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Reciprocal Causation Between Functional Independence and Mental Health 1 and 2 Years After Traumatic Brain Injury: A Cross-Lagged Panel Structural Equation Model

Perrin, Paul B. PhD; Stevens, Lillian F. PhD; Sutter, Megan MS; Lequerica, Anthony H. PhD; Krch, Denise PhD; Kolakowsky-Hayner, Stephanie A. PhD; Arango-Lasprilla, Juan Carlos PhD

American Journal of Physical Medicine & Rehabilitation: June 2017 - Volume 96 - Issue 6 - p 374–380
doi: 10.1097/PHM.0000000000000644
Original Research Articles CME Article . 2017 Series . Number 8

Objective: The research attempting to disentangle the directionality of relationships between mental health and functional outcomes after traumatic brain injury (TBI) is growing but has yielded equivocal findings or focused on isolated predictors or isolated outcomes. The purpose of the current study was to use cross-lagged panel and structural equation modeling (SEM) techniques to examine causality between comprehensive indices of mental health (depression, anxiety, and life satisfaction) and functional independence in a national sample of individuals with TBI over the first 2 years after injury.

Design: Participants were 4,674 individuals with TBI from the TBI Model Systems Database.

Results: The SEM, which yielded good fit indices, suggested that individuals with TBI with greater mental health problems at 1 and 2 years after injury had lower functional independence at those same time points. The standardized path loadings for mental health problems and for functional independence over time were large, suggesting a high degree of consistency in mental health and functional independence across 1 and 2 years. In terms of cross-lag, mental health at Time 1 did not exert a unique effect on functional independence at Time 2, but functional independence at Time 1 exerted a statistically significant but quite small unique effect on mental health at Time 2.

Conclusions: This combination of results suggests that functional independence is only slightly more causal than mental health in the relationship between mental health and functional independence over the first 2 years post-TBI, and that instead, reciprocal causality is a more likely scenario.

To Claim CME Credits: Complete the self-assessment activity and evaluation online at

CME Objectives: Upon completion of this article, the reader should be able to: (1) understand the nature of the relationship between mental health problems and functional independence after traumatic brain injury; (2) learn about a novel methodological technique for examining the connections between variables over time; and (3) understand when ongoing support for individuals with traumatic brain injury is necessary.

Level: Advanced

Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

From the Virginia Commonwealth University, Richmond, Virginia (PBP, MS); Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia (LFS); Kessler Foundation, West Orange, New Jersey (AHL, DK); Santa Clara Valley Medical Center, San Jose, California (SAK-H); BioCruces Health Research Institute, Cruces University Hospital Barakaldo, Bizkaia, Spain (JCA-L); and IKERBASQUE, Basque Foundation for Science, Bilbao, Spain (JCA-L).

All correspondence and requests for reprints should be addressed to: Paul B. Perrin, PhD, Department of Psychology, Virginia Commonwealth University, 800 West Franklin St., Room 201, P.O. Box 842018, Richmond, VA 23284-2018.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.