•   Postdeployment TBI screening of military personnel returning from Operation Enduring Freedom in Afghanistan (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) conflicts are positive approximately 20% of the time [1].

        It is essential to appreciate that screening positive for TBI on a questionnaire is not definitive evidence that the injury actually occurred. Rather, the gold standard for TBI diagnosis is a thorough clinical evaluation [7].

        DoD Policies direct TBI screening following exposure to a potential injury event and at specified predeployment, postdeployment, and periodic health assessments [10,11]. Most concussion patients are managed by primary care, but a comprehensive system of specialty TBI clinics are available to treat those with more severe injuries, complex comorbidities, or refractory symptoms.

        In the VA, patients who screen positive are sent to a TBI specialty clinic for a comprehensive TBI evaluation (CTBIE) to determine the likelihood of TBI and direct further treatment. The estimated numbers of TBIs per year, based on DoD surveillance statistics and stratified by severity, are provided in Table 66.2.

•   PTSD: A recent meta-analysis estimated the average PTSD prevalence among OEF/OIF veterans at 23% [13]. The proportion of veterans who screened positive for TBI and had PTSD was more than double those who had PTSD alone (32% vs 13%) [14].

        Screening positive for PTSD is associated with number of deployments [15], deployment-related stressors [16], greater combat exposure [17], getting wounded [18], sustaining an MTBI [8], and greater general medical burden [19].

        Careful diagnostic interviewing by a clinician results in more accurate identification of combat-related PTSD and reduces false-positive diagnoses [20,21]. Depression frequently co-occurs with PTSD in military personnel [8,21].

        Service members who sustain an MTBI and have high levels of combat stress symptoms have a 3- to 8-times increased likelihood of experiencing postconcussive symptoms, compared to those with low levels of combat stress [22].

•   Depression: In postdeployment surveys, 5.7% to 15.7% of service members screen positive for depression [23,24], although some surveys of those in the Veterans Administration (VA) care system have shown rates of 39% to 48% [25].

        Similar to screening estimates for MTBI and PTSD, these prevalence estimates decline when screening is followed by interviewing with a clinician [21].

        There is significant symptom overlap between depression and postconcussion syndrome. [26]. In those with MTBI, the presence of loss of consciousness (LOC) and/or Posttraumatic Amnesia (PTA), PTSD, and self-reported cognitive problems were associated with worse depression [27, 28].

•   Amputation: Between October 2001 and May 2015, there were 1,645 service members who underwent an amputation [29], often associated with orthopedic, internal organ, and brain injuries.

        Service members undergoing amputation are at significant risk for depression, anxiety, PTSD, chronic pain, and body image problems [30].

        Patients who have both a combat-related TBI and amputation utilize more medical and rehabilitative services than those with amputation alone [31].

•   Body image: Military personnel who suffer facial disfigurement, complex scars to their limbs or torsos, spinal cord injuries, or amputations frequently deal with psychological problems relating to their body images. Psychological adjustment issues and problems associated with body image can interfere with social and occupational functioning.

        Despite the expectation that the symptom burden increases proportionally with severity of bodily injury, some studies suggest otherwise. In fact, those patients with more extensive bodily injuries report fewer posttraumatic stress and postconcussion symptoms than those who experience minor bodily injuries [32].

•   Chronic pain: Pain lasting more than 6 months is defined as chronic. Chronic pain is a common problem in veterans [33], and it is frequently comorbid with TBI [3,34].

        People who suffer from chronic pain often report subjectively experienced cognitive impairment [35], and they are likely to report postconcussion-like symptoms in the absence of a past MTBI [36]. Those with chronic pain are also at risk for comorbid depression.

•   Insomnia: Problems with sleep often occur during deployment [37], and are commonly reported postdeployment [38], both in low- and high-combat stress groups [28]. In patients with TBI, and especially those with concurrent TBI and PTSD, insomnia can be especially problematic [28].

        Persistent problems with falling asleep, staying asleep, or waking too early can occur as a primary insomnia condition or be associated with a comorbid condition (e.g., PTSD or chronic pain) [39]. Sleep problems can be associated with obesity [40], tinnitus [41], and perceived impairments with cognition when they become chronic [38].

        Sleep hygiene counseling and PTSD severity reduction in patients with MTBI has been associated with sustained improvements in headaches, cognitive function, and daytime sleepiness [42].

•   Substance misuse, abuse, and dependence: Substance use is a prevalent issue amongst service members and veterans. It can co-occur with mental health problems and cause problems with social and occupational functioning.

        In those with concurrent TBI, substance abuse can exacerbate cognitive dysfunction and have an adverse effect on underlying mood disturbances, making an accurate diagnosis more challenging [43].

•   Life stress and community re-entry issues: Some service members struggle with resuming their home and work lives and responsibilities following deployment [44]. These problems can be compounded by the stress of being deployed again after less than a year home. Repeated deployments can contribute to PTSD symptoms [15] as well as substance misuse and mental health problems.

        Veterans with TBI have greater challenges with community reintegration than those without TBI, but this may be influenced by the presence of comorbid depression and/or chronic pain [45].

•   Suicidality: The suicide rate among U.S. military personnel has risen steadily since the initiation of the OEF/OIF conflicts. TBI is thought to be one of the factors contributing to this rising rate [46].

        In a recent study, a history of TBI, PTSD, alcohol problems, and poor social support were associated with suicidal ideations among veterans accessing VA health care [34].

        Because TBI is associated with numerous well-established suicide risk factors, the number of lifetime TBIs appears to increase the likelihood of suicidal ideation and risk. [46,47].