Co-designing for behavioural change: understanding barriers and enablers to addressing sexuality after traumatic brain injury and mapping intervention strategies in a multi-disciplinary rehabilitation unit.

Background Persistent changes in sexuality often follow traumatic brain injury (TBI). However, health professionals remain reticent about discussing sexuality and have reported barriers including uncertainties around whose role it is and limited educational and institutional support. This study employed a co-design and implementation process, aiming to promote team-wide behavioural change, whereby health professionals at a TBI rehabilitation unit would attempt to address sexuality with patients routinely. Methods Focus group sessions with multidisciplinary health professionals were conducted to identify barriers and enablers to behavioural change, identify areas for development, and co-design intervention options. Implementation deliverables were then finalised and provided to the team. The Theoretical Domains Framework was used to map factors influencing behaviours and the Behaviour Change Wheel was used to map interventions. Thematic analysis was used to further analyse barrier themes. Results Thirty-five barriers and eight enablers falling within 12 theoretical domains to behavioural change were identified. Thematic analysis revealed highly correlated barriers in initiating and sustaining change. Nine co-designed intervention options aligned with five intervention functions of the Behaviour Change Wheel, resulting in six final implementation deliverables. Conclusions Barriers were highly interrelated, influencing the approach to implementation deliverables. Simultaneously addressing multiple barriers could potentially alleviate discomfort associated with discussing sexuality. Concerns around initiating change were related to confidence in achieving sustainable changes. Achieving change requires organisational and team-level environmental restructuring and enablement. The next step involves evaluating the effectiveness of the co-design and implementation process in driving behavioural change and potential impacts on patient satisfaction and sexuality outcomes.

Considering the Importance of Personal and Injury Factors Influencing Outcome After Traumatic Brain Injury.

OBJECTIVE: Given the high variability in traumatic brain injury (TBI) outcomes and relative lack of examination of the influence of noninjury factors on outcome, this study aimed to examine factors associated with functional outcome at 1 and 2 years after moderate to severe TBI, including both preinjury and injury-related factors. DESIGN: Observational cohort study. SETTING: Inpatient hospital recruitment with outpatient follow-up at 1 and 2 years post injury. PARTICIPANTS: Individuals with moderate to severe TBI were recruited prospectively into a Longitudinal Head Injury Outcome Study. Of the eligible 3253 individuals who were eligible, 1899 participants consented to the study (N=1899). MAIN OUTCOME MEASURE: Functional outcome was measured using the Glasgow Outcome Scale-Extended (GOS-E). RESULTS: 1476 participants (73.6% males) and 1365 participants (73% males) completed the GOS-E at 1 and 2 years post injury. They had a mean age at injury of 40 years and mean duration of post-traumatic amnesia (PTA) of 26 days. Good recovery, representing return to previous activities on the GOS-E (score 7-8), was present in 31% of participants at 1 year post injury and 33.5% at 2 years post injury. When predictor variables were entered into regression together, good outcome was significantly associated with not being from a culturally and linguistically diverse background and not having preinjury mental health or alcohol treatment, shorter PTA duration, and absence of limb injuries at both 1 and 2 years; higher education was also a significant predictor at 1 year post injury. CONCLUSIONS: Alongside consideration of injury severity, understanding and addressing preinjury factors is important to maximize outcomes.

The impact of age on outcome 2 years after traumatic brain injury: Case control study.

BACKGROUND: Age is associated with outcome after traumatic brain injury (TBI). However, there are mixed findings across outcome domains and most studies lack controls. OBJECTIVES: This cross-sectional study examined the association between age group (15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, and 65 years or more) and outcomes 2 years after TBI in independence in daily activities, driving, public transportation use, employment, leisure activities, social integration, relationships and emotional functioning, relative to healthy controls. It was hypothesized that older individuals with TBI would have significantly poorer outcomes than controls in all domains except anxiety and depression, for which it was expected they would show better outcomes. Global functional outcome (measured using the Glasgow Outcome Scale-Extended) was also examined, and we hypothesized that older adults would have poorer outcomes than younger adults. METHODS: Participants were 1897 individuals with TBI (mean, SD age 36.7, 17.7 years) who completed measures 2 years post-injury and 110 healthy controls (age 38.3, 17.5 years). RESULTS: Compared to controls, individuals with TBI were less independent in most activities of daily living, participated less in leisure activities and employment, and were more socially isolated, anxious and depressed (p < 0.001). Those who were older in age were disproportionately less likely to be independent in light domestic activities, shopping and driving; and participated less in occupational activities relative to controls. Functional outcome was significantly higher in the youngest age group than in all older age groups (p < 0.001), but the younger groups were more likely to report being socially isolated (p < 0.001), depressed (p = 0.005) and anxious (p = 0.02), and less likely to be married or in a relationship (p < 0.001). CONCLUSION: A greater focus is needed on addressing psychosocial issues in younger individuals with TBI, whereas those who are older may require more intensive therapy to maximise independence in activities of daily living and return to employment.

Factors Influencing Self-Esteem After a Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) and its consequences can significantly impact an individual's identity and self-esteem. However, there is limited research with respect to the trajectory of change over time and factors that may influence self-esteem levels. This study aimed to investigate: (1) changes in self-esteem over 3 years post-TBI; and (2) factors associated with self-esteem post-TBI. SETTING: Outpatient. PARTICIPANTS, DESIGN, AND MEASURES: Self-esteem was measured in 1267 individuals with predominantly moderate to severe TBI (mean age = 36.38 years, mean days in posttraumatic amnesia = 26.16 days) using the Rosenberg Self-Esteem Scale at 1-, 2, and 3 years post-injury. Participants also completed the Structured Outcome Questionnaire and the Glasgow Outcome Scale-Extended (GOS-E). RESULTS: Linear mixed modeling indicated that self-esteem significantly declined between 1 and 2 years but remained stable between 2 and 3 years post-injury. Higher self-esteem was significantly associated with better functional outcomes (as measured by the GOS-E), more years of education, more participation in leisure activities, and lower reported anxiety and depression levels. CONCLUSIONS: Findings suggest that functional impacts of injury and emotional functioning influence self-esteem increasingly between 1 and 2 years post-injury. This highlights the importance of timely psychological interventions to maximize self-esteem in individuals with TBI post-injury.

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study.

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

The experience of traumatic brain injury in a culturally and linguistically diverse sample in Australia.

PURPOSE: Individuals from culturally and linguistically diverse (CALD) backgrounds experience poorer outcomes following traumatic brain injury (TBI), including poorer quality of life. The reasons for these poorer outcomes are unclear. Therefore, this study aimed to qualitatively investigate the experience of injury, rehabilitation, and recovery amongst individuals from a CALD background following TBI. MATERIALS AND METHODS: Fifteen semi-structured interviews were conducted, and qualitatively analysed using reflexive thematic analysis. RESULTS: It was demonstrated that: (a) the cognitive and behavioural consequences of TBI were accompanied by stigma and loss of independence; (b) participants held many beliefs related to their TBI, ranging from bad luck to acceptance. Participants' personal values and beliefs provided strength and resilience, with many viewing the injury as a positive event in their lives; (c) participants were appreciative of the high standard of care they received in hospital and rehabilitation, although communication barriers were experienced; (d) many participants identified with Australian culture, and few believed their cultural background negatively impacted their experience of TBI; (e) external support, particularly from family, was considered central to recovery. CONCLUSION: These findings offer insight into the challenges CALD individuals face and factors that may facilitate their recovery and improve functional outcomes.

Access to family support is very important to individuals with traumatic brain injury (TBI) from culturally and linguistically diverse (CALD) backgrounds.Education of family and close others is important to minimise stigma following TBI.Healthcare services should provide competent and qualified interpreters for individuals with TBI who cannot speak English.Rehabilitation professionals should receive cultural competency training, to maximise cultural sensitivity of their care provision to individuals from CALD backgrounds.

Comparison of the accuracy of the 7-item HADS Depression subscale and 14-item total HADS for screening for major depression: A systematic review and individual participant data meta-analysis.

The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of ≥7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and ≥15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from -0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02-0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and feasibility testing of a psychoeducational tool to support the return to work (RTW) of individuals with traumatic brain injury (TBI): The RTW after TBI app.

To document the development and clinician evaluation of a psychoeducational and support tool: the return to work after traumatic brain injury app (RTW after TBI app). Co-design of the app involved the collaboration of traumatic brain injury (TBI) /vocational rehabilitation (VR) expert researchers (n = 4) and lived experience co-designers (individuals with TBI who had previously returned to work; n = 4). Twelve TBI/VR clinician reviewers then evaluated the app. Content analysis of TBI/VR clinician reviewers' interviews revealed four themes: content, usability (functional ease of use), utility (applicability to RTW after TBI) and suggestions for improvements. All clinicians reported that they would use the RTW after TBI app in their clinical practice. Although several aspects were reported to potentially limit the app's appropriateness for some TBI clients, many feasible improvements were suggested to address limitations. These improvements aim to increase the utility of the app with a wider range of clients and extend its use to other settings. Future research should evaluate, in a clinical trial, the efficacy of the RTW after TBI app in supporting individuals with TBI and their vocational providers and optimizing RTW success.

Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines.

There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild-severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.

Factors associated with employment stability following traumatic brain injury, in a sample who have received comprehensive vocational rehabilitation.

PURPOSE: To quantify employment stability of individuals with traumatic brain injury (TBI) who received comprehensive vocational rehabilitation (VR) using different measures to identify difficulties experienced and factors associated with employment stability. MATERIALS AND METHODS: 72 individuals with predominantly moderate-severe TBI were interviewed. Neuropsychological assessment scores were collected. Three employment stability measures were used: number of post-injury employers, duration with employer and average weekly hours. Descriptive and predictive analyses were performed. RESULTS: 90.2% remained employed at time of interview (Mean = 4.83 years post-injury). However, participants worked significantly fewer hours, 63.9% had changed roles or employers at least once and only 51% achieved their pre-injury level of responsibility. 61% reported a high level of employer support. Self-reported difficulties included physical sequelae, memory problems and fatigue. Post-injury testing found impaired memory (34.4%) and processing speed (49.2%). After accounting for time since injury, demographic and employment variables (older age, male gender, higher pre-injury skill-level, higher level of employer support), higher level of injury-related difficulties and lower level of cognitive function significantly predicted employment stability. CONCLUSION: Injury-related difficulties impact employment long-term, necessitating ongoing work modifications. Individualised VR is important, not only to facilitate return to work but to support long-term employment stability after TBI.Implications for rehabilitationBeing male was associated with working more hours, and having faster processing speed, lower levels of fatigue and ongoing physical sequelae were associated with a longer duration with the same employer.Initial return to work is often the first step on a long journey as injury-related difficulties can continue to impact work in the-long term and require lasting modifications to duties and working hours.VR should include ongoing follow-up to facilitate work modifications and support both the employer and the employee in adjusting to these.VR should be individualised to support the impact of the unique cognitive and physical limitations experienced by each individual with TBI, based on the needs and employment demands of each workplace.

Exploring employment following traumatic brain injury in persons who completed an insurer funded vocational rehabilitation program in Australia.

PURPOSE: To extend the authors' previous research by investigating the maintenance of work performance over time and the long-term experience of employment following traumatic brain injury (TBI). MATERIALS AND METHODS: Semi-structured interviews were conducted with a sample of 72 individuals with predominantly severe TBI, up to 10-years post-injury. Thematic analysis of transcribed interviews was conducted. RESULTS: Four key themes were identified: brain injury influences on work performance and long-term employment; factors optimising long-term employment; and need for compromise and acceptance, which all impacted the final theme, quality of life outcome. While TBI-related difficulties such as fatigue, cognitive, and emotional difficulties still impacted work many years post-injury, work modifications and employer and vocational rehabilitation (VR) support were important factors optimising long-term employment. The timing of return to work (RTW) was also an important and potentially modifiable factor influencing work performance, which appeared to have long-term effects on the maintenance of employment. Support for acceptance of altered career goals is needed. CONCLUSION: Findings support the need for early VR to facilitate employer contact, to maximise adjustment and preparation time before RTW, to educate both employees and employers and to implement work modifications to support continuing employment after TBI.Implications for rehabilitationThe maintenance of employment following TBI is of critical importance for financial independence, psychological and social well-being, and improved quality of life.Injury-related difficulties still impact work performance many years after injury requiring individuals with TBI to continue working in modified roles and for reduced hours over the long-term.Ongoing VR and employer support is needed to facilitate long-term work modifications and compensatory strategies to support work performance.Early VR involvement to facilitate employer contact and maximise adjustment and preparation time before returning to work is necessary to avoid the negative and potentially dire consequences of returning too early.Psychological support to facilitate acceptance of role changes and career compromises is also important.

The experience of employers of individuals with traumatic brain injury.

OBJECTIVES: To understand the experience of employers of individuals with traumatic brain injury (TBI) who have received comprehensive vocational rehabilitation (VR), the factors involved in supporting an individual with TBI to return to work (RTW), and the support needs of employers. METHODS: 12 employers completed semi-structured interviews, which were recorded, transcribed, and analysed thematically. RESULTS: Five main themes were identified: challenges and impact on employer, managing employee post-injury changes, looking after employee wellbeing, managing conflicting emotions, and utilizing sources of support. Although employers received support with operational challenges, findings suggest they were not prepared for the emotional journey. While they struggled to support employees through the difficult process of realizing they could no longer perform at their pre-injury level, employers strove to find appropriate roles and ensure wellbeing for their injured employees. Despite employers' endeavours, they felt this process was demoralizing for some employees. CONCLUSIONS: Advising employers on operational as well as emotional support needs of both employees and employers is an ongoing challenge for VR providers. Although unsupportive employers were not well-represented in this sample, the study highlights the challenges faced and strategies used by employers who have a strong personal investment in the successful RTW of their employees.

Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury.

Following acquired brain injury (ABI), sexuality, self-esteem and practices are often negatively impacted. Whilst sexuality is recognized as an essential part of a person's life regardless of medical condition, it is poorly understood in the ABI rehabilitation context. This study examined current assessment and treatment practices for sexual health and wellbeing in ABI rehabilitation, including perceived barriers and facilitators to discussing sexuality with individuals after ABI. We also assessed the need for further education and training in this area. Two hundred and thirty-nine Australian healthcare professionals predominantly working with both traumatic brain injury (TBI) and stroke populations completed an online survey comprising thirty-four questions. The 12-item sexuality attitudes and beliefs survey (SABS) was included as an additional objective outcome measure. Findings suggest that healthcare professionals infrequently raise sexuality with individuals with ABI. Inadequate education and training, not knowing whose role it is and when to raise the topic, and the view that individuals with ABI will ask for the information were all identified as key barriers contributing to poor sexuality management after ABI. More education and training opportunities with greater access to resources are needed to facilitate the incorporation of sexuality into routine practice across the continuum of ABI care.

Positive behaviour support for adults with acquired brain injury and challenging behaviour: A randomised controlled trial.

BACKGROUND: Challenging behaviours are common and disabling consequences of acquired brain injury (ABI), causing stress for close-others and disrupting community integration. Positive Behaviour Support (PBS) interventions have support from case studies as a means of reducing these behaviours, but controlled trials are lacking. OBJECTIVES: This study aimed to evaluate, with a randomised waitlist-controlled trial, the efficacy of a 12-month PBS intervention, termed PBS+PLUS, in reducing challenging behaviours after ABI. METHODS: Participants included 49 individuals with ABI (PBS+PLUS Intervention and Waitlist Treatment-as-usual groups) and their close-others. The design was a randomised waitlist-controlled trial with 12-month follow-up. PBS+PLUS involved setting collaborative goals toward a more meaningful life with the individual with ABI and addressing barriers to achieving these, including challenging behaviours, through skill-building, restructuring environments and executive strategies. The primary outcome measure was the Overt Behaviour Scale (OBS). The Challenging Behaviour Self-Efficacy Scale (CBSES) was a secondary outcome, assessing close-others' self-efficacy in addressing challenging behaviour. Measures were completed at baseline and every 4 months. Data analyses involved mixed-effects and negative binomial regressions examining change over time by group. RESULTS: The PBS+PLUS Intervention group included 24 participants and the Waitlist group 25 participants. On the OBS, the Intervention group showed a significant reduction in challenging behaviour over the 12-month intervention. However, the Waitlist group showed similar improvement on the OBS over the 12-month waitlist period. The Waitlist group was not denied an intervention from other providers during this period. Gains continued for 8 months post-intervention. The PBS+PLUS intervention resulted in significantly greater gains in close-others' confidence in addressing challenging behaviours on the CBSES, relative to those in the Waitlist group, who showed no such gains. CONCLUSIONS: Although we cannot say this intervention is more effective than any other, the study did show that PBS+PLUS can result in significant and sustained reductions in challenging behaviour in individuals with severe ABI and increased confidence of close-others in addressing these difficult behaviours. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: #ACTRN12616001704482.

"It's been a long hard road": challenges faced in the first three years following traumatic brain injury.

PURPOSE: There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges. MATERIALS AND METHODS: Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location). RESULTS: Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports). CONCLUSION: Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

A qualitative study on the attitudes and approaches of Australian clinicians in addressing sexuality after acquired brain injury.

PURPOSE: Studies indicate that up to 50% of survivors of acquired brain injury (ABI) experience persistent changes in sexuality. However, research on clinicians' perspectives in addressing sexuality issues post-ABI is limited. This study explored the attitudes and approaches, barriers and facilitators, and training preferences of Australian clinicians in addressing sexuality in individuals post-ABI. METHOD: Purposive sampling was used to recruit 20 Australian multi-disciplinary clinicians from a related survey study. Semi-structured interviews were conducted and qualitatively analysed using thematic analysis. RESULTS: Three broad themes were identified: ABI results in multi-faceted changes in sexuality; there is a fundamental discomfort in talking about sexuality; and, strategies proposed by clinicians may help to improve sexuality support. Participants also provided suggestions for sexuality training, which they believed should start at university. CONCLUSION: Most clinicians are aware of sexuality issues post-ABI but fail to adequately address sexuality in individuals post-ABI due to personal levels of discomfort, perpetuated by institutional factors. Therefore, participants believe that changes made at individual and institutional levels may increase sexuality support for individuals with ABI. However, further research on the causes and treatment of sexual problems and patient perspectives is required to provide the evidence-based guidelines and training programs that clinicians require.Implications for rehabilitationUp to half of individuals experience changes in sexuality after ABI that restrict quality of life and relationships.The consequences of ABI and their impacts on sexuality are understood by Australian clinicians but remain largely unaddressed due to individual discomfort, perpetuated by institutional factors.This study suggests that professional training targeted towards understanding, assessing and treating sexuality issues post-ABI may help to reduce the discomfort.Adjustments should also be made at individual, policy and procedural levels to ensure that sexuality is addressed within rehabilitation post-ABI.

Factors facilitating recovery following severe traumatic brain injury: A qualitative study.

Given the significant impact of severe traumatic brain injury (TBI), understanding factors influencing recovery is critical to inform prognostication and treatment planning. Previous research has focussed primarily on factors negatively associated with outcome, with less focus on factors facilitating the recovery process. The current qualitative study examined positive factors identified for recovery by individuals who had sustained severe TBI three years earlier. Semi-structured interviews were conducted with nine participants with TBI and 16 close-others. Participants were asked to identify factors about themselves (or the injured individual), those around them, and the care they received that they felt were positive for recovery. Using reflexive thematic analysis, three themes were identified as positive for recovery after a TBI. Having a support network included social supports such as family and friends, and receiving other funded/non-funded assistance towards improving independence and participation. Being positive and engaged included being able to participate, being positive, using compensatory strategies, and becoming fit, healthy and happy. Getting good care included patients perceiving they had a comprehensive and good quality hospital experience, and access to multidisciplinary outpatient services. A focus on enhancing these positive environmental, personal and service factors in service provision may enhance outcomes following severe TBI.

Surviving the "silent epidemic": A qualitative exploration of the long-term journey after traumatic brain injury.

Previous studies examining life after traumatic brain injury (TBI) have taken a predominantly short-term and quantitative perspective, with generally narrow focus, and have not specifically investigated changes in experience over time post-injury to gain a uniquely long-term perspective. This study therefore aimed to qualitatively explore the broad long-term experience of living for 10 years or more with TBI. Thirty participants completed semi-structured interviews investigating the impact of TBI on various life domains, the rehabilitation experience and support received, and overall perspectives of the long-term journey after TBI. Results demonstrated that: (a) although some participants reported full recovery, several experienced persistent physical, cognitive and emotional problems that impacted their independence, employment and interpersonal relationships; (b) early rehabilitation was very helpful, but some participants experienced difficulties accessing ongoing services; (c) family and social support were important to recovery; (d) most participants drew upon inner strength to find positives in their experience. These findings have identified factors that facilitate and impede long-term recovery from TBI, which may inform better support and care for injured individuals over the years after injury to improve their quality of life.

Depression prevalence using the HADS-D compared to SCID major depression classification: An individual participant data meta-analysis.

OBJECTIVES: Validated diagnostic interviews are required to classify depression status and estimate prevalence of disorder, but screening tools are often used instead. We used individual participant data meta-analysis to compare prevalence based on standard Hospital Anxiety and Depression Scale - depression subscale (HADS-D) cutoffs of ≥8 and ≥11 versus Structured Clinical Interview for DSM (SCID) major depression and determined if an alternative HADS-D cutoff could more accurately estimate prevalence. METHODS: We searched Medline, Medline In-Process & Other Non-Indexed Citations via Ovid, PsycINFO, and Web of Science (inception-July 11, 2016) for studies comparing HADS-D scores to SCID major depression status. Pooled prevalence and pooled differences in prevalence for HADS-D cutoffs versus SCID major depression were estimated. RESULTS: 6005 participants (689 SCID major depression cases) from 41 primary studies were included. Pooled prevalence was 24.5% (95% Confidence Interval (CI): 20.5%, 29.0%) for HADS-D ≥8, 10.7% (95% CI: 8.3%, 13.8%) for HADS-D ≥11, and 11.6% (95% CI: 9.2%, 14.6%) for SCID major depression. HADS-D ≥11 was closest to SCID major depression prevalence, but the 95% prediction interval for the difference that could be expected for HADS-D ≥11 versus SCID in a new study was -21.1% to 19.5%. CONCLUSIONS: HADS-D ≥8 substantially overestimates depression prevalence. Of all possible cutoff thresholds, HADS-D ≥11 was closest to the SCID, but there was substantial heterogeneity in the difference between HADS-D ≥11 and SCID-based estimates. HADS-D should not be used as a substitute for a validated diagnostic interview.

Understanding the Multidimensional Nature of Sexuality After Traumatic Brain Injury.

OBJECTIVE: To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI). DESIGN: Survey. Individuals with TBI completed measures at a mean average of 2.78 years post injury (range, 1-10.3y). SETTING: All participants were community based at the time of data collection. PARTICIPANTS: Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex-, and education-matched controls with TBI recruited from the general community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Brain Injury Questionnaire of Sexuality. RESULTS: Individuals with TBI performed significantly worse on sexuality, mood, and self-esteem measures than the control group without TBI, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological, and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression, and lower self-esteem were significant predictors of poorer sexuality post injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI. CONCLUSIONS: These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may affect sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.