Returning Home from Iraq and Afghanistan Assessment of Readjustment Needs of Veterans, Service Members, and Their Families (2013) / Chapter Skim
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5 Screening, Assessment, and Treatment
5 Screening, Assessment, and Treatment
Pages 147-256
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, posttraumatic stress disorder (PTSD) , major depressive disorder (MDD)
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. That potentially presents opportunities for VA and DOD to collaborate with each other and with others in the field to advance clinical performance measurement aimed at improving the quality of mental health care and care for brain injury.
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TRAUMATIC BRAIN INJURY A TBI is the result of a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. In 2007, DOD formally defined TBI as a "traumatically induced structural injury or physiological disruption of brain function as a result of an external force" (DCoE, 2012e)
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This section's emphasis is on mild TBI, inasmuch as such cases are the most common and the most frequently underrecognized and undertreated. Department of Defense and Department of Veterans Affairs Guidance for Screening for Mild Traumatic Brain Injury Detecting mild TBI close to the time of injury is best for preventing symptoms, optimizing care, and improving outcomes; however, mild TBI can be difficult to identify.
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. The TBI screen used in the DOD health assessments is a modified version of the Brief Traumatic Brain Injury Screen (BTBIS)
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. BOX 5.1 TBI Screening Questions in DOD's PDHA and PDHRA 9.a.
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. VHA's screening tool, the Traumatic Brain Injury Screening Instrument (TBISI)
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. FIGURE 5.1 Flow chart for VHA screening and evaluation of possible traumatic brain injury in OEF and OIF veterans.
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. Brief Traumatic Brain Injury Screen Initial research with the BTBIS postdeployment TBI screen suggested that it was a reasonably accurate screening tool for TBI.
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Screening for Mild Traumatic Brain Injury This section presents information available to the committee on the extent to which DOD and VA are implementing and tracking screening procedures to identify possible TBI.
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. Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Mild Traumatic Brain Injury There is no biologic "gold standard" for diagnosing mild TBI.
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Mild Traumatic Brain Injury This section presents information available to the committee on the extent to which DOD and VA conduct followup and evaluation of service members and veterans who have positive TBI screens.
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. Department of Defense and Department of Veterans Affairs Guidance for Treatment for Mild Traumatic Brain Injury The DVBIC published its recommendations for the Acute Management of Mild TBI in Military Operational Settings in 2006 (DVBIC, 2006)
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VA/DOD Clinical Practice Guideline: Management of Concussion/Mild Traumatic Brain Injury (VA and DOD, 2009b) was designed to provide guidance for treatment more than 7 days after mild TBI.
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Recommendations for treatment of military personnel for mild TBI have been published for various aspects of management, such as the role of neuropsychology (McCrea et al., 2009) , rehabilitation psychology (McCrea et al., 2009)
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162 TABLE 5.1 Comparison of Department of Veterans Affairs and Department of Defense Guidelines with Other Guidelines for Mild Traumatic Brain Injury Aspect of Care VA/DOD DVBICa DCOEb ONFc 3rd ICC Sportsd NICEe Target population Military, Military in Military Civilians, Athletes Civilians with mild to postdeployment theater athletes severe TBI Postinjury period Over 7 days Acute Over 4–6 weeks Acute, subacute, Acute Acute covered chronic Overall treatment Comprehensive Testing, Case manage- Comprehensive Assessment, Assessment, strategy assessment, referral, ment assessment, management management en route management treatment management to and in emergency based on room symptoms Rates level of evidence supporting the recommendations Treatment of headache Pharmacologic, Pharmacologic, Including nonpharmacologic nonpharmacologic prophylactic pharmacotherapy Treatment of f memory SSRI, stimulants, SSRI, stimulants, Cognitive rest impairment, other nonpharmacologic nonpharmacologic cognitive methods methods symptoms Treatment of balance problems Treatment of irritability Treatment of sleep disturbance Treatment of mood changes
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acute stress PTSD, SUDs anxiety, PTSD, reaction SUDs, somatoform disorder a Defense and Veterans Brain Injury Center. b Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury.
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Treatment for Traumatic Brain Injury This section presents information available to the committee on the extent to which DOD and VA monitor and implement their treatment guidelines.
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Studies are also needed to address the extent to which DOD's use of civilian guideline recommendations for head CT scanning identify clinically significant brain injury in military settings. Of the guidelines reviewed, the VA/DOD and DCOE guidelines are the only ones that provide for specific pharmacologic and nonpharmacologic interventions.
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A substantial contribution to the body of literature on PTSD that is reflected in the present report is the recently published IOM report Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment (IOM, 2012)
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. Department of Defense and Department of Veterans Affairs Guidance for Screening for Posttraumatic Stress Disorder Evidence suggests that identifying PTSD early and referring people to treatment can decrease symptoms and lessen the severity of functional impairment (VA and DOD, 2010)
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SOURCE: VA and DOD, 2010. BOX 5.3 The Primary Care PTSD Screen In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: 1.
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Validity of Tools for Screening for Posttraumatic Stress Disorder A wide array of PTSD screening tools are available for identifying undiagnosed cases of PTSD (National Center for PTSD, 2004) , but there is little evidence to support recommending one PTSD screening tool over another (VA and DOD, 2010)
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Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Posttraumatic Stress Disorder Figure 5.3 shows the process presented in the VA/DOD guideline for managing the assessment and diagnosis of PTSD in patients who have a positive PTSD screen. For patients who screen positive for PTSD, the VA/DOD guideline states that clinicians should perform a comprehensive clinical assessment to obtain relevant information to guide accurate diagnosis and appropriate clinical decision making.
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However, the deployment health assessments and the RESPECT-Mil program use different scoring thresholds for purposes of diagnosis and treatment. According to clinician training materials for the DOD deployment health assessment, a PCL score of less than 30 means no PTSD symptoms, scores of 30–39 correspond to mild PTSD symptoms, scores of 40–49 correspond to moderate PTSD symptoms, and a score of 50 or more means severe PTSD symptoms (Vythilingam et al., 2010)
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As a result of the different definitions for symptom severity, the treatment recommendations are inconsistent between the deployment health assessment and the RESPECT-Mil programs.
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. See IOM's Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment for a discussion of those and other instruments used in screening for and assessment of PTSD (IOM, 2012)
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Although the PCL threshold recommended by VA is consistent with the thresholds reported in the literature, the committee is not aware of the evidence underlying the specific thresholds used in DOD's deployment health assessment and RESPECT-Mil programs. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Posttraumatic Stress Disorder This section presents the information on the extent to which DOD and VA conduct followup and evaluation of service members and veterans who have positive PTSD screens.
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Department of Defense and Department of Veterans Affairs Guidance for Treatment for Posttraumatic Stress Disorder In general, treatment for PTSD symptoms includes three broad intervention categories: psychotherapy (based on psychology techniques) , pharmacotherapy (using prescription medication)
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In addition, the guideline recommends the atypical antipsychotics risperidone or olanzapine as adjunctive treatment with antidepressants. Comparison of Guidelines for Treatment for Posttraumatic Stress Disorder In addition to the recommendations by the VA/DOD guideline, major CPGs for treatment for PTSD have been published by the American Psychiatric Association (APA)
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SCREENING, ASSESSMENT, AND TREATMENT 177 Treatment Modality VA/DOD APA NICE NHMRC ISTSS Relaxation C Dialectic behavioral therapy I Acceptance and I commitment therapy Family therapy I Pharmacotherapy Antidepressants SSRI A I B B A SNRI A I A Tricyclic and MOAIs B II B B A Mirtazapine B III B B A Nefazodone D A Anticonvulsants D III Not efficacious Antipsychotics Conventional I Atypical B (as adjunct) III A (as adjunct)
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. In addition, the earlier committee considered the evidence base for numerous other psychosocial therapies, including psychodynamic psychotherapy, brief eclectic psychotherapy, hypnosis, relaxation, stress inoculation training, interpersonal therapy, skills training in affect and interpersonal regulation, and group therapy.
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Implementation of Department of Defense and Department of Veterans Affairs Guidance for Treatment for Posttraumatic Stress Disorder This section presents information available to the present committee on the extent to which DOD and VA provide treatment for service members and veterans who have PTSD. There is a striking lack of data to inform conclusions about the extent to which PTSD treatments are offered, delivered, and completed and about whether they are leading to improved patient outcomes.
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Department of Veterans Affairs VA reports that there is no mechanism for tracking the delivery of evidence-based therapies in the VA centralized databases. The VHA is developing progress-note templates for CPT, PE, and other evidence-based treatments that will allow documentation of care in the computerized record in a manner that will facilitate the collection of centralized aggregate data (IOM, 2012)
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Chapter 4 presents the diagnostic criteria of MDD and gives details about the prevalence of MDD in the military and veteran populations. To assess the efficacy of current screening, assessment, and treatment approaches to MDD in DOD and VA, the committee reviewed the VA/DOD Clinical Practice Guideline for Management of Major Depressive Disorder (MDD)
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Patients who screen positive on the PHQ-2 should be given a more detailed quantitative questionnaire and a full clinical interview that includes evaluation for suicide risk.
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The reminder presents the two PHQ-2 questions; a cutoff score of 3 is used to define a positive screen. Veterans who screen positive are assessed for suicide risk and then, if it is warranted, evaluated by either a primary care provider or a mental-health specialist.
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Implementation of Department of Defense and Department of Veterans Affairs Guidance for Screening for Major Depressive Disorder This section presents information available to the committee on the extent to which DOD and VA are implementing and tracking screening procedures to identify MDD. The sparse data suggest that there is room for improvement in DOD and VA screening practices for MDD.
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. Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Major Depressive Disorder For patients who screen positive for depression, the VA/DOD guideline states that the primary care provider should perform a clinical interview that focuses on relevant history, physical and mental-status examinations, relevant laboratory tests, drug inventory, and comorbid conditions.
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. Any patient who has a PHQ-9 score over 10 or a response to question 9 of the PHQ9 other than "not at all" must have an assessment for suicide risk and disposition by a provider within a day of the positive screen (VA, 2007)
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. Department of Defense and Department of Veterans Affairs Guidance for Treatment for Major Depressive Disorder For initial treatment for mild or moderate MDD, the VA/ DOD guideline advocates the use of monotherapy -- either psychotherapy or pharmacotherapy with a single antidepressant.
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Patients who have severe MDD or any complicated MDD and comorbidities should be referred to specialty care for treatment. Figure 5.5 is the algorithm from the VA/DOD guideline for treatment for MDD in primary care.
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Among the possible complementary and alternative treatments, the guideline recommends the use of exercise as an adjunct to other empirically supported treatments for depression, particularly antidepressant medication. It recommends the consideration of light therapy for some patients who have MDD, particularly if they have seasonal affective disorder.
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TABLE 5.3 Summary of Guideline Recommendations for Treatment for Depression Treatment Modality VA/DOD APA NICE Psychotherapy Cognitive behavioral therapy (CBT) A I Interpersonal psychotherapy (IPT)
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However, a more recent systematic review of the evidence could not provide clear evidence supporting the augmentation of pharmacotherapy with psychotherapy in treatment for chronic depression (von Wolff et al., 2012)
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, taking place over 9–12 weeks. A synthesis of findings of systematic reviews and trials encompassing 1,716 patients who had MDD or depressive symptoms found that brief CBT and PST (up to eight sessions)
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. A recent systematic review and meta-analysis concluded that insufficient data are available to determine the efficacy of VNS (Martin and Martin-Sanchez, 2012)
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The one exception, as discussed above, is VA's emphasis on the use of ACT despite its lack of efficacy in treating for MDD. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Treatment for Major Depressive Disorder This section presents information available to the committee on the extent to which DOD and VA provide treatment for service members and veterans who have received a diagnosis of MDD.
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. Department of Veterans Affairs VA reports that there is no mechanism for tracking the delivery of evidence-based therapies in the VA centralized databases.
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For many, a SUD is a chronic disorder that requires multiple interventions and continuing monitoring. To assess the efficacy of current screening, assessment, and treatment approaches to SUDs in DOD and VA, the committee reviewed the VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders (SUD)
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. Department of Veterans Affairs VA provides SUD services in SUD-specific settings that include inpatient programs, residential rehabilitation treatment programs, outpatient programs that provide intensive treatment (at least 3 hours per day 3 days per week)
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. Department of Defense and Department of Veterans Affairs Guidance for Screening for Substance-Use Disorders The VA/DOD SUD guideline recommends universal screening for alcohol use; however, it does not recommend universal screening for other drug use, because there is a lack of evidence of the efficacy of screening for substances other than alcohol and tobacco (Polen et al., 2008)
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Brief interventions can be a single session or multiple sessions involving motivational interviewing techniques focused on drinkingrelated consequences and benefits of reducing alcohol use. The guideline recommends referral to specialty SUD care for addiction treatment for a patient who has an AUDIT-C score of 8 or higher or who meets one of the following criteria: needs additional evaluation, does not respond to brief intervention, has a DSM diagnosis of alcohol or other substance dependence, or has received previous treatment for SUDs.
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[E] Sidebar 4: When to Offer Referral to SUD Specialty Care 6 Provide brief intervention No (See sidebar 3)
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SOURCE: HHS, 2005. Department of Defense In DOD, routine alcohol screening with the AUDIT-C occurs during DOD's periodic health assessments, the PDHA and the PDHRA, which are briefly described in the introduction to this chapter.
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Department of Veterans Affairs VA implemented routine screening for alcohol misuse in 2004 and since 2006 has required that the AUDIT-C be used for screening in either an outpatient or an inpatient setting. VA policy stipulates that all veterans coming to VA for the first time must be screened for alcohol misuse and again annually for patients in primary care, appropriate medical specialty care settings, and mental-health care services (VA, 2008a)
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Screening for Substance-Use Disorders Below is information available to the committee on the extent to which DOD and VA are implementing and tracking screening procedures to identify possible SUD.
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was not statistically significant. Researchers noted one possible study limitation: the study sample reflects a period that preceded VA's implementation of a performance measure that requires documentation of brief intervention for patients who screen positive for alcohol misuse and the implementation of the electronic clinical reminder that facilitates appropriate screening and followup (Hawkins et al., 2010)
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FIGURE 5.7 Algorithm for SUD care in primary care.
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The guideline indicates that patients may be referred to specialty care on the basis of the following indications for treatment: an AUDIT-C score of 8 or more for men and women, hazardous use of a substance, substance abuse, substance dependence, risk of relapse, suspected or possible SUD, and mandated referral within DOD. The guideline identifies care-placement criteria that were developed by the American Society of Addiction Medicine (ASAM)
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, but further research is warranted. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Substance-Use Disorders This section presents information available to the committee on the extent to which DOD and VA conduct followup and evaluation of service members and veterans who have positive SUD screens.
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(2010) reported that half the veterans who screened positive for alcohol misuse had a documented brief intervention or referral to alcohol treatment.
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As adjunct interventions in pharmacotherapy, the guideline identifies cognitive behavioral therapy (CBT) and contingency management as effective psychosocial therapies for opioid dependence.
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Standard clinical practice for treatment for alcohol dependence supports the use of complementary approaches -- medications, professional counseling, and mutual help groups -- to address the neurobiologic, psychologic, and social aspects of alcohol dependence. Table 5.4 compares treatment recommendations of these guidelines and their various systems for indicating their strength.
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. Each guideline recommends naltrexone and acamprosate as first-line pharmacologic treatments for alcohol dependence.
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. The guidelines are in agreement that there is no evidence that combining any of the medications to treat alcohol dependence improves outcomes over the use of any one medication alone, according to the Combining Medications and Behavioral Interventions (COMBINE)
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Naltrexone C I NOTE: VA/DOD: A = good evidence that the intervention improved outcomes; B = a fair amount of evidence supported the use of the intervention; C = the working group did not make a recommendation for or against the routine use of the intervention as the risk-benefit ratio was too close to make a general recommendation; D = presence of evidence that either the intervention was harmful or the risks outweighed the benefits offered by it; I = evidence was lacking, of insufficient quality, or conflicting; therefore, a recommendation could not be made for or against providing the treatment routinely. APA: I = intervention recommended with substantial clinical confidence; II = intervention recommended with moderate clinical confidence; III = intervention recommended on the basis of individual circumstances.
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Treatment for Substance-Use Disorders This section presents information available to the committee on the extent to which DOD and VA provide treatment for service members and veterans who have diagnoses of SUD.
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received psychotherapy with documentation of relapse-prevention therapy, one-fourth (24.8%) in the SUD cohort that had opiate dependence had documentation that maintenance pharmacotherapy was offered or contraindicated within 30 days of a new treatment episode, and only 1.0% had documentation that they had received contingency management.
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. Regarding types of treatment interventions provided to veterans who are alcoholdependent, the Altarum–RAND evaluation found that 71.3% had documentation of a brief intervention, current specialty care, or a completed referral to specialty mental-health care during FY 2007 and that 16.4% had documentation in the medical record that pharmacotherapy (naltrexone, disulfiram, or acamprosate)
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Chapter 4 further defines the scope of the problem of suicide in military and veteran populations by presenting rates of suicide and suicide attempts; it also provides details about risk factors for suicide and suicidal ideation. In this section, to assess the efficacy of current screening, assessment, and treatment approaches for suicidal ideation, the committee examines a number of major clinical guidelines, policy directives, and research studies related to the management of suicidal ideation in DOD and VA populations.
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. Suicide Prevention The DOD and VA have many programs, policies, and interventions in place to prevent and manage suicidal ideation in service members and veterans.
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. Department of Defense and Department of Veterans Affairs Guidance for Screening for Suicidal Ideation In the absence of a joint VA/DOD CPG for the management of suicidal behavior, screening and assessment of suicidal ideation in VA and DOD is guided by a variety of policies and programs.
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Assess other risk factors for suicide, including interpersonal conflicts, Yes, no social isolation, current alcohol or substance abuse, hopelessness, severe agitation or anxiety, diagnosis of depression or other psychiatric disorder, recent loss, financial stress, legal disciplinary problems, serious physical illness SOURCE: Adapted from Vythilingam et al., 2010. According to DOD training materials for administering the periodic health assessments (Vythilingam et al., 2010)
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On the basis of insufficient evidence on the accuracy of screening tools in identifying suicide risk in the primary care setting, the USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. The USPSTF found that commonly used screening instruments -- the Scale for Suicidal Ideation, the Scale for Suicidal Ideation–Worst, and the Suicidal Ideation Questionnaire -- have not been validated for assessing suicide risk in primary care settings and that there has been little testing of the Symptom-Driven Diagnostic System for Primary Care (USPSTF, 2004)
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. Implementation of Department of Defense and Department of Veterans Affairs Guidance for Screening for Suicidal Ideation This section presents information available to the committee on the extent to which DOD and VA are implementing and tracking screening procedures to identify people who are at risk for suicide.
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Generally, the guidelines recommend the identification of risk factors and the use of a direct line of questioning to elicit details about suicidal thoughts and intent (for example, the VA/DOD MDD guideline recommends a group of questions modified from Hirschfeld and Russell, 1997)
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They analyzed medical records of 154 veterans who had TBI and documented instances of suicidal behavior in the 2 years after PAI administration. The results suggest that the PAI may assist in assessing suicide risk in those who have TBI, particularly when populationbased cutoffs are considered (on a score range of 0 to 20, a score of 15 or higher yields a sensitivity of 90.9% and a specificity of 95.1%)
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. Department of Defense and Department of Veterans Affairs Guidance for Treatment for Suicidal Ideation The Air Force MSB guide recommends that treatment plans specifically target suicidal symptoms and risk factors (Air Force Medical Operations Agency, undated)
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The VA/DOD guidelines for MDD, PTSD, and SUD address the sequencing of treatment for suicidal ideation in the context of comorbidity with these conditions. The guidelines indicate that if severe suicidality is identified during the clinical assessment, the clinician should first concentrate on management of suicide risk before initiating treatment for any other condition.
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. Although numerous studies have documented the efficacy of psychotherapy, especially CBT, in treating for mental disorders that increase suicide risk, such as MDD and PTSD, far fewer studies have documented the direct effects of therapy on suicidal behavior (IOM, 2002)
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Likewise, there is a recognized need to improve the training of VA and DOD health care providers and chaplains in assessing suicide risk. Interventions for suicidal ideation have focused principally on treatment for underlying psychiatric conditions.
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. Among military and veteran personnel, rates of comorbid diagnosis are high; the most common overlapping disorders are PTSD, SUD, MDD, and postconcussive symptoms attributed to mild TBI.
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. Department of Defense and Department of Veterans Affairs Guidance for Comorbid Conditions The various VA/DOD clinical guidelines reviewed by the committee acknowledge that few published trials can provide clinicians with guidance in treating for conditions that are complicated by comorbid illness.
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Of all the guidelines, the TBI guideline expresses this most directly: The expected outcome of intervention should be to improve the identified problem areas, rather than discover a disease etiology or "cure." The presence of comorbid psychiatric problems such as a major depressive episode, anxiety disorders (including post-traumatic stress disorder) , or substance abuse -- whether or not these are regarded as etiologically related to the mild TBI -- should be treated aggressively using appropriate psychotherapeutic and pharmacologic interventions (VA, 2009)
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As discussed later, the SUD guideline indicates that a growing body of research is demonstrating that integrated services produce better outcomes for people who have co-occurring disorders, particularly serious or complex conditions. Clinician Toolkits The Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury developed a clinical tool, Co-Occurring Conditions Toolkit: Mild Traumatic Brain Injury and
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Traumatic Brain Injury and Posttraumatic Stress Disorder In 2009, the VA Office of Mental Health Services (OMHS) and Office of Rehabilitation Services sponsored a consensus panel to make practice recommendations related to the diagnosis and management of PTSD, pain, and a history of mild TBI in veterans.
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. Posttraumatic Stress Disorder and Substance-Use Disorder In 2009, VA's OMHS convened a consensus panel to develop recommendations related to the clinical management of veterans who had comorbid SUD and PTSD.
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(2011) identified studies of the effectiveness of various integrated treatment approaches for veterans for combinations of pain, mild TBI, and PTSD, including cognitive processing therapy (CPT)
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Summary The co-occurrence of mental-health problems or the combination of mental-health problems with neurologic disorders places additional demands on treatments designed for one of these conditions in isolation. The current literature emphasizes the need for research to develop an evidence base and identify best practices for patients who have comorbid conditions.
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However, there are gaps in the empirical base that warrant additional systematic research: Studies of the psychometric properties of screening and assessment instruments to determine appropriate screening and diagnostic thresholds specifically for VA and DOD populations, determine the validity and reliability of VHA's TBI screening tool, and determine the accuracy of the DOD head computed-tomography guidelines (adapted from American College of Emergency Physicians guidelines) for detecting clinically significant brain injury in theater.
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The committee recommends that the Department of Defense and the Department of Veterans Affairs select instruments and their thresholds for mental-health screening and assessment in a standardized way on the basis of the best available evidence. The committee also recommends that the two departments ensure that treatment offerings are aligned with the evidence base, particularly before national rollouts, and that all patients consistently receive first-line treatments as indicated.
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. The committee recommends that the Department of Defense and the Department of Veterans Affairs conduct systematic assessments to determine whether screening and treatment interventions are being implemented according to clinical guidelines and department policy.
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2008. Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat.
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2009. Assessment and diagnosis of mild traumatic brain injury, posttraumatic stress disorder, and other polytrauma conditions: Burden of adversity hypothesis.
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2011. Prevalence, assessment and treatment of mild traumatic brain injury and posttraumatic stress disorder: A systematic review of the evidence.
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2011c. Co-Occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health, Revised September 2011.
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2009. Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury.
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2011a. Report to Congress on Expenditures for Activities on Traumatic Brain Injury and Psychological Health, Including Posttraumatic Stress Disorder, for 2010.
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2008. VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain.
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2010. Cognitive rehabilitation for military personnel with mild traumatic brain injury and chronic post-concussional disorder: Results of April 2009 consensus conference.
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2010. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the veterans health administration.
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2009. An integrated review of recovery after mild traumatic brain injury (mTBI)
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2006. Evidence-Based Best Practice Guideline: Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation.
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2011. Complicating factors associated with mild traumatic brain injury: Impact on pain and posttraumatic stress disorder treatment.
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2011. Evaluation of the Veterans Health Administration traumatic brain injury screening program in the upper Midwest.
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2009. A systematic review of psychological treatments for mild traumatic brain injury: An update on the evidence.
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2009b. VA/DOD Clinical Practice Guidelines for Management of Concussion/Mild Traumatic Brain Injury (mTBI)
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2010. Physical therapy recommendations for service members with mild traumatic brain injury.
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