Good morning. Welcome to the APA annual meeting here in San Francisco. Just a few bookkeeping items. So after the presentation, we'll have Q&A and we'll ask that you come up to the microphone. And we've been told to make sure that you state your question in 30 seconds or less just to encourage participation and ask appropriate questions rather than long comments so that we can get more people to answer questions. So I'm very proud to hold up the mantle from Dr. Rebecca Brindel about innovate, collaborate, and motivate. Roadmap for the future. So that brings to mind and bearing, you know, where are we, where are we going? You know, looking at innovate. So within the field of TBI, that might be the use of progressive return to activity, the MACE 2 Intrepid Spirit Centers and the TBI Centers of Excellence where there's collaboration within the model itself involving embedded behavioral health, active duty psychiatrists, social workers, Oscars, civilians, peers and support, buddy groups, and veterans. So the purpose of this talk is to not only focus on active duty but through to veteran care and afterwards. The involvement of residents, fellows, and medical students to motivate the next generation to pick up the mantle and to help those that serve as we are now actively doing. I'd like to thank Dr. Tanev and Commander Lacroix. And I'd also like to thank all of my active duty mentors, including Lieutenant Commander Gaylord, Commander Ormeño, Captain Sargent, to name a few. And in my opinion, they exemplify excellence. And so some of the things that I use to look at innovation are something called human-centered design. So taking a three-box solution. So looking at what we're doing at the present, which oftentimes we're understaffed, overworked, and underprepared to take care of those that serve. And we're tasked with so many different missions. So how do we optimize what we're doing in the present while not being chained down to the past where we can envision a future that's better than what we're doing now at the moment? So with that, I'd like to introduce today's topic, which is From the Battlefield to Home Base, Traumatic Brain Injury Advances in Active Duty Military to Veteran Healthcare. Our objectives today are to learn about military combat, TBI, and recognize post-concussive sequelae in both active duty and veteran populations. Recognize overlapping constellations of symptoms including depression, anxiety, insomnia, PTSD, and chronic pain. And to recognize lessons learned from current models of rehabilitation among neurology, psychiatry, and physiatry to comprehensively address the needs of military service members and veterans with TBI. And to learn about the long-term impact of military TBI advances in military and veteran TBI research including MRI techniques, virtual reality-based interventions, post-traumatic headaches, and comorbid PTSD. None of us have relevant financial relationships to disclose. And I'd like to go ahead and introduce our speakers today. So Commander Lacroix received her BA in classical languages and classical civilization from Fordham University. She received her osteopathic medical degree from Midwestern University. She is board certified in physical medicine and rehabilitation, psychiatry, and brain injury. She has served as head of inpatient and outpatient PMR, director of DME and director of PMR at Walter Reed National Military Medical Center, department chief of consult liaison service at Fort Belvoir Community Hospital, director of medical services and director of behavioral health at the Intrepid Spirit Center at Fort Belvoir. Commander Lacroix was head of research at Intrepid Spirit and principal investigator on many multi-center research projects on traumatic brain injury. She was voted by her peers as the first ever recipient of the Colonel Peter J. Wisema Award for Excellence in Research, researcher of the year at Fort Belvoir Community Hospital. She currently serves as assistant professor of both PMR and psychiatry at USIS, and she has been the recipient of the Defense Meritorious Service Medal, Joint Service Commendation Medal, Navy Marine Corps Achievement Medal, twice, and Armed Forces Achievement Medal, twice. Additionally, I'm humbled to present Dr. Kailo Tanev who completed his undergraduate and medical degree from High Medical Institute, Medical Academy in Sofia, Bulgaria. He completed his psychiatry residency at Brown University and his neuropsychiatry fellowship at Dartmouth Medical School. He is board certified in psychiatry and certified by the United Council for Neurological Subspecialties in Neuropsychiatry. He has completed an NIMH career development award on whether cognitive performance, MRI, and DTI brain changes can predict the response to cognitive behavioral therapy in military service members and veterans with PTSD and comorbid TBI. He has served as PI for clinical research involving sleep disturbances in hospitalized patients with dementia and site PI for multi-site studies of Huntington's disease. He serves as the senior director of research and as interim chief medical officer of the MGH Home Base Program as well as the MGH Division of Neuropsychiatry where he serves as medical director of the TBI clinical and research program. The Home Base Program is a joint venture of the MGH and the Boston Red Sox Foundation with a mission to serve the psychiatric and other medical needs of OEF, OND, active duty service members, reservists, veterans, and their families. He is an assistant professor of psychiatry at Harvard Medical School. He has served as the president of the American Neuropsychiatric Association and as the president of the New England Society of Clinical Hypnosis. So with that, I'd like to introduce Commander Lacroix. So good morning, everyone. So it is my pleasure and privilege to bring to you the first part of this presentation. And so just as Dr. Mattock pointed out, I make absolutely no money. But moreover, these opinions that I'm expressing are purely my own and do not in any way represent the Department of Defense, the Navy, the university where I teach. So, all right, so I want to begin discussing about the issue with TBI by the numbers. So if you see the numbers that were supplied here, total fall severities is close to half a million. And I will comment that like in the civilian population, this is probably underreported for a number of reasons. And I also do want to comment that although the majority as you see on the pie graph, the biggest piece of the pie, is mild, this does not imply that there is no residual disability in these patients. Okay, so common causes of TBI are severe head impact, explosive device exposure, and penetrating ballistic injuries. But by far, blast injury is the most common mechanism of injury. So I'm going to talk a little bit about explosive injury in general, which is classified into four subtypes. So primary, secondary, tertiary, and quaternary. So primary is basically due to the supersonic overpressurization blast wave, which is unique to high order explosives, right? So that's basically when the blast overpressure hits the body surfaces. You can have things like pulmonary barrel trauma, rupture of the eardrum, rupture of the gallbladder. But additionally, you can have rupture of the globe of the eye and obviously concussion even in the absence of obvious head injury. So secondary blast injury is low order explosives. And it's when the subsonic wave isn't quite as powerful. But usually what occurs with this is that injury will happen due to like flying debris, bomb fragments, projectiles causing plunt and penetrating injuries. So tertiary blast injury is, which is the most common in our military members, is when it actually, when the body is thrown by the actual blast. And it can manifest as fractures, traumatic amputations, and also brain injuries. So males have approximately twice the rate of injury of females. And the incidence of emergency craniotomy is less in females. And it's really unknown about the incidence of post-TBI sequelae in the female population. Because I always get asked that question. There's some evidence that estrogens are somewhat protective, but the literature is very mixed. And I will be frank that this is sort of a lack in the literature. So I wanted to go back and talk a little bit about TBI in the military, like in terms of history. So we can talk about where we came from and then currently where we are, and then hopefully maybe a little bit about where we're going. So trinitrotoluene was first synthesized in 1863. But fortunately, it was not used in weaponry until World War I, for the most part, when it was first utilized in trench warfare. Now unfortunately, during trench warfare, the people exposed to like usually thousands of blasts per day. And the soldiers would return and have many symptoms. So they would present with persistent headache, amnesia, inability to concentrate, difficulty sleeping, mood disturbances, periods of depression. And many of these soldiers would end up killing themselves. And so people really didn't understand what was going on with that. So there was sort of a thought process that a lot of this was like psychoneurosis. So they were often diagnosed with neurasthenia, which maybe some of us remember, or shell shock, or not yet diagnosed neurologic, whatever that's supposed to mean. So there was a British physician, Major Frederick Mott, who was both a neurologist and a pathologist, who in 1916 did some post-mortem of some of these soldiers. And though that they had no skull fractures and no evidence of penetrating head injury, there was actually particular hemorrhages throughout the brain for many of these soldiers. And he hypothesized that it was blast injury that had actually in the end caused death in these soldiers. Now, you'd think that would be kind of universally accepted, right, because we have pathology evidence. But unfortunately, there was so many soldiers that suffered during World War I that the hospitals were overflowing. And so he was only one physician at one hospital. And so there was a big division. So while he was saying, I believe that this physical pathology, many people were still calling it like combat or battle fatigue. You know what I'm saying? And calling it was like a psychiatric diagnosis. And, you know, unfortunately, none of that studies in terms of blast injury was replicated until about 1949, actually doing post-mortem, even though Dementia Pugilista or dementia from an actual, you know, impact to the head, even recognized as early as 1928, it was still very, very controversial. So that being said, there was really no standardized treatment given for these soldiers, and particularly the United States because we were so late in entering the war. So moving on, right? So in World War II, the first neurological center was set up at Walter Reed Army Medical Center. And survival rates were higher due to introduction of antibiotics and cranioplasty. So basically, from the beginning of the war, there was about a 40% death rate. And by the end of the war, there was about 14% death rate for head injuries. So that meant we had a lot more people we had to take care of, though, right? And so rehabilitation was still kind of a gray area. If they had any motor issues, then they got physical rehabilitation. Any cognitive or mental issues, oh, it's psych. It's got to be psych, right? So they got psychiatric treatment. Now, there was one psychiatrist at Brooke Army Medical Center, a Dr. John Ada, who actually did multi-D rehabilitation at that time and had a 60% return to work, school for these soldiers, which is quite impressive. But unfortunately, once the war was over, then that model was discarded. Again, because it was still kind of controversial about the cause of this. So I think some of us are familiar with the TV show MASH, right? So we're very familiar with the Mobile Army Surgical Hospitals, right? And so they did a lot of wonderful things. Because basically, they were units that were positioned within close proximity of the forward battle locations in order to get the casualty to neurosurgical care as quickly as possible. But one of the other major innovations and probably saved a lot more lives and a lot more brains, was actually that now helmets became mandatory. Because prior to this time, they were not, which is people are very surprised when I say that, but it's true. And the other advantage that I would say that actually came out of this is that the Korean War was the first time when patients reported with symptoms of psychiatric symptoms due to TBI, they would get treated and then could often return to duty. So this was the first time that was recognized that the soldier could still serve, which was very, I think, psychologically very helpful in those patients. And so moving on to the Vietnam War, the MASH TV show, we saw a lot of helicopters, but actually helicopter was not very efficient at that time. It was actually during the Vietnam War that the helicopter became utilized in these patients to help them get to definitive management. So for example, during World War I, if I had some kind of neurological injury, it would have taken me about 18 hours to get to a neurosurgeon for definitive management. With the use of the helicopter in the Vietnam War, it was one and a half hours. So it's quite a difference. Another thing that occurred was the diagnostic criteria for PTSD was added to DSM-3. And this was actually in advance because now we started thinking about a lot of these symptoms the soldiers had and trying to parse out what was like neurologic versus psychiatric. So now we had something at least to hold on to from the psychiatric realm. And then the Vietnam head injury study was started. Now that was when they had over 2000 Vietnam veterans who had penetrating head injuries, not blast injuries admittedly, but they studied them for 40 years and they found that decades later they could have cognitive issues or epilepsy. So that was the first time they were like trying to view these people long-term. So then we're moving on to the Global War of Terror. So the first time the blast injuries were the primary injury during the conflict, right? So even when people had a penetrating head injury, 70% of the time it was due to debris from the blast. Only 30% was a gunshot wound to the head. So that's a big change from the other conflicts. And then the combat support hospitals actually became a way that we started treating these patients, right? And so they would do, they had CT, they had cerebral angiography, transcranial Doppler and hypertonic resuscitative fluids. Now the decompressive craniotomy, right? Originally that was considered extremely dangerous, but it became on the front line something like a damage control procedure, right? So injuries that would have been lethal in prior conflicts actually were aggressively decompressed at far forward combat support hospitals. And there actually is really good evidence that decompressive craniotomy does make a difference in these patients. For example, there was one study that they had over 200 service members and their risk of death radically increased if they had greater than a five hour wait time to have that compressive craniotomy. So obviously many important advances, but of course the death rate went down and so we have to get more of these patients to care for, so which is a good thing. So, all right. So there was a lot of questions about like, well, what do we do? Because we were recognizing the fact that people were having these injuries and there was an increasing concern that the higher frequency of TBI or possible TBI were unrecognized. And by first responders or command. And a lot of the blast injuries seemed to cause invisible injuries to our service members. With headaches, sleep problems, PTSD, right? And then there was just this additional concern that failure to recognize this, right, incur more risk to service members returning to duty and then getting another TBI. And during the war on terror, it was observed that more service members were now dying by suicide than from enemy assault. And they were thinking a lot of that was secondary to these unrecognized brain injuries. So a lot of things occurred in terms both from Congress and the DOD, right? So in 2005, Congress established funding to the VA for polytrauma system of care. And that is a program which was supposed to basically give access to our service members with specialized expertise in TBI. And it's composed of polytrauma rehabilitation centers, network sites, clinic support teams, and then points of contact for these service members. And today, it's widespread through the country. And then 2006, the DOD directive was basically issued by the Secretary of the Army to establish policies and responsibilities for these soldiers, for the prevention, mitigation, and treatment of blast injuries. And that was the first time. And the same year, Congress passed the NDAA for fiscal year 2007. And it called for the 15-year longitudinal study of TBI incurred by veterans Operation Enduring Freedom and Operation Iraqi Freedom. And it also developed a panel of experts to help these families with these service members that return with these injuries. And then in 2008, the NDAA required pre-deployment neurocognitive testing of all service members. Now this might seem obvious to you, but we have service members returning and they had to be like, well, what was baseline? Like, how can we understand this if we don't understand how the service member was before they were in the blast? And so they required the use of the automated neuropsychological assessment metrics. And actually currently, these baseline test results are currently available for both pre and post-concussive for all deployed service members. That was definitely an advancement. So then in 2006, the Military Acute Concussion Evaluation MACE was created. In 2008, it was introduced in the theater for TBI care. And currently, it is the standard concussion screening tool used by the DoD. So a little MACE card there for those maybe not as familiar with it. To be frank, though, even after it was introduced, application was extremely limited. In 2009, the Chairman of the Joint Chiefs of Staff, he was concerned because it seemed as if people in forward units, there was not identification of these injuries or treatment or even a recognition of the psychological distress in our deployed service members. He organized a team of medical experts with representatives from each of the services, and they went for about approximately ten days to different locations in Iraq and Afghanistan. They were known as the Gray Team. Gray Team 1 found serious deficiencies in the TBI care. Basically, it was only about 5% of people utilizing the MACE. The service members, well, they had a 95% return to duty, but what did that mean? Had they actually been evaluated? Did they have these invisible injuries? No one could really answer that. Gray Team 2, coming back in that same year, found improvements, and so one of the recommendations they had was that not only would these injuries be documented, which believe it or not, up to that time, they were not in the medical record, but also the 50-meter rule. In other words, if anyone was within 50 meters of a blast, they should have a medical evaluation and a period of rest, and this should be documented. And then Gray Team 3 found further improvements. They also went back twice. Over time, these things were more encouraged and were actually being utilized. But the whole point of the Gray Team was that the shift was now to leadership for accountability. It was no longer on the service member, I've been injured, I've been in a blast. Now it became more on the leadership. So these are some of the DOD and DHA directives that came out of some of these findings. I will not read every slide, but I did want to point out that the DOD directive took the advice of the Gray Team and required rest periods and medical evaluations when they were in a presence within 50 meters of a blast, a direct blow to the head, exposure to more than one blast event, or a vehicle rollover. Then the follow-up DOD guidance, again, was about the recognition of the necessity of a computerized neurocognitive assessment tool for the evaluation of all service members with a concussion. The policy memorandum was actually directed to the leadership. In other words, they were saying that we needed to have more comprehensive histories, baseline tests, assessment tools to help leadership make decisions on how to treat these patients and also if they had return to duty. And then finally, just to talk about the DHA directive, it actually follows upon many of these prior DOD directives and is actually more extensive, if anything, including things like tracking with actually validated scales and making more protocols, more standardized protocols for how we treat our service members. So just a little bit about, because we have so many policies, so many directives and so many patients, so there was this need to consolidate information, have people talk to one another, integrate information, help the service members. So the DCO was created in November 2007 to help them with both psychological health and traumatic brain injury. It's divided into three departments, but the one we're going to focus on is the TBICO, which some of us may have heard of formally as DVBIC. But it was actually originally founded in 1992, but was folded into the others, right, because it had a lot of, to have more communication in a silo. And so this is given by the DOD, the Office of Responsibility for creation of that TBI surveillance database for the design and execution of that 15-year longitudinal study on the service members with TBI. And they have many other duties. So they gather the data mandated by Congress and the DOD, they oversee research, they screen and brief service members, they provide pre-deployment provider training for folks at the MTF, the providers, and they provide many educational materials for service members, family members, and also veterans. So they do a lot of excellent work. So you can see right here, this is many of the network sites. But then obviously, you know, well, this is really great, all this data they're collecting and all this research that they're doing. But you know, at the end of the day, it's all about the patients, right? So it's all about the patients, it's all about the service members, right? So it became an issue, but what about clinical care for these complicated patients? And so many of you may have heard of the Intrepid Fallen Heroes Fund, right? So it's a nonprofit with the mission of helping service members with traumatic brain injury or post-traumatic stress. And they are actually funded by, not by Congress or taxpayer dollars, but actually by concerned people giving donations. And to be very clear, they make it very clear that it's not a way of trying to cut the government out or they don't feel that the government or taxpayers have their best interest at heart, they just feel they can do things quicker if they don't have to worry about those things, which I'm inclined to agree. And the first one was opened in 2010, and it was followed by the following Intrepid Spirit Centers. Now Fort Belvoir is no longer Fort Belvoir, and Fort Bragg will be Fort Liberty, but these are the prior names for them. But as you see, there's multiple of these centers and another map showing some of the Intrepid Spirit Centers. So what is the goal of these Intrepid Spirit Centers? So it's actually multidisciplinary care, right? And so you see this list, I won't bore you by reading all this to you, but basically these are all basically services that are usually provided in Intrepid Spirit Center or any conjoined hospital that they work with. So for example, often like sleep studies, you may see the sleep physician at the Intrepid Spirit Center, but then the sleep study would be at like an associated hospital. But then you say, well, if I have a service member coming in, are they going to get all these treatments? It's like, well, no. The way it would work is, because I was working at them as well, I was one of the intake physicians, is the patient would come in and then you would deal with whatever they were concerned with, and then you would write a prescription, and then they would continue with the care that you advised. And then you would have multi-D meetings like once or twice a week with the entire team, with the understanding that if the patient then required other services, we would loop them in. So the patients themselves are very involved, and the families are very involved, and it's constant communication, and it's actually extremely effective. So I talked a little bit about policy, I talked a lot about history, but at the end of the day, it's about the patients, it's about the service members, it's about the patients. So I get a lot of questions like, how do you treat these patients? So my textbook answer, or not so textbook, it depends, because it's very frustrating to my residents, like, what do you mean it depends? Because it depends, because every patient is different. So I'm not smart enough to provide you with an algorithm, but I'd like to at least talk about one patient, maybe to give you some idea of how we would approach one of these patients. So we had a patient, 15 years of service, so he was in a blast, and he had a lower left extremity amputation, and he initially had a diagnosis when he was screened at the hospital for mild TBI. He had an initial injury, right? So he came to us because his command wanted him to come, to be direct, and he's like, I'm not really sure why I'm here, and my wife is divorcing me. So I think one of the things is, also I think one of the problems was, is that he had a very bad relationship with his command, and part of it was, some of these other issues, but part of it was the fact that he was no longer boots on the ground, because he's kind of stuck behind a desk due to his amputation. But anyway, but anyway, he had no idea why he was here, he was actually a little bit kind of hostile, right? But you know, further interview, he had endorsed only sleeping three hours a night, he complained of some nightmares, phantom pain, he said he was drinking one to two bottles of wine a night to get to sleep, use of chronic short-acting pain meds for amputation pain, poor fitting prosthetic device, he actually had skin breakdown, poor memory and concentration, irritability, heck, he was irritable with me, issues with command and family due to arguments and emotional isolation. This is a gentleman who would basically tell me like, on the weekend, I just go down to my basement, and I close the door, and my wife basically just leaves meals for me outside, because I'm too irritable and I can't deal with anyone, right? So you know, he reported that he didn't acknowledge he had the ID blast that resulted in the amputation, but he also had exposures to other head injuries, including rollovers and blast exposures, which he never got care for. He said he needed to get, keep going, he wanted to go to different schools, he had all these goals for himself that he felt that that would get in the way, if he started becoming a complainer. And then he also reported other military incidents, including exposures to dead bodies. And he did not want to answer directly about suicidal ideation with initial interview, because with my intake nurse, he was very cagey, he basically refused to answer. And with me, eventually, I basically was able to get out of him that he did not have active suicidal ideation, but he had a lot of morbid thoughts, and he had a lot of passive hopes that someday he just wouldn't wake up. So what do you do with this patient, right, like, gosh, right? So question marks, right? So I always start off with getting some buy-in and establishing trust. A lot of these soldiers, I'll be frank, they feel like they've gotten to work around, they feel like no one's listening. And then you just don't jump into the neuropsychological psychiatric eval, as long as safety is an immediate concern. If it is, obviously, do not, pass go, do not collect $200, you know, we jump right to that. But with this patient, for example, there was, I didn't, you know, I didn't need to necessarily address it on that day. I actually kind of have a advantage here, because I would evaluate them as a physiatrist, but the whole time I'd be evaluating them as a psychiatrist. And so they were comfortable with that, but in any case, but anyway, but the first day I actually was talking to the patient about alcohol use, a little motivational interviewing, let him talk about it himself, right, poor sleep. He actually would, he actually went to substance use treatment pretty much right off, because the individual we had doing substance abuse treatment was a 30-year army soldier who had a lot of deployments. And I basically told him, I said, he'll get you, and so he was okay with that. And then we ordered a sleep study, it showed pretty severe sleep apnea, right? And so for a lot of his pain, and because he was no longer using alcohol, I started the patient on Effexor and gabapentin. And I'm not saying you necessarily start every patient on this, for this patient with his chronic pain, and his underlying alcohol use, those, in my field, were appropriate choices, but there were a number of medications we could have started him on. And I was very frank that they did have psychiatric indications, but he was okay with that, because like, I'm really giving it to you for your pain, but it also helps folks that have some of the other things we talk about, and he was okay with that, right? So I sent him to PT for gait, because a lot of times when people have amputations, their limbs shrink over time, and so his gait was off, he didn't have proper prosthetic fit. So I got him to the prosthetic clinic, I went right to the wound clinic, we don't want this gentleman developing osteomyelitis, so he went for there. We got him in with the acupuncturist for pain or sleep, I actually also do acupuncture, but I actually got him in with the Chinese medicine doctor, because I feel like more eyes would be better, and she could spend more time with him for that specific indication. And then we sent him to OT for his sleep hygiene, his neuropathic pain, his ADLs, but also to open the door. So a lot of times in the military system, OTs are very familiar with these patients, and they're very familiar with some of their psychiatric needs. And so a lot of times I would send patients when they're not quite ready to talk to me about the psychiatric things, OT is your friend. So you send them to OT, and it's okay, because we're talking about sleep hygiene. So once sleep was normalized, I got a patient into speech language for memory concerns, so he was working with them. So the pain was controlled, the sleep was improved, and then I referred the patient for neuropsychology. Now it seemed to me that the patient did have residual neurological things, but I like to get things in print. It helps with buy-in. And as you see, I didn't send him until a lot of the correctables were already corrected, because it wouldn't give me no information. And he might not have even done best effort, right? So obviously what it showed, it showed information processing, impaired long-term memory, attention, working memory, executive function, social cognition. But he also had a lot of findings that existed with anxiety. So I discussed with the patient the findings. This opened the door further of discussion of past trauma. He's like, well, you think I'm anxious? I'll tell you why. I'm like, okay, I'm here to listen. So he was started on cognitive processing therapy, and also marital counseling, just so you know, is that marital counseling is a really good way to work with the patient, because you're working through the spouse and their relationship. So it was a good way to actually unpack some of this, and I felt like his wife had a better understanding of what he was going through, since they really started communicating. So then we worked simultaneously with art and music therapy to process trauma. In my experience, a lot of patients who don't like the talky therapy, or are not comfortable, they'll process it with the art and music therapy, because they can do it non-verbally. And it actually was multiplicative, not additive, right? So he actually still is active duty, right? He's actually working well with his command, right? He's still married, and he's not abusing alcohol or painkillers. So basically he said to me, he's like, didn't know why I was here, didn't really have buy-in, and a lot of this sounded a little cuckoo, right? He says, but you saved my life, doc. You saved my life. And I was like, well, it wasn't just me. It was our team, but thank you. You know what I'm saying? So, all right. So let's just talk a little bit, though, about some of the issues with TBI in the military. And some of this may be self-evident, but I just kind of wanted to sort of hammer that home. It's, you know, obviously it's difficult to assess in theater, right? So if I have a quadruple amputee in a blast, right, and he's bleeding out, or his inner organs are on his outside, right, I'm not really assessing whether he had a TBI or not at that moment, right? And some servicemembers do not want to admit they've had a TBI. They don't feel comfortable with that. They're just like, well, I'm not brain damaged, or I'm not, you know, used up, and I still want to serve in the Army. And so they'll minimize it, or say, like, I don't have these kind of problems. Or say, everyone has these problems, so don't treat me. And then some servicemembers, you know, on the contrary, exaggerate effects. And there's a number of reasons for that. Some of it is actually, like, psychiatric concerns, because, you know, it's easier to say it's from the blast I had than it is to talk about some of the things they've experienced. So they may exaggerate, and occasionally, I mean, most of the folks I work with, you know, it's not the reason. There are some people with secondary gain, like there is everywhere, but it doesn't mean that we don't take whatever a patient tells us seriously, but I will say it does exist. And then the neurological symptoms can be confused or compounded with psychological ones. And there's a number of reasons you can imagine why this is. So many of the symptoms of PTSD and TBI overlap, alcohol use is a confounder, drug abuse is a confounder. And also because these people rarely present purely, like they have a tendency to cross diagnostic boundaries, not quite fit all the criteria in the DSM-5, so, you know, it can be very complicated. So there's a lot of questions that people have in the military. So I did think we should just at least talk briefly about AHI, anomalous health incidents, because, you know, there is a concern actually now with the military. I can't go into too much of it because quite a bit of it is classified, but I can tell you that since 2016, U.S. and Canadian personnel, they've reported strange symptoms, usually if they're in a foreign country, particularly Cuba or China, and they describe it as sounds pressure or heat, involved mechanisms that are poorly understood. We can speculate. I can refer you to some papers if you're interested, but the jury's still out on that, right? But the reported symptoms resemble those of TBI, right? It's formerly called Havana syndrome or anomalous health incidents, but now referred to as acquired idiopathic neurological syndrome, for those of you that are interested, right? And TB Co. has been developing training or assessment treatment strategies because we have to take care of these patients as well. I will tell you that many of their symptoms are very similar to those of people with TBI, and the treatment for TBI is actually quite effective, so these patients, but I just thought I would mention it. It's not moving. I'm so sorry. Sorry about that. Okay. So what's the way forward? We talked a lot about where we've been, where we're going, and what are we going to do moving forward? So there's a lot happening right now, and so I'm going to just touch on some of it. We can talk offline if you have any specific questions about it. So for example, there's a lot of excitement about biomarkers, right? So I know a lot of you may have heard about glial filiburate acidic protein, GFAP, and ubiquitin carboxyl terminal hydrolase L1, UCH L1, say those all five times fast, right? So these are biomarkers which people are getting more interested in using, and particularly in our military folks. We actually have written a directive for this. The GFAP, right, is intermediate filament protein. So it's uniquely found in astrocytes in the CNS, and non-myelinating Schwann cells in the PNS, and enteral glial cells, right? So it's fairly specific for what we're looking at. And then the UCH L1 is less specific, because it basically puts a little indicator for the protozoan pathway to degrade, like misfolded or damaged proteins. But we do know that when patients have severe TBI, that UCH L1 is elevated in the CSF for several days. And we also know that people that die have higher levels than people that don't. Like, that's pretty clear in the literature. And we do know that the GFAP is actually more sensitive and specific, but if we test with both, we actually get a more effective result, and it's very helpful to indicate who has had a TBI. However, you see that there's a lot of problems with this, because, like, if I'm in theater and you have been in a blast, I'm not going to necessarily be drawing your blood to test this. And honestly, sometimes in a forward unit, you're not going to necessarily have the facilities to do this. And so there are a lot of limitations with it. We do want to go that way, but there's a lot of limitations with that. And also, after about three months, it's completely useless. So if some service member says, well, I got blown up three months ago, it won't really help me. So genetic studies, right? So genetic studies, one of the holy grails, right? So why do some people, you know, TBI, we've noticed even with mild TBI, like, why some people not get better, right? So we're kind of leaning on the genetic studies, right? And there's a lot of genes that are studied. We can divide them up into basically three types of categories, right? So it's those that influence the extent of the injury, right? So pro or anti-inflammatory cytokines would be one group of genes that have been studied. Another group that has been studied is repair and plasticity, right? So the neurotrophic genes. And then thirdly, we actually have another category, which is for pre and post-injury cognitive and neurobehavioral capacity, right? Like catecholamine genes, right? So we study a whole bunch of genes, right? And I'd love to say there's like one gene and we've proven that this will do this. Sorry, no one's proven it yet. So, but we are trying to move forward that way, because we might be able to direct treatment that way as well, if we can figure out what the characteristic genes are. So management of headache following concussion interactive provider training is a training which is being directed toward our primary care doctors, because so many of these patients need care, and so many of them complain about headache, that one of the things was let's let the primary care have some say in how they treat these patients and some education so they feel comfortable treating these patients. And actually it showed that actually by training our primary care doctors, it promotes patient compliance. It allowed for timely care, more follow-up visits, and more monitoring within the primary care clinic and patients had better outcomes. So these are all really good things. And I'm currently working on the DOD CPG for headache which is directed specifically at primary care and we are very concerned with making sure that they feel comfortable treating the TBI patients because headache is such a universal concern. And so there's also been some study about the autonomic nervous system because as we're aware, right, the TBI does affect the autonomic nervous system and you know that's one of the reasons why we give exertional tests when people have had TBI. That's one of the reasons they have issues with exertion. And so there's been a lot of studies on this. Unfortunately, you know, the heart rate variability, you know, that's one of the exciting buzzwords that people talk about. It's not as effective as one might think in the patients post-TBI. One of the reasons is because it's also affected in PTSD so it's kind of, you know, and how do we monitor it because, you know, the technology using a less invasive wearable heart rate variability monitor is not there. So we do think that pupillary studies may have some validity but again, they're hard to do and there's a lot of confounders in that. So even though it seems like there's a little bit more validity there, again, it's very hard to apply to patients. Blast research, I'll be frank, even though we've had many soldiers dealing with blasts since World War I, we're still kind of behind. And so one of the things was developed by the DOD was the Blast Injury Research Coordinating Office. And basically, it's basically designed to push forward research on blast injury but also sort of facilitate communication because again, when people are in silos because it's like the medical community is separate from the material development community, separate from the operational community and this is an attempt to kind of get everyone under the same umbrella and be talking about the same things. So I mentioned to you the 15 longitudinal studies of TBI. A lot of it showed was positive. A lot of people do extremely well after TBI but unfortunately, a lot of people don't and they don't have a lot of necessarily access to as much care as we might like. And then just to touch briefly on our next research gaps and priorities, there was a lot of concern about not just how effectively we collect information and how we analyze the data, right, or how we recognize TBI, but we also additionally figure out some of the risks for poor outcomes. But one of the things that was the emphasis that needs to be emphasized more is that actually preventing, primary prevention of TBI. So but anyway, so do you have any questions? I thank you so much for your attention. And for the sake of time, if we can move on to Dr. Tanev and then we'll take questions at the end. Okay. So Commander LaCroix, thank you so much for this wonderful historical presentation and bringing it up to today and the future. That was awesome. I learned quite a few things. All right. So my presentation is kind of a high-level presentation. I do this yearly at the MGH Psychopharmacology Conference, and it lasts between an hour and a half and two, and this is half of this presentation, so I won't be able to present things in detail, but I will give you high-level issues that, as psychiatrists or neighboring professions dealing with TBI, you will encounter, and I rely on meta-analyses for the brevity of the presentation because they combine data from lots of different studies. So the presentation is divided into two. One is just hand-picked areas of concern of neuropsychiatric symptoms after TBI and some useful information that you may be aware or not. And the second is what we at the home-based program, which is part of Mass General Hospital, what programs we've developed, again, just to review for some ideas and a model of care. So path physiology, just very briefly here, path physiology of all TBIs could be divided into primary, first there is a physical forces on the head that translate onto the brain, and then there are primary mechanisms of brain injury and secondary mechanisms of brain injury. Primary mechanisms think of what happens at the time the brain is injured, the seconds and minutes. Secondary mechanisms happen over days, weeks, and months afterwards. So some of the primary mechanisms, there's the sudden acceleration of the head physical forces on the brain and they translate into, on the skull, and they translate into forces on the brain that's inside the skull. There's the compressive strain or coup where there is increased pressure at the place of impact. And then because the skull is rigid and the brain is not so rigid, on the other side, and it floats in the cerebrospinal fluid, on the other side of the coup is the counter coup, which is decreased pressure, which actually could be more damaging to vessels. The diffuse axonal injury, which no doubt anyone who has read anything about TBI knows about one of the most common injuries, happens when there's twisting, turning, stretching of axons and white matter. You can see here some of the most vulnerable sites. Then there's the contusions and hematomas. This is from the brain being moved against rigid and sometimes sharp contours of the brain. So some of the most common areas of hematoma is the orbitofrontal cortices because there are ridges in the frontal fossa, and when the brain gets moved, there are hematomas. In blast injuries, so in addition to the wonderful overview by Clement Lacroix, there are shock waves, and these shock waves impact the air-tissue interfaces. Where do we have air-tissue interfaces that are most exposed to the environment? It's tympanic membranes and lungs. These are the two places where a shock wave could reach tissues. So then there's the question, well, how does a shock wave, which impacts the body and the rigid skull, which would protect, how does it reach the brain? It's an interesting question. Not fully resolved, but I'll give you a, this Courtney and Courtney 2015 article gets into some hypotheses about how this may happen. So they come up with three possible mechanisms. One is the acceleration, which is that the forces and acceleration of the body and the skull get transmitted to the brain because of the movement. The second one is this idea of direct cranial entry, meaning that to a certain degree, the skull is protective, but past a certain threshold, it is no longer protective and the shock wave does go, get transmitted directly to the brain. That's been worked out with animals, but of course, the human skull and the animal skull are not similar, so there hasn't been an established threshold for the human skull. And then the third, which is very, very interesting, the thoracic mechanism, and the two hypotheses about it. One is that as the shock wave goes into the bronchi and bronchioli and to the alveoli, there's a pressure on the thorax. There's a volumetric blood surge, which increases intracranial pressure and leads to damage of the blood-brain barrier. It's one hypothesis. The other one is that the shock wave itself is being propagated by the vasculature to the brain like the tissue propagates the shock wave itself and leads to damage, direct damage to the brain. Consequences of TBI, and I'm going to talk about some of them. So the acute to post-acute, post-concussive symptoms, polytrauma associated with the brain injury, and then chronic consequences that could last for years. So mood disorders, a conservative estimate of the incidence of major depressive disorder after TBI is about a third. So there are different studies, different ranges, and then the prevalence is up to two-thirds. And then there's dysthymia, mania, et cetera, all more frequent than in the general population. Then there's the question, what is this thing depression after TBI? Is this the same depression that we know? Not exactly. So there's the interplay of biopsychosocial factors and neurological factors as part of the bio because there are disrupted brain circuits which color the symptoms of depression. So, for example, here you can see that aggressive behavior, 57%, this is Ricardo Jorge's research, fatigue, anxiety, distractibility, so cognitive impulse control symptoms that are likely influenced by the disrupted brain networks. Medications that we might use in the treatment of post-TBI depression. And I have to say that the literature does not clearly distinguish between people who never had depression before the TBI and developed it after the TBI versus people who had depression before the TBI and developed depression after the TBI. So it's lumped together. Maybe in the future you will, but right now it's lumped together. Anyone who has depression after TBI. So, as I said, I'm relying on meta-analysis here and systematic reviews mostly. The results of this meta-analysis showed that sertraline, prophylactic sertraline, meaning sertraline given for people after TBI who did not meet criteria for major depressive disorder at the time of sertraline, reduces the odds of depression or is prophylactic against it. I would add to this while people are taking it because once the couple of studies that discontinued and then rechecked depressive symptoms, I think three or six months later, there was no difference. So it wasn't protective after it was stopped. TMS had reduction in depression severity and stimulants, that's an important take-home point, were the only treatment superior to control. So they said that sertraline reduced the incidence of depression when taken. They didn't say that sertraline separated from placebo. And there are a few studies on sertraline versus placebo. They both show pre-to-post great improvement and they don't separate from placebo. Suicide and suicidal thoughts. This is a busy slide and I almost see it. So first, the American Foundation for Suicide Prevention says that the annual suicide rate is 13.5 per 100,000 and men die by suicide four times more than women. And the firearms account for a little bit more than 50% of all suicide deaths. So then Simpson and Tate, who did a review in 2007, said that, this is in TBI, said that the relative risk for suicide after TBI is three to four times that of the general population. So three to four times that of 13.5 per 100,000. And cumulative suicide rate is 1% after the first 15 years after TBI. Also that clinically significant suicidal ideas happen in about a fifth, 21, 22% of people with TBI. Next is an observational study of close to 600 adults with mild complicated through severe TBI. Just to remind you, terms mild complicated is mild TBI meeting definition, whichever definition, ACRM or VADOD, but with findings on MRI. So this is one year after TBI. 25% reported suicidal ideas at one or more points. Seven to 10% reported suicidal ideas at each assessment point. And suicidal ideas were highest during months two to eight after TBI. Then predictors of suicidal ideation, there was another study. Having Medicaid insurance relative to commercial or private, this likely speaks to lower socioeconomic status. History of depression, bipolar or other anxiety disorder predating the TBI. Prior suicide attempt, past behavior predicts future behavior. And having less than high school education, so lesser means. And then in the military, the systematic review and meta-analysis of suicide in the military, which included multiple studies totaling 709,000 people with MTBI and more than 6 million controls without TBI. So they found that in this meta-analysis, MTBI was associated with a two-folding higher risk of suicide. And that MTBI was associated with higher risk of suicide attempt and suicidal ideation. Overall, that experiencing mild TBI was associated with a higher risk of suicide. So something that is very important in general, and especially in military populations, is the comorbidity between PTSD and TBI. As you know, frequently, the event that causes TBI is also very traumatic. When people go through blasts, they also lose friends. They may be injured themselves. They see things, and so they experience trauma, psychological trauma, and neurological trauma. So these two share multiple symptoms, as you can see. So this is another way to visualize the commonality between the two. So on the left-hand side, you have the PCL-5, the post-traumatic checklist for DSM-5. And then on the right-hand side is the NSI, Neurobehavioral Symptom Inventory. So of 20 symptoms on the PCL-5 highlighted in yellow, 10 of them are shared with MTBI. And 13 of 22 symptoms on the NSI are shared with PTSD. So as you can see, the differentiation between the two is quite difficult, especially with mild TBI. And I have frequently lawyers call me, my TBI clinic, and say, can you just write one sentence that the symptoms that the person experiences are due to MTBI? I said, no. It depends. Complicating or confounding things further, there is bona fide cognitive dysfunction in PTSD itself. People who have never experienced TBI have, different in different populations, but definite intentional impairment in specific populations, sometimes learning, memory, et cetera. Aggression in TBI, frequent. Aggression, irritability. So aggression is irritability on steroids. It is frequent. It is frequent immediately after TBI. Again, one to two-thirds or more immediately after TBI in rehabilitation. This is weeks to months after TBI and years post-injury. Associations are substance abuse, depression, orbitofrontal lesions, which are one of the brain areas responsible for comportment and impulse control. Males, older males, poor pre-morbid functioning, language disorders, if people can't express themselves well then they may resort to impulsive violence. Noisy environments, so typical thing that people with TBI would say and I would ask them, how do you do when you're in a room with multiple conversations and you're trying to attend to one? Oh, I totally can't do it, and males would say, I feel like decking someone, so I leave the room. So, being flooded and overwhelmed, and of course if people have seizures that may be responsible for the, if there is violence after TBI, it's usually reactive, it's non-purposeful, non-planned, and people feel bad about it, so it's egotistonic, and it usually is explosive without buildup. Sleep is very important, dear to my heart, it's one of the few, it's one of the few symptoms that are quantifiable, that get disrupted by many disorders, and that once they're disrupted, nothing else works well. So, in TBI, about close to 50% of people have a diagnosable sleep disorder, so it's worth paying attention to, and if you look at the numbers here, everything is higher than the general population, so insomnia, 30% versus 10%, sleep apnea, 23% after TBI versus 2% in the general population. So, it is really out of proportion, so TBI does affect the sleep, and so it's worth asking, and it's worth sending people to sleep medicine or a sleep study if, after asking, you have suspicion. And the usual signs of TBI in military also don't work so well, like one does not have to be overweight and have to have the double chin, and people who are very fit could have sleep apnea. So, sleep changes, again, another meta-analysis, the results are that people with TBI compared to those without TBI demonstrate poorer sleep efficiency, shorter total sleep time, and greater wake after sleep onset, meaning they sleep less, they wake up more times once they're asleep, and therefore, their sleep efficiency, which is the ratio between total amount of sleep time versus total amount of the first time falling asleep and last time when they wake up, is poorer. What to do, many things to do, but one of those is melatonin. And so, it's worth knowing about melatonin. People use it for jet lag and other reasons, but it's really helpful as a signal to the brain, it is time to sleep. So, another meta-analysis here, which involved preclinical data in animals as well as human data, shows that melatonin in preclinical data improved neurological status that decreased the size of the contusion. That's because animals, after they administered a shock, they are sacrificed and their brains are examined, so you could tell that. Clinical studies, on the other hand, were heterogeneous, low quality, so fewer conclusions could be drawn. But melatonin is a very good first go-to not medication, supplement, because there are very few side effects. Some people feel tired the following day. Also, CBT or CBTI, CBT for insomnia, there are good trials now that it functions and it improves sleep quality. Cognitive rehabilitation, another good thing to refer people to, there are two reviews by the Cognitive Task Force by ACRM, the American College of Rehabilitation Medicine, reviewing the evidence between 2003 and 2008, followed in 2019, the evidence following that up until 2018. The conclusions were that, based on multiple, multiple studies, the cognitive rehabilitation is of greater benefit than conventional rehabilitation, PT, OP, OT. That cognitive rehabilitation is the best treatment for people with cognitive impairment and functional limitations after TBI. And then that cognitive rehab falling under the heading of metacognitive strategies, meaning strategies that attempt to generalize the improvement seen in the office to everyday tasks. Someone may perform great in a neuropsychologist's office and then go home or go at a workplace where there are multiple distractors and not perform great. So these metacognitive strategies attempt to generalize what's done in the cognitive rehab office to the real world employment. That these strategies such as feedback, self-monitoring, self-regulation, strategy use are very helpful in social communication deficits after TBI training. So an overall kind of systematic review meta-analysis on pharmacotherapies for cognitive and behavioral, so everything, cognitive behavioral outcomes. In post-acute TBI, included RCTs, so randomized control trials, and open-label trials, quite a few patients. And that found that, again, methylphenidate improved behavior, anger and aggression, and psychosocial function, not just cognitive, which is the reason why it's usually prescribed. And donepezil improved cognition, memory and attention. There's donepezil data, it was very promising but likely in a subset of TBI patients who have severe memory problems to start with. Treatments that were started in acute TBI and continued post-acute TBI, amantadine, a medication that I stole the use of from physiatrists, and I've been using it now for 15 or more years, and have grown to like it a lot. If you haven't used it, you should. So it's clinically useful for both cognition and behavior, so there's some evidence that it helps irritability. And then, in this particular study, sertraline markedly impaired cognition and psychomotor speed. That said, there's evidence on both sides for SSRIs. Some evidence shows that they improve, some evidence shows that they decrease cognitive function. Hearing problems, that's a major issue because of air tissue interfaces and panic membranes. So this is, there are a few studies, I chose one. Service members and veterans with TBI or blast TBI reported difficulty understanding speech in complex environments. So this study involved both subjective and objective measures of hearing. 212 U.S. service members and veterans completed subjective and objective measures, and the results were that TBI status predicted objective speech recognition performance. Blast exposure predicted subjective hearing complaints. More severe TBI was associated with more tinnitus. And that high-frequency hearing loss and more severe PTSD symptoms predicted hearing complaints, subjective complaints. And that speech recognition deficits, objective deficits, and tinnitus complaints, subjective, were associated with poorer cognitive function. So something to pay attention to, something to refer people to audiologists or EMTs. So in the last 10 minutes or so, I'll just tell you what the Homebase program is. It was started in 2009 by donations by the Red Sox Foundation and Mass General Hospital. The Red Sox visited Walter Reed and were very impressed and heartened by the suffering of military service members and decided to do something about it. So they approached Mass General Hospital, put up $3 million, Mass General Hospital put $3 million, and it was started in 2009, has grown exponentially. And it's the largest private sector clinic in America that serves military service members and veterans. Programs are divided into New England programs, so regional programs. We're located in Boston, more specifically Charlestown, Massachusetts. And we have an outpatient clinic. We have a family care and support, very important. We evaluate and treat family members. We evaluate and treat couples, which is part of the network that's supportive of the veteran. We have a substance use and alcohol use program. We have something non-clinical called Warrior Health and Fitness, where we teach exercise and resilience skills. Then we have partnerships with two health systems in Southwest Florida. And so that area did not have many resources to treat veterans, but in collaboration with these two healthcare systems, now there are places for veterans to be treated. And expanding to other states as well. And then we have national programs. So in collaboration with the Wounded Warrior Project and the Warrior Care Network with three other academic medical centers, we have the intensive clinical program, which I'll show you a little bit about, which is a two-week immersive program for PTSD or TBI. People from anywhere in the U.S. come, stay in a nearby hotel, and for two weeks they're immersed in this treatment. A little bit about the ICP, intensive clinical program. So it's comprehensive. It includes many, many different components. It includes individual and group therapy and stress reduction and integrative therapies, and also art therapy, very important. We, at any one point, so it's two weeks, and we have up to two cohorts, up to 12 people in each. So we have between 22 and 26 people every two weeks that we process in this program. We've adapted prolonged exposure and cognitive processing therapy to an eight-session model. So it's one a day for the eight days. It's 10 working days. First day is evaluation, last day is graduation. So days in between, they get individual therapy, PE or CPT, for the PTSD track, CBT for the TBI track. And people improve quite a bit. The PTSD and TBI tracks are quite similar, except in the TBI track, people get CBT, not anything focused on trauma, and get cognitive rehab. And also there's physical therapy, vestibular or oculomotor therapy, things more specific to associated injuries in TBI. There's an extensive screening process for the ICP, which starts months before a person comes in. Starts with screening, collection of records, review of records by both psychology and psychiatry and internal medicine person. Then collection of labs, if they haven't had them in the last six months. And then once the person is approved, scheduling the date of coming. So here, I already said, so PTSD is, the PTSD track is for people who have a primary complaint of PTSD. The TBI track is for people who believe that they have cognitive rehabilitation goals and their treaters agree with that. So it's kind of subjective slash objective clinician assessment of needs. They could have comorbidity between PTSD and TBI, but there's a clinical decision of what's the focus of treatment. Exclusion criteria are based on someone who is not stable enough. This is not a partial hospitalization program. It's an intensive clinical program, so it requires the ability to tolerate groups, the ability to not become dysregulated, not become suicidal. So mainly we assess these exclusion criteria, screen out people who are not, at the time of consideration, unstable. Selected assessments, many of them, but we assess for PTSD, for post-concussive symptoms, for alcohol and drug use, sleep, et cetera. Some demographics, and I will go through this fairly quickly. About 18% of our patients are female, 82% are male. This is outcomes, two of our outcomes, the PCL-5 and PHQ-9. People start at a moderate level of PTSD symptoms of 51 and end up after two weeks at 36. Over time, we get fewer responses over time, but the response we get are that they maintain. They gain a few points, but they maintain. Same with the PHQ-9. They start at 15, end up at close to 11, and then stay around 12 to 13. Outpatient clinic, more traditional, draws primarily from Massachusetts, and then Maine, and New Hampshire, and Connecticut, and Rhode Island. We converted, in March 2020, we pivoted and converted everything into telehealth, and still, for the outpatient clinic, still function primarily via telehealth. The ICP is primarily in-person. It's a multidisciplinary clinic, so we refer people based on needs. We have individual therapy, we have group therapies, we have case management, and psychopharm, and then TBI services, as well, in the outpatient clinic. And we have, since 2013, we have averaged between 20 and 60 new referrals per month, with the notable exception of this here, which was March of 2020. We dropped substantially, yeah. Because the outpatient clinic, not everyone has PTSD as primary, so people come for all kinds of problems, marital problems, adjustment problems, PTSD, alcohol. The average PCO5 is 32, so that's average across many different conditions that people come for. Combat program started in 2019, specifically to provide services to special operators. And this is a four to five day comprehensive brain and body assessment, which includes many, many different things. I'll show you some of the, so these are some of the areas that are being assessed, some of which are housed within home base, some of which are housed within MGH. We have referrals to ENT and to sleep medicine, many others. The model here is that special operators have greater lifetime combat exposure, have more deployments, greater demands, highly kinetic missions. And this results in this model that states that the pre-injury factors, injury exposure, post-injury factors, which result in cognitive, emotional behavior, and physical disturbances, and therefore to the physical complaints that people come to us with. There's a lot of case management, making sure that after the evaluation, people are connected to care where they live. And so here, the majority are male, majority have some kind of college education, and the majority are active duty. Psychiatric diagnosis, not surprisingly, the most common ones are PTSD, PTSD-lite, or other trauma and stressor-related disorder, and others. Baseline measures are fairly similar to the outpatient program. And I have to say that at the beginning of the combat program, most special operators say, PTSD, no, I don't have it. After they've been thoroughly evaluated for TBI complaints, the clinicians, PMR, have to say, PTSD, no, I don't have it. After they've been thoroughly evaluated for TBI complaints, the clinicians, PMR clinicians, say you know, you trust us when we say that you have TBI and you have some hormonal problems. Please trust us when we say you do have PTSD. So they're motivated not to. And in conclusion, some areas of research interest that we have, psychophysiology, measuring heart rates can conduct some facial electromyogram in response to some stimuli. We have psychophysiology lab. Neurophysiology, because there's some evidence that some auditory evoked response potentials could be predictive of SSRI treatment response. And then sleep is very important, so we have portable PSG. I'm not going to go over this, but these are some selected research topics that we have. Some funded, some not funded pilot in both TBI and PTSD. One is a novel combination, buspiron melatonin, for depression after traumatic brain injury. Another one is using VR technology to quantify neurological function after TBI. Another one is treatment of headaches, characterization, and then treatment of headaches in response to sphenopelatine ganglion block. And that's it. Thank you. Thank you both for your presentation. We'll go ahead and take some questions. Hi, I'm a psychiatrist. I work within the VA system. I guess my question, I was interested in the ANAM test being something that's now used in all deployed veterans, and if that's something that's accessible through CPRS, that's my first question. You guys might not know. There's been a lot of changes in the electronic health records right now, so I unfortunately can't comment on that. Okay. Can you just repeat the question, please? The ANAM test, A-N-A-M, that was that pre- and post-deployment test, that'd be very useful to have anything objective. My second question is just about medication. I mean, it seems like we're moving towards stimulants, but things with insomnia, just increase in aggression, anxiety, I just see a lot of downsides. I know that sort of seems like the trend, but I guess when I was training, we would manage a lot of mood symptoms with things like Depakote, bar none being like one of the most effective treatments. And I guess I just don't know if, you know, I guess I'm just worried about the potential downsides of using stimulants or amantadine and stuff like that in this population. I just don't prioritize attention compared to significant mood symptoms personally. Can I take this one? Is that okay? Please. So at Intrepid Spirit at Naval Hospital Camp Pendleton, I actually did use a decent amount of Ritalin and service members with documented clearly MTBI. Oftentimes we did have not only just ANAM scores, but significant, you know, signs and symptoms in working with speech and language pathology and OT showing that they had cognitive problems like forgetting where they would put their cap, you know, their keys, their wallet and just like frustration and difficulty with daily tasks in addition to the symptoms of other symptoms of TBI and PTSD. So you know, weighing the risks and benefits is obviously very important, but not just giving it to everyone and just knowing who would potentially benefit from it. You know, so not just giving it to everyone and that also differed from the other active duty population that I treated when I wasn't at Intrepid Spirit. So you know, because there are a number of service members who actually want them for various reasons, whether it's, you know, to lose weight or, you know, to stay up or for other reasons. So it's about judicious and thoughtful use within the correct populations. If I add something, so membrane stabilizing agents, mood stabilizers, are great in TBI. They're great for aggression. They're great for irritability. They're great for migraine prevention. So this was a highlight, kind of high level highlight. It's not that we're moving towards that. That's what that specific meta-analysis showed, but mood stabilizing agents are great and with everything, you individualize the treatment based on patient's complaints, side effect profile, and prior response. Thanks. I also had a question about medication. So I work with a lot of people who have TBI and also PTSD, and this kind of constellation of all these different post-TBI symptoms and also aggression and irritability is something I've read about, and a lot of books do recommend amantadine, and when I tried to figure out how to prescribe it, it kind of scared the hell out of me because my interaction checker, you know, thing is like common reactions are hallucinations, dizziness, dry mouth, nausea, insomnia, anxiety, anorexia, depression, irritability, vomiting, confusion, fatigue, blurred vision, and I have people with vestibular symptoms and all these other things already, and they're irritable, and they're anxious, and they're depressed, and they have PTSD, and I'm like, am I going to cause these people to be suicidal? How do I dose this? And my drug thing doesn't have like a TBI dosing, even though it's like clearly a use for it. I was wondering if you could comment on like what do you see commonly, and what is the dosing you use, and like what is your start low doses, that kind of thing. Sure. And I totally understand the fear. So there's no substitute for experience with something, so you got to start at some point. And then when you have 10 or 20 or 50 patients on it, you're going to get familiar because you're going to get repeated side effects and repeated experiences. So in terms of what I do, my usual starting dose is 100 milligrams in the morning, which I may increase to 200 milligrams in the morning, which I may increase to 200 plus 100, meaning 200 in the morning, 100 in the early afternoon, or 200 and 200. In cases where patients are known to be really sensitive to medications, there's this profile of patients who you give them a smidgen of something, and they have terrible side effects. And after five times, you understand that that's how they react. Then I may use 50 milligrams. But my usual is this. I would suggest you start using it, and you will find both the pluses and minuses of it. And could you also describe your ideal patient for that medicine? Like who would you for sure give it to? So I see amantadine as a combination of a stimulant that increases dopamine and is a little bit neuroprotective like memantine and MDA antagonist. So ideal person, I don't know that I have one, but I would prescribe it for people who need some stimulant-like action, and maybe I would prefer not to prescribe a stimulant at this point. So there's cognitive enhancement or improvement from amantadine, and there's some of the side effects as well that come with stimulants. And there's the very rare, but does happen, levator reticularis, the bluish discoloration of the skin. But in the multiples of hundreds of patients I've prescribed, I've seen it maybe four times. So you should warn people about this, because it does happen. In the back, please. Hi. Thank you so much for your presentation. I am so happy I got here at 8 a.m. I'm in Northern Kentucky. My name is Nicole Abbott, and I have no experience with the VA. My program did not rotate to the VA, and I have a patient who came to our private group practice because he was so dissatisfied with his service in the VA, and he does have all the constellation of symptoms that you mentioned, the cross-section of PTSD and TBI. And I must say that I focus so heavily on the PTSD, and you guys kind of opened my eyes to the TBI, because he did have a blast injury. And I struggled because I don't have all the resources that you guys spoke about. So I'm just wondering, how can I get him reconnected? I mean, I did personally call the VA. I did get a call back after a month, and I'm glad I picked it up. I thought it was spam. And I asked them at least to get him into trauma-based therapy, individual therapy, because they were having a hard time navigating that. But I think he needs a lot more, and I'm wondering if you could help direct me. And then secondly, I also have another case. She's not a veteran, but I'm extrapolating from what you guys presented her. And she had a fall injury, and this was a lady who was an executive in HR and was doing her PhD. And after the fall injury, it's everything, depression, lots of cognitive symptoms. And she's now out of a job. She's now struggling just to finish a chapter in a book, and is supposed to be working on her thesis. And I'm supposed to treat. So I did send her for a neuropsych eval, and it came back as nothing objective. Probably treat the depression and the anxiety. So of course I was disappointed, because I wanted some justification, maybe to start a stimulant, based on what she's telling me. So I was hoping that, and you kind of mentioned it, I'm glad you did, but is there some kind of explanation why there will not be objective measures? So actually the data shows that the higher the baseline intellect before the injury, the more likely they are not to have a positive result. And the data shows that it's more the absence of high scores in previously high-functioning individuals that will indicate injury, rather than the presence of low scores, if that makes sense. So they'll plot out as if they're on average, but it's because they're coming from a higher baseline. And she lacked any high scores from what you're telling me, she had an injury. Yes. That makes a lot of sense. So thanks for that. I guess, lastly, maybe I could talk to you guys privately about that. about how I could help my other patient and also just resources on the med management because at least from my experience, that's sparse. I don't know of the go-to for med management and thank you so much for your talk. Thank you. I just have a couple comments just in terms of what Commander LaCrosse said. Also, really meeting the patient where they are is super important and ask them, what are your challenges? What's going on in your life right now? What are your problems? You know, I cannot tell you how many times, you know, patients with tinnitus that I diagnosed with, you know, sensorineural hearing loss and, you know, got them hearing aids or vestibular problems or sleep problems and diagnosed them with sleep apnea. And as you start to get them better physically, they start to trust you more in terms of their mental health because you can imagine this population is very mistrustful. They, you know, they call psychiatrists wizards, you know, so you've got to be really careful with how you engage them and really meet them at where they are and work on getting them better together and asking motivational questions like where would you like to see yourself? Where would you like to see yourself in six months to a year? What do you imagine your life to be like when it's better? And really getting them to say that is super important. Okay, your turn. Thank you. I do inpatient, outpatient. Can you just speak up? Maybe subclinical head injuries, not to this severity, but very useful ideas. I'm wondering if you're thinking about some of the newer agents coming out now in psychopharmacology, such as glutaminergic agents, orexin receptor agents for sleep, and sublingual presidex, which seems like it might have a role in, you know, autonomic nervous dysfunction that you see so commonly in these disorders. Thank you. Sure, I mean the answer would be simple, which is there's no evidence whatsoever about the use of these medications. In fact, for better or for worse, TBI and symptoms of TBI are an area of inadequate research, which is bad if you want to treat, great if you want to study. So, so, you know, in the absence of evidence, there's no problem with weighing pros and cons and trying different things than writing case reports or case series. One more and we have to end. Just a question about a couple comments. I'm Dr. Dan Hart. I work at Fort Bragg with this community. And so thank you for your presentation. I'm happy to be a colleague of Christina's. So two comments you made were about the vaguely mediated injury and also the impulse, like the venous impulse mediated injury. And if you could explain just a little bit more about the vagal mediation. And then the second part would be any, there are a couple devices that were being kind of like tantalized with, like the Q collar, which which reduces the venous impulse and you know, transdermal TMS, like TacStim, that, I'm sorry, vagal stimulation that can potentially prevent injury. I'm just wondering any thoughts about that and my most specific question is about vaguely mediated injury. Thank you. So there's some fairly good evidence that people do have vagal changes post-TBI. But how to address that and prevent it and actually how to tease it out from, particularly in this population, that's the issue. So and in terms of like these devices, they have very good theoretical basis. But as we know in medicine, there's plenty of theories that we have that are neat, perfect, agree with everything we know. And are completely wrong. So while I think that these are very intriguing prospects, because I've read some of the things you have, I, it just, like I said, it's something that more research would need to be done. Go ahead. Hi, I'm Dr. Oshinowa. I work in Toledo, Ohio. My question is the intrepid spirit centers, how does one access those? How do the veterans access that? So the intrepid spirit centers are primarily for active duty. They do have some veterans, but they're usually people who already engaged prior to detaching from the military. So, but active duty get a referral from their primary care provider for an evaluation and then the patient is either accepted or or referred for other management. I think my colleague here might want to comment more on people, veterans, getting to treatment. I don't have any comments on referrals to the intrepid spirits. We, to VAs, I could, yeah. So we have, our way of doing this is we have an employee who is a VA liaison. And so everyone who goes through our intensive clinical program meets with that person and wherever they came from, that's Arizona, Florida, or Texas or wherever, the veteran liaison, he's embedded in our clinic, is helping them to connect with the VA resources. So, is it possible for someone, like how does someone get referred to home base? Oh, to home base, okay. They could, they could access this by calling us or by sending a message to the website, if they would do it individually. We get a good number of our referrals through just individual messages to us. Within less than a week, they would receive a call from a veteran outreach coordinator, who is a veteran himself or herself. And then they would do a screening interview and then they would schedule an interview with the clinician. It depends on where they are located, so that would determine which programs they may be eligible for. But they could certainly approach us in one of these ways. Another big part of our referrals come through the Wounded Warrior Project, that our foundation, whose mission is to bring people into care, and so they have their own screeners and then they send them to one of the four academic medical centers throughout the country. Is that what your question, am I answering your question? To assist you guys, I'm actually with the Wounded Warrior Project and we assist with only home base, but several other facilities. We have Rush, Emory, different ones, but we also work outside with other different facilities for TBI programs. So, if they, veterans post 9-11 reach out to us and that is something they're interested in. Of course, it's all voluntary, very specialized complex care coordination, and so we work with a lot of these AMCs and other facilities and we help them navigate the VA system, because the VA system is complicated as it is. You take someone that is already struggling emotionally, psychologically, all these other ways, and so it just makes that so much more difficult. So, yeah, I'm here. Thank you so much for what you do. Thank you.

APA annual meeting

traumatic brain injury

military personnel

veterans

Commander Lacroix

Dr. Kyrlo Tanev

innovation

collaboration

Intrepid Spirit Centers

multidisciplinary support

neuropsychiatric symptoms

mood disorders

cognitive rehabilitation

medication management