In a study conducted by Coronado, Xu, Basavaraju, et al., (2011), it was reported that on average, 53,000 people die annually from Traumatic Brain Injury (TBI) related complications making it the leading cause of death and disability in the US. Despite the evident decrease in TBI related deaths over the years, 21.9 to 19.4 and 19.3 to 17.8 deaths per 100,000 population between 1989-1998 and 1997-2007 respectively, TBI remains a major public health and socioeconomic issue in the US and worldwide (Coronado, Xu, Basavaraju et al. , 2011; Roozenbeek, Maas, & Menon, 2013). Traumatic Brain Injury also called Acquired Brain Injury is a medical condition that develops following a dysfunction in the brain cause by an external mechanical force such as a violent jolt or blow or penetration of the skull by an object. Millions of Americans suffer from brain injury with more than half of them serious enough for hospitalization. According to MedlinePlus (2017), over half of TBIs result from motor vehicle accidents, and military personnel are also noted to be at high risk. According to Roozenbeek, Maas, and Menon (2013), challenges in quantification of the burden from TBI is an outcome of inadequate and incomplete standardization and capture of incidence and outcome data, which partly owes to the variability in the definition of condition. These developments have complicated the developments of management strategies for people with TBI. This paper summarizes the findings in a study by Kinga and Wray (2012) pertaining to the management pf health needs of veterans with TBI.
Article Summary
The article by Kinga and Wray (2012), “ Managing behavioral health needs of veterans with Traumatic Brain Injury (TBI) in primary care ”, recognizes the epidemiological trends of TBI among Americans, including the emphasis placed on the veteran population. This article established that recent estimates indicate a 20% incidence of TBI among veterans. The findings corroborate those in Risdall and Menon (2011) which showed the incidence of military TBI to be on the rise, not just among veterans, but also among civilians in military war zones or terrorist incidents. The US involvement in the Iraq and Afghanistan conflicts is a recent notable case where blast-induced TBI is applicable. Clinical care strategies have been noted to be at per with civilian TBI, but protocols need to be revised to include novel techniques in the field of brain imaging to ensure aspects related to intracranial pressure are optimally addressed. According to MedlinePlus (2017), injuries such as TBI heal differently from other injuries, with recovery being a functional one and dependent on factors that remain uncertain. Therefore, the management of people with TBI is of critical importance to prevent progression of the condition into long-term complication or death.
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Under such circumstances, it is important understand the health needs of patients especially those comorbid with TBI. This was the objective of the article with specific focus on informing practice by developing recommendations for practitioners. In laying the groundwork for fulfilling its objective, the article begins by highlighting the high prevalence of TBI among US veterans, notably those who recently served in Iraq and Afghanistan and those serving in other high risk areas and stations. The current situation in regards to how placed primary care personnel are to cater for victims of TBI is highlighted, with specialist noted to readily available to offer unique and timely assessment, psychoeducation, and management intervention to veterans with TBI (Kinga & Wray, 2012). The role of primary care personnel in referrals to special care and mental health services, patient-centered care, support, and education is also highlighted. However, the article identifies that these services may not always prove to be the end as more health needs of veterans with TBI emerge due to existence of comorbid factors such as “psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse” (p. 376). Therefore, it is paramount to examine how such incidences can be addressed to ensure comprehensive care and management of veterans with TBI.
According to Kinga and Wray (2012), the severity of TBI may be dependent on the magnitude and nature of the external force and injury to the brain, which has a crucial role in determining the type and extent of comorbid factors and specific health needs for each patient. The first comorbid problem in veterans with TBI identified in the article, are symptoms of Cognitive Disturbance and Persistent Post-concussion, which are frequently reported by patients after concussions. The condition may be accompanied by a number of physical, emotional, sensory, and cognitive complaints including irritability, poor concentration, dizziness, sensitivity to light, and post traumatic headache, which may need specialized attention beside the TBI primary care guidelines. According to Kinga and Wray (2012), patients who manifest these symptoms are treated in primary care settings with non-steroidal analgesics, SSRI-class antidepressants, muscle relaxants, and other off-label agents. Neuropsychological referrals are also identified as an option where extended diagnosis is needed for quantification of cognitive deficits and guide treatment.
Another comorbid factor identified in the article is affective disturbance , which is manifested through irritability and minor anxiety in the acute phase, but they tend to resolve quickly. However, a much stronger link has been established between TBI and emotional distress. A significant number of veterans with TBI have been shown to have at least one formal psychiatric diagnosis, thought to be an outcome of injury induced physical or neurological changes. Depression has also been noted as the leading affective comorbid issues in civilians with TBI, justifying its inclusion as in health needs of patients with TBI. However, Post-traumatic Stress Disorder (PTSD) is the most widely recognized comorbid psychiatric condition in TBI. Management of affective conditions in TBI involves screening and assessment of anxiety and mood disorders, which Kinga and Wray (2012) recognize to be a common phenomenon among practitioners in primary care settings. Early detections is done by screening patients acutely after injury to establish the existence of pre-injury psychiatric conditions. Primary healthcare providers also practice brief interventions for general anxiety and depression, and PTSD is management via supported, evidence-based interventions such as exposure based interventions and cognitive processing therapy, delivered under special mental health settings.
Suicidality is another comorbid condition in TBI with evidence showing frequent suicide ideation and risk for self-harm, which have been reported to occur in over a quarter of TBI patients. Clinicians are advised to recognize the tendency for suicide and self-harm and institute interventions such as development and promotion of compensatory cognitive strategies and emotional coping skills. Teaching patients how to handle their mental and physical burdens and distancing themselves from specific problems have also been proved to work in such cases. Aggression, impulsivity, and other health concerns have also been linked with TBI. But most evidence points towards patients with moderate to severe TBI that required hospitalization, or with history of violence prior to injury (Kinga &Wray, 2012). The article identifies interventions for lethality as effective in the management of health needs of TBI patients with aggression and impulsivity.
Substance abuse has been examined as a precursor for TBI as several studies have linked it to pre-injury use. Among the patients admitted to hospitals following injury, over 50% are intoxicated and the rate of substance use among this population is estimated at 79% (Kinga & Wray, 2012). Alcohol is cited as the most abused, and the condition may be complicated by the fact that risk for subsequent TBI increases in cases where substance use was responsible for the initial injury. While evidence on civilians remains limited, alcohol use and abuse in bases and camps may be attributed to severity of TBI among veterans. Limited understanding exists in relation to screening of TBI patients for substance use. However, screening is practiced in primary care as a component of behavioural procedure, and tools are available to clinicians to attend to patients with such health needs. Referrals are also recommended for cases showing dependent substance use.
Kinga and Wray (2012) identified physical injury, chronic pain, and variability in the quality of life as other factors common among individuals with TBI, and over half of recent combat veterans have reported having these symptoms. The variation in these conditions makes there diagnosis and management a challenge, which is made complex by availability of little unique information on pain management. Other critical factors identified in the paper are needs of the family members and caregivers. Evidence shows that caregivers, especially of veterans, report increase in demands of individual with TBI compared to other populations, and their family members are vulnerable to anxiety and depression. This implies that management should focus on the workload on the patient and family members if need be.
Conclusion
In conclusion, the article gives recommendations for clinicians and practitioners while prioritizing screening for TBI, assessment of existing cognitive, affective, and somatic symptoms to ensure health needs of each individual are identified and addressed in a primary healthcare setting. This should be the first line of intervention to minimize progression of the injury into chronic state leading to death. Validation of patients concerns is highlighted as a necessary step to establish existence of conditions that may or may not be linked to TBI for effective management and treatment. Education of patients is also necessary, especially where psychiatric conditions are involved to promote self-care and awareness of one’s surroundings. In general, the article identifies health needs of veterans with TBI and corresponding management approaches that exist for each specific condition, and provides recommendations aimed at improving practice on the same.
References
Coronado, V. G., Xu, L., Basavaraju, S. V., McGuire, L. C., Wald, M. M., Faul, M. D., ... & Hemphill, J. D. (2011). Surveillance for traumatic brain injury-related deaths: United States, 1997-2007 (p. 32). Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention.
King, P. R., & Wray, L. O. (2012). Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care. Journal of clinical psychology in medical settings , 19 (4), 376-392.
MedlinePlus. (2017, February). Traumatic Brain Injury (TBI). Retrieved 25/02/2017 from: https://medlineplus.gov/traumaticbraininjury.html.
Risdall, J. E., & Menon, D. K. (2011). Traumatic brain injury. Philosophical Transactions of the Royal Society of London B: Biological Sciences, 366(1562), 241-250.
Roozenbeek, B., Maas, A. I., & Menon, D. K. (2013). Changing patterns in the epidemiology of traumatic brain injury. Nature Reviews Neurology , 9 (4), 231-236.
