Mental Health Disorders

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Mental health symptoms and outcomes must be understood within the biopsychosocial context of the individual and consider that multiple factors can influence related mental health disorders. In the case of concussion, biologically the individual may suffer an insult to the brain and injuries to the body (e.g., whiplash injuries, etc.), with consequences to their experience of pain and ability to sleep, which can further cause changes in the neurobiology of the brain. At the psychological level they may experience acute stress due to their experience of trauma or injury, as well as in response to the consequences of their functional abilities resulting from the injury. People with persistent symptoms may become isolated from others as they may be intolerant of or unable to engage in social interactions. Their injury status may disrupt their occupational status, leisure activities and interpersonal interactions. They may also incur losses (e.g., reduced quality of life and independence; lowered income or reduced educational attainment; changes in relationship functioning, etc.). When assessing and managing disorders of mental health post concussion, it is important to consider all of these potential factors; additionally, individuals who have suffered a concussion may also have a pre-existing history of biopsychosocial factors/issues that may affect the expression of mental health symptoms or the duration of recovery including the ability to return to pre-injury status.

Screening for mental health symptoms early on and determining their etiology as well as prescribing treatment is crucial to facilitating a positive recovery. For example, in a primary care setting this may include screening for disturbances of sleep, or presence of chronic pain, loss, metabolic status etc when patients report low affect. Intervening at the level of improving sleep, managing pain and correcting metabolic imbalances may result in improving reports of low affect. 

There is no current evidence to indicate that the mental health problems of individuals who have suffered a concussion should be treated any differently than mental health problems of other etiologies. As such, pharmacological and nonpharmacological interventions including therapeutic interventions that have been found to be helpful in the general population should be considered for individuals who have developed mental health problems post concussion. Strategies used to treat mental health symptoms post concussion/concussion should follow the same logic as that applied to similar symptoms found secondary to their conditions or circumstances which include the potential for treatments to worsen other concussion outcomes. For example, some antidepressant medications, particularly those that are more sedating and/or have greater anticholinergic activity, can worsen the anergia and cognitive impairments that arise directly from concussion. In general, psychotropic medications should be used with caution, and non-medication options selected as much as possible. If selecting a medication intervention, start at low doses, allow adequate time for response to be assessed for, and carefully monitor for both efficacy and side effects.

8.1

In assessing mental health symptoms following a concussion, determine whether the symptoms meet criteria for a mental health disorder, which include but are not limited to:

  • Depressive disorders (see Appendix 8.1)
  • Anxiety disorders (see Appendix 8.2)
  • Post-traumatic Stress Disorder (see Appendices 8.3 and 8.4) and other trauma and stressor-related disorders
  • Behavioral changes (e.g., lability, irritability)
  • Adjustment disorders
  • Substance use disorders (see Appendix 8.5)
  • Somatoform disorders

Elements of assessment should include taking a comprehensive history (including pre-morbid mental health symptoms and conditions, medical issues, and psychosocial issues), structured clinical interview, use of self-report questionnaires, and behavioural observation. Include information from collateral sources if possible.

Disturbances in mood, cognition, and behaviour, can be commonly experienced following injury and may signal the presence of a mental health disorder. Pre-existing mental health conditions and symptoms with post-injury onset have been found to be predictive of prolonged post-concussive symptomatology. Thus, primary care providers should identify and treat changes in mood to facilitate recovery of post-concussive symptoms.

References supporting context:

  1. Booker, J., Sinha, S., Choudhari, K., Dawson, J., & Singh, R. Description of the predictors of persistent post-concussion symptoms and disability after mild traumatic brain injury: the SHEFBIT cohort. British Journal of Neurosurgery. 2019;33(4): 367-375.
  2. Cnossen, M. C., Winkler, E. A., Yue, J. K., Okonkwo, D. O., Valadka, A. B., Steyerberg, E. W., Lingsma, H. F., Manley, G. T., Dams-O’Connor, K., Gordon, W. A., Hricik, A. J., Maas, A. I. R., Menon, D. K., Mukherjee, P., Puccio, A. M., Schnyer, D. M., Vassar, M. J., & Yuh, E. L. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. Journal of Neurotrauma. 2017;34(16): 2396-2408.
  3. Hellewell, S. C., Welton, T., Pearce, A. J., Maller, J. J., & Grieve, S. M. Diffusion MRI as a complementary assessment to cognition, emotion, and motor dysfunction after sports-related concussion: a systematic review and critical appraisal of the literature. In Brain Imaging and Behavior. 2021;15(3): 1685-1704.
  4. Rice, S. M., Parker, A. G., Rosenbaum, S., Bailey, A., Mawren, D., & Purcell, R. Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review. Sports Medicine. 2018;48(2): 447-465.
Level of Evidence A
Last updated  
8.2

If a mental health disorder is determined to be present, then the choice of existing practice guidelines for the treatment of the diagnosed condition should be followed (e.g., depressive disorder, generalized anxiety disorder, PTSD, etc.).

Level of Evidence A
Last updated  
8.3

For identified mental health disorders, the primary care provider should initiate treatment including psychoeducation and medication as appropriate. Immediate referral to a regulated mental health practitioner should be completed if the mental health symptoms are complex and/or severe (e.g., suicide risk).

Worsening symptoms can hinder recovery and result in long term negative functional outcomes. Primary care providers should initially consider psychoeducational interventions, such as providing the patient with informational resources regarding expected prognosis and appropriate management of their mental health condition. Evidence suggests that early education may have a positive influence on mental health outcomes and may promote resilience in the post-concussive population. When mental health symptoms present risk to the patient, or are resistant to initial treatment attempts, immediate referral to a mental health practitioner is advised due to the increased risk of suicidality post-concussion. It is not necessary for the mental health practitioner to be someone who has a specialty in the treatment of concussion.

References supporting context:

  1. Bevan Jones, R., Thapar, A., Stone, Z., Thapar, A., Jones, I., Smith, D., & Simpson, S. Psychoeducational interventions in adolescent depression: A systematic review. Patient Education and Counseling. 2018;101(5): 804-816.
  2. Bryan, C. J., Clemans, T. A., Hernandez, A. M., & Rudd, M. D. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. Journal of Head Trauma Rehabilitation. 2013;28(1): 13-20.
  3. Donker, T., Griffiths, K. M., Cuijpers, P., & Christensen, H. Psychoeducation for depression, anxiety and psychological distress: A meta-analysis. BMC Medicine. 2009;7.
  4. Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-S264.
Level of Evidence C
Last updated  
8.4

While awaiting referral to a regulated mental health practitioner, the primary care provider should continue to clinically manage:

  • Mental health symptoms
  • General medical issues (e.g., rule out hormonal disturbances, viral infection)
  • Physical symptoms (e.g., headache, sleep disturbances, dizziness, pain)
  • Accommodations (return-to-activity, school, work)
Level of Evidence B
( Sleep )
Level of Evidence C
( Pain )
Level of Evidence C
( Remaining )
Last updated  
8.5

Cognitive behavioural therapy (CBT) and other psychotherapeutic modalities should be recommended for patients with mental health conditions following concussion.

Psychotherapeutic interventions are generally considered the first line of treatment for mood disorders of mild severity. Cognitive behavioural therapy (CBT) has well established efficacy for the treatment of mood, anxiety, and trauma and stressor-related disorders. CBT has been shown to be effectively delivered across various modalities, such as telehealth virtual psychotherapy. Remote delivery of CBT may promote patient retention due to its accessibility and flexibility. Evidence also suggests that related psychotherapeutic modalities such as Cognitive Processing Therapy, Trauma-Focused therapy, and Mindfulness based interventions may promote positive outcomes.

 

Counselling Resources:

  • Distress Centre of Ottawa Crisis Line Information - http://www.crisisline.ca/ 613-722-6914 or https://www.dcottawa.on.ca 613-238-3311: If you feel you are in crisis or are having thoughts of self-harm or of harming others, please call the Ottawa Crisis Line which is open 24 hours per day, 7 days per week.
  • TeleCBT.ca - www.teleCBT.ca: OHIP-funded cognitive behavioural therapy counseling for adults with symptoms of depression or anxiety.
  • AbilitiCBT - https://myicbt.com/home: Cognitive behavioural therapy counselling, offered by Morneau Shappell, and currently free to Ontario residents.
  • Ontario Structured Psychotherapy (OSP) Program - AccessMHA.ca : OHIP-funded cognitive behavioural therapy to help manage depression, anxiety and anxiety-related conditions.
  • The Walk-In Counselling Clinic - https://walkincounselling.com 

 

Free self-help resources:

  • Bounce Back Ontario - https://bouncebackontario.ca (available in multiple languages)
  • Kelty's Key - https://www.keltyskey.com/self-help/
  • Positive Coping with Health Conditions - http://www.sfu.ca/carmha/publications/positive-coping-with-health-conditions.html
  • Mindfulness-Based Stress Reduction - https://palousemindfulness.com
  • Online Chronic Disease Self-Management Program - https://www.selfmanagementontario.ca
  • Progressive muscle relaxation - https://www.anxietycanada.com/articles/how-to-do-progressive-muscle-relaxation/

 

References supporting context:

  1. Acabchuk, R. L., Brisson, J. M., Park, C. L., Babbott-Bryan, N., Parmelee, O. A., & Johnson, B. T. Therapeutic effects of meditation, yoga, and mindfulness-based interventions for chronic symptoms of mild traumatic brain injury: a systematic review and meta-analysis. Applied Psychology: Health and Well-Being. 2021;13(1): 34-62.
  2. Ackland, P. E., Greer, N., Sayer, N. A., Spoont, M. R., Taylor, B. C., MacDonald, R., McKenzie, L., Rosebush, C., & Wilt, T. J. Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury. Journal of Affective Disorders. 2019;252: 493-501.
  3. Cuthbert, K., Parsons, E. M., Smith, L., & Otto, M. W. Acceptability of telehealth CBT during the time of COVID-19: Evidence from patient treatment initiation and attendance records. Journal of Behavioral and Cognitive Therapy. 2022;32(1): 67-72.
  4. Jak, A. J., Jurick, S., Crocker, L. D., Sanderson-Cimino, M., Aupperle, R., Rodgers, C. S., Thomas, K. R., Boyd, B., Norman, S. B., Lang, A. J., Keller, A. V., Schiehser, D. M., & Twamley, E. W. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: A randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry. 2019;90(3): 333-341.
  5. Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., Hasnain, M., Jollant, F., Levitt, A. J., MacQueen, G. M., McInerney, S. J., McIntosh, D., Milev, R. V., Müller, D. J., Parikh, S. V., Pearson, N. L., Ravindran, A. V., & Uher, R. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological Treatments. Canadian Journal of Psychiatry. 2016;61(9): 540-560.
  6. Little, A., Byrne, C., & Coetzer, R. The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review. NeuroRehabilitation. 2021;48(1): 67-82.
  7. Mikolić, A., Polinder, S., Retel Helmrich, I. R. A., Haagsma, J. A., & Cnossen, M. C. Treatment for posttraumatic stress disorder in patients with a history of traumatic brain injury: A systematic review. Clinical Psychology Review. 2019;73.
  8. PM&R Ottawa Division. Outpatient Virtual Care Playbook, Version May 2022. Ottawa, ON: May 2022.
  9. Zhang, A., Borhneimer, L. A., Weaver, A., Franklin, C., Hai, A. H., Guz, S., & Shen, L. Cognitive behavioral therapy for primary care depression and anxiety: a secondary meta-analytic review using robust variance estimation in meta-regression. Journal of Behavioral Medicine. 2019;42(6): 1117-1141.
Level of Evidence A
Last updated  
8.6

When prescribing any medication for patients who have sustained a concussion, the following should be considered:  
 
a. Start at the lowest effective dose and titrate slowly upwards.  
b. Avoid making more than one medication change at a time.  
c. Use caution when initiating pharmacologic interventions to minimize potential adverse effects.  
d. Follow-up should occur at regular intervals.  
 
For more details regarding pharmacotherapy after concussion, refer to Table 8.1.

Level of Evidence C
Last updated  
8.7

If medication is considered necessary for the treatment of depression and anxiety after concussion, a Selective Serotonin Reuptake Inhibitor (SSRI) is recommended as the first-line pharmacological treatment.

If treatment is unsuccessful with this pharmacological option, the combination of sedative, analgesic and headache prophylaxis effects from a tricyclic (TCA) may be desirable, yet these agents may generally be considered second line. Other second-line options include mirtazapine, an alternate SSRI, or a Selective Norepinephrine Reuptake Inhibitor (SNRI).

References supporting context:

  1. Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., Hasnain, M., Jollant, F., Levitt, A. J., MacQueen, G. M., McInerney, S. J., McIntosh, D., Milev, R. V., Müller, D. J., Parikh, S. V., Pearson, N. L., Ravindran, A. V., & Uher, R. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological Treatments. Canadian Journal of Psychiatry. 2016;61(9): 540-560.
Level of Evidence A
( Depression )
Level of Evidence C
( Anxiety )
Last updated  
8.8

After successful treatment with an SSRI or other first line pharmacological treatment: 

  • Maintain the treatment for at least 6-9 months to reduce the risk of relapse.
  • Avoid making significant medication changes during return to functional or productivity-related activities.

The risk of relapse of depressive symptoms is elevated with immediate discontinuation of antidepressant treatment following recovery. Relapse may also be likely with changes in medication when transitioning back to regular functional and occupational activities. It is general practice to maintain antidepressant therapy for at least 6-9 months to effectively promote recovery. Patients who demonstrate improvements may gradually discontinue the medication following this period.

References supporting context:

  1. Kato, M., Hori, H., Inoue, T., Iga, J., Iwata, M., Inagaki, T., Shinohara, K., Imai, H., Murata, A., Mishima, K., & Tajika, A. Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis. Molecular Psychiatry. 2021;26(1): 118-133.
  2. Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., Hasnain, M., Jollant, F., Levitt, A. J., MacQueen, G. M., McInerney, S. J., McIntosh, D., Milev, R. V., Müller, D. J., Parikh, S. V., Pearson, N. L., Ravindran, A. V., & Uher, R. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological Treatments. Canadian Journal of Psychiatry. 2016;61(9): 540-560.
Level of Evidence A
Last updated  
Appendix 8.1
Patient Health Questionnaire 9-Item Scale (PHQ-9) for Depression
appendix-8-1.pdf
 

EVALUATION

Title of Resource: Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales (PHQ-SADS) - with Alcohol section appended

Reference: Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-59.

Description: The PHQ depressive (PHQ-9), anxiety (GAD-7) and somatic symptom (PHQ-15) scales that have been developed, studied and clinically applied over the past decade constitute valid and efficient instruments for detecting, differentiating and monitoring the SAD triad. The PHQ-SADS combines all three scales plus panic symptoms from PHQ to provide a continuous severity measure of each of these common and overlapping symptom domains.

**The substance-related piece (alcohol section) was appended by our group (with permission from the author) as this is another important symptom scale for our population. This also aligns well with recommendation 8.1 which suggests screening for substance use disorders, as well as depressive, anxiety and somatoform disorders, irritability and other personality changes.

Resource Criteria:

Population

Mental health disorders

Reliability/ Validity

PHQ-9 (Depression)
Criterion validity was demonstrated in primary care patients (n=580) who underwent an independent re-interview by a mental health professional. Construct validity was established by the strong association between PHQ-9 scores and functional status, disability days, and symptom-related difficulty.  Sensitivity of 88% and a specificity of 88% for major depression.1 Reliability for the PHQ-9 has also been shown in a sample of 1063 primary care patients (a = 0.83 at baseline and 0.92 at the end of treatment).2

GAD-7 (Anxiety)
Demonstrated good reliability, as well as criterion, construct, factorial, and procedural validity in 2740 primary care patients.3 Though originally developed to diagnose generalized anxiety disorder, the GAD-7 also proved to have good sensitivity and specificity as a screener for panic, social anxiety and post-traumatic stress disorder. 4

PHQ-15 (Somatic symptoms)
The internal reliability of the PHQ-15 was found to be excellent (Cronbach’s r 0.80) in both the primary care and obstetrics-gynecology samples (n = 6000 total). Convergent validity was established by the strong association between PHQ-15 scores and functional status, disability days, and symptom-related difficulty. Discriminant validity was shown by the differential effects of somatic and depressive symptoms on various outcomes.5

Proprietary?

No (public domain scale that is available without cost in several languages)

Time to Administer
3-5 minutes

Method to Administer

Self-report, multiple-choice questionnaire

Formal Instructions (Mention if special environment/ equipment is needed)

To be completed by the patient and scored by the clinician. The PHQ-SADS can also be administered repeatedly, which can reflect improvement or worsening of symptoms in response to treatment.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9): 606-13.

2 Cameron IM, Crawford JR, Lawton K, Reid IC. Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract 2008;58(546):32-6. doi: 10.3399/bjgp08X263794. 

3 Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder — the GAD-7. Arch Intern Med 2006;166:1092–7.

4 Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317–25.

5 Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;62(2):258-66.

Appendix 8.2
Generalized Anxiety Disorder 7-Item Scale (GAD-7)
appendix-8-2.pdf
 

EVALUATION

Title of Resource: Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales (PHQ-SADS) - with Alcohol section appended

Reference: Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-59.

Description: The PHQ depressive (PHQ-9), anxiety (GAD-7) and somatic symptom (PHQ-15) scales that have been developed, studied and clinically applied over the past decade constitute valid and efficient instruments for detecting, differentiating and monitoring the SAD triad. The PHQ-SADS combines all three scales plus panic symptoms from PHQ to provide a continuous severity measure of each of these common and overlapping symptom domains.

**The substance-related piece (alcohol section) was appended by our group (with permission from the author) as this is another important symptom scale for our population. This also aligns well with recommendation 8.1 which suggests screening for substance use disorders, as well as depressive, anxiety and somatoform disorders, irritability and other personality changes.

Resource Criteria:

Population

Mental health disorders

Reliability/ Validity

PHQ-9 (Depression)
Criterion validity was demonstrated in primary care patients (n=580) who underwent an independent re-interview by a mental health professional. Construct validity was established by the strong association between PHQ-9 scores and functional status, disability days, and symptom-related difficulty.  Sensitivity of 88% and a specificity of 88% for major depression.1 Reliability for the PHQ-9 has also been shown in a sample of 1063 primary care patients (a = 0.83 at baseline and 0.92 at the end of treatment).2

GAD-7 (Anxiety)
Demonstrated good reliability, as well as criterion, construct, factorial, and procedural validity in 2740 primary care patients.3 Though originally developed to diagnose generalized anxiety disorder, the GAD-7 also proved to have good sensitivity and specificity as a screener for panic, social anxiety and post-traumatic stress disorder. 4

PHQ-15 (Somatic symptoms)
The internal reliability of the PHQ-15 was found to be excellent (Cronbach’s r 0.80) in both the primary care and obstetrics-gynecology samples (n = 6000 total). Convergent validity was established by the strong association between PHQ-15 scores and functional status, disability days, and symptom-related difficulty. Discriminant validity was shown by the differential effects of somatic and depressive symptoms on various outcomes.5

Proprietary?

No (public domain scale that is available without cost in several languages)

Time to Administer
3-5 minutes

Method to Administer

Self-report, multiple-choice questionnaire

Formal Instructions (Mention if special environment/ equipment is needed)

To be completed by the patient and scored by the clinician. The PHQ-SADS can also be administered repeatedly, which can reflect improvement or worsening of symptoms in response to treatment.

No special environment or equipment needed.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9): 606-13.

2 Cameron IM, Crawford JR, Lawton K, Reid IC. Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract 2008;58(546):32-6. doi: 10.3399/bjgp08X263794. 

3 Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder — the GAD-7. Arch Intern Med 2006;166:1092–7.

4 Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317–25.

5 Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;62(2):258-66.

Appendix 8.3
Primary Care PTSD Screen (PC-PTSD)
appendix-8-3.pdf
 

EVALUATION

Title of Resource: Primary Care PTSD Screen (PC-PTSD-5)

Reference: Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). [Measurement instrument].

Description: The PC-PTSD-5 is a 5-item screen that was designed for use in primary care settings to measure and identify respondents with probable PTSD. The questions refer to exposure to a traumatic event and how the trauma has affected the respondent over the past month. 

Resource Criteria:

Population

Adult persons suspected of PTSD  

Reliability/ Validity

In a sample of 398 Veterans, the PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 % C.I.: 0.912– 0.969). Whereas a cut score of 3 maximized sensitivity (?[1]) = 0.93; SE = .041; 95 % C.I.: 0.849–1.00), a cut score of 4 maximized efficiency (?[0.5] = 0.63; SE = 0.052; 95 % C.I.: 0.527–0.731), and a cut score of 5 maximized specificity (?[0] = 0.70; SE = 0.077; 95 % C.I.: 0.550–0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report. This is the first study to provide evidence of the PC-PTSD-5’s utility in screening for DSM-5 PTSD.1

Proprietary?

No

Time to Administer
2-3 minutes

Method to Administer

Self-administered. 

Formal Instructions (Mention if special environment/ equipment is needed)

Respondents are asked whether or not he/she has had any exposure to traumatic events. If a respondent denies exposure, the PC-PTSD-5 is complete with a score of 0. However, if a respondent indicates that he or she has experienced a traumatic event over the course of his or her life, the respondent is instructed to respond to five additional yes/no questions about how that trauma exposure has affected him or her over the past month. Add up the score for the five questions. Validation studies suggest that the PC-PTSD-5 should be considered "positive" (i.e., the individual has probable PTSD) if a respondent answers "yes" to any three of the five questions about how the traumatic event(s) have affected him or her over the past month.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1. Prins A, Bovin MJ, Smolenski DJ, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. Journal of General Internal Medicine. 2016;31(10):1206-1211. 

Appendix 8.4
PTSD Checklist (PCL-5)
appendix-8-4.pdf
 

EVALUATION

Title of Resource: PTSD Checklist for DSM-5 (PCL-5)

Reference: Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5) – Standard  [Measurement instrument]. 

Description: The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including: monitoring symptom change during and after treatment, screening individuals for PTSD and making a provisional PTSD diagnosis. The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.

Resource Criteria:

Population

Adult persons suspected of PTSD  

Reliability/ Validity

Psychometric properties of the PCL-5 were examined in 2 studies involving trauma-exposed college students. In Study 1 (N = 278), PCL-5 scores exhibited strong internal consistency (a = .94), test-retest reliability (r = .82), and convergent (rs = .74 to .85) and discriminant (rs = .31 to .60) validity. In addition, confirmatory factor analyses indicated adequate fit with the DSM-5 4-factor model. In Study 2 (N = 558), PCL-5 scores demonstrated similarly strong reliability and validity.1

PCL-5 test scores demonstrated good internal consistency (a = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD.2

There was strong agreement between the order of hypothesized and observed correlations among PCL-5 and criterion measure scores. The best-fitting structural model was a 7-factor hybrid model (Armour et al., 2015), which demonstrated closer fit than all other models evaluated, including the DSM-5 model. The PCL-5's sensitivity to clinical change, pre- to posttreatment, was comparable with that of the PSS-I. Optimally efficient cut scores for predicting PTSD diagnosis were consistent with prior research with service members (Hoge, Riviere, Wilk, Herrell, & Weathers, 2014).3

Proprietary?

No

Time to Administer
5-10 minutes

Method to Administer

Self-administered. 

Formal Instructions (Mention if special environment/ equipment is needed)

Respondents rate each item from 0 ("not at all") to 4 ("extremely") to indicate the degree to which they have been bothered by that particular symptom over the past month. Thus, total possible scores range from 0 to 80. A total symptom severity score (range - 0-80) can be obtained by summing the scores for each of the 20 items.

DSM-5 symptom cluster severity scores can be obtained by summing the scores for the items within a given cluster, i.e., cluster B (items 1-5), cluster C (items 6-7), cluster D (items 8-14), and cluster E (items 15-20). A provisional PTSD diagnosis can be made by treating each item rated as 2 = "Moderately" or higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires at least: 1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items (questions 15-20). Preliminary validation work is sufficient to make initial cut-point suggestions, but this information may be subject to change. A PCL-5 cut-point of 33 appears to be a reasonable value to propose until further psychometric work is available.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. Posttraumatic Stress Disorder Checklist for DSM-5: Development and Initial Psychometric Evaluation. Journal of Traumatic Stress. 2015;28(6):489-498.

2Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment. 2016;28(11):1379-1391. 

3Wortmann JH, Jordan AH, Weathers FW, et al. Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment. 2016; 28(11): 1392-1403. 

Appendix 8.5
CAGE and CAGE-AID Questionnaire
appendix-8-5.pdf
 

EVALUATION

Title of Resource: CAGE-AID Questionnaire

Reference: Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal . 1995;94(3):135-140

Description: The CAGE 4-item questionnaire is used to test for alcohol abuse and dependence in adults. The CAGE-AID version of the tool has been adapted to include drug use. The questionnaire is not used to diagnose diseases, but only to indicate whether a problem might exist. 

Resource Criteria:

Population

Adult persons suspected of abusing alcohol and/or drugs

Reliability/ Validity

CAGE has demonstrated high test-retest reliability (0.80-0.95), and adequate correlations (0.48-0.70) with other screening instruments. The questionnaire is a valid tool for detecting alcohol abuse and dependence in medical and surgical inpatients, ambulatory medical patients, and psychiatric inpatients (average sensitivity 0.71, specificity 0.90). Its performance in primary care patients has been varied, while it has not performed well in white women, prenatal women, and college students. Furthermore, it is not an appropriate screening test for less severe forms of drinking.1

Proprietary?

No

Time to Administer
1-2 minutes

Method to Administer

Self-administered. 

Formal Instructions (Mention if special environment/ equipment is needed)

Respondents answer “yes” or “no” to 4 “have you ever” questions pertaining to alcohol and drug abuse. Respondents are scored 0 for “no” and 1 for “yes” answers. 
Add up all items for a total score out of 4. A higher score is an indication of alcohol and/or drug problems. A total score of 2 or greater is considered clinically significant.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007;30(1):33-41

Table 8.1
General Considerations Regarding Pharmacotherapy after mTBI
Algorithm 8.1
Assessment and Management of Persistent Mental Health Disorders Following mTBI
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013;28(1):13-20.  

DOWNS & BLACK: 17/32

Associated with recommendation 8.1

Haarbauer-Krupa J, Taylor CA, Yue JK, et al. Screening for Post-Traumatic Stress Disorder in a Civilian Emergency Department Population with Traumatic Brain Injury. J Neurotrauma. 2017;34(1):50-58.  

DOWNS & BLACK: 14/32

Associated with recommendation 8.1

Campbell-Sills L, Jain S, Sun X, et al. Risk Factors for Suicidal Ideation Following Mild Traumatic Brain Injury: A TRACK-TBI Study. J Head Trauma Rehabil. 2021;36(1):E30-E39.  

STROBE: 18/23

Associated with recommendation 8.1

Chang HK, Hsu JW, Wu JC, et al. Risk of attempted suicide among adolescents and young adults with traumatic brain injury: A nationwide longitudinal study. J Affect Disord. 2019;250:21-25.   

STROBE: 18/23

Associated with recommendation 8.1

Donders J, Pendery A. Clinical Utility of the Patient Health Questionnaire-9 in the Assessment of Major Depression After Broad-Spectrum Traumatic Brain Injury. Arch Phys Med Rehabil. 2017;98(12):2514-2519.   

STROBE: 16/23

Associated with recommendation 8.1

Donders J, Darland K. Psychometric properties and correlates of the PHQ-2 and PHQ-9 after traumatic brain injury. Brain Inj. 2017;31(13-14):1871-1875.

STROBE: 18/23

Associated with recommendation 8.1

Karr JE, Iverson GL, Huang SJ, Silverberg ND, Yang CC. Perceived Change in Physical, Cognitive, and Emotional Symptoms after Mild Traumatic Brain Injury in Patients with Pre-Injury Anxiety or Depression. J Neurotrauma. 2020;37(10):1183-1189.   

STROBE: 20/23

Associated with recommendation 8.1

Teymoori, A., Gorbunova, A., Haghish, F. E., Real, R., Zeldovich, M., Wu, Y. J., Polinder, S., Asendorf, T., Menon, D., Center-Tbi Investigators And Participants, & V Steinbüchel, N. (2020). Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury. Journal of clinical medicine, 9(3), 873.   

STROBE: 16/23

Associated with recommendation 8.1

Langer LK, Alavinia SM, Lawrence DW, et al. Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score. PLoS Med. 2021;18(7):e1003652.

STROBE: 20/23

Associated with recommendation 8.1

Brett BL, Kramer MD, Whyte J, et al. Latent Profile Analysis of Neuropsychiatric Symptoms and Cognitive Function of Adults 2 Weeks After Traumatic Brain Injury: Findings From the TRACK-TBI Study. JAMA Netw Open. 2021;4(3):e213467.

STROBE: 22/23

Associated with recommendation 8.1

Doroszkiewicz C, Gold D, Green R, Tartaglia MC, Ma J, Tator CH. Anxiety, Depression, and Quality of Life: A Long-Term Follow-Up Study of Patients with Persisting Concussion Symptoms. J Neurotrauma. 2021;38(4):493-505.

STROBE: 19/23

Associated with recommendation 8.1

Hellewell SC, Beaton CS, Welton T, Grieve SM. Characterizing the Risk of Depression Following Mild Traumatic Brain Injury: A Meta-Analysis of the Literature Comparing Chronic mTBI to Non-mTBI Populations. Front Neurol. 2020;11:350.

AMSTAR 2: 12/20

Associated with recommendation 8.1

Madhok DY, Yue JK, Sun X, et al. Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study. Brain Sci. 2020;10(5):269.

STROBE: 17/23

Associated with recommendation 8.1

Moriarty H, Robinson KM, Winter L. The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury. Nurs Outlook. 2021;69(2):167-181.

STROBE: 20/23

Associated with recommendation 8.1

Popov N, Mercier LJ, King R, Fung T, Debert CT. Factors Associated with Quality of Life in Adults with Persistent Post-Concussion Symptoms. Can J Neurol Sci. 2022;49(1):109-117. 

STROBE: 16/23

Associated with recommendation 8.1

Ramanathan-Elion DM, Baydoun HA, Johnstone B. Psychological predictors of functional outcomes in service members with traumatic brain injury. Brain Inj. 2020;34(9):1183-1192.

STROBE: 16/23

Associated with recommendation 8.1

Vikane E, Frøyland K, Næss HL, Aßmus J, Skouen JS. Predictors for Psychological Distress 2 Months After Mild Traumatic Brain Injury. Front Neurol. 2019;10:639.

STROBE: 22/23

Associated with recommendation 8.1

Yue JK, Cnossen MC, Winkler EA, et al. Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol. 2019;10:343.

STROBE: 16/23

Associated with recommendation 8.1

Zachar-Tirado CN, Donders J. Clinical utility of the GAD-7 in identifying anxiety disorders after traumatic brain injury. Brain Inj. 2021;35(6):655-660.

STROBE: 19/23

Associated with recommendation 8.1

Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016;61(9):540-560.   

Quality Rating: N/A (not assessed in previous version of the guidelines)

Associated with recommendations 8.2, 8.7 (depression), and 8.8

Sullan, M. J., Crocker, L. D., Thomas, K. R., Orff, H. J., Davey, D. K., Jurick, S. M., Twamley, E. W., Norman, S. B., Schiehser, D. M., Aupperle, R., & Jak, A. J. Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment. Behaviour research and therapy. 2021;143: 103892.  

DOWNS & BLACK 21/28

Associated with recommendation 8.4 (sleep)

Saksvik SB, Smevik H, Stenberg J, et al. Poor sleep quality is associated with greater negative consequences for cognitive control function and psychological health after mild traumatic brain injury than after orthopedic injury [published online ahead of print, 2021 Aug 12]. Neuropsychology.

STROBE: 20/23

Associated with recommendation 8.4 (sleep)

Brett BL, Meier TB, Savitz J, Guskiewicz KM, McCrea MA. Research Letter: Sleep Mediates the Association Between Prior Concussion and Depressive Symptoms. J Head Trauma Rehabil. 2021;36(4):E284-E288.

STROBE: 17/23

Associated with recommendation 8.4 (sleep)

Khokhar BR, Lindberg MA, Walker WC. Post-mTBI Pain Interference in a U.S. Military Population: A Chronic Effects of Neurotrauma Consortium Study. Mil Med. 2021;186(3-4):e293-e299.

STROBE: 20/23

Associated with recommendation 8.4 (sleep and pain)

Ackland, P. E., Greer, N., Sayer, N. A., Spoont, M. R., Taylor, B. C., MacDonald, R., McKenzie, L., Rosebush, C., & Wilt, T. J. Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury. Journal of affective disorders. 2019; 252: 493-501. 

AMSTAR 2: 13/20

Associated with recommendation 8.5

Bedard M, Felteau M, Marshall S, et al. Mindfulness-based cognitive therapy reduces symptoms of depression in people with a traumatic brain injury: results from a randomized controlled trial. J Head Trauma Rehabil. 2014;29(4):E13-22  

PEDro: 7/11

Associated with recommendation 8.5

Little, A., Byrne, C., & Coetzer, R. (2021). The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review. NeuroRehabilitation. 2021;48(1): 67–82.   

AMSTAR 2: 9/20

Associated with recommendation 8.5

Mikolić, A., Polinder, S., Retel Helmrich, I., Haagsma, J. A., & Cnossen, M. C. (2019). Treatment for posttraumatic stress disorder in patients with a history of traumatic brain injury: A systematic review. Clinical psychology review. 2019;73: 101776.   

AMSTAR 2 13/20

Associated with recommendation 8.5

Jak AJ, Jurick S, Crocker LD, et al. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2019;90(3):333-341.

Downs & Black: 21/28

Associated with recommendation 8.5

Rytter HM, Graff HJ, Henriksen HK, et al. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open. 2021;4(11):e2132221.

AMSTAR 2: 14/20

Associated with recommendation 8.5

Kreutzer JS, Marwitz JH, Sima AP, Mills A, Hsu NH, Lukow HR 2nd. Efficacy of the resilience and adjustment intervention after traumatic brain injury: a randomized controlled trial. Brain Inj. 2018;32(8):963-971.

Downs & Black: 20/28

Associated with recommendation 8.5

Novakovic-Agopian T, Posecion L, Kornblith E, et al. Goal-Oriented Attention Self-Regulation Training Improves Executive Functioning in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury. J Neurotrauma. 2021;38(5):582-592.

Downs & Black: 22/28

Associated with recommendation 8.5

Thomas RE, Alves J, Vaska Mlis MM, Magalhaes R. Therapy and rehabilitation of mild brain injury/concussion: Systematic review. Restor Neurol Neurosci. 2017;35(6):643-666.

AMSTAR 2: 13/20

Associated with recommendation 8.5

Silverberg ND, Cairncross M, Brasher PMA, et al. Feasibility of Concussion Rehabilitation Approaches Tailored to Psychological Coping Styles: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2022;103(8):1565-1573.e2.

Downs & Black: 22/28

Associated with recommendation 8.5

Fann JR, Hart T, Schomer KG. Treatment for depression after traumatic brain injury: a systematic review. J Neurotrauma. 2009;26(12):2383-2402.  

AMSTAR 2: 11/20

Associated with recommendation 8.7 (depression)

Reyes NGD, Espiritu AI, Anlacan VMM. Efficacy of sertraline in post-traumatic brain injury (post-TBI) depression and quality of life: A systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg. 2019;181:104-111.

AMSTAR 2: 12/20

Associated with recommendation 8.7 (depression)