WE GREATLY APPRECIATE the opportunity to respond to the thoughtful commentary by Vanderploeg and Belanger, and concur with their assertion that the traumatic brain injury (TBI) screening and referral procedures implemented by the Veterans Health Administration (VHA) in 2007 should be revisited. Like all newly implemented medical practices, processes should be reevaluated to identify whether the change is needed or beneficial.1 Ultimately, the question of cost and harm versus benefit is an empirical one; however, we would like to assert that existing data, some of which is presented below, supports TBI screening. At the same time, we propose potential modifications/enhancements to current procedures including (1) collecting and making data from all questions available to both Veterans and their providers to facilitate education regarding TBI prevention and (2) providing further education to all stakeholders regarding the purpose of screening and second-level evaluation procedures (assessing for exposure, providing educational materials aimed at prevention of future TBIs, reinforcing the expectation of recovery, evaluating risk for co-occurring conditions and symptoms, and intervening to manage symptoms when needed).
BASIS FOR TBI SCREENING WITHIN THE VHA
Screening for TBI and associated symptoms in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans occurs as part of a larger comprehensive VHA screening process that is designed to help identify a range of health concerns that are uniquely related to the nature of combat operations and military service in Iraq and Afghanistan.2 Screening questions presented in the form of clinical reminders target a range of mental health problems, infectious diseases, and military-specific incidents, such as blast exposures and military sexual trauma, all of which have implications for the mental and physical well-being of Veterans.
Characteristics unique to military operations in the Middle East, such as multiple deployments and high incidence of blast exposures, make this cohort of service members particularly vulnerable to bodily injuries. Although innovations in body armor and trauma medicine have contributed to higher survival rates, the reality of such advances are that a significant number of service members are left to cope with physical injuries and/or psychological symptoms postdeployment. The types of physical injuries being sustained have been largely impacted by the nature of the warfare. Compared with previous conflicts, OEF/OIF military personnel have sustained increased numbers of explosion-related injuries (OEF/OIF 81%, Vietnam 65%, World War II 73%) and injuries to the head and neck region (OEF/OIF 30.0%, Vietnam 16.0%, World War II 21.0%).3 Taken together these findings demonstrate that OEF/OIF Veterans represent a population at increased risk of having sustained exposure to physical trauma. Screening for such exposure may be necessary to ensure that returning service members and Veterans receive the care and services needed to facilitate recovery and restore function.
The 4-item TBI clinical reminder currently administered to OEF/OIF Veterans could be more accurately described as a screen for possible TBI plus current symptoms, which may or may not be associated with the previously endorsed exposure to physical trauma.4 Specifically, questions 1 and 2 assess potential history of TBI (potential injury event with subsequent alteration in consciousness), while questions 3 and 4 examine acute and chronic symptoms associated with TBI (eg, headaches, dizziness, fatigue). A positive response on all 4 questions results in a positive screen. As such, the TBI screen, as currently conceptualized, is not specifically focused on identifying all who may have had a history of TBI, rather it is designed to identify individuals with a history of exposure to physical trauma and persistent symptoms (which may or may not be related to the physical trauma) who may benefit from further assessment and treatment.
TBI SCREENING AND RISK STATUS
Vanderploeg and Belanger assert that a core component of medical screening is early detection of progressive disease, and therefore TBI screening is not justified because TBI is a historical event, not a progressive disorder. While we acknowledge that TBI is not a progressive disorder, we argue that TBI screening for the purpose of risk identification fits within the definition of medical screening provided by Vanderploeg and Belanger. As described in the article, “screening is designed to identify a disease, condition, or risk factor early, thus enabling earlier intervention and management in the hope of reducing mortality and suffering.” This definition suggests that medical screening is not limited to identification of disease but can also be used to identify risk factors for different health conditions. By broadening the scope of medical screening to include identification of risk, the potential merits of TBI screening become more evident.
The empirical link between TBI and various health risks has been well-established. For example, a number of studies have shown that TBI compared to non-TBI physical injury confers additional risk of posttraumatic stress disorder (PTSD) above and beyond the trauma itself. Bryant et al5 found that among civilians, PTSD symptoms were significantly greater 3 and 12 months postinjury among individuals with mild TBI (mTBI) than among those with non-TBI injuries. Similarly, Hoge et al6 found that compared to both Veterans who were not injured and those who sustained injuries not involving the head, the highest rates of PTSD were observed in Veterans who suffered injuries involving the head. In another study, Brenner and colleagues7 found that although mTBI and PTSD were independently associated with postconcussive (PC) symptom reporting, OEF/OIF soldiers with both conditions were at greater risk for PC symptoms than those with PTSD, mTBI, or neither of these condition. Such findings suggest that a history of mTBI, even when it co-occurs with PTSD, is not inconsequential and does in fact contribute to symptoms and clinical manifestations above and beyond other deployment-related conditions.
Traumatic brain injury (all severity levels) has also been associated with increased risk for all cause mortality, as well as suicide. In a recent study, Brenner et al8 found that Veterans with TBI were at increased risk for death by suicide compared with those without a history of TBI after adjusting for demographic and psychiatric covariates. Along these lines, emerging data suggests that screening all individuals seeking mental health care for a lifetime history of TBI may increase understanding regarding the relationships between TBI, risky behaviors (eg, substance abuse), and negative psychiatric outcomes.9,10
Knowledge regarding TBI
Most of what is known about mTBI is based on sports and acceleration/deceleration injuries. However, the pathophysiology, natural history, and prognosis of deployment-related mTBI, the majority of which are blast-induced, may in fact be quite different than those sustained by athletes or civilians.11 As with previous conflicts12–16 efforts to assist returning military personnel have contributed to advancements in our understanding of TBI, comorbid mental health conditions, and associated sequelae. Despite increased knowledge regarding the potentially important impact of sustaining multiple mTBIs, and the relationship between mTBI and psychiatric conditions, understanding regarding persistent symptoms and the long-term implications of deployment-related mTBI remains in its infancy.
Factors contributing to enduring symptoms following mTBI are multifaceted and likely influenced by a range of neuropathological and psychosocial risk factors.17 Furthermore, the extent to which circumstances associated with deployment, such as repeated exposures to blasts, co-occurring emotional trauma and chronic physiological stress secondary to adverse physical and environmental conditions, impact the natural history of mTBI is unclear. Each of these stressors, in and of themselves, may be viewed as a potential neurobiological insult. The fact that the individual and cumulative impact of these insults varies across individuals suggest that differences in cognitive reserve/resiliency may play an important role in understanding the heterogeneity of responses and outcomes following TBI.
For example, though TBI itself is not a progressive disease, it has been identified as a risk factor for neurodegenerative disorders such as Alzheimer disease (AD).18 What remains unknown is if and how early impairments associated with TBI, many of which are similar to those expressed by individuals with AD, increase risk for progressive debilitating disease, and for whom. Theoretically, the potential impact of TBI and associated sequelae on functioning and neurodegenerative processes can be conceptualized developmentally over the course of the adult life. That is, short- and long-term challenges associated with poor functioning are “inextricably tied to... the unfolding of biological, psychological, and social processes through time.”19(p134) As such, over time historical information regarding an individual's history of exposure may provide important information regarding an accumulation of factors that would be expected to negatively impact functioning. For further information regarding cumulative disadvantage theory as it pertains to OEF/OIF Veterans, see Brenner et al.20
POSSIBLE MODIFICATIONS/ENHANCEMENTS TO CURRENT PROCEDURES
We suggest that current screening efforts could be modified/enhanced and reconceptualized to achieve identification of Veterans: (1) with any history of deployment-related TBI in the aim of strengthening prevention strategies in terms of future TBIs, negative psychiatric outcomes, and risky behaviors; and (2) with current symptoms in the aim of providing evidence-based treatments. Screening to detect probable history of TBI may help identify individuals at risk for subsequent health problems and conditions. Specifically, it provides an index of someone's risk status that takes into account exposure to a neurobiological insult (questions 1 and 2) and the potential manifestation of the exposure over time (questions 3 and 4). In this vein, positive and negative screens represent inequalities or differences in risk status that may have short- and long-term health implications. The extent of this impact and the degree to which these inequalities result in greater differentiation of health outcomes over time may be largely influenced by intervening factors that serve to mitigate the impact of current risk (intervention) and/or reduce exposure to future risk (prevention).
On the basis of this conceptual model, TBI screening may inform prevention strategies designed to reduce subsequent exposure to risky behaviors, while increasing health promoting behaviors. With respect to prevention, efforts are needed to educate stakeholders on the nature, course, and prognosis of mTBI and to explain how co-occurring conditions, such as PTSD, depression, and pain, contribute to symptoms and functioning. Prevention of reinjury and strategies aimed at reducing maladaptive behaviors such as substance abuse to cope with symptoms should also be top prevention priorities given the potential detrimental impact these behaviors may have on overall risk status. By preventing the accumulation of multiple risk factors over a life span, such strategies may ultimately shift a person's health trajectory away from chronic illness and disability. This is particularly important to consider over a life course as studies examining the impact of TBI on various health outcomes suggest that some risks associated with TBI are proximal (eg, PTSD), while others may be more distal (eg, AD).
As stated by Vanderploeg and Belanger, evidence-based treatments for mTBI are limited. However, the same cannot be said for many of the symptoms highlighted in the screen. In fact, a number of evidence-based/informed practices to treat symptoms frequently reported by Veterans are outlined in the Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Concussion/Mild Traumatic Brain Injury.21 Moreover, findings supporting the interrelated nature of postdeployment symptoms show that treating some (e.g., PTSD symptoms) may decrease others (PC symptoms).22
Currently, there is very limited empirical evidence demonstrating that TBI screening has iatrogenic effects. The VHA screen itself is noninvasive and occurs in the context of a larger deployment-related health screen. Veterans may also choose to opt out of screening. Abandoning TBI screening on the basis of such limited evidence would be premature, as more research is clearly needed to properly weigh the cost-benefit ratio of TBI screening. Perhaps the bigger and more important empirical question is whether screening for deployment-related TBI results in effective prevention strategies such as managing expectations, improving symptom management, and reducing risk, or if the harms and costs do in fact outweigh the potential benefits. These and other efforts to evaluate current screening procedures, as well as the natural history of combat-related mTBI, continue to receive significant attention, and findings are expected to shape policy and practice.
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