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Update on Traumatic Brain Injury

July 2, 2013
by Alison Knopf
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Vanessa Seaney and Walter Koroshetz

The first thing behavioral healthcare providers should know about TBI is that it is not a mental illness. It is a neurological disorder. But many behavioral healthcare patients – especially veterans – have it, and to make matters more complicated, it’s usually worse in patients who have depression or other mental health problems.

Vanessa Seaney, chief operating officer of the Community Partnership of Southern Arizona, the regional behavioral healthcare authority, calls traumatic brain injury (TBI) an “enigma” for the behavioral healthcare field. “First of all, we really don’t treat TBI independently,” said Seaney. Her program, a community mental health center, specializes in treating veterans. “But if they have TBI, we always work in collaboration with the Southern Arizona Veterans Administration Health Care Center,” she said. “We are not experts in TBI,” said Seaney. “We are experts in behavioral health.”

Seaney is fortunate in that the VA center is a “center of excellence” for polytrauma, treating TBI, post-traumatic stress disorder (PTSD), and other comorbid conditions. In her estimation, the VA centers are a repository of the best expertise on TBI.

In fact, TBI, even in its mild form (known as mTBI), needs to be taken seriously, and specialists such as those found in the VA centers must be consulted when patients are presenting with a history that includes a concussion, she said.

Walter Koroshetz, M.D., deputy director of the National Institute of Neurological Disorders and Stroke (NINDS) at the National Institutes of Health, couldn’t agree more. In the field, service members who have any level of TBI are sent to “concussion management centers,” to get them out of harm’s way, and to let the brain recover. Anyone suspected of having a TBI, such as being exposed to a blast, is immediately screened, he said. “The military is much more organized than civilian healthcare” when it comes to TBI, he said.

The VA has put together a comprehensive and supportive system to care for patients with TBI, said Koroshetz. This is more than care during the acute phase. “It really requires a multidisciplinary approach,” he said. Even patients who are in a behavioral healthcare setting need a neurologic evaluation to make sure something else isn’t going on, he said. At Walter Reed National Military Medical Center (Bethesda, Md.) there is a special unit, called the National Intrepid Center of Excellence, where veterans (active service members) with TBI  and PTSD – both of which have very similar symptoms at first – receive treatment.

Working with the VA – and without it
Where there is TBI, the VA can bring in a specialized multidisciplinary team, said Seaney. “The VA has the research, the focus, the subject matter experts to do this,” she noted. But some patients with TBI – including veterans – are on Medicaid and don’t qualify for VA benefits, said Seaney. They may have been in the National Guard or the Reserves. So those patients can’t access the VA system. “We established community-based programs for them, and work with other service providers to help them,” she said.

If patients give a history of TBI on their initial evaluation, they will have a comprehensive service plan which includes working closely with primary care, said Seaney. Even if they are not eligible for VA benefits, they will have a full assessment, she said. “With this client, we’re going to be working across systems, with behavioral and medical,” she said. “This is why integration is so important.”

And so far, what seems to make the biggest difference in outcomes is not a neurological treatment – because even diagnosis is still difficult – but a support system, a concept well known to behavioral healthcare. “The stronger the support system they get, the better they do,” said Koroshetz, who calls the National Intrepid Center of Excellence “Cadillac treatment” for people with a combination of PTSD and TBI.

In treatment, veterans learn what their weaknesses are and how to compensate for them. They learn what makes their symptoms worse – in particular, substance abuse. And then, they work on progressively increasing their physical activity. “Exercise seems to be really important,” said Koroshetz. “You shouldn’t overdo it, because that can make headaches and fatigue worse,” he said. “But if you don’t exercise at all, that’s not good.”

Post-concussion syndrome
The good news is that with TBI, outcomes can be excellent, said Koroshetz. “They come in in a coma, and a year later they’re walking around fine,” he said. “The ones who get worse are usually the ones who develop PTSD or depression. But with TBI, the rule is, you get better. The brain is trying to recover.”

The bigger problem for behavioral healthcare providers is not the management of the acute phase of a TBI, but the management of the after-effects, known as “post-concussion syndrome.” About 10 percent of people who have a mild TBI develop this syndrome.

Early symptoms of post-concussion syndrome – trouble with mood, volatility, poor executive function, sleep disorder, depression, and suicidality – look like many other behavioral conditions. “There are no hardcore neurological symptoms,” said Koroshetz. “For the behavioral healthcare folks, this is a real problem.”

“There is nothing wrong with treating the symptoms” of TBI, said Koroshetz. “But the question is, what is causing the symptoms?”

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