Participation Mediates the Relationship Between Postconcussive Symptoms and Suicidal Ideation Among Veterans

Participation in personally meaningful activities mediates the relationship between multimorbidity and suicidal ideation among post-9/11 veterans

BACKGROUND

United States veterans who served after September 11, 2001 (i.e., post-9/11) frequently experience multimorbidity, the presence of two or more chronic health conditions. Common multimorbidity clusters in this veteran cohort include mental health conditions and the polytrauma clinical triad (i.e., traumatic brain injury, posttraumatic stress disorder, and pain). Previous research has demonstrated veterans with multimorbidity are more likely to also experience suicidal ideation, although the underlying mechanism is unclear. The objective of the present study was to determine if decreased participation in life activities mediated the relationship between multimorbidity and suicidal ideation.

METHODS

This was an analysis of data from 8063 veterans who participated in the Comparative Health Assessment Interview Research Study, a national survey of post-9/11 veterans. Multimorbidity clusters were identified using latent class analysis. The relationships between multimorbidity clusters and suicidal ideation were estimated with path analysis, with participation in multiple life activities included as potential mediators.

RESULTS

Latent class analysis identified a Healthy cluster and three multimorbidity clusters: Mental & Behavioral Health; Traumatic Brain Injury and Musculoskeletal Disorder; and Polytrauma Clinical Triad and Depression. Multimorbidity clusters were associated with a greater likelihood of suicidal ideation. Participation in personally meaningful activities mediated the relationships between multimorbidity clusters and suicidal ideation.

CONCLUSIONS

Multimorbidity is associated with reduced participation in personally meaningful activities, which in turn is associated with increased risk for suicidal ideation. Interventions that promote participation in activities that are consistent with the values and interests of veterans with multimorbidity may protect against suicidal ideation.

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Background

Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.

Materials and Methods

This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).

Results

87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).

Discussion

Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.