Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury

Alicia A Swan; Eamonn Kennedy; Douglas B Cooper; Megan E Amuan; Jamie Mayo; David F Tate; Kangwon Song; Blessen C Eapen; Anne C Van Cott; Maria R Lopez; Mary Jo Pugh

doi:10.3389/fneur.2023.1228377

Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury

Front Neurol. 2023 Jul 19:14:1228377. doi: 10.3389/fneur.2023.1228377. eCollection 2023.

Authors

Alicia A Swan^{1

2}, Eamonn Kennedy^{3

4

5}, Douglas B Cooper^{1

6}, Megan E Amuan^{3

4}, Jamie Mayo^{3

4}, David F Tate^{3

5}, Kangwon Song⁷, Blessen C Eapen^{8

9}, Anne C Van Cott^{10

11}, Maria R Lopez^{12

13}, Mary Jo Pugh^{3

4}

Affiliations

¹ Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, United States.
² Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, United States.
³ Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States.
⁴ Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States.
⁵ University of Utah School of Medicine Department of Neurology, Salt Lake City, UT, United States.
⁶ Departments of Rehabilitation Medicine and Psychiatry, The University of Texas Health San Antonio, San Antonio, TX, United States.
⁷ Augusta University Medical Center, Augusta University, Augusta, GA, United States.
⁸ Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.
⁹ Division of Physical Medicine and Rehabilitation, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States.
¹⁰ Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States.
¹¹ Department of Veterans Affairs, Pittsburgh Healthcare System, Pittsburgh, PA, United States.
¹² Bruce Carter Hospital, Miami Veterans Health Administration, Miami, FL, United States.
¹³ Miller School of Medicine, University of Miami, Miami, FL, United States.

Abstract

Objective: The study aimed to examine the association between post-concussive comorbidity burdens [post-traumatic stress disorder (PTSD), depression, and/or headache] and central nervous system (CNS) polypharmacy (five or more concurrent medications) with reported neurobehavioral symptoms and symptom validity screening among post-9/11 veterans with a history of mild traumatic brain injury (mTBI).

Setting: Administrative medical record data from the Department of Veterans Affairs (VA) were used in the study.

Participants: Post-9/11 veterans with mTBI and at least 2 years of VA care between 2001 and 2019 who had completed the comprehensive traumatic brain injury evaluation (CTBIE) were included in the study.

Design: Retrospective cross-sectional design was used in the study.

Main measures: Neurobehavioral Symptom Inventory (NSI), International Classification of Diseases, Ninth Revision, and Clinical Modification diagnosis codes were included in the study.

Results: Of the 92,495 veterans with a history of TBI, 90% had diagnoses of at least one identified comorbidity (PTSD, depression, and/or headache) and 28% had evidence of CNS polypharmacy. Neurobehavioral symptom reporting and symptom validity failure was associated with comorbidity burden and polypharmacy after adjusting for sociodemographic characteristics. Veterans with concurrent diagnoses of PTSD, depression, and headache were more than six times more likely [Adjusted odds ratio = 6.55 (99% CI: 5.41, 7.92)]. to fail the embedded symptom validity measure (Validity-10) in the NSI.

Conclusion: TBI-related multimorbidity and CNS polypharmacy had the strongest association with neurobehavioral symptom distress, even after accounting for injury and sociodemographic characteristics. Given the regular use of the NSI in clinical and research settings, these findings emphasize the need for comprehensive neuropsychological evaluation for individuals who screen positively for potential symptom overreporting, the importance of multidisciplinary rehabilitation to restore functioning following mTBI, and the conscientious utilization of symptom validity measures in research efforts.

Keywords: concussion; headache; multimorbidity; polypharmacy; post-traumatic stress disorders; veterans.

Grants and funding

This work was supported by the Department of Defense, through Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium (LIMBIC) award no. W81XWH-18-PH/TBIRP-LIMBIC under awards W81XWH1920067 and W81XWH-13-2-0095 (PI Cifu) and by US Department of Veterans Affairs award no. I01 RX003443-01 (MP as PI). The US Army Medical Research Acquisition Activity is the awarding and administering acquisition office. This study was also supported by award no. I01 RX003443-01 from the US Veterans Administration Health Services Research and Development Service (to MP as principal investigator).