Assessment of comorbidities is essential for traumatic brain injury

In 2013, there were 282,000 hospitalizations related to traumatic brain injury (TBI) and 56,000 deaths, according to the Centers for Disease Control and Prevention (CDC). What’s unique about the injury is that the symptoms can often be misdiagnosed as behavioral health issues, while at the same time, TBI patients are at risk for comorbid depression and addiction disorders.

Clinicians might equate sports participation or military enlistment with TBI, but other populations can experience risk. For example, while 8.5% of the population overall reports TBI, the prevalence among those incarcerated has been reported as high as 87%, according to CDC.

“About 1.7 million people in the United States have traumatic brain injury, and about 80% of those are thought to be mild,” says Nicholas DePrima, PsyD, a psychologist and neuropsychologist at Palm Beach Neuroscience Institute and St. Mary's Medical Center. “But keep in mind that information is often collected in emergency rooms, so it might be an underestimation because some people might present with symptoms later on.”

Life expectancy for those with TBI is about nine years lower than the overall life expectancy.

Behavioral health

When considering risks, the behavioral health of a TBI patient must be evaluated both as a symptom of the injury and as a pre-existing condition. Some estimates indicate as many as half of the individuals with brain injury have some history of substance use disorder, and about 30% of brain injuries occur while under the influence of alcohol or substances, DePrima says. In addition, clinical teams must evaluate patients for attention deficit, learning disabilities, depression, stress and pain. SAMHSA also suggests that suicide risk must be assessed.

“Being under the influence can affect your balance, and falls can certainly lead to brain injury,” DePrima says. “Motor vehicle accidents can lead to brain injury, and being under the influence increases that risk. And when someone is under the influence, they might engage in violent behaviors.”

Among those presenting in the hospital for brain injury, about three-fourths have alcohol in their systems at the time, according to SAMHSA. Additionally, substance misuse is associated with recurrent TBI.

Recovery must be managed

According to DePrima, most brain injuries are temporary, with recovery times of weeks or months. However, the prevailing idea of a long rest after a concussion has been updated by experts, who now indicate that a briefer rest time of one to two days is often sufficient for most cases, followed by a gradual return to normal activity without exacerbating the head injury.

“Traditionally, you rest, rest, rest,” DePrima says. “But if you rest too much, you’re lying around inactive, which can increase depression, anxiety and sleep symptoms.”

The increased symptoms can be confused with symptoms from the initial head injury, he says. And comorbid conditions can make assessment even more challenging, so it’s imperative for clinicians to monitor recovery as well as providing the diagnosis.

Those with pre-existing substance misuse history are at risk to re-engage in substance use after a head injury to cope with pain, disability or emotional difficulties. It makes sense because the frontal lobe of the brain could be affected by the injury and impair judgment, resulting in risky or impulsive behavior. DePrima says lack of support or psychosocial factors could drive additional risk for brain injury patients with behavioral health disorders.

SAMHSA offers a publication for behavioral health clinicians treating TBI, which includes screening tools.