- Welcome on this rather sweltering evening.
Thank you for coming out for this event.
For those of you who don't know me,
I'm Kathryn Basham, nice to see a lot of familiar faces
and some new faces here in the audience.
I am one of the co-directors of the PhD program
and I've been here quite a while and glad to see
some of the students who've been actively involved
in our military social work initiatives.
Those of you may know, some of you don't know,
that we are 99 years old as a school
and next year, we'll celebrate our 100th anniversary.
The school was started basically to serve
veterans of World War I with shell shock.
And the history is fascinating to really trace
what social work students actually did.
Clinical social work students were summoned to be educated
to actually work with this population who were in Europe,
in theater at the time, students were recruited
to come in the summers, was considered a very odd plan.
No other social work program had this plan
and thus, The Block Plan, so the education
was primarily in social work, clinical social work
'cause it was mental health orientated, shell shock related.
And the efforts were trying to really work with the veterans
and their families, so it's an interesting history
and I'm very pleased to be a part of this ongoing commitment
and a number of us here in the audience
are very involved as well, so I am delighted to be able
to present and honored to present Dr. Lisa Brenner.
This is one of our, the second
in our public series of lectures.
And Dr. Brenner has specialized in working
with the mental health issues surrounding veterans
with a vast research background and tonight,
she's particularly going to focus on traumatic brain injury
with issues of suicide risk.
So Dr. Brenner, no, no, no, no, you have to be introduced.
(audience laughs)
Excuse me, a little more detail, come on.
Okay, she is a board-certified rehabilitation psychologist
and a professor of physical medicine in rehab
at the University of Colorado Anschutz School of Medicine
and the director of the Rocky Mountain Mental Illness,
Research, Education and Clinical Center.
She's also a fellow of the American Psychological
Association Division 22 Rehabilitation Psychology.
Her primary area of research interest
is traumatic brain injury, comorbid psychiatric conditions,
and negative psychiatric outcomes, including suicide.
She serves as the research division director
for the American Association of Suicidology
and has reviewed publications, participates
on national advisory boards, and is currently co-authoring
a book regarding neuro-disability and suicide.
So please join me in welcoming Dr. Brenner.
(audience applauding)
- Thank you so much, I think I have,
is this working now, where's my good friend?
Thank you, okay, great, I should tell you
before I get started that I came to this work
in a very unusual work in that I spent,
I actually went to a very psycho-dynamically oriented
school, I was trained in psycho-dynamic theory
at a place called The Wright Institute in Berkeley
and I went to Brandeis before that so,
and at Brandeis, I majored in psychology and women's studies
so I thought that my life would like very, very different
than it does, I didn't think that I would be working
with mostly men and veterans, that wasn't the career path
I had in mind, I also didn't think I'd be working
with more physical manifestations and physical illness.
For me, really, it all changed when I was doing
my training and I was doing my training
at the Denver VA and I realized that this was,
there was some avenues that I'd never thought
about explored and so my trajectory changed
and I then focused on doing very specific inpatient work
with folks who had lots of physical conditions
and then about 10 years later, somebody said,
"Hey, do you wanna try to do research?"
And I was like, okay, I didn't really think
about doing that, I'd done a lot of training
and so I got a change about, it was about 10 years ago
to start doing research and that really worked out for me.
So I guess all of you who think you know what I wanna do
or think about you know the path that you're gonna take
and you have it all set, I would just say be open.
Really amazing things can happen that you would
never anticipate and I would certainly say that
about my career in the VA, I've had many, many careers
in the VA and it's been a great place for me.
So that's not really what I'm supposed to be talking
about today but I felt inspired to say that
just so you know where I'm coming from in talking about this
today, I should also say that everything I say today
is all me, it's not the VA, so if I say anything
particularly crazy today, that's definitely not the VA,
that's me, okay, so in my research,
and you'll see, I'm gonna show you lots
of different methods, qualitative methods,
more epidemiologic methods, interventional methods,
this is a quote from a veteran.
We were doing a qualitative study, I'll talk
a little bit more about it later, and the veteran said,
"I think it took a while before I realized
"and then when I started thinking about things
"and realizing that I was gonna be like this,"
like this is with a big ole brain injury,
"for the rest of my life, it gives me a really down
"feeling and it makes me think, why should I be around
"like this for the rest of my life?"
And this is very common, particularly for folks
who have moderate to severe TBI and I'll talk
more about, if you don't know what moderate to severe TBI
is, you will be the end of this lecture.
But really how do we help people create meaning?
And one thing you'll hear over and over again tonight
is that folks in mental health often think
brain injury is not my purview, brain injury's
a physical health condition, I need to refer out
for brain injury and if you're not gonna hear anything else
tonight and this is like the end, the punchline
right now is actually brain injury is your purview.
And we actually need it to be your purview,
not just for military veterans but actually everybody
because this is all happening in the brain, right?
I know you all probably feel pretty comfortable
with thinking about major depressive disorder
or post-traumatic stress disorder, all that's originating
also in the brain, these are all brain-based conditions
and you actually have many of the skills necessary
to work the best with folks who have brain injuries
so I hope that that will be something you are convinced
about over the next time we're talking.
The other thing I would say is if you wanna be a researcher,
pick something that nobody's doing.
(audience chuckles) Right?
Then you can be really famous, right?
Because nobody else is doing it, so you see
this PubMed, TBI and suicide.
And you can see that this has become an area
of big interest, not just with military populations
but with all populations and this is for a number
of different reasons and you can see look
at these tiny little numbers over there, zero to 20, right?
If you do this same kind of search with major depression
and suicide, it'll be in the thousands.
It's pretty hard to make a name for yourself
if it's in the thousands, so try to pick something
that's an intersection of things that people are looking at
but nobody's look at really specifically yet.
And that's how you get to, and then all you have to do
is bring this whole school of thought here
and this whole school of thought here together
and people think, holy smokes, you're really smart.
And actually what you're doing is just bridging, okay?
All right, so this is when I started doing research,
right about here, and it's actually really gratifying to me
to see that lots and lots of people are starting
to do this work now 'cause really what you're trying
to do is plant the seed and that other people need to do it.
Okay, so here we're gonna play some games.
It's gonna be participatory today, okay, so this is,
if you're in the military and you know this,
do not answer (laughs).
How many people do you think have been deployed
in Iraq and Afghanistan since 2001?
How many?
- 100,000? - 100,000.
Higher or lower?
- Higher. - Higher, okay, what?
- [Man] Three million?
- Three million, do people think three million,
higher or lower?
- [Audience] Lower.
- Lower, 300,000.
- [Woman] (faint speaking) higher.
- Okay, three million and 300,000, that's a lot.
(audience laughs)
What, come on, higher than 300,000.
- 600,000? - 600,000.
- [Woman] 1.5.
- 1.5 million.
Okay.
Our three million was right.
- [Woman] Wow.
- Okay, so the interesting thing
is that these three million, these folks live in communities
that maybe you don't intersect with.
These folks, many of them have been deployed multiple times
and, of course, this is 2.7 million individuals
but each of these individuals has family members,
has children, has coworkers, and so if you think
about all the people this has touched, it's much bigger
than that, but it may be a community that you have nothing
to do with and there are certain communities
where everybody is in it, right, or if you work in the VA,
you're in this all the time.
I always try to think this is going on right now still.
Unfortunately, I'm still saying that.
I've been saying that for a long time.
Soldiers were killed just this weekend, right,
in Afghanistan so this is still happening.
It may be for a number of reasons easy not to have
in the forefront of our minds but it is still happening.
Okay, I have some slides, I have a lot of numbers.
I'm really sorry but I did want to share
some of this with you and I think this is really good data
to start to think about what's out there.
What you can see is on the far side over there.
You've got years, and this is defense casualty data
and the wars started in 2001 in Iraq, I'm sorry,
in Afghanistan, and then 2003, sorry, I'm saying that right,
in Afghanistan and Iraq, okay, so then you see
this is first year, total deaths and you see hostile action
is 12, and then you self inflicted, 153, okay?
But what you start to notice down here.
Oh, this is shorter than me, okay, see down here?
what you start to see is 346
but what, 302, so this number is almost,
and there were further years where this number
actually was equal to or higher
than that number and that, for many good reasons
starting getting people's attention, what was going on
with this cohort that those numbers
were flipping in those ways.
This is just another way of looking at the data
and I think a good indication of why it's important
to look more closely at data.
This is the DoD suicide rate per year.
This is in numbers of deaths and this is per 100,000.
If you just look at these, you might think,
okay, there's maybe a little bit of a problem.
But if you break out the right data, you can see
the problem is really much greater for different cohorts.
This is by service so this is Army.
And so much higher rates in the Army than other services.
Okay, and you might miss that too if you're looking
at the per 100,000 also, so just different ways
that you can look at data that really doesn't give you
the story you need, I would say this
is the most important part over here,
what's happening with folks in the Army
who really are deployed and on the ground
more than other folks that is contributing or not.
So then the other thing I always like to do,
I always try to fight context before we get really into it
and so if you think about that 2.7 million,
all those individuals actually at this point, this was,
it's actually very hard to get data in real time
but there's one million, probably 1.2 million,
1.5 million, probably more now, individuals who are eligible
for VA care now, so every time you hear a story
about the VA on the news, this is the Lisa part
talking not the VA talking, every time you think
about the VA on the news, I'm sure,
who's heard the VA on the news?
Yes, of course, I want you to think
about a healthcare system integrating 1.5 million
new people, okay, 'cause that's a very different way
of thinking about it, and not only 1.5 million new people
but what you have here and this number doesn't look huge,
the 12.3 but we did have 12.3% women when I started working
at the VA, right, so these individuals need
very different kind of healthcare and we also didn't have
this when I started working at the VA, much younger folks
with much younger health-related conditions.
There's another thing you'll notice, mostly enlisted,
so folks that may have less resources than officers
and again, mostly Army, I mean active duty and then Army.
That won't surprise you with the Army, right?
Okay, and then here, just to highlight,
this is what people are actually getting care for,
cumulatively, and you'll see these numbers
don't add up to 100, but the bigger numbers
are mental disorders and disease of the nervous system
and sense organs, brain injury, mental health conditions.
That's what people are getting care for,
amongst all other things.
I was talking to somebody earlier today, we're also seeing
lots of interesting conditions amongst these cohorts,
things that are unusual in younger veterans,
things like sleep apnea, much higher rates.
GERD actually and GI problems, I've been reviewing
a lot of charts lately and almost all the veterans
I've been seeing are on medication
for stomach-related problems, so things that you just
wouldn't expect and that's a different lecture
for a different day, okay, so now we're gonna get
more into the suicide and TBI thing.
Before we do that, I think it's really important
to make sure that we're on the same page
about what do these variables mean, right?
I think of them as variables, behaviors, what do they mean?
And so when I started doing research,
I realized that there was no classification system
for suicide, there was no common language for suicide
and that seems kinda crazy, right?
There was no common language for suicide
and suicide-related behavior, which is a really big problem
for a number of reasons, so clinically,
this is the participatory part, you all can help
'cause I can see you all.
Clinically, why would it be a problem if I think a suicide
attempt is different than somebody on an inpatient unit?
So I'm doing intake and somebody in the inpatient unit
thinks something, suicide attempt defines it differently.
Why would that be a problem?
I know you people at Smith are way smarter than this.
(audience laughs)
Why would it be a problem if I have a different definition
or a different understanding of a term than somebody
that works in the same hospital that I do?
Yep, yep, what was?
(faint speaking)
That's a different problem, that's a policy problem.
So on a person level, so I'm doing the intake diligently
in the ED, I transfer the person and the person
on the inpatient unit has a different definition.
We are not treatment planning, we are not assessing risk
in the same way, that's a big problem.
Okay, how is it a research problem?
- [Woman] There's no way to quantify.
- There's no way to quantify. - Separate the data.
There's no way to quantify and separate the data
so if I'm quantifying and separating the data,
if I'm not operationalizing it in the same way, right?
And then I'm trying to pull together research,
I may be lumping where I shouldn't be, right?
So if I'm trying to think across studies
and my excellent study and your excellent study
your excellent study, we're all defining suicide attempts
in different ways, we can't lump.
And then that becomes a big problem, right?
Because we can't get bodies of research together, okay,
and then our policy problem, how much resources
should be put towards something if we
aren't really counting it correctly?
So three big problems, it doesn't matter what you're doing.
This is a problem, so we thought, okay, we're gonna work
with the CDC and come up with something
that actually helps define this.
And this is something we created.
I'm not gonna go too far into this today.
I mostly just highlighted here, this is on our website.
See what you can do to find this.
Do you see I put a little clue down there,
how you can find stuff, all you do is google.
I know you know how to do that, Rocky Mountain MIRECC
and this stuff I'm gonna show you today is on there, okay.
And this is the classification system.
There is definitions, there is a tool.
There's also an online decision tree
and this has been implemented in the VA and DoD on whole.
This is what it looks like, ta-da, I'm not gonna show you
the clinical tool today but the clinical tool
is actually pretty good, all you do is ask
two or three questions and it gets you to the right term.
And there's the online version and the not online version.
The way this is organized, it's by thoughts
and then behaviors.
Okay, what's a thought?
- [Woman] I'm hungry!
- I'm hungry, great, so it's something you think, right?
Thoughts and then a behavior is what?
Something you do, right, so in this classification system,
behaviors trump thoughts, right, okay.
And what you can do is you, with these few questions,
I'm not gonna show this tool today, you can get
to the right term, and that means that I,
like the person on the inpatient unit,
and I can have the same idea, okay, when we're working
with the person or if I'm doing research or policy.
The other thing that has really different
than we had done before, had been existed
before is this idea of undetermined.
Undetermined, in my mind, means I don't have
enough information, okay, as a clinician, I don't have
enough information yet, so I need to keep working
to get enough information to figure out if this
is a suicide attempt or not or suicidal behavior or not.
So I think of undetermined as a placeholder.
The other thing that's on here is preparatory behavior.
Preparatory behavior is behavior that is leading
towards a suicidal act but not yet the act.
Now, I can, there's a different lecture I could give today
on this, I'm not gonna give that lecture
but if you go to this website you can watch this lecture.
Okay, and so this is something you all can do
and I will tell you if you do this and use this
and use this in your charting, you will be so far ahead
of the game in terms of your clinical work, okay, all right,
so we all know what we're talking about with suicide
and suicide attempts 'cause we have the same ideas now,
the same terms, okay, so let's talk about brain injury.
So much confusion about what brain injury is,
so much confusion.
So a brain injury is actually, first of all,
a historical event, it's something that already happened.
It's like a broken ankle, it's something
that already happened, and there's
only two really easy parts to it.
You have an injury event and an alteration in consciousness.
That's it, right, that's a brain injury.
Injury event, alteration in consciousness.
Now the hard part can be the alteration in consciousness.
The alteration in consciousness can range
from I had my bell rung to I'm in
a persistent vegetative state, and that's what creates
all the confusion, right, okay, and TBIs can result
in long- or short-term problems.
Who gets more brain injuries, guys or gals?
Guys, guys, okay, why?
That's right, it's not sports, it's crazy business.
Guys more than gals age ranges for brain injury,
there's three. - 13 to 23.
- Yeah, 15 to, like 15 to 24.
What else?
When do I get all the phone calls about oh my god,
my kid is learning how to walk and they got a goose egg?
So little kids, and what's the third group?
- [Women] Elders.
- Elders, okay, how do older people get brain injuries?
- [Audience] Falls.
- Falls, and we already said how younger people
get brain injuries, crazy business, okay.
80% of the brain injuries that occur are mild, okay?
And when I say mild, moderate, and severe,
I don't mean how bad was your headache?
How bad are your symptoms after?
I mean how bad, how serious was the alteration
in consciousness, okay, and so mild, you can see
I'm not not gonna go so, so far into this.
Mild is you don't have a significant loss of consciousness.
It's less than 30 minutes, mild TBI is the same
as concussion, I won't make you raise your hand
if you've ever had a concussion, it's many of you,
I already know, okay, lots of people get concussions.
It's fine, most people have multiple concussions
in them and they will be fine.
The part of the problem is we don't know
what the number concussions is per person
so maybe someday it'll be really fancy.
I can have a blood test and they'll say,
oh, Lisa, you could be a professional boxer
'cause could you get 100 TBIs, mild TBIs
and you'd be good to go but maybe somebody else
over here can only get two, but we don't know that yet.
Does that make sense, like a lifetime load?
Okay, that would be genetics, that would be a whole bunch
of things that would contribute to that,
but right now, we don't know that.
So we're doing a lot of guessing around sports.
I know you've all seen this around sports, right?
Like when's too many, when should you quit playing,
all that stuff, that's a mild TBI.
Okay, moderate and severe, I think of mild as by itself,
moderate severe goes together more significant loss
of consciousness, more expected long-term symptoms, okay?
And for mild, you can't have any positive imaging.
When I say positive imaging here, I'm talking
about a CAT scan or MRI.
I'm not talking about super fancy imaging
that you can pay a lot of money for that doesn't really mean
anything, so I don't know if you've all seen
that there's fancy places you can go and get
really pretty pictures taken if you've had a brain injury.
Do people know what I'm talking about?
Like SPECT scans or PET scans?
I won't anyway the names of companies.
Somebody's making lots of money off this,
also lots of money from people who don't have a lot of money
to pay for these, okay, and they are really amazing pictures
and they are amazing for research.
We actually don't know how to interpret the pictures yet.
So you will get the report and it says beautiful picture,
could be brain injury, could be ADHD,
could be bipolar disorder, I'm like that's
not particularly helpful so I would say right now
if you could discourage people from getting those
really pretty pictures, it's like 3,000 bucks,
I would do that, okay, so right now we know
how to interpret CAT scans and MRIs.
If you have any imaging on CAT scans or MRIs,
that's not a mild TBI anymore.
But really 80% of TBIs are mild.
And most people go on to have symptoms, like worst headache
of their life with mild TBI and then they're fine.
Most individuals return to baseline functioning in a year.
If we think about common mild TBI symptoms,
we break it into thinking and remembering
physical symptoms, emotional mood, and sleep.
Now part of the challenge with these symptoms,
these are really post-concussive symptoms,
is they are completely nonspecific, right?
So we're gonna play another game, you have to play.
I'll play too, I'm gonna start reading them
and I want you to raise your hand if you had one
in the past week, okay, ready, headache?
Dizziness, irritability, trouble falling asleep?
Oh, irritability, it was like whoa!
The heat today was like a winner, everybody's like,
I'm really irritable, okay, right, so everybody's got
their hand up, and then I would say to you, if you had
a brain injury, keep your hand up, everybody else
put their hand down, everybody would put their hands down.
The problem is all of these are completely non-specific.
In past week, right, and so using symptoms to diagnose
brain injury, particularly mild TBI, is a no-no.
We can talk about a different day, different lecture
why these are really common symptoms
that are the same symptoms that you have when you have
the flu or the cold and it's probably related
to inflammation but that's a neurobiology lecture
for different day, so don't use the symptoms
to make the diagnosis.
Okay, so this is data that we collected at Fort Carson
sometime ago and what we found,
headache is usually what people talk about.
I had the worst headache of my life, then it went away,
so and what we did is we said, okay, which of these symptoms
did you have at the time you were injured
and which did you have post deployment when you came back?
You can see these nice decreases of headache,
dizziness, balance problems, but not so much here and here,
irritability, memory, so then we said, okay,
well, this is kinda not so good, let's look at the data
again a different way and we said, okay,
which of these symptoms did you have at the time
of the injury and which were new onset post deployment?
Okay, and what you had is see these big red blocks,
these were really post-deployment symptoms
and what we were having was TBI symptoms going down
and PTSD symptoms going up, and so what you see
is this overlap, it could look like it's weird
or it could look like it's two conditions overlaying
on each other, and if you've ever worked at the VA
or the DoD, this is really what it looks like.
So I have veterans come into my office
and they say, "I have some problems with attention.
"I have depression, I'm kinda irritable, I'm anxious,
"and I've got chromic pain, which of my symptoms
"are related to TBI, which are related PTSD
"and which are something else?"
And you know what I say to them?
I say I don't know 'cause that's actually the honest answer.
I actually have no idea, and I don't actually think
of people like that, I think of these as all happening
in the brain, and it's even really more complicated
than this, we did timelines, qualitative data timelines
of folks from Fort Carson and so here's one
of the timelines, this veteran deployed.
They were exposed to a traumatic stressor.
They sustained a TBI and they had post-concussive symptoms.
They returned to the U.S., they were still having
mTBI-related symptoms, they were diagnosed with PTSD
and they received medication and then they redeploy.
So take out the suicide attempt, this was did have a suicide
but if I take this off, and then have three deployments,
I don't see how I can parse out these symptoms
and I'm not even sure that's a useful task,
although we did spend a lot of time in the VA and DoD
trying to parse TBI or PTSD and there's many reasons
for that, not to mention, not the least of which
is the way that our care systems are set up,
TBI and PTSD don't live in the same system of care.
And that's not just the VA's issue.
That's actually everybody (chuckles).
Mental health is not the same as neurology or rehab.
And to help those providers actually start to work together,
that's why we need you 'cause people feel very comfortable
working in their own lane, and so we spend a lot
of time trying to be in our own lane
and parsing in our own lanes, and I don't think
that's actually particularly helpful for veterans.
Okay, and then to make matters worse,
we do know or more complicated, we do know
that patients with mild TBI are twice as likely
to develop PTSD and that is both in military,
not military populations, so there is something
about the brain, if you get a TBI and have a traumatic event
at the same time emotionally and physically traumatic
at the same time, the odds of developing PTSD are greater
if you have the TBI, now why that is, we don't know.
But that is true and I would say that it's true
for all kinds of psychiatric conditions.
Okay, and we've seen this over and over again.
This, I think, is just a helpful chart to think
about all these different conditions.
This has nothing to do with TBI but this is comorbidities
of mental conditions, mental health conditions
in those that are returning from Iraq and Afghanistan.
You can see how these all cluster in a way
that is, I think, very complicated
and not particularly satisfying
if you're trying to say it's this or this.
Is this what you all are seeing, people who work in VAs?
Yes, my friend over here, she's working in a VA.
(faint speaking) Sort of?
Okay, okay, okay, so let's talk about TBI and suicide.
Any questions about that before we go, is it clear, am I?
Okay, good, not too overheated, okay, good.
All right, TBI and suicide so this right here
is a seminal article, it came out actually
not that long ago, in 2001 and what these folks did
and I think this highlights what I'm gonna say in a bit
about what the importance of having centralized medicine
or electronic medical records for huge populations.
Many of these early studies were done in Europe
where they had much larger populations
and what Teasdale and Engberg did was found
that people who had a history of TBI, mild
or moderate and severe, were about three times
more likely to die by suicide.
And that doesn't mean that the reason the mild contributes
and moderate severe contributes is the same.
It's interesting to think about how those
might be the same and different, we haven't looked
at that yet, so I'd like to think about mild TBI
as a risky behavior, getting concussions is a risky behavior
and risky behaviors travel together like suicide
and other risky behaviors, I think there's other things
that contribute to more moderate to severe that result
in that same increased risk, okay, but that's me
making something up, I don't really know.
But the other thing that they found out
that I thought was really interesting is that the risk
wasn't right after the TBI, the risk persisted
for the 15 years of the study.
And they had a maximum of 15-year follow
so my guess is this continued.
And so I can just tell you from my clinical experience,
I have veterans that I work with.
I had a veteran with a brain injury, took care of him
in the hospital, he was long post his injury.
He had actually gone back to school, done really,
really well, gotten married, having the career he wanted
and then there was a series of really challenging events
and he just didn't have the resources
and the coping strategies and he died by suicide.
And he was what you would've thought well beyond
the transition, but really, when life changes
start happening again, he, there wasn't enough onboard,
enough structure, enough scaffolding to help him work
through those things, and that was probably,
I'm trying to think how long post his injury.
It was long, I think it was like 12 years post his injury.
And seemingly, and I know not for him,
but for me, I'd gotten an email from him
maybe two years ago, doing great
and so seemingly kind of out of the blue.
Everything seems okay and then things can change
very quickly, okay, so in terms of another align,
another way to do research, this is a systematic review
that we did, we really wanted to get an idea
of all the literature that was out there (chuckles).
My dad's texting me jokes right now just 'cause I guess
it's my lucky day, so that's hilarious actually.
(laughs)
Okay.
(audience laughs)
(chuckles) Okay, so this is a systematic review that we did
and who have done systematic reviews here?
Okay, so this would be something that Smith
could really. (audience laughs)
Come on, Smith, all right, systematic reviews
are really important and really a way to understand
what's out there in terms of the literature
but not just the literature but the quality of literature.
I know aren't you glad you asked me to come?
Now you're probably like, oh my god.
Okay, so it lets you do is really, if you're interested
in looking at an area of research, I really recommend
doing this, if you're really interested in an area
of research and you haven't googled the topic yet,
that would be a really great place to start, by the way,
'cause I probably get two or three people a week
that email me and say, I have this really great idea
and I say, have you done a lit search on it?
'Cause actually somebody else already had
that really good idea, okay? (audience chuckles)
So just make sure that somebody else hadn't already had
that great idea, it probably is a great idea
but somebody may have already had it, so this lets you look,
it lets you also rate how good
the literature is or how good the study is.
And so what you can see is in the history
since 2007 to 2012, there's actually only been
five total studies looking at suicide and TBI.
You might think it's a lot more than that, it's not.
I know, you hear a lot about suicide and TBI
in the news, everything else, but there's only five studies.
This includes, I took out all my CTE slides today.
Do people know what CTE is?
It's chronic traumatic encephalopathy, it's the thing
that sports thing, I took out, but even including
all that, there's five studies around death by suicide.
And only one of them has low risk of bias.
This is a study that we did in the VA.
I just wanna highlight this.
It took eight million records to be able to do this study.
That's why it's really, really hard.
Suicide, every suicide is super bad news
but it is a relatively low base rate behavior
so if you need a population that's large enough
that has TBIs plus suicide, you need a large sample
and so this was everybody with a history of TBI
in the system at that time between FY 2001, 2006
and those without a TBI and, again,
we found, we were very overly cautious.
We controlled for all psychiatric conditions
so we probably took out a lot of our TBI symptoms.
Does that make sense, remember I already talked
about psychiatric symptoms and we still found
about two times increased risk with those with TBI.
This is the other thing I wanna show you.
So this is those who did not die by suicide,
those who did die by suicide, and this
is major depressive disorder, on the top here,
you have really more concussions, mild TBI moderate
to severe and I just wanna show you the really high rates
of major depressive disorder.
So those who did die by suicide, 30% had
major depressive disorder, those who didn't, still 10%
and 21% and 8%, so just really highly rates of individuals
walking around with these conditions
with untreated mental health disorders
and I'll talk more about that as I go.
This is a nice study that was done
at University Washington, actually a great rehab folks
in Seattle and what they get is they looked
at accumulative onset of depression post TBI
and they found that their sample, almost 50% of the sample
in the first year post TBI had major depressive disorder.
Okay, so if you think you're going to go out
and have a clinical practice in social work
and not see people who have TBI, you are wrong (chuckles).
You're just wrong and if you're in practice already
and you're not asking about history of TBI,
you're probably treating people who have history of TBI
and you just don't know it, okay, so that would be
another thing to take from today is it's really helpful
to know if this part of somebody's history.
And my sense is you're probably already doing this work.
You just may not know it.
Okay, this was why I did go back to actually look
'cause I was thinking, okay, I'm going to Smith
and I wanna make sure I can talk about women and TBI
'cause that seemed like the right thing to do
and embarrassingly, we have no women in this study.
And actually I started to look at a bunch of studies.
There is no women in any of these studies
so if you are looking for a research career,
there is a career out there to be had
about women and TBI, there is this great group
called Pink Concussions if you're on Twitter.
They're starting to do some work but finding large enough
cohorts of women, where people are recording TBI
and negative psychiatric outcomes, that would be a challenge
but something worth us thinking about together
so I invite you to help me think about how to do that
but I just wanna tell you this was a sad moment for me
when I realized this, so thank you for inviting me
here so I could look so I realized this work
still really needs to be done.
Okay, let's talk about ideation and attempts
so this is actually engaging in behavior
that you don't die from and thinking about it.
There's only two studies in this period, two total studies,
and they both actually stink, I know,
'cause they're both from my lab.
Okay (chuckles) they're really bad studies.
They actually weren't done to identify rates,
prevalence rates, so they're really bad.
So like no studies really about suicide attempts
in those with TBI, and then really, again,
two studies about ideation, this is total.
This one's pretty good, this is our colleagues
at Mount Sinai, about 28, you'll see 25% to 28% of people
thinking about dying by suicide after a TBI.
And so what you really see is that we know that people die
by suicide about three times the rate.
We have very little data about attempts
and very little data about ideation.
Remember how I said it's really gratifying
to see other people starting to do this work?
So this is since the systematic review, again, 25%
are reporting SI, this is another study
from University of Washington and about
a threefold increase, so if you wanna just take some things
home, attempt data we don't have anything good
on yet really, three times the rate of suicide deaths
in about 25% of people thinking about suicide anytime
after a brain injury, just that's a lot, it's a quarter.
Okay, so risk factors in this population.
So one big thing is this loss of sense of self.
This is a qualitative study that we did.
We interviewed folks about what it was like to live
with a TBI after and this veteran spoke consistently
about this not being who they used to be, losing themselves
and this is, when you have a brain injury,
it's kinda like two different people that splits.
It's like a split personality.
You have the person that's still walking around
but then you have the other person who's the brain trauma
and this, I think, is really important
'cause there's nothing beyond for this person
than their brain injury.
Psychiatric and emotional distress,
we've talked about risk factor quite a bit.
I get depressed about a lot of things and figured my wife
could use the $400,000 tax-free life insurance plan
a lot better, I went jogging one morning, felt this bad,
and said, "Well, it's gonna be easier for me
"to slip and fall into the next truck that goes by."
Okay, this is particularly concerning if you have
impulse control and problem-solving difficulties.
And this is a study that was done.
You'll hear me talk more about my colleague Grahame Simpson.
They looked and they found that if folks had psychiatric
and emotional disturbance of any kind, plus substance abuse,
21 times more likely to have made a suicide attempt
with a history of TBI, right?
So if you are doing your clinical practice,
you have somebody you know (chuckles) has a history of TBI
and substance abuse and any psychiatric,
emotional disturbance and you are not doing safety planning
and doing suicide risk assessment, not only are you doing
bad clinical care, but I think you're opening yourself up
to malpractice, all right, so this would be something
that you really need to be paying attention to.
That is just a huge increased risk.
Okay, and hopelessness, about 33% of those with TBI
endured moderate to severe hopelessness
between one and 10 years post injury.
And you see that idea that it doesn't end.
10 years post is only 'cause they stopped measuring
at 10 years, it's not 'cause everything
got better at 10 years.
And then also cognitive impairment was identified
by veterans as a risk factor, I knew what I wanted to say
although I'd get a thought about halfway through it
and it would just dissolve in my brain.
I wouldn't know where it was, and five minutes later,
I couldn't even remember that a had the thought.
And that added to a lot of frustration
because of the condition, a couple of days later,
you can't even remember what you were frustrated about.
And this one I think is really pertinent
with the hopelessness, I get to the point where I fight
with my memory and other things and it's just not worth it.
Okay, and so then I'm particularly interested
in cognitive functioning so I like this
because this is qualitative data telling me
that cognitive functioning is a problem,
but when I do research I like to converge on ideas
from all different sides using different methods.
So that's the qualitative side.
Here's the quantitative side, we did,
used neuropsych measures to look at things,
decision-making, impulsivity, aggression
and other executive dysfunctions,
and I won't get too into the neurospychyness of it here
but I think some really interesting data that came out here,
we looked at four groups, no suicide, no TBI.
No suicide, yes TBI, yes suicide, no TBI, and both.
And I just want you to look at number
of lifetime psychiatric diagnoses in this group here,
12, right, 12 people have more, 12, I'm sorry.
12 had more than two lifetime psychiatric diagnoses
and here, what you see is number of psychoactive medications
currently being taken, so these folks are already taking
three medications in this group and still not,
what I would say, doing particularly better.
Right, does that make sense?
And then this is just some outcome questionnaire 45
just psychological distress, this group's
much more distressed than the other groups
and also has much more ideation
than other groups, so even this group, even much more
so than the suicide group and the TBI group,
just much more complicated, this group.
And so what we did is gave them the Iowa gambling test.
Are people familiar with Iowa gambling test?
So it's actually this pretty cool test that you have.
It's like gambling, which is fun for people, right?
And it's this game and it's high risk, high reward
and people either do impulsive way-out-of control gambling
on it or they realize if you're cautious,
you can make more money over time.
Okay, so we thought we had all these ideas.
We thought we were really smart about all these ideas
about what people were gonna do on the test
but what we actually found out is that the group
that had both, they actually just didn't do the test.
They just gave up.
They didn't problem solve, they didn't try.
They couldn't think about it, they just stopped trying.
And I think this is really important based on some
of the qualitative data we've see already.
The qualitative data helps me make sense
of it's just not worth it, I'm just giving up.
I can't figure this out and if we think
about suicide prevention in a group who is just,
doesn't know how to start to figure it out.
That is a huge problem, right, 'cause I'll talk later
about safety planning, if I say to somebody,
use your safety plan, and they just can barely get
into it and start to just stop,
that's not particularly helpful, does that make sense?
I know that's kinda neuropsychy, but I think it's important.
Okay, so let's talk about intervention.
So how many interventions, I showed you the five
and the two and the two, how many interventions do you think
had been done to date around those interventions
for people with TBI around suicide?
Zero, zero, it's better than zero.
One.
One study, 17 people, that was the total, right?
Another really good area for research.
So this is the total that we had.
We actually have been more than this now.
This was a 10-session intervention targeting hopelessness.
It was done by our colleague in Australia, Grahame Simpson,
and basically what Grahame found is if he did
this small group intervention, I'm gonna tell you
a little bit about the intervention, folks got
significantly less hopeless, and what you have basically
is that folks, the wait-list group got the intervention too
and they, both groups got better after.
And so this is the idea, that TBI results in hopelessness.
Hopelessness results in suicide ideation,
then suicide attempt.
It uses a lot of things that you know about already.
You may not think that they're good but they're really good,
especially for this group, things like learning
about how to be behaviorally activated
and having a positive lifestyle, working on thoughts,
working on problem-solving, using compensatory techniques,
and it is really trying to help people address
their negative feelings and learning ways
to deal with their problems.
The intervention, so this is the window, window to hope,
and so what you're doing, you know folks
have memory-related problems so you have a small group
so that there's people in the group, two or three people
so other people can tell, they can tell each other things
that you may not want to tell them as the therapist
but you can also be there but there's plenty of time
for scaffolding and support.
Each of the window panes is a concept.
Each of the concept has mnemonics and you're teaching
the mnemonics, you're helping them overlearn the concepts,
and you're managing very complicated relationships
in the room so what you're trying to do is manage
very complicated relationships and very intense feelings
around loss, but trying to teach skills.
And that is really hard, that's very hard therapeutic work.
If you cannot create relationships with these folks
and help them create relationships with each other,
none of these concepts are actually gonna matter
'cause they're gonna be like, "This sucks,
"and I'm not learning, I don't like going there," right?
Lots of homework and things around behavioral activation,
helping keep track of things.
I'm just showing you some of the different things.
They should look familiar, cognitive restructuring,
very basic concepts, problem-solving, and this idea
of building hope, so I really, I thought, this is awesome
and Grahame is awesome so maybe we could bring this
to the U.S., so we brought it to the U.S.
This is the DoD, Grahame had a different window
that the DoD thought wasn't masculine enough.
This was my more masculine window, do you like it?
(audience laughs)
My staff is searching for four-pane windows
for quite some time, it actually sends,
people have told us it's like looking up to heaven
so maybe not that great for suicide-prevention intervention
so if you have a better window for me,
I'm very happy to see it.
This took a lot of effort and time.
We did a randomized clinical trial.
You can see my beautiful consort diagram
and what we did and just this is your hint for the day
around clinical trials, we made sure everybody had
a Beck score of nine, which meant that there was
moderately hopeless so they could actually benefit
from the intervention, we were having a lot of trouble
recruiting and a lot of times people were like,
why don't you just bring that Beck score down?
We could get people, we have a people who have fives.
We have a lot of people who have sixes.
I was like, if we let everybody who is fives and sixes,
there's nowhere to go for the intervention.
We'll have a negative trial.
I cannot tell you how many negative TBI trials there's been.
So just if you're gonna be a clinical trialist, hold fast
on giving yourself room to go down.
And basically this is what we found.
So this is the Beck Hopelessness Scale
and this is group one, so this is people who got
the intervention first, this is their hopelessness
at baseline, post treatment, and then they maintain.
This is baseline, they're the weight group
and then they got the intervention.
So positive trial for window to hope, woo!
And also just a other thing is just like we had
statistical significance but did we have
clinically meaningful change, and we do.
I read lots and lots of papers where I have these
really beautiful big statistical change numbers
but they're clinically meaningless, that make sense?
So please make sure you have both.
Here's the million-dollar question though.
We've had two trials that are positive,
neither of them huge, now what?
How do we implement this nationally or beyond
our multi-site trial and who wants to fund that?
That's a different issue for a different day
but it's really, really hard to get new interventions
out there, particularly for specialized populations.
And I'm not gonna go through all of these
but I just wanna show you we also collect qualitative data
as well as our quantitative data to help us understand
why the people like the intervention, okay?
So I'd really recommend doing that.
I'm not gonna go through those.
Okay, and then this study, I can't get it out of my mind.
So I was like, okay, what are we gonna do?
So I'll tell you one thing I don't have slides
in here about, we're doing this thing where we're having,
it's an app on people's phones
and it passively monitors their behavior
and what is it just runs in the background and so if they,
you get a baseline, they get a texts, they go out
in the community, they do their normal living
and I get a dashboard every day that shows
how they're doing and so even if you don't recognize
you're having a hard time, I can recognize you're having
a hard time by watching your dashboard.
So that's one intervention that we're doing right now.
We thought veterans would hate it 'cause they'd think
it's like a privacy problems, they don't care.
They've been great, they're really happy to have somebody
looking after them, it's been really interesting to see
that they feel like the VA's taking care of them.
We are but like really it's like me and my staff watching
their numbers every day but they feel very cared for,
even though I'm using computer algorithms to monitor them.
So there's different ways we can extend ourselves
that are creative and it doesn't require anything
from them, other than letting us load it on their phone.
We can also push measures on here too.
I can present on this a different time.
I had to really choose (chuckles) what I presented
on today, so I didn't present on that.
But this was another intervention that we tried, yeah?
(faint speaking)
So we're working this company actually, it's in Boston,
and so they've created these algorithms
and so some of the main stuff that goes into it
is actually out and about, so are they actually leaving
their house, and it measures GPS wise,
are they actually leaving, it measures how many texts
and phone calls they're getting so things like isolation
so it's really just very basic things that it's monitoring
and then we also do push measures to them.
Okay, so this is another model, right
so if you're gonna do interventional trials,
you need to think about what's the mechanism.
Don't just tell me you think something's a good idea
for intervention, think about why is it a good intervention,
what's the mechanism for change.
So this is here we have the failed problem-solving.
We have a stressful life event.
We already know that people have cognitive impairment,
hopelessness, failed problem-solving, increased distress.
I can't think of any other options, right?
You see how I got from here to something that seems
much more clinical here, I don't like research.
It's boring, actually it's very helpful.
Do you see how research helps me make a mechanism
that actually could have an intervention?
If I don't have this, I don't think of this.
Does that make sense?
And then I think of this, oh, we need intervention
so we create an intervention based off this,
which is really based off this boring neuropsych study.
Does that make sense? - Yeah.
- Okay, so we did this thing where we paired problem-solving
therapy, who here knows problem-solving therapy?
If you don't, it's really good transdiagnostic therapy.
You should know it, it's way helpful.
It's actually really helpful, problem-solving therapy.
Art Nezu is a prince, he is amazing.
You should have Art come, he's way smarter than I am
and he's super nice, probably way nicer than I am too,
actually. (audience laughs)
So we paired problem-solving therapy with safety planning
and we did, again, some really basic things
about how do you do problem-solving, how do you recognize
triggers, problem-solving steps.
And this is the basic premise of the intervention.
There's stress, there's problem-solving ability
and if you don't, if your stress gets too great
and you don't have enough problem-solving strategies,
skills, and crisis-response planning,
then it's gonna break, it's not like rocket science.
But actually, I know you all spend a lot of time
thinking about your thoughts, feelings, and behaviors.
Most people in America do not do that, right?
People don't think about this all the time.
I know you like to, I like to.
My husband's a therapist, I have four children,
think about it, even though they don't want to.
Most people don't think about this.
They don't think, wow, I'm feeling really triggered
and I don't have enough problem-solving skills.
I should use my safety plan, right?
So we teach problem-solving steps, triggers,
really very basic but stuff, people haven't thought
about this before, they really haven't, warning signs.
Warning signs are actually better than risk factors
in terms of individual thoughts, feelings and behaviors
that contribute to people feeling more suicidal
so risk factors are epidemiologically based.
Warning signs are person specific.
Warning signs would be something to learn more about.
I'm sorry I don't have enough time for it today
but so beliefs, physical sensations, behaviors, and emotions
person specific, unhelpful thoughts.
This is my favorite one, PASTA, we were trying to think
of something that was a different acronym
that I really didn't like around pausing,
becoming aware, slowing down, thinking, and acting.
And one of the people in the group said how about PASTA?
I was like, I love you, so the veteran thought
of this acronym, which is PASTA, okay.
And then what we're doing is we're teaching
all these problem-solving skills and we're using
the second half of each section to fill out
their safety plan, okay, and this is what a safety plan
looks like, it has warning signs, it has different strategy
you can do by yourself, and when we first had the veterans
fill these out, they were very, very meager.
They were very sparse and what happened is they keep
filling them out with the new problem-solving strategies
over the course of the session so they're all working
on their safety plans over time and over learning it
and what they had was really beautiful safety plans
by the end, so we used this to facilitate
a shared problem-solving activity.
It worked pretty well and so we did a feasibility
and acceptability trial, the veterans loved it.
This is just satisfaction and again,
we did qualitative data with it, and now we need
to find somebody to fund this trial.
Okay, so we're almost there, you've done
a very nice job hanging with me, okay, these
are my two top things, two top things for you to take home.
One is please think about a common nomenclature.
We talked about this at the beginning.
Please think about how you're charting.
I know charting stinks, I'm really bad at charting
but if I don't chart well, then the next person
doesn't know where to start, and so think about how
you're charting things and how people can carry things
forward, if you're in charge of healthcare systems
or bigger groups, think about how you can implement
templates that actually help people chart in a way
that's going to be helpful, the VA is moving towards
one risk assessment for the entire VA system
with this very same idea and having one strategy
so that we can all talk to each other in the VA.
And my next thing is that this a social work issue.
TBI is a social work issue and please be part
of the solution in helping me get this message out.
We created this toolkit for you all and for ourselves too
that helps you and us have this information.
This is online, again, if you google Rocky Mountain MIRECC
and you google TBI toolkit, you'll get this.
It was specifically developed for all of you.
It has tons of resources in it and the resources
are about military and veteran culture,
traumatic brain injury, in general,
co-occurring mental health conditions and resources,
in each section, there's information
around background, screening assessment, intervention,
and resources, we tried to put all the stuff
in there that's free and that you can just get online
while you're sitting in clinic.
There's tons in there, I didn't put tons on here today
for you but there's tons of resources.
We're actually, we got another grant and we're now adding
a justice-involved section and a pediatric section,
and a pediatric justice-involved section
so those will all be in the same toolkit.
Okay, and just this is the kind of take-home.
What would you do, what do you need, talk to a professional.
That's why you guys are here, professionally trained
to deal with people with my problems or problems
like I have, left to myself, I'd probably kill myself
but that didn't feel right so I turned
towards professionals, you guys, and to me,
that just means this is like all of our work,
we need to do this together and I thank you for listening.
A few things I'd check out, the Rocky Mountain MIRECC
has a podcast, it's all around suicide
and suicide prevention, so if you like to take walks
and listen to podcasts, which I do, I think there's
really good, there's actually a really, really good one
on risk assessment that was just on recently.
I'm also on Twitter, who tweets?
Oh my lord, folks, Twitter is the way to get tons
of information! (audience chuckles)
Really, you guys don't tweet for academic stuff?
Oh, you're so lucky you don't work for me.
Okay, so I hope I see you on Twitter
and if you are on Twitter, then you can get lots of stuff
pushed to you, rather than having to pull stuff,
you can get stuff pushed to you that you're interested in.
So I really recommend you getting on Twitter
and I thank you and I think we have some time for questions.
(audience applauds)
Yes?
- [Woman] So I was wondering how long does the window
(faint speaking) and--
- We have three months' worth of maintenance data
at this point.
- [Woman] But not (faint speaking) (laughs).
- No, no, three months, if you're a clinical researcher,
three months is a great start because sometimes
it's no months, and then it's super stinky
but the question is do you need things to help
booster sessions and things to keep it going,
probably yes.
- [Woman] And how often (faint speaking)
but how often (faint speaking) veterans (faint speaking)
returning to (faint speaking)?
- So that intervention was provided as part
of a clinical trial so it was outside
of general clinical care but I mean I think
what you're getting at, maybe I'm just gonna make it up
'cause I wanna say the story so I had a veteran
who had a brain injury that had been
psychiatrically hospitalized 21 times
and you'd think at the point at like at 21,
someone's not like maybe I'm not picking up
on something here, like what am I missing
and I'm not that great of a therapist but I understood
her history, I started working with her
and she hasn't been hospitalized since.
I mean I was a good match for her mostly because I realized
she had a brain injury, and so if you are not picking up
on these things, people are going to continue to create
treatment plans that don't work for people, right?
And so if you keep having that happen, you might wanna think
what am I missing, yeah?
(faint speaking)
I'm sure it's not.
- [Woman] How many people really know they have a TBI?
(faint speaking) professionals like I remember
you saying after you have one, but faint speaking)
normal that someone knows they have one?
(faint speaking)
- Okay, so this is kind of a complicated question
and I didn't put specific stuff in here
about screening or assessment so like if you're older
like me, nobody thought about brain injury concussions,
so I could have people in this room who rolled around
in the back of station wagons went on family trips.
I mean TBI wasn't really like a thing
and so we're really in a challenging place right now
where parents, particularly parents who have resources
are overly focused on TBI (chuckles)
and then other folks are under focused, right?
And so I'll have parents at Children's Hospital.
They'll come to a clinic there and we're doing a study
over there and they're super worried
and they're flipping out about their kid
having a concussion and then we have other folks
who are like I've had veterans who they're intoxicated
but they also get a brain injury.
The police think they're intoxicated, which they are,
they put them in jail but they're actually bleeding
into their brains at the same time, right?
And get very minimal rehab so what is happening a little bit
that's concerning to me and this is, again,
also I have specific interest in homeless veterans
and homeless adults and also incarcerated veterans.
In those populations, huge numbers of individuals
actually have a TBI like something like don't quote me
on this but well above 50%, but probably about 30%
have moderate to severe injuries so but what's happening
a little bit is everybody's over focusing on all the people.
And what I'd really like what people to do is focus
on people with moderate to severe injuries.
They would expect to impact their day-to-day functioning.
Does that make sense, that being said,
there's really easy screening questions you can ask,
happy to send 'em ahead, they're also in the toolkit.
And I think about putting down history of TBI
as part of a medical history, a good psychosocial history
and also good for prevention.
So how many of you in here ask your folks
if they wear helmets?
I do, why not prevent, more brain injury isn't better.
Right, okay.
Yeah?
- [Woman] Do you think there's a role for family members
(faint speaking)?
- That would be great, we did initially write it that way
but we were concerned that too many veterans
wouldn't have family members to bring
so we did it without, but I think family member
and family member involvement always really helpful.
For the problem-solving intervention, we definitely had
people go home and talk to their family members
about the skills that they were learning
and trying to get feedback, self-awareness is a huge problem
with people with moderate to severe injuries,
and so it isolation, so unfortunately, the group setting
is so helpful sometimes 'cause people actually don't have
a lot of people in their lives or had kinda burnt out
a lot of the relationships that they have, yeah.
- [Woman] I have kind of a research question.
- Okay.
- [Woman] I loved when you were looking at the data
in different ways and I'm wondering if you have a system
for how you do that or how you, what you play with
when you start to look at (faint speaking).
- I guess I don't, I should think
of a better answer to that.
No, I don't, I guess I just try to approach it
from lots of different angles and see how things
start to have convergence and then if I find something
that doesn't have convergence, like no,
I need to keep looking so I don't know if that's really
a system but I'm usually not pretty satisfied.
I'm not satisfied till I want more understanding.
Maybe that's the strategies, keep going (chuckles).
Keep going, don't think you understand
'cause at first when we saw that flat line,
I was like, I have no idea what this means.
We actually, I didn't put this in but we actually went back
and asked some of those veterans what happened
when they were doing it and they were just like,
we just gave us, we didn't try.
So I had to go back 'cause I didn't understand it.
Yeah?
- [Woman] I'm wondering about implementation
(faint speaking) so I know (faint speaking)
so I'm wondering how clinicians in the field
(faint speaking) what kind of (faint speaking)
what kind of (faint speaking) what kind of something
that is so (faint speaking).
- Yeah, well, let me actually talk
about something bigger than this but the VA
is one of the few healthcare systems
that has mandated evidence-based treatments
and there are specific evidence-based treatments
and the evidence-based treatments are
'cause they actually work and so I know we like
to think of ourselves as very skilled and philosophical
but what I try to ask people to think about is
if your family member had cancer, would you like a therapist
that's very philosophical, would you like a doctor
that's very philosophical or would you like a doctor
that's using the best evidence?
You would never, ever want to go to an oncologist
who says, "Well, the best evidence says do this
"but I actually have my own special way of doing it."
And I don't actually think mental health is any different
than that, I do think the relationship is important,
whether you're an oncologist or a psychologist
or a social worker, the relationship to me is the hard part
and using the data to figure out how to intervene
but it is very, very hard, not just in the VA,
but outside the VA to have people do, adhere
to evidence-based interventions.
People, we like to think we know better, right?
And I would say, I don't know if you're familiar
like this is a different side deck.
I wish I had a (mumbles) to show you but if you think
about the best cancer treatment centers,
I don't know what the one in Boston is,
like Seattle's, oh, Dana-Farber?
Okay, Dana-Farber, Seattle has Fred Hutchinson,
is that right?
University of Colorado is, Sloan Kettering,
I mean, any, MD Anderson, any of the places,
the best oncologists are, like if you are at the top
of your game, researcher, clinician, oncologist,
you're at one of these places.
They all follow the same protocols and they actually get
reimbursed more and have a whole system together
of evaluating the evidence to give their patients
the best protocols, the other things that's awesome
about this is it doesn't matter if you go to Sloan-Kettering
or Dana-Farber or Fred Hutchinson,
you're going to get the best treatment.
We are not there yet 'cause we, I don't know why.
We have a special idea about ourselves.
It's kind of a problem, that doesn't really answer
your question, right?
- [Woman] It does, I mean I think a lot
about (faint speaking) trauma
to the real world so I mean (faint speaking).
- So one thing that we did with these,
so part of the challenge is one thing we did
with these is we created very specific manuals.
We spent tons of time on the manuals and so the manuals have
like if you do these 10 things, you've done the session
so these would be much easier to implement.
In the VA, I was saying the VA, and I don't wanna be mean
to VA psychologists 'cause VA mental health people
are amazing, this would be out of the VA also,
but I was doing, I was a consultant for CBT
for major depression so it was totally this big thing
like we went to this training, listened to these,
we go to this training and then people would tape sessions
for six months and then I'd listen to the sessions
and I'd provide feedback and I'd listen to the tapes
and I'd be like, next session do this.
When they say this, do this, and guess what would happen?
(faint speaking)
So guess what is in the next consultation?
Why, like I just told you when they said do this, do this.
It's just really hard for us.
When I say us, I mean people, we really like to do
what we like to do so I would say early in your career
is the time for really good habits.
I try to have really good habits.
Sometimes I like to think I know better
but I really do follow protocols
but I have to have a relationship with my patients,
they keep them coming and good diagnostic skills.
That's where I think I can be particularly helpful.
Yes?
- [Woman] I'm sorry, I'm curious, so (faint speaking)
commitment, and I think a lot about kind of discussion
and cultural context and how does that matter
or really engaging to have that relationship
with your (faint speaking) so I'm curious how
(faint speaking) other identities
because you have (faint speaking).
- I do.
- [Woman] Have you been able to (faint speaking)
through different ways to see what really works
with this group (faint speaking) gender but more--
- We do, so this is an interesting question,
and I thought you were going to ask something different
and I had a good answer for the other one
and now I don't have a good answer for this.
(faint speaking) Now I don't remember
'cause now I'm like, oh, my gosh, that's not what I thought
she was gonna ask, so part of the interesting thing
is in VA, we actually didn't collect a lot
of the diversity variables because it's hard.
It's hard, it's complicated to get people to declare
or not to get people to declare, to get people to ask
has has been problematic so we don't have
that good diversity data in the charts.
And you could even say that we have very binary data
on gender, we're getting, actually the VA,
if you don't know, the VA actually is one
of the most amazing healthcare system for LGTBQ.
There's a whole policy around it and mandates
and guidance and amazing VA stuff around that.
So if you don't know that about the VA,
you gotta check out it 'cause it awesome.
Michael Kauth put it in place, it's amazing.
Yes?
- [Woman] I'm just curious about the intersection
of veterans who are attempting to access services
who have a TBI, I guess I would just imagine
that that could be a difficult barrier to treatment,
having talked to some vets who have tried to get into the VA
(faint speaking) and have you ever considered researching
some kind of interventions for that?
- So, okay. - That's a couple questions.
- That was a couple questions, so let me talk about access.
Again, this is totally me talking, not the VA
but I mean part of the reason I show people those numbers
at the beginning is 'cause access
is like it's just really hard and I'd say it's really hard
but I'd say that there's things in the VA
that you all and I, in the private sector, too,
that the private sector could never adhere to.
I mean we have same-day access for psychiatric services
in the VA, I don't know if folks can find that
in the community, I know in Denver if you need to find
a psychiatrist in the community, it's not same day.
So same-day access in the VA, basically the deal
with the VA is once you're in, people really think
the services are terrific, and that's not across the board.
That's not, there are good days, bad days, clinicians
have good days, bad days, patients have good days,
bad days, but on whole, the other thing
that's really challenging is oftentimes it's the VA
compared to nothing, if you look at studies,
it's VA compared to there is nothing to compare it to.
Maybe Kaiser, maybe group health but there's
not a lot to compare it to, and I'm not saying the VA
can't do better the VA can always do better.
I've spent 20 years with the VA doing better (chuckles).
I'm totally committed to VA doing better
but so and then just in terms of the TBI,
I think there is a lot of issues around people
not being followed appropriately in mental health
and I think some of them, if you think
about somebody not showing up to sessions
or you think about somebody missing sessions
or you think about somebody not doing homework,
you could interpret that as resistance
or you could just interpret that as a big ole brain injury.
I do things in my sessions but probably,
if you were a very psychodynamically oriented,
you would think that I am not good.
(audience chuckles) I do phone calls.
I do reminders, I have them call me between sessions.
I do all kinds of crazy business 'cause I'm trying
to facilitate the treatment and so how do you do that?
I know there's like more questions in there too.
I'd say folks who were injured in theater
with a moderate to severe TBI have very good access
by the way too, those people have been tracked
into the system, okay, all right, yes?
- [Woman] Wondering you're familiar with (faint speaking)
Colombia-- - I so am familiar.
(faint speaking)
Do you give it?
- [Woman] I think (faint speaking).
- Okay, so Kelly Posner is a very strong advocate of it
and it has been adopted in a number of places.
Okay, I'll say one thing, so the Columbia is,
we've been doing some research on it.
There are some good thing about the Columbia.
I'd say the number one not good thing
about the Columbia is there's actually no treatment,
there's no manual for the assessment tool
so we've been asking them to write a manual
for like five years so I just say if you have
a measure without a manual, that's not
a great starting point, okay, so what that results
in is huge variance in people giving it.
We use it all the time in our studies and we have
a whole team, we have a smart, what's called the smart team,
the measures training team that trains people how to do it
but it is really hard for people to be adherent to it.
Okay, and so the other thing about the Columbia
is a lot of the data is on people who are already known
to be at risk and so in terms of its predictability
and this is probably way more information than you wanted
on the Columbia, you and I could have a drink
and a personal party about the Columbia,
so the predictive problem is it's already people at risk
so we don't know how well it works
in terms of people who we don't know that are at risk.
The other thing with it too is it starts at a person
already having a challenge, so and if you say
you don't have suicide ideation, you're out, right?
And so it's good for getting a suicide-related history,
whether it's the best thing to assess risk,
I wouldn't say it's the best thing to assess risk.
But if you do want to get somebody's lifetime history,
I think it can be helpful and that's probably
a very unsatisfying answer and Kelly would totally disagree
with everything I just said, maybe not the manual part.
- [Woman] Two questions, one relates
to the treatment protocol, think of the risk factors,
of data, of (mumbles) with TBI, plus depression,
suicidality, and substance abuse, so I see how the treatment
interventions attune to the thought and behavior.
I don't see the substance abuse would fit in
(faint speaking) the rates or the risk--
- Right, right, I agree with that.
- [Woman] So that's one, I have a second question.
- Can I answer that one first?
- What? - Can I answer that one
first and then-- - Yes, and the second one--
- Okay, so John Corrigan has done a lot of good research
around substance abuse and TBI and it's interesting,
you can look at TBI amongst those who identified,
I'm sorry, substance abuse among those who identify
with TBI are actually if you look
at substance abuse populations, a huge amount
of those folks also have a TBI, same, like there's
big overlap with that population and homeless population.
We had data, other people have data.
There's great data from Canada, there's a group
that are looking at homelessness.
Folks who have TBI actually have way worse outcomes
in homeless populations than those who don't
so and there's, for a long time, people were like,
well, if you get a TBI, you'll stop drinking.
TBI does not seem to be a good substance abuse intervention.
(audience laughs)
Obviously, right, and so this is like a whole,
I would say, other area that needs a lot of work.
I would check out work by John Corrigan.
It's excellent in this, he's been trying to work
with traditional substance abuse programs to help them
facilitate compensatory strategies, and on the toolkit,
there's a whole section about compensatory things
that you can do in the context of evidence-based treatment
to make them more accessible to people who have TBIs
so I encourage you to check that out.
And if you think about the problem-solving,
I think, in particular, hopelessness, if people drink
when they're feeling hopeless or they are using it
because they can't think of other interventions,
we have had substance abuse come up in the context
of those though they are not substance abuse interventions.
Do you have a second question?
- [Woman] Yeah, my second question is we have a fair number
of our students who work in the VA and DoD
and very difficult cases (faint speaking) fabulous work
and we always talk here about the care provider
Can you talk about that?
When you think of the population we're talking about here
TBI and then suicide, then substance abuse
and whatever family problems might exist,
how would you address the students you work with
who are masters' (faint speaking) in terms of sustaining
one's own sense of hope and (mumbles) and balance any--
- Yes, so I'd say one thing is just don't work in isolation.
Work in teams, I think most of the VAs are working in teams
and do have case conferences and settings
where they do work with teams.
The other thing I'd say is there's something
called the National Consult Service.
The National Consult Service, I wish I had, it's on
the website, it's run out of the Rocky Mountain MIRECC.
Any person that works in the VA system that has a case
that they're concerned about and actually pretty soon,
any person not in the VA system, any person,
can put in a consult and you can get consultation
with experts around how to deal with really hard cases.
And so I'd say don't deal with this alone.
If you have cases that are really contributing
to you worrying, don't worry alone, get consultation,
either from supervisors, from teams
or from National Consult Service.
And I think just talking about it too and just saying,
like being willing to say when we were doing the study
for Carson, we were actually interviewing guys and gals
as they got off the airplane and we did like hundreds
of interviews, and I'm pretty okay usually
and I was watching a movie and all of a sudden,
I started having all these intrusive thoughts.
And I was like (chuckles) oh my gosh, there it is,
like I'm not okay, and so I think in another big thing
is like it's okay, it's okay to not be okay sometimes.
It's okay to get help, it's okay to take a step back.
It's okay to do all those things.
And so certainly we need the VA to do that together.
The other thing, there is actually this
is more of an interesting (mumbles) in your idea.
There's an app, the VA has a bunch of apps.
There's actually a self-help app for providers.
I don't know if people have seen that
so I mean I think all these things are all small pieces
that consultation, working in teams, self-help,
taking care of yourself, taking vacations.
I'm not very good at that one, but all these things
that you need to do, and I think it's hard.
And I think we, unfortunately, are burning out people
at a high rate, and I'm open to any ideas
about how to do that.
You know, the interesting thing, they're actually doing
a lot of interesting work on the crisis lines
to do more self-care stuff, the VA crisis line
so I'm happy to talk about that another time.
It's very interesting, yes?
- [Man] I'm sorry, but I got stuck on something
that you (faint speaking) when you were answering
her first question. - Okay.
- [Man] About hopelessness and drinking when
you're hopeless. - Yes.
- [Man] How about self-medicating instead of being hopeless?
- Totally.
- [Man] I mean I've been there.
- Yes.
- [Man] And that was my experience of hopelessness.
It was always alcohol makes things go away.
- Absolutely, I mean there's many, many different reasons
and if it's chicken or egg, right, and so if it's
chronic pain that we're not treating sufficiently,
if it's sleeplessness that we're not treating sufficiently,
there's many things that contribute to substance use
and substance use can provide short-term relief for people,
right, and so--
- [Man] Those short-term solutions are long term--
- Yes, but sometimes it is right there, right, and it can--
- [Man] It works.
- It can work in the short term and so the question
is how do we help people have other alternatives.
And none of that addresses the biological underpinnings
of addiction that is a different, very problematic thing.
And how do we have AA and all the other things that we know
that work that actually address people's cognitive problems
and help people stay engaged?
But I agree with you.
- [Man] The group of veterans in the circles I travel in--
- Yeah.
- [Man] Most are frustrated with the psychopharmacological
solution. - I completely agree.
- [Man] And again, why they go to alcohol
because they what the effect is but (faint speaking)
becoming a problem when they can't, that's their only go-to.
- Yes, and I think psychopharm is a huge problem
so I could not agree more with you.
We need to be looking at other ways to help people
so I mean I'm not talking about any of this here.
I finally got a yoga trial for post-concussive headaches
funded after seven times in but so there are other things
that we need to study, I also have a probiotics trial
for stress, so yes, we need to be looking at other things.
I could not agree with you more more.
That's not in any of my lecture today
but you are totally on track, medications are not the answer
for everybody and sometimes medications work great.
Okay, yes.
Last one.
- [Man] Roughly slightly less than half of veterans
choose not to be treated at the VA system.
- Okay.
- [Man] Which puts the responsibility for TBI
addictions, all those things in civilian healthcare
provider community, do you have, in your toolkit here
resources for translating this kind of highly detailed
submission into the clinical work that a family practitioner
or a GP or a pediatrician, and if so,
what's the sources for that?
- There's tons of different sources for the information
that's in there, what I would love it if you would look at
it and tell me if you think I do or not
'cause if I don't, I need to add more things in.
- [Man] And so you would suggest the (mumbles) .gov?
- Yeah, yeah, I don't think I can go back, yeah.
I'm sorry I didn't put in more about the toolkit here
but yeah, I would love, and if there's stuff
that you're like why isn't this in here?
It's so obvious, then you should tell me
and we'll put it in, it's like a living toolkit though.
Also, do people know about the crisis line
and the chat line, no?
Okay, veterans' crisis line 24 hour a day,
VA provider staffed, they can see VA charts
if veterans will let them, same with chat line.
Amazing, amazing individuals that work there.
Unbelievable, I was there for their clinical advisory board
last week, two weeks ago, amazing resource.
I mean VA has some amazing resources that if you don't know,
you should check 'em out, all right?
Thank you all so much, I know it's late.
(audience applauds)