Traumatic Brain Injury History Among Individuals Using Mental Health and Addictions Services: A Scoping Review : The Journal of Head Trauma Rehabilitation

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Traumatic Brain Injury History Among Individuals Using Mental Health and Addictions Services: A Scoping Review

Davies, Julia RN, MN; Dinyarian, Camellia RN, BSc, BScN; Wheeler, Anne L. PhD; Dale, Craig M. PhD, RN, CNCC(C); Cleverley, Kristin PhD, RN, CPMHN(C)

Author Information
Journal of Head Trauma Rehabilitation 38(1):p E18-E32, January/February 2023. | DOI: 10.1097/HTR.0000000000000780

Abstract

EVIDENCE IS INCREASINGLY highlighting a relationship between traumatic brain injury (TBI) and psychiatric disorders. Existing mental health or substance use problems elevate a person's risk of experiencing a TBI,1,2 and individuals with a TBI are at heightened risk for developing novel psychiatric problems, including depression, anxiety, psychosis, and substance use disorders,3 suggesting there may be a significant number of persons with a history of TBI among mental health and addictions (MHA) service users. Unfortunately, due to gaps in care-seeking and follow-up for TBIs,4–7 overlap in symptoms of TBI and psychiatric disorders,8 and poor integration between TBI and MHA service sectors,9 there may be significant underrecognition of TBI history among MHA service users. However, literature examining assessment and rates of TBI among individuals receiving MHA services has not, to our knowledge, been reviewed.

Individuals with a history of TBI are at risk for poorer mental health, but are also more likely to have comorbid physical health concerns, as well as cognitive challenges such as difficulties with memory or impulse control,10–13 making TBIs a potential source of added complexity for persons seeking mental health care. Individuals with a psychiatric history are also at particular risk for experiencing the emotional, physical, and cognitive symptoms of TBI beyond the typical recovery period.14 Identifying a prior TBI as part of their assessment may help MHA clinicians better understand the etiology of their patients' presenting behaviors or symptoms. TBI has also been linked to increased risk for suicide, self-harm, violence, and victimization,15–18 meaning that identifying prior injuries could be highly relevant to MHA clinicians' risk assessments and subsequent care planning. If clinicians understand the demographic and clinical predictors and outcomes of TBI among MHA service users, they may better be able to identify when screening is indicated. Again, however, the current extent of knowledge on this topic has not previously been described, creating barriers to understanding whether there are clinical features associated with TBI history among individuals accessing MHA care.

In this instance, a scoping review is recommended to identify and summarize the existing evidence as well as knowledge gaps where further research is needed.19 The purpose of this review is to understand: (a) the prevalence of TBI history among individuals accessing MHA services; (b) how TBI history has been identified within MHA service settings; and (c) what predictors or outcomes of TBI have been reported in these service settings.

METHODS

This scoping review was designed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR).20 The methods were guided by Levac et al's21 expansion on Arksey and O'Malley's22 methodological framework for conducting scoping reviews.

Stage 1: Identifying the research question

The research questions guiding this scoping review were:

  1. How prevalent is a history of TBI among individuals of all ages who are accessing any type of MHA service?
  2. What methods are used to identify a history of TBI within MHA service settings?
  3. What predictors and outcomes of TBI have been reported in samples of individuals accessing MHA services?

Stage 2: Identifying relevant studies

The search strategy was initially developed in Medline in consultation with librarians experienced in mental health research. Key words and subject headings representing the concepts of TBI, MHA settings, and screening were developed, combined, and limited to human studies published in English (See Supplemental Table 1, available at: https://links.lww.com/JHTR/A537). The search was translated to CINAHL, EMBASE, PsycINFO, and SPORTDiscus. Results were pulled from the inception of each database up to the date of the search (April 16, 2020).

A gray literature search was also carried out using the Grey Matters Checklist, a structured tool for comprehensive gray literature searching.23 Four Advanced Google Searches (limited to Canada, the United States, Australia, or the United Kingdom) were carried out using simplified key words. Potentially relevant documents from the first 50 results for each search were added to the Grey Matters search results for screening.23

Following screening, the reference lists of included documents were also screened for additional relevant articles.

Stage 3: Study selection

Database search results were deduplicated and24 then screened using Covidence.25 Studies were included if they: (a) were written in English; (b) recruited participants of any age from MHA service settings; (c) had a primary aim of screening participants for TBI history; and (d) focused on a civilian population. Particularly high rates of blast-related injury and comorbid TBI and psychiatric disorders, as well as targeted efforts within Veterans Health systems for early identification and treatment of TBI and associated health problems,26–28 suggest that veterans/military service members are a complex group not representative of the general population accessing MHA care, warranting separate study. Commentaries, case studies, and editorials were excluded, as the goal was to find empirical data answering the research questions. MHA settings were defined as any clinical service with a primary goal of providing MHA assessment, treatment, or resources.

To test the eligibility criteria, randomly selected results were independently screened by title and abstract in rounds of 50 by 2 reviewers (J.D. and C.D.). After each round, the reviewers discussed and refined the eligibility criteria as needed until more than 90% agreement was reached (after 3 rounds). Another random 10% of the database search results were then screened independently by both reviewers, maintaining this level of agreement. The remaining records were screened by one reviewer (J.D.). All records appearing to meet the eligibility criteria were independently assessed in full-text review by both J.D. and C.D.. The gray literature search results, not having abstracts, were imported into a Microsoft Excel file and independently assessed by full text for eligibility by J.D. and C.D. Any disagreements between screeners at any stage were resolved by discussion and consensus.

Stage 4: Charting the data

One reviewer (J.D.) extracted data for all the included documents, and a second (C.D.) extracted data for 5 randomly selected documents to ensure reliability of the extraction form, which was created in Microsoft Excel. Data for extraction included bibliographic information, study design, research questions, setting and sample descriptions, inclusion/exclusion criteria, TBI definition, screening method, prevalence and characteristics of reported TBIs (eg, severity of TBIs if reported), potential predictors/outcomes of TBI assessed, variables found to be associated with TBI history, analysis methods, psychometric testing of the screening tool, and future research recommendations.

Stage 5: Collating, summarizing, and reporting the results

Questions 1 and 2

The reported prevalence of TBI found in each sample, as well as methods used to assess TBI history, were collated in table format alongside other descriptors of the study (eg, design, sample, and setting). Prevalence of TBI was summarized as a percentage of participants identified as having a TBI history (either as reported in the study or by dividing the number of participants with TBI by study sample size). The number of studies using each type of TBI screening method was also summarized numerically.

Question 3

Variables which were examined for a potential relationship to TBI, including key demographics and broad clinical variables, by at least 2 studies were synthesized in table format, identifying the number of studies that did or did not find a relationship between the variable and TBI status based on their analysis. These were also synthesized narratively to review trends in the relationship between each variable and TBI status.

RESULTS

Sources of evidence

The search and screening results are presented in Figure 1. Twenty-seven journal articles and 2 dissertations were included in the review, describing 28 unique studies (1 study being reported by both a dissertation and journal article29,30). Included documents were published between 1990 and 2018, originating from the United States (n = 23), Canada (n = 2), the United Kingdom (n = 2), New Zealand (n = 1), and Norway (n = 1). Studies were recruited from diverse inpatient, outpatient, and community-based programs described as psychiatry/mental health,29–48 substance use,49–53 concurrent disorders,54,55 and forensic programs.56,57 Only 3 studies focused on participants with a specific psychiatric diagnosis35,38,46 and all but one52 included male and female participants. Most (n = 24) studies focused on primarily adult samples (mean age 30-44 years). Three studies recruited participants from MHA services specifically for children and adolescents (mean age 10-12 years).31,42,43 One study recruited from geriatric psychiatry services (mean age 66 years).38

F1
Figure 1.:
PRISMA flow diagram for study selection.

Question 1: Prevalence of TBI

The prevalence of TBI reported by the included studies is summarized in Table 1. TBI was operationalized heterogeneously between the included studies. For example, 10 studies included only head injuries resulting in loss of consciousness and/or requiring medical care,33,34,38,39,47–49,53,55 while others sought specifically mild TBIs.41,46

TABLE 1 - Characteristics of included studies, screening methods, and prevalence of TBI history
Author Study design Country and MHA setting MHA sample size, n MHA sample characteristics (mean age ± SDa, sexb, diagnoses)
If included, non-MHA comparison group characteristics (recruitment setting, sample size, mean age ± SD a, sex b )
Operationalization and assessment of TBI TBI prevalence
Albicini et al31 Cross-sectional
  • New Zealand

  • 3 child and adolescent mental health services

149
  • 12 ± 4 y

  • 47% female

  • Various mental health concerns

  • Self-report

  • Ohio State University TBI Identification Method Short Form

28.3%
Burg et al32 Retrospective chart review
  • USA

  • Inpatient psychiatry unit

100
  • 35 ± 11 y

  • 51% female

  • Various diagnoses; psychotic and mood disorders most common

  • Self-report

  • Head injury questionnaire unique to organization

  • Injury with LOC or dazed

68%
Burg)30
Burg et al29
Cross-sectional
  • USA

  • Inpatient psychiatry unit

74 Age and sex reported by TBI status
  • TBI-positive (n = 49)

    • 35 ± 10 y

    • 51% female

  • TBI-negative (n = 25)

    • 32 ± 11 y

    • 80% female

  • Various diagnoses; depressive disorder most common

  • Self-report

  • Head injury questionnaire unique to organization

  • TBI with LOC or became dazed or dizzy

66%
Colantonio et al56 Retrospective chart review
  • Canada

  • Forensic program at a single center: 6 inpatient units and 1 outpatient service

394
  • 40 y

  • 16% female

  • Various diagnoses; schizophrenia and SUD most common

  • Clinical chart audit

  • Head injuries with and without LOC

22.6%
Corrigan and Deutschle55 Prospective cohort
  • USA

  • Community mental health center programs for co-occurring SUD and mental illness

50
  • 38 ± 10 y

  • 38% female

  • Various concurrent mental and substance use disorders

  • Self-report

  • Single-item question

  • Injury to head that resulted in LOC or going to hospital

72%
Dinn et al33 Cross-sectional
  • USA

  • Neuropsychology service with referrals from inpatient psychiatry

63
  • 37 ± 10 y

  • 7% female

  • Various diagnoses; schizophrenia and psychotic disorders most common with high-comorbid SUD

  • Self-report

  • Questions embedded within interview

  • Closed head injury with LOC

NR
Doherty et al34 Cross-sectional
  • United Kingdom

  • Service for refugees with trauma-related mental health problems

103
  • 36 ± 9 y

  • 59% female

  • Diagnoses NR

  • Self-report

  • Customized intake screening questionnaire

  • Head injury with LOC

51%
Drange et al35 Cross-sectional
  • Norway

  • 17 psychiatric hospitals and outpatient clinics

505
  • 42 ± 14 y

  • 57% female

  • All bipolar disorder or cyclothymia

  • Self-report

  • Questions embedded in admission questionnaire

  • Medically diagnosed TBI prior to age of bipolar disorder onset only, with or without LOC

7.3%
Felde et al53 Cross-sectional
  • USA

  • University alcohol-drug program

550 Sex and age reported by TBI status
  • TBI-positive (n = 218)

    • 30 ± 9 y

    • 61% men, 39% women

    • Various psychiatric and/or SUD diagnoses

  • TBI-negative (n = 332)

    • 32 ± 11 y

    • 50% men, 50% women

    • Various psychiatric and/or SUD diagnoses among whole sample

  • Self-report

  • Single-item question

  • Head injury acquired during adulthood, which resulted in LOC

39.6%
Fox et al36 Cross-sectional
  • USA

  • Outpatient psychological treatment

400
  • 38 ±14 y

  • 55% female, 9% unknown sex

  • Diagnoses NR

  • Self-report

  • Question embedded within symptoms checklist

  • Asked whether knocked unconscious or bumped head within past 2 y only

3.5% knocked unconscious
9.3% bumped head
Gargaro et al37 Cross-sectional
  • Canada

  • Assertive community treatment team for homeless persons

48
  • 43 ±13 y

  • 31% female

  • Various diagnoses, primarily schizophrenia and other psychosis

  • Self-report

  • Ohio State University TBI Identification Method Short Form

56%
Graves et al38 Case-control
  • USA

  • 2 geriatric psychiatry clinics (1 academic hospital, 1 Veterans Affairs Center)

130
Cases
  • 66 y

  • 46% female

  • Alzheimer's diagnosis

Nonclinical controls recruited from MHA patients' nonbiological relatives and friends
  • n = 130

  • 64 y

  • 46% female (matched by sex to cases)

  • Surrogate respondent (eg, spouse) report

  • Head injury resulting in physician/hospital care or LOC

MHA cases: 23.9%
Nonclinical controls: 8.5%
Hawley and Maden57 Retrospective chart review
  • United Kingdom

  • 5 medium-secure inpatient units

113
  • 36 ± 13 y

  • 18% female

  • Various diagnoses, primarily psychosis/schizophrenia

  • Clinical chart audit

  • Previous head injury

41.6%
Holtzer et al39 Mixed prospective cohort and retrospective chart review
  • USA

  • 3 acute inpatient psychiatry units

46
  • 61% female

  • Mood, anxiety, and adjustment disorders

  • Age reported by TBI status

    • Confirmed TBI: 38 ± 8 y

    • Unconfirmed TBI: 37 ± 17 y

    • TBI-negative: 36 ± 11 y

  • Self-report

  • Traumatic Brain Injury Questionnaire

  • TBI with LOC of at least 1 min

  • Reported TBIs confirmed through record review or eyewitness interviews where possible

Reported and confirmed 32.6%
Reported but not confirmed 28.3%
Hux et al40 Cross-sectional
  • USA

  • Community-based mental health referral service

69
  • 35 y

  • 49% female

  • Primary diagnosis not reported

Non-MHA comparison groups recruited from vocational rehabilitation service, homeless shelter, and domestic abuse facility
  • Vocational rehabilitation

    • n = 1648

    • 36 y

    • 49% female

  • Homeless shelter

    • n = 240

    • 36 y

    • 86% female

  • Domestic abuse facility

    • n = 42

    • 30 y

    • 100% female

  • Self-report

  • HELPS screening tool

  • Positive screen for TBI requires all of (a) injury to head, (b) LOC/altered consciousness or medical assessment, and (c) ≥2 injury-related chronic problems

Mental health service group: 58.0%
Vocational rehabilitation group: 25.6%
Homeless shelter group: 19.6%
Domestic abuse center group: 52.8%
Malloy et al51 Cross-sectional
  • USA

  • Outpatient alcohol treatment program at private psychiatric hospital

60 NR for entire screened sample
  • Self-report

  • Inventory of injuries

  • Head injury with LOC, hospitalization, or major neurologic alterations

NR
Mateo et al41 Mixed prospective cohort and retrospective chart review
  • USA

  • Inpatient psychiatric unit

106 Reported by TBI status
  • mTBI group (n = 54)

    • 35 y

    • 50% female

    • Mixed psychiatric diagnoses, primarily affective disorders

  • Matched no TBI group (n = 52)

    • 34 y

    • 50% female

    • Matched on diagnostic category

  • Screened on admission—not specified

  • Mild TBI only based on American Congress of Rehabilitation Medicine criteria: head trauma with one of (a) LOC <30 min, (b) GCS ≥ 13, (c) altered mental acuity, and (d) focal neurologic signs

NR
Max and Dunisch42 Retrospective chart review
  • USA

  • Child and adolescent outpatient psychiatric clinic

1333 screened
Final n = 148
  • NR for entire screened sample, reported only for TBI-positive group and matched controls (n = 148)

  • Clinical chart audit

  • “Definite TBI”: head injury with one of the following: LOC, postconcussive symptoms, skull fracture, decreased functioning, CT scan, surgical intervention, or hospitalization; or recorded as “concussion” or “closed head injury”

  • “Possible TBI”: other head or facial injuries recorded without the above details, history of seizure-related fall, head-banging, or physical abuse, or when recorded information from one source was contradictory

Definite TBI: 5.6%
Possible TBI: 15.5%
Max et al43 Retrospective chart review
  • USA

  • Inpatient child psychiatry unit

694 screened
Final n = 112
  • NR for entire screened sample, reported only for TBI-positive group and matched controls (n = 112)

Definite TBI: 8.1%
Possible TBI: 24.5%
McGuire et al44 Cross-sectional
  • USA

  • 2 inpatient and 2 outpatient mental health programs

231
  • 37 ± 12 y

  • 49% female

  • Primary diagnoses NR

Non-MHA comparison group recruited from a medical clinic and from university and hospital staff and students
  • Medical clinic patients

    • n = 59

    • 40 ± 16 y

    • 54% female

  • University/hospital staff/students

    • n = 534

    • 35 ± 14 y

    • 70% female

  • Self-report

  • Traumatic Brain Injury Questionnaire

  • Injury where hit head with LOC

MHA group: 33%
Medical clinic patients: 19%
Hospital and university staff and students: 13%
McHugo et al54 Cross-sectional
  • USA

  • Integrated treatment program for concurrent disorders within an urban mental health agency

295
  • 44 ± 9 y

  • 61% female

  • All concurrent SUD and mental illness

  • Self-report

  • Ohio State University TBI Identification Method

80.3%
Murrey et al45 Retrospective chart review
  • USA

  • 7 inpatient psychiatric programs

3133
  • 82% between ages of 18 and 62

  • 60% men

  • Primary diagnosis NR

  • Clinical chart audit

  • Documented history of TBI

16.7%
Murrey et al52 Cross-sectional
  • USA

  • Substance use treatment program

2198
  • 31 y (range 16-80)

  • 100% female

  • Primary SUD diagnosis NR

  • Self-report

  • Questionnaire (not specified)

  • Head trauma with change in/loss of consciousness

42.3%
Poppe46 Cross-sectional
  • USA

  • 1 inpatient and 1 outpatient psychiatry program

60 Reported by TBI status
  • mTBI group (n = 34)

    • 39 ± 10 y

    • 59% female

  • No TBI group (n = 26)

    • 37 ± 12 y

    • 73% female

  • All diagnosed with major depression

  • Self-report

  • Questionnaire to screen for mTBI created from American Congress of Rehabilitation Medicine criteria

56.7%
Sacks et al50 Cross-sectional
  • USA

  • 27 addiction treatment programs (inpatient, outpatient, transitional living, methadone maintenance)

845
  • 35 ± 10 y

  • 21% female

  • Primary diagnoses NR

  • Self-report

  • Brain Injury Screening Questionnaire

NR
Salloum et al47 Mixed prospective cohort and retrospective chart review
  • USA

  • Community mental health center (outpatient, day treatment, and family system programs)

56
  • Age range 21-69

  • 39% female

  • Various psychiatric diagnoses

  • Self-report

  • Screening form

  • Head injury resulting in LOC

NR
Schneeberger et al48 Cross-sectional
  • USA

  • 7 outpatient psychiatry clinics

183
  • Age NR

  • 39% women; 61% men

  • Various psychotic and mood disorders

  • Self-report

  • Single-item question

  • Traumatic head injury with LOC

19.7%
Walker et al49 Cross-sectional
  • USA

  • Substance abuse programs including outpatient, case management, and residential

7784
  • 65% men

  • Primary diagnoses NR

  • Age reported by TBI status

    • No TBI: 33 y

    • 1 TBI: 34 y

    • 2+ TBI: 34 y

  • Self-report

  • Single-item question

  • Lifetime head injuries resulting in LOC or hospitalized at least 1 night

31.7%
Abbreviations: GCS, Glasgow coma scale; LOC, loss of consciousness; MHA, mental health and addictions; NR, not reported; SUD, substance use disorder; TBI, traumatic brain injury.
aFigures presented are rounded to nearest whole number from reported figures for consistency between studies.
bSex presented as percentage female; when sex not reported, all reported genders presented.

Among studies reporting total lifetime history of TBI (n = 20), prevalence ranged from approximately: 6% to 28% in pediatric settings; 32% to 59% in services focused primarily on substance use; and 17% to 58% in settings described as psychiatry/mental health services in primarily adult samples. Two studies recruited from services for concurrent psychiatric and substance use disorders and reported lifetime TBI history prevalence of 72%55 and 80%.54 Two studies assessed patients in forensic services and found lifetime TBI prevalence of 23%56 and 42%.57 Three studies38,40,44 made comparisons between MHA service users and other groups, and all found the MHA service user samples had a higher rate of prior TBI.

Question 2: Screening methods

TBI history was assessed by self-report (n = 21), surrogate report (n = 1), or retrospective chart audit (n = 5), while 1 study did not identify their assessment method41 (see Table). Among the studies reporting on lifetime TBI history, self/surrogate-report and chart audits identified prevalence ranging from 24% to 80% and 6% to 42%, respectively. Self-report screening methods were not always described in detail, but studies reported using 1- or 2-item questions as well as longer structured questionnaires.

Question 3: Predictors and outcomes of TBI history

Twenty-two studies examined whether certain variables were associated with TBI (see Supplemental Table 2, available at: https://links.lww.com/JHTR/A538). Twelve studies used bivariate analyses (eg, t tests or χ2 tests) to establish an association between TBI and other variables,31,34,37,42–44,47,50,54–57 while 10 studies included multivariable analyses to establish a relationship between variables and TBI history.29,30,33,35,36,38,39,41,46,49,53

Demographic variables

Eleven studies reported on sex or gender and TBI status. Gender was not clearly defined and was reported as man/woman or male/female, thus appearing to be conflated with biological sex. Among 5 studies finding a relationship between TBI history and sex/gender, male participants were consistently found to have a higher prevalence of TBI.29,30,34,49,53,56

Two studies reported on the association between race and TBI, and 3 on ethnicity. One study reported that participants with a TBI were more likely to be White than African American,49 and another that there was a greater proportion of Caucasians among participants with mild TBI compared an uninjured control group.41

Clinical variables

Eight clinical variables were examined by at least 2 studies for association with TBI history (see Supplemental Table 2, available at: https://links.lww.com/JHTR/A538).

Psychiatric diagnosis

Ten studies examined diagnostic categories in relation to TBI history.29–31,42,43,47,53–57 Diagnostic conceptualizations varied between studies (eg, using different editions of the Diagnostic and Statistical Manual of Mental Disorders). Presence or increased severity of TBI was associated with increased likelihood of having a personality disorder diagnosis in 3 studies.54–56 In 1 pediatric sample, TBI history was linked to increased likelihood of communication disorders, but decreased likelihood of developmental disorders such as autism.42

Mental health symptoms

Seven studies assessed the severity of participants' mental health symptoms.29–31,35,37,39,49,53 Four studies used various structured scales for symptom assessment29,30,35,39,53 and 3 used unstructured methods.31,37,49 Five studies found that TBI status was associated with more severe mental health symptoms29,30,37,39,49,53 (such as increased psychological distress29,30 or depression scale scores39,53), while 2 found no relationship.31,35

Substance use

Eleven studies assessed indicators of substance use severity including the number of days or months of recent substance use49,54 or use of multiple substances,37 structured scale score,53 age of initial substance use,50,55 whether participants have historically used substances,39 or presence of previous or current substance use problems.29–31,46,57 Nine studies reported that TBI history increased the measured indicators of substance use severity29,30,37,39,46,49,50,53–55 while the other 2 studies reported no relationship.31,57

Physical health concerns

Nine studies reported on physical health concern variables including previous contact with the medical care system,42,43,46 presence of current physical symptoms,35,36,55 or history of other injuries or medical disorders.31,34,53,55 Two found that TBI history was linked to current symptoms including migraines35 or dizziness, numbness, and tremors.36 Another 2 studies found that history of TBI was associated with a history of other injuries (eg, fractures)53 or contact with a neurologist,46 while 5 found no relationship.31,34,42,43,55

Functioning

Of 3 studies assessing functioning, 2 found no link between TBI history and functioning based on different scales, which measured participants' abilities to meet elements of functioning such as personal care, social, and occupational demands.41,47 One study measured current functioning (rated by clinical staff following treatment completion or when the program grant ended),55 finding that service users with TBI were over 3 times more likely to be judged as having deteriorated or ongoing unstable functioning.

Cognition and learning

This variable was assessed in different ways by 12 studies, including formal neuropsychological test batteries,29,30,39,46,51 clinically recorded indicators such as IQ or use of special education services,31,42,43 and self-reported difficulties with cognitive function or school/learning.36,37,46,53,55 Seven studies reported that TBI status was associated with challenges including recent difficulty with understanding, concentrating, and remembering,37,49 word-finding problems,36 academic challenges,46,53 or worse performance on one or more neuropsychological tests.29,30,39 Four studies found no relationship,31,43,51,55 and, notably, 1 reported no difference in cognition variables between participants with and without TBI history of any severity, but found that participants with mild TBI history only had slightly higher performance IQ than participants with no TBI.42

Risk to self

Six studies assessed variables related to suicidal ideation, self-harm, or previous suicide attempts,31,35,37,49,53,57 4 of which found no relationship with TBI history.31,35,37,53 One study found that service users with a history of TBI were more likely to have had suicidal thoughts or a suicide attempt in the past 12 months.49 Another found that while service users with a TBI did not have a higher rate of previous self-harm problems, clinicians were more likely to consider them being at risk of harm to self.57

Risk to others

Six studies assessed and found a link between TBI history and increased hostility,47 difficulty controlling violent behavior,37,49 or a history of violence or aggression toward others.33,54,57 Of note, one study47 found that TBI increased hostility scores among female participants only when the injury required medical care, and another33 found that the relationship between TBI history and violence became insignificant after controlling for substance use.

DISCUSSION

This scoping review identified that nearly three-quarters of studies reporting on lifetime TBI found that more than 25% of MHA services users had a history of self-reported or documented TBI, and nearly half of them found rates over 50%. A 2013 meta-analysis reported a 12% prevalence of lifetime TBI among adults in the general populations of high-income countries.58 Since then, other studies of general populations have found prevalence rates ranging from 13% up to 43%,5,59–62 suggesting an overrepresentation of individuals with prior TBI in many MHA settings compared with nonclinical populations. Comparison across settings is, however, extremely difficult given the high variability in operationalization of TBI across the available literature. This has been noted as a challenge in other reviews, which have assessed TBI prevalence in special populations such as offenders or individuals experiencing homelessness.63,64 Use of a standardized definition of TBI is needed in ongoing research to compare findings across populations of interest.

Within this review, the studies using chart audits to assess TBI history generally reported lower prevalence than those utilizing self-report methods. Available literature suggests that approximately 20% to 30% of individuals experiencing a TBI do not seek any medical assessment or care for their injury, particularly for milder injuries.4,5,65,66 Relying on medical documentation alone could thus result in considerable underreporting of previous injuries. This issue may be exacerbated among individuals with psychiatric disorders, who face significant barriers to accessing physical health care.67 Structured self-report questionnaires are currently considered best practice for assessing a history of TBI,68 and MHA clinicians should consider using these during assessments instead of relying on medical charts for injury history. This scoping review identified structured tools that could be used to screen for TBI among MHA service users. These measures are thought to be more accurate than single-item questions for capturing past injuries,69 although rates of TBI appear to be comparable between the studies using single questions and those using more structured methods in this review.

The diversity in TBI definition and assessment methods may also have contributed to the inconsistent findings regarding the relationship between TBI history and several of the examined clinical variables. However, some trends were identified. For example, history of TBI was consistently linked to increased indicators of aggression or hostility. This finding aligns with research suggesting that TBI prevalence is disproportionately high among offender populations63 and that TBI increases the risk of engaging in violent crimes.70 MHA clinicians may thus consider screening patients for TBI history, as it could be relevant to their understanding of the etiology of aggressive behaviors, their formulation of risk level, and subsequent treatment planning. TBI was also frequently linked to indicators of more severe or risky substance use. As individuals with moderate or severe TBI are 10 times more likely to die of unintentional poisoning than the general population,71 identifying history and consequences of TBI may also help MHA clinicians make decisions with their patients about prescribing and monitoring commonly used psychiatric medications with increased potential for addiction, such as benzodiazepines. Cognitive consequences of brain damage such as impaired decision-making and reduced self-awareness have been speculated to make it more difficult for patients to successfully engage in addiction treatment.72,73 Interestingly, cognitive challenges were not consistently associated with prior TBI in this review, but there was evidence that subjective difficulties with functions such as remembering or concentrating were more likely to be a problem for patients with TBI. Cognitive impairments are already common features of many psychiatric disorders,74 but TBI-related deficits in planning, memory, or decision-making could warrant modifications to treatment modalities that require increased cognitive engagement such as cognitive behavioral therapy, though robust assessment of modified interventions has been limited thus far.75 Future research using structured TBI history assessments may establish whether there are specific TBI-linked symptom clusters experienced by MHA service users, such as difficulties with aggression, higher-risk substance use, or cognitive challenges. This understanding will provide opportunities to develop and evaluate targeted MHA care plans for individuals with a TBI history, who are currently at high risk for service gaps.9

This review highlighted some significant limitations to the current body of knowledge in this topic. First, the cross-sectional and chart review methods used in most of the included studies reduce clarity on the direction of the relationship between TBI and examined clinical variables. Prospective longitudinal studies incorporating TBI identification at treatment entry are needed to identify clinical and service use outcomes of TBI history across a MHA service use trajectory, further identifying opportunities for targeted care.

Also, this review found that males were often more likely to have a TBI history, in alignment with findings in the general population.76 However, sex and gender were often poorly defined in the included studies. Clearly delineating and examining both sex and gender as separate variables is important, as both may have unique roles in the emotional or behavioral impacts of TBI.77

Finally, only 3 studies were conducted in pediatric settings, with a mean participant age of 10 to 12 years.31,42,43 As adolescents 13 years and older are presenting to healthcare settings for TBI at a rapidly increasing rate,78,79 and adolescence and emerging adulthood represent the peak age of onset for most mental illnesses,80–82 further exploration of TBI among youth MHA service users is warranted. Additionally, only one study assessed TBI in an older adult sample,38 which, given the particularly high risk for falls among older MHA service users,83 represents a significant gap in the current literature.

Limitations

This scoping review included an extensive search of academic and gray literature. However, as we aimed to include studies with a primary focus of screening for TBI in MHA settings, some studies, which included TBI among several variables of interest, may have been excluded. The inclusion criteria would have also resulted in the exclusion of qualitative studies, which could provide in-depth understanding of MHA service user experiences of TBI screening and outcomes, and studies not published in English. Finally, while methodological limitations of the current body of evidence were discussed, we did not conduct a formal critical appraisal of each study. While this is not a necessary step in scoping reviews, it may have helped further explore current knowledge gaps.

CONCLUSION

This scoping review identified a relatively high prevalence of prior TBI among individuals using MHA services. Screening for TBI in these settings may provide insight into behaviors or ability to engage with care. Continued research with a focus on prospective studies and use of consistent screening methods for TBI across settings will allow better understanding of the relationship between TBI and clinical profiles and outcomes.

REFERENCES

1. Eskander N, Prabhudesai S, Imran H, Ceren Amuk O, Patel RS. Alcohol use disorder increases risk of traumatic brain injury related hospitalization: Insights from 3.8 million children and adolescent inpatients. Cureus. 2020;12(6):e8740. doi:10.7759/cureus.8740
2. Agnafors S, Torgerson J, Rusner M, Kjellström AN. Injuries in children and adolescents with psychiatric disorders. BMC Public Health. 2020;20(1):1273. doi:10.1186/s12889-020-09283-3
3. Izzy S, Tahir Z, Grashow R, et al. Concussion and risk of chronic medical and behavioral health comorbidities. J Neurotrauma. 2021;38(13):1834–1841. doi:10.1089/neu.2020.7484
4. Rao DP, McFaull S, Thompson W, Jayaraman GC. At-a-glance—traumatic brain injury management in Canada: changing patterns of care. Health Promot Chronic Dis Prev Can. 2018;38(3):147–150. doi:10.24095/hpcdp.38.3.05
5. Whiteneck GG, Cuthbert JP, Corrigan JD, Bogner JA. Prevalence of self-reported lifetime history of traumatic brain injury and associated disability: a statewide population-based survey. J Head Trauma Rehabil. 2016;31(1):E55–E62. doi:10.1097/HTR.0000000000000140
6. Fridman L, Scolnik M, Macpherson A, et al. Annual trends in follow-up visits for pediatric concussion in emergency departments and physicians' offices. J Pediatr. 2018;192:184–188. doi:10.1016/j.jpeds.2017.09.018
7. Seabury SA, Gaudette É, Goldman DP, et al. Assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: results from the TRACK-TBI study. JAMA Netw Open. 2018;1(1):e180210. doi:10.1001/jamanetworkopen.2018.0210
8. Iverson GL, Silverberg ND, Mannix R, et al. Factors associated with concussion-like symptom reporting in high school athletes. JAMA Pediatr. 2015;169(12):1132–1140. doi:10.1001/jamapediatrics.2015.2374
9. Munce SEP, Laan RV, Levy C, Parsons D, Jaglal SB. Systems analysis of community and health services for acquired brain injury in Ontario, Canada. Brain Inj. 2014;28(8):1042–1051. doi:10.3109/02699052.2014.890744
10. Voormolen DC, Polinder S, von Steinbuechel N, Vos PE, Cnossen MC, Haagsma JA. The association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injury. Injury. 2019;50(5):1068–1074. doi:10.1016/j.injury.2018.12.002
11. Dams-O'Connor K, Spielman L, Singh A, et al. The impact of previous traumatic brain injury on health and functioning: a TRACK-TBI Study. J Neurotrauma. 2013;30(24):2014–2020. doi:10.1089/neu.2013.3049
12. McMahon P, Hricik A, Yue JK, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI Study. J Neurotrauma. 2014;31(1):26–33. doi:10.1089/neu.2013.2984
13. Taylor KM, Kioumourtzoglou MA, Clover J, et al. Concussion history and cognitive function in a large cohort of adolescent athletes. Am J Sports Med. 2018;46(13):3262–3270. doi:10.1177/0363546518798801
14. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941–948. doi:10.1136/bjsports-2017-097729
15. Chang HK, Hsu JW, Wu JC, et al. Risk of attempted suicide among adolescents and young adults with traumatic brain injury: a nationwide longitudinal study. J Affect Disord. 2019;250:21–25. doi:10.1016/j.jad.2019.02.059
16. Gardner W, Pajer K, Cloutier P, et al. Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study. CMAJ. 2019;191(44):E1207–E1216. doi:10.1503/cmaj.190188
17. Ganson KT, O'Connor J, Benabou SE, Nagata JM. Associations between interpersonal violence victimisation and concussions among US college students. Health Soc Care Community. 30(1):175–183. doi:10.1111/hsc.13387
18. O'Sullivan M, Glorney E, Sterr A, Oddy M, da Silva Ramos S. Traumatic brain injury and violent behavior in females: a systematic review. Aggress Violent Behav. 2015;25:54–64. doi:10.1016/j.avb.2015.07.006
19. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. doi:10.1186/s12874-018-0611-x
20. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–473. doi:10.7326/M18-0850
21. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. doi:10.1186/1748-5908-5-69
22. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. doi:10.1080/1364557032000119616
23. Canadian Agency for Drugs and Technology in Health. Grey matters: a practical tool for searching health-related grey literature [Internet]. Published 2018. Accessed October 22, 2019. https://www.cadth.ca/resources/finding-evidence/grey-matters
24. Bramer WM, Giustini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc. 2016;104(3):240–243. doi:10.3163/1536-5050.104.3.014
25. Veritas Health Innovation. Covidence Systematic Review Software. www.covidence.org
26. Lindquist LK, Love HC, Elbogen EB. Traumatic brain injury in Iraq and Afghanistan veterans: new results from a national random sample study. J Neuropsychiatry Clin Neurosci. 2017;29(3):254–259. doi:10.1176/appi.neuropsych.16050100
27. Armistead-Jehle P, Soble JR, Cooper DB, Belanger HG. Unique aspects of traumatic brain injury in military and veteran populations. Phys Med Rehabil Clin N Am. 2017;28(2):323–337. doi:10.1016/j.pmr.2016.12.008
28. Carlson KF, Nelson D, Orazem RJ, Nugent S, Cifu DX, Sayer NA. Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. J Trauma Stress. 2010;23(1):17–24. doi:10.1002/jts.20483
29. Burg JS, Williams R, Burright RG, Donovick PJ. Psychiatric treatment outcome following traumatic brain injury. Brain Inj. 2000;14(6):513–533. doi:10.1080/026990500120439
30. Burg JS. Psychiatric treatment outcome following traumatic brain injury. Dissertation Abstracts Int Section B Sci Engineering. 1997;57(12-B):7717.
31. Albicini M, Eggleston M, McKinlay A. The prevalence of traumatic brain injury, comorbid anxiety and other psychiatric disorders in an outpatient child and adolescent mental health service. J Ment Health. 2020;29(4):439–445. doi:10.1080/09638237.2017.1385733
32. Burg JS, McGuire LM, Burright RG, Donovick PJ. Prevalence of traumatic brain injury in an inpatient psychiatric population. J Clin Psychol Med Settings. 1996;3(3):243–251. doi:10.1007/BF01993910
33. Dinn WM, Gansler DA, Moczynski N, Fulwiler C. Brain dysfunction and community violence in patients with major mental illness. Crim Justice Behav. 2009;36(2):117–136. doi:10.1177/0093854808327507
34. Doherty SM, Craig R, Gardani M, McMillan TM. Head injury in asylum seekers and refugees referred with psychological trauma. Glob Ment Health (Camb). 2016;3:e28. doi:10.1017/gmh.2016.23
35. Drange OK, Vaaler AE, Morken G, Andreassen OA, Malt UF, Finseth PI. Clinical characteristics of patients with bipolar disorder and premorbid traumatic brain injury: a cross-sectional study. Int J Bipolar Disord. 2018;6(1):19. doi:10.1186/s40345-018-0128-6
36. Fox DD, Lees-Haley PR, Earnest K, Dolezal-Wood S. Post-concussive symptoms: base rates and etiology in psychiatric patients. Clin Neuropsychol. 1995;9(1):89–92. doi:10.1080/13854049508402064
37. Gargaro J, Gerber GJ, Nir P. Brain injury in persons with serious mental illness who have a history of chronic homelessness: could this impact how services are delivered? Can J Community Ment Health. 2016;35(2):69–77. doi:10.7870/cjcmh-2016-034
38. Graves AB, White E, Koepsell TD, et al. The association between head trauma and Alzheimer's disease. Am J Epidemiol. 1990;131(3):491–501. doi:10.1093/oxfordjournals.aje.a115523
39. Holtzer R, Burright RG, Lynn SJ, Donovick PJ. Behavioural differences between psychiatric patients with confirmed versus non-confirmed traumatic brain injuries. Brain Inj. 2000;14(11):959–973. doi:10.1080/02699050050191904
40. Hux K, Schneider T, Bennett K. Screening for traumatic brain injury. Brain Inj. 2009;23(1):8–14. doi:10.1080/02699050802590353
41. Mateo MA, Glod CA, Hennen J, Price BH, Merrill N. Mild traumatic brain injury in psychiatric inpatients. J Neurosci Nurs. 2005;37(1):28–33. doi:10.1097/01376517-200502000-00005
42. Max JE, Dunisch DL. Traumatic brain injury in a child psychiatry outpatient clinic: a controlled study. J Am Acad Child Adolesc Psychiatry. 1997;36(3):404–411. doi:10.1097/00004583-199703000-00020
43. Max JE, Sharma A, Qurashi MI. Traumatic brain injury in a child psychiatry inpatient population: a controlled study. J Am Acad Child Adolesc Psychiatry. 1997;36(11):1595–1601. doi:10.1016/S0890-8567(09)66570-9
44. McGuire LM, Burright RG, Williams R, Donovick PJ. Prevalence of traumatic brain injury in psychiatric and non-psychiatric subjects. Brain Inj. 1998;12(3):207–214. doi:10.1080/026990598122683
45. Murrey GJ, Starzinski DT, LeBlanc AJ. Base rates of traumatic brain injury history in adults admitted to state psychiatric hospitals: a 3-year study. Rehabil Psychol. 2004;49(3):259–261. doi:10.1037/0090-5550.49.3.259
46. Poppe CJ. Neuropsychological functioning in acute, depressed psychiatric patients with and without a reported history of TBI. Dissertation Abstracts Int Section B Sci Engineering. 2003;63(8-B):3934.
47. Salloum IM, Jenkins EJ, Thompson B, Levi D, Burnett Y. Treatment compliance and hostility levels of head-injured psychiatric outpatients. J Natl Med Assoc. 1990;82(8):557–564.
48. Schneeberger AR, Muenzenmaier KH, Battaglia J, Castille D, Link BG. Childhood abuse, head injuries, and use of medical emergency services in people with severe mental Illness. J Aggress Maltreat Trauma. 2012;21(5):570–582. doi:10.1080/10926771.2012.678468
49. Walker R, Cole JE, Logan TK, Corrigan JD. Screening substance abuse treatment clients for traumatic brain injury: prevalence and characteristics. J Head Trauma Rehabil. 2007;22(6):360–367. doi:10.1097/01.HTR.0000300231.90619.50
50. Sacks AL, Fenske CL, Gordon WA, et al. Co-morbidity of substance abuse and traumatic brain injury. J Dual Diagn. 2009;5(3/4):404–417. doi:10.1080/15504260903182755
51. Malloy P, Noel N, Longabaugh R, Beattie M. Determinants of neuropsychological impairment in antisocial substance abusers. Addict Behav. 1990;15(5):431–438. doi:10.1016/0306-4603(90)90029-w
52. Murrey GJ, Dallas R, Maki A. History of reported head trauma in a sample of women in substance abuse treatment. Am J Drug Alcohol Abuse. 2007;33(2):327–332. doi:10.1080/00952990601175110
53. Felde AB, Westermeyer J, Thuras P. Co-morbid traumatic brain injury and substance use disorder: childhood predictors and adult correlates. Brain Inj. 2006;20(1):41–49. doi:10.1080/02699050500309718
54. McHugo GJ, Krassenbaum S, Donley S, Corrigan JD, Bogner J, Drake RE. The prevalence of traumatic brain injury among people with co-occurring mental health and substance use disorders. J Head Trauma Rehabil. 2017;32(3):E65–E74. doi:10.1097/HTR.0000000000000249
55. Corrigan JD, Deutschle JJ Jr. The presence and impact of traumatic brain injury among clients in treatment for co-occurring mental illness and substance abuse. Brain Inj. 2008;22(3):223–231. doi:10.1080/02699050801938967
56. Colantonio A, Stamenova V, Abramowitz C, Clarke D, Christensen B. Brain injury in a forensic psychiatry population. Brain Inj. 2007;21(13/14):1353–1360.
57. Hawley CA, Maden A. Mentally disordered offenders with a history of previous head injury: are they more difficult to discharge? Brain Injur. 2003;17(9):743–758. doi:10.1080/0269905031000089341
58. Frost RB, Farrer TJ, Primosch M, Hedges DW. Prevalence of traumatic brain injury in the general adult population: a meta-analysis. Neuroepidemiology. 2013;40(3):154–159. doi:10.1159/000343275
59. Osborn AJ, Mathias JL, Fairweather-Schmidt AK, Anstey KJ. Anxiety and comorbid depression following traumatic brain injury in a community-based sample of young, middle-aged and older adults. J Affect Disord. 2017;213:214–221. doi:10.1016/j.jad.2016.09.045
60. Gardner RC, Langa KM, Yaffe K. Subjective and objective cognitive function among older adults with a history of traumatic brain injury: a population-based cohort study. PLoS Med. 2017;14(3):e1002246. doi:10.1371/journal.pmed.1002246
61. Kumar RG, Ornstein KA, Bollens-Lund E, et al. Lifetime history of traumatic brain injury is associated with increased loneliness in adults: a US nationally representative study. Int J Geriatr Psychiatry. 2020;35(5):553–563. doi:10.1002/gps.5271
62. Corrigan JD, Yang J, Singichetti B, Manchester K, Bogner J. Lifetime prevalence of traumatic brain injury with loss of consciousness. Inj Prev. 2018;24(6):396–404. doi:10.1136/injuryprev-2017-042371
63. Allely CS. Prevalence and assessment of traumatic brain injury in prison inmates: a systematic PRISMA review. Brain Injur. 2016;30(10):1161–1180. doi:10.1080/02699052.2016.1191674
64. Stubbs JL, Thornton AE, Sevick JM, et al. Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis. Lancet Public Health. 2020;5(1):e19–e32. doi:10.1016/S2468-2667(19)30188-4
65. Demakis GJ, Rimland CA. Untreated mild traumatic brain injury in a young adult population. Arch Clin Neuropsychol. 2010;25(3):191–196. doi:10.1093/arclin/acq004
66. Setnik L, Bazarian JJ. The characteristics of patients who do not seek medical treatment for traumatic brain injury. Brain Inj. 2007;21(1):1–9. doi:10.1080/02699050601111419
67. Chadwick A, Street C, McAndrew S, Deacon M. Minding our own bodies: reviewing the literature regarding the perceptions of service users diagnosed with serious mental illness on barriers to accessing physical health care. Int J Ment Health Nurs. 2012;21(3):211–219. doi:10.1111/j.1447-0349.2011.00807.x
68. Corrigan JD, Bogner J. Preface: Screening and identification of TBI. J Head Trauma Rehabil. 2007;22(6):315–317.
69. Diamond PM, Harzke AJ, Magaletta PR, Cummins AG, Frankowski R. Screening for traumatic brain injury in an offender sample: A first look at the reliability and validity of the Traumatic Brain Injury Questionnaire. J Head Trauma Rehabil. 2007;22(6):330–338. doi:10.1097/01.HTR.0000300228.05867.5c
70. Fazel S, Lichtenstein P, Grann M, Långström N. Risk of violent crime in individuals with epilepsy and traumatic brain injury: a 35-year Swedish population study. PLoS Med. 2011;8(12):e1001150. doi:10.1371/journal.pmed.1001150
71. Harrison-Felix C, Pretz C, Hammond FM, et al. Life expectancy after inpatient rehabilitation for traumatic brain injury in the United States. J Neurotrauma. 2015;32(23):1893–1901. doi:10.1089/neu.2014.3353
72. Bjork JM, Grant SJ. Does traumatic brain injury increase risk for substance abuse? J Neurotrauma. 2009;26(7):1077–1082. doi:10.1089/neu.2008.0849
73. Weil ZM, Corrigan JD, Karelina K. Alcohol use disorder and traumatic brain injury. Alcohol Res. 2018;39(2):171–180.
74. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association; 2013.
75. Gallagher M, McLeod HJ, McMillan TM. A systematic review of recommended modifications of CBT for people with cognitive impairments following brain injury. Neuropsychol Rehabil. 2019;29(1):1–21. doi:10.1080/09602011.2016.1258367
76. Rao DP, McFaull S, Thompson W, Jayaraman GC. Trends in self-reported traumatic brain injury among Canadians, 2005-2014: a repeated cross-sectional analysis. CMAJ Open. 2017;5(2):E301–E307. doi:10.9778/cmajo.20160115
77. Mollayeva T, Mollayeva S, Colantonio A. Traumatic brain injury: sex, gender and intersecting vulnerabilities. Nat Rev Neurol. 2018;14(12):711–722. doi:10.1038/s41582-018-0091-y
78. Zemek RL, Grool AM, Rodriguez Duque D, et al. Annual and seasonal trends in ambulatory visits for pediatric concussion in Ontario between 2003 and 2013. J Pediatr. 2017;181:222–228.e2. doi:10.1016/j.jpeds.2016.10.067
79. Zhang AL, Sing DC, Rugg CM, Feeley BT, Senter C. The rise of concussion in the adolescent population. Orthop J Sports Med. 2016;4(8):232596711666245. doi:10.1177/2325967116662458
80. de Girolamo G, Dagani J, Purcell R, Cocchi A, McGorry PD. Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles. Epidemiol Psychiatr Sci. 2012;21(1):47–57. doi:10.1017/S2045796011000746
81. Jones PB. Adult mental health disorders and their age at onset. Br J Psychiatry Suppl. 2013;54:s5–s10. doi:10.1192/bjp.bp.112.119164
82. Solmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. Published online Jun 2, 2021. doi:10.1038/s41380-021-01161-7
83. Stubbs B, Perara G, Koyanagi A, et al. Risk of hospitalized falls and hip fractures in 22,103 older adults receiving mental health care vs 161,603 controls: a large cohort study. J Am Med Dir Assoc. 2020;21(12):1893–1899. doi:10.1016/j.jamda.2020.03.005
Keywords:

addiction; concussion; mental health; prevalence; psychiatry; traumatic brain injury; substance use; screening

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