Researcher: Mental health issues often progress after brain injury

Some people will shake off a mild concussion. They’ll take it lightly or even ignore it. But research being done among military patients, with a lead researcher from the University of Washington, is showing that those mild brain injuries can have a lasting effect on mental health.

UW researcher Christine MacDonald has worked since 2008 in a long-term study of brain injuries among military service members. That intense focus, along with advances in imaging technology, has helped researchers connect more dots between brain injury and mental health. It shows that a high number of military patients who experience even mild concussions can suffer psychologically years later, MacDonald said.

Service members often sustain head trauma during combat and in training. MacDonald, an associate professor in UW’s department of neurological surgery, is a lead investigator in a team following military patients soon after brain injuries and in follow-up intervals over about 10 years.

“The high-arching, one-sentence theme is evolution, not resolution, of you name it – of symptoms, of disability, of whatever the outcome,” MacDonald said. She will give a talk in Spokane at 6:30 p.m. Tuesday on “Brain Injury & Psychological Health Following Combat Deployment: The Invisible Wounds of War.”

By following individual military patients so long, researchers can monitor and ask individuals about whether they were worsening, recovering, staying the same and everything in between, she said.

“The study has found that when you follow the same patient over time, those with combat head injuries – and these are the mild concussions, the supposed to be shake-them-off-and-walk-away ones – that a disproportionate number of those individuals have worsening of symptoms that progresses even after one year.

“When we look at the one-year to five-year follow-ups, we actually see a disproportional number of those concussion patients getting worse.”

Separately, recent media attention has spotlighted concussions among U.S. athletes, including some who committed suicide and had Chronic Traumatic Encephalopathy (CTE), diagnosed postmortem. The Centers for Disease Control and Prevention says traumatic brain injury can be caused from a bump, blow, jolt to the head or penetrating head injury that disrupts normal brain function.

MacDonald said her speech is aimed at educating the public, rehab physicians, providers and students about patient outcomes following brain injuries, and the topic of suicide will come up. The increasing rate of suicide among veterans also has drawn wide attention.

“Unfortunately, some of those exposures do end in suicide, so in all fairness to the challenges faced by this patient population, yes the discussion will come up,” MacDonald said.

“I’ll touch on some of the work we’re doing to understand when these tragedies happen, that we learn as much we can and try to better inform next-generation treatment targets, from the examination of postmortem brain tissue in those who passed from suicide and other exposures.”

MacDonald said the study involved military members initially evacuated to the Landstuhl Regional Medical Center in Germany, the main U.S. triage point for casualties. Between 2008 and 2013, she lived in Germany on and off as a study lead. She also does follow-up evaluations.

She said it’s only been in the past five to 10 years that people have heard more about connections between brain injury and mental health. Earlier studies typically looked at brain injury patients at one point in time.

This study has shown different trajectories over that longer period of time, she added. “Some people get better and stay better; some people aren’t doing so hot and then get better later; some people look like they’re doing great and then get worse.”

Using MRI technology in new ways is pushing the study’s brain injury research to another level.

In the future, the method could become a universal diagnostic tool and marker for changes happening in the brain. The imaging approach has shown brain abnormalities, or changes in the brain, among study participants that are consistent with what is known about brain injury, she said.

“The conventional imaging did not identify these brain changes, but new imaging did, and that these brain injuries were consistent with what we know about brain injury pathology and brain injury lesions,” MacDonald said.

“The evidence to date supports, and it’s informed by imaging, the hypothesis that there are underlying brain changes that are happening at point of injury that are interacting with the post-injury mental health symptoms. For many patients, those symptoms seem to be more severe than patients without head injuries.”

Researchers are examining how brain changes might be affecting a patient’s recovery. If a brain network or “wiring” is cut or injured, traditional mental health treatments might fall short, she said. With medication, for example, if the drug is“trying to hit a receptor, but those receptors no longer exist, the treatment’s not going to work.”

Many of the military study participants sought mental health support and completed treatment, but only a small percentage have found any resolution, she said. Researchers are just beginning to understand why.

“We’re starting to appreciate that there might be alternations in the brain anatomy, the brain networks, that are causing those mental health symptoms to be worse or exasperated, or more severe, in somebody who has had a head injury,” MacDonald said.

“Unfortunately some of the networks in our brain that are important for mood regulation, emotional control and extinguishing fearful or stressful memories can be injured.”

But the hope is eventually to have more focused treatment plans, while better recognizing symptoms, “so we’re catching it earlier.”

Over the years, MacDonald has listened to multiple stories from family members, asking about a veteran’s unusual behaviors. They might include irritability, rapid mood changes, angry outbursts, confusion, being easily irritated or annoyed, headaches and changes in sleep patterns.

Sometimes, the veterans say they can’t concentrate as well or can’t remember a list of items. It’s tough both for the veterans and their families.

“A lot of patients are struggling every day, and their families too, because they look the same or close to the same as when they deployed, but they’re acting very differently.”

But sometimes, the veterans she works with are simply relieved to understand some brain changes happened.

“I tell the story often of young woman I worked with,” she said. “We did this new imaging and we did find changes consistent with brain injury, a disconnect in a network. She had tried really hard to have rehabilitative therapy work for her, but she was struggling immensely.”

MacDonald told her about the imaging discoveries, while apologizing that she didn’t yet know of a treatment or cure. As they headed out the door, the woman called out to MacDonald and asked if she could hug her.

“She had tears in her eyes and said, ‘Thank you for showing me I’m not crazy,’” she said. “It didn’t matter to her that we didn’t have the treatments figured out, that we didn’t have the cure, just the knowledge meant the world to her.”

A larger body of research could broaden understanding, whether the brain injury happened in the military, in sports or from intimate partner violence, she said. With spikes in veteran mental health issues, along with incidents among civilians, “the more you look, the more you find,” she said.

“I will say it’s not just the military who has an increased frequency and severity of mental health symptoms following these mild traumatic injuries.

“We have to do these studies to understand this entire complex condition and then try to track it back to a single patient sitting in front of you. No two patients are alike and no two brain injuries are alike.”