Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury

The Evaluation and Management of Concussion to Optimize Safe Recovery

Concussion is a mild traumatic brain injury causing temporary neurologic dysfunction. Symptoms following concussion are variable and generally are expected to resolve within about 1 month, but some patients experience persistent and prolonged symptoms. An early return to safe, symptom-limited activity is now favored, using targeted rehabilitation and treatments. Accommodations may be needed to facilitate return-to-school and work following concussion. Athletes should not be cleared for a full return to sport until they have recovered from a concussion and completed a return-to-play progression, in addition to returning to work/school fully.

Acceptance and Commitment Therapy is feasible for people with acquired brain injury: A process evaluation of the BrainACT treatment

OBJECTIVE

To evaluate the feasibility of Acceptance and Commitment Therapy for people with acquired brain injury.

DESIGN

A process evaluation of the BrainACT treatment was conducted alongside a randomised controlled trial.

SETTING

Psychology departments of hospitals and rehabilitation centres.

SUBJECTS

Tweny-seven participants with acquired brain injury and 11 therapists.

INTERVENTION

BrainACT is an Acceptance and Commitment Therapy adapted for the needs and possible cognitive deficits of people with acquired brain injury, provided in eight one-hour face-to-face or video-conference sessions.

MEASUREMENTS

The attendance and compliance rates, engagement, satisfaction, and perceived barriers and facilitators for delivery in clinical practice were investigated using semi-structured interviews with participants and therapists and therapy logs.

RESULTS

212 of the 216 sessions in total were attended and 534 of the 715 protocol elements across participants and sessions were delivered. Participants were motivated and engaged. Participants and therapists were satisfied with the intervention and participants reported to have implemented skills in their daily routines acquired during therapy. Key strengths are the structure provided with the bus of life metaphor, the experiential nature of the intervention, and the materials and homework. Participants and therapists often preferred face-to-face sessions, however, when needed video-conferencing is a good alternative.

CONCLUSION

BrainACT is a feasible intervention for people with anxiety and depressive symptoms following acquired brain injury. However, when the content of the intervention is too extensive, we recommend adding two extra sessions.

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study

INTRODUCTION

This protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve psychosocial adjustment to TBI across different phases of injury (acute, postacute, and chronic), and (2) undertake an evaluation of efficacy, acceptability, and feasibility.

METHODS AND ANALYSIS

A three-stage mixed-methods research design will be used. The study will be undertaken across four postacute community-based neurorehabilitation and disability support services in Western Australia. Stage 1 (interviews and surveys) will use consumer-driven qualitative methodology to: (1) understand the recovery experiences and psychosocial challenges of people with TBI over key stages (acute, postacute, and chronic), and (2) identify required areas of psychosocial support to inform the psychoeducation platform development. Stage 2 (development) will use a Delphi expert consensus method to: (1) determine the final psychoeducation modules, and (2) perform acceptance testing of the myTBI platform. Finally, stage 3 (evaluation) will be a randomised stepped-wedge trial to evaluate efficacy, acceptability, and feasibility. Outcomes will be measured at baseline, postintervention, follow-up, and at final discharge from services. Change in outcomes will be analysed using multilevel mixed-effects modelling. Follow-up surveys will be conducted to evaluate acceptability and feasibility.

ETHICS AND DISSEMINATION

Ethics approval was granted by North Metropolitan Health Service Mental Health Research Ethics and Governance Office (RGS0000005877). Study findings will be relevant to clinicians, researchers, and organisations who are seeking a cost-effective solution to deliver ongoing psychoeducation and support to individuals with TBI across the recovery journey.

TRIAL REGISTRATION NUMBER

ACTRN12623000990628.

The Effectiveness of Brain Injury Family Intervention in Improving the Psychological Well-Being of Caregivers of Patients With Traumatic Brain Injury: Protocol for a Randomized Controlled Trial

BACKGROUND

Globally, traumatic brain injury (TBI) is recognized as one of the most significant contributors to mortality and disability. Most of the patients who have experienced TBI will be discharged home and reunited with their families or primary caregivers. The degree of severity of their reliance on caregivers varies. Therefore, the task of delivering essential care to the patients becomes demanding for the caregivers. A significant proportion of caregivers expressed considerable burden, distress, and discontentment with their lives. Therefore, it is critical to comprehend the dynamic of TBI and caregivers to optimize patient care, rehabilitation, and administration. The effectiveness of the Brain Injury Family Intervention (BIFI) program tailored for caregivers of patients with TBI has been widely proven in Western countries. However, the impact is less clear among caregivers of patients with TBI in Malaysia.

OBJECTIVE

This study aims to assess the effectiveness of BIFI in reducing emotional distress and burden of care, fulfilling the needs, and increasing the life satisfaction of caregivers of patients with TBI at government hospitals in Malaysia.

METHODS

This is a 2-arm, single-blinded, randomized controlled trial. It will be conducted at Hospital Rehabilitasi Cheras and Hospital Sungai Buloh. In total, 100 caregivers of patients with TBI attending the neurorehabilitation unit will be randomized equally to the intervention and control groups. The intervention group will undergo the BIFI program, whereas the control group will receive standard treatment. Caregivers aged ≥18 years, caring for patients who have completed >3 months after the injury, are eligible to participate. The BIFI program will be scheduled for 5 sessions as recommended by the developer of the module. Each session will take approximately 90 to 120 minutes. The participants are required to attend all 5 sessions. A total of 5 weeks is needed for each group to complete the program. Self-reported questionnaires (ie, Beck Depression Inventory, Positive and Negative Affect Schedule, Caregiver Strain Index, Satisfaction With Life Scale, and Family Needs Questionnaire) will be collected at baseline, immediately after the intervention program, at 3-month follow-up, and at 6-month follow-up. The primary end point is the caregivers' emotional distress.

RESULTS

The participant recruitment process began in January 2019 and was completed in December 2020. In total, 100 participants were enrolled in this study, of whom 70 (70%) caregivers are women and 30 (30%) are men. We are currently at the final stage of data analysis. The results of this study are expected to be published in 2024. Ethics approval has been obtained.

CONCLUSIONS

It is expected that the psychological well-being of the intervention group will be better compared with that of the control group after the intervention at 3-month follow-up and at 6-month follow-up.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20180809040746N1; https://irct.behdasht.gov.ir/trial/33286.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/53692.

Nature and correlates of self-esteem in young adult survivors of childhood traumatic brain injury

Despite growing research linking childhood traumatic brain injury (TBI) with reduced wellbeing, self-esteem, and psycho-social health, very few studies have examined self-esteem and its correlates in young adult survivors of childhood TBI. This very-long-term follow-up study evaluated self-esteem in 29 young adults with a history of childhood TBI (M time since injury = 13.84 years; SD = 0.74), and 10 typically developing controls (TDCs). All participants were originally recruited into a larger, longitudinal case-control study between 2007 and 2010. In the current follow-up study, both groups completed well-validated measures of self-esteem and mental health in young adulthood. Although group means for self-esteem did not significantly differ between TBI and TDC groups, a higher proportion of TBI participants rated their self-esteem in the clinical range (TBI group = 17%; TDC group = 0%). While self-esteem was not significantly associated with injury or pre-injury child or family characteristics, lower self-esteem was significantly correlated with greater concurrent feelings of loneliness (p = 0.007) and higher concurrent mood symptoms (p < 0.001).Our results suggest that social isolation and low mood may represent meaningful targets for psycho-social interventions to address poor self-worth in young adults with a history of childhood TBI.

Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis

BACKGROUND

Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature.

METHODS

Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome.

RESULTS

Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT.

CONCLUSION

This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.

Biopsychosocial correlates of fatigue in young adult survivors of childhood traumatic brain injury: A prospective cohort study

This prospective cohort study aimed to evaluate the potential role of injury, socio-demographic and individual psychological factors in predicting long-term fatigue outcomes in young adult survivors of childhood TBI at 16-years post-injury. The study included 51 young adults diagnosed with childhood TBI from 2-12 years of age. Twenty age-and-sex-matched controls were included for comparison. Findings showed that almost one-in-four TBI participants (24%) endorsed clinically elevated fatigue at 16-years post-injury. Despite the relatively large proportion of TBI participants endorsing clinically significant fatigue, group comparisons revealed that the TBI and control groups did not significantly differ on fatigue symptom severity or rates of clinically elevated fatigue. For the TBI group, post-injury fatigue was significantly associated with socio-demographic and psychological factors, including lower educational level, higher depression symptom severity, and more frequent substance use. Higher fatigue was also associated with lower self-reported quality of life (QoL) in the physical, psychological, and environmental domains, even after controlling for depressive symptom severity, socio-demographic, and injury-related factors. Overall, findings show that a substantial proportion of young adults with a history of childhood TBI experience clinically elevated fatigue at 16-years post-injury. Identification and treatment of modifiable risk-factors (e.g. depression symptoms, substance use) has potential to reduce fatigue.

Addressing Cyberscams and Acquired Brain Injury ("I Desperately Need to Know What to Do"): Qualitative Exploration of Clinicians' and Service Providers' Perspectives

BACKGROUND

People with acquired brain injury (ABI) may be more susceptible to scams owing to postinjury cognitive and psychosocial consequences. Cyberscams result in financial loss and debilitating psychological impacts such as shame and mistrust, interference with neurorehabilitation, and reduced independence. Despite these significant consequences, there are no psychological treatments to support cyberscam survivors. There is limited evidence regarding how the current workforce is addressing post-ABI cyberscams.

OBJECTIVE

This study aims to understand the perspectives and needs of clinicians and service providers in addressing post-ABI cyberscams.

METHODS

Overall, 20 multidisciplinary clinicians and service providers were recruited through purposive sampling across Australia. Semistructured interviews explored post-ABI scam experiences and vulnerabilities, treatments and their efficacy, and recommendations for future cybersafety recovery interventions. Reflexive thematic analysis was used.

RESULTS

In total, 8 themes encompassing a biopsychosocial understanding of scam vulnerabilities and impacts were identified: "genuine lack of awareness: cognitive-executive difficulties"; "not coping with the loss of it all"; "needing trust and connection"; "strong reactions of trusted others"; "nothing structured to do"; "financial stress and independence"; "cyberability"; and "scammer persuasion." Each theme informed clinical recommendations including the need to provide psychological and cognitive support, enhance financial and cybersafety skills, promote meaningful social engagement, and foster collaboration between families and clinical support teams.

CONCLUSIONS

The multifaceted range of scam vulnerabilities and impacts highlighted the need for individualized, comprehensive, and targeted treatments using a biopsychosocial approach to enable cyberscam recovery among people with ABI. These findings will guide the development of a co-designed intervention.

Conservative Management of Acute Sports-Related Concussions: A Narrative Review

This review explores the application of the conservative management model for pain to sports-related concussions (SRCs), framing concussions as a distinct form of pain syndrome with a pathophysiological foundation in central sensitization. Drawing parallels with proven pain management models, we underscore the significance of a proactive approach to concussion management. Recognizing concussions as a pain syndrome allows for the tailoring of interventions in alignment with conservative principles. This review first covers the epidemiology and controversies surrounding prolonged concussion recovery and persistent post-concussion symptoms (PPCS). Next, the pathophysiology of concussions is presented within the central sensitization framework, emphasizing the need for early intervention to mitigate the neuroplastic changes that lead to heightened pain sensitivity. Five components of the central sensitization process specific to concussion injuries are highlighted as targets for conservative interventions in the acute period: peripheral sensitization, cerebral metabolic dysfunction, neuroinflammation, glymphatic system dysfunction, and pain catastrophizing. These proactive interventions are emphasized as pivotal in accelerating concussion recovery and reducing the risk of prolonged symptoms and PPCS, in line with the philosophy of conservative management.

Utility of in-session assessments during cognitive behavioral therapy for depression after traumatic brain injury: Results from a randomized controlled trial

BACKGROUND

The development of depression after moderate to severe traumatic brain injury (TBI) is common. Cognitive-behavioral therapy (CBT) can be used to treat post-TBI depression, but the symptoms response is poorly described.

OBJECTIVE

This secondary analysis assessed: (1) the trajectory of depression symptoms up to 12 sessions of CBT, (2) which depressive symptom clusters were responsive to in-person and phone CBT, and (3) whether interim depression thresholds predict 16-week treatment response.

METHOD

This secondary analysis of the IRB-approved Life Improvement Following Traumatic Brain Injury trial included 100 adults with major depressive disorder (MDD) within ten years of moderate to severe traumatic brain injury from throughout the US. We used a combination of descriptive, graphical, and diagnostic accuracy methods.

RESULTS

Cardinal and cognitive-affective symptom clusters improved most from CBT over 16 weeks. At 8 and 16 weeks, the most responsive individual symptoms were anhedonia, depressed mood, and fatigue; the least responsive were sleep and appetite. PHQ-9 thresholds with a Negative Predictive Value greater than 0.7 for sessions 6, 7, and 8 were, respectively: >15, >10, and >9.

CONCLUSION

In-person and phone CBT led to similar symptom responses during treatment. Additionally, using PHQ-9 thresholds for predicting intervention response within eight sessions may help identify the need for treatment adjustments.

Environmental Enrichment for Stroke and Traumatic Brain Injury: Mechanisms and Translational Implications

Acquired brain injuries, such as ischemic stroke, intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), can cause severe neurologic damage and even death. Unfortunately, currently, there are no effective and safe treatments to reduce the high disability and mortality rates associated with these brain injuries. However, environmental enrichment (EE) is an emerging approach to treating and rehabilitating acquired brain injuries by promoting motor, sensory, and social stimulation. Multiple preclinical studies have shown that EE benefits functional recovery, including improved motor and cognitive function and psychological benefits mediated by complex protective signaling pathways. This article provides an overview of the enriched environment protocols used in animal models of ischemic stroke, ICH, and TBI, as well as relevant clinical studies, with a particular focus on ischemic stroke. Additionally, we explored studies of animals with stroke and TBI exposed to EE alone or in combination with multiple drugs and other rehabilitation modalities. Finally, we discuss the potential clinical applications of EE in future brain rehabilitation therapy and the molecular and cellular changes caused by EE in rodents with stroke or TBI. This article aims to advance preclinical and clinical research on EE rehabilitation therapy for acquired brain injury. © 2024 American Physiological Society. Compr Physiol 14:5291-5323, 2024.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.

The needs of families caring for patients with traumatic brain injury: a scoping review

PURPOSE

This scoping review was conducted to synthesize existing literature into a map of the common needs of families caring for patients with traumatic brain injury (TBI) at home.

MATERIALS AND METHODS

A systematic search of studies published between January 2012 and December 2022 was conducted across databases. The selected studies reported the needs or unmet needs of patients with TBI and/or their family caregivers (FCs).

RESULTS

A total of 12 publications were identified. The results suggest that the common needs of families caring for patients with TBI at home include: information about TBI as a disease; information about the continuum of TBI healthcare services; information about adaptive technologies; education and skilling of FCs; psychological support and counseling; physical and occupational therapy services; follow-up care and transitional care management; respite care; peer support; financial assistance, advocacy, and legal services; emotional support from the family and community; and assistance with physical patient care and instrumental activities of daily living.

CONCLUSION

The mapped needs provide insight into supportive interventions required to enhance the health outcomes of patients with TBI and their families during and after rehabilitation. The needs also highlight directions for research and healthcare services for patients with TBI.

Network analysis of anxiety and depressive symptoms one year after traumatic brain injury

We used network analysis to explore interrelationships between anxiety and depressive symptoms after traumatic brain injury (TBI). At one year post-injury, 882 adult civilians who received inpatient rehabilitation for moderate-severe TBI self-reported anxiety and depressive symptoms (Hospital Anxiety and Depression Scale). The severity of TBI was characterized acutely by the duration of post-traumatic amnesia (PTA), and TBI-related functional disability was rated by an examiner at one year post-injury using a structured interview (Glasgow Outcome Scale - Extended). We estimated two cross-sectional, partial correlation networks. In the first network, anxiety and depressive symptoms were densely interconnected yet formed three distinct, data-driven communities: Hyperarousal, Depression, and General Distress. Worrying thoughts and having difficulty relaxing were amongst the most central symptoms, showing strong connections with other symptoms within and between communities. In the second network, TBI severity was directly negatively associated with hyperarousal symptoms but indirectly positively associated with depressive symptoms via greater functional disability. The results highlight the potential utility of simultaneous, transdiagnostic assessment and treatment of anxiety and depressive symptoms after moderate-severe TBI. Worrying thoughts, having difficulty relaxing, and the experience of disability may be important targets for treatment, although future studies examining symptom dynamics within individuals and over time are required.

Bifactor analysis of the Hospital Anxiety and Depression Scale (HADS) in individuals with traumatic brain injury

Anxiety and depression symptoms are commonly experienced after traumatic brain injury (TBI). However, studies validating measures of anxiety and depression for this population are scarce. Using novel indices derived from symmetrical bifactor modeling, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) reliably differentiated anxiety and depression in 874 adults with moderate-severe TBI. The results showed that there was a dominant general distress factor accounting for 84% of the systematic variance in HADS total scores. The specific anxiety and depression factors accounted for little residual variance in the respective subscale scores (12% and 20%, respectively), and overall, minimal bias was found in using the HADS as a unidimensional measure. Further, in a subsample of 184 participants, the HADS subscales did not clearly discriminate between formal anxiety and depressive disorders diagnosed via clinical interview. Results were consistent when accounting for degree of disability, non-English speaking background, and time post-injury. In conclusion, variance in HADS scores after TBI predominately reflects a single underlying latent variable. Clinicians and researchers should exercise caution in interpreting the individual HADS subscales and instead consider using the total score as a more valid, transdiagnostic measure of general distress in individuals with TBI.

A Cost-Effective Analysis of Motivational Interviewing with Palliative Care Versus Usual Care: Results from the Living Well Project

Little is known about the impact of early palliative care (EPC) combined with motivational interviewing (MI) for persons living with AIDS (PWA). We compared the cost and quality-adjusted life-years (QALYs) of EPC + MI (n = 61) versus usual care (UC) (n = 60) for patients with AIDS, not on antiretroviral medications, enrolled into the Living Well Project trial. Data on clinic, emergency department, and hospital visits were collected through self-report and billing records. Risk-adjusted average annual health care costs were estimated using a generalized linear model with a gamma log-link function. QALYs were calculated using the SF-12v2. Cost-effectiveness was defined as cost per QALY gained. Estimated intervention costs were $165 per participant. EPC + MI reduced costs by 33% (AOR = 0.67; CI 95%: 0.15, 0.93). QALYs did not differ between groups. Results suggest EPC + MI for PWA is cost-saving and maintains quality of life compared to UC due to reduced hospital and ED costs.

Motor vehicle crash concussion mechanism displays a greater total number of symptoms and greater affective symptom severity but no neurocognitive differences compared with sport-related concussion mechanism

Previous research among adolescents has shown differences in symptoms and neurocognitive performance between sport-related (SRC) and motor vehicle crash (MVC) concussion mechanisms. Limited research has focused on young adults. The purpose of our study was to compare symptoms, balance, and neurocognitive performance between SRC and MVC mechanisms in young adults. Forty-three (58.1% female, age = 25.5 ± 3.2 years, days since concussion = 12.8 ± 12.7) and 26 (76.9% female, age = 24.1 ± 5.6 years, days since concussion = 12.6 ± 8.3) individuals with an SRC and MVC mechanism, respectively, participated. Primary outcome measures included the total number, severity, cluster (disorientation, migraine, lethargy, and affective) of post-concussion symptoms endorsed, Balance Error Scoring System (BESS), and CNS Vital Signs scores. Clusters are subgroups of symptoms used for targeted rehabilitation. We used independent t-tests and Mann-Whitney U tests to compare symptoms, BESS, and neurocognitive performance. Cliff's Delta effect size was interpreted as negligible (<0.15), small (0.15-0.33), medium (0.34-0.47), and large (≥0.48). There were no group differences for any demographic factors or preexisting conditions (p-range = 0.112-0.991). Participants with an MVC mechanism reported a greater number of total post-concussion symptoms (p = 0.025, Cliff's Delta = 0.32) and a more severe affective symptom cluster (p = 0.010, Cliff's Delta = 0.37). There were no group differences for BESS or neurocognitive performance after correcting for multiple comparisons. The MVC mechanism resulted in a greater total symptom burden relative to the SRC mechanism. Medical practitioners and individuals experiencing a concussion should know that concussions are heterogeneous within and across various mechanisms.

Factors predicting first appointment attendance at a traumatic brain injury clinical neuropsychology outpatient clinic: a logistic regression analysis

BACKGROUND

The purpose of our study was to investigate factors which predicted first appointment attendance within a traumatic brain injury (TBI) neuropsychology outpatient department.

MATERIALS AND METHODS

A newly introduced telephone triaging system was implemented in a clinical neuropsychology service for individuals with a TBI. The effects of receiving a triage telephone call, amongst other variables, were analysed as predictors of attendance at the first face-to-face clinic appointment. The data from 161 individuals were analysed using routine patient information collected by the clinical neuropsychology service. Logistic regression analyses were performed to investigate predictors of first appointment clinic attendance.

RESULTS

Logistic regression analyses identified higher age, shorter waiting times, and answering the triage call as potential predictors of attendance, highlighting where the service might focus efforts to facilitate attendance.

CONCLUSIONS

Both patient and service factors were found to be significant predictors of patient attendance. Further service evaluation could explore patients' experiences of triage telephone calls, and investigate relationships between waiting times and neuropsychological outcomes.IMPLICATIONS FOR REHABILITATIONIdentifying predictors of appointment attendance can allow the service to focus on the needs of particular patient groups.Implementing a telephone triage initiative had positive effects, both on waiting times and efficient use of face-to-face clinic time.The analysis highlighted the need to think about better ways of reaching out to younger individuals and those who have waited longer to attend appointments, who are less likely to attend once invited.

A Systematic Review of Treatments of Post-Concussion Symptoms

Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.

Effect of Cognitive Behavioral Therapy on Stress Disorder, Cognitive Function, Motor Function, and Daily Living Ability of Patients with a Traumatic Brain Injury

Purpose

The aim of the study is to observe the effects of cognitive behavioral therapy on stress disorder, cognitive function, motor function, and daily living ability of traumatic brain injury (TBI) patients.

Methods

84 patients with TBI admitted to our hospital from June 2019 to May 2021 were selected as the research subjects. They were divided into a control group (from June 2019 to May 2020) and an observation group (from June 2020 to May 2021), with 42 cases in each group. The control group received routine intervention; the observation group received cognitive behavioral therapy on the basis of the control group. Before and after intervention, the posttraumatic stress disorder (PTSD), cognitive function, motor function, and daily living ability of the two groups were observed.

Results

After intervention, the PTSD-self-rating scale (PTSD-SS) scores of both groups were lower than those before intervention, and the PTSD-SS scores of the observation group were lower than those of the control group (P < 0.05). After intervention, the scores of the Montreal cognitive assessment (MoCA) scale, Fugl-Meyer assessment (FMA), and modified Barthel index (MBI) in both groups were higher than those before intervention, and the scores of MoCA, FMA, and MBI in the observation group were higher than those in the control group (P < 0.05).

Conclusion

The application of cognitive behavioral therapy to TBI patients is beneficial to reduce the degree of PTSD and improve cognitive function, motor function, and daily living ability, which is worthy of clinical application.

Predictors of Treatment Response to a Psychoeducational Intervention for Anger in Chronic Moderate-Severe Traumatic Brain Injury

OBJECTIVE

The investigators examined predictors of treatment response to anger self-management training (ASMT) among patients with chronic moderate-severe traumatic brain injury (TBI).

METHODS

A multicenter randomized clinical trial comprising 90 participants with moderate-severe TBI was conducted. Fifty-four participants who were randomly assigned to receive active treatment and provided complete data were included in the current secondary analysis. Model averaging was used to examine the relative importance and significance of pretreatment variables for predicting change during treatment. Dependent variables were pre- to posttreatment changes in trait anger (TA) and anger expression-out (AX-O) subscale scores of the State-Trait Anger Expression Inventory-Revised. Predictors included demographic, injury-related, and neuropsychological variables, including both objective and self-reported measures of executive function, as well as readiness to change and participation of a significant other in treatment.

RESULTS

Change in both dependent variables was predicted by higher baseline anger. Greater change in TA was additionally predicted by White race, higher education, shorter posttraumatic amnesia, and worse self-reported (but not objectively measured) executive dysfunction; the latter predictor may have indicated better self-awareness. Greater change in AX-O was additionally predicted by better episodic memory and, paradoxically, lower readiness to change.

CONCLUSIONS

Further research should focus on adapting psychoeducational anger treatments to better serve the diverse populations affected by moderate-severe TBI. These findings suggest that providing memory aids to support the use of learned strategies after treatment cessation would be beneficial. Further research should also examine the construct of readiness to change and specific aspects of executive function that may affect treatment response in psychoeducational treatments. These findings were derived from only one model of anger intervention, and the relevance to other treatment approaches cannot be assumed.

Technology-Delivered Motivational Interviewing to Improve Health Outcomes in Patients with Chronic Conditions. A Systematic Review of the Literature

AIM

Provide an overview of remote Motivational Interviewing (MI) interventions for chronically-ill patients, and understand their degree of effectiveness on different health outcomes.

METHODS AND RESULTS

A systematic review with meta-analysis was conducted using the following databases: PubMed, CINAHL, PsychInfo, and Web of Science. Eligibility criteria included studies that administered remote MI alone or in combination with other remote approaches. A narrative synthesis and two meta-analyses were performed. Fifteen studies met the inclusion criteria. MI administration almost exclusively occurred by telephone and individual sessions. Eight studies reported treatment fidelity aspects, and four declared adopting a theoretical framework. Most targeted outcomes were therapeutic adherence, physical activity, depression, quality of life, and mortality. Risk of bias varied markedly, with the largest source resulting from selection process and intervention performance. The two meta-analyses indicated a significant effect of MI on depression (Standardized Mean Difference = -0.20, 95%CI: -0.34, -0.05, Z = 2.73, p = 0.006, I2 = 0%), and no effect of MI on glycosylated hemoglobin (Mean Difference = -0.02, 95%CI: -0.48, 0.45), p = 0.94, I2 = 84%).

CONCLUSION

Remote MI can be a promising approach for improving depression in chronic disease patients. However, studies are inconclusive due to risks of bias, heterogeneity, and lack of reporting of interventionist's training, treatment fidelity, and theoretical frameworks' use. More studies with solid designs are needed to inform clinical decision-making and research.

Treatment Patterns of Anxiety and Posttraumatic Stress Disorder Following Traumatic Brain Injury

OBJECTIVE

Symptoms of mental disorders are common, are underrecognized, and contribute to worse outcomes after traumatic brain injury (TBI). Post-TBI, prevalence of anxiety disorders and prevalence of posttraumatic stress disorder (PTSD) are comparable with that of depression, but evidence-based treatment guidelines are lacking. The investigators examined psychotropic medication use and psychotherapy patterns among individuals diagnosed with anxiety disorders and PTSD post-TBI.

METHODS

Administrative claims data were used to compare the prevalence and patterns of pharmacotherapy and psychotherapy utilization among individuals diagnosed with an anxiety disorder or PTSD post-TBI.

RESULTS

Among 207,354 adults with TBI, prevalence of anxiety disorders was 20.5%, and prevalence of PTSD was 0.6% post-TBI. Receipt of pharmacotherapy pre- and post-TBI (anxiety: pre-TBI=58.4%, post-TBI=76.2%; PTSD: pre-TBI=53.7%, post-TBI=75.2%) was considerably more common than receipt of psychotherapy (anxiety: pre-TBI=5.8%, post-TBI=19.1%; PTSD: pre-TBI=11.2%, post-TBI=36.0%). Individuals diagnosed with anxiety were 66% less likely to receive psychotherapy compared with individuals diagnosed with PTSD, although engagement in psychotherapy decreased faster over time among those with PTSD. Overall, psychotropic medication use and rates of antidepressant prescription use in the anxiety group were higher compared with those in the PTSD group. Benzodiazepines were the second most commonly prescribed medication class in the anxiety group, even though judicious use is warranted post-TBI.

CONCLUSIONS

Further exploration of differences and risks associated with pharmacotherapy for anxiety and PTSD post-TBI is warranted to refine treatment guidelines. The low level of psychotherapy engagement suggests that barriers and facilitators to psychotherapy utilization post-TBI should be examined in future studies.

Mood Disorders in Young People With Acquired Brain Injury: An Integrated Model

Purpose/Objective

Young people with paediatric acquired brain injury (pABI) are twice as likely to develop a mood disorder as their peers, frequently have significant unmet socio-emotional needs, and are at over double the risk of going on to use adult mental health services. Recent years have seen significant advances in the development of interventions for young people with mood disorders. However, evidence-based approaches to mood disorders in pABI are lacking and surprisingly little work has evaluated clinical and neuro-developmental models of mood disorders in this population.

Method

We review the literature regarding key mechanisms hypothesised to account for the increased vulnerability to mood disorders in pABI: First, we summarise the direct neurocognitive consequences of pABI, considering the key areas of the brain implicated in vulnerability to mood disorders within a neurodevelopmental framework. Second, we outline five key factors that contribute to the heightened prevalence of mood disorders in young people following ABI. Finally, we synthesise these, integrating neuro-cognitive, developmental and systemic factors to guide clinical formulation.

Results and Implications

We present a framework that synthesises the key mechanisms identified in our review, namely the direct effects of pABI, neurocognitive and neuroendocrine factors implicated in mood and anxiety disorders, maladaptive neuroplasticity and trauma, structural and systemic factors, and psychological adjustment and developmental context. This framework is the first attempt to provide integrated guidance on the multiple factors that contribute to elevated life-long risk of mood disorders following pABI.

Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines

There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild–severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

Psychotherapeutic Intervention for Adults With Acquired Brain Injury: A Case Study Using BackUp

A moderate-to-severe acquired brain injury (ABI) can have tremendous lifelong consequences for ABI-survivors and their families. Despite rehabilitation practice since the 1980s aspiring to a dynamic, coherent and holistic approach, the psychological dimension still seems to be a challenge and research has revealed persisting psychosocial impairments after ABI. Therefore, we developed BackUp©, a manual based short term psychological intervention for adults with ABI. This study explores the effect of the intervention though a small feasibility study, employing a single case design. One client received the intervention. Self-report measures were collected, and a semi structured interview was conducted. While results from pre, post and follow-up measures do not show clear positive results, the interview reveals positive experiences and the participant reported achieving his therapy goal. This case study provides support for a psychological intervention to support the psychological rehabilitation after an ABI.

Does Integrating Cognitive and Psychological Interventions Enhance Wellbeing After Acquired Brain Injury? Study Protocol for a Phase II Randomized Controlled Trial of the VaLiANT (Valued Living After Neurological Trauma) Group Program

Background and Objectives

Cognitive and emotional changes affect the majority of individuals with acquired brain injury (ABI) and are associated with poorer outcomes. The evidence for “siloed” rehabilitation approaches targeting cognition and mood separately remains mixed. Valued living (i.e., acting consistently with personal values) is associated with better psychological functioning and participation in work and other productive activities. Rehabilitation interventions that concurrently address cognitive and emotional barriers to valued living may therefore result in improved outcomes. VaLiANT (Valued Living After Neurological Trauma) is an 8-week group intervention developed by our team, which uniquely combines cognitive rehabilitation and psychological therapy to improve wellbeing and meaningful participation (i.e., valued living) following ABI.

Method

This protocol describes the design and implementation of a Phase II parallel-group randomized controlled trial with blinded outcome assessors, to evaluate the potential efficacy of VaLiANT and the feasibility of a Phase III trial. Participants are adults with a history of ABI at least 3 months prior to study entry, who experience cognitive and/or emotional difficulties and associated reduced participation in valued activities. Random allocation to the treatment condition (8-week VaLiANT group program) or a usual care waitlist control condition occurs at a 2:1 treatment: control ratio. The primary outcome is wellbeing, measured by the Warwick-Edinburgh Mental Wellbeing Scale. Secondary outcomes include measures of valued living, mood, cognitive complaints, quality of life, community participation, post-traumatic growth, and self-efficacy. All measures are collected across three time points by blinded assessors (baseline, 8-week follow-up, 16-week follow-up). Trial feasibility will be evaluated against recruitment rates, drop-out rates, intervention acceptability, and treatment fidelity (manual adherence and therapist competence).

Discussion

This trial will extend current knowledge on how to improve long-term outcomes following ABI by evaluating an innovative integrated, multi-domain approach to rehabilitation concurrently addressing cognitive and emotional barriers to participation in meaningful life roles.

Intranasal delivery of interleukin-4 attenuates chronic cognitive deficits via beneficial microglial responses in experimental traumatic brain injury

Traumatic brain injury (TBI) is commonly followed by long-term cognitive deficits that severely impact the quality of life in survivors. Recent studies suggest that microglial/macrophage (Mi/MΦ) polarization could have multidimensional impacts on post-TBI neurological outcomes. Here, we report that repetitive intranasal delivery of interleukin-4 (IL-4) nanoparticles for 4 weeks after controlled cortical impact improved hippocampus-dependent spatial and non-spatial cognitive functions in adult C57BL6 mice, as assessed by a battery of neurobehavioral tests for up to 5 weeks after TBI. IL-4-elicited enhancement of cognitive functions was associated with improvements in the integrity of the hippocampus at the functional (e.g., long-term potentiation) and structural levels (CA3 neuronal loss, diffusion tensor imaging of white matter tracts, etc.). Mechanistically, IL-4 increased the expression of PPARγ and arginase-1 within Mi/MΦ, thereby driving microglia toward a global inflammation-resolving phenotype. Notably, IL-4 failed to shift microglial phenotype after TBI in Mi/MΦ-specific PPARγ knockout (mKO) mice, indicating an obligatory role for PPARγ in IL-4-induced Mi/MΦ polarization. Accordingly, post-TBI treatment with IL-4 failed to improve hippocampal integrity or cognitive functions in PPARγ mKO mice. These results demonstrate that administration of exogenous IL-4 nanoparticles stimulates PPARγ-dependent beneficial Mi/MΦ responses, and improves hippocampal function after TBI.

A single-case experimental evaluation of a new group-based intervention to enhance adjustment to life with acquired brain injury: VaLiANT (valued living after neurological trauma)

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

Application of neuropsychology and imaging to brain injury and use of the integrative cognitive rehabilitation psychotherapy model

BACKGROUND

An early approach to cognitive rehabilitation therapy (CRT) was developed based on A. R. Luria's theory of brain function. Expanding upon this approach, the Integrative Cognitive Rehabilitation Psychotherapy model (ICRP) was advanced.

OBJECTIVE

To describe the ICRP approach to treatment of clients post brain injury and provide a comprehensive list of evaluation tools to determine the client's abilities and needs. Finally, to provide a link between CRT and functional imaging studies designed to improve rehabilitation efforts.

METHODS

History of cognitive rehabilitation and neuropsychological testing is reviewed and description of cognitive, academic, psychiatric, and substance abuse tools are provided. Cognitive and emotional treatment techniques are fully described. Additionally, a method of determining the client's stage of recovery and pertinent functional imaging studies is detailed.

RESULTS

Authors have been able to provide a set of tools and techniques to use in comprehensive treatment of clients with brain injury.

CONCLUSIONS

Inclusive treatment which is outlined in the ICRP model is optimal for the client's recovery and return to a full and satisfying life post brain injury. The model provides a framework for neuropsychologists to integrate issues that tend to co-occur in clients living with brain injury into a unified treatment plan.

Video-consulting to address mental health needs after traumatic brain injury: evaluation of a training workshop to build capacity among psychologists

BACKGROUND

Traumatic brain injury (TBI) can lead to significant psychological distress, but few psychologists in Australia are trained in working with this complex clinical group. Despite government funding to provide video-consulting (VC) services in Australia, uptake before COVID-19 was limited.

OBJECTIVE

This mixed methods study evaluated whether training in eHealth and evidence based TBI psychological therapies increased provider uptake of VC in clinical practice, and delivery of mental health services to individuals with TBI.

METHODS

Mental health professionals completed a range of self-report measures before (n = 50), after (n = 48), and four months following (n = 30) a one-day workshop. Participants' TBI knowledge, client-base and levels of access, confidence, motivation and attitudes toward VC were assessed. Knowledge did not increase after training but participants had significant increases in their confidence and motivation to using VC at follow up. Significant reductions in pragmatic barriers to using VC were reported post training and at follow up, all barrier categories indicated significant reductions. There was no significant change in clinical practice of the participants.

CONCLUSIONS

Training to increase TBI knowledge requires specific assessment tools and although training appears to reduce barriers to using VC, uptake in clinical practice may require additional supervision and warrants further research.

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review

BACKGROUND

Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.

OBJECTIVE

There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.

METHOD

Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.

RESULTS

A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.

CONCLUSIONS

This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

Integrated neuropsychological and cognitive behavioural therapy after acquired brain injury: A pragmatic randomized clinical trial

After acquired brain injury (ABI) many patients suffer from persistent cognitive and emotional disturbances. The aim of this study was to investigate the treatment outcome of an integrated intervention, combining neuropsychological and cognitive behavioural therapy (nCBT), against waitlist (WL) in outpatients with ABI. Individuals seeking outpatient treatment for cognitive and emotional problems after ABI were randomly allocated to nCBT (n = 27) or WL (n = 29) and completed assessments at baseline, post-treatment/WL and at six-month follow-up. The primary outcome measures were general psychopathology and functional activity in daily life. The nCBT group showed significant improvement for general psychopathology post-treatment when compared to WL. nCBT was also superior to WL regarding the secondary outcomes, i.e., the reduction of negative affect and the improvement of quality of life. No significant differences for functional activity and community integration were observed. Significant pre-post effect sizes ranged between small for functional activity and medium for quality of life. The positive effects were maintained at follow-up. The majority of patients with cognitive and emotional problems after ABI benefit from an integrated approach that offers cognitive remediation and psychotherapy. However, the heterogeneous sequelae of ABI and the moderate sample sizes in clinical trials present a methodological challenge to ABI research.

Protocol for a Phase Two, Parallel Three-Armed Non-inferiority Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT-Adjust) Comparing Face-to-Face and Video Conferencing Delivery to Individuals With Traumatic Brain Injury Experiencing Psychological Distress

Background: People with traumatic brain injury (TBI) face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI.

Methods: This paper outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial (RCT) of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales (NSW) and the NSW icare scheme will be randomly allocated to three conditions; (1) video consulting (VC), (2) face-to-face (FtF) and, (3) a waitlist control (WL).

Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy (ACT-Adjust) delivered via video consulting for individuals with a moderate to severe TBI.

Trial Registration:www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112.

Addressing the mental health needs of adolescents in South African communities: a protocol for a feasibility randomized controlled trial

BACKGROUND

Like many low- and middle-income countries, almost half of the proportion of the South African population is under the age of 25. Given the peak age of onset for most mental health problems is in adolescence, it is vital that adolescents have access to mental health counselling. There are several initiatives to increase access to mental health counselling in South Africa, primarily through the integration of counselling for common mental disorders (CMD) into primary health care services, but adolescents (15-18 years of age) generally do not utilize these services. To address this gap, we will undertake a study to explore the feasibility of conducting a trial of the effectiveness of a community-based mental health counselling intervention for adolescents at-risk for a CMD.

METHODS

The study is a feasibility trial of the ASPIRE intervention, a four-session blended multi-component counselling intervention adapted for South African adolescents at risk for depression and alcohol use disorders. We will enrol 100 adolescents from community settings and randomly assign them to the ASPIRE intervention or a comparison condition. Feasibility measures, such as rates of recruitment, consent to participate in the trial and retention, will be calculated. Qualitative interviews with participants and counsellors will explore the acceptability of the intervention. The primary outcomes for a subsequent trial would be reductions in symptoms of depression and days of heavy drinking which will be measured at baseline, 6 weeks, and 3 months post-randomization.

DISCUSSION

This feasibility trial using a mixed-methods design will allow us to determine whether we can move forward to a larger effectiveness trial of the ASPIRE intervention.

TRIAL REGISTRATION

The trial is registered with the Pan African Clinical Trials Registry (PACTR20200352214510). Registered 28 February 2020-retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9795.

An intervention to improve coping strategies in adult male prisoners with a history of traumatic brain injury: A pilot randomised clinical trial

OBJECTIVE

To determine whether a psychological intervention improves coping, post-concussion symptoms and decreases in-prison infractions in adult males with a history of traumatic brain injury.

DESIGN

A single centre, randomised, wait-list, pilot study.

SETTING

A high security prison in New Zealand.

SUBJECTS

Fifty-five adult male participants who had experienced at least one traumatic brain injury in their lifetime (mean age 37.29 +/-9.81 years).

INTERVENTION

A manualised ten session, in-person, group based combined Cognitive Behavioural Therapy /Mindfulness Based Stress Reduction intervention versus wait list control.

MAIN MEASURES

The Negative Affect Repair Questionnaire and Rivermead Post-concussion Symptom Questionnaire were completed at baseline, post-intervention (five weeks) and at 12 week follow up. In-prison misconduct charges and negative file notes were reviewed for the previous five weeks at each assessment time point.

RESULTS

There was an improvement in the use of calming and distraction strategies in the intervention group from baseline (x̄ = 17.38, SD = 3.57) to post-intervention (x̄ = 18.67, SD = 3.84) and 12-week follow up (x̄ = 18.13, SD = 2.63). Participants in the intervention group had significantly higher negative affect repair on the calming and distractive strategies subscale following completion of the intervention, compared to wait-list controls (F = 4.69, P = 0.04) with a moderate effect size (η_p² = 0.11). Improvements in use of calming and distractive strategies was not sustained at the twelve-week follow-up (F = 0.87, P = 0.36). There was no-significant improvement on other negative affect subscales or for post-concussion symptoms or decrease in-prison infractions.

CONCLUSION

A manualised psychological intervention may have the potential to facilitate the development of positive coping strategies in prisoners with a history of traumatic brain injury.

Evaluating telehealth delivery of a compensatory memory rehabilitation programme following stroke: A single-case experimental design

Rehabilitation of memory remains an unmet need for many stroke survivors. Telehealth methods may provide a solution, however evidence supporting the efficacy of remotely-delivered therapy is needed. A non-concurrent multiple baseline design was used with randomized onset of intervention across five individuals with chronic stroke-related memory complaints. A six-week compensatory memory skills programme was delivered individually via internet videoconferencing. Target behaviours of frequencies of self-reported lapses of everyday and prospective memory were measured weekly across baseline, intervention, and follow-up phases. A secondary outcome of functional goal attainment was measured once per phase, with participants setting two personal rehabilitation goals. Data were analysed visually and statistically. Improvements in memory functioning were statistically significant on at least one measure of target behaviour for four out of five participants at intervention or follow-up. Visual evidence of level change indicated at least modest improvements for all participants by follow-up. All participants attained at least one functional goal by follow-up. High rates of treatment adherence and participant satisfaction were observed. Technological issues were minimal and did not impact content delivery or engagement. These results provide preliminary support for the efficacy of a telehealth-delivered rehabilitation programme in improving memory function and achieving memory-related goals for stroke survivors.

A Role for the Amygdala in Impairments of Affective Behaviors Following Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) results in chronic affective disorders such as depression, anxiety, and fear that persist up to years following injury and significantly impair the quality of life for patients. Although a great deal of research has contributed to defining symptoms of mild TBI, there are no adequate drug therapies for brain-injured individuals. Preclinical studies have modeled these deficits in affective behaviors post-injury to understand the underlying mechanisms with a view to developing appropriate treatment strategies. These studies have also unveiled sex differences that contribute to the varying phenotypes associated with each behavior. Although clinical and preclinical studies have viewed these behavioral deficits as separate entities with unique neurobiological mechanisms, mechanistic similarities suggest that a novel approach is needed to advance research on drug therapy. This review will discuss the circuitry involved in the expression of deficits in affective behaviors following mild TBI in humans and animals and provide evidence that the manifestation of impairment in these behaviors stems from an amygdala-dependent emotional processing deficit. It will highlight mechanistic similarities between these different types of affective behaviors that can potentially advance mild TBI drug therapy by investigating treatments for the deficits in affective behaviors as one entity, requiring the same treatment.

Therapeutic benefits of pharmacologic and nonpharmacologic treatments for depressive symptoms after traumatic brain injury: a systematic review and network meta-analysis

BACKGROUND

Depression is a common morbidity after traumatic brain injury. This network meta-analysis investigated the efficacy and tolerability of pharmacologic and nonpharmacologic interventions for depression after traumatic brain injury.

METHODS

We extracted randomized controlled trials examining pharmacologic or nonpharmacologic interventions with placebo- or active-controlled designs from PubMed, the Cochrane Library and ScienceDirect, from inception to October 30, 2018. We based study selection and extraction of a predefined list of variables on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, and conducted meta-analysis procedures using random effects modelling. Primary outcomes were changes in depressive symptom severity after pharmacologic or nonpharmacologic treatment; the secondary outcome was tolerability, reflected in overall patient dropout rates.

RESULTS

Our analysis of 27 randomized controlled trials (10 pharmacologic, total n = 483, mean age = 37.9 yr; 17 nonpharmacologic, total n = 1083, mean age = 38.0 yr) showed that methylphenidate had significantly superior efficacy compared to placebo or control (standardized mean difference -0.91, 95% confidence interval [CI] -1.49 to -0.33). Sertraline was associated with significantly lower tolerability (i.e., a higher dropout rate) compared to placebo or control (odds ratio 2.65, 95% CI 1.27 to 5.54). No nonpharmacologic treatment was more effective than the others, and we found no significant differences in tolerability (i.e., dropout rates) among the nonpharmacologic treatments.

LIMITATIONS

Heterogeneity in participant characteristics (e.g., comorbidities), study designs (e.g., trial duration) and psychopathology assessment tools, as well as small trial numbers for some treatment arms, could have been confounders.

CONCLUSION

The present network meta-analysis suggests that methylphenidate might be the best pharmacologic intervention for depressive symptoms related to traumatic brain injury. None of the nonpharmacologic interventions was associated with better improvement in depressive symptoms than the others or than control conditions. None of the pharmacologic or nonpharmacologic treatments had inferior tolerability compared to placebo or controls except for sertraline, which had significantly lower tolerability than placebo.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Effects of cognitive behavioral therapy for adults with post-concussion syndrome: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Although the mechanism of post-concussion syndrome remains unclear, psychological factors are thought to be associated with its development. Cognitive behavioral therapy is the gold standard for psychological disorders; however, its effects on post-concussion syndrome remain unclear. Through this meta-analysis, we assessed the effects of cognitive behavioral therapy on post-concussion syndrome following traumatic brain injury.

METHODS

Six electronic databases were searched from inception to September 15, 2019, for randomized controlled trials evaluating the effects of cognitive behavioral therapy for adults with post-concussion syndrome. Primary outcomes included the severity of symptoms of post-concussion syndrome, depression, anxiety, and social integration. Secondary outcomes were fatigue, cognitive function, and quality of life. Effects were estimated through the calculation of Hedge's g and 95% confidence interval using a random effects model. Sensitivity analyses were conducted by excluding studies in which an intention-to-treat analysis was not employed.

RESULTS

In total, 24 studies were included. Most studies had risk of bias. Significant effects were found for most outcomes, except for severity of symptoms of post-concussion syndrome, fatigue, executive function, and problem solving. After sensitivity analyses, the effects of cognitive behavioral therapy remained significant for immediate and mid-term effects on depression, anxiety, and social integration.

CONCLUSIONS

This study does not support the effectiveness of cognitive behavioral therapy for severity of symptoms of post-concussion syndrome; however, it might be an effective treatment option for improving depression, anxiety, and social integration in individuals with traumatic brain injury.

Getting motivated: long-term perspectives on engaging in community-based programs after acquired brain injury

BACKGROUND

Low motivation is a common problem after acquired brain injury (ABI) and can persist for years after injury. Little is known, however, about perspectives of motivation with respect to engaging in the community, many years after ABI.

PURPOSE

To explore the client with ABI perspective of motivation and engagement in individuals based in community ABI programs.

METHOD

Interpretive description methods were utilized. Semi-structured interviews were conducted with 21 individuals with an ABI.

FINDINGS

Participants felt that both internal factors, such as feelings of hope, and external factors, such as social support, influence levels of motivation to engage. When positive internal and external motivators were enhanced, and negative internal and external motivators reduced, this gave rise to a sense of choice and control, which led to increased engagement.

IMPLICATIONS

Fostering positive aspects of rehabilitation and increasing choice and control may promote engagement. External motivators, such as reducing repetitiveness and promoting peer support, are motivators that community and clinical settings can implement relatively easily, whilst internal motivators such as attitudes toward therapy may need to be addressed continuously to enhance motivation and engagement.

The Effect of Antidepressants on Depression After Traumatic Brain Injury: A Meta-analysis

OBJECTIVE

Following traumatic brain injury (TBI), depressive symptoms are common and may influence recovery. We performed a meta-analysis to estimate the benefit of antidepressants following TBI and compare the estimated effects between antidepressants and placebo.

PARTICIPANTS

Multiple databases were searched to find prospective pharmacological treatment studies of major depressive disorder (MDD) in adults following TBI.

MAIN MEASURES

Effect sizes for antidepressant medications in patients with TBI were calculated for within-subjects designs that examined change from baseline after receiving medical treatment and treatment/placebo designs that examined the differences between the antidepressants and placebo groups.

DESIGN

A random-effects model was used for both analyses.

RESULTS

Of 1028 titles screened, 11 were included. Pooled estimates showed nonsignificant difference in reduction of depression scores between medications and placebo (standardized mean difference of 5 trials = -0.3; 95% CI, -0.6 to 0.0; I = 17%), and a significant reduction in depression scores for individuals after pharmacotherapy (mean change = -11.2; 95% CI, -14.7 to -7.6 on the Hamilton Depression Scale; I = 87%).

CONCLUSIONS

This meta-analysis found no significant benefit of antidepressant over placebo in the treatment of MDD following TBI. Pooled estimates showed a high degree of bias and heterogeneity. Prospective studies on the impact of antidepressants in well-defined cohorts of TBI patients are warranted.