The report is a product of the VA/HSR Evidence Synthesis Program.

A Systematic Review: Relationship of Deployment-related Mild TBI to Psychiatric Conditions

Approximately 10% of active duty service members deployed to Iraq and/or Afghanistan between 2003 and 2014 received a new diagnosis of traumatic brain injury (TBI) within three years of their return. From the start of required screening for this injury in 2007 through September 2016, more than one million Veterans were screened for TBI in the VA healthcare system: 83,318 Veterans were diagnosed with TBI, mostly mild TBI (mTBI).

Veterans who served in Iraq and/or Afghanistan also are at increased risk for psychiatric conditions including PTSD, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders. However, it is unknown whether these psychiatric conditions are more common among these service members and Veterans with a deployment-related TBI than among those without TBI — and whether mental illness treatment effectiveness varies based on TBI status. Therefore, this systematic review focused on the prevalence of psychiatric conditions and the effectiveness of mental health interventions in service members and Veterans with a history of deployment-related mTBI.

Investigators with VA's Evidence-based Synthesis Program (ESP) Center in Minneapolis, MN searched MEDLINE, PsycINFO, the Published International Literature on Traumatic Stress (PILOTS) database, VA HSR&D publications, and the Defense and Veterans Brain Injury Center (DVBIC) for English language publications indexed from 2000 to October 2017. They also reviewed suggested articles from Operational Partners and a five-member Technical Expert Panel (TEP) — both of which provided consultation and feedback. After screening 1,215 articles, 41 studies were included in this review.

Summary of Findings
Reports from national samples provide moderate-strength evidence of increased PTSD prevalence and low-strength evidence of increased prevalence of depressive disorders, substance use disorder, and anxiety disorders in active duty service members and Veterans with a history of mTBI compared to those with no TBI. In geographically diverse samples, results were generally similar. Overall, there was little reporting of the prevalence of suicidal ideation.

Specific findings from the national samples include

• No eligible studies reported PTSD prevalence for active-duty service members.
• Depressive disorders were more prevalent in Veterans and service members with a history of mTBI versus no-TBI. The differences ranged from 5% to 37%.
• Suicidal ideation was not reported. Only one study reported on the prevalence of attempted suicides, finding a higher prevalence in Veterans with a history of mTBI versus no-TBI.

Behavioral treatments for PTSD achieved minimal clinically important differences for changes in PTSD and depressive symptoms in Veterans with a history of TBI, with no indication of harm. Results from studies that included groups with and without a history of TBI suggest that TBI status does not affect treatment outcomes. Lacking usual care or wait-list control groups in the predominantly pre- to post-treatment studies, the strength of the evidence for the effectiveness of interventions for psychiatric conditions in service members and Veterans with a history of mTBI is insufficient. Some specific findings include:

• No randomized controlled trials (RCTs) evaluated pharmacologic or behavioral intervention effectiveness for the treatment of PTSD, depressive disorders, substance use disorder, suicidal ideation or attempts, or anxiety disorders in service members or Veterans with a history of deployment-related mTBI.
• Limited data from one pre-post study and two secondary analyses of RCTs, designed to examine the effectiveness of psychotherapy (i.e., prolonged exposure therapy, cognitive processing therapy, etc.) in Veterans who served in Iraq and/or Afghanistan, did not find a differential treatment effect in individuals with a history of TBI compared to those without a history of TBI.

Future Research
Future research is needed to address gaps in evaluating the prevalence, severity, and persistence of psychiatric conditions in service members and Veterans with and without a history of mTBI. A cohort study with in-person data collection by appropriately trained personnel, using validated measures, and including follow-up at regular time intervals would be useful. Ideally, baseline data from the time of entering military service, including relevant history prior to service, and details of TBI events and other exposures should be well-documented (i.e., etiology, duration of loss of consciousness if appropriate, etc). In addition, RCTs are needed to evaluate the effectiveness of interventions for psychiatric conditions, including physical, behavioral and pharmacological interventions, in service members and Veterans with a history of mTBI. Ideally, a trial would include both short- and long-term outcomes post-treatment, such as functioning and quality of life measures in addition to symptom measures. Finally, harms of interventions including physical, mental, financial, and opportunity costs are not known.

**A cyberseminar session titled "The Relationship of Mild TBI to PTSD, Depression, Substance Abuse, Suicidal Ideation, and Anxiety Disorders: A Systematic Review" will be held on Thursday, November 8, 2018 from 12:00pm to 1:00pm (ET). Register for this session.**

Reference
Greer N, Ackland P, Sayer N, Spoont M, Taylor B, MacDonald R, McKenzie L, Rosebush C, Wilt TJ. Relationship of Deployment-related Mild Traumatic Brain Injury to Posttraumatic Stress Disorder, Depressive Disorders, Substance Use Disorders, Suicidal Ideation, and Anxiety Disorders: A Systematic Review. VA ESP Project #09-009; 2018.

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http://vaww.hsrd.research.va.gov/publications/esp/tbi-mentalhealth.cfm
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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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