Risk of Traumatic Brain Injury, PostTraumatic Stress Disorder, and

Risk of Traumatic Brain Injury, PostTraumatic Stress Disorder, and Suicide in OEF/OIF Veterans Hal S. Wortzel, MD Director, Neuropsychiatric Consultation Services and Psychiatric Fellowship VISN 19 MIRECC, Denver Veterans Hospital Faculty, Program in Forensic Psychiatry and Neurobehavioral Disorders Program, University of Colorado, Department of Psychiatry

Objectives Operation Enduring Freedom/Operation Iraqi Freedom and Mental Health Veteran/Military Personnel and Suicide TBI and Suicide PTSD and Suicide

Projected U.S. Veterans Population: 23,067,000 {Female 1,824,000-8%} Total US Population 310,238,161 Number of Total Enrollees in VA Health Care System (FY 09): 8,061,000 http://www1.va.gov/VETDATA/PocketCard/4X6 summer10 sharepoint.pdf

1.9 million warriors have deployed for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)

“In times of war, there are collective and individuals shifts in perceptions, thought and behavior. All of this is necessary so that man [woman] is able to go to war. No one is immune to it.” HOW IS ONE TO COPE WITH THESE SHIFTS UPON RETURNING HOME? Vetter 2007

“What Kind of War-Zone Stressors Did Soldiers in Iraq Confront?” Preparedness (or lack thereof) Combat exposure Aftermath of battle Perceived threat Difficult living and work environment Perceived radiological, biological, and chemical weapons exposure Sexual or gender harassment Ethnocultural stressor Concerns about life and family disruptions Cozza et al. 2004 http://images.google.com/imgres?imgurl http:// www.defendamerica.mil/images/photos/may2006/ photoessays/pi051106a1.jpg&imgrefurl http:// www.defendamerica.mil/photoessays/may2006/ p051106a1.html&h 353&w 500&sz 19&hl en&start 16&u m 1&tbnid 1mIilHAUe7T8VM:&tbnh 92&tbnw 130&prev / images%3Fq%3Dsandstorm%2Biraq%26svnum

Mental Health Problems Post Deployment OIF (n 222,620) OEF (n 16,318) Combat Experiences (Any) 144,978 (65.1%) 7,499 (46.0%) Any MH Concern 42,506 (19.1%) 1,843 (11.3%) Suicidal Ideation Some – 2,411 (1.1%) A lot – 467 (.2%) Some – 107 (.7%) A lot – 20 (.1%) Psychiatric Hospitalization in the First Year Post Deployment 1,214 (5.9%) (Distinct Individuals) 45 (2.9%) (Distinct Individuals) Hoge, Auchterloine, & Milliken 2006

Approximately 1/3 of OIF veterans accessed mental health services in their first year post-deployment Hoge, Auchterloine & Milliken 2006

OEF/OIF and TBI TBI is most common physical injury for combatants in Afghanistan and Iraq explosion or blast injury is most common 2006 survey of more than 2,500 recently returned army infantry soldiers: 5% reported injuries with LOC during a yearlong deployment, 10% reported injuries with altered mental status RAND report with even higher rates: 19% with probable TBI on survey of almost 2,000 previously deployed service personnel. Terrio et al. with similarly high rate (23%) of clinician-confirmed TBI in a U.S. Army brigade combat team with at least one deployment 320,000 veterans have experienced a probable TBI during deployment Stein 2009

PTSD and OEF/OIF Exposure to combat greater among those deployed to Iraq The percentage of study subjects who met screening criteria for major depression, generalized anxiety disorder, or PTSD – Iraq 15.6%-17.1% – Afghanistan 11.2% Hoge et al. 2004

Alcohol Problems PostDeployment 11.8% for Active Duty 15.0% for Reserve/Guard Milliken, Auchterloine, & Hoge 2007

Army findings indicate that suicide is on the rise among Soldiers, with 2006 having the highest number of confirmed cases since 1990 Lorge 2008

5 years from 2005 to 2009, more than 1,100 members of the Armed Forces took their own lives, an average of 1 suicide every 36 hours Army Suicides more than doubled HTTP://WWW.PRNEWSWIRE.COM/NEWSRELEASES/JOINT-DOD-TASK-FORCERELEASES-REPORT-ON-PREVENTINGSUICIDE-IN-US-MILITARY-101313419.HTML

http://www.health.mil/dhb/downloads/ Suicide%20Prevention%20Task%20Force %20final%20report%208-23-10.pdf

Suicide and Army Suicide rate has continued to climb despite increased efforts and programs for suicide prevention and intervention Historically, being in the military was a protective factor for suicide – Military rate being well below the civilian rate Since 2005, the Army’s suicide rate has exceeded that of the U.S. civilian population http://www.health.mil/dhb/downloads/ Suicide%20Prevention%20Task%20Force %20final%20report%208-23-10.pdf

Veterans are Potentially at Increased Risk for Suicide Thompson (2002) Suicide rate 2-3X general population’s. Depression, psychotic disorders, and substance abuse associated. Price (2004) Major depression and drug dependence with largest effect on the timing of suicidality. Zivin (2007) Male, white race, substance abuse associated. Younger veterans (age 18-44) with higher rates. Service connection as protective factor. Desai (2007) Higher rates in younger and older veterans. Bipolar disorder with highest rates. PTSD/anxiety disorders marginally protective. 100 per capita increased spending 6% reduction in suicide. Kaplan (2007) Suicide rate 2X general population’s. White race, 12 years education, activity limitations with greater risk.

Kaplan (2007) Most prior authors used VA data National Health Interview Survey 1986-1994 Compared suicide risk veterans v. general population Nearly twice as likely to die of suicide (adjusted hazard ratio 2.04, 95% CI 1.10 to 3.80) Reflects risk among entire U.S. veteran population But what is the impact of OEF/OIF?

CBS “Suicide Epidemic” Sought data from all 50 states on death record suicides for vets and non-vets 45 states with 6256 veteran suicides in 2005 Reports age and gender adjusted suicide rates of 18.8-20.8 per 100,000 for vets vs. 8.9 per 100,000 in general population Vets age 20-24 with rates 2-4 times civilian rates (22.9-31.9 per 100,000 vs. 8.3 per 100,000)

TBI 101

General Definition of TBI Application to the brain of an external physical force or rapid acceleration and/or deceleration forces – not due to congenital, degenerative, vascular, hypoxic-ischemic, neoplastic, toxic-metabolic, infectious, or other causes Produces an immediately apparent physiological disruption of brain function manifested by cognitive or neurological impairments Results in partial or total functional disability (regardless of the duration of such disability)

American Congress of Rehabilitation Medicine Definition of Mild TBI: A traumatically induced physiological disruption of brain function, as manifested by at least one of the following: – any period of loss of consciousness (LOC) – any loss of memory for events immediately before or after the accident (posttraumatic amnesia, PTA) – any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused) – focal neurologic deficit(s) that may or may not be transient Kay, T., Harrington, D. E., Adams, R. E., Anderson, T. W., Berrol, S., Cicerone, K., Dahlberg, C., Gerber, D., Goka, R. S., Harley, J. P., Hilt, J., Horn, L. J., Lehmkuhl, D., & Malec, J. (1993). Definition of mild traumatic brain injury: Report from the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. Journal of Head Trauma Rehabilitation, 8(3), 86-87.

American Congress of Rehabilitation Medicine Definition of Mild TBI: The severity of the injury does not exceed the following: – LOC 30 minutes – after 30 minutes, Glasgow Coma Scale 13-15 – PTA 24 hours TBI producing disturbances that exceed these criteria is classified as moderate or severe

Posttraumatic Amnesia Trauma Encoding events Retrograde Amnesia LOC Posttraumatic Amnesia TIME Thanks John Kirk, PhD

Recovery from Mild TBI 1st week post-TBI: 90% (or more) endorse postconcussive symptoms 1 month post-TBI: 50% are recovered fully 3 months post-TBI: 66% are recovered fully 6-12 months post-TBI: 10% still symptomatic Those who remain symptomatic at 12 months are likely to continue experiencing postconcussive symptoms thereafter

Recovery from Moderate-to-Severe TBI About 35-60% of persons with moderate to severe TBI will develop chronic neurobehavioral and/or physical symptoms related to TBI – more severe initial injury increases the likelihood of incomplete neurological, neurobehavioral, and functional recovery Successful return to work and/or school is inversely related to the severity of persistent neurobehavioral and physical symptoms

Self-diagnosis of TBI “Gold standard” for diagnosis of TBI remains self-report and requires caution: – under-reporting vs. over-reporting – poor understanding of TBI – misunderstanding symptoms as reflective of TBI when other diagnoses offer better explanations – stigma vs. secondary gains Avoid missed opportunities to target other treatable conditions (PTSD, MDD, etc.)

Self-diagnosis of TBI mTBI without evidence in the medical record require careful evaluation of the history and other available evidence – use ACRM definition of mild TBI as an anchor for the clinical history – interview witnesses, if any, to the injury – review medical, neurological, and neuropsychological evaluations (including comparison to pre-injury whenever such data can be obtained) – review (by visual inspection, not just reports) any structural neuroimaging (CT, MRI) for findings consistent with traumatic brain injury Biomechanical trauma frequently co-occurs with psychological trauma, especially in combat settings

TBI in a VA Mental Health Setting TBI – 4 (n 509) Question # Yes % Yes Have you ever been hospitalized or treated in Have you an emergency ever been room knocked out following an or injury? (If yes) unconscious Did you injure following an your head or accident or neck? injury? 207 226 41% 44% Have you ever injured your head or neck in a car accident or Have you from some ever injured other moving your head or vehicle neck in a fight accident? or fall? 169 210 33% 41% Brenner, L., Homaifar, B., Huggins, J., Olson-Madden, J. , Harwood, J., Nagamoto, H. Use of a Traumatic Brain Injury Screen in a Veteran Mental Health Population: Prevalence, Validation and Psychiatric Outcomes

A Model of Influences on Neurobehavioral Outcome after TBI Pre-Injury Factors Cognitive Disturbance Emotional Disturbance Traumatic Brain Injury Post-Injury Psychosocial Factors Behavioral Disturbance Physical Disturbance (Adapted from Silver and Arciniegas 2006) Disturbed Consciousness Impaired Attention Slowed Processing Working Memory Problems Memory Disturbance Functional Communication Impairments Executive Dysfunction Depression Anxiety Irritability/Lability Rage Agitation Aggression Disinhibition Apathy Sleep Disturbance Headaches Pain Visual Problems Dizziness/Vertigo Seizures

Pre-Injury Factors Age and gender Baseline intellectual function Psychiatric problems & substance abuse Sociopathy “Risk-taking” and “novelty-seeking” behavior Premorbid behavioral problems Social circumstances and SES Neurogenetic (ie, APOE-4, COMT, ?other)

Injury Factors Biomechanical Injury – – – – – acceleration/deceleration translational/rotational angular acceleration/deceleration cavitation (“microexplosive”) diffuse axonal injury (DAI) Cytotoxic Injury – – – – – cytoskeletal & axonal injury disturbance of cell metabolism Ca and Mg dysregulation free radical release neurotransmitter excitotoxicity Secondary Injury – – – – traumatic hematomas cerebral edema hydrocephalus increased intracranial pressure (ICP) – systemic complications hypoxia/hypercapnia anemia electrolyte disturbance infection (Reviewed in: Meythaler et al. 2001; Nuwer 2005; Povlishock and Katz 2005; Bigler 2007)

Injury Factors: Translation, Rotation, & Angular Acceleration Forces Rotational force vector Translational force vector Center of mass Figure adapted from Arciniegas and Beresford 2001

Post-injury Factors Untoward medical complications Failure to receive timely medical, neurological, psychiatric, or other needed rehabilitative services – early engagement in neurorehabilitation is associated with improved functional outcomes Lack of education regarding the course of recovery and interpretation of symptoms Lack of family, friends, or resources to support recovery Premature return to work/school with ensuing failure to perform at expected levels Poor adjustment to or coping with disability by injured person or family Litigation or other legal entanglements

Posttraumatic Cognitive Impairments In the acute and late periods following TBI, the domains of cognition most commonly affected by TBI include: – arousal/disturbances of consciousness – processing speed/reaction time – attention (selective, sustained, alternating, divided) – working memory – memory (new learning, retrieval, or [usually] both) – functional communication (use of language) – executive function (Reviewed in: Bigler 2007; Arciniegas and Silver 2006; Nuwer 2005; Meythaler et al. 2001)

Common Posttraumatic Emotional and Behavioral Problems Depression Mania Pathological Laughing and Crying Anxiety Irritability or loss of temper (“rage episodes”) Disinhibition Agitation/Aggression (“socially inappropriate behavior”) Apathy (loss of drive to think, feel, and/or behave) Psychosis

Common Mild TBI/Posttraumatic Symptoms Headache Sleep Disturbances Fatigue Dizziness Light sensitivity Sound sensitivity Immediately post-injury 80% to 100% describe one or more symptoms Most individuals return to baseline functioning within a year Ferguson et al. 1999, Carroll et al. 2004; Levin et al. 1987

Common TBI Symptoms – NOT to be confused with the injury itself TBI is a historical event

Simpson & Tate (2007) Suicide risk compared to general population Standardized Mortality Ratios and 95% CI Males with TBI 3.9 3.13-4.59 Females with TBI 4.7 3.06-7.06 Age at injury 21 3.5 1.92-6.27 21-40 4.7 3.35-6.50 41-60 5.2 3.73-7.17 60 2.5 1.55-4.01 Concussion 3 2.82-3.25 (Severe) Lesion 4.1 3.33-4.93 Comorbid Substance Abuse 7.4 4.32-12.82

PTSD – A101 Review PTSD

Definition of PTSD An anxiety disorder resulting from exposure to an experience involving direct or indirect threat of serious harm or death; may be experienced alone (rape/assault) or in company of others (military combat) www.ncptsd.va.gov

DSM-IV Criteria - PTSD Re-experiencing symptoms (nightmares, intrusive thoughts) Avoidance of trauma cues and Numbing/detachment from others Hyperarousal (increased startle, hypervigilance) APA, 2000

Symptoms of PTSD Recurrent thoughts of the event Flashbacks/bad dreams Emotional numbness (“it don’t matter”); reduced interest or involvement in work our outside activities Intense guilt or worry/anxiety Angry outbursts and irritability Feeling “on edge,” hyperarousal/ hyper-alertness Avoidance of thoughts/situations that remind person of the trauma Depression APA, 1994

Potential Consequences of PTSD Social and Interpersonal Problems: - Relationship issues - Low self-esteem - Alcohol and substance abuse - Employment problems - Homelessness - Trouble with the law - Isolation www.ncptsd.va.gov

Those with PTSD at Increased Risk for Suicidal Behavior 14.9 times more likely to attempt suicide than those without PTSD (community sample) Davidson et al., 1991

Why? Veteran Population – Survivor guilt (Hendin and Haas, 1991) – Being an agent of killing (Fontana et al., 1992) – Intensity of sustaining a combat injury (Bullman and Kang, 1996)

Interface of TBI and PTSD Stein & McAllister 2009 Unfortunately, the overlap also seems to involve suicide risk.

Interpersonal-Psychological Theory of Suicide Risk Joiner 2005 Those who desire death Perceived Burdensomeness Failed Belongingness Suicidal Ideation Those capable of suicide Acquired Ability (Habituation) Serious Attempt or Death By Suicide

Aggression Suicide Kerr et al. (2007)

Shared Anatomy of TBI & PTSD This shared anatomy also implicates aggression Stein & McAllister 2009

“Across America, Deadly Echoes of Foreign Battles” January 13, 2008 Matthew Sepi, left, shot two people, one fatally, after he was confronted in a Las Vegas alley in 2005. Seth Strasburg, right, is serving a prison term of 22 to 36 years for shooting and killing Thomas Tiffany Varney on Dec. 31, 2005.

Cases, Victims, and Charges

Suicide Among Incarcerated Veterans Incarcerated Population Suicide Risk ? Veteran Population Incarcerated Veterans lie at the intersection of two populations with elevated suicide rates. The risk incurred by this status remains unknown. Wortzel HS, Binswanger IA, Anderson CA, Adler L: Suicide Among Incarcerated Veterans. Journal of the American Academy of Psychiatry and the Law 37(1):82-91, 2009

Release from Prison — A High Risk of Death for Former Inmates Background Period immediately after release may be challenging for former inmates and involve substantial health risks. Binswanger et al. (2007) studied the risk of death among former inmates after release from Washington State prisons. Methods Retrospective cohort study of all inmates released from Washington State Department of Corrections from July 1999 through December 2003. Prison records linked to National Death Index. Mortality rates among former inmates compared with other state residents with indirect standardization and adjustment for age, sex, and race. Results Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. Overall mortality rate 777 deaths per 100,000 person-years. Adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During first 2 weeks after release, risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). Leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide. Conclusions Former prison inmates are at high risk for death after release from prison, particularly during first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison. N Engl J Med 2007;356:157-65

CRICC Grant: Veteran Status and the Risk of Death Following Release from Prison Principal Investigator: Hal S. Wortzel, MD Mentor: Ingrid A. Binswanger, MD, MPH Mentor: Lawrence E. Adler, MD Merge existing data base with VBA to identify Veterans and determine: 1) What is the mortality rate of Veterans after release from prison, and how does it vary over time? 2) Do Veterans have a higher risk of death after release from prison than non-Veterans? 3) Are Veterans more prone to specific causes of death (such as suicide) upon release? 4) Among Veterans released from prison, does service connection and VA benefits provide a protective effect? 5) Does the protective effect offered by service connection and VA benefits vary by cause of death?

Aggression as a Target for Suicidality Medical illness Substance Abuse Adverse Environment Depression Agitation Aggression Psychosis Anxiety Figure adapted from Silver 2005 Insomnia

Summary OEF/OIF veterans at high risk for TBI and PTSD TBI and PTSD both carry increased risk for suicide Need to identify and target these conditions with our best evidence-based practices Be particularly vigilant for depression and/or substance abuse in the setting of TBI and/or PTSD; both magnify suicide risk even further Assess hopelessness and suicidal ideation proactively in this population Recognize risk regardless of time post-injury Aggression, burdensomeness, and belongingness my be novel targets to engage and thereby enhance patient safety

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