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Written evidence submitted by Blind Veterans UK and UK Acquired Brain Injury Forum

 

Traumatic Brain Injury and Mental Health Implications in Veterans

 

Written evidence submission by Dr Renata SM Gomes1 and Dr Michael J Grey2,3

1 Blind Veterans UK; 2 UK Acquired Brain Injury Forum; 3 Acquired Brain Injury Research Alliance, University of East Anglia

Executive Summary

Traumatic brain injury (TBI) is an intracranial injury that can result from impact, penetration or blast, which manifests in brain dysfunction or pathology. It is an acquired injury occurring frequently in the military setting, with mild TBI (mTBI) widely acknowledged as the signature injury of our recent conflicts in Iraq and Afghanistan. The most common mTBI symptoms are headache, confusion, dizziness, blurred vision, fatigue, insomnia, and difficulties with concentration and attention. TBI and Post-Traumatic Stress Disorder (PTSD) share many common symptoms and both may be present in the same individual.

mTBI can be followed by a large variety of persistent physical, cognitive and/or emotional symptoms known as post concussion syndrome (PCS). The effects of PCS are related to the severity of injury, repetitive exposures, and time between successive insults. Increasing evidence suggests repetitive mTBI can produce long-term degradation of brain nerve cells and their connections, thus accelerating age-related neurodegeneration and dementia.

Given the importance of TBI to veterans and serving personnel, there is significant scarcity on prevalence data. Further veteran-focussed research would begin to fill these knowledge gaps; robust testing, potentially with regular cognitive and depression screening would facilitate the early detection of mental health problems; researchers and clinicians would benefit from access to anonymised data; and increased awareness about TBI when addressing PTSD and mental health complications would improve veterans’ treatment.

Background

Blind Veterans UK (BVUK) helps blind ex-Service men and women lead independent and fulfilling lives by supporting them with our in-depth expertise, experience and comprehensive range of services. We give veterans much-needed, life-long support to adjust to sight loss, overcome the challenges of blindness and enjoy daily life. Our charity has been offering physical and emotional support to vision-impaired veterans since 1915.

 

The UK Acquired Brain Injury Forum (UKABIF) aims to promote better understanding of all aspects of Acquired Brain Injury; to educate, inform and provide networking opportunities for professionals, service providers, planners and policy makers and to campaign for better services in the UK.  UKABIF is a membership organisation and charity, established in 1998 by a coalition of organisations working in the field of Acquired Brain Injury.

BVUK and UKABIF are collaborating on acquired brain injury research, specifically looking at sight loss as a consequence of traumatic brain injury (TBI) and mental health implications.

Traumatic Brain Injury

Traumatic brain injury (TBI) is an intracranial injury that can result from impact, penetration or blast, which manifests in brain dysfunction or pathology.1,2 It is an acquired injury that occurs frequently in the military setting, with mild TBI (mTBI) often characterised as the signature injury of our recent conflicts in Iraq and Afghanistan.3 In the military, blast TBI is particularly prevalent due to improvised explosive devices (IED), whilst blunt TBI is common both in-theatre and in training (sport, road traffic accidents etc.).

TBI is classified primarily based on the severity of injury as mild, moderate or severe, with the severity of the consequences (physical, cognitive, emotional and behavioural) being directly linked to the level of injury.4 mTBI accounts for more than 80% of the TBI cases but is it the least well understood.5 It has a complex pathology and is difficult to diagnose partly because the multifaceted pathology leads to the wide range of symptoms and partly because the clinician must rely to a large extent on self-reporting of symptoms.

The most common mTBI symptoms are headache, confusion, dizziness, blurred vision, fatigue, insomnia, and difficulties with concentration and attention.6 Diagnosis of mTBI is exacerbated by the fact that it requires the individual to report symptoms. However, there exists a strong set of military values that put that emphasis the needs of the group over personal needs, therefore seemingly mild injuries may go unreported. In this respect military personnel are similar to elite athletes in which there is a culture not to report mTBI for fear of letting down the group.7,8 As a result, many mTBI injuries are likely not reported. Whilst the vast majority of mTBI resolves quickly if the brain is allowed to rest, it can be followed by a large variety of persistent physical, cognitive and/or emotional symptoms collectively known as post concussion syndrome (PCS). The effects of PCS are related to the severity of injury, repetitive exposures, and the time between successive insults. Increasing evidence suggests repetitive mTBI produces long-term gray matter (nerve cell bodies) and white matter (nerve tracts) degeneration (i.e. both loss of nerve cells and their ability to communicate with one another). Furthermore, repetitive mTBIs may precipitate or accelerate age-related neurodegeneration, including chronic traumatic encephalopathy (CTE), a form of dementia.9,10 Whilst this is a growing area of research, there remains a scarcity of data on the prevalence of chronic TBI with persisting symptoms, particularly with respect to individuals who sustain multiple mTBIs. 

Traumatic Brain Injury and Mental Health Implications

There has been considerable recent literature investigating the link between TBI/PCS and post-traumatic stress disorder (PTSD). In contrast to TBI/PCS, post-traumatic stress disorder (PTSD) is a psychiatric disorder resulting from a maladaptive stress response to a traumatic event. Whilst TBI/PCS and PTSD are distinctly different disorders, they present with similar symptoms including confusion, poor concentration, irritability, fatigue, and insomnia (see Figure 1),11 ,12 and they share comorbidities such as depression and alcoholism.13,14 Both disorders are prevalent in the military and veteran populations and it may be difficult to distinguish between them as they can occur at the same time.15  As a result, brain injuries can be misdiagnosed as PTSD, thus making treatment and recovery more difficult.


Currently, neither the PTSD NICE guidelines nor the Royal College General Practitioners leaflet for Veterans mention TBI. In contrast, the American Psychiatric Association’s DSM 5 addresses both TBI and PTSD under the section for trauma- and stressor-related disorders. As a result, it is arguable that information that may be important for veterans’ mental health may not be reaching the NHS health care professionals charged with their care once they leave the military. In a recent publication from the TRACK-TBI study, Seabury et al., highlighted a shocking lack of follow-up PCS care for patients admitted to A&E with TBI.16 Only 44% of their patient sample were seen by a doctor within three months of discharge following TBI, with fewer than 7% seen by a head injury specialist. Furthermore, only half of the patients were discharged with TBI education material. It is therefore reasonable to speculate that statistics for veterans will be even worse as they transition from military to civilian care.

Moderate and severe TBI can be detected with structural and function neuroimaging. For example, advanced neuroimaging has been used to detect progressive gray matter (nerve cell bodies) and white matter tract (information pathways between nerve cells in the brain) degradation associated with moderate and severe TBI. It is not currently possible to use structural or functional neuroimaging to detect mTBI. Whilst proton magnetic resonance spectroscopy (1H MRS) can detect mTBI in the acute stage, these scans return to normal levels within days to weeks following injury.17 Therefore, PCS cannot be detected with neuroimaging. Similarly, neuroimaging cannot be used to diagnose CTE, at present, with conclusive diagnosis requiring post-mortem histological examination. However, promising research involving advanced imaging techniques is being pursued to detect CTE in vivo and it is reasonable to expect a breakthrough in this area within the next few years. In some cases structural and/or functional neuroimaging can show changes in the brain associated with PTSD. However, the regions of the brain that are implicated with PTSD are the same regions that are implicated with moderate and severe TBI, therefore neuroimaging alone cannot be used to differentiate between the two disorders.

The prevalence of TBI and PTSD in veterans has led many to believe that these two conditions are linked.13,18 Veterans with PTSD have twice the incidence and prevalence of being diagnosed with dementia as those without PTSD, but it is unclear if PTSD itself is a risk factor for dementia or if PTSD and dementia have common underlying risk factors.19,20  Furthermore, it has been suggested that TBI may predispose the individual to PTSD.21

There is now evidence linking moderate and severe TBI to neurodegeneration and early-onset dementia and many are hypothesising that both repetitive mTBI or even repetitive sub-concussive exposure increases this.9,15,22,23 It is important to note that the onset of dementia can greatly exacerbate the effects of PTSD.24 It has also shown that upon developing Alzheimer’s Disease, many of those who had previously experienced PTSD demonstrated a re-occurrence or worsening of PTSD symptoms suggesting a bidirectional link between dementia and PTSD. 20 Given the clear links between TBI and dementia, further research in the veteran population is required in order to determine the extent of the relationship between PTSD and dementia.

It is well-established that early diagnosis of dementia is beneficial to allow the best possible treatment and management plan. In 2015, the International Association of Gerontology and Geriatrics published a consensus paper recommending that all persons 70 years and older receive annual cognitive testing as a screen for dementia and depression.25 At present, many clinicians and researchers are advocating for universal screening, however, universal guidelines have not been yet been established. Given the greater risk of TBI-related mental health problems associated with veterans, we believe annual cognitive and depression screening would be advantageous.

Key recommendations

Research

There is a need to address evidence gaps. Additional research is needed to validate tests that would allow a clear differential diagnosis between TBI/PCS and PTSD. Further research is needed to provide the evidence-base that should include physiologic and neuropsychologic testing in addition to the current psychiatric assessment.

Given that the US Military deals with larger numbers of TBI and/or PTSD cases, and other allied Nations also research these areas, it would be highly beneficial to establish clear collaborative paths on this matter.

Awareness

There is a profound need to significantly increase awareness about TBI and its mental health implications among health care professionals, families and caregivers. Furthermore, better information should be available regarding TBI and PTSD in guidance notes supplied to healthcare professionals and within PTSD NICE guidelines.

Care Provision

Given that optimal recovery from PTSD requires prolonged treatment and/or treatment top ups26, a brain and eye health check could also be included as part of an early-screening process. Currently, the NHS offers an NHS health check, every 5 years for all those above the age of 40, although no brain or eye health check assessments are included. For Veterans, who are at greater risk of experiencing mental health and/or PCS issues the offer of serial assessment of brain and mental health should be considered.

Veterans who have TBI require a multidisciplinary approach to their rehabilitation, and a seamless integration between primary and secondary care. This can be facilitated by using the rehabilitation prescription mandated in the major trauma pathway as highlighted in the recent All Party Parliamentary Group on Acquired Brain Injury Report. Furthermore, greater efficiency is needed in the exchange of medical records from the military to civilian health care system for veterans who have transitioned out of the military.

 

6 December 2018

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