postinjury. DSM-based diagnostic interviews of both traumatic brain injury (TBI) participant and informant. Participants: One hundred community-based participants, aged 19–74 years, with traumatic brain injury sustained 0.05–5.5 years previously. Setting: Community-based patients previously treated at a rehabilitation hospital. Main measure: The Structured Clinical Interview for DSM-IV diagnosis. Results: A psychiatric history was a high-risk factor for having the same disorder postinjury. However, the majority of cases of depression and anxiety were novel, suggesting that significant factors other than pre-TBI psychiatric status contribute to post-TBI psychiatric outcome. Female gender, lower education, and pain were also associated with postinjury depression and unemployment and older age with anxiety. Conclusion: Findings suggest that long-term screening and support are important for individuals with TBI, regardless of preinjury psychiatric status.

OBJECTIVES To retrospectively establish the nature and frequency of Axis I psychiatric disorders pre- and post-TBI. PARTICIPANTS One hundred participants who were 0.5 to 5.5 years post mild to severe TBI and 87 informants, each evaluated at a single time point. MAIN MEASURE The Structured Clinical Interview for DSM-IV Disorders (SCID-I). RESULTS Preinjury, 52% received a psychiatric diagnosis, most commonly substance use disorder (41%), followed by major depressive disorder (17%) and anxiety (13%). Postinjury, 65% received a diagnosis, of which major depression became the most common (45%), followed by anxiety (38%) and substance use disorder (21%). Frequency of depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and phobias rose from preinjury to postinjury. More than two-thirds of postinjury depression and anxiety cases were novel and showed poor resolution rates. Few novel cases of substance use disorder were noted. Psychotic disorders, somatoform disorders, and eating disorders occurred at frequencies similar to those in the general population. CONCLUSIONS A high frequency of postinjury psychiatric disorders was evident up to 5.5 years postinjury, with many novel cases of depression and anxiety. Individuals with TBI should be screened for psychiatric disorders at various time points post-injury without reliance on history of psychiatric problems to predict who is at risk, so that appropriate intervention can be offered.

OBJECTIVES: To investigate the association of psychosocial outcome 10 years following traumatic brain injury (TBI) with demographic variables, injury severity, current cognitive functioning, emotional state, aggression, alcohol use, and fatigue. SETTING: Community-based follow-up. PARTICIPANTS: Fifty-three participants with mild to very severe TBI sustained 10 years previously and significant others. MEASURES: Sydney Psychosocial Reintegration Scale, Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, NFI Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function. RESULTS: Psychosocial functioning was lowest in the occupational activity domain and highest in the living skills domains. Variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, aggression, anxiety, and depression were all significantly associated with psychosocial outcome, although the strength of correlations varied between ratings of participants with TBI and relatives. Posttraumatic amnesia duration was most strongly associated with psychosocial outcome measured by relatives; anxiety, aggression, and depression were the strongest predictors when ratings were assigned by participants with TBI. Self-reported fatigue, depression, and alcohol use were the strongest predictors of aggression. CONCLUSIONS: It is important to address problems with anxiety, depression, fatigue, and alcohol use as a possible means of improving long-term psychosocial outcome following TBI. Language: en

AIMS To compare motivation for and participation in rehabilitation, outcome, and distress over role changes in persons with traumatic brain injury (TBI) from the dominant English-speaking culture in Australia versus those from minority culturally and linguistically diverse (CALD) backgrounds. MAIN MEASURES Motivation for Traumatic Brain Injury Rehabilitation Questionnaire; Craig Handicap Assessment Reporting Technique. PARTICIPANTS Two groups of persons with TBI, 38 of English-speaking backgrounds and 32 of CALD backgrounds. RESULTS Groups had similar education and preinjury employment status, both showed positive attitudes toward rehabilitation and participated equally in rehabilitation. However, CALD participants showed poorer outcomes in several domains, including postinjury employment status, cognitive independence, mobility and social integration, and showed greater distress about changes in ability to perform certain life roles. CONCLUSIONS Differences in outcome and levels of distress over role changes may occur in those from CALD backgrounds following TBI, independent of socioeconomic background and access to rehabilitation. There is a need to further investigate possible reasons for this, including beliefs, coping style, and emotional response to injury.