Development of the traumatic brain injury Rehabilitation Needs Survey: a Veterans Affairs TBI Model Systems study.

PURPOSE: To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery. MATERIALS AND METHODS: RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented. RESULTS: Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p < 0.05) suggesting support for convergent validity of the RNS. CONCLUSION: The RNS is a new measure of rehabilitation needs following TBI. Further investigation into its psychometrics and clinical utility is recommended.Implications for rehabilitationVeterans and Service Members with traumatic brain injury across the severity spectrum have ongoing rehabilitation needs during the chronic phase of recovery.The Rehabilitation Needs Survey is a standardized measure of rehabilitation needs following traumatic brain injury.Identification of unmet rehabilitation needs is important for raising awareness of service gaps and providing justification for resource allocation.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study.

OBJECTIVE: To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS). PARTICIPANTS: A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations. DESIGN: Secondary analysis from multicenter prospective longitudinal study. MAIN MEASURES: Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale. RESULTS: The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores. CONCLUSION: Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years). DESIGN: Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations. RESULTS: Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites. CONCLUSIONS: The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Protocol for a Randomized Controlled Trial of CI Therapy for Rehabilitation of Upper Extremity Motor Deficit: The Bringing Rehabilitation to American Veterans Everywhere Project.

Constraint-induced movement therapy (CI therapy) has been shown to reduce disability for individuals with upper extremity (UE) hemiparesis following different neurologic injuries. This article describes the study design and methodological considerations of the Bringing Rehabilitation to American Veterans Everywhere (BRAVE) Project, a randomized controlled trial of CI therapy to improve the motor deficit of participants with chronic and subacute traumatic brain injury. Our CI therapy protocol comprises 4 major components: (1) intensive training of the more-affected UE for target of 3 hour/day for 10 consecutive weekdays, (2) a behavioral technique termed shaping during training, (3) a "transfer package," 0.5 hour/day, of behavioral techniques to transfer therapeutic gains from the treatment setting to the life situation, and (4) prolonged restraint of use of the UE not being trained. The primary endpoint is posttreatment change on the Motor Activity Log, which assesses the use of the more-affected arm outside the laboratory in everyday life situations. Data from a number of secondary outcome measures are also being collected and can be categorized as physical, genomic, biologic, fitness, cognitive/behavioral, quality of life, and neuroimaging measures.

Postrehabilitation Mental Health Treatment Utilization in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To identify preinjury variables related to mental health treatment utilization at 2 years post-traumatic brain injury (TBI). SETTING: Veterans Affairs (VA) TBI Model Systems includes 5 VA Polytrauma Rehabilitation Centers. PARTICIPANTS: Veterans and service members enrolled in TBI Model Systems who completed the year 2 follow-up assessment and provided mental health information. Sample was largely male (97%) and White (72%), with median age of 30 years. DESIGN: Participants with elevated mental health symptoms were identified by measures of depression, anxiety, and posttraumatic distress; suicide attempt in the past year; or problematic substance use in the past year. Forty-seven percent of participants had elevated mental health symptoms at 2 years postinjury. Among those with elevated symptoms, comparisons were made between those who sought mental health treatment in past year and those who did not. MAIN MEASURES: Demographic, historic, environmental, psychological/mental health, and injury/rehabilitation variables. RESULTS: Within the sample, 23% denied utilizing mental health services. Nonutilizers were more likely to deny a preinjury mental health treatment history, to report problematic substance use at year 2, and to report lower levels of internalizing symptoms than the treatment utilizers. CONCLUSION: Veterans and service members with elevated mental health symptoms may require tailored tactics to promote treatment utilization post-TBI.

Provider perceptions of the assessment and rehabilitation of sexual functioning after Traumatic Brain Injury.

OBJECTIVE: To explore how health care professionals who work with individuals with TBI address issues related to the assessment and treatment of sexuality after TBI. METHODS: A survey composed of 53 questions was developed to evaluate professional training, assessment of sexuality in individuals with TBI and attitudes towards sexuality. The sample consisted of 324 self-identified TBI health care professionals. RESULTS: Ninety seven per cent of participants believed that sexuality should be discussed during rehabilitation; however, 36% reported talking about it. Seventy nine per cent reported that their patients have asked about sexuality after TBI, with 60% feeling calm and competent addressing the topic. The main reason for not discussing the topic was that patients do not ask for information (42%). Assessment (87%) and treatment of sexuality (82%) in individuals with TBI are considered a part of their professional responsibility. CONCLUSION: Despite recognition of the importance of addressing the topic and the belief of it being their professional responsibility, many professionals reported lack of training. Working to increase comfort with the topic and providing comprehensive education on treating sexuality may be beneficial.

Comparison of the VA and NIDILRR TBI Model System Cohorts.

OBJECTIVE: Within the same time frame, compare the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and VA Traumatic Brain Injury Model System (TBIMS) data sets to inform future research and generalizability of findings across cohorts. SETTING: Inpatient comprehensive interdisciplinary rehabilitation facilities. PARTICIPANTS: Civilians, Veterans, and active duty service members in the VA (n = 550) and NIDILRR civilian settings (n = 5270) who were enrolled in TBIMS between August 2009 and July 2015. DESIGN: Prospective, longitudinal, multisite study. MAIN MEASURES: Demographics, Injury Characteristics, Functional Independence Measures, Disability Rating Scale. RESULTS: VA and NIDILRR TBIMS participants differed on 76% of comparisons (18 Important, 8 Minor), with unique differences shown across traumatic brain injury etiology subgroups. The VA cohort was more educated, more likely to be employed at the time of injury, utilized mental health services premorbidly, and experienced greater traumatic brain injury severity. As expected, acute and rehabilitation lengths of stay were longer in the VA with no differences in death rate found between cohorts. CONCLUSIONS: Substantial baseline differences between the NIDILRR and VA TBIMS participants warrant caution when comparing rehabilitation outcomes. A substantive number of NIDILRR enrollees had a history of military service (>13%) warranting further focused study. The TBIMS participant data collected across cohorts can be used to help evidence-informed policy for the civilian and military-related healthcare systems.

Predictors of Satisfaction With Life in Veterans After Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To identify predictors of satisfaction with life in Veterans 1 year after traumatic brain injury (TBI). SETTING: The VA TBI Model Systems (TBIMS) project includes 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: Veterans enrolled in the VA TBIMS study who completed the Satisfaction With Life Scale at year 1 follow-up. The sample is largely male (96%) and Caucasian (72%), with a median age of 27 years upon enrollment. DESIGN: Prospective observational cohort study measuring including demographics (eg, education), preinjury variables (eg, mental health history and employment), and military variables (eg, injury during deployment and injury during active duty status). MAIN OUTCOME MEASURE: Satisfaction With Life Scale. RESULTS: Multivariate regression analyses revealed that age, marital status, preinjury employment status, preinjury mental health history, and active duty status at the time of injury were significant predictors of life satisfaction at year 1 follow-up. CONCLUSIONS: Results of this study suggest that satisfaction with life in Veterans with TBI is mediated by several factors that might inform rehabilitation interventions and discharge recommendations. Preinjury variables and active duty status (a unique aspect of the Veteran population) influence life satisfaction at 1 year postinjury. Limitations and future clinical implications will be discussed.

Supervision Needs Following Veteran and Service Member Moderate to Severe Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To characterize supervision levels across residential settings at 1 year post-TBI and explore predictors of supervision in a Veteran and Service-member population. SETTING: Five VA Polytrauma Rehabilitation Centers. PARTICIPANTS: A total of 302 individuals enrolled in the VA TBI Model Systems (TBIMS) research program. DESIGN: Prospective, longitudinal, multisite. MAIN MEASURES: Primary residence and supervision levels measured via scores on the Supervision Rating Scale. For predictive modeling, scores were dichotomized into 2 groups: those that were fully independent/living alone or required only some supervision during the day (independent group, n = 195) and those that required overnight supervision, full-time indirect supervision, and full-time direct supervision (dependent group, n = 107). RESULTS: Thirty-five percent were receiving supervision at 1 year post-TBI across residential settings and 28% were living in alternative settings. Multivariate modeling indicated that older age and longer posttraumatic amnesia (PTA) were predictive of having a need for supervision at 1 year postinjury. CONCLUSIONS: Supervision needs are long-term features of moderate and severe TBI. Results of this study lend support to the shift toward conceptualizing TBI as a chronic disease.

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study.

OBJECTIVE: To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma. SETTING: Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs). PARTICIPANTS: A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury. DESIGN: Prospective, longitudinal, multisite. MAIN MEASURES: Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment. RESULTS: At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change. CONCLUSIONS: The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Profession of neuropsychology in Latin America.

The purpose of this study was to analyze characteristics of individuals working in the profession of neuropsychology in Latin America in order to understand their background, professional training, current work situation, assessment and diagnostic procedures used, rehabilitation techniques employed, population targeted, teaching responsibilities, and research activities. A total of 808 professionals working in neuropsychology from 17 countries in Latin America completed an online survey between July 2013 and January 2014. The majority of participants were female and the mean age was 36.76 years (range 21-74 years). The majority of professionals working in neuropsychology in Latin America have a background in psychology, with some additional specialized training and supervised clinical practice. Over half work in private practice, universities, or private clinics and are quite satisfied with their work. Those who identify themselves as clinicians primarily work with individuals with learning problems, ADHD, mental retardation, TBI, dementia, and stroke. The majority respondents cite the top barrier in the use of neuropsychological instruments to be the lack of normative data for their countries. The top perceived barriers to the field include: lack of academic training programs, lack of clinical training opportunities, lack of willingness to collaborate between professionals, and lack of access to neuropsychological instruments. There is a need in Latin America to increase regulation, improve graduate curriculums, enhance existing clinical training, develop professional certification programs, validate existing neuropsychological tests, and create new, culturally-relevant instruments.

Reciprocal Causation Between Functional Independence and Mental Health 1 and 2 Years After Traumatic Brain Injury: A Cross-Lagged Panel Structural Equation Model.

OBJECTIVE: The research attempting to disentangle the directionality of relationships between mental health and functional outcomes after traumatic brain injury (TBI) is growing but has yielded equivocal findings or focused on isolated predictors or isolated outcomes. The purpose of the current study was to use cross-lagged panel and structural equation modeling (SEM) techniques to examine causality between comprehensive indices of mental health (depression, anxiety, and life satisfaction) and functional independence in a national sample of individuals with TBI over the first 2 years after injury. DESIGN: Participants were 4,674 individuals with TBI from the TBI Model Systems Database. RESULTS: The SEM, which yielded good fit indices, suggested that individuals with TBI with greater mental health problems at 1 and 2 years after injury had lower functional independence at those same time points. The standardized path loadings for mental health problems and for functional independence over time were large, suggesting a high degree of consistency in mental health and functional independence across 1 and 2 years. In terms of cross-lag, mental health at Time 1 did not exert a unique effect on functional independence at Time 2, but functional independence at Time 1 exerted a statistically significant but quite small unique effect on mental health at Time 2. CONCLUSIONS: This combination of results suggests that functional independence is only slightly more causal than mental health in the relationship between mental health and functional independence over the first 2 years post-TBI, and that instead, reciprocal causality is a more likely scenario. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) understand the nature of the relationship between mental health problems and functional independence after traumatic brain injury; (2) learn about a novel methodological technique for examining the connections between variables over time; and (3) understand when ongoing support for individuals with traumatic brain injury is necessary. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Pilot Study of a Newly Developed Intervention for Families Facing Serious Injury.

Background: There is a need to develop interventions that address the entire family after spinal cord injury (SCI), especially in Latin America, where rehabilitation resources are limited and little is known about family adjustment to SCI. Objective: To evaluate the short-term (post-intervention) and longer term (6-month) effectiveness of the newly developed, 8-session manualized family intervention for individuals with SCI and their family members compared to a control group. Methods: In this clinical demonstration project, longitudinal self-report data were collected from 8 individuals with SCI and their family members in Colombia, South America. The 8 families were randomly assigned to either the SCI intervention group or the waitlist control group. The intervention group included 10 individuals from 4 different families, with a mean age of 41.40 years (SD = 14.18). The control group was composed of 13 individuals from 4 different families with a mean age of 44.38 years (SD = 14.76). All participants completed Spanish versions of instruments that assessed depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden (Zarit Burden Interview), and perceived problem-solving skills (Problem-Solving Inventory). Results: Results provide preliminary evidence that symptoms of depression, anxiety, and burden as well as problem-solving appraisals improved significantly for individuals who participated in the intervention, whereas no change in symptoms was observed among those in the waitlist control group. Conclusions: Findings suggest that this newly developed intervention for families facing SCI can be beneficial; however, this pilot study represents only the first step in the examination of the efficacy and effectiveness of this intervention.

The Relationship between Training and Mental Health among Caregivers of Individuals with Polytrauma.

This was a hypothesis-generating exploration of relationships between caregiver training during TBI/polytrauma rehabilitation and caregiver mental health. In this cross-sectional study, 507 informal caregivers to US service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center from 2001 to 2009 completed a retrospective, self-report survey. Embedded in the survey were measures of caregiver mental health, including the National Institutes of Health's Patient Reported Outcome Measurement Information System (PROMIS) Anxiety and Depression Short Forms, the Rosenberg Self-Esteem scale, and the Zarit Burden Short Form. Though no groups endorsed clinical levels, mental health symptoms varied by caregiver training category (Trained, Not Trained, and Did Not Need Training). Caregivers who did not receive training on how to navigate healthcare systems endorsed higher depression and burden and lower self-esteem than those who did. Caregivers who did not receive training in supporting their care recipients' emotions endorsed higher anxiety, depression, and burden and lower self-esteem than those who did. Analyses also suggested a different association between training and mental health based on caregivers' relationship to the care recipient and the intensity of care recipient needs. Potential hypotheses for testing in future studies raised by these findings are discussed.

Health-related quality of life and mental health outcomes in Mexican TBI caregivers.

Research has documented the deleterious effects on caregivers of providing care for an individual with traumatic brain injury (TBI). TBI caregivers in Mexico specifically have reduced health-related quality of life (HRQOL) across both physical and mental health domains. The purpose of the current study was to uncover the system of connections between Mexican TBI caregivers' HRQOL and their mental health. A cross-sectional survey was conducted at a public medical facility in Guadalajara, México. Ninety family caregivers of individuals with TBI completed measures of HRQOL, satisfaction with life, depression, and burden. A canonical correlation analysis revealed that the better the caregivers' HRQOL, the better their mental health was, with the effect reaching a large-sized effect. A distinct pattern emerged linking caregivers' higher energy levels and better social functioning to lower depression and greater satisfaction with life. A series of multiple regressions similarly uncovered that the most robust independent HRQOL predictors of caregiver mental health were vitality and social functioning. Especially for TBI caregivers with poor health, behavioral health interventions in Latin America that target the HRQOL domains of social functioning and vitality may significantly improve caregiver mental health, and as a result, informal care for TBI.

Factor analysis of the Spanish Multidimensional Attitudes Scale Toward Persons with Disabilities.

PURPOSE/OBJECTIVE: To study the psychometric properties of a Spanish version of the Multidimensional Attitudes Scale toward Persons with Disabilities (MAS) and examine its factor structure using confirmatory and exploratory factor analyses on data from a Colombian collegiate sample. RESEARCH METHOD/DESIGN: Five hundred students from Sur Colombia University in Neiva, Colombia, completed the Multidimensional Attitudes toward People with Disability scale. Forty-eight percent were male, and the average age for the entire sample was 21.25 years (SD = 3.50). Ninety-eight percent were undergraduates, 23% of whom were business majors and 33% of whom were education majors. RESULTS: An exploratory factor analysis (EFA) of data from half of participants suggested the retention of 4 factors and the deletion of 4 items. A confirmatory factor analysis (CFA) on the data from the second half of participants using the 30 retained items and 4-factor structure suggested that the 4-factor model fit adequately with the remaining 30 items. High internal consistency was found for the overall scale (α = .77, .78) and for the 4 resulting subscales: Affect (α = .88, .87), Cognition (α = .92, .90), Behavior (α = .88, .88), and Calm (α = .90, .89). CONCLUSIONS/IMPLICATIONS: This study modified the MAS to assess attitudes toward persons with disabilities in Colombia. The adequate reliability and fit of the factor structure of the Spanish MAS suggests that it holds promise to help researchers investigate attitudes toward persons with disabilities in Latin America, an important topic to the global disability community.

The influence of TBI impairments on family caregiver mental health in Mexico.

PURPOSE: This study examined the influence of five types of impairments in individuals with traumatic brain injury (TBI)-and caregiver stress due to these impairments-on the mental health of family caregivers in Guadalajara, Mexico. METHOD: Ninety caregivers completed measures of TBI impairments and of their own mental health. The majority were female (92.20%) with a mean age of 47.12 years (SD = 12.67). Caregivers dedicated a median of 50 hours weekly to caregiving and had spent a median of 11 months providing care. RESULTS: Two canonical correlation analyses suggested that these two sets of variables were broadly related, such that more severe impairments in individuals with TBI and more caregiver stress due to those impairments were associated with lower caregiver mental health. Across both analyses, social impairments were most associated with increased caregiver burden. Follow-up analyses also uncovered that caregiver stress due to cognitive impairments was uniquely associated with caregiver burden and anxiety. CONCLUSIONS: These results are the first to provide evidence that social and cognitive impairments in individuals with TBI from Latin America are the impairments most associated with caregiver mental health and highlight the need for interventions that target social and cognitive functioning.

Using multiple views of family dynamics to predict the mental health of individuals with TBI and their caregivers in Mexico.

PURPOSE: To examine differences in ratings of family dynamics between individuals with traumatic brain injury (TBI) and their family caregivers in Mexico, as well as differences in the prediction of caregiver and patient mental health outcomes from those ratings. METHOD: Forty-two patient-caregiver dyads (n = 84) from the National Institute of Rehabilitation in México City participated in a comprehensive evaluation of their family dynamics and mental health. RESULTS: Patients' and caregivers' ratings of family dynamics were significantly correlated and did not differ across five of six types of family dynamics, but caregivers rated their family's level of empathy higher than patients, p < 0.001. Additionally, all patient and caregiver ratings of family dynamics were significantly correlated. Patients', caregivers', and combined (using structural equation modeling latent constructs) ratings of family dynamics robustly predicted four times as many caregiver mental health outcomes as patient mental health outcomes. CONCLUSIONS: Family dynamics influence both TBI patient and caregiver mental health but much more so in caregivers. Research on families of individuals with TBI in Mexico should incorporate both patient and caregiver perspectives to more comprehensively depict the environment in which TBI rehabilitation occurs.

Exploring the connections between traumatic brain injury caregiver mental health and family dynamics in Mexico City, Mexico.

OBJECTIVE: To examine the patterns of family dynamics that are most associated with the mental health of traumatic brain injury (TBI) caregivers from Mexico. It was hypothesized that healthier family dynamics would be associated with better caregiver mental health. DESIGN: A cross-sectional study of self-reported data collected from TBI caregivers through the Mexican National Institute of Rehabilitation in Mexico City, Mexico, the premier public medical facility in Mexico that provides rehabilitation services to patients with various disabilities. SETTING: One public outpatient medical and rehabilitation facility. PARTICIPANTS: Sixty-eight caregivers of individuals with moderate-to-severe TBI from Mexico City, Mexico, were related to an individual with TBI who was ≥3 months after injury, a primary caregiver for ≥3 months, familiar with the patient's history, and without neurologic or psychiatric conditions. The average (standard deviation) age of caregivers was 50.94 ± 12.85 years), and 82% were women. METHODS: The caregivers completed Spanish versions of instruments that assessed their own mental health and family dynamics. MAIN OUTCOME MEASUREMENTS: Outcomes assessed included family dynamics (Family Adaptability and Cohesion Evaluation Scale-Fourth Edition; Family Communication Scale; Family Satisfaction Scale; Family Assessment Device-General Functioning; and Relationship-Focused Coping Scale), and caregiver mental health (Patient Health Questionnaire-9, Zarit Burden Interview, and Satisfaction with Life Scale). RESULTS: Results of canonical correlation analyses suggested that caregiver mental health and family dynamics were positively related, with a large effect size. Caregivers with high family satisfaction and cohesion tended to have a low burden and high satisfaction with life. In addition, caregiver depression and burden were positively related to each other and were both inversely related to caregiver satisfaction with life. CONCLUSIONS: TBI caregiver interventions in Latino populations would likely benefit from including programming or techniques to improve family dynamics, especially family cohesion, given the strong potentially reciprocal influence of these dynamics on caregiver mental health.