Untreated Brain Injury: Scope, Costs, and a …treatnow.org/wp-content/uploads/2015/10/Untreated-Brain... · Web viewUntreated Brain Injury: Scope, Costs, and a Promising New Treatment

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…………………………………………………………………………………………………


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Executive Summary:Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality, accounting for approximately 2 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 causing cellular damage as the bubbles pass (Air Embolism in NHS UK, 2009; Reimers et al., 2011).


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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 do 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), TBI-related 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 post-TBI 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 Loss of coordination, and/or increased confusion Restlessness Agitation


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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 do 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 0 to 4 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 3 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 5 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 1 year following injury and approximately 40% will experience at least 1 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 1 displays the annual rates of death attributable TBI and its place among other leading causes of death affecting Americans.

Figure 1


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* 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 9th leading cause of death in the U.S (CDC Leading Causes of Death, 2007).

TBI and Psychiatric ProblemsMounting 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


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at a significantly increased risk for several psychiatric problems compared to non-TBI 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 results indicated that patients with TBI are at "great risk" for developing


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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 8 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 1 month of their injury and again at 6 months post-injury using standardized measures. Acute Stress Disorder was found in 14% of patients at 1 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 6 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 9 percent to 10 percent of people have depression” .

The Agency for Healthcare Research and Quality states that 3 out of 10, or 30% of individuals with a brain injury will experience depression. For those who do 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 re-hospitalizations 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 brain-injured 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 do 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 do 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 2003. In particular, studies have shown that the lost productivity associated with a mental


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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 UnemploymentIn 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 1 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 post-injury (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 1 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 unemployment was higher among males, those with higher education, persons


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with greater severity of injuries, and more impaired neuropsychological and fictional status.

Figure 1

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 2 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 safety net costs. Using the above employment studies as a reference point, there was an


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average post-injury employment drop of 44.8%. In other words, 45% of individuals who were previously employed were unable to return to work following their injury. Applying percentage to the individuals who continue to struggle post-injury (340,000 x .45) results with approximately 153,000 individuals who are unable to return to work. Given that the average salary for Americans in 2009 was $40,711.61 (Social Security Online, National Average Wage Index, 2009), and that 25% of that income would be taxed, for every unemployed individual there is a potential loss of $10,000 in tax revenue per year. Applying that figure to our example cohort, that yields a total tax loss of $1.53 billion.

Table 2Loss of Tax Revenue and Increase in Social Safety Net Expenditures Due to Unemployment

TBI

Annual incidence rate of TBI 1.7 million

Number of individuals with lingering disability (20%)

340,000

Estimated drop in employment status one-year post-injury for individuals with lingering disability

45%

Number unemployed post-injury 153,000

National average wage index 2009 $40,700

Loss of tax revenue per individual $10,000

Total loss of tax revenue for one year $1.53 Billion

Increase in social safety net expenditures per individual

$5,000 to $10,000

Total increase in social safety net expenditures (using the $5,000 low end estimation)

$765 Million

Annual total for both loss of tax revenue and increase in social safety net costs (not including on-going costs from TBIs in prior years)

$2.3 Billion

TBI and HomelessnessThe homeless represents one of the populations most affected by TBI for several reasons which often work synergistically with one another. The first is that TBI is known to result in socioeconomic decline (socioeconomic factors include socioeconomic status, education,


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income, occupation, marital status, etc), which may put persons at higher risk of becoming homeless (Lafferty, 2010). Individuals who have suffered a TBI are also more likely to develop a substance abuse problem and suffer from anger and/or emotional issues, all factors that increase the risk of homelessness. The second is that homeless persons’ frequent exposure to violence, high incidences of trauma and accidents, and prevalence of substance abuse serves to increase the risk of obtaining a TBI, or multiple TBI’s (Waldman et al., n.d.). Thus, while sustaining a TBI serves to increase one’s risk for homelessness, being homeless further increases one’s risk for TBI and/or multiple brain injuries.

Several large-scale studies highlight severity of the problem:

A recent study conducted by The Boston Health Care for the Homeless Program (Waldmann et al., n.d.) found that 67% of homeless reported having experienced least one head injury, and 71% of subjects with head injuries reported having experienced more than one brain injury. Of those who reported experiencing a TBI, 62% reported being 20 years old or younger at the time of their first head injury and 26% reported being 10 years or younger. The authors state that the young age of first head injury suggests that experiencing a TBI as a youth increases the risk of being homeless as an adult. Compared to subjects with no head injury, those with head injuries reported a significantly higher use of alcohol (92% v. 77%) and narcotics (56% v. 36%) as well as reported experiencing higher levels of depression (52% v. 31%), irritability and anger (65% v. 39%), mental illness (52% v. 31%), crime conviction rates (67% v. 45%), and veteran status (32% v. 14%).

A recent Canadian study of nearly 1,000 homeless individuals found that the lifetime prevalence for any TBI was 53%, with 12% reporting having suffered a moderate to severe TBI. For 70% of participants, their first TBI preceded their onset of homelessness.1 Compared to those without a history of TBI, participants with a history of TBI had a significantly higher prevalence of mental health problems (33% v. 43%), alcohol problems (28% v. 42%), and drug problems (40% v. 57%) (Hwang et al., 2008).

The RAND report found a similar pattern in their results, evidenced by their report that 75% of homeless individuals were found to have had PTSD before they became homeless (RAND, 2008).

Thus, the above studies provide compelling evidence that experiencing a TBI serves to increase the likelihood of homelessness as well as a host of other psychological and social problems.

Cost of Homelessness: While homelessness represents not only a humanitarian problem, it is also costly problem for taxpayers. According to the National Alliance to End Homelessness (the Alliance), people experiencing homelessness are more likely to utilize the most costly heath care services, spend more time in jail or prison, and use emergency shelters as a permanent living situation (The Alliance, Costs of Homelessness, 2011).

Regarding health care, a study of hospital admissions of homeless people in Hawaii found that 1,751 adults were responsible for $4 million in admission costs during the two-year study period. Further, the rate of psychiatric hospitalizations was more than 100 times greater than their non-homeless cohort (Martell et al., 1992). According to the researchers conducting this study, the excess cost for treating these homeless individuals was an

1 (Hwang, et al., 2008)WORKING DRAFT: For pre-release to Policy Officials ONLY.August 31, 2011

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estimated $3.5 million, or about $2,000 per person. This is in agreement with a study in the New England Journal of Medicine, which found that homeless people spent an average of 4 days or longer per admission compared to their non-homeless comparisons and that this extra cost ranged from $4,094 to $2,414 per hospitalization depending on the reason for medical treatment (Salit et al, 1998). Regarding incarceration, the Alliance, citing a University of Texas 2-year survey of homeless individuals, states that each homeless person costs taxpayers $14,480 per year, primarily for overnight jail (The Alliance, Costs of Homelessness, 2011). Emergency shelter is also a costly service. The Alliance also states that the cost of an emergency shelter bed funded by the Department of Housing and Urban Development (HUD) Emergency Shelter Grants program is approximately $8,067 more than the annual cost of a federal housing subsidy (The Alliance, Costs of Homelessness, 2011).

TBI and IncarcerationWhile the prevalence and impact of TBI in the prison population has not been well recognized, its influence is quite great (Slaughter, Fann & Ehde, 2003; Wald, Helgeson & Langlois, n.d.). According to a recent report by the Department of Justice (DOJ), approximately 2.3 million people are currently being held in U.S. prisons and jails (DOJ Largest Increase in Prison and Jail Inmate Populations Since Midyear 2000, 2007). Of that number, the rate of TBI is high and ranges from 25% to 87% of incarcerated individuals (CDC Traumatic Brain Injury in Prisons and Jails, n.d.; Wald et al., n.d.). In contrast, the rate of TBI in non-incarcerated adults is estimated to be at lower 8.5%.

Several recent findings provide insight on the epidemiology of TBI in the U.S. prison population (Morrell et al., 1998; Wald et al., n.d.):

Using a structured interview format, 249 (24.9%) of 1,000 consecutively admitted offenders in a Midwestern state prison were found to have experienced at least one head injury. Of the head injured prisoners, 188 (76%) of prisoners reported experiencing a loss of consciousness and 51 (20%) reported having at least one residual symptom. Post-injury difficulties included learning and memory problems (11%), changes in mood or behavior (10%), and post-injury seizures (10%) (Morrell et al).

In a cross-sectional, observational study using standardized interviews of 69 randomly selected inmates from Washington state, 87% reported TBI over their lifetime and 36.2% reported TBI in the year prior to incarceration. The later group had significantly worse anger and aggression scores, tended to score worse on cognitive tests, and had a higher prevalence for psychiatric disorders. (Slaughter, Fann, & Ehde, 2003)

A New Zealand survey of conducted in a minimum to high-medium security prison found 86% of 118 male prisoners has sustained a TBI, with 56.7% reporting more than one. All those with TBI reported difficulties with general memory and socialization with no relationship between level of difficulty and severity of the TBI. (Barnfeild & Leathem, 1998).

In a recent survey using the Traumatic Brain Injury Questionnaire (TBIQ) on 998 Minnesota male state prisoners, 82.8% reported having had one or more head injuries during their lifetime (Diamond et al., 2007).

The high incidence of TBI among the prison population is disconcerting given the connection between head injury and the development of psychiatric disorders discussed previously. According to the CDC, “prisoners who have had head injuries may also


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experience mental health problems such as severe depression and anxiety, substance use disorders, difficulty controlling anger, or suicidal thoughts and/or attempts” (CDC Traumatic Brain Injury in Prisons and Jails, n.d.). This statement is in line with the published literature. A systematic review of the published, peer-reviewed literature by Hesdorffer, Rauch & Tamminga, 2009) found that there was sufficient evidence of an association between TBI and depression as well as similarly compelling evidence of an association between TBI and aggression. As such, the cognitive problems associated a past history of TBI may adversely affect inmates’ potential to succeed in rehabilitation and may increase the risk of recidivism (Valiant et al., 2003).

Cost of Incarceration: Given that a) in 2008, federal, sate and local governments spent nearly $75 billion on corrections (with the bulk of that amount going to incarceration), b) that the U.S. incarceration rate is higher than any other industrialized nation, and c) that our rate of incarceration has been on a steady increase since 1880, finding a treatment solution that reduces any hindrances to rehabilitation and encourages a successful reintegration has both social and budgetary benefits (Center for Economic Policy and Research: The High Budegetary Cost of Incarceration, 2010).

Veterans: “Signature Injuries of the war”- TBI and PTSDWhile TBIs represent a systemic problem for the general population, one of groups most disproportionately affected by TBIs are active military and veteran populations. Since the start of military operations in Iraq and Afghanistan in 2001, more than 1.64 million military personnel have been deployed (RAND, Stop Loss, 2008). Since 2003, the use of improvised explosive devices (IEDs) in terrorist and insurgent activities has increased substantially with each year such that by the end of 2009, they were responsible for nearly 60% of U.S. casualties (iCasualties.org, 2009, IED Fatalities). Due to advancements in protective equipment a higher percentage of soldiers are surviving injuries that would have been fatal in previous wars (Hodge et al., 2008; Okie, 2005). While such advancements have improved overall survival rates and greatly reduced penetrating body injuries, the gear cannot completely protect vital areas such as the head, face and neck (Hodge, 2008; Kocsis & Tessler, 2009; Okie, 2005; Taber, Warden & Hurley, 2006). Subsequently, blast related head, and neck injuries are common among injured service members and account for approximately one- to three-quarters (Gondusky & Reiter, 2005; Hodge et al., 2008; Murray et al., 2005; Okie, 2005; Taber et al., 2006; United States Government Accountability Office: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain, 2008) of service members wounded in action, depending on the source. In addition to the above injuries, blast exposure also causes damage to air containing structures, which body amour protects from penetrating injuries, but not from changes in air pressure. The lungs have been found to be particularly vulnerable. A hypothesis has been advanced that a potential mechanism of TBI is transient AE from blast initiated lung damage (Reimers et al., 2011).

Estimates of soldiers who sustained a TBI while deployed vary and research into the prevalence rates of brain injury among returning troops is sparse (RAND, 2008). This may be attributable to methodological limitations that hinder estimates of the prevalence of TBI in epidemiological surveys (RAND, 2008) and that symptoms associated with TBI may not manifest for a substantial period after the injury was obtained. Further, while identifying penetrating brain injuries (when an object penetrates the skull) is a fairly straightforward


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procedure, estimating the prevalence of non-penetrating, closed head injuries (when an object hits the head but does not penetrate the skull) and primary blast injuries (injuries caused by pressure-wave changes) is difficult. Also adding additional complexity to diagnosis is that the symptoms of TBI and those with other conditions, such as PTSD overlap considerably (Colarusso, 2007). Both disorders are often marked by depression, mood swings, irritability, difficulty concentrating, and memory problems (Colarusso, 2007). Such similarities can cause health care professionals to overlook mTBI, especially when the patient lacks visible wounds. Jordan Grafman, a neuroscientist who studies Vietnam veterans at the NIH states that “mild brain injuries are really difficult to evaluate” because of the overlap in symptomoloy and that “doctors are likely to default to psychological diagnoses especially when they see a lot of PTSD” (Colarusso, 2007).

That being said, the Department of Defense released numbers for TBI totaling 202,481 for the span of 2000-2010 (Defense and Veterans Brain Injury Center, DoD Worldwide Numbers for Traumatic Brain Injury, 2011). For that same 10-year period, a Congressional Research Service (CRS) for Congress (2010) estimates the total number of TBIs during to be 178,876. A recent article by Marion et al. (2011) state that approximately 28,000 service members sustain a TBI each year in the U.S. military, yielding a total of 280,000 for the recent decade long war. Terrio et al. (2009) found confirmed rates of TBI among soldiers in an Army brigade combat team returning from a one-year deployment to Iraq to be 22.8%. Applying that percentage to the current 1.64 million troops deployed would bring the number up to 373,920. The RAND report estimates the number of TBIs to be closer to 320,000 with a strong caution that the figure is an underestimation (Rand, Invisible Wounds, n.d.), a statement seconded by Marion et al. (2011) as many service members often ignore or deny their symptoms so they will be allowed to return to duty.

Regardless of which statistic is espoused, the number of returning veterans suffering from TBI remains substantial and will only continue to grow within the next foreseeable years as more and more currently deployed service members return.

Depression, PTSD and TBIThe connection between TBI and psychiatric disorders seen above with civilian statistics also holds true for military personnel, particularly PTSD or PTSD-like symptoms and/or depression. As with the civilian population, the presence of TBI, PTSD, depression or any other physical, cognitive and/or psychological disorder can significantly interfere with a successful transition from military to civilian life. Adding further concern is high likelihood of co-morbid disorders (two or more conditions occurring simultaneously). In civilian populations, PTSD and depression frequently co-occur (RAND, 2008). A survey conducted by the RAND corporation indicates that this trend occurs in the military population as well as approximately two-thirds of individuals with PTSD also have probable major depression. Some evidence in military literature indicates that individuals with co-morbid PTSD and depression have more negative consequences than individuals with either disorder alone (Campbell et al. 2007).

As previously discussed, depression following TBI is common and can be experienced weeks, months to even years following the injury (RAND, 2008). Rates of depression following TBI varies from 15 and 61% (Deb et al., 1999; Kim et al., 2007). This wide range in estimates may be in part due substantial overlap in symptoms between TBI and depression, which makes it difficult to differentiate between afflictions (RAND; Kim et al., 2007).


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Although the role of subtle persistent brain injury in the development of either acute stress disorder (ASD) or PTSD is not without controversy, many clinicians and medical authorities, as well as the public and media, believe that a relationship exists (Kennedy et al. 2007). Furthermore, research consistently supports a strong connection between combat exposure and PTSD. A summary of recent findings is as follows:

A program evaluation data of US marines indicate that combat troops reporting an exposure to blasts had significantly higher levels of PTSD (Kennedy et al., 2007). Koren et al. (2005) found that physical injury due to combat is a major risk factor for the development of PTSD.

Studies investigating the relationship between PTSD and injury in Vietnam veterans found that rates of PTSD were two- to threefold higher in injured veterans than with their unharmed counterparts (Kula, 1990; Pitman, Altman & Macklin, 1989).

A review of the literature by van Reekum et al. (2000) shows an increased rate of PTSD after TBI, with the reviewed data yielding an estimated relative risk of 1.8 of those who developed PTSD over a maximum period of 7.5 years.

An analysis of a subsample from the National Comorbidity Survey (NCS) found that men who reported combat as their worst trauma were more likely to have lifetime PTSD, delayed symptom onset and unresolved PTSD symptoms than men who reported other types of trauma as the worst. They were also more likely to be unemployed, fired, divorced, and physically abusive to their spouses (Holley, et al., 2001).

A long-term follow-up of Vietnam veterans found that combat exposure predicted PTSD more strongly than any of the other risk factors examined (e.g., perceived social support, depression, anger, alcohol consumption, community involvement) (Koenen, Stellman, Stellman & Sommer, 2003).

An investigation into the prevalence of PTSD symptoms, as opposed to diagnosis, nine to ten months after the war in a group of over 4,000 soldiers of the Persian Gulf war found that 69% of those exposed to combat reported at least one intrusive symptom, 37% reported at least three avoidance symptoms, and 46% reported at least two arousal symptoms (Adler, 1994).

Hodge et al. (2004) studied a group of Army and Marine Corps personnel either before or three to four months after deployment. Their results evidenced that 16 to 17% of those returning from Iraq met strict screening criteria for depression, PTSD, or generalized anxiety disorder and approximately 11% returning from Afghanistan met the same criteria. The rate was 9.3% before deployment. For all groups after deployment, there was a strong relation between combat experiences (e.g., being shot at, handling dead bodies, knowing someone who was killed, killing enemy combatants) and PTSD prevalence with the prevalence of PTSD increasing in a linear manner with the number of combat experiences during deployment.

Researchers believe that combat trauma may be different than other traumatic experiences in that combat trauma may produce more severe and/or chronic PTSD (Kennedy et al., 2007). Combat exposure and/or trauma are also likely to result in high instances of TBI either by direct force or through blast pressure waves. The development of PTSD symptoms after TBI may be related to the type of brain injury sustained, as certain areas of the brain are more susceptible to damage from a blast (Gilliland, 2010). This holds particularly true for the cortical areas. Damage to susceptible cortical areas- particularly the prefrontal and temporal areas- can lead to an inability of the brain to regulate fear and anxiety responses (Gulliland, 2010). Additionally, individuals with PTSD have been shown


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in neuroimaging studies to have an overactive amygdala and insular cortex, which are two areas of the brain responsible for evoking fear and emotional responses, respectively (Stein, McAllister, 2009). PTSD individuals also have been found to have underactive cortical regions, such as the anterior cingulated and other parts of the ventromedial prefrontal cortex believed to regulate the expression of fear by limbic regions (Stein & McAllister, 2009). Further, it is well known that exposure to blast can cause lung damage at modest overpressures. A recent paper has point out that this lung injury may lead to transient air embolism, which in turn produces cognitive brain damage much like what is seen with dialysis and major thoracic surgery patients. This potentially devastating combination of physical, cognitive and psychological challenges produces a unique problem for returning soldiers, a point that is underscored by the oft-cited statement that TBI and PTSD are the “signature injuries” of OEF and OIF (Gilliland, 2010). Depression, however, is also emerging as a common and debilitating injury.

The RAND (2008) report also estimates that approximately 18.5% (303,400) of returning service members meet the criteria for PTSD or depression, 14% (229,600) meet the criteria for PTSD alone and approximately 7% (114,800) meet the criteria for a mental health problem and report a possible TBI (See Figure 3). In total, approximately one-third, or 541,200 of all returning service members report symptoms of a mental health or cognitive condition (RAND, 2008). The Congressional Research Service however, places the overall PTSD prevalence rate at a lower 66,935 (CRS, U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, 2010). Figure 4 shows graphically the yearly delineation of new PTSD cases diagnosed across all branches of services. Important to note is that these figures do not take into account those soldiers who seek no treatment out of fear of reprisal or because they worry treatment will have a negative affect on their career (Guilliland, 2010). Considering that four years after the RAND estimate, the current wars are still ongoing, the above figures are now unquestionably higher; thus, these figures should be interpreted as underestimations as to the actual number of affected veterans. Indeed, a recent 2010 CBS investigative report found that over 1.5 million troops have asked for psychiatric assistance, indicating that the number of affected soldiers struggling with TBI and/or mental health issues is high. You wanted me to add a statement that civilian data suggests something- that many diagnoses of PTSD could be TBI . I do not see that suggestion, and if we are inferring that, then we need to tread cautiously drawing that conclusion.

Figure 3Rates of PTSD, Depression, and TBI Across All Military from Operation Enduring Freedom and Iraqi Freedom


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Source: RAND, Invisible Wounds

Figure 4Annual New Post-Traumatic Stress Disorder Diagnoses in All Services As of 2010

Source: U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and

Operation Enduring Freedom (Fischer, 2010).


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Regardless of which statistic is used to enumerate the number of returning soldiers who suffer from TBI, PTSD, and/or depression, the number is substantial and is only going to increase as more and more soldiers return from the war. The RAND report estimates that the two-year costs resulting from PTSD and major depression for the approximately 1.6 million troops who have been deployed since the start of military operations in 2001 could range from $4.0 to $6.2 billion dollars, depending on how lives lost to suicide are calculated. However, the RAND also cautions “if service members continue to be deployed in the future, expected costs will increase beyond the range discussed” (p. 171). Considering that the RAND report was released in 2008, the figures are likely to be higher than their previous estimations.

Providing these soldiers with evidenced based treatment, or treatment that has “been proven to work”, (p.9) could likely reduce the costs by as much as 27%. Hodge et al. (2003), however, found that less than half of returning soldiers and marines with probable mental health condition(s) received care within the three to four months from returning from OEF or OIF and an even smaller percentage received evidence-based care. A survey conduced by the RAND corporation found that approximately only 50% of post-deployed servicemen with mental health conditions received any treatment. Increasing the percentage of veterans who receive care would greatly improve health outcomes and increasing the number of veterans who receive evidenced based care would yield even greater improvements (RAND, book).

Healing these soldiers is paramount as studies have found that veterans with PTSD have a lower probability of working (Smith, Schnurr, and Rosenheck, 2005), miss more work days (Hodge et al., 2007), demonstrate reduced productivity while at work (Stewart et al., 2003), and have lower earnings (Sovoca and Rosenheck, 2000) than peers without a mental health condition (RAND). Further, there may be significant costs stemming from their mental illness including but not limited to: increased non-mental health related medical costs, caregiver burden, strain on family relationships, domestic violence, substance abuse, crime, and homelessness (RAND, Dekel and Solomon, 2006; Brooks, 1991; Solomon et al., 1992), several of which will be discussed in further detail below.

Cost of Veteran PTSD, Depression and TBIPTSD and DepressionThe most comprehensive and frequently cited statistics for the costs of mental health and cognitive conditions to the individual and society comes from the RAND report. Using a microsimulation model, the RAND report estimated that the two-year costs (costs incurred within the first two years after service members return home) on a per-case basis for PTSD were approximately $5,904 to $10,298, depending on whether or not lives lost to suicide were included*. The two-year costs associated with depression were approximately $15,461 to $25,757 and for co-morbid PTSD and depression, the costs were $12,427 to $16,884. RAND estimated the total two-year costs of PTSD and depression in 2007 could range from $4.0 to $6.2 billion. Approximately 55 to 95% of total costs can be attributed to loss of productivity making it a key cost driver for PTSD and major depression.

* On the basis of several studies and systemic reviews, the RAND estimates the value of a statistical life to be $7.5 million. Theoretically speaking, this value would capture all costs associated with death that would be valued by a worker, which includes lost quality of life, grief and loss to family members, and pain and suffering


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Regarding TBI, RAND used one-year costs using a standard cost-of-illness approach for calculations as opposed to two-year cost projections due to insufficient data. As such, the one-year cost for service members who had accessed the healthcare system and received a diagnosis of TBI were substantially higher and ranged from $25,572 to $30,730 in 2005 for mild cases (2007 costs would range from $27,259 to $32,759). For moderate to severe cases, the costs ranged from $252,251 to $383,221(2007 costs would range from $268,902 to $408,519). Applying these costs to the total number of identified TBI cases in 2007, the total costs incurred within the first year after diagnosis could range from $591 million to $910 million (in 2007 dollars). For mTBI, productivity losses may account for 47 to 57% of total costs whereas moderate to severe TBI can account for upwards of 70 to 80% due to higher rates of mortality associated with such an injury. You said why not use 2011 costs here? Because the author’s data is based on 2007 figures. We cannot change what her findings were when we are reporting her numbers.

In a separate assessment, Gilliland used raw medical data to assess the direct medical costs associated with mTBI and PTSD. Over a two-year period (2007 to 2008), Gilliland found that the average military cost per incidence of outpatient PTSD was $340 per incidence. During the two-year period, 66,169 patients were treated for PTSD and incurred a cost of $22.6 million (approximately $3,400 per patient). Thus, assuming the number of outpatient PTSD incidences are consistent thorough the war, Gilliland estimated that the 2003-2010 DoD bill for PTSD alone would rise to $90.6 million. Inpatient PTSD treatment was more costly. According to the data, there were 3,031 inpatients that were treated for PTSD alone, yielding a per-patient cost of approximately $10,600, and a total cost of $33.2 million for PTSD.

Important to note is that none of these cost estimations include potential later costs from substance abuse, domestic violence, homelessness, family strain, as well as several other factors. Thus, both Gilliland and RAND caution that these figures are underestimations of the true scope of the problem.

TBI RAND calculated TBI costs using civilian data, as they were unable to collect any data from the military or VA. Similarly, information on standard treatments and/or rehabilitation was unavailable at the time of the report as well. As such, the data presented by RAND relies heavily on civilian TBI patients. Perhaps not surprisingly, the cost of TBI varies substantially according to the severity of the injury. The estimated one-year cost per case of mild TBI ranges from $27,260 to $32,760. For moderate to severe TBI, the estimated one-year per case related cost ranges from $268,900 to $408,520. Many of the costs associated with TBI will continue into the long-term, thus RAND cautions that their estimations are conservative.

Additionally, there is considerable uncertainty regarding the societal costs of TBI. Serious concerns remain regarding the number of TBI cases, the severity of those cases and the extent of co-morbidity with PTSD and major depression. The RAND estimates that based on the relatively small number of 2,726 cases of post deployment TBI, the total one-year cost of TBI ranges from $591 to $910 million, depending on different assumptions about treatment levels, impact on wages, suicides and other related deaths. Additionally, these figures only account for the cases of diagnosed TBI and do not include those who have either not sought treatment or who have not formally been treated. Table 3 provides a more detailed breakdown of the estimated total costs and per-case total costs of


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deployment related TBI in 2005. As shown in the table, cost varies considerably by injury severity. For mTBI, the total per-case cost including hospital care, rehabilitation, and unemployment ranged from $25,571 to $30,730, yielding a total cost of $7,134,344 to $8,573,713. For moderate to severe TBI the figures include rehabilitation, suicide costs, unemployment and loss of productivity and range from $252,251 to $383,221 on a per-cast basis, resulting in totals ranging from $83,495,045 to $126,846,060.

Table 3Total and Per-Case Costs of Deployment-Related TBI in 2005

Overall Mild Severe

High Low High Low High Low

Treatment Costs

Hospital acute care

$14,328,355 $6,918,625 $4,119,778 $2,922,792 $10,208,577 $3,995,833

Inpatient rehabilitation

$1,952,535 $1,952,535 0 0 $1,952,535 $1,952,535

Outpatient rehabilitation

$906,734 $376,941 $414,836 $172,453 $491,898 $204,489

Mortality costs

TBI-related deaths

$88,715,289 $66,709,380 0 0 $88,715,289 $66,709,380

Suicide costs

Deaths from suicide

$14,721,421 0 0 0 $14,721,421 0

Suicide attempts

$123,533 0 0 0 $123,533 0

Productivity costs

Unemployment (lost productivity)

$13,465,192 $13,465,192 $4,039,099 $4,039,099 $9,426,092 $9,426,092

Reduced wages for those working

$1,206,715 $1,206,715 0 0 $1,206,715 $1,206,715

TOTALS

Total cost of TBI

$135,419,733 $90,629,389 $8,573,713 $7,134,344 $126,846,060 $83.495,045

Total cost per case of TBI

$222,000 $148,573 $30,073 $25,571 $383,221 $252,251

Source: RAND

The RAND used an adjusted per-case cost estimate for 2005 to generate a total cost of all deployment-related TBI cases identified since September 2001 (2,726) as reported in Serve, Support, Simplify, the report of the President’s Commission on Care for America’s Returning Wounded Warriors (2007, cited). The model developed by RAND eliminates the residual moderate/severe TBI cases from prior years, so that the per-case cost reflects only the costs incurred in the first year post-injury. The results of the model, as shown in Table WORKING DRAFT: For pre-release to Policy Officials ONLY.August 31, 2011

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4, indicate that the overall cost of deployment-related TBI for 2,726 wounded soldiers ranges between $554 million and $854 million. However, given that the DoD current estimate of TBI amongst service members is approximately 202,000, the RAND reports figures are unquestionably gross underestimations of the actual cost of TBI. While the 2,726 brain-injured soldiers would have been counted in the 202,000 DoD figure, that still leaves approximately 199,274 TBIs that need treatment and/or rehabilitation that were not included in the RAND analysis. Thus, if we took the low-cost estimation for mTBI ($25,571), excluded the already counted 2,726 TBIs, and assumed that all the remaining TBIs (199,274) were mild, the current cost of TBI would be approximately $5.1 billion. However, that is a conservative estimate, as it does not take into account any moderate/severe TBI, which in the RAND numbers accounted for nearly a third of their 2,726 total (this percentage is also supported by CDC civilian TBI statistics, which shows that approximately 25% of TBIs are moderate/severe). Additionally, the discrepancy between the RAND one-year TBI estimates and the current DoD total estimate strongly suggests that the underlying condition that produced the symptoms of PTSD and major depression were in reality undiagnosed TBI.

Table 4Total and Per-Case Cost of Deployment-Related TBI

Mild Moderate/Severe Total

High Low High Low High Low

Number of cases

1,800 1,800 926 926 2,276 2,276

Per-case cost

$30,730 $25,571 $862,621 $549,183 $313,317 $203,438

Total $55,314,277 $46,028,025 $798,786,7974 $508,543,345 $854,101,071 $554,571,370

In a separate analysis, Gilliland estimates that the over the 2003-1010 period, the DoD will incur a bill of 11.5 million for outpatient mTBI alone (at $373 average outpatient cost). When a person has mTBI and PTSD, the average outpatient cost drops to $340 per patient. The author suggests that the lower cots for the co-morbid disorder could be the result of a low number of people admitted to the outpatient clinic for both disorders. The total estimated outpatient cost for mTBI and PTSD was $264,178. The figure jumps, however, to $22,901,662 when considering PTSD patients also present with some mTBI diagnosis. Considering the difficulty with accurately identifying closed head injuries, of which mTBIs usually represent, and the overlap between TBI and PTSD symptoms, the later figure is more representative of the true cost figure.

Inpatient mTBI costs were significantly higher because of bed days. For patients diagnosed with mTBI alone, the average cost was $10,983 per patient. If the patient also has PTSD, the figure increases by $560, a jump of 4.9%. The authors state that while that figure may seem


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small, there were thirty-nine key entries that contained PTSD when mTBI data was pulled, which yielded an additional medical bill of $21,840 to treat those patients.

Unemployed VeteransWhile it is tempting to think that having veteran status would yield attractive employment opportunities, statistics show that this is not the case. In fact, for the younger veterans returning form the current wars, the exact opposite appears to be true. According to the Bureau of Labor Statistics, veterans between the ages of 18 and 24 had an unemployment rate in 2008 of 14.1 percent; nearly double the rate of those ages 25 to 34 (7.3 percent), and almost three times the rate for 35 to 44 year olds (4.9 percent) (http://www.bls.gov/opub/ted/2009/mar/wk4/art01.htm). While one hypothesis for the high unemployment rates is that service members often have a hard time translating their military skills to ones useful in the civilian sector (http://news.yahoo.com/s/ac/20110208/bs_ac/7797370_veterans_unemployment_rate_reaches_an_alarming_15_percent), employment department officials cite high rates of PTSD, depression and brain injury as the reason for such high unemployment (http://www.signonsandiego.com/news/2010/nov/18/young-veterans-high-unemployment/).

Figure XUnemployment Rate of Veterans Who Served Since September 2001 and Non-Veterans, Selected Age Groups 2008

(http://www.bls.gov/opub/ted/2009/mar/wk4/art01.htm

While the downstream consequences of TBI, PTSD, and/or PTSD-like symptoms seen with the veteran population are reflected in unemployment, the consequences of such mental health issues are also reflected in two other important social areas: veteran homelessness and incarceration.


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http://www.bls.gov/opub/ted/2009/mar/wk4/art01.htm

http://www.signonsandiego.com/news/2010/nov/18/young-veterans-high-unemployment/

http://www.signonsandiego.com/news/2010/nov/18/young-veterans-high-unemployment/

http://news.yahoo.com/s/ac/20110208/bs_ac/7797370_veterans_unemployment_rate_reaches_an_alarming_15_percent

http://news.yahoo.com/s/ac/20110208/bs_ac/7797370_veterans_unemployment_rate_reaches_an_alarming_15_percent

http://www.bls.gov/opub/ted/2009/mar/wk4/art01.htm


Homeless VeteransEmbedded in the overall homeless population discussed above are a shockingly high proportion of veterans. According to the National Coalition for Homeless Veterans (NCHV), only 8% of the general population can claim veteran status, however, approximately 23% of the adult homeless population is comprised of veterans. Included in this population are veterans who served in World War II, the Korean War, Cold War, Vietnam War, Grenada, Panama, Lebanon, Afghanistan and Iraq. Two-thirds served our country for a minimum of three years and one-third were stationed in a war zone. The vast majority served our country valiantly and well; in fact 89% of homeless veterans received an honorable discharge.

Due to the transient nature of homeless populations, obtaining a truly accurate number of homeless veterans is impossible. However, the Veterans Association estimates that approximately 154,000 veterans were homeless in 2008. On any given night the VA estimates that there are approximately 107,000 homeless veterans on the streets or in shelters15. According to the NCHV, over the course of a year, nearly two times that amount may be homeless. The NCHV further states that an estimated 1.5 million veterans are considered to be at risk of homelessness due to poverty, lack of support networks, and substandard housing conditions.

According to the United States Interagency Council on Homelessness (USICH), the majority of homeless veterans (96%) are males, however, the number of homeless women veterans is increasing dramatically as is the number of homeless veterans who have dependent children. According to the VA, there are an estimated 6,500 homeless female veterans on the streets, nearly double the number of a decade ago. In general, veterans as a whole have high instances of PTSD, TBI, and sexual trauma, all of which are factors that can increase the risk of homelessness (USICH).

Other relevant findings related to the homeless veteran population:2,3,4

85% of homeless veterans finished high school or have a GED equivalent, compared to 56% of non-veteran homeless.

33% of the total male homeless population is veterans. 76% experience of homeless veterans experience alcohol, drug or mental

health problems. According to the National Coalition for the Homeless, 38% of the general homeless population are addicted to alcohol, 26% dependent on other drugs, and 20-25% have a mental illness. 21

According to the USICH “about half of homeless Veterans have serious mental illness and 70 percent have substance abuse problems”. http://www.ich.gov/PDF/FactSheetVeterans.pdf

Obtaining a figure on the number of homeless veterans who suffer from a TBI was not possible at the time this paper was disseminated. However, in light of the above discussion on the association between TBI and psychiatric disorders, the preponderance of veterans who have sustained a TBI during their service, and the VA’s estimation that the majority of homeless veterans suffer from a disability, the likelihood that the disability many homeless veterans are suffering from is a TBI is high. Further, given that nearly 90% of homeless veterans received an honorable discharge, it would be difficult to assert the argument that

2 (National Coalition for Homeless Veterans, 2009)3 (Longley, 2008)4 (The Urban Institute, et al., 1999) NOT CITEDWORKING DRAFT: For pre-release to Policy Officials ONLY.August 31, 2011

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the veterans who comprise this unfortunate group are the derelicts or castaways of the service. Indeed, such a high percentage of men and women honorably discharged provide strong indication that some event(s) occurred to these service members that rendered a successful transition back to civilian life impossible.

Despite the 3.5 billion dollars the U.S, government spent in 2010 on issues pertaining to homeless veterans in 2010, the rate of veteran homelessness continues to be a problem (Navy times). The VA is now asking for $4.2 billion in 2011. VA secretary Eric Shinseki stated that while the overall estimates of homeless veterans is down from a decade ago, the problem still represents a “national shame”.

Incarcerated VeteransIn addition to homelessness being a significant concern for veterans, clashes with the criminal justices system appear to be problematic as well. The most recent report by the Bureau of Justice Statistics on incarcerated veterans was obtained from data examined in 2004 (http://bjs.ojp.usdoj.gov/content/pub/pdf/vsfp04.pdf). The report was released in 2007. According to this report, there were an estimated 1,496,629 inmates in both federal and state prisons. Out of that number, approximately 140,000 were veterans. Of the total 1,496,629 inmates, there were 127,500 veterans in state prisons, and 12,500 veterans in federal prisons. In 2004, the U.S. Army accounted for 46% of veterans living in the United States but 56% of veterans in state prison. Approximately 54% of state prison veterans reported having served during a wartime era and 20% saw combat duty. In federal prison, approximately 75% of veterans had served during wartime and 25% saw combat. Veterans were also better educated than other prisoners. Nearly all veterans in state prisoners (91%) reported at least a high school diploma or GED while approximately 40% of non-veterans lacked either. Again, a high proportion of these veterans served our country valiantly as evidenced by the 62% of incarcerated veterans (or 6 in 10) who received an honorable discharge. (http://www.nchv.org/background.cfm#questions)

While it is true that historically, veterans as a whole have consistently lower incarceration rates (630 out of 100,000 adult males) than their nonveteran peers, (1,390 out of 100,000 adult males), several disturbing trends have emerged since the two current wars have commenced. The first is reflected in problems with interpersonal relationships and intimate-partner violence. According to RAND, returning service members suffering from mental health disorders report experiencing problems with restraining negative emotions, especially anger and aggression. According to a conceptual framework developed by Chemtob et al. (1997), in veterans with PTSD the experience of traumatic events during combat results with a chronic and excessive sensitivity to threats, even after they return home, and to a corresponding tendency to respond to perceived threats with hostility. Survey research conducted on veterans with PTSD supports this assertion as veterans with PTSD experience higher levels of anger than nonveterans with PTSD or veterans with other psychiatric diagnoses (Chetomb et al., 1994). Perhaps in part as a result of this first trend, the second trend is born, which is a growing number of state and criminal courts solely devoted to U.S. war veterans returning from Iraq and Afghanistan. These courts have emerged in response to the increasing number of soldiers showing up as defendants with a “special set of problems” ( http://www.law.com/jsp/nlj/PubArticleNLJ.jsp?id=1202426915992&slreturn=1&hbxlogin=1). According to a recent article in law.com, “State court judges are joining with local prosecutors, public defenders, U.S. Department of Veterans Affairs officials and local lawyer volunteers to create courts with veterans-only


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http://www.law.com/jsp/nlj/PubArticleNLJ.jsp?id=1202426915992&slreturn=1&hbxlogin=1

http://www.law.com/jsp/nlj/PubArticleNLJ.jsp?id=1202426915992&slreturn=1&hbxlogin=1

http://www.nchv.org/background.cfm#questions


case proceedings, because they have seen a common thread of post-traumatic stress disorder (PTSD), substance abuse, head injuries and mental illness underlying the veterans' crimes” (same article cited above).

According to the Center for Economic and Policy Research (CEPR), the U.S. currently incarcerates a higher proportion of its population than any other country in the world. In 2008, the U.S. incarceration rare was 753 per 100,000 people, that is 240% higher than it was in 1980. In 2008, state governments spent a combined 75 billion dollars on corrections- the large majority of which was spent on incarceration. Reducing the number of non-violent offenders by half would result with an annual savings of $16.9 billion per year, with the largest portion of theses savings accruing to financially squeezed state and local governments. Applying this to veterans, if we assume that the 2004 BJS statistic that approximately 20% of the prison population report prior military service holds true for today, getting veterans with mental health issues appropriate treatment could yield a savings of $1.9 billion annually if only 10% (or half) of veterans could be treated and kept out of the criminal justice system. However, given that the 2004 statistics do not capture the last 6 years of the current wars, there is reason to believe that the percentage of incarcerated veterans is likely to be higher, or at the very least grow, as more and more veterans with mental health issues continue to either return home, or struggle at home, yielding a savings greater than $1.9 billion. (All citations for this paragraph can be found at: http://www.cepr.net/documents/publications/incarceration-2010-06.pdf)

Ways to Reduce Costs The importance of identifying and implementing a successful, evidence based treatment for TBI cannot be understated for several reasons. One is that the suffering individual pays dearly in loss of quality of life for the rest of their life. The other is that unsuccessfully treated brain injury causes a significant economic strain in loss of productivity and medical expenses. These two points are underscored by the fact that two of the civilian age ranges (ages 1-4, and 15-25) with the highest rates of TBI are under the age of 25, and the average age of an active duty soldier is 2722. Thus, survivors may have relatively long life spans to deal with their disability (Kim et al). Similarly, the societal costs of dealing with those disabilities continue for the survivors remaining life span

RAND estimates that by investing in more evidence based treatment, defined as “treatments that has been proven to work” (p. 9), the costs associated with PTSD and major depression would pay for itself within two-years, even without including the costs related to substance abuse, homelessness, family strain, and other indirect consequences of mental health conditions. See Appendix A for a delineation of the levels of evidence-based care.

Current research indicates that the “status quo” for treatment rates is that approximately 30% of individuals with mental health conditions receive care and of that, 30% receive evidence-based care (RAND). As such, the projected cost savings associated with investing in more evidenced based care for a cohort of E-5’s is reflected in Table 1. As evidenced by the table, society would save approximately $32.6 million, if the rates of evidenced based care were increased from 30 to 50% and by $86.2 million if all treatment was evidence based. Table 2 provides a more detailed breakdown of the average Department of Defense (DoD) cost associated with each disorder and the relative savings WORKING DRAFT: For pre-release to Policy Officials ONLY.August 31, 2011

26

“What’s been happening for a long period of time is that we’ve been admiring the problem. We haven’t really affected behaviors to get these (soldiers) the treatment they need.”

-Brig. Gen. Richard Thomas

http://www.cepr.net/documents/publications/incarceration-2010-06.pdf


associated with increasing evidence based treatment per each disorder. Figure 3 shows the same costs-per case that would be saved graphically by investing in more evidence-based care.

Table 1Projected Savings Relative to Status Quo With Increasing Treatment: A cohort of 50,000 E-5’s taken from the RAND Report

Treatment Scenario Baseline Low-Cost* High-Cost**

A. Savings relative to status quo, including cost of lives lost to suicide

50% receive treatment; 30% of treatment is evidence based

$13,936,899 $13,514,394 $19,238,061

50% receive treatment; all treatment is evidence based

$32,667,902 $10,129,509 $21,335,384

100% receive evidence based treatment

$86,241,152 $40,530,609 $71,527,859

* Low cost scenario assumed that a mental health condition had no effect on productivity for active duty personnel** High cost scenario assumed that a mental health condition has the same effect on productivity for active duty personnel as it does for civilian veterans

Table 2Approximate DoD Average Cost per Individual Associated with Each Disorder Assuming Status Quo And Savings Associated With Increasing Evidence Based Treatment taken from the RAND Report

Conditions Approximate DoD average “Status quo*” COST per disorder

Savings if 50% receive treatment; 30% of treatment is evidence based

Savings if 50% receive treatment; all treatment is evidence based

Savings if 100% receive evidence based treatment

A. Including lives lost to suicide

PTSD $10,298 $445 $819 $2,306

Co-morbid PTSD and major depression

$16,884 $1,264 $551 $2,997


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Major depression

$25,757 $5,327 $2,483 $9,240

* Note: Status quo assumed based on existing research that 30% of individuals suffering with a mental health disorder receive treatment, and of that number, 30% receive evidence-based treatment.

Figure 3 Costs per Case (including medical costs, productivity costs, and costs of lives lost to suicide) That Would Be Saved By Investing In More Evidence-Based Care.

Certain treatments have been shown to be effective in treating mTBI, PTSD, PTSD-like symptoms, and depression; however, three major barriers to care remain. One is that not all of these evidence-based treatments are widely available in all treatment settings (RAND). The other is that certain treatments that have well documented empirical support are not yet recognized or espoused by military physicians. One such evidenced-based treatment is hyperbaric oxygen therapy (HBOT), which has been used by civilian physicians for decades to treat mTBI and the neurological and psychiatric sequelea that such an injury foments. While HBOT will be explained in brief detail below, a more in depth explanation of HBOT, its mechanisms of action and supporting science can be found in the attached “Statement of the science 1.5: Hyperbaric oxygen therapy effectively treats traumatic brain injury and PTSD”. The last barrier, and perhaps the most disturbing, is that while the military has improved screening of mTBI with returning soldiers, little is being done by the military to get service members to definitive care.


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Regarding the latter of the three barriers, Brig. Gen. Richard Thomas states, “What’s been happening for a long period of time is that we’ve been admiring the problem. We haven’t really affected behaviors to get these (soldiers) the treatment they need.”(http://www.army.mil/-news/2011/05/01/55479-could-be-more-than-a-headache/). This sentiment is echoed by a recent federal appeals court in California which ordered the Veterans Affairs Department to develop a system wide mental health care plan, citing “unchecked incompetence” in the department’s care for veterans (http://www.nextgov.com/nextgov/ng_20110511_7685.php?oref=rss?zone=NGtoday). The lack of action regarding screening, educating and treating brain injured soldiers sooner has resulted with affected soldiers performing at suboptimal levels and thus running the risk of being concussed again before they were fully healed, leading to long-term problems (http://www.army.mil/-news/2011/05/01/55479-could-be-more-than-a-headache/). The severity of the problem is underscored by the high rates of veteran suicides. According to Judge Stephen Reinhardt, the delay in getting veterans care has resulted with an average of 18 veterans committing suicide each day and another 1,000 attempting suicide each month. According to the DoD, military suicides have more than doubled in the Army, exceeding the national average over the past five years (http://www.defense.gov/home/features/2010/0810_restoringhope/). Judge Reinhardt stated, “No more veterans should be compelled to agonize or perish while the government fails to fulfill its obligations”. http://www.nextgov.com/nextgov/ng_20110511_7685.php?oref=rss?zone=NGtoday.

Thus, while it is important to identify brain-injured soldiers, it is an incomplete solution if the process stops there. In order to effectively reduce costs and give soldiers with TBI what is essentially society’s obligation, we need to be identifying and effectively treating those soldiers and veterans who have suffered a mTBI, or those who have had multiple mTBIs with treatments that have been proven to work. Doing little to nothing, except attempt to screen and enumerate the problem, is only going to increase costs associated with TBI and the neuropsychological sequelea that follows. As stated by previously, providing injured soldiers with evidence-based care would significantly reduce, if not eliminate the costs associated with PTSD and major depression, which are strongly related to TBI. In other words, espousing evidence-based treatment would pay for itself within two-years, even if the costs related to substance abuse, homelessness, family strain, and other indirect consequences of mental health conditions are considered.

To provide a relevant example of how critically important and cost effective providing evidence-based care can be, a recent report emerged on August 22, 2011 that the VA had spent $717 million dollars over the past decade to purchase risperidone, the generic name for the anti-psychotic Risperidal to treat PTSD, and that department researchers found that that the drug was no more effective than a placebo. The results of the study were published August 2, 2011 in the Journal of the American Medical Association. On August 11, 2011 the VA awarded a contract to the pharmaceutical company that manufactures risperidone for more than 200,000 bottles of the drug containing more than 20 million pills in multiple dosages. While the Food and Drug Administration has approved risperidone for the treatment of schizophrenia, bipolar disorder, and irritability associated with autistic disorder in children and adolescents, it is not approved for the treatment of PTSD and research indicates it is not effective. Thus, the evidence supporting further use of this drug is severely limited.


29

http://www.nextgov.com/nextgov/ng_20110511_7685.php?oref=rss?zone=NGtoday

http://www.nextgov.com/nextgov/ng_20110511_7685.php?oref=rss?zone=NGtoday

http://www.defense.gov/home/features/2010/0810_restoringhope/

http://www.army.mil/-news/2011/05/01/55479-could-be-more-than-a-headache/

http://www.army.mil/-news/2011/05/01/55479-could-be-more-than-a-headache/


HBOT for TBI: An evidence-based treatment

What can be done? Hyperbaric oxygen therapy (HBOT) is the intermittent delivering of 100-percent pure oxygen at greater than normal atmospheric pressure. HBOT is a non-invasive and non-pharmaceutical way to repair damaged tissue. The positive effect HBOT has on the tissue repair is the result of two oxygen-dependent processes, the activation of growth factors at the DNA level and the improvement of blood supply to poorly perfused tissues. As a result, HBOT positively impacts, and is approved to treat some of the most difficult and costly health disorders such as:

Gas gangrene Crush injuries Acute traumatic ischemias Air or gas embolism Decompression sickness (DCS) Necrotizing fasciitis Osteomyelitis Chronic wounds Radiation wounds.

HBOT is also approved to treat the following four neurological disorders:

Intracranial abscess Carbon monoxide poisoning Arterial gas embolism (AGE) Neurological decompression sickness (DCS).

Table X shows the current conditions where treatment with HBOT is indicated.

The positive effects of HBOT on tissue repair occur regardless of the location of the wound(s) in the body. Accordingly, when correctly dosed, HBOT acts on non-healing brain injuries in much the same manner as with more visible non-healing wounds on the body (e.g., diabetic foot wounds, necrotizing fasciitis). While HBOT for the treatment of neurological disorders is nothing new- the navies of the world have been using it to treat neurological DCS since the 1930’s- what is new is the understanding that HBOT can be used to treat other forms of TBI.

While the healing effects of HBOT in the acute treatment of decompression illness (DCS) have been known for decades, the condition of the injured brain after the acute phase of illness was thought to be more or less “permanent”38. However, Harch et al have demonstrated the efficacy of HBOT at 1.5 ATA (HBOT 1.5) in healing decompression sickness brain injury late after injury in the chronic phase of illness 39,40,41,42. Importantly, clinically stable divers with residual brain injury from decompression sickness had a significant positive response to HBOT 1.5, even when their condition was thought to be unchangeable43.

In addition to its role in treating neurologic DCS, HBOT has been shown to be clinically effective in mediating the effects of other forms of brain injury44. For example, Lin et al randomly included 22 TBI patients into a HBOT group while the other 22 corresponding condition patients were assigned into a matched control group. Results evidenced that the HBOT group showed significant improvement in Glasgow Coma Scores and in Glasgow Outcome Scores45. Rockswold has also demonstrated improvement in the Glasgow Coma Scale as well as reduced mortality in acute TBI patients undergoing HBOT with minimal


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risk46,47. HBOT 1.5 in this group of acute patients appears safe and does not produce oxygen toxicity48.

The positive effects of HBOT occur even if treatment occurs months to years after the initial injury. A number of clinicians have demonstrated that HBOT 1.5, when used late after brain injury from a variety of causes (cerebral palsy, hypoxia, carbon monoxide, drowning, and stroke) is capable of promoting clinical improvement. Harch et al treated the first blast-induced combined case of TBI/Post-concussion syndrome/PTSD in a U.S. veteran years after the injury. Wright et al treated two airmen injured in roadside explosive blast four months after the initial injury with HBOT 1.5. Upon completion of the hyperbaric treatments nine months after their initial injury, both showed improvement in all measured areas, with most measures improving to pre-injury baseline levels (see Attachment 2). Hoggard et al treated a brain-injured patient 15 months post-injury. Pre-test and post-test measures for speech, language and cognitive deficits were obtained. The patient demonstrated improvement in all three measured areas49. Hardey et al found that HBOT improved neuropsychological and electrophysical improvements in a chronically brain injured patient one year post-injury50. In sum, the number of reports and cases demonstrating the repeatedly beneficial effects of HBOT 1.5, when applied late after initial brain injury, makes it seem quite unlikely that these effects are mere chance51,52,53,54,55,56,57,58,59,60,61.

An additional benefit to HBOT is that the treatment is safe with very few negative side effects. The most commonly reported side effect is barotrauma to the soft tissues such as the ears and sinuses, also known as a “squeeze”, but these are easily dealt with both prior to and during treatment. HBOT is also often less expensive than current treatments for mTBI and PTSD, which only treat the symptoms and not the underlying disorder or injury. Further, as discussed above, the mechanisms of action of HBOT are now well understood in the scientific literature, providing justification for the treatment of certain disorders and injuries.

For summaries of previous research and the science behind HBOT in treating mTBI and the neurological sequelea, please see “HBOT 1.5: Statement of the Science”

Table X:

FDA Accepted Conditions for HBOT

1. Actinomycosis 2. Air or Gas Embolism

3. Carbon Monoxide Poisoning and Smoke Inhalation

4. Clostridial Myonecrosis (Gas Gangrene)

5. Cyanide Poisoning 6. Crush Injury, Compartment Syndrome, and other Acute Traumatic Ischemias

7. Decompression Sickness 8. Diabetic Wounds

9. Necrotizing Soft Tissue Infections 10. Osteomyelitis (Refractory)

11. Radiation Tissue Damage (Osteoradionecrosis)

12. Severe Anemia

13. Skin Grafts and Flaps (Compromised) 14. Thermal Burns


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How much could be saved if HBOT were provided?In addition to the costs associated with TBI, PTSD and depression discussed previously in the paper (which took into account hospitalization, rehabilitation and loss of productivity), providing brain injured service members with effective evidence-based treatment would also save considerable costs in other areas, two of which are in taxable income and disability payout savings.

To illustrate, Table X provides a similar example as one used previously to demonstrate tax savings, however we will extend the example to include disability savings, costs of HBOT and savings accrued over a 10-year period.

Using the DoD’s estimate of TBI (202,481) we applied the same 45% employment drop after TBI found in civilian TBI. In this example, we did not apply the NINDS 20% estimation of individuals with lingering disability from TBI and apply it to the overall 202,481 because we assumed that if the military is willing to diagnose a service member with a TBI, then that service member is likely to be unable to function at their pre-injury rate, and therefore has a lingering disability. Thus, approximately, 91,116 veterans will be unable to find employment in the civilian sector due to their injuries. For this group, we also assumed that they would be receiving 100% disability benefits. Given that the average salary for Americans in 2009 was $40,711.61 (http://www.ssa.gov/oact/cola/AWI.html), and that 25% of that income would be paid to taxes, for every unemployed veteran there is a potential loss of $10,175 in tax revenue per year. Applying that figure to our example cohort, that yields an annual total tax loss of $927 million dollars and an annual disability payout of $3 billion. Cumulatively, that is an annual loss of $4 billion, and an annual savings of as much if the approximately 91,116 veterans could be restored to pre-injury levels. Even if only 50% were restored to pre-injury level, that would still yield a savings of $2 billion.

Table X

TBI

DoD estimate of war-related TBI 202,481

Estimated drop in employment status one-year post-injury

45%

Number unemployed post-injury 91,116

National average wage index 2009 $40,700

Loss of tax revenue per individual $10,175

Total loss of tax revenue for one year $927 million


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Average disability payment (no dependants)*

$32,076

Disability savings if treatment is 100% effective, per year

$3 billion

Disability savings if treatment is 50% effective, per year

$1.5 billion

Total amount saved if 100% of service members were restored, per year

$4 billion

Savings Accrued with Restoring Brain-Injured Veterans to Pre-Injury Levels*http://www.military.com/benefits/veteran-benefits/va-compensation-tables**http://www.2k.army.mil/faqs.htm#costper

The cost of HBOT is approximately $25,000 for the total 80 treatments. While it may seem expensive compared to other treatment modalities, it has few if any side effects relative to other treatments and the effects are permanent. Important to note, however, is that this treatment more than pays for itself within the span of ten years, even only half experience benefit sufficient to be able to return to gainful employment. Table XX outlines the cost/benefit analysis for a cohort of 1,000 brain-injured soldiers for three scenarios: a) a 50% treatment efficacy rate (efficacy = return to gainful employment), b) 80% efficacy rate (as seen with the NBIRR study) and c: maintenance of the status. As evidenced by the table, cost of maintaining the status quo for this group would be $32 million for the first two years, and would balloon to a total of $288 million by year ten. The one-time cost of HBOT for those 1,000 veterans would total $25 million. Across all categories, we assumed that during Year 1, there would be 100% disability payments and no income earned, therefore, no taxable revenue. If only 50% (500) veterans experienced benefit from HBOT, there would be an annual gain of approximately $5 million in taxable revenue (based on the national average and a 25% income tax), and a disability payout of zero for those healed and a payout of $16 million for those not healed. Therefore, annually the savings relative to the status quo accrued Year Two and later are approximately $21 million and total $165 million after 10 years. If 80% of the veterans were restored, as has been seen in the NBIRR trials, then the annual savings Year Two and later would amount to $33 million and would total $279 million after 10 years.

Table XX

Year 1 Costs Annual Costs, starting Year 2

10 Year Totals

Achieve 50% Gainful Employment

Number of individuals treated 1,000

Number of individuals treated and returned to employment

500


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Number of individuals treated and still not employed (50%)

500

HBOT treatment costs -$25,000,000 -$25,000,000

Tax revenue from persons returned to employment, Year 2 and after

0 $5,087,000 $45,787,500

Disability payments to persons treated and returned to gainful employment

-$16,038,000 0 0

Continuing disability payments to persons treated who failed to return to gainful employment

-$16,038,000 -$16,038,000 $144,342,000

Sub-totals -$57,076,000 -$10,950,500 -$123,554,500

Net savings relative to maintaining the status quo in $

$21,125,500 $165,129,500

Achieve 80% Gainful Employment

Number of individuals treated 1,000

Number of individuals treated and returned to employment

800

Number of individuals treated and still not employed (20%)

200

HBOT treatment costs -$25,000,000 -$25,000,000


0 $8,140,000 $73,260,000

Disability payments to persons treated and returned to gainful employment

-$25,660,800 0 0

Continuing disability payments to persons treated who failed to return to gainful employment

-$6,415,200 -$6,415,200 -$57,736,800


34


Sub-totals -$57,076,000 $1,724,800 -$9,476,800

Net savings relative to maintaining the status quo in $

$33,800,800 $279,207,200

Do Nothing Except Maintain Status Quo

Number of individuals in the cohort 1,000

Number of individuals treated 0

Number of individuals treated and still not employed

0

HBOT treatment costs 0 0


0 0

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 do 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


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http://www.2k.army.mil/faqs.htm#costper


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.


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Appendix A

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 do 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. 4. 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):

1. 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.

2. 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, do not control for confounding factors as completely as RCTs

3. Textbooks, opinions, or descriptive studies. Many recommendations may be based on practices conducted in the field, but lack rigorous empirical evaluation.


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RAND

TBI:

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 1 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/)


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https://www.braintrauma.org/coma-guidelines/