By Ida Babakhanyan, Ph.D.
June 28, 2022

MHS Photo by Janet Aker

There are a number of symptoms that overlap with various psychological conditions and mild traumatic brain injury —commonly known as concussion.^{1, 2} Mental health conditions and mild TBI are also often simultaneously present in the same patient (also known as "comorbid"). ^3-5 The link between mild TBI and mental health conditions makes diagnosing and planning their treatments separately challenging. As a result, guidelines for treatment incorporate psychological interventions as part of the multi-disciplinary approach to TBI treatment within the Department of Defense.⁶ This article will discuss TBI and the prevalence of comorbid psychological conditions, the challenges of access to mental health resources for service members and veterans, and the importance of treating co-occurring psychological conditions within the scope of TBI rehabilitation care.

Mild TBI prognosis is impacted by comorbid psychological conditions such as posttraumatic stress disorder. A range of 15-30% of service members who complete a TBI rehabilitation program do not show improvement.^{7, 8} Analysis of treatment outcomes at the Intrepid Spirit Center Camp Pendleton shows that patients who present for TBI care with elevated PTSD symptoms, including hyperarousal and avoidance, are less likely to benefit from the TBI rehabilitation care.⁹ These challenges don't just have an immediate impact; they also affect long-term quality of life. Severity of mental health issues—up to 10 years after mild traumatic brain injury—is one of the most powerful predictors of long-term functioning in service members and veterans.¹⁰ Mental health needs left untreated and unaddressed can lead to a multitude of challenges for service members and their families. It is estimated that 10-40% of patients who experience mild TBI will develop emotional, cognitive, and behavioral difficulties which can persist and lead to stress, poor sleep, PTSD, depression, anxiety, unemployment, and reduced quality of life.^{1, 2} 

Stigma associated with mental health care is also a factor. Service members can be reluctant to seek care directly. Patients often feel it's more acceptable to seek treatment for their history of concussions than to ask for help for psychological distress related to combat, loss, and experiences of war. Consequently, service members and veterans with mental health needs are not seeking appropriate treatment.¹¹ As the conflicts in Iraq and Afghanistan came to an end and service members with two decades of war experience reach retirement, many of these service members come for TBI rehabilitation care, where their mental health needs can also be considered and treated given the limited resources available elsewhere. The evidence suggests that behavioral health interventions are a necessary part of treatment for service members and veterans with mild TBI and should be considered a primary intervention. ^{12, 13}

When should mental health treatment be considered?

• When TBI symptoms are not improving or getting worse following extensive rehabilitation
• When patients have a history of combat deployment(s) AND have:
  • Lost a friend(s) or teammate during combat operations
  • Experienced battlefield loss or trauma
  • Been involved in kinetic combat deployments (either self-reported or informed by military occupational specialties—or MOS— that put our warfighters in direct combat roles)
  • Indicated moral injury. A moral injury can occur in response to acting or witnessing behaviors that go against an individual's values and moral beliefs (https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
• If there is childhood history of abuse or trauma and the patient expresses readiness to explore and process these earlier traumas along with potential impacts of earlier traumas on most recent trauma
• When patients are currently going through major life stressors or transitions, such as divorce, and indicate interest in additional support or treatment to bolster coping mechanisms related to these stressors
• When there is indication of substance misuse—often an unhealthy coping mechanism used to lessen the sensation of psychological distress

By getting to know a service member's life experiences, we can provide a more comprehensive TBI treatment approach to address their needs. This can ultimately impact treatment response, improve return to duty rates, and provide a better prognosis for long term-outcomes.

Dr. Ida Babakhanyan is a licensed clinical psychologist who specializes in neuropsychology and TBI research through the Traumatic Brain Injury Center of Excellence.

References

1. Chen, C., Lin, M., Huda, M. and Tsai, P. (2020). Effects of cognitive behavioral therapy for adults with post-concussion syndrome: A systematic review and meta-analysis of randomized controlled trials. Journal of Psychosomatic Research. https://pubmed.ncbi.nlm.nih.gov/32712533/
2. Teo, S. H., Fong, K. N. K., Chen, Z., & Chung, R. C. K. (2020). Cognitive and Psychological Interventions for the Reduction of Post-Concussion Symptoms in Patients with Mild Traumatic Brain injury: A Systematic Review. Brain Injury, 34(10), 1305-1321. https://pubmed.ncbi.nlm.nih.gov/32772725/
3. Chin, D. L., & Zeber, J. E., (2019). Mental Health Outcomes among Military Service Members after Severe Injury in Combat and TBI. Military Medicine. https://pubmed.ncbi.nlm.nih.gov/31889174/
4. Farmer, C. M., Krull, H., Concannon, T. W., Simmons, M., Pillemer, F., Ruder, T., Parker, A., Purohit, M. P., Hiatt, L., Batorsky, B. S., & Hepner, K. A. (2017). Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System. Rand Health Q, https://pubmed.ncbi.nlm.nih.gov/28845349/
5. Cooper, D. B., Bunner, A. E., Kennedy, J. E., Balldin, V., Tate, D.F., Eapen, B.C., & Jaramillo, C. A. (2015). Treatment of Persistent Post-Concussive Symptoms after Mild Traumatic Brain Injury: A Systematic Review of Cognitive Rehabilitation and Behavioral Health Interventions in Military Service Members and Veterans. Brain Imaging and Behavior, 9, 403–420. https://pubmed.ncbi.nlm.nih.gov/26330376/
6. DeGraba, T. J., Williams, K., Koffman, R., Bell, J. L., Pettit, W., Kelly, J. P., Pickett, T. C. (2020). Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions. Frontiers in Neurology. https://pubmed.ncbi.nlm.nih.gov/33536993/
7. Miller, K. J., Kennedy, J. E., & Schwab, K. A., (2017). Long-Term Outcomes and Needs of Military Service Members after Noncombat-Related Traumatic Brain Injury. Military Medicine. doi: 10.7205/MILMED-D-16-00175.
8. Rabinowitz, A. R., Li, X., McCauley, S.R., Wilde, E. A., Barnes, A., Hanten, G., Mendez, D., McCarthy, J.J., & Levin, H.S. (2015). Prevalence and Predictors of Poor Recovery from Mild Traumatic Brain Injury. Journal of Neurotrauma. https://pubmed.ncbi.nlm.nih.gov/28291465/
9. >Ettenhofer, M., Stuessi, K., Babakhanyan, I., & Hungerford, L. (2021). When Treatment Fails: Factors Associated with Negative Outcomes from Military TBI Treatment Programs. Oral presentation at the Military Health Systems Research Symposium’s annual conference.
10. Lange, R. T., French, L. M., Lippa, S. M., Bailie, J. M., & Brickell, T. A. (2020). Posttraumatic Stress Disorder is a Stronger Predictor of Long-Term Neurobehavioral Outcomes than Traumatic Brain Injury Severity. Journal of Traumatic Stress. https://pubmed.ncbi.nlm.nih.gov/32379932/ (doi:10.1002/jts.22480)
11. Peck, B. S., & Parcell, E. S. (2021). Talking about Mental Health: Dilemmas U.S. Military Service Members and Spouses Experience Post Deployment. Journal of Family Communication. https://www.tandfonline.com/doi/abs/10.1080/15267431.2021.1887195
12. Prince, & Bruhns, M. E. (2017). Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology. Brain Sciences. https://pubmed.ncbi.nlm.nih.gov/28817065/
13. Cooper, D. B., Bowles, A.O. Kennedy, J. E., Curtiss, G., French, L. M., Tate, D.F., Vanderploeg, R.D. (2017). Cognitive Rehabilitation for Military Service Members with Mild Traumatic Brain Injury: A Randomized Clinical Trial. Journal of Head Trauma Rehabilitation. https://pubmed.ncbi.nlm.nih.gov/27603763/