Untreated-Brain-Injuries_Costs-to-Society

WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 Untreated Brain Injury: Scope, Costs, and a Promising New Treatment Reimers Systems, Inc www.reimerssystems.com Nicole Doering, Demario Dayton, Rob Beckman The Costs of Untreated Brain Injury Table of Contents _  Introduction: What is brain injury?……………………………………………………  Civilian Statistics: Prevalence of TBI in the U.S……………………………………  TBI and Psychiatric Problems…………………………………………………………  TBI and Unemployment…………………………………………………………………  Cost of Unemployment………………………………………………………  TBI and Homelessness……………………………………  Cost of Homelessness…………………………………………………………  TBI and Incarceration……………………………………  Cost of Incarceration…………………………………………………………  Veterans: “Signature Injuries of the War”- TBI and PTSD………………………  Depression, PTSD and TBI…………………………………………………………  Cost of Veteran Depression, PTSD and TBI…………………………………  Unemployed Veterans………………………………………………………………  Homeless Veterans……………………………………………………………………  Incarcerated Veterans………………………………………………………………  Ways to Reduce Costs………………………………………………………………  HBOT for TBI: An Evidence Based Treatment…………………………………………  How Much Could Be Saved If HBOT Were Provided?  Conclusions…………………………………………………………………………………………  References…………………………………………………………………………………………… Appendix A………………………………………………………………………………………………… WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury Executive Summary: Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality, accounting for approximately million emergency room visits, 230,000 (National Institute of Neurological Disorders and Stroke) to 500,000 hospital admissions, and 52,000 deaths annually in the United States (Kim et al., 2007) Every year, there are approximately 80,000 new individuals who live with significant, and usually permanent disabilities as a result of their TBI, yielding a total estimation of 5.8 million survivors- a number that continues to grow (Kim et al.) While such disabilities can be physical, they are often psychological Evidence consistently indicates that survivors of TBI are at increased risk for the development of severe, long-term psychiatric disorders, particularly depression, generalized anxiety disorder, and post-traumatic stress disorder (Rogers et al, 2007) Further, the presence of any one of these psychiatric disorders frequently complicates the affected individual’s rehabilitation and recovery from TBI as these disorders may significantly disrupt the individual’s independence, interpersonal relationships and ability to work (Kim et al., Rogers, et al.) Lack of independence and an inability to work takes a toll not only on the suffering individual, but on their family and society as well According to the Centers for Disease Control and Prevention (CDC), the direct (e.g., medical) and indirect costs (e.g., loss of productivity) of TBI in the United States totaled an estimated $60 billion annually in 2003 (Injury Prevention and Control, CDC, 2009) Complicating and prolonging the problems associated with TBI are treatments for TBI that offer little more than palliative care Thus, following the current record in treating TBI, there is little hope that the cost paid by the suffering individuals in the loss of their quality of life and costs paid by society will ever improve This does not mean, however, that there is no hope Hyperbaric oxygen therapy (HBOT) has emerged as a promising and effective treatment in healing injured brains and subsequently reducing, and in some cases completely alleviating, the symptoms associated with the TBI This paper purports to identify what constitutes a TBI, explore its prevalence, scope and costs, address what groups are most affected, and discuss HBOT as a promising new treatment that stands alone in its ability to promote healing of damaged brain tissue Introduction: What is traumatic brain injury? The Brain Injury Association of America defines traumatic brain injury (TBI) as an alteration in brain function, or other evidence of brain pathology, caused by an external force (About Brain Injury, BIAA, 2011) According to the National Institute of Neurological Disorders and Stroke (NINDS), damage to the brain can be focal (confined to one area of the brain), or diffuse (involving more than one area of the brain) (NINDS Traumatic Brain Injury Information Page, 2011) TBI can result from a closed head injury or a penetrating head injury A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull (e.g., a blow to the head, hitting the ground, or the brain hitting the inside of the skull itself) A penetrating injury occurs when an object pierces the skull and enters the brain tissue (e.g., gunshot wound to the head) A third form of TBI can also occur as a result of air embolism (AE) (e.g., diving accidents, blast exposure), which involves air entering into they systemic circulation, traveling to the brain and either becoming lodged in an artery or passing through the circulatory system, but WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury causing cellular damage as the bubbles pass (Air Embolism in NHS UK, 2009; Reimers et al., 2011) According to NINDS, the symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain Some symptoms emerge immediately, while others not surface until several days, weeks or even months after the injury Individuals who have suffered a mild TBI may remain conscious or may experience a loss of consciousness for only a few seconds or minutes (NINDS Traumatic Brain Injury Information Page) According to a press release from the American Psychological Association (APA), TBIrelated changes will vary depending on the specific areas of the brain affected by the injury, with predominate injuries occurring in the areas of the frontal and temporal lobes of the brain (Rehab for the Brain After Traumatic Injuries, APA, 2011) The most common postTBI symptoms involve a cluster of physical, emotional and cognitive problems, with cognitive challenges being the hallmark of TBI These challenges include problems with attention and concentration, impaired memory and learning, slowed processing speed, and reduced problem-solving skills The APA further states that emotional and behavioral problems are also common and can include delayed onset of depression and/or anxiety, as well as anger management problems, irritability and difficulty with emotional control The person may also report feeling dazed or not like themselves for several days or weeks, even years after the initial injury According to the NINDS (NINDS Traumatic Brain Injury Information Page) and the APA (Rehab for the Brain After TBI), other frequent symptoms of mild TBI include:               Headache Confusion Lightheadedness Dizziness Weakness Difficulty with language expression and/or comprehension Blurred vision Tired eyes Ringing in the ears Bad taste in mouth Fatigue Change in sleep patters Behavioral or mood changes Trouble with memory, concentration, attention, or thinking A person with a moderate or severe TBI may exhibit same of the same symptoms seen with mild TBI, but may also experience (NINDS Traumatic Brain Injury Information Page):        A headache that gets worse or does not go away Repeated vomiting or nausea Convulsions or seizures Inability to awaken from sleep Dilation of one or both pupils of the eyes Slurred speech Weakness or numbness in the extremities WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury    Loss of coordination, and/or increased confusion Restlessness Agitation Civilian Statistics: Prevalence of TBI in the U.S According to the CDC’s Injury Prevention and Control statistics (2009), there are approximately 1.7 million brain injuries in the United States a year The majority of these injuries (75%) are in the form of concussions or mild TBI (mTBI) Out of the 1.4 million TBI emergency room visits each year, 500,000 require hospitalization and 52,000 to 70,000 lead to death These are conservative figures however, as they not include people with TBI who are not seen in an emergency department, those who seek no treatment, and military statistics (Injury Prevention and Control, CDC; Figueora & Love, 2011) The groups of individuals most likely to sustain a TBI are children aged to years; older adolescents aged 15 to 19 years, and adults aged 65 years or older In all age groups, TBI rates are higher for males than females (CDC Injury Prevention and Control and Statistics) While evidence indicates that many brain injuries appear to improve naturally within to 12 months (Carroll et al 2004; Paniak et al., 1998, 2000; Levine, 1987; RAND, 2008), approximately 20 of patients with mTBI continue to live with significant disabilities as a result of their injury (NINDS Traumatic Brain Injury, Hope Through Research, 2002, 2011) Every year approximately 60,000 new cases of epilepsy occur as a result of head trauma, approximately 230,000 people are hospitalized from TBI and survive, and approximately 80,000 of these survivors live with significant disabilities as a result of their injury (Traumatic brain Injury: hope through research, 2002) The CDC and the NINDS both estimate that as a result of the cumulative effects of past brain injuries, approximately million Americans currently have a long-term or lifelong need for help to perform activities of daily living as a result of a TBI (CDC Traumatic brain injury in the United States: A report to congress, 1999; NINDS Traumatic Brain Injury, Hope Through Research, 2011) Corrigan et al., (2004) found that approximately 60% of persons hospitalized with TBI experienced at least one unmet need year following injury and approximately 40% will experience at least unmet need one year after injury Most frequently experienced needs were related to memory improvement, managing emotions and upsets and managing money The challenge of healing and/or recovery from mTBI can be further compromised in individuals who suffer more serious TBIs and/or experience more than one TBI According to the CDC “repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal” (CDC Sports related-recurrent brain injuries) Examples of individuals who are likely to suffer from the consequences of repeated TBIs are those playing contact sports (i.e football, boxing, hockey), soldiers and veterans (Brain injury and sports, 1998; Singer, 2008) Figure displays the annual rates of death attributable TBI and its place among other leading causes of death affecting Americans Figure WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury * CDC Leading Causes of Death 2007 Important to note is that according to the above figures, of the 121,599 deaths from accidents each year, TBI is a contributing factor to a third (30.5%) of all injury related deaths in the U.S (CDC, Prevention and Control and Statistics) http TBI is the th leading cause of death in the U.S (CDC Leading Causes of Death, 2007) TBI and Psychiatric Problems Mounting psychological and neurobehavioral evidence consistently indicates that TBI is a risk factor for subsequent psychiatric disorders, particularly depression, substance abuse, generalized anxiety and post-traumatic stress disorder (PTSD) (Kennedy et al., 2007; Kim et al.; Rogers & Read, 2007; van Reekum, Cohen & Wong, 2000) According to both the CDC and NINDS, TBI can cause a wide range of functional short- or long-term changes that affect thinking (i.e., memory and reasoning), sensation (i.e., tough, taste, smell), language (i.e., communication, expression, and understanding), and emotion (i.e., depression, anxiety, personality changes, aggression) (CDC Features and TBI Signs, Symptoms and how to Respond, 2011; NINDS Traumatic Brain Injury Information Page) The following are findings from relevant studies:  In a large epidemiological study of 5,034 participants from the New Haven CT, area, 361 participants admitted to a history of brain injury associated with loss of consciousness or confusion After controlling for sociodemographic factors, quality of life indicators and alcohol use, individuals who had experienced a TBI remained WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury       at a significantly increased risk for several psychiatric problems compared to nonTBI individuals Specifically, major depression (11.1% v 5.2%), alcohol abuse (24.5% v 10.1%), drug abuse/dependence (10.9% v 5.2%), panic disorder (3.2% v 1.3%), phobic disorder (11.2% v 7.4%), and obsessive-compulsive disorder (4.7% v 2.3%), respectively Individuals who suffered a TBI were also more likely to have had a history of suicide attempt (8.1% v 1.9%), respectively (Silver, Kramer, Greenwald, & Weissman, 2001) In an extensive review of recent research regarding TBI and the development of psychiatric disorders, van Reekum et al (2000) state “the evidence is convincing for a strong association between TBI and mood and anxiety disorders” and that “evidence for the correct temporal sequence is present” regarding TBI as a causative factor The systematic and exhaustive review found that instances of major depression were the most commonly reported psychiatric disorder, occurring at approximately 44% across all available studies Anxiety disorders were also common, ranging from approximately 6.5% for OCD to approximately 14% for PTSD Substance abuse was also fairly common, at 22% In a large epidemiological study involving 7,485 participants in Australia, it was found that a history of TBI was associated with increased symptoms of depression, anxiety, negative affect, and suicidal ideation Further, the TBI was reported on average, to have occurred 22 years in the past (Anstey et al., 2004) A 30-year follow-up study that evaluated the occurrence of psychiatric disorders after TBI found that between 48% and 61% of patients developed psychiatric difficulties after TBI The most common were major depression (26.7%), alcohol abuse or dependence (11.7%, panic disorder (8.3%), phobias (8.3%), and psychotic disorders (6.7%) Further, approximately one-quarter (23.3%) had at least one personality disorder The most prevalent were avoidant (15.0%), paranoid (8.3%), and schizoid (6.7%) The results lead the researchers to conclude, “traumatic brain injury may cause decades-lasting vulnerability to psychiatric illness in some individuals” (Koponen et al., 2002) Jorge et al (2004) found that major depressive disorder occured in 33% of the patients during the first year following a TBI Additionally, patients with major depression often exhibited comorbid anxiety (76.7%) and aggressive behavior (56.7%) Patients with major depression had significantly greater executive dysfunction than their non-depressed counterparts Major depression was also associated with poorer social functioning at the 6-and 12-month follow-up, as well as significantly reduced left prefrontal gray matter volumes, particularly in the ventrolateral and dorsolateral regions (deactivation of lateral and dorsal prefontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala) Zohar et al (2004) used a weight drop model to inflict closed mild brain injury to mice, which closely mimics real-life injures and symptoms observed in mTBI patients Using a variety of cognitive and behavioral tests, their results indicate that 90 days post-injury, closed head mTBI causes profound and long-lasting, irreversible learning and memory impairments, accompanied by depressive-like behavior in the mice The National Institute on Disability and Rehabilitation (NINDS) research conducted a multicenter investigation to determine the frequency of depression after TBI and the factors contributing to develop this mood disorder (Seel et al., 2003) The study consisted of 666 participants who were evaluated 10-126 months post-injury The WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury      results indicated that patients with TBI are at "great risk" for developing depressive symptoms The most commonly cited depressive symptoms were fatigue (29%), distractibility (28%), anger or irritability (28%), and rumination (25%) Further, it was stated that unemployment and poverty may be substantial risk factors for the development of depressive symptoms Hibbard et al (1998) evaluated 100 adults an average of years post-TBI and found a prevalence rate of 61% of major depressive disorder following TBI A separate analysis of major depressive disorder with the onset following TBI yielded a lower, but still sizable 48% Bryant and Harvey (1998) assessed 79 patients with a mild TBI within month of their injury and again at months post-injury using standardized measures Acute Stress Disorder was found in 14% of patients at month post-injury, and PTSD was identified in 24% of patients at follow-up Eight-two percent of those patients diagnosed with acute stress disorder developed PTSD during the follow-up period Bryant et al (2000) interviewed 96 survivors of severe TBI months post-injury and found that 27% met the criteria for PTSD despite the fact that most did not have any cohesive recall of the traumatic event A recent study conducted by Vanderbuilt University researchers Guillamondegui and McPheeters (2011) found that 30% of TBI patients, or approximately 360,000 patients each year, will suffer from depression after their head injury Dr Guillamondegui stated that, “Any patient who has a traumatic brain injury is at real risk for developing depression, short and long term It doesn’t matter where on the timeline that you check the patient population- six months, 12 months, two years, five years- the prevalence is always around 30 percent across the board In the general population about percent to 10 percent of people have depression” The Agency for Healthcare Research and Quality states that out of 10, or 30% of individuals with a brain injury will experience depression For those who not have a TBI, the rate is one in 10, or 10% The AHRQ also states that the onset of depressive symptoms may occur right after the injury or a year or more later (Depression after brain injury: A guide for patients and their caregivers, 2011) The increased probability that individuals suffering from a TBI will face decades of psychiatric difficulty may explain the frequent re-hosptializations seen with these patients in the years following their injury A recent multicenter analysis of re-hospitalizations of 895 rehabilitation patients one to five years after TBI found relatively high rates of hospitalization in the long term for those who suffered a TBI (Marwitz et al 2001) Five years after injury, the incidence of readmissions for seizures and psychiatric difficulties increased substantially Marwitz et al (2011) also noted that the costs of these rehospitalizations over the long term should be considered when evaluating long-term consequences of injury Complicating the path to adequate care for mTBI is the fact the vast majority of braininjured patients are seen by athletic trainers and other nonmedical providers, if they are seen at all (Ling, Watson & Moore, 2011) According to Ling et al., many patients not recognize that they may have been significantly injured and thus will not seek medical care- it may take two, three, or four more subsequent head injuries before such individuals realize that they are “hurt” Of those who recognize that they are injured and seek medical treatment, the cost of care is substantial As previously stated, according to the CDC the direct (e.g., medical) and indirect costs (e.g., loss of productivity) of TBI in the United States totaled an estimated $60 billion annually in WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 2003 In particular, studies have shown that the lost productivity associated with a mental health condition represents a substantial cost to society and employers (RAND, 2008; Ettner, Frank & Kessler, 1997), with one study reporting that workers suffering from depression cost employers as much as $44 billion dollars a year (Stewart et al., 2003) TBI and Unemployment In addition to the psychological difficulties that individuals who suffer from TBI(s) often endure, they also face other challenges that directly and adversely affect their wellbeing As previously discussed, the sequelea of TBI can impair the domains of cognition, movement, sensation and/or emotion, all of which may make return to pre-injury employment unlikely, create barriers to finding employment, and contribute to chronic unemployment (Shigaki, Jonstone & Schopp, 2009; Yasuda et al., 2001) While much of the existing literature focuses on employment for American’s with disabilities in general, relatively few studies have directly examined changes in employment over time, post-TBI and unemployment rates among existing studies vary widely (Yasuda et al.) An accurate snapshot of post-injury unemployment is further complicated by the use of various measures for injury severity, a lack of distinction between mild, moderate and severe TBI, inclusion of relevant demographic factors, absence of long-term follow-up, and the inclusion of sheltered or subsidized and unpaid work (i.e., volunteer, homemaker and student are provided in their definition of employment) (Doctor et al., 2005; Shigaki, et al., Yasuda et al.) However, even when controlling for the above factors the reported unemployment rates are extremely high post-injury (Yasuda et al.) The following is a summary of current findings:      The TBI Model Systems National Data and Statistical Center (TBIMS) indicates that 62% of brain-injured individuals were employed at the time of their injury, however; only 32% were employed after two years Figure provides a more detailed breakdown of their findings (TBIMS TBI Model Systems Presentation, 2011) Levine and Grossman (1979) in a 1-year follow-up of 27 persons with TBI found that while only 4% were unemployed pre-injury, 78% were unemployed postinjury (Levin, Yasuda) Brooks et al (1987) examined 98 severely head injured patients during the first seven years after the injury The employment rate dropped from 86% prior to the injury to 29% post-injury The authors found that younger patients, and those with technical/managerial jobs prior to injury were more likely to return to work than those over 45 years of age, or in unskilled occupations Further, physical deficits were not related to return to work, however, the presence of cognitive, behavioral and personality changes were significantly related to failure to return to work Shigaki et al (2009) in a two year follow-up study of 49 brain injured persons found that 68% of participants were employed at the time of injury, but only 38% reported being employed after the two years Consistent with the decline in employment, participants also reported declines in frequency and amount of earned income relative to their pre-injury baselines Doctor et al (2005) examined the risk of unemployment year after TBI relative to the expected risk of unemployment for the general US population Their study consisted of 418 mild TBI individuals who were employed at the time of their injury Results indicated that 42% of TBI cases were unemployed after injury versus 9% expected, yielding a relative risk (RR) of 4.5 The relative risk for WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 10 unemployment was higher among males, those with higher education, persons with greater severity of injuries, and more impaired neuropsychological and fictional status Figure Data obtained from the TBI Model Systems National Data and Statistical Center While difficulty in obtaining employment post-injury is not only detrimental to the suffering individual, it is also carries economic ramifications The loss of productivity, lack of taxable income, and increased demands on state and federal safety net programs by individuals suffering from TBI undoubtedly account for a large portion of the annual $60 billion cost of TBI Unfortunately, obtaining an accurate estimate of the indirect, economic costs of TBI is difficult as the exiting literature is both outdated and largely focused on direct, health-care related costs (Borg et al., 2004; Holm et al, 2005) Nonetheless, in an extensive review, the results of the World Health Organization collaborating center task force on mTBI (Borg et al, 2004) state that “as with other health problems, indirect costs are much higher than direct costs” (p 82) Cost of Unemployment: While an accurate estimate of the indirect economic costs of TBI is difficult, Table provides a conservative hypothetical example as to how TBI impacts loss of state and federal tax revenue using the above figures and studies As shown in Table 2, and as previously stated by the CDC, there are an estimated 1.7 million instances of brain injury every year According to NINDS, approximately 20% (80,000) of TBI patients live with significant disabilities as a result of their injury that can interfere with their daily activity (NINDS Traumatic Brain Injury, Hope Through Research, 2011) That means that every year, approximately 340,000 individuals will continue to struggle post-injury We assumed that it is this cohort of individuals who would most likely struggle to return to employment, as they would be the most adversely affected by their injury and subsequently used them as a reference point for calculating loss of tax revenue and social WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 35 Sub-totals -$57,076,000 Net savings relative to maintaining the status quo in $ $1,724,800 -$9,476,800 $33,800,800 $279,207,200 Do Nothing Except Maintain Status Quo Number of individuals in the cohort 1,000 Number of individuals treated Number of individuals treated and still not employed 0 HBOT treatment costs 0 Tax revenue from persons returned to employment, Year and after Disability payments to persons not treated -$32,076,000 -$32,076,000 Sub-Totals -$32,076,000 -$32,076,000 -$288,684,000 Additionally, for active duty service members with TBI, restoring them to their pre-injury level allows the military to retain their services and thus, spare the cost of training a new recruit (See Table XXX) According to the Army, the average cost of training a new recruit from the time the individual walks into a recruiting station until he reaches his first duty station is $75,000 (http://www.2k.army.mil/faqs.htm#costper) While figures for other branches could not be obtained, we will use the Army’s figure as a reference and assume that the other branches not very substantially in training costs Again, we will use the DoDs TBI prevalence of 202,481 for deployment-related TBI We assume that moderate/severe TBIs would be type of brain-injury most likely to result with the injured individual being unable to continue to serve in their current position and therefore, would be an injury that would most likely result the need to train a new recruit and incur the additional cost To estimate the prevalence of that injury severity, we use the RAND finding that approximately 30% of TBIs were moderate/severe, which is also supported by civilian data (25% of all TBIs are moderate/severe) Thus, of the 202,481 TBIs, approximately 60,744 would need to be replaced by a new recruit If none of these injured soldiers could be restored, that would be an additional cost of $4.5 billion Table XXX Estimated Costs and Benefits of Treating Active Duty Members WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 36 TBI DoD estimate of war-related TBI 202,481 30% sustain moderate/severe TBI 60,744 Cost of a new recruit $75,000 Total cost to replace with new recruit $4.5 billion Conclusions: TBI is a costly health condition in both the civilian and military sector While many individuals who suffer a TBI will experience a remittance in their symptoms, many will continue to struggle months, if not years post-injury These problems affect virtually every aspect of the suffering individual’s life and can impinge upon their autonomy, employment, personal relationships and psychological well-being For members of the armed services, suffering a combat-related TBI can have devastating consequences that directly interfere with a successful transition to civilian life For those men and women who suffer more than one TBI within quick succession, the damage can be catastrophic While society would unquestionably benefit financially by helping all individuals who suffer from the long-term consequences of TBI, society and the military arguably has an obligation to provide effective treatment to the armed service members who were injured serving their country WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 37 Works Cited: Adler, AB (1994) Post-Traumatic Stress Symptoms in U.S veterans of the Gulf war Walter Reed Army Institute of Research Washington D.C 1994 Report no A245882 Agency for Healthcare Research and Quality (2011) Depression after brain injury: A guide for patients and their caregivers Retrieved August 10, 2011 from: http://www.effectivehealthcare.ahrq.gov/ehc/products/77/647/TBIDepression_ConsumerGuide_04-13-2011.pdf Anstey, K.J., Butterworth, P., Jorm, A.F., Christensen, H., Rodgers, B & Windsor, T.D (2004) A population survey found an association between self-reports of traumatic brain injury and increased psychiatric symptoms Journal of Clinical Epidimiology, 57, 1202-1209 Aizenman, N C (2008) The high cost of incarceration Retrieved January 26, 2011, from DenverPost.com: http://www.denverpost.com/ci_8400051 American Psychological Association (2011) Rehab for the Brain After Traumatic Injuries Retrieved on August 9, 2011 from: http://www.apa.org/news/press/releases/2011/04/brain-rehab.aspx Barnfield, T.V & Leathem, J.M (1998) Neuropsychological outcomes of traumatic brain injury and substance abuse in a New Zealand prison population Brain Injury, 12, 951-962 Borg J., Holm L., Peloso P.M., Cassidy J.K., Carroll L.J., von Holst H., Paniak C., & Yates D (2004) Non-surgical intervention and cost for mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury Journal of Rehabilitative Medicine, 36, 76-83 Brain Injury 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E.F (2007) Prevalence of depression-PTSD comorbidity: Implications for clinical practice guidelines and primary care-based interventions Journal of General Internal Medicine, 22, 711-718 14 Carroll, L., Cassidy, J., Peloso, P., Borg, J., von Holst, H., Holm, L., et al (2004) Prognosis for mild traumatic brain injury: resuls of the Who Collaborating Center Task Force on Mild Traumatic Brain Injury 43 15 Centers for Disease Control and Prevention N.D Traumatic Brain Injury in Prisons and Jails Retrieved on August 21, 2011 from: www.cdc.gov/traumaticbraininjury/pdf/Prisoner_TBI_Prof-a.pdf 16 Centers for Disease Control and Prevention (1997) Sports-related recurrent brain injuries—United States MMWR , 46, 224–227 17 Centers for Disease Control and Prevention (1999) Traumatic Brain Injury in the United States: A Report to Congress (1999) Retrieved on August 8, 2011 from: http://www.cdc.gov/traumaticbraininjury/pdf/TBI_in_the_US.pdf 18 Centers for Disease Control and Prevention (2007) Leading Causes of Death Retrieved on August 10, 2011 from: http://www.cdc.gov/nchs/fastats/lcod.htm 19 Centers for Disease Control and Prevention (2010) Injury Prevention and Control: Traumatic Brain Injury Retrieved August 9, 2011 from: http://www.cdc.gov/traumaticbraininjury/statistics.html 20 Centers for Disease Control and Prevention (2011) Learn TBI Signs, Symptoms and How to Respond Retrieved August 10, 2011 from: http://www.cdc.gov/Features/BrainInjury/ 21 Center for Economic and Policy Research (2010) The High Budgetary Cost of Incarceration Retrieved on August 22, 2011 from: http://www.cepr.net/documents/publications/incarceration-2010-06.pdf 22 Colarusso, L (2007, June) Concerns grow about war veterans’ misdiagnoses: Brain injuries can defy easy detection Boston Globe Retrieved August 24, 2011 from: http://www.boston.com/news/nation/articles/2007/06/10/concerns_grow_abou t_war_veterans_misdiagnoses/ 23 Congressional Research Service (2010) U.S Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom By Fischer, H (CRS-7-5700 CRS- RS22452) 24 Corrigan J.D., Whiteneck G., & Mellick D (2004) Perceived needs following traumatic brain injury Journal of Head Trauma Rehabilitation, 3, 205-16 25 Deb, S., Lyons, I., Koutzoukis, C., Ali, I & McCarthy G (1999) Rate of psychiatric illness year after traumatic brain injury American Journal of Psychiatry, 156, 374378 26 Defense and Veterans Brain Injury Center (2011) DoD Worldwide Numbers for Traumatic Brain Injury Retrieved on April 20, 2011 from: http://www.dvbic.org/TBI-Numbers.aspx 27 Department of Justice (2007) Largest Increase in Prison and Jail Inmate Populations Since Midyear 2000 Press Release released on June 27, 2007 WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 39 28 Diamond, P.M., Harzke, A.J., magaletta, P.R., Cummins, A.G & Frankowski, R (2007) Screening for traumatic brain injury in an 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Moon RE, Gorman DF Treatment of the Decompression Disorders, Chapter 18 In: The WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 46 Physiology and Medicine of Diving, 4th Edition, eds Bennett P, Elliott D W B Saunders Company, Ltd London, 1993 122 39 Harch PG, Gottlieb SF, Van Meter KW, Staab P SPECT brain imaging in the diagnosis and treatment of type II decompression sickness Undersea Hyper Med, 1992;19(Suppl):42 123 Harch PG Late treatment of decompression illness and use of SPECT brain imaging In: Moon RE, Sheffield PE, editors Treatment of decompression illness 45th Workshop of the Undersea and Hyperbaric Medical Society Kensington (MD) UHMS, 1995, 203-42; Barratt DM, Harch PG, Van Meter K Decompression illness in divers: A review of the literature Neurologist 2002; 8:186-202 124 40 Harch PG, Van Meter KW, Gottlieb SF, Staab P 29 Harch PG, et al Delayed treatment of type II DCS: the importance of HBOT 1.5 and HMPAO SPECT brain imaging in its diagnosis and treatment Undersea Hyper Med, 1993;20(Suppl):51 125 41 Harch PG, Van Meter KW, Gottlieb SF, Staab P The effect of HBOT tailing treatment on neurological residual and SPECT brain images in type II (cerebral) DCI/CAGE Undersea and Hyper Med, 1994;21(Suppl):22-23 126 42 Harch PG Late treatment of decompression illness and use of SPECT brain imaging In: Moon RE, Sheffield PE, editors Treatment of decompression illness 45th Workshop of the Undersea and Hyperbaric Medical Society Kensington (MD) UHMS, 1995, 203-42; Barratt DM, Harch PG, Van Meter K Decompression illness in divers: A review of the literature Neurologist 2002; 8:186-202 127 43 Harch PG Late treatment of decompression illness and use of SPECT brain imaging In: Moon RE, Sheffield PE, editors Treatment of decompression illness 45th Workshop of the Undersea and Hyperbaric Medical Society Kensington (MD) UHMS, 1995, 203-42 128 44 Shi XY, Tang ZQ, Xiong B, Bao JX, Sun D, Zhang YQ, Yao Y Cerebral perfusion SPECT imaging for assessment of the effect of hyperbaric oxygen therapy on patients with postbrain injury neural status Chin J Traumatol 2003 Dec;6(6):346-9 129 45 Lin JW, Tsai JT, Lee LM, Lin CM, Hung CC, Hung KS, Chen WY, Wei L, Ko CP, Su YK, Chiu WT Effect of hyperbaric oxygen on patients with traumatic brain injury Acta Neurochir Suppl 2008;101:145-9 130 46 Rockswold SB, Rockswold GL, Zaun DA, Zhang X, Cerra CE, Bergman TA, Liu J A prospective, randomized clinical trial to compare the effect of hyperbaric to normobaric hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury J Neurosurg 2010 May;112(5):1080-94 131 47 Rockswold SB, Rockswold GL, Defillo A Hyperbaric oxygen in traumatic brain injury Neurol Res 2007 Mar;29(2):162-72 Review 132 48 Rockswold SB, Rockswold GL, Defillo A Hyperbaric oxygen in traumatic brain injury Neurol Res 2007 Mar;29(2):162-72 Review 133 49 Hoggard ML, Shirachi DY, Johnson KE, Hannigan-Downs S The effect of hyperbaric oxygen therapy on improvement of speech, language and cognitive deficits observed ina traumatic brain injury Web site: http://www.hbotreatment.com/The%20Effect%20Of%20Hyperbaric%20Oxygen %20Therapy%20On%20Improvement%20Of%20Speech,%20Language, WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 47 %20And%20Cognitive%20Deficits%20Observed%20In%20A%20Traumatic %20Brain%20Injury.pdf Accessed January 21, 2011 134 50 Hardy P, Johnston KM, Beaumont LD et al Pilot case study of the therapeutic potential of hyperbaric oxygen therapy on chronic brain injury J Neurol Sci 2007; 253 (1-2): 94-105 135 51 Neubauer RA The effect of hyperbaric oxygen in prolonged coma Possible identification of marginally functioning brain zones Minerva Med Subaecquea ed Iperbarica, 1985;5:75 136 Shn-rong Z Hyperbaric oxygen therapy for coma (a report of 336 cases) In: Procedures of the XIth International Congress on Hyperbaric Medicine, eds Li W-ren, Cramer FS Best Publishing Co, Flagstaff, AZ, 1995 p.279-285 137 52 Shn-rong Z Hyperbaric oxygen therapy for coma (a report of 336 cases) In: Procedures of the XIth International Congress on Hyperbaric Medicine, eds Li W-ren, Cramer FS Best Publishing Co, Flagstaff, AZ, 1995 p.279-285 138 53 Neubauer RA Severe natural gas poisoning successfully treated with hyperbaric oxygen – years later Neurotoxicology and Occupational Neurology, 1990;10 139 54 Eltorai I, Montroy R Hyperbaric oxygen therapy leading to recovery of a 6- week comatose patient afflicted by anoxic encephalopathy and posttraumatic edema J Hyperbaric Med, 1991;6: 189-198 140 55 Neubauer RA Severe natural gas poisoning successfully treated with hyperbaric oxygen – years later Neurotoxicology and Occupational Neurology, 1990;10; Harch PG, Van Meter KW, Gottlieb SF, Staab P HMPAO SPECT brain imaging of acute CO poisoning and delayed neuropsychological sequelae (DNSS) Undersea & Hyperbaric Medicine, 1994; 21 (Suppl): 15 141 56 Neubauer RA, Gottlieb SF, Miale A, Jr Identification of hypometabolic areas in the brain using brain imaging and hyperbaric oxygen Clin Nucl Med 1992;17(6):477-81 142 57 Harch PG, Neubauer RA (1999) Hyperbaric oxygen therapy in global cerebral ischemia/ anoxia and coma In Jain KK (ed) Textbook of Hyperbaric Medicine, 3rd Revised Edition, Chapter 18 Hogrefe & Huber Publishers, Seattle WA 1999: 319-345 143 58 Neubauer RA, James P Cerebral oxygenation and the recoverable brain Neurol Res, 1998;20(Suppl 1): S33-S36 144 59 Harch PG, Van Meter KW, Gottlieb SF, Staab P HMPAO SPECT brain imaging and HBOT 1.5 in the diagnosis and treatment of chronic traumatic, ischemic, hypoxic and anoxic encephalopathies Undersea and Hyperbaric Medicine, 1994;21(Suppl):30 145 60 Harch PG, Van Meter KW, Gottlieb SF, Staab P HMPAO SPECT brain imaging and HBOT 1.5 in the diagnosis and treatment of chronic traumatic, ischemic, hypoxic and anoxic encephalopathies Undersea and Hyperbaric Medicine, 1994;21(Suppl):30 146 61 Golden ZL, Neubauer R, Golden CJ, Greene L, Marsh J, Mleko A Improvement in cerebral metabolism in chronic brain injury after hyperbaric oxygen therapy Intern J Neuroscience 2002;112:119-131 147 Appendix A WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 48 Level of Care guidelines for “evidence-based” treatment per disorder: PTSD RAND and Fao, Keane, and Friedman (2000b) provide the following guidelines for rating different therapies according to a literature review of trials that specifically studied the efficacy of different therapies:       Level A: Evidence is based on randomized, well-controlled clinical trials for those with PTSD Level B: Evidence is based on well-designed clinical studies that not use randomization or placebo comparison for those with PTSD Level C: Evidence is based on service or naturalistic (non-experimental) clinical studies in conjunction with clinical observations that are sufficiently compelling to warrant the use of the treatment technique or to follow the specific recommendations Level D: Evidence is based on long-standing and widespread clinical practice that has not been subjected to empirical tests in PTSD Level E: Evidence is based on long-standing practice by circumscribed groups of clinicians that has not been subjected to empirical tests in PTSD Level F: Evidence is based on recently developed treatment that has not been subjected to clinical or empirical tests in PTSD Roa, EB, Keane TM, Friedman MJ 2000 Guidelines for the treatment of PTSD Journal of Traumatic Stress, vol 13, no 539-588 RAND Depression: According to RAND, studies are typically assigned one of three levels of evidence, which provide a level of confidence that the study findings can be given (RAND): Randomized clinical trial (RCT) RCTs are considered the gold standard for scientific evidence in health care because they eliminate spurious casualty and bias RCTs use random selection and random assignment to different treatment groups to ensure that any confounding factors are evenly distributed between groups This allows outcomes to be linked with treatment in a reliable way Non-randomized controlled trials, cohort or case analysis, or multiple time series These are studies that utilize various different quasi-experimental designs and statistical methods to control for spurious causality and bias These types of studies, however, not control for confounding factors as completely as RCTs Textbooks, opinions, or descriptive studies Many recommendations may be based on practices conducted in the field, but lack rigorous empirical evaluation RAND TBI: WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011 The Costs of Untreated Brain Injury 49 RAND, citing the Brain Trauma Foundation, provide the following three levels of recommendations for which to assign a level of confidence regarding study findings:    Level 1: Recommendations represent principles of patient management that reflect a high degree of clinician certainty Level 2: Recommendations reflect a moderate degree of clinical certainly Level 3: Recommendations reflect a degree of certainty that is not clinically established Important to note is that there is currently only one Level recommendation: The use of steroids should not be used to manage increased intracranial pressure (RAND) The following chart was obtained from Guidelines for the Pre-hospital Emergency Care on the Brain Trauma Foundation website (https://www.braintrauma.org/coma-guidelines/) WORKING DRAFT: For pre-release to Policy Officials ONLY August 31, 2011