Traumatic Brain Injury and Posttraumatic Stress Disorder Are Associated with Physical Health Burden Among Post-9/11 Women Veterans

Abstract

Background:

Little research focuses on physical health outcomes of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) among post-9/11 women veterans (WVs). This study examined lifetime TBI, current PTSD, and their associations with biomarkers of cardiometabolic health, sleep, pain, and functional disability among post-9/11 WVs.

Methods:

WVs (n = 90) from the Translational Research Center for TBI and Stress Disorders longitudinal cohort study were included in this study. Gold standard clinician administered interviews assessed lifetime TBI (Boston Assessment of TBI-Lifetime) and current PTSD symptoms (Clinician-Administered PTSD Scale-IV). Objective measures of health included waist-hip ratio (WHR) and fasted blood biomarker (high density lipoprotein [HDL], low density lipoprotein [LDL], blood glucose, triglycerides) levels. Self-reported surveys assessed sleep, pain, and functional disability.

Results:

Just under two-thirds (58.9%) of WVs experienced a lifetime TBI, and just over half (53.3%) of this sample had a current PTSD diagnosis at the time of testing. Lifetime TBI was significantly associated with higher WHR, triglycerides levels, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.01 to 1.12). Current PTSD was significantly associated with higher WHR, lower HDL, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.009 to 1.19). PTSD was significantly associated with lower total functioning and each of its subdomains (βs = −0.58 to 0.63; ps = <0.001 to 0.02). Lifetime TBI was significantly associated with total functioning, mobility, and life/work (βs = −0.20 to 0.30; ps = <0.01 to 0.02).

Conclusions:

These findings highlight the importance of screening for lifetime TBI and cardiovascular disease for WVs and support transdiagnostic treatment approaches targeting physical health outcomes.

Introduction

Women veterans (WVs) are the fastest growing subpopulation of veterans, and WV enrollment in healthcare services through the Veterans Health Administration (VHA) is rapidly increasing.^1,2 Currently, 16.3% of active duty service members are women, and the number of WVs is projected to increase to over 2.2 million over the next 25 years, due in part to the large number of women involved in post-9/11 conflicts.^1,3 WVs experience high rates of co-occurring physical health comorbidities. Cardiovascular disease is the number one cause of death among women, and WVs experience disproportionate risk for poor cardiometabolic health.^4,5 In addition, up to 75% of WVs accessing VHA care experience chronic pain, and over half (52.3%) experience insomnia or other sleep-related issues.^6

–9 Yet, systemic sex and gender biases often result in under identification and treatment of pain and cardiovascular risk among women, and personal characteristics make treatment engagement challenging among WVs (e.g., racial/ethnic minority status, childcare responsibilities, partner, and sexual violence).^4,10

–14 Moreover, post-9/11 WVs are uniquely impacted by posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), which may exacerbate physical health concerns.¹⁵ Despite recognition of the unique risk factors WVs experience, limited research explores sex- and gender-specific physical health outcomes related to TBI and PTSD. This has left a dearth of evidence around outcomes and recovery for WVs.

TBI is defined as a physiological disruption in brain functioning resulting from an external force to the head. Although symptoms of mild TBI or subconcussive injuries typically resolve within days or weeks, moderate and severe TBI can result in chronic physical and mental health symptoms.^16,17 Reports estimate that between 11% and 15% of post-9/11 WV VHA patients screen positive for TBI.^18
–20 Experiences of TBI differ between women and men veterans. WVs are more likely to experience TBI secondary to partner and sexual violence during and post-military service and less likely to experience combat-related TBIs when compared to their men counterparts.^21,22 Research on TBI across several populations (e.g., military, athletes, general population) has revealed associations between TBI and increased cardiovascular risk, as well as negative impacts on pain and sleep.^23
–25 Yet, few studies focused on TBI have explored sex and gender-specific outcomes.²⁶ This small body of work has found that WVs with a history of TBI report more neurobehavioral symptoms and headaches, increased depression diagnoses, as well as increases in concurrent mental and physical health symptoms when compared to men veterans.^15,27

–30 More research is needed to better assess if differences persist in physical health outcomes among WVs with a history of TBI.

Women are twice as likely as men to develop PTSD, with the highest rates of PTSD (estimated between 12% and 22%) occurring among WVs.^31,32 WVs are more likely to experience partner- and sexual-based violence throughout their lifetime, which contributes to high rates of PTSD among this group. Although most research on PTSD and physical health in veterans is focused on men,^33
–35 research among nonveteran women suggests that PTSD, as well as exposure to sexual violence without a mental health diagnosis, is associated with high risk for acute and chronic cardiovascular disease among women.^36,37 The limited research focused on WVs with PTSD and sexual trauma also suggests associations with chronic and acute cardiometabolic disease^38,39 and high rates of pain and sleep disturbances.^7,13 Despite the increasing recognition of PTSD on diverse physical health outcomes, it is not widely accepted as a risk factor for physical health burdens. This emphasizes the need for more information on PTSD as a risk factor for physical and behavioral health concerns among WVs.

Both TBI and PTSD exacerbate physical and mental health concerns and contribute to complex clinical presentations including increased morbidity and mortality, decreased functioning, and poor quality of life among post-9/11 veterans.^40,41 It is hypothesized that a complex combination of biological (e.g., inflammation, hypothalamic–pituitary–adrenal axis dysregulation), psychological (e.g., anxiety, depression), and behavioral (e.g., low physical activity, low social support) factors combine to contribute to poor health among this cohort and make these symptoms challenging to effectively treat.^29,40,42,43 Although there is increasing acknowledgment of complex interactions of TBI and PTSD on outcomes for veterans within VHA, little research focuses on their contributions to physical health and functioning among WVs.^44,45 This lack of knowledge is problematic given the rapidly expanding population of WVs, the acknowledged sex- and gender- differences in TBI and PTSD related symptoms, and the impact that these physical health burdens may have on functioning.

This study therefore examines the associations between TBI, PTSD, and physical health burden among post-9/11 WVs enrolled in the Translational Research Center for TBI and Stress Disorders (TRACTS) longitudinal cohort study. The primary aim of the current study was to examine whether lifetime TBI and current PTSD are associated with markers of cardiometabolic health (waist-to-hip ratio [WHR], triglycerides, high density lipoprotein [HDL], low density lipoprotein [LDL], blood glucose), and common physical health concerns (pain, sleep) among WVs. A secondary aim was to explore how TBI and PTSD contribute to functional disability and its subdomains (cognition, mobility, self-care, getting along, life activities, participation in society) among post-9/11 WVs.

Methods

Procedures were approved by the Institutional Review Board at VA Boston Healthcare System (Research and Development #2354).

Participants

This study is a secondary analysis of data collected at the Translational Research Center for TBI and Stress Disorders (TRACTS), a VA National Network Center for TBI, located at Boston and Houston VA Healthcare Systems. The TRACTS longitudinal cohort study began in 2009 and assesses the biological, psychological, cognitive, and neural functioning of post-9/11 veterans of the Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) conflicts. Inclusion criteria are age between 18 and 75 years, military deployment in OEF/OIF/OND or other post-9/11 conflict, or scheduled deployment. Exclusion criteria are history of neurological illness other than TBI; history of seizures (unrelated to TBI); current diagnosis of schizophrenia spectrum or other psychotic disorders, bipolar, or related disorders; current suicidal and/or homicidal ideation with intent or plan; or cognitive disorder due to general medical condition other than TBI. In depth information about TRACTS is available in McGlinchey et al., 2017.⁴⁶ Participants in this specific analysis consisted of all veterans who completed baseline (Time 1) appointments and self-identified their sex assigned at birth as female.

Procedures

Measures

TBI and PTSD

TBI and PTSD were assessed with gold standard clinician-administered interviews. The Clinician-Administered PTSD Scale (CAPS-IV⁴⁷) determined the presence of current PTSD and its symptom severity. Diagnostic and Statistical Manual of Mental Disorders IV (DSM-'IV) criteria were used, given these were the criteria when the TRACTS longitudinal cohort study began enrollment (2010). The Boston Assessment of TBI-Lifetime (BAT-L⁴⁸), a validated, semi-structured clinical interview with strong interrater reliability (> 0.80), documented TBI history. The BAT-L has demonstrated strong correspondence with The Ohio State University TBI Identification Method (OSU-TBI-ID; Cohen κ = 0.89; Kendall τ-b = 0.95⁴⁷). For this analysis, positive history of lifetime TBI indicates that the participant sustained at least one head injury that meets the minimum criteria for mild TBI defined by the American Congress of Rehabilitation Medicine.⁴⁹ The TBI burden score is used to assess the cumulative impact of TBIs experienced across the lifespan, considering TBI severity. Lifetime TBI history was used in this investigation, given that WVs experience more civilian TBIs than combat and other military-related TBIs. TBI and PTSD assessments were conducted by doctoral or master’s level clinicians and reviewed at weekly diagnostic consensus meetings consisting of at least three doctoral-level psychologists.

Physical exam

Participants completed a physical exam to assess anthropometric and physiological markers of health. Waist and hip circumference was used to the calculate WHR. Participants fasted for 12 h, and a certified phlebotomist drew 80 mL of blood upon arrival at their appointment. Biomarkers (LDL, HDL, blood glucose, triglycerides) included in this study were consistent with clinical guidance for measuring risk for cardiometabolic disease.

Self-reported measures

Demographics were determined with self-reported questionnaires. Functional disability and its domains were measured using the World Health Organization (WHO) Disability Assessment Schedule II (WHODAS).^50,51 We used the WHODAS simple scoring method, which has a total functioning score, along with six subdomains: Understanding and Communicating, Getting Around, Self-Care, Getting Along With People, Life Activities, and Participation in Society. The WHODAS has been shown to have high internal consistency, stable factor structure, and high test–retest reliability with TBI populations.⁵²

The Pittsburgh Sleep Quality Index,⁵³ which has previously been validated in TBI populations,⁵⁴ was used to determine the presence of sleep disturbance. The recommended global score cutoff of >5 was used to define sleep disturbance. Pain was assessed using the Short Form McGill Pain Questionnaire,^55,56 which has been used previously in mild to moderate TBI.^24,25 Overall pain score was used for this analysis, where scores ranged from 0 (no pain) to 5 (excruciating pain).

Data Analysis

All analyses were conducted with SPSS (version 20). Each test ran in this study was two-sided, and a p-value of <0.05 was used for reporting statistically significant results. Descriptive statistics of this sample are reported. Associations between current PTSD diagnosis (yes/no), history of lifetime TBI (yes/no), objective (WHR, triglycerides, HDL, LDL, and blood glucose), and self-reported (sleep, pain) physical health outcomes were assessed with two-way analysis of variance (ANOVA). Interaction terms between TBI and PTSD were tested. As a follow-up exploratory analysis, we also used bivariate correlations to assess associations between PTSD symptom severity (total score) and characteristics of TBI (time since last TBI, number of TBIs, and lifetime TBI burden score from the BAT-L) with each physical health measure. The false discovery rate was used to correct for multiple comparisons, and associated Q-values are reported.⁵⁷ Effect sizes were calculated with Cohen’s d, and absolute values are reported. Multiple linear regressions analyzed the contribution of PTSD and TBI to functional disability (total) and its associated domains (Cognition, Mobility, Self-Care, Getting Along with People, Life/Work Activities, and Participation in Society) as measured by WHODAS II. We controlled for covariates age, race, and education level.

Results

Participants

The final sample included 90 WVs with baseline data. Table 1 displays demographic characteristics and descriptive information for key study variables. In sum, just over half of this sample was White (57.8%), with an average age of 35.9 ± 9.7 years; most had received either a bachelor’s or advanced degree (88.8%) and completed their military service with the Army (65.6%). Approximately half (53.3%) met diagnostic criteria for PTSD, and 58.9% experienced a lifetime TBI. The average total number of TBIs was 1.0 ± 1.2, and the average time since the last TBI was 11.2 ± 9.4 years. Lifetime TBI burden score assessed with the BAT-L (average: 1.8 ± 2.4) was higher than military TBI burden score (average: 1.1 ± 1.9). Table 2 displays baseline descriptive information regarding physical health outcomes and associated recommended values. Markers that fell outside of recommended values included LDL (mean LDL = 113.7 mg/dL; recommended <100 mg/dL), self-reported sleep (mean score = 10.5; recommended <5), and pain (mean score = 1.2; recommended <1).

Table 1.

Baseline Characteristics

Full sample (n = 90)	N(%)/mean ± SD
Age	35.9 ± 9.73
Race
White	52 (57.8)
Black	23 (25.6)
Other/Unknown	15 (16.6)
Hispanic/Latina	19 (21.1)
Education
High School/GED	10 (11.1)
Bachelor’s Degree	61 (67.7)
Graduate +	19 (21.1)
Service Branch
Army Navy	59 (65.6) 8 (8.9)
Airforce	20 (22.8)
Marines	4 (4.4)
Lifetime PTSD	77 (85.6)
Current PTSD	48 (53.3)
Lifetime TBI	53 (58.9)
Total number of Lifetime TBIs	1.07 ± 1.29
Average time since last TBI (years)	11.26 ± 9.04
Average lifetime TBI burden (BAT-L)	1.82 ± 2.4
Average Military TBI Burden	1.13 ± 1.96

SD, standard deviation; PTSD, posttraumatic stress disorder; TBI, traumatic brain injury.

Table 2.

Baseline Cardiometabolic Markers, Pain, Sleep, and Reference Values

Marker	Baseline mean (SD)	Recommended
WHR	0.81 (0.08)	<0.86
HDL (mg/dL)	59.16 (14.57)	≥50
LDL (mg/dL)	113.76 (33.47)	<100
TG (mg/dL)	106.89 (74.03)	<150
BG (mg/dL)	87.13	<99
Sleep	10.56 (4.82)	<5
Average Pain	1.28 (1.16)	<1

SD, standard deviation; WHR, waist-hip ratio; HDL, high-density lipoprotein; LDL, low-density lipoprotein; TG, triglycerides; BG, blood glucose.

Physical health outcomes

The results from the two-way ANOVAs for PTSD and TBI demonstrated the deleterious associations between TBI, PTSD, and physical health (see Table 3). History of lifetime TBI was significantly associated with higher WHR [F(3,86) = [12.11], p = <0.01, d = 0.82), triglycerides levels [F(3,86) = [6.16], p = 0.01, d = 0.62], worse pain [F(3,86) = [18.77], p = <0.01, d = 1.12], and worse sleep [F(3,86) = [9.95], p = <0.01, d = 0.77]. Current PTSD was significantly associated with higher WHR [F(3,86) = [5.67], p = 0.02, d = 0.063], lower HDL [F(3,86) = [6.16], p = 0.01, d = 0.59], worse pain [F(3,86) = [11.77], p = <0.01, d = 0.89], and sleep [F(3,86) = [23.86], p = <0.01, d = 1.19]. No interaction terms were significant (ps > 0.05). Follow-up bivariate correlations between PTSD symptom severity and TBI characteristics yielded no significant results (ps > 0.05).

Table 3.

Differences in Cardiometabolic Markers, Pain, and Sleep by TBI and Current PTSD

Variable (means)	Lifetime TBI n = 53	No TBI n = 36	p-value	Q	d	Current PTSD n = 48	No PTSD n = 40	p-value	Q	d
WHR	0.84	0.77	<0.001	0.003	0.82	0.84	0.78	0.002	0.005	0.63
TG	124.85	80.24	0.01	0.02	0.62	123.37	89.05	0.17	0.23	0.47
HDL	58.31	60.43	0.25	0.29	0.14	55.35	63.75	0.01	0.02	0.60
LDL	113.79	113.71	0.71	0.75	0.01	118.98	108.21	0.18	0.23	0.32
BG	89.12	84.17	0.10	0.16	0.34	87.15	87.02	0.75	0.75	0.009
Pain	1.82	0.68	<0.001	<0.001	1.12	1.74	0.77	<0.001	0.003	0.89
Sleep	12.06	8.54	<0.001	0.001	0.77	12.75	7.92	<0.001	<0.001	1.19

TBI, traumatic brain injury; PTSD, posttraumatic stress disorder; WHR, waist-hip ratio; HDL, high-density lipoprotein; LDL, low-density lipoprotein; TG, triglycerides; BG, blood glucose; effect sizes measured in Cohen’s d and absolute value of d is reported.

Contributions of PTSD and TBI to functional disability and related domains

Table 4 displays detailed results of regression models examining WHODAS II and its associated domains. Regression models include TBI and PTSD, along with sociodemographic covariates (age, education level, race), and predicted overall functional disability [R2 = 0.50, F(5,73] = 14.60, p < 0.001) and each of its subdomains, cognition [R2 = 0.47, F(5,73) = 13.21, p < 0.001], mobility [R2 = 0.36, F(5,73) = 8.22, p < 0.001], self-care [R2 = 0.22, F(5,73) = 4.14, p < 0.001], getting along [R2 = 0.41, F(5,73) = 10.15, p < 0.001], life/work [R2 = 0.27, F(5,73) = 5.42, p < 0.001], and participation in society [R2 = 0.50, F(5,73) = 14.82, p < 0.001]. PTSD was significantly associated with lower total functioning and each of its subdomains (βs = 0.22 to 0.63; ps = <0.001 to 0.02). Lifetime TBI was significantly associated with lower total functioning (β = 0.20; p = 0.02) subdomains of mobility (β = 0.30; p = 0.003) and life/work (β = 0.27; p = 0.01).

Table 4.

Associations Between Covariates, TBI, and PTSD with Functional Disabilities and Their Subdomains

Covariates	Total			Cognition			Mobility			Self-care			Getting along			Life/work			Participation
Covariates	β	P	Q	β	p	Q	β	p	Q	β	p	Q	β	p	Q	β	p	Q	β	p	Q
Age	0.23	0.03	0.06	0.25	0.005	0.01	0.16	0.08	0.13	0.19	0.07	0.12	0.18	0.04	0.07	0.07	0.44	0.53	0.27	0.002	0.008
Race	0.02	0.75	0.82	0.002	0.95	0.97	−0.28	0.001	0.005	−0.03	0.76	0.82	0.15	0.12	0.17	0.02	0.84	0.88	0.24	0.12	0.17
Education	−0.06	0.42	0.52	0.02	0.27	0.35	−0.24	0.01	0.02	−0.19	0.06	0.11	−0.02	0.75	0.82	−0.05	0.57	0.67	0.001	0.99	0.99
TBI	0.20	0.02	0.04	0.14	0.12	0.17	0.30	0.003	0.01	0.18	0.10	0.16	0.10	0.26	0.35	0.27	0.01	0.02	0.08	0.36	0.46
PTSD	0.58	<0.001	<0.001	0.59	0.004	0.01	0.22	0.02	0.04	0.25	0.02	0.04	0.57	<0.001	<0.001	0.37	0.002	0.008	0.63	<0.001	<0.001
R ²	0.50	<0.001	<0.001	0.47	<0.001	<0.001	0.36	<0.001	<0.001	0.22	0.009	0.02	0.41	<0.001	<0.001	0.27	0.003	0.01	0.50	<0.001	<0.001

TBI, traumatic brain injury; PTSD, posttraumatic stress disorder.

Discussion

This study helps fill a significant research gap to better understand the associations between TBI, PTSD, and physical health burden among post-9/11 WVs. A notable characteristic of this sample is the high burden of TBIs occurring over the lifetime, rather than exclusively during military service. This extends prior work demonstrating that WVs experience high rates of lifetime TBI, often related to interpersonal violence (e.g., sexual and intimate partner violence), and is in contrast with men veterans who experience more TBIs related to military service.⁴⁴ Furthermore, WVs who experience TBI during military service are more likely to experience training and other military-related TBIs (including TBI secondary to military sexual trauma) than combat-related TBI. Given the high rates of lifetime TBI and its associations with cardiovascular disease, these findings emphasize the clinical relevance of screening WVs for lifetime TBI (e.g., injuries occurring before and after military service) and cardiovascular health. Current TBI screenings for WVs within VHA focus primarily on combat-related injuries, missing a significant opportunity to capture injuries most relevant for WVs. Screening for lifetime TBIs, including those caused by interpersonal violence, military sexual trauma, and other noncombat military-related TBI etiologies (e.g., training, motor vehicle accidents, falls), can enhance care for WVs by effectively identifying, validating, and addressing WVs' unique experiences and needs from a trauma-informed lens. Clinical interviews such as the BAT-L, which cues veterans to potential injury contexts across the lifespan, have substantial opportunity for wide use in clinical settings (including VHA) and could be used to inform tailored screening tools.^48,58 Moreover, effective screening and assessment for cardiovascular risk is a critical concern for WVs. There have been notable reductions in cardiac disease mortality rates for civilian women, but not among WVs,⁵⁹ emphasizing the need for effective screening for cardiometabolic risk factors (e.g., TBI) and clinical interventions for WVs.

Findings regarding physical health outcomes underscore the importance of understanding the complex clinical presentations and health implications of TBI and PTSD among WVs. The associations between TBI, PTSD, and poor physical health outcomes in this analysis are consistent with research on male-dominated veteran samples, athletes, and the general population,^60
–62 although understudied among WVs. The results suggest that WVs with histories of TBI and PTSD may experience complex physical health multimorbidity. Although the interaction term between TBI and PTSD in this analysis was not significant, previous research has suggested that co-occurring TBI and PTSD is associated with more severe mental health outcomes than either on their own.^40,63 The lack of interaction found here may be for several reasons. These may include small sample size or a ceiling effect for physical health outcomes, as post-9/11 WVs have demonstrated they have more physical health concerns than men veterans.¹⁵ Future work examining co-occurring physical and psychological trauma among WVs would greatly benefit the field. Further, these findings underscore the importance of treatments that can address co-occurring mental and physical health concerns among WVs. Although resources and referrals for trauma and mental health (e.g., PTSD treatments and group therapy) are readily available for WVs, relatively few are available for multimorbid physical and mental health concerns. The growth of integrative initiatives like Whole Health has begun to provide accessible treatment options that address these concerns.⁶⁴ Testing and development of gender-sensitive transdiagnostic treatments that can address complex and co-occurring conditions would greatly benefit WVs, given that these physical health concerns are often underidentified and undertreated among women.⁸

The current data indicated that PTSD was consistently associated with worse overall functioning as well as functional outcomes in all domains. This result was unsurprising, given the array of research with similar findings.⁶⁵ TBI was associated with worse overall functioning, as well as mobility and life/work health domains. Although this result was expected given previous work has demonstrated TBI results in poor functioning across mental health domains,^66
–68 the current study is novel in its focus on WVs. The negative association between TBI and mobility was somewhat unexpected but is consistent with research done among civilian women with histories of partner violence.⁶⁹ Poor mobility among WVs with a history of TBI may negatively impact their ability to engage in lifestyle activities like physical activity that reduce risk for physical health conditions,^70,71 further exacerbating their risk for cardiometabolic disease, pain, and poor sleep. Altogether, these results emphasize that both lifetime TBI and PTSD are significant considerations for improving functional outcomes among WVs. Treatments for WVs should thus consider TBI and PTSD and should specifically include considerations relevant for WVs, including injuries and traumas that occur over the lifetime.

Limitations

This study was retrospective and cross-sectional. As such, causal relationships could not be determined. Gender and history of military sexual trauma were not available for this sample, and future work examining the associations between these factors would improve the research. Self-reported biases may have impacted responses to the survey questions. However, gold standard clinically administered interviews were used to assess TBI and PTSD. Objective assessments of physical health were used alongside self-reported data, therefore strengthening this analysis. Finally, sample size was modest for this analysis, which limited our ability to test associations. Future work replicating these findings and further exploring aspects of TBI (e.g., time since injury, context of injury) in larger samples is warranted.

Conclusions

This investigation addresses several significant gaps in understanding TBI, PTSD, and physical health among WVs and has several implications for care and treatment. First, screening for lifetime TBIs, especially in the VHA, where the focus is exclusively on military TBI and most often on combat-related TBI, would benefit care for WVs given their burden of TBIs across the lifespan and their associations with poor health. Screening only for military-related TBIs represents a missed opportunity to provide holistic care. High physical health burden among this group also emphasizes the need for treatments that effectively address co-occurring cardiometabolic health, pain, sleep, mental health, and functional outcomes. Development and testing of more transdiagnostic, sex-, and gender-sensitive treatments that consider PTSD and TBI would greatly benefit WVs.

Footnotes

Authors’ Contributions

Conceptualization: All authors; Methodology: All authors; Formal Analysis; M.P., J.W., and A.C.; Investigation: All authors; Data: A.C. and M.P.; Writing—Original Draft: M.P.; Writing—Review and Editing: All authors; Funding Acquisition: C.F.

Data Availability Statement

The datasets presented in this article are not readily available because the data are owned by the Boston Veteran Affairs Healthcare System and are subject to oversight by the VA.

Author Disclosure Statement

No competing financial interests exist.

Funding Statement

This research was supported by the Translational Research Center for TBI and Stress Disorders (TRACTS), a VA Rehabilitation Research and Development National Research Center for Traumatic Brain Injury (B3001-C). C.B.F. is supported by funding from VA Rehabilitation Research and Development Merit Review (RX002907 and RX004535). J.W.W. is supported by a VA Rehabilitation Research and Development Career Development Award (5IK2RX003564-02).

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