Traumatic brain injury rehabilitation: State of the science

We reviewed 183 studies pertaining to psychosocial functioning and interventions after TBI. Although a wide variety of outcome studies that document the breadth of TBI's impact have been published, the samples described are often small and are rarely representative of the TBI population. Thus, questions regarding the generalizability of findings often remain. This problem is sometimes compounded by a lack of detailed information about the demographic characteristics of the sample, and insufficient attention is paid to cultural mediators of outcomes. Thus, although evidence suggests that significant functional, emotional, behavioral, and social difficulties remain for many years after TBI,^171-173 that severity of injury and premorbid factors predict psychosocial outcomes,^{170,174-179,183} and that friends and family members of people with TBI often experience significant difficulties,^344-347 it remains far from clear whether these findings are applicable to all persons with TBI and in which areas interventions might be effective, for which particular subgroups of individuals with TBI, and for which members of their family-caregiver networks. The fact that terms and measurements are not standardized is also problematic in psychosocial research focused on TBI. For example, although research suggests that premorbid, acute, and rehabilitation variables in multiple domains predict vocational outcomes,²³⁰ productivity is defined, operationalized, and measured in a number of ways across studies. The same problem applies to community integration research. Furthermore, instruments viewed as "gold standards" in measuring a variety of constructs have not been adopted. Although this is obviously not a problem limited to TBI research, it makes it difficult to make global statements about outcomes research and interventions in these areas. In general, prospective, controlled studies with blinded assessors are a rarity, as are truly randomized trials of interventions. In the domain of psychiatric disorders, where there are generally accepted definitions of constructs (e.g., mental disorders operationalized using the DSM) and measures (e.g., the SCID), the evidence suggests that TBI is associated with increased psychopathology, particularly in the areas of mood and anxiety disorders, and impulsive or destructive behaviors, such as aggression and substance abuse. Research in other areas of psychopathology is lacking. Furthermore, there is a dearth of adequate research on interventions for mental disorders in persons with TBI.