Update on Traumatic Brain Injury

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?”

Not long ago, concussions were thought to be something completely benign, said Koroshetz. “But things are changing pretty rapidly in this area,” he said. The post-concussion syndrome consists of persistent problems measured after three weeks. Symptoms of concussion include headache, fatigue, trouble with attention and concentration, and sleep disorder. And, when patients don’t get better, this affects their mood as well. “So now, there’s more attention being paid toward preventing the post-concussion syndrome from happening.”

Multiple concussions and tauopathy
There is no way to diagnose the chronic condition that comes from multiple hits to the head, said Koroshetz. But the condition has been known since 1928, when it was called dementia pugilista – a fancy word for being “punch drunk.” The dementia was caused by being punched in the head, not by drinking alcoholic punch. “They were boxers, and they were really impaired,” Korshetz said.

The brains of boxers and others with TBI have been studied after their deaths. Unfortunately, many of those deaths were due to suicide, said Koroshetz. What has been learned is that the brains are severely affected by tauopathy. Tau is a protein which has also been linked to Alzheimer’s. Tauopathy occurs when tau builds up in the brain, forming insoluble aggregates inside cells, said Koroshetz. “When it gets all over the brain, it causes neurodegeneration,” he said. The condition has been found in the brains of many football players who may never have had a loss of consciousness, but have had many hits to the head.

There are “tiny dots of tau deposition” in the brains of people who have died after multiple TBIs, he said. And in the brains of people who were more severely symptomatic, the dots are larger and more widespread, though they are not found throughout the brain.

Tau deposition may be far more common than is documented. So far, the chronic condition that follows multiple concussions has been described in only 70 people, said Koroshetz. But he cites the work of Thomas W. McAllister, M.D. of Harvard, who has studied football and hockey players by putting a monitor in their helmets. McAllister found that many of these athletes sustain more than 5,000 hits to the head in the course of a season, with most occurring during practice.

NINDS has a partnership with the National Football League, which is very interested in this issue. Researchers hope to study the brains of more people who have died after a history of multiple concussions. NINDS also hopes to submit these brains to neuroimaging facilities, which will use scans to determine ways to diagnose the condition. The goal is to be able to find some marker for tau, so that diagnosis can be done on living people and help can be delivered before it’s too late.