Is the VA Overdiagnosing Traumatic Brain Injury?

By: Associated Press

Mild brain injuries — once considered an under-recognized problem in returning military troops — are being overdiagnosed because the government is using soft criteria instead of hard medical evidence, an Army doctor and two other officials contend.

The three are taking aim at Department of Veterans Affairs’ rule for treating such veterans and determining disability pay. They want to call many mild cases “concussions” rather than “brain injuries.” They say the latter implies an ongoing, incompletely healed problem rather than a temporary one that’s in the past.

“I think it’s fair to say there’s overdiagnosis of concussions going on,” said Dr. Charles Hoge, a top Army psychiatrist. He’s one of three authors of an article published in Thursday’s New England Journal of Medicine.

Some veterans groups applaud efforts to better diagnose traumatic brain injuries, but say it’s more likely that the military has been undertreating the problem.

“It stretches credulity to believe that all the people who have suffered traumatic brain injuries in Iraq and Afghanistan are getting the treatment they need. That’s a laughable notion,” said Jason Forrester, director of policy at Veterans for America, an advocacy group.

The military defines a concussion — or mild traumatic brain injury — as a blow or jolt to the head that caused loss of consciousness, altered consciousness or amnesia. Most are due to pressure waves from being near bomb blasts.

Flawed questionnaire

More than 300,000 U.S. veterans of the wars in Afghanistan and Iraq have suffered head injuries, many of them concussions that have gone untreated, according to a Rand Corp. study released last year.

Part of that estimate stems from a questionnaire given to service members as they finish their deployment, which may be months after a blow or jolt occurred, Hoge and his colleagues wrote. Service members can’t always get a thorough medical assessment on the battlefield.

According to the authors, here’s the problem: The questionnaire asks whether the person became dazed or confused at the time of an injury or blast, and it attributes such symptoms to concussion.

But a soldier can become dazed from stress, lack of sleep, the confusion of war, or other causes, they argue. In fact, Hoge published a study last year in the New England journal showing that many brain injury symptoms were actually due to post-traumatic stress syndrome, or PTSD.
The Rand study said some troops may incorrectly blame their problems on head injuries.

Trained doctors should be able to sort out the cause of symptoms. But Hoge and his colleagues argue that a concussion diagnosis can still occur, because of subjectivity and the fuzzy concussion definition.

“The problem is we’re attempting to measure concussion many months after injury,” said Hoge, director of psychiatry and neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. He wrote the article with Herb Goldberg, a communications specialist at Walter Reed, and Carl Castro, a psychologist at the U.S. Army Medical Research and Materiel Command at Fort Detrick, Md.

The questionnaire should be revised and questions should be asked closer to the time of the incident, the authors said, and the military should refine its definition of concussion. They feel “concussion” better reflects the mild nature of the injury and promotes an expectation of recovery.

“It’s a very, very, very mild physical injury” that often doesn’t need medical treatment, Castro said.

Disability category

The VA last year created a disability category for residual effects of traumatic brain injury that was based on subjective, poorly defined symptoms, Castro and his colleagues argued. More scientific diagnosis criteria are needed “to ensure that disability regulations do not generate disability,” the authors wrote.

Treatment of mild traumatic brain injuries can cost up to $32,000 per case, the Rand report said. But if the diagnosis is wrong, patients are exposed to drug side effects and other risks, according to Hoge.

VA officials issued a statement this week saying they are proud of their efforts to treat traumatic brain injuries. Forrester, the veterans advocate, said estimates of concussions are probably low because some service members fear that being diagnosed with a neurological or psychological problem would hamper a military career.

Better assessment is needed for a complicated problems, he added. “These are the most difficult, thorny wounds of war,” he said.

Suicide Risk Doubles with Insomnia

By: Reuters

People who suffer chronic sleep problems are more likely to think about suicide or actually try to kill themselves, researchers said on Wednesday.

The more types of sleep disturbances a person had — such as waking up too early, difficulty falling asleep or lying awake at night — upped the odds of suicidal thoughts, planning a suicide, or attempting it, researchers told a conference.

"People with two or more sleep symptoms were 2.6 times more likely to report a suicide attempt than those without any insomnia complaints," Marcin Wojnar, a researcher at the University of Michigan in Ann Arbor and the Medical University of Poland, who led the study, said in a statement.

"This has implications for public health as the presence of sleep problems should alert doctors to assess such patients for a heightened risk of suicide even if they don't have a psychiatric condition."

According to the World Health Organization, some 877,000 people worldwide kill themselves each year. For every suicide death, anywhere from 10 to 40 attempts are made, the U.N. agency estimates.

Scientists have linked sleep disturbances to increased suicidal risk in people with psychiatric disorders and in adolescents but it is unclear whether the association also exists in the general population, the researchers said.

In the study presented at the World Psychiatric Association International Congress in Florence, Italy, Wojnar and colleagues looked at the relationship between sleep problems and suicidal behaviors among 5,692 U.S. men and women.

About a third of the volunteers reported at least one type of sleep disturbance over the preceding year, which included either difficulty falling asleep, trouble staying asleep or waking at least two hours earlier than desired.

After adjusting for factors such as substance abuse and depression as well as for the influence of age, gender, marital and financial status, the researchers found the most consistent suicide link with waking up early.

People who reported that problem were twice as likely to have had suicidal thoughts or planned a suicide and were nearly three times more likely to have tried to kill themselves.

The researchers do not know exactly why, but said lack of sleep may affect cognitive function and lead to poorer judgment and increased hopelessness. A malfunction involving the brain chemical serotonin may also play a role, Wojnar added.

"Our findings also raise the possibility that addressing sleep problems could reduce the risk of suicidal behaviors," Wojnar said.