Identifying and Treating Concussion/mTBI in Service Members and Veterans
A Course for Civilian Health Care Providers From BrainLineMilitary.org
SECTION 1 of 7
With Capt. J.L. Hancock, M.D., U.S. Navy
VIDEO: Capt. J.L. Hancock Introduces the Course
Begin the course by watching this video with Capt. J.L. Hancock, physician and Naval officer.
"Knowing if your patient has been to war can help you offer better care. Concussions are treatable, the prognosis is good, and this course will get you started."
Your feedback makes us stronger! Please take five minutes to complete our survey about this course.
What You’ll Learn
This course from BrainLineMilitary.org will teach you the following:
- Signs and symptoms of a concussion or mild traumatic brain injury (mTBI) sustained during military service (while deployed and stateside), including the most common presenting symptoms
- Diagnostic criteria for concussion/mTBI and key information to elicit during a patient interview when military concussion/mTBI is suspected
- Prognosis for patients with concussion/mTBI
- Best practice treatments for the most common signs and symptoms of concussion/mTBI
- Resources for patients with concussion/mTBI and their families that provide useful information about concussion/mTBI and recovery
How This Course Works
This course includes six sections:
And it includes a post-test that will be instantly scored once you complete it.
You can follow the course from start to finish by using the "next" button at the bottom right of each page. You can move back and forth between pages using the arrows on the right and left of each page. You can jump around among the sections by clicking on the section titles across the top of the course.
If you're moving through the course from start to finish, it should take you about two hours to complete it. You can choose to spend more time learning about concussion/mTBI by looking at the related resources you'll see at the bottom of most pages in the course.
Need More Information?
If you have questions that are not answered by this course, please feel free to contact Sherray L. Holland, PA-C, Neuroscience Clinical Advisor at the Defense and Veterans Brain Injury Center by email:
SECTION 2 of 7
Many thousands of men and women in the U.S. military have sustained concussions (also called mild traumatic brain injuries, or mTBIs) while serving in Iraq and Afghanistan. In fact, traumatic brain injury has been called one of the signature injuries of these wars.
Some of these service members may present to your office with symptoms such as headaches or insomnia. Unless you know that your patient has been in combat and you ask the appropriate questions, it would be easy to overlook concussion/mTBI as an underlying cause.
Whether you are a doctor, physician assistant, nurse, physical therapist, social worker, or any other kind of civilian health care provider, knowing if your patient has been in combat can help you provide more effective treatment.
What Is a Traumatic Brain Injury (TBI)?
In order to understand concussion/mild TBI, it is important to first understand the general characteristics of traumatic brain injury or TBI. The Department of Defense and the Department of Veteran Affairs define a TBI as follows:
A traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event:
- Any period of loss of or a decreased level of consciousness (LOC)
- Any loss of memory for events immediately before or after the injury (post-traumatic amnesia or PTA)
- Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) (Alteration of consciousness/mental state or AOC)
- Neurological deficits (weakness, loss of balance, change in vision, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient
- Intracranial lesion
External forces may include any of the following events:
- the head being struck by an object
- the head striking an object
- the brain undergoing an acceleration/deceleration movement without direct external trauma to the head
- a foreign body penetrating the brain
- forces generated from events such as a blast or explosion
- or other forces yet to be defined
Not all individuals exposed to an external force will sustain a TBI, but any person who has experienced such an event and immediately showed the above signs and symptoms likely has had a TBI.
What Is a Concussion/mTBI?
As noted before, a concussion is synonymous with a mild traumatic brain injury (mTBI). Concussions can result from a collision of the head with an object, a pressure wave from a blast that passes through the head, or simply from sudden acceleration or deceleration of the head without impact. A service member or veteran may be diagnosed with a concussion/mTBI when such blows or jolts to the head are immediately followed by:
- A change in mental status of at least one of the following durations:
a. loss of consciousness for no more than 30 minutes
b. altered consciousness (mental confusion) for no more than 24 hours
c. an inability to remember events that lasts no more than 24 hours (post-traumatic amnesia)
- Normal results on standard neuroimaging
- Highest Glasgow Coma Scale (GCS) score within 24 hours between 13 to 15
You have probably encountered concussions in your practice with patients who have been in automobile crashes or taken a hit on the football field. Military service members certainly can receive concussions by these same mechanisms.
But the most common cause of concussion/mTBI among service members who deployed to Iraq and Afghanistan is a blast from an improvised explosive device (IED). A blast can result in a TBI even when the head does not collide with an object. Blast can affect the entire body, injuring limbs, eyes, and ears, for example.
Blast injuries are divided into four classes:
- Primary blast injuries are caused by the blast's shock wave traveling through the body.
- Secondary blast injuries are caused by shrapnel and other flying debris hitting the body.
- Tertiary blast injuries occur when the service member is accelerated into a solid object such as the ground or the interior of a vehicle.
- Quaternary injuries include crush injuries, burns, and inhalation of smoke or noxious gases.
Watch this slideshow on blast injuries to the brain:
"Since 2006, blasts have been the most common cause of injury among American soldiers treated at Walter Reed Army Hospital "
Blast Injury A Personal Account
Watch this video segment from Capt. J.L. Hancock, who sustained a concussion/mTBI in Afghanistan:
VIDEO: TBI in Theater
TBI in Theater
Blast waves are the primary cause of brain injury in theater; and they can be complicated by falls or crashes in military vehicles or by being thrown against a vehicle wall or building.
More than 233,000 service members sustained a TBI between 2000 and 2011, of which more than three-quarters were categorized as mild.
These statistics include service members injured on the battlefield ("in theater") and in non-combat settings and is a good reminder that asking about a history of concussion/mTBI should not be limited only to a service member's deployment experiences.
Moderate and severe TBIs, including penetrating cranial injuries, are usually diagnosed at the time of injury; their diagnosis requires a period of unconsciousness of more than 30 minutes and post-traumatic amnesia that lasts longer than a day. What you are most likely to encounter in your civilian practice is concussion/mTBI.
Diffuse Axonal Injury
The trauma that causes a concussion/mTBI can injure the brain's neurons in a variety of ways that are not easily identified using standard neuroimaging techniques. One kind of damage is called diffuse axonal injury (DAI), in which axons (the output fibers of neurons) are twisted, stretched, or severed.
Watch this video from Georgia Health Sciences University illustrating diffuse axonal injury:
VIDEO: Understanding Diffuse Axonal Injury
Understanding Diffuse Axonal Injury
Diffuse axonal injury affects nerve fibers, which can lead to a disruption in nerve communication that affects a person's physical and cognitive abilities.
SECTION 3 of 7
How to Diagnose a Concussion/mTBI
When you see a patient who has sustained a concussion/mTBI, you're going to make your diagnosis primarily based on patient history. (Remember, concussion/mTBI injuries are not typically visible with standard brain imaging techniques.) Under most circumstances, the concussion/mTBI will have occurred a long time before you actually see the patient, which can affect how much detail your patient can recall. As mentioned previously, concussion/mTBI is diagnosed by one or more of the following signs immediately after a traumatic blow or jolt to the head:
- Loss of consciousness for less than 30 minutes
- Loss of memory for events before or after the injury resolving within 24 hours
- Alteration of consciousness (confusion, disorientation, or dazed feeling) resolving within 24 hours
IMPORTANT: While a loss of consciousness is sufficient for a diagnosis of concussion/mTBI, it is not necessary.
Up to 85% of traumatic brain injuries are mild. A TBI is classified as mild if the alteration of consciousness (including amnesia) has resolved within 24 hours of the trauma. If the patient lost consciousness, the period of unconsciousness must be less than 30 minutes for the designation concussion/mTBI.
Symptoms of Concussion/mTBI
As a civilian health care provider, you won't be seeing a veteran until some time after the initial trauma. It may be months before a service member seeks help, and he may not associate his symptoms with an injury during combat. So you should be prepared to recognize the most common signs and symptoms associated with concussion/mTBI that can linger months after trauma to the head:
- Dizziness, balance, and coordination problems
- Cognitive deficits (e.g., issues with concentration or memory, getting organized)
- Fatigue and/or insomnia
- Emotional changes, including irritability, depression, and anxiety
Watch a short video of Adam Anicich, an Iraq war veteran who sustained a concussion/mTBI. Here he describes his symptoms three to six months following his injury:
VIDEO: Changes in Temperament
Changes in Temperament
"I started to notice that there was differences in my personality, differences in my behavior, differences in my level of temperament "
Critical: Taking a Detailed Case History
If your patient's symptoms lead you to suspect a concussion/mTBI, it can be helpful to determine if your patient served in the military. If so, ascertain if your patient experienced a blast, vehicle crash, or fall any trauma that might have caused a concussion/mTBI. (Please remember that these injuries also happen away from the field of battle on base or off duty.) If you discover a possible triggering event, then making the diagnosis requires assessing your patient's level of consciousness and symptoms in the past, right after the trauma. This can only be accomplished by getting a good case history or chronology of the incident.
To take a good case history, allow your patient to narrate the story; but question him or her in sufficient detail to uncover any gaps in your patient's memory or consciousness following the trauma. Remember from an earlier page that two of the diagnostic criteria are a loss of consciousness and loss of memory.
Watch this short demonstration of how to take a case history with Dr. Wendy Law, clinical neuropsychologist at the Walter Reed National Military Medical Center, and a Marine Corporal who sustained a concussion/mTBI in Afghanistan:
VIDEO: Dr. Wendy Law How to Unearth What Happened at the Time of Injury
How to Unearth What Happened at the Time of Injury
Diagnosis of TBI is based on what happened at the time of injury. It is often hard for service members to remember the moment-by-moment details.
NOTE: The name of the service member is not included to protect his confidentiality.
Making Your Diagnosis
Once you have the patient's history, carefully consider the criteria of diagnosing concussion/mTBI from the previous pages. It is evident that your patient has sustained a concussion/mTBI if he or she reports loss of consciousness or blacking out (even for a few seconds but less than 30 minutes). Post-traumatic amnesia (not remembering a period of time before or after the event) is easily identified too, but distinguishing alteration of consciousness (AOC; confusion, disorientation) is challenging at times. AOC should not be confused with a normal psychological response to stress, such as feeling startled or stunned by a sudden event.
Once you have determined your diagnosis, you can assess the current symptomatology by using two clinical tools:
- The Neurobehavioral Symptom Inventory (NSI) Form is a validated measure that captures information on 22 common subjective complaints which may occur following TBI.
- The PTSD Checklist (PCL) is a 17-item, self-report measure of the 17 DSM-IV symptoms of PTSD (or acute stress disorder depending on the length of time following the TBI).
The combination of both of these questionnaires is useful in identifying the critical needs of your patient and guiding the treatment plan.
Following the assessment, you should perform a neurological exam, documenting any abnormal findings (or refer as appropriate). The key aspects are vision, hearing, cranial nerves, muscle strength and sensation (pinprick, light touch, temperature, proprioception), balance and coordination, reflexes, and cognitive assessment (e.g. mini-mental status exam). Note the service member's behavior, appearance, and speech along with your focused evaluation.
Neuropsychological testing and bloodwork are often recommended as part of the comprehensive examination depending on the symptoms that the service member or veteran endorses. You will be able to use these findings in the treatment section.
Concussion/mTBI and Neuropsychological Symptoms
Concussions can cause neuropsychological symptoms, affecting memory, attention, and other aspects of cognition. The most common cognitive symptoms reported by patients or family members are problems with memory, attention, and processing speed (slowed thinking). Patients occasionally have insight into such changes, but it's frequently beneficial to ask their loved ones to get an independent perspective on how the patient has changed after the injury.
Though the majority of individuals will recover from the direct effects of concussion/mTBI within three months of injury (with many showing full recovery within days of the injury), some continue to have symptoms beyond three months. The symptoms for most of these people tend to vary in intensity and type over time, showing a waxing and waning pattern that is not typical of permanent injury to the brain.
In these instances, complaints of forgetfulness, poor attention, and slowed thinking may be due to other complicating conditions that developed at or around the time of injury (sleep disorders, for example). Treating these residual symptoms may help resolve the neuropsychological issues.
Some service members may have sustained multiple concussions. It's important to determine if that's the case — for example, was the individual exposed to a number of blasts? Sustaining multiple concussions can require more time for recovery after each subsequent injury. What is not clear from the literature is if multiple concussions increase the severity and duration of symptoms.
The military takes the issue of cumulative concussions very seriously. Service members receive a mandatory evaluation after any event that could possibly cause a concussion/mTBI. Additionally, those who have sustained three or more concussions must receive a more detailed evaluation before being cleared to return to combat.
Watch Dr. James Kelly, head of the National Intrepid Center of Excellence, talk about the military's protocol for caring for service members who sustain three or more concussions:
VIDEO: New Military Protocol for Three or More Concussions
New Military Protocol for Three or More Concussions
Soldiers who have sustained three concussions will receive a more detailed, mandatory evaluation before returning to combat.
*Note: The video interview with Dr. Kelly was shot in August 2010. Some information may have changed.
For more on this topic, please review BrainLine Military's cumulative concussions page.
Concussion/mTBI and PTSD
Concussion/mTBI frequently co-occurs with PTSD (post-traumatic stress disorder) in this population.
Watch this short video with Dr. Michael McCrea of the ProHealth Care Neuroscience Center and Research Institute:
VIDEO: PTSD & mTBI: Teasing Out the Differences for Treatment
PTSD & mTBI: Teasing Out the Differences for Treatment
"The dilemma that the clinician faces is trying to split that hair as to determining whether or not this military person in front of me in clinic has primarily post-traumatic stress disorder or primarily the lingering effects of mild traumatic brain injury "
So when evaluating a patient for concussion/mTBI, consider the possibility that your patient may have PTSD, or PTSD and concussion/mTBI. If your patient has PTSD (with or without concussion/mTBI), making the diagnosis is valuable because evidence-based treatments are available.
Here is a brief overview of PTSD treatments from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
The signs and symptoms of concussion/mTBI and PTSD overlap considerably, so use the following chart to learn the symptoms that can help you discriminate between concussion/mTBI and PTSD for patients who have only one or the other.
Reference: Stein MB, McCallister TW (2009). Exploring the convergence of post-traumatic stress disorder and mild traumatic brain injury. Am J Psychiatry; 166:766-776.
Regardless of the cause of the symptoms, treating the symptoms themselves is the right approach.
SECTION 4 of 7
The overall prognosis for patients with concussions is good. With minimal intervention and a proper diagnosis, a large majority of patients who sustained a single concussion/mTBI will recover within hours or days with no lasting ill effects. Generally 85-90% of individuals with concussion/mTBI recover within a 30-day window from the time of injury. A minority of patients experience longer-lasting signs and symptoms of concussion/mTBI. Failure to diagnose and treat concussion/mTBI may explain why signs and symptoms persist in some cases. But a complex mix of physical, genetic, and psychosocial factors may account for other cases of slower recovery.
Concussion/mTBI is a complex injury to a complex system, and that’s why patients with similar injuries may have different symptoms and different courses of recovery.
Watch this short video with Dr. Michael McCrea of the ProHealth Care Neuroscience Center and Research Institute
VIDEO: Why Do Some Recover Faster?
Why Do Some Recover Faster?
Learn more about the relationship between symptom reporting and ultimate recovery.
One Soldier's Story
A minority of concussion/mTBI patients report symptoms lasting a month or longer, and it's these patients you're most likely to be seeing in civilian practice. Read this account of one soldier's more complicated recovery:
"I found that connecting with others who 'got it' was my way to flip the switch, my way to get my hands on the flashlight my flashlight out of that dark space."
The treatment of longer-lasting effects of concussion is described in the next section.
SECTION 5 of 7
Regardless of the time elapsed since the concussion/mTBI, you should treat your patient symptomatically. Treatment guidelines follow for the common longer-lasting signs and symptoms of concussion/mTBI:
- Dizziness and balance problems
- Cognitive problems
- Emotional problems
Download the following PDF from the CDC for a quick guide to treating concussion/mTBI.
"Because the effects of mTBI can be so diverse, no standard treatment exists. But physicians can take many actions to improve outcomes for patients with mTBI "
For more detail, download the VA/DOD clinical practice guidelines on concussion/mTBI.
Insomnia is one of the most common symptoms in concussion/mTBI patients. Sleep problems can be caused directly by the brain trauma or indirectly by self-medication, anxiety, and depression. Insomnia is particularly crucial to address because often when it resolves, other symptoms such as headaches, fatigue, and cognitive problems will likely also diminish.
- Urge your patient to avoid any of the following within three hours of bedtime:
- Heavy exercise
- Heavy eating
- Advise your patient to try to go to sleep
- Only when tired
- On a regular schedule
- In a pleasant and suitable room quiet, dark or dimly lit, and at a comfortable temperature
For more information about sleep hygiene consult this printer-friendly online resource from the Defense and Veterans Brain Injury Center.
- If behavioral interventions are not effective, medications can be used to assist with sleep regulation. The VA-DoD guidelines suggest a short trial of non-benzodiazepine hypnotics Proceed with caution and avoid sedatives and sleep aid medications if you suspect sleep apnea.
- Refer your patient to specialty care or to a sleep study if you suspect a more serious sleep disorder.
Read this short piece from the National Sleep Foundation on cognitive behavioral therapy, an innovative way to treat insomnia without the use of pharmaceuticals:
"Cognitive Behavioral Therapy for Insomnia, often called CBT-I, is an approved method for treating insomnia without the use of sleeping pills. Sound impossible? It isn't "
Watch Dr. Alison Cernich acting senior liaison for TBI for the U.S. Department of Veterans Affairs describe the warning signs for sleep disorders:
VIDEO: Getting to the Root of Fatigue Post-TBI
Getting to the Root of Fatigue Post-TBI
Overwhelming fatigue post-injury can be due to disrupted sleep patterns and there are strategies to help.
Watch a brief segment with Adam Anicich, a veteran with concussion/mTBI, talking about his headaches:
VIDEO: Headaches Can Make It Impossible to Focus
Headaches Can Make It Impossible to Focus
Headaches can be so severe they feel like a "pulsating, rumbling fight inside your head."
Watch a brief video with Dr. Alison Cernich on how to treat headache:
VIDEO: Post-Traumatic Headache
"Sometimes simple changes like eating during the day, limiting caffeine, and getting good sleep will improve headaches."
Headache is the most common and complex complaint after a concussion/mTBI. You have multiple treatment options before referring your patient to specialty care.
- Encourage your patient to maintain a headache diary and present it at appointments. The patient should detail:
- The time and duration of headaches
- Intensity (on a 1-10 scale)
- Where in the cranium the pain was experienced
- Other symptoms
- Aggravating and alleviating factors (for example, is the headache better or worse after a meal or a workout?)
- What the patient was doing when the episode occurred (resting, taking medications, turning off the lights, and so on)
With this information you can better characterize the headaches (e.g., tension, cluster, or migraine) and refine your treatment plan. This chart from the Defense Centers of Excellence Case Studies Series can also help. Please note: It includes the two most common types of headaches following concussion/mTBI, but there are other types that occur (cluster, occipital neuralgia, etc.).
- Be aware that excessive use of and withdrawal from caffeine and nicotine can trigger headaches.
- If your patient's headaches are mild, you can advise over-the-counter analgesics that don't contain caffeine.
- You should avoid prescribing narcotics, prescription medications containing caffeine, and benzodiazepines because of the risk of rebound headaches and addiction.
- For acute headache episodes, consider the following: NSAIDs, Triptans, rest, and applications of heat.
- Consider referring your patient to specialists for alternative care such as biofeedback, massage, stress management, and acupuncture.
- For prophylactic measures, refer your patient to specialty care where abortive agents such as tricyclic antidepressants, anticonvulsants, or beta-blockers can be used and monitored. Some of these medications are contraindicated with certain co-morbidities, so the specialist must first review the patient's complete medical history.
|Pain Intensity||Mild-moderate||Often severe/debilitating|
|Pain Character||Dull, aching, or pressure. Can be sharp but that is not predominant||Throbbing/pulsatile, can be sharp/stabbing or electric-like|
|Duration||Usually less than 4 hours||Can be longer than 4 hours|
|Phono- or photo-phobia||One but not both may be present||One or both usually present|
|Able to carry out routine activities/work||Usually||Usually not or decreases ability to participate|
|Location||Bilateral frontal, retro-orbital, temporal, cervical and occipital or holocephalic||Usually unilateral & may vary in location among episodes|
|Nausea/malaise||Not present||Usually present|
|Palpable muscle tenderness/contraction||Pericranial muscles (temporalis, masseter, pterygoid, posterior neck, sternocleidomastoid, splenius, or trapezius||Local muscle tenderness not typical but can be present with long duration headaches|
Read this symptom management sheet from DVBIC, and feel free to share it with your patients:
Headache is one of the most common symptoms after traumatic brain injury. Over 30% of those injured report having headaches which continue long after injury.
Dizziness and Balance Problems
Vestibular dysfunction is one of the top complaints that patients report after a concussion/mTBI. There are several possible causes for dizziness, and it must be assessed appropriately to rule out other organic causes such as anxiety and medication side effects.
Injuries to the cranial nerves (vestibulocochlear, optic, and oculomotor nerves) and cerebellum are possible causes that need further evaluation with a specialist based on a neurological exam and on your patient's report from the Dizziness Handicap Inventory questionnaire.
A referral to vestibular rehabilitation or physical therapy, neuro-optometry, and/or neuro-otology may be warranted, especially if symptoms change or get worse. If a patient presents with neck pain or stiffness along with dizziness, this may indicate a neuromuscular injury and would require an evaluation with physiatry, sports medicine or orthopedics, and/or physical therapy. Once the initial evaluation is complete, a service member or veteran may be able to complete therapy from home, but encourage them to stay within their symptom tolerance.
Read this information sheet from the Defense and Veterans Brain Injury Center:
Dizziness is one of the symptoms that you may experience after a concussion/mild traumatic brain injury. There are several possible causes of your dizziness
Watch this brief video with Dr. Alison Cernich about assessing cognitive problems:
VIDEO: Attention and Memory Issues
Attention and Memory Issues
"It's important to learn what the symptom like attention or memory is and when it happens and what's happening around the person experiencing it."
Treating Cognitive Problems
Among the most typical signs and symptoms after concussion/mTBI are changes in cognition, in particular, problems with attention, memory, speed of processing, and executive function.
These are challenging symptoms to treat, because patients frequently have co-occurring conditions. For example, pain, poor sleep, and depression can each reduce cognitive performance. When trying to treat cognitive problems, be sure to consider not just TBI but other conditions as well.
- Encourage your patient to record important information (such as appointments, errands, and medication schedules).
- Promote better sleep hygiene, diet, and exercise to improve mental well-being.
- If cognitive deficits are not improving, refer your patient to specialty care for complete neuropsychological testing and assessment. Also consider referrals to rehabilitation medicine professionals who work specifically on cognitive challenges following TBI (e.g., neuropsychologists, rehabilitations psychologists, speech-language pathologists, and occupational therapists). If the patient is a veteran and not able to access specialty services for brain injury available to active duty service members, encourage him or her to pursue treatment at Veteran’s Health Administration facilities. Please see www.polytrauma.va.gov for facility locations and services.
- If the service member or veteran has documented cognitive difficulties, cognitive rehabilitation can be effective in helping them to either compensate for or treat their cognitive problems. Evidence varies for the specific cognitive problems that present commonly following concussion/mTBI, but patients often find guidance related to how to compensate for their deficits very helpful, according to a recent Institute of Medicine report.
- If behavioral problems persist, refer your patient to a behavioral health worker.
Watch Adam Anicich, an Iraq veteran with concussion/mTBI, as he describes his cognitive rehabilitation with occupational therapy:
VIDEO: The Benefits of Cognitive Rehabilitation
The Benefits of Cognitive Rehabilitation
Occupational therapy can help a person with TBI with everyday life from learning to make lists and set priorities to improving interpersonal relationships.
Watch Dr. Law describe the reasons for emotional trauma:
VIDEO: The Emotional Trauma Service Members Can Experience
The Emotional Trauma Service Members Can Experience
"There is no single reason for emotional trauma post-TBI, post-combat. It can range from depression to family readjustment."
Watch Dr. Hancock describe his own emotional trauma:
VIDEO: The Emotional Chaos of a Devastating Day
The Emotional Chaos of a Devastating Day
"Being in combat and losing fellow service members can feel like losing brothers emotions run high, nights go sleepless."
Treating Emotional Problems
Inform your patient that changes in emotions are common after a concussion/mTBI and that emotions usually return to normal with time.
- Encourage your patient to discuss his thoughts and feelings.
- Refer your patient to a behavioral health provider for psychotherapy or counseling, and to a psychiatrist if medication may be beneficial.
- Don't overlook the possibility that the patient's caregiver may also need psychological support.
- Concussions are often associated with other psychological health problems, such as anxiety or depression, and the veteran or service member may require specific treatment for those issues. Also, pain disorders or substance use disorders are commonly reported with individuals who have been diagnosed with concussion/mTBI and should be explored to see if they are contributing to the emotional picture.
Addressing Thoughts of Suicide
You should inquire about depression and suicidal ideation with any patient who has been deployed. Suicidal ideation should always be taken seriously. Notify your patient’s behavioral health provider if he/she expresses signs of depression or thoughts of suicide. Or call the VA's suicide hotline:
- Veterans Crisis Line: Dial 1-800-273-8255 and press 1.
Alternatively, report your patient to your emergency department, take your patient to the nearest emergency room, or call 911.
Watch Dr. Wendy Law as she asks a veteran with concussion/mTBI about suicidal thoughts:
VIDEO: Suicidal Ideation
During a case history, it is crucial to listen carefully to service members and vets about possible thoughts of suicide.
With Capt. J.L. Hancock, M.D., U.S. Navy
VIDEO: Final Thoughts
Watch Capt. J.L. Hancock share some final thoughts:
"Most of these patients have an excellent prognosis and don't need a referral to a specialist. What they need is someone like you "
Need More Information?
If you have questions that are not answered by this course, please feel free to contact Sherray L. Holland, PA-C, Neuroscience Clinical Advisor at the Defense and Veterans Brain Injury Center by email:
SECTION 6 of 7
Resources for Health Care Providers
If you require one-on-one advice or information, please call the DCoE 24/7 Outreach Center: 1-866-966-1020.
Here are the clinical practice guidelines for the management of concussion/mTBI from the Department of Veterans Affairs and the Department of Defense.
Here is the Veterans Health Initiative study guide on TBI.
The Defense and Veterans Brain Injury Center (DVBIC) offers an online guide for health care providers which links providers to general information, clinical training, and additional resources: DVBIC TBI Information and Resources for Providers
If you are confused by military jargon or acronyms, please refer to the following website: War Psychiatry Acronyms and Abbreviations
The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) offers a pocket guide to concussion/mTBI: Mild Traumatic Brain Injury Pocket Guide You can request print copies by emailing firstname.lastname@example.org
The Centers for Disease Control (CDC) has published the following fact sheet: Magnitude of Traumatic Brain Injury (TBI) and MTBI Facts.
To understand the wartime experience of your patients, read this piece: A Flashlight Out of the Dark.
Resources for Patients and Families
Your patients and their families can get more information about concussion and what resources are available at any of the following sites:
- Defense and Veterans Brain Injury Center: Family & Friends Resources
- BrainLineMilitary.org Resource Directory: Finding Help Near You
- BrainLine.org: For Family and Friends
- Traumatic Brain Injury: The Journey Home
- Afterdeployment.org Getting Help
- Brain Injury Association of America
Each of the branches of the military Army, Navy, Marines, and Air Force has targeted resources for injured service members:
- Army Wounded Warrior Program: Dial 1-877-393-9058 or e-mail email@example.com.
- Air Force Wounded Warrior Program: Dial 1-800-581-9437 or e-mail firstname.lastname@example.org.
- Navy Safe Harbor: Dial 1-877-746-8563 or e-mail email@example.com.
- USSOCOM Care Coalition: Dial 1-877-672-3039.
- Veterans Crisis Line (suicide): Dial 1-800-273-8255 and press 1.
- Marine Wounded Warrior Regiment Call Center Phone: Dial 1-877-4USMCWW or 1-877-487-6299
This article from DVBIC can help family members sort through those resources: Support for Wounded Service Members and Their Families
Defense and Veterans Brain Injury Center
Lead Content Producer: Sherray Holland, PA-C, Neuroscience Clinical Advisor
Executive-in-Charge: Michael Wilmore, MPAS, PA-C, Director of Clinical Affairs
Executive Producer: Sherry Chiasson, MBA/HA, BSW, Manager, Multimedia Education Materials and Distribution
Co-Executive Producer: Leslie Shupenko, MS, CCRP, Manager, Office of Clinical Initiatives
Copy Editor: Susan Schept, Medical Writer
TBI Subject Matter Experts
Adam Anicich, Assistant Director of the Congressional Liaison Service, Department of Veterans Affairs
Dr. Alison Cernich, VA Senior Liaison for TBI, DCoE
Capt. J. L. Hancock, M.D., U.S. Navy
Dr. Wendy Law, Clinical Neuropsychologist, Walter Reed National Military Medical Center
Producer: John Rubin, Ph.D., John Rubin Productions, Inc.
Co-Producer: James Donald, John Rubin Productions, Inc.
Medical Consultant: John Whyte, M.D., Ph.D., Moss Rehabilitation Research Institute
Special Thanks: Victor Medina
Web Producer: Kelly Deckert
Web Developer: Ian Collins
Associate Project Manager: Krystal Klingenberg
Editor: Victoria Tilney McDonough
Project Coordinator: Justin Rhodes
Project Consultant: Vicky Youcha
Executive Producer: Christian Lindstrom
SECTION 7 of 7