Search

Objective: Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI., Setting: Nationwide VA-purchased care from 2016 through 2019., Participants: Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144)., Design: This was a retrospective, observational study., Main Measures: Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019., Results: Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use., Conclusions: Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine whether post-9/11 veterans who screened positive for mild traumatic brain injury (mTBI) but did not complete a Comprehensive TBI Evaluation (CTBIE) were at higher risk of subsequent adverse events compared with veterans who screened positive and completed a CTBIE. Upon CTBIE completion, information assessed by a trained TBI clinician indicates whether there is mTBI history (mTBI+) or not (mTBI-)., Setting: Veterans Health Administration (VHA) outpatient services., Participants: A total of 52 700 post-9/11 veterans who screened positive for TBI were included. The follow-up review period was between fiscal years 2008 and 2019. The 3 groups studied based on CTBIE completion and mTBI status were: (1) mTBI+ (48.6%), (2) mTBI- (17.8%), and (3) no CTBIE (33.7%)., Design: This was a retrospective cohort study. Log binomial and Poisson regression models adjusting for demographic, military, pre-TBI screening health, and VHA covariates examined risk ratios of incident outcomes based on CTBIE completion and mTBI status., Main Measures: Incident substance use disorders (SUDs), alcohol use disorder (AUD), opioid use disorder (OUD), overdose, and homelessness documented in VHA administrative records, and mortality as documented in the National Death Index, 3 years post-TBI screen. VHA outpatient utilization was also examined., Results: Compared with the no CTBIE group, the mTBI+ group had 1.28 to 1.31 times the risk of incident SUD, AUD, and overdose, but 0.73 times the risk of death 3 years following TBI screening. The mTBI- group had 0.70 times the risk of OUD compared with the no CTBIE group within the same period. The no CTBIE group also had the lowest VHA utilization., Conclusions: There were mixed findings on risk of adverse events for the no CTBIE group relative to the mTBI+ and mTBI- groups. Future research is needed to explore the observed differences, including health conditions and healthcare utilization, documented outside VHA among veterans who screen positive for TBI., Competing Interests: The authors declare no conflict of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Veterans and service members (V/SM) may have more risk factors for arrest and felony incarceration (e.g., posttraumatic stress disorder and at-risk substance use) but also more protective factors (e.g., access to health care) to mitigate behaviors that may lead to arrest. As such, understanding which factors are associated with criminal justice involvement among V/SM could inform prevention and treatment efforts. The current study examined relationships between lifetime history of arrests and felony incarceration and sociodemographic, psychological, and brain injury characteristics factors among combat V/SM., Materials and Methods: The current study was a secondary data analysis from the Chronic Effects of Neurotrauma Consortium multicenter cohort study, approved by local institutional review boards at each study site. Participants were V/SM (N = 1,540) with combat exposure (19% active duty at time of enrollment) who were recruited from eight Department of Veterans Affairs and DoD medical centers and completed a baseline assessment. Participants were predominantly male (87%) and white (72%), with a mean age of 40 years (SD = 9.7). Most (81%) reported a history of at least one mild traumatic brain injury, with one-third of those experiencing three or more mild traumatic brain injuries (33%). Participants completed a self-report measure of lifetime arrest and felony incarceration history, a structured interview for all potential concussive events, the post-traumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the Alcohol Use Disorders Identification Test-Consumption. Three groups were compared on self-reported level of lifetime history of criminal justice system involvement: (1) no history of arrest or incarceration (65%); (2) history of arrest but no felony incarceration (32%); and (3) history of felony incarceration (3%)., Results: Ordinal regression analyses revealed that hazardous alcohol consumption (β = .44, P < .001; odds ratio = 1.56) was positively associated with increased criminal justice involvement after adjusting for all other variables. Being married or partnered (β = -.44, P < .001; odds ratio = 0.64) was negatively associated with decreased criminal justice involvement., Conclusions: The rate of lifetime arrest (35%) in this V/SM sample was consistent with rates of arrests in the U.S. general population. One modifiable characteristic associated with lifetime arrest and felony incarceration was hazardous alcohol consumption. Alcohol use should be a top treatment target for V/SM at risk for arrest and those with history of criminal justice involvement., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD., Objective: Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017., Methods: All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores., Results: About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization., Conclusions: Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses., (©Bhanu Pratap Singh Rawat, Joel Reisman, Terri K Pogoda, Weisong Liu, Subendhu Rongali, Robert H Aseltine Jr, Kun Chen, Jack Tsai, Dan Berlowitz, Hong Yu, Kathleen F Carlson. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 24.07.2023.)

Objective: While outcome from mild traumatic brain injury (mTBI) is generally favorable, concern remains over potential negative long-term effects, including impaired cognition. This study examined the link between cognitive performance and remote mTBIs within the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter, observational study of Veterans and service members (SMs) with combat exposure., Method: Baseline data of the participants passing all cognitive performance validity tests ( n = 1,310) were used to conduct a cross-sectional analysis. Using multivariable regression models that adjusted for covariates, including age and estimated preexposure intellectual function, positive mTBI history groups, 1-2 lifetime mTBIs (nonrepetitive, n = 614), and 3 + lifetime mTBIs (repetitive; n = 440) were compared to TBI negative controls ( n = 256) on each of the seven cognitive domains computed by averaging Z scores of prespecified component tests. Significance levels were adjusted for multiple comparisons., Results: Neither of the mTBI positive groups differed from the mTBI negative control group on any of the cognitive domains in multivariable analyses. Findings were also consistently negative across sensitivity analyses (e.g., mTBIs as a continuous variable, number of blast-related mTBIs, or years since the first and last mTBI)., Conclusions: Our findings demonstrate that the average veteran or SM who experienced one or more mTBIs does not have postacute objective cognitive deficits due to mTBIs alone. A holistic health care approach including comorbidity assessment is indicated for patients reporting chronic cognitive difficulties after mTBI(s), and strategies for addressing misattribution may be beneficial. Future study is recommended with longitudinal designs to assess within-subjects decline from potential neurodegeneration. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Importance: Traumatic brain injury (TBI) was common among US service members deployed to Iraq and Afghanistan. Although there is some evidence to suggest that TBI increases the risk of cardiovascular disease (CVD), prior reports were predominantly limited to cerebrovascular outcomes. The potential association of TBI with CVD has not been comprehensively examined in post-9/11-era veterans., Objective: To determine the association between TBI and subsequent CVD in post-9/11-era veterans., Design, Setting, and Participants: This was a retrospective cohort study conducted from October 1, 1999, to September 30, 2016. Participants were followed up until December 31, 2018. Included in the study were administrative data from the US Department of Veterans Affairs and the Department of Defense from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium. Participants were excluded if dates did not overlap with the study period. Data analysis was conducted between November 22, 2021, and June 28, 2022., Exposures: History of TBI as measured by diagnosis in health care records., Main Outcomes and Measures: Composite end point of CVD: coronary artery disease, stroke, peripheral artery disease, and cardiovascular death., Results: Of the 2 530 875 veterans from the consortium, after exclusions, a total of 1 559 928 veterans were included in the analysis. A total of 301 169 veterans (19.3%; median [IQR] age, 27 [23-34] years; 265 217 male participants [88.1]) with a TBI history and 1 258 759 veterans (80.7%; median [IQR] age, 29 [24-39] years; 1 012 159 male participants [80.4%]) without a TBI history were included for analysis. Participants were predominately young (1 058 054 [67.8%] <35 years at index date) and male (1 277 376 [81.9%]). Compared with participants without a history of TBI, diagnoses of mild TBI (hazard ratio [HR], 1.62; 95% CI, 1.58-1.66; P < .001), moderate to severe TBI (HR, 2.63; 95% CI, 2.51-2.76; P < .001), and penetrating TBI (HR, 4.60; 95% CI, 4.26-4.96; P < .001) were associated with CVD in adjusted models. In analyses of secondary outcomes, all severities of TBI were associated with the individual components of the composite outcome except penetrating TBI and CVD death., Conclusions and Relevance: Results of this cohort study suggest that US veterans with a TBI history were more likely to develop CVD compared with veterans without a TBI history. Given the relatively young age of the cohort, these results suggest that there may be an increased burden of CVD as these veterans age and develop other CVD risk factors. Future studies are needed to determine if the increased risk associated with TBI is modifiable.

Objective: Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs., Methods: A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period., Results: The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period., Conclusions: In keeping with IPS’s intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n = 541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P = 0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P = 0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objective: To describe associations of demographic, military, and health comorbidity variables between mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD) status in a sample of Former and current military personnel., Setting: Participants recruited and tested at seven VA sites and one military training facility in the LIMBIC-CENC prospective longitudinal study (PLS), which examines the long-term mental health, neurologic, and cognitive outcomes among previously combat-deployed U.S. Service Members and Veterans (SM/Vs)., Participants: A total of 1,540 SM/Vs with a history of combat exposure. Data were collected between 1/1/2015 through 3/31/2019., Design: Cross-sectional analysis using data collected at enrollment into the longitudinal study cohort examining demographic, military, and health comorbidity variables across PTSD and mTBI subgroups., Main Measures: PTSD Checklist for DSM-5 (PCL-5), mTBI diagnostic status, Patient Health Questionnaire 9-item (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), AUDIT-C, and other self-reported demographic, military, and health comorbidity variables., Results: Ten years following an index date of mTBI exposure or mid-point of military deployment, combat-exposed SM/Vs with both mTBI history and PTSD had the highest rates of depression symptoms, pain, and sleep apnea risk relative to SM/Vs without both of these conditions. SM/Vs with PTSD, irrespective of mTBI history, had high rates of obesity, sleep problems, and pain., Conclusion: The long-term symptom reporting and health comorbidities among SM/Vs with mTBI history and PTSD suggest that ongoing monitoring and intervention is critical for addressing symptoms and improving quality of life.

Objective: To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment., Method: We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program., Results: VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners., Conclusions and Implications for Practice: There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Introduction: Deployment-related mild traumatic brain injury (mTBI) affects a significant proportion of those who served in Post-9/11 combat operations. The prevalence of head injuries, including those that lead to mTBI, is often reported quantitatively. However, service member (SM) and Veteran firsthand accounts of their potential concussive events (PCEs) and mTBIs can serve as a rich resource for better understanding the nuances and context of these exposures., Materials and Methods: Post-9/11 SMs and Veterans with a history of combat deployment were recruited through the Chronic Effects of Neurotrauma Consortium's observational study of deployment-related mTBI. During a comprehensive assessment, participants completed the Virginia Commonwealth University retrospective Concussion Diagnostic Interview, a specialized validated interview measure which obtains detailed narratives of deployment-incurred blast and non-blast-related PCEs. Qualitative thematic analysis was used to identify and code recurring themes within the narratives., Results: Among the sample of 106 SMs and Veterans, deployment-related mTBI was highly prevalent (67.0%). Over half (50.9%) of the participants identified a blast as the cause of their worst PCE, frequently with accompanying themes of self-reported acute neurological symptoms, intense physical blast forces, and tertiary head impact. Exposure to blast at close range, such as driving directly over an improvised explosive device, occurred in 24.7% of all blast-related narratives and in 59.3% of narratives where blast was identified as causing the worst PCE. Themes of potentially preventable head impacts experienced during noncombat circumstances were also frequent, accounting for 35% of all non-blast-related head injuries in the sample., Conclusions: Prevalence of deployment-related close-range blast exposure, non-blast impact PCEs, and mTBIs among this Post-9/11 combatant sample was substantial, and in many cases potentially preventable. The use of detailed semi-structured interviews may help health care providers and policymakers to better understand the context and circumstances of deployment-related PCEs and mTBIs., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Many female veterans have deployed to Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), and some experience traumatic brain injury (TBI). Although TBI is increasingly recognized as an important health issue for female OEF/OIF/OND veterans, there is little attention to stressful experiences that may exacerbate health problems or hinder recovery among veterans who may have experienced TBI. Lifetime intimate partner violence (IPV) is common among general samples of female veterans. Given the negative implications of IPV on women's health, it is important to understand whether there is a relationship between lifetime IPV and health functioning among female veterans who have experienced possible TBI. This study provides an exploration of lifetime IPV and its associations with physical and mental health, as well as community reintegration, among female OEF/OIF/OND veterans who have been evaluated for TBI. The sample comprised 127 female veterans who participated in a larger study that examined reintegration among OEF/OIF/OND veterans who received a TBI evaluation in the Veterans Heath Administration (VHA) and completed an assessment of lifetime IPV. Primary and secondary data sources included survey responses (e.g., health symptoms and reintegration) and VHA administrative data (e.g., health diagnoses). Results indicated that nearly two thirds (63.0%) of women who completed a TBI evaluation reported lifetime IPV, though clinician-confirmed TBI was not associated with IPV. Women who experienced IPV, compared with those who did not, reported higher levels of neurobehavioral symptoms and were significantly more likely to have diagnoses of back pain (48.6% vs. 30.0%, respectively) and substance abuse (12.2% vs. 0%, respectively). Notwithstanding, women with and without lifetime IPV reported similar levels of reintegration. Findings provide evidence that lifetime IPV may be common among female OEF/OIF/OND veterans who are evaluated for TBI, and that IPV is associated with several treatable health problems among this population.

Objective: To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans., Setting: Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA)., Participants: Post-9/11 veterans with at least 3 years of VA care., Design: Cross-sectional, retrospective, observational study., Main Measures: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory., Results: Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination., Conclusions: There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.

Background: Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance)., Purpose: To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services., Methods: Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26)., Findings: Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity., Discussion: Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role., (Published by Elsevier Inc.)

Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans' perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Traumatic brain injury (TBI) may be a predisposing factor to pain syndromes other than headache. We conducted a longitudinal cohort study among veterans evaluated for TBI in the US Department of Veterans Affairs (VA). Among 36,880 veterans at baseline, 55% reported back pain. TBI history was classified by trained clinicians according to VA-US Department of Defense criteria. 14,223 Veterans without back pain were followed for up to 6 years for new (incident) episodes of VA care for back pain. We estimated adjusted odds ratios (aORs), adjusted hazard ratios (aHRs), and 95% confidence intervals (CI), accounting for covariates. Deployment-related mild TBI was significantly associated with self-reported back pain in cross-sectional analyses (aOR = 1.27, 95% CI = 1.21-1.35), but not with incident episodes of VA care for back pain in longitudinal analysis (aHR = 1.07, 95% CI = 0.99-1.17). Deployment-related moderate to severe TBI was significantly associated with self-reported back pain in cross-sectional (aOR = 1.74, 95% CI = 1.58-1.91), and longitudinal analyses (aHR = 1.20, 95% CI = 1.05-1.38; P = .01). These findings indicate that deployment-related moderate to severe TBI confers increased back pain risk, but do not support a causal effect of deployment-related mild TBI on back pain. PERSPECTIVE: Findings from this longitudinal study of veterans indicate that deployment-related moderate to severe TBI confers increased back pain risk, but do not support a causal effect of deployment-related mild TBI on back pain., (Published by Elsevier Inc.)

Objectives: The goal of this study was to investigate predictors of employment status in male and female post-9/11 Veterans evaluated for traumatic brain injury (TBI) in the Veterans Health Administration. Prior research suggests there are gender differences in psychosocial characteristics among this cohort., Methods: This was a cross-sectional analysis of post-9/11 Veterans who completed a TBI evaluation between July 2009 and September 2013., Results: Women had lower prevalence of deployment-related TBI (65.5%) compared with men (75.3%), but the percentages of those unemployed across the TBI diagnostic categories were similar for men (38%) and women (39%). Adjusted log-binomial regression found that unemployment was significantly associated with age, education, marital status, moderate/severe TBI, suspected posttraumatic stress disorder, depression, and drug abuse/dependence, and neurobehavioral symptom severity for men, whereas for women only more severe affective and cognitive symptoms were associated with unemployment., Conclusions: Although the unemployment rate was similar across gender, there was a clearer pattern of demographic and health factors, including TBI severity, that was significantly associated with employment status in men. There may be other factors contributing to the female Veteran unemployment rate, underscoring the need to investigate unique contributors to unemployment, as well as how treatment and employment services can be expanded and tailored for post-9/11 Veterans.

Objectives: To quantify the need for, and interest in, supported employment (SE) among recent military veterans with traumatic brain injury (TBI); and to examine characteristics associated with veterans' interest in SE., Design: Stratified random sample of Iraq and Afghanistan War veterans confirmed to have TBI through the Veterans Health Administration (VHA) screening and evaluation system., Setting: Community-based via mailed survey., Participants: We recruited 1800 veterans with clinician-confirmed TBI (mild TBI: n=1080; moderate/severe TBI: n=720) through multiple mailings. Among 1451 surveys that were not returned undeliverable, N=616 (42%) responded., Interventions: Not applicable., Main Outcome Measures: Veterans rated their interest in SE after reading a script describing the program. Additional measures assessed mental health and pain-related comorbidities, employment, financial/housing difficulties, demographics, and military service characteristics. Estimates were weighted to represent the population of veterans with VHA clinician-confirmed TBI., Results: Unemployment was reported by 45% (95% confidence interval [CI], 43-47) of veterans with TBI. Although 42% (95% CI, 40-44) reported they would be interested in using SE if it were offered to them, only 12% had heard of SE (95% CI, 11-14) and <1% had used it. TBI severity and comorbidities were not associated with veterans' interest in SE. However, those who were unemployed, looking for work, experiencing financial strain, or at risk for homelessness were more likely to be interested in SE., Conclusions: Our research highlights an important gap between veterans' vocational needs and interests and their use of SE. Systematically identifying and referring those with employment and financial/housing difficulties may help close this gap., (Published by Elsevier Inc.)

Objective: To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes., Design: Prospective cohort study., Setting: Department of Veterans Affairs (VA) outpatient clinics., Participants: Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE)., Interventions: Not applicable., Main Outcome Measures: The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders., Results: Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (β [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (β [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (β [SE]=.66 [.09], P<.001) and longitudinal analyses (β [SE]=.18 [.09], P=.04)., Conclusions: Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache., (Published by Elsevier Inc.)

Objective: To effectively diagnose and treat women who have experienced intimate partner violence (IPV), it is important to identify the full range of physical and mental health consequences, including hidden wounds such as traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). We aimed to identify the occurrence of IPV-related TBI and associated PTSD symptoms among women veterans who experienced IPV., Methods: A web-based survey was administered in 2014 to a national sample of U.S. women veterans. Among 411 respondents (75% participation rate), 55% reported IPV during their lives. These participants (N=224) completed screening measures of IPV-related TBI, PTSD, and past-year IPV and comprised the current sample., Results: A total of 28.1% (n=63) met criteria for IPV-related TBI history, and 12.5% (n=28) met criteria for IPV-related TBI with current symptoms. When adjusting for race, income, and past-year IPV, women with IPV-related TBI with current symptoms were 5.9 times more likely to have probable IPV-related PTSD than those with no IPV-related TBI history. Despite symptom overlap between TBI and PTSD, women with IPV-related TBI with current symptoms were significantly more likely to meet criteria for all four DSM-5 PTSD symptom clusters compared to women with an IPV-related TBI history without current symptoms (Cramér's V's=.34-.42)., Conclusion: Findings suggest there may be clinical utility in screening women who experience lifetime IPV for both TBI and PTSD symptoms in order to help clinicians better target their examinations, treatment, and referrals., (Published by Elsevier Inc.)

Objective: We review health services and reintegration practices that contribute to the rehabilitation of US active duty service members (ADSMs) and Veterans who experienced traumatic brain injury (TBI), especially mild TBI (mTBI), as discussed at the 2015 Department of Veterans Affairs (VA) TBI State-of-the-Art (SOTA) Conference., Methodology: We reviewed the state-of-the-art at the time of the previous 2008 TBI SOTA Conference, advances in the field since then, and future directions to address gaps in knowledge., Main Results: We reviewed: (1) mTBI and its comorbid conditions documented in ADSMs and Veterans, and recognized the need for additional healthcare utilization, health cost and quality of care studies; (2) VA vocational rehabilitation programmes and the effectiveness of supported employment for helping those with workplace difficulties; (3) the application of technology to assist in TBI rehabilitation, including mobile device applications for self-management, videoconferencing with providers, and virtual reality to help with behavioural and cognitive challenges, and (4) Department of Defense (DoD)-VA partnerships on identification, evaluation and dissemination of TBI best practices., Conclusions: There have been significant advances in TBI rehabilitation, but multiple areas across the DoD and VA care continuum need further exploration and development to meet the needs of ADSMs and Veterans.

Objective: To examine the relations among demographic characteristics, traumatic brain injury (TBI) history, suspected psychiatric conditions, current neurobehavioral health symptoms, and employment status in Veterans evaluated for TBI in the Department of Veterans Affairs., Study Design: Retrospective cross-sectional database review of comprehensive TBI evaluations documented between October 2007 and June 2009., Participants: Operation Enduring Freedom/Operation Iraqi Freedom Veterans (n = 11 683) who completed a comprehensive TBI evaluation., Main Measures: Veterans Affairs clinicians use the comprehensive TBI evaluations to obtain information about TBI-related experiences, current neurobehavioral symptoms, and to identify suspected psychiatric conditions., Results: Approximately one-third of Veterans in this sample were unemployed, and of these, the majority were looking for work. After simultaneously adjusting for health and deployment-related variables, significant factors associated with unemployment included one or more suspected psychiatric conditions (eg, posttraumatic stress disorder, anxiety, depression), neurobehavioral symptom severity (ie, affective, cognitive, vestibular), former active duty status, injury etiology, age, lower education, and marital status. The associations of these factors with employment status varied by deployment-related TBI severity., Conclusions: Simultaneously addressing health-related, educational, and/or vocational needs may fill a critical gap for helping Veterans readjust to civilian life and achieve their academic and vocational potential.

Background: Intimate partner violence (IPV) is prevalent among women Veterans and is known to increase women's risk for traumatic brain injury (TBI). IPV-related TBI has not been examined in the women Veteran population., Objectives: To identify the occurrence of IPV-related TBI in a sample of women Veterans and examine the associations of IPV-related TBI with sociodemographic characteristics, health symptoms, health care utilization, and IPV experiences., Research Design: Cross-sectional mail survey conducted in 2013., Subjects: The sample comprised 176 New England Department of Veterans Affairs (VA) women Veteran patients., Measures: Self-reported IPV-related TBI was assessed with a modified VA TBI screening tool. The survey included validated measures of depression (Center for Epidemiologic Studies Depression Scale) and posttraumatic stress disorder (PTSD; Posttraumatic Disorder Checklist) symptoms, as well as overall mental and physical health (SF-12), and IPV (Conflict Tactics Scales-Revised-2). Questions assessed past-year VA and non-VA health care use., Results: A total of 18.8% (n=33) met screening criteria for IPV-related TBI history. Women who experienced IPV-related TBI reported significantly higher depression (mean Center for Epidemiologic Studies Depression Scale scores: 26.6 vs. 20.7, P<0.0001) and PTSD (mean Posttraumatic Disorder Checklist scores: 53.2 vs. 34.1, P<0.0001) symptoms, and poorer perceptions of physical health (mean SF-12 34.6 vs. 42.3, P<0.01) than women who experienced IPV to the head without TBI. IPV-related TBI was also associated with poorer perceptions of mental health, as well as more frequent VA health care utilization and overall IPV., Conclusions: IPV-related TBI is associated with poorer mental and physical health in women Veterans. This invisible injury is associated with greater VA health care utilization and IPV exposure. Implications for VA practice and policy are discussed.

Objective: To determine the demographic and service characteristics that differentially impact utilization and cost of Veterans Health Administration (VHA) services for Operation Enduring Freedom and Operation Iraq Freedom (OEF/OIF) Veterans screened or evaluated for traumatic brain injury (TBI)., Setting: We examined Department of Defense (DoD) and VHA administrative records of OEF/OIF Veterans who were screened or evaluated for TBI., Participants: Our study population was OEF/OIF Veterans who separated from DoD in Fiscal Years 2003-2009 and who were screened or evaluated in VHA for TBI between October 2008 and July 2009., Design: We describe the demographics and service characteristics of separated Veterans and those who accessed the VHA. We report the cost of VHA utilization and estimate a probit regression model to assess determinants of VHA utilization and costs by OEF/OIF Veterans screened and evaluated for TBI by VHA., Results: Females and Veterans older than 37 years utilize VHA services more intensely. Across all services, the Reserve Components utilize health services more than the Active Components placing more demand on VHA for services., Conclusion: VHA utilization and costs is impacted by the demographic and service characteristics of Veterans. The variation in Veteran groups incurring higher costs and utilization indicates different usage patterns of VHA services by each group with implications for patient load as the DoD deploys higher numbers of females and the Reserve Components., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Background: Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI)., Methods: The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE)., Findings: Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs., Conclusion: As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting., (Published by Elsevier Inc.)

The concordance of Department of Veterans Affairs (VA) clinician judgment of mild traumatic brain injury (mTBI) history with American Congress of Rehabilitation Medicine (ACRM)-based criteria was examined for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans. In order to understand inconsistencies in agreement, we also examined the associations between evaluation outcomes and conceptually relevant patient characteristics, deployment-related events, current self-reported health symptoms, and suspected psychiatric conditions. The Veteran sample comprised 14,026 OIF/OEF VA patients with deployment-related mTBI history (n = 9,858) or no history of mTBI (n = 4,168) as defined by ACRM-based criteria. In the majority of cases (76.0%), clinician judgment was in agreement with the ACRM-based criteria. The most common inconsistency was between clinician judgment (no) and ACRM-based criteria (yes) for 21.3% of the patients. Injury etiology, current self-reported health symptoms, and suspected psychiatric conditions were additional factors associated with clinician diagnosis and ACRM-based criteria disagreement. Adherence to established diagnostic guidelines is essential for accurate determination of mTBI history and for understanding the extent to which mTBI symptoms resolve or persist over time in OIF/OEF Veterans.

Background: Traumatic brain injury (TBI) research among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans has focused primarily on men. We examine associations between probable deployment-related TBI and postdeployment mental and physical health symptoms separately by gender. To identify unique associations of probable TBI with health symptoms, analyses were also conducted separately for veterans with and without probable posttraumatic stress disorder (PTSD)., Methods: A mail survey, including self-report measures of probable deployment-related TBI and mental and physical health symptoms, was completed by 2348 OEF/OIF veterans (51% female), sampled randomly within gender from a national roster. We conducted logistic regressions stratified by gender and probable PTSD status to evaluate associations between probable TBI and health symptoms., Results: Of the respondents, 10.7% of women and 19.7% of men screened positive for probable deployment-related TBI. Probable TBI was significantly associated with increased risk of mental and physical health symptoms for both genders, even after adjusting for potential confounders. Odds ratios for the associations of probable TBI with health symptoms ranged between 2.63 and 9.20 for women and between 1.94 and 7.44 for men. Among veterans with probable PTSD, symptomatic anxiety and symptomatic physical health remained associated with probable TBI. Among veterans without probable PTSD, TBI remained strongly associated with all health symptoms for women and symptomatic anxiety and physical health for men, suggesting an association between TBI and some health symptoms independent of PTSD., Conclusions: Strong associations between probable TBI and health symptoms for women and men confirm the importance of screening for TBI and treatment of associated health symptoms for all OEF/OIF veterans.

With the use of Veterans Health Administration and Department of Defense databases of veterans who completed a Department of Veterans Affairs comprehensive traumatic brain injury (TBI) evaluation, the objectives of this study were to (1) identify the co-occurrence of self-reported auditory, visual, and vestibular impairment, referred to as multisensory impairment (MSI), and (2) examine demographic, deployment-related, and mental health characteristics that were potentially predictive of MSI. Our sample included 13,746 veterans with either a history of deployment-related mild TBI (mTBI) (n = 9,998) or no history of TBI (n = 3,748). The percentage of MSI across the sample was 13.9%, but was 17.4% in a subsample with mTBI history that experienced both nonblast and blast injuries. The factors that were significantly predictive of reporting MSI were older age, being female, lower rank, and etiology of injury. Deployment-related mTBI history, posttraumatic stress disorder, and depression were also significantly predictive of reporting MSI, with mTBI history the most robust after adjusting for these conditions. A better comprehension of impairments incurred by deployed servicemembers is needed to fully understand the spectrum of blast and nonblast dysfunction and may allow for more targeted interventions to be developed to address these issues.

Objective: To describe the prevalence of self-reported rates of auditory, visual, and dual sensory impairment (DSI) in Afghanistan and Iraq war Veterans receiving traumatic brain injury (TBI) evaluations., Design: Retrospective medical chart review., Participants: Thirty-six thousand nine hundred nineteen Veterans who received a TBI evaluation between October 2007 and June 2009. Final sample included 12,521 subjects judged to have deployment-related TBI and a comparison group of 9106 participants with no evidence of TBI., Main Outcome Measure: Self-reported auditory and visual impairment., Results: Self-reported sensory impairment rates were: 34.6% for DSI, 31.3% for auditory impairment only, 9.9% for visual impairment only, and 24.2% for none/mild sensory impairment. Those with TBI and blast exposure had highest rate of DSI. Regression analyses showed that auditory impairment was the strongest predictor of visual impairment, and vice versa, suggesting these impairments may derive from a common source., Conclusions: Veterans who self-report clinically significant hearing or vision difficulty during routine TBI evaluation should be evaluated systematically and comprehensively to determine the extent of sensory impairment. Identifying DSI could allow clinicians to collaborate and maximize rehabilitation.

Background: Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI., Methods: This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms., Findings: Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains., Conclusion: Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI., (Published by Elsevier Inc.)

We studied the prevalence and characteristics of self-reported driving difficulties and examined their association with traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans who were seen at a Department of Veterans Affairs outpatient polytrauma clinic. In this study, we used a brief driving questionnaire and chart reviews to assess the prevalence and characteristics of driving difficulties in the following four groups of patients: TBI only, PTSD only, TBI + PTSD, and Neither (neither TBI nor PTSD). Compared with before deployment, 93% of OIF/OEF veterans seen in the polytrauma clinic reported more difficulties with driving in at least one domain, with the most common areas of difficulty being (1) problems with anger or impatience (82%), (2) general driving difficulties (65%), and (3) experiences with near misses (57%). Patients with PTSD (with or without TBI) reported the most significant driving impairments, whereas respondents with a history of only TBI endorsed driving difficulties similar to veterans without either diagnosis. Qualitative analysis of veterans' comments also revealed similar patterns. Self-reported driving problems were common among OIF/OEF returnees. Respondents who had a diagnosis of PTSD (with or without TBI) reported the most severe driving difficulties since returning from deployment. The association between PTSD and driving problems warrants further investigation.

Background: Studies have demonstrated that individuals diagnosed with traumatic brain injury (TBI) frequently use medical and recreational cannabis to treat persistent symptoms of TBI, such as chronic pain and sleep disturbances, which can lead to cannabis use disorder (CUD). We aimed to determine the Veterans Health Administration (VHA) healthcare utilization and costs associated with CUD and dementia diagnosis in veterans with TBI. Methods: This observational study used administrative datasets from the population of post-9/11 veterans from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium and the VA Data Warehouse. We compared the differential VHA costs among the following cohorts of veterans: (1) No dementia diagnosis and No CUD group, (2) Dementia diagnosis only (Dementia only), (3) CUD only, and (4) comorbid dementia diagnosis and CUD (Dementia and CUD). Generalized estimating equations and negative binomial regression models were used to estimate total annual costs (inflation-adjusted) and the incidence rate of healthcare utilization, respectively, by dementia diagnosis and CUD status. Results: Data from 387,770 veterans with TBI (88.4% men; median [interquartile range (IQR)] age at the time of TBI: 30 [14] years; 63.5% white) were followed from 2000 to 2020. Overall, we observed a trend of gradually increasing healthcare costs 5 years after TBI onset. Interestingly, in this cohort of veterans within 5 years of TBI, we observed substantial healthcare costs in the Dementia only group (peak = $46,808) that were not observed in the CUD and dementia group. Relative to those without either condition, the annual total VHA costs were $3,368 higher in the CUD only group, while no significant differences were observed in the Dementia only and Dementia and CUD groups. Discussion: The findings suggest that those in the Dementia only group might be getting their healthcare needs met more quickly and within 5 years of TBI diagnosis, whereas veterans in the Dementia and CUD group are not receiving early care, resulting in higher long-term healthcare costs. Further investigations should examine what impact the timing of dementia and CUD diagnoses have on specific categories of inpatient and outpatient care in VA and community care facilities. [ABSTRACT FROM AUTHOR]

Objective: To describe rates of mild traumatic brain injury (mTBI) with and without concurrent posttraumatic stress disorder a sample of former and current military personnel, and to compare the factor structure of the Neurobehavioral Symptom Inventory (NSI) based on whether participants sustained mTBI with and without a positive posttraumatic stress disorder (PTSD) screen. Setting: Participants recruited and tested at 7 Veterans Affairs (VA) sites and 1 military training facility as part of a national, longitudinal study of mental health, physical, and cognitive outcomes among veterans and service members. Participants: Total of 1540 former and current military personnel with a history of combat exposure. Design: Cross-sectional analysis of observational data, including confirmatory factor analysis. Main Measures: NSI and PTSD Checklist for DSM-5 (PCL-5). Results: Most participants (81.5%) had a history of mTBI and almost half of these screened positive for PTSD (40.5%); only 23.9% of participants without a history of mTBI screened positive for PTSD. Participants with a history of mTBI reported higher elevations of NSI and PCL-5 symptoms compared with those without a history of mTBI. Confirmatory factor analyses of the NSI demonstrated good model fit using a 4-factor structure (somatosensory, affective, cognitive, and vestibular symptoms) among groups of participants both with and without a history of mTBI. Conclusion: Symptoms of mTBI and PTSD are strongly associated with each other among veterans and service members with a history of combat exposure. The 4-factor NSI structure is supported among participants with and without a history of mTBI. These findings suggest the potential benefit of a holistic approach to evaluation and treatment of veterans and service members with concurrent and elevated postconcussive and posttraumatic stress symptoms. [ABSTRACT FROM AUTHOR]

The Veterans Health Administration (VHA) Supported Employment (SE) program provides a highly individualized vocational rehabilitation service. To deliver SE, providers traditionally spend most of their time meeting in-person with veterans, employers, and clinicians. This article explores the impact of COVID-19 on the implementation of SE programs for veterans with a history of traumatic brain injury. In interviews with 29 SE providers and their nine Compensated Work Therapy managers across 10 VHA medical centers, we analyzed stakeholders' descriptions of how they adjusted their practices during the pandemic. These included switching from in-person to telephone or video communications, identifying new jobs created by COVID-19 conditions, focusing on work-from-home opportunities, and finding other modalities for collaborating with clinicians. Implications for rehabilitation practice are discussed. [ABSTRACT FROM AUTHOR]

Background: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). Methods: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. Results: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. Conclusions: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare. [ABSTRACT FROM AUTHOR]

Objective To identify any pilot and nonpilot site differences regarding current (1) provision of supported employment (SE) to veterans with traumatic brain injury (TBI); (2) staffing and communication between the SE and polytrauma/TBI teams; and (3) provider perceptions on facilitators and barriers to providing, and suggestions for improving, SE. Design Mixed methods cross-sectional survey study. Setting Veterans Health Administration SE programs. Participants Respondents (N=144) included 54 SE supervisors and 90 vocational rehabilitation specialists. Interventions Not applicable. Main Outcome Measures Web-based surveys of forced-choice and open-ended items included questions on SE team characteristics, communication with polytrauma/TBI teams, and experiences with providing SE to veterans with TBI history. Results SE was provided to veterans with TBI at 100% of pilot and 59.2% of nonpilot sites ( P =.09). However, vocational rehabilitation specialists at pilot sites reported that communication with the polytrauma/TBI team about SE referrals was more frequent than at nonpilot sites ( P =.003). In open-ended items, suggestions for improving SE were similar across pilot and nonpilot sites, and included increasing staffing for vocational rehabilitation specialists and case management, enhancing communication and education between SE and polytrauma/TBI teams, and expanding the scope of the SE program so that eligibility is based on employment support need, rather than diagnosis. Conclusions These findings may contribute to an evidence base that informs SE research and clinical directions on service provision, resource allocation, team integration efforts, and outreach to veterans with TBI who have employment support needs. [ABSTRACT FROM AUTHOR]