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Association between traumatic brain injury and mental health care utilization: evidence from the Canadian Community Health Survey
Injury Epidemiology volume 10, Article number: 16 (2023)
Mental health disorders are a common sequelae of traumatic brain injury (TBI) and are associated with worse health outcomes including increased mental health care utilization. The objective of this study was to determine the association between TBI and use of mental health services in a population-based sample.
Using data from a national Canadian survey, this study evaluated the association between TBI and mental health care utilization, while adjusting for confounding variables. A log-Poisson regression model was used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI).
The study sample included 158,287 TBI patients and 25,339,913 non-injured individuals. Compared with those were not injured, TBI patients reported higher proportions of chronic mental health conditions (27% vs. 12%, p < 0.001) and heavy drinking (33% vs. 24%, p = 0.005). The adjusted prevalence of mental health care utilization was 60% higher in patients with TBI than those who were not injured (PR = 1.60, 95%; CI 1.05–2.43).
This study suggests that chronic mental health conditions and heavy drinking are more common in individuals with TBI. The prevalence of mental health care utilization is 60% higher in TBI patients compared with those who are not injured after adjusting for sociodemographic factors, mental health conditions, and heavy drinking. Future longitudinal research is required to examine the temporality and direction of the association between TBI and the use of mental health services.
Traumatic brain injury (TBI) is a major cause of mortality in Canada, contributing to approximately 23% of all injury-related deaths (Public Health Agency of Canada 2020). TBI is also related to many adverse health outcomes (Oddy et al. 2012; Hwang et al. 2008), such as physical and mental health conditions (Mackelprang et al. 2014; Topolovec-Vranic et al. 2012; Silver et al. 2001), cognitive impairment (Andersen et al. 2014), suicidality (Bahraini et al. 2013), substance use (Taylor et al. 2003), victimization (Bushnik et al. 2015), increased mortality (McMillan et al. 2015), increased health care utilization (Bushnik et al. 2015), and incarceration (Farrer and Hedges 2011). In addition to its impact on patients' health, TBI is also immensely burdensome on the health care system.
Individuals who sustain TBI have a higher burden of comorbid illness which results in increased health care utilization (Bushnik et al. 2015; Albrecht et al. 2019). Mental health disorders are commonly observed in TBI patients. In the first-year post-injury, up to 77% receive a psychiatric diagnosis: anxiety, mood and substance-use disorders are common and often present co-morbidly (Alway et al. 2016; Koponen et al. 2002). The high rates of mental health disorders are associated with worse health outcomes, increased mental health care utilization, and poorer quality of life. Studies using Anderson’s Behavioral Model (Andersen and Newman 2005) have found that a variety of predisposing characteristics, enabling characteristics, and need factors are associated with mental health care utilization. Among predisposing characteristics, military service and older age are significantly associated with mental health service utilization (Coxe et al. 2021). Notably, veterans are much more likely to utilize services, which may be due to comorbidity of combat-related mental health problems and TBI (Miles et al. 2017). As adults with TBI become older, they are less likely to obtain mental health services which may be due to physical or cognitive problems affecting service access (Coxe et al. 2021; Fasoli et al. 2010). Among enabling resources, TBI patients without health insurance are less likely to utilize services, indicating that lack of insurance continues to be a reason for not seeking mental health treatment in the USA (Albrecht et al. 2017). Need factors including worse self-reported health, medical comorbidities and psychiatric comorbidities are consistently reported as the strongest predictors of mental health care utilization. TBI is associated with higher rates of psychiatric comorbidities including posttraumatic stress disorder (PTSD), anxiety, mood disorders, schizophrenia, and substance use disorders; many of these conditions are significantly associated with increased mental health care utilization (Coxe et al. 2021; Narrow et al. 2000).
The available literature examining the association of TBI with mental health care utilization is largely limited to veterans in the USA (Miles et al. 2017; Fasoli et al. 2010; Drag et al. 2013). To date, no population-based studies in Canada have been conducted to highlight differences in mental health care service use by TBI patients versus those who are not injured. The objective of the study was to determine whether participants with TBI are associated with a higher probability of mental health care utilization using a population-based sample from Canada.
This study utilized individual-level data from the 2017 to 2018 Canadian Community Health Survey (CCHS). The CCHS is a cross-sectional population-representative survey which collects sociodemographic measures, health status, health care utilization, and other health determinants. Individuals who are full-time members of the Canadian Forces, reside in prisons or care facilities, or live on First Nations Reserves, Crown Lands, or in some remote regions of Quebec are excluded from the survey. The CCHS captures approximately 98% of the Canadian population that are 12 years of age or older. Person-level survey weights enable representative estimates across provinces and sociodemographic strata. Detailed methodology and sampling characteristics of the CCHS are described elsewhere (Statistics Canada. Canadian Community Health Survey - Annual Component (CCHS) 2021).
Study setting and participants
Exposure and outcome variables
All respondents who reported that their most serious injury in the past 12 months was a concussion or other brain injury were selected to form the TBI group. Nonrespondents (i.e., those in the categories of “don’t know” and “refusal”) were excluded. Patients with TBI were compared to non-injured respondents, which were defined as those respondents who did not experience an injury in the 12 months prior to the survey interview.
The outcome variable of interest was mental health care utilization, measured based on self-reporting on health professional consults for mental health issued in the past 12 months in patients with and without TBI. Mental health care utilization was determined by asking respondents if they had seen or talked on the telephone to any of the following people in the past 12 months about problems with their emotions, mental health or use of alcohol or drugs: psychiatrist, psychologist, family doctor, nurse, social worker, or other health professional.
Guided by the current literature, the following variables were identified as important covariates to consider as potential confounders: age, sex, level of education, race, household income, mental health comorbidities, and heavy drinking.
The following variables were recoded to reduce the total number of categories compared owing to the difficulties in making comparisons. Any differences in model Akaike information criterion (AIC) were examined to ensure that reduction of category levels did not impact model fit.
Based on evidence of greater mental health utilization in older adults from previous studies, age was dichotomized at 65 years.
Sex was modeled as male or female.
Respondents were divided into white and non-white categories.
Respondents were grouped into three categories based on the highest level of education attained: less than secondary school graduation, secondary school graduation, or post-secondary certificate diploma or university degree.
Household income from CCHS responses was used to measure socioeconomic status (all respondents are asked: “what is your best estimate of the total income received by all household members, from all sources, before taxes and deductions, in the past 12 months?”). The CCHS classified household income into five groups (no income or less than $20,000; $20,000–$39,999; $40,000–$59,999; $60,000–$79,999; $80,000 or more). To reduce sparsity of data among these categories, income was recoded into low, middle and high categories. We first determined that the median household income after tax was $59,800 in 2017. Using the definition of middle class as those who earn between three-quarters and double the median household income after tax, Canada’s middle class in 2017 included households that earn between $44,850 and $119,600 after tax. Using this definition range, we recoded household income into three groups: low income ($0-$39,999), middle income ($40,000–$79,999), and high income (≥ $80,000).
Mental health comorbidities
Questions on professionally diagnosed mood and anxiety disorders included “Do you have a mood disorder such as depression, bipolar disorder, mania or dysthymia?” and “Do you have an anxiety disorder such as a phobia, obsessive compulsive disorder or a panic disorder?” Responses to these questions were combined to produce a binary variable for any mental health comorbidity.
Substance abuse was initially defined as heavy drinking and use of illicit drugs in the past year. However, owing to the high non-response for illicit drugs in the study cohort, only heavy drinking was included as a covariate. Respondents were asked, “How often in the past 12 months have you had four or more drinks on one occasion?” Heavy alcohol consumption was defined as responses of “once a month,” “2–3 times a month,” “once a week” or “more than once a week.”
Frequencies and percentages were calculated for all variables. We report the prevalence ratio (PR) instead of the odds ratio (OR) given the cross-sectional study design (Barros and Hirakata 2003). The OR may be equivalent to the PR for rare events, but reporting of PR is preferred for cross-sectional studies (Santos et al. 2008). A log binomial model was initially attempted but did not converge. In the final analysis, a log Poisson regression model was used to estimate unadjusted and adjusted prevalence ratios and 95% confidence intervals (CI) for the association of TBI with mental health care utilization and to assess the impact of sociodemographic factors on this association. PRs were interpreted as the relative prevalence of mental health care utilization, considering the TBI cohort as the exposed group and the non-injured population as the unexposed group. A PR of < 1 indicates that a given factor is associated with a decreased occurrence of mental health care utilization, compared with the non-injured population, while a PR > 1 indicates that a factor is associated with an increased occurrence of mental health care utilization. Multicollinearity among the explanatory variables was checked using Variance Inflation Factors (VIF). Interactions were tested between significant variables to assess additive effects.
As a sensitivity of the adjusted model, we compared finer grained age and income categories in estimating mental health utilization. To carry out this comparison, we developed candidate models for age and income modeled as 2, 3, 4, or 5 levels in addition to sex, education, race, mental health comorbidities, and heavy drinking. Using the model with 5 levels of age and income as a the full model, we used the likelihood ratio test (LRT) to compare each candidate model against the full model. AIC differences were calculated as Δi = AICi − AICmin, where AICi is the AIC for the ith model and AICmin is the minimum AIC among all the models. Based on the rule outlined by Burnham & Anderson, models having Δi ≤ 2 have substantial support (evidence), those in which 4 ≤ Δi ≤ 7 have considerably less support, and models having Δi > 10 have essentially no support (Burnham et al. 2004).
Statistics Canada produced sampling weights for each of the study participants from the CCHS. To account for nonequal probability of selection in the CCHS due to the complex sampling design, sample weights were applied to obtain population-based estimates. Bootstrap weights provided with the CCHS data were used to produce reliable estimates weighted to be representative of the Canadian population. All analyses employed the survey library (svy) in R to address the stratified, complex sampling design of the data. Statistical significance for all analyses was set at a two-sided alpha level of p < 0.05.
The original CCHS for 2017–18 had 31,274,372 respondents and the study sample included 158,287 TBI patients and 25,339,913 non-injured respondents. The response rate for the 2017–18 CCHS was 58.8%; Statistics Canada handles total non-response by adjusting the weight of persons who respond to the survey to compensate for those who do not respond. Weights of the nonrespondents are redistributed to respondents within response homogeneity groups. In order to create the response homogeneity groups, a scoring method is used to define a response probability based on characteristics available for both respondents and nonrespondents (Statistics Canada. CCHS 2020).
TBI and non-injured groups were significantly different across most covariates (Table 1). With respect to demographics, compared with those who were not injured, a higher proportion of TBI patients were < 65 years of age (89% vs. 79%, p < 0.001). Fewer patients with TBI reported attainment of postsecondary education (47% vs. 59%). A significantly higher proportion of TBI patients were White (85 vs. 75%, p = 0.004). In line with previous reports, chronic mental health conditions were more common in TBI patients versus the non-injured group (27% vs. 12%, p < 0.001). The proportion of TBI patients who reported heavy drinking was also significantly higher than those who were not injured (33% vs. 24%, p = 0.005).
A greater proportion of TBI patients utilized mental health services compared with non-injured patients (24% vs. 13%, p = 0.005, Table 2). Those who were ≥ 65 years of age used less mental health care services than those who were younger (6% vs. 16%, p < 0.001) and females reported almost twice the amount of service use than males (18% vs. 10%, p < 0.001). Among those who reported chronic mental health conditions, 56% used mental health services, but only 16% of the cohort who reported heavy drinking sought help from mental health professionals.
In an unadjusted analysis (Table 3), we observed an increased prevalence of mental health service use by the TBI cohort (PR = 1.88, 95% CI 1.22–2.91). Respondents who were female (PR = 1.86, 95% CI 1.70–2.05), had postsecondary education (PR = 1.28, 95% CI 1.14–1.44), received an income of < CAD $39,999 (PR = 1.12, 95% CI 1.00–1.24), and identified as White (PR = 1.35, 95% CI 1.12–1.63) reported significantly greater use of mental health care services. Those who were > 65 years of age had a 40% lower prevalence of mental health service use (PR = 0.40, 95% CI 0.35–0.45). Individuals who reported chronic mental health conditions had a six times higher prevalence of mental health care utilization (PR = 6.58, 95% CI 6.10–7.10) than those who did not. Heavy drinkers accessed mental health services 12% more than those who did not report heavy drinking (PR = 1.12, 95% CI 1.01–1.25).
The prevalence of mental health care utilization was 60% higher in patients with TBI than those were not injured (adjusted prevalence rate [aPR] = 1.60, 95% CI 1.05–2.43), adjusted for age, sex, race, education, income, mental health conditions, and heavy drinking (Table 3). The prevalence of mental health service use remained significantly higher in females (aPR = 1.70, 95% CI 1.52–1.91) and those with postsecondary education (aPR = 1.25, 95% CI 1.10–1.46) in the adjusted model. Age ≥ 65 years was associated with a 59% lower prevalence of mental health care utilization (aPR = 0.41,9 5% CI 0.35–0.49). Similar to the unadjusted model, the prevalence of mental health care utilization was six times in higher in those with a history of mood disorders or anxiety (aPR = 5.99, 95% CI 5.41–6.63). Heavy drinking was associated with a 7% increase in mental health care service after adjusting for other covariates, but this association was not statistically significant (p = 0.24). Model comparisons using LRT confirmed that the selected model was not significantly different from the full model and had Δi = 2 (Table 4).
This study examined the association of TBI with mental health care utilization in a representative sample of the Canadian population. Compared with the non-injured group, the TBI cohort was comprised largely of young White individuals who had attained less than postsecondary education. Heavy drinking was significantly more common in patients with TBI and these individuals reported more than twice the prevalence of chronic mental health conditions including mood disorders and anxiety. In this large population-based sample, the prevalence of consultation requests for mental health services was 60% higher in patients with TBI than those who were not injured, after adjusting for age, sex, education, income, mental health conditions, and drinking history.
Among socioeconomic factors, age, sex, and education were significantly associated with mental health service utilization. We observed that individuals ≥ 65 years had a 59% lower prevalence of mental health service use in our study sample. Previous research indicates that there is a disproportionate underutilization of professional mental health services with increasing age, where negative attitudes toward mental health care and lack of perceived need for treatment are the main barriers (Lavingia et al. 2020). Research examining the connection between sex and the utilization of outpatient health services for emotional or psychiatric issues, largely reveals that women are more likely to seek care than men (Albizu-Garcia et al. 2001). In line with this finding, our study found that females had a 70% higher prevalence in seeking mental health treatment than males. Individuals in the study cohort with postsecondary education had a 27% higher prevalence of mental health service use; higher educated patients may have greater health knowledge and be better informed about the reasons why they may require health services.
Mental health conditions
Other studies report that past mental health care utilization and diagnoses of schizophrenia, depression, or substance abuse (Fasoli et al. 2010) and previous history of mental health disorders (Miles et al. 2017; Fasoli et al. 2010; Narrow et al. 2000) are important predictors of mental health care utilization after TBI. Mental health conditions assessed in this study include mood disorders such as depression, bipolar disorder, mania, and dysthymia, as well as anxiety disorders such as a phobia, obsessive compulsive disorder, and panic disorder. Chronic mental health conditions were twice as commonly reported by TBI patients than non-injured respondents; however, the unadjusted rate of mental health service use was 88% higher in TBI patients, suggesting that service utilization underestimates mental health conditions in this population. According to a recent systematic review (Schnyder et al. 2017), help-seeking is often delayed or completely avoided in the general population. Stigma and personal attitudes toward mental disorders or mental health services are regarded as main reasons for insufficient help-seeking. The adjusted PR suggests that mood/anxiety disorders and heavy drinking cannot fully explain the differences in mental health service use between TBI patients and non-injured patients. This notion is supported by Drag et al. who reported that although psychiatric disorders are more prevalent in veterans with TBI and associated with increased medical and mental health care utilization, they cannot entirely account for the significant differences in mental health service use among veterans with and without TBI (Drag et al. 2013).
Mental health care utilization
Outpatient mental health service use is commonly observed during the pre-injury and post-injury period in major trauma patients (Evans et al. 2023). In our study, TBI was significantly associated with utilization of mental health services, after adjusting for demographic characteristics and mental health diagnoses. Several studies have reported a similar association of mental health care utilization with TBI, especially in the veteran population (Coxe et al. 2021; Miles et al. 2017; Fasoli et al. 2010; Drag et al. 2013). In a subsample of returning veterans who were newly diagnosed with PTSD, depression, and/or anxiety, PTSD and TBI history, but not depression or anxiety, were associated with a greater number of psychotherapy visits when controlling for demographic and clinical variables (Miles et al. 2017). In another study which examined predictors of outpatient and inpatient health care utilization in veterans with a history of TBI, mental health disorders such as mood disorders, substance use disorders, PTSD, and schizophrenia were associated with inpatient and outpatient mental health care utilization (Drag et al. 2013). Although our study did not control for PTSD, schizophrenia, and other less common psychiatric disorders, we similarly observed that TBI history was related to greater mental health care utilization independent of mood and anxiety diagnoses as well as demographic characteristics.
Given the cross-sectional nature of the data, it is impossible to determine whether the mental health service utilization preceded or followed TBI in our study sample. Head injuries and mental health conditions increase the risk of mental health service utilization and are well-known correlates; however, with regards to how and when one increases the likelihood of the other, particularly when controlling for demographic risk factors, remains unknown. The present results, combined with previous research, suggest that the association between TBI and mental health service utilization is intricate and potentially bidirectional (Sheldrake et al. 2022; Zahniser et al. 2019). In individuals with TBI, an increased prevalence of mental health service use may be attributed to multiple factors including past psychiatric disorders, substance abuse, distress related to the injury, cognitive complaints, emotional lability, and behavioral problems. Conversely, individuals with a history of psychiatric disorders may be at increased risk of TBI, further compounding the need for mental health services. Thus, a prospective investigation of the temporality and direction of the relationship between TBI and mental health service utilization seems warranted.
Strengths and limitations
Strengths of this study include its large sample size of adults with TBI in Canada, a sample whose data were drawn from a national database. This is in contrast to the majority of previous studies which have been conducted in military personnel and are not generalizable to the larger population (Fasoli et al. 2010; Drag et al. 2013; Graves et al. 2019; Dismuke-Greer et al. 2020; Finn et al. 2018; Kehle-Forbes et al. 2017). There are several limitations to our study that must be acknowledged. The survey did not specifically evaluate substance abuse, PTSD, schizophrenia, neurodevelopmental conditions, psychoses, and personality disorders. The CCHS assesses self-reported measures of TBI which may increase the likelihood of misclassification, potentially resulting in conservative estimates. Given the survey questionnaire design, it was not possible to distinguish between severities of TBI in the cohort. Survey questions assessed respondent habits in the previous 12-month period and, therefore, the prevalence of mental health care utilization reported herein is likely an underestimate of the long-term outcome of TBI patients. Finally, due to the cross-sectional study design of the CCHS, a temporal relationship between TBI and mental health care utilization cannot be established, and this precludes any causal inference.
This study provides a national picture of mental health care utilization by Canadian TBI patients.
Compared with the non-injured population, TBI patients have a significantly higher prevalence of chronic mental health conditions and heavy drinking. The use of mental health services by community-dwelling individuals with TBI is 60% more compared with non-injured individuals after adjusting for sociodemographic factors, presence of mental health conditions, and heavy drinking. Future longitudinal research is required to examine the timing and direction of the association between TBI and the use of mental health services.
Availability of data and materials
The public use microdata file (PUMF) from the Canadian Community Health Survey (CCHS) 2017–18 are available through Statistics Canada.See https://www150.statcan.gc.ca/n1/en/catalogue/82M0013X
Canadian Community Health Survey
Posttraumatic stress disorder
Traumatic brain injury
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The primary author (NK) received funding for her doctoral studies from the Canadian Institutes of Health Research (CIHR) through the Frederick Banting and Charles Best Canada Graduate Scholarship (Doctoral Research Award). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The contents are those of the authors and do not necessarily represent the official views of, nor the endorsement, by CIHR.
Ethics approval and consent to participate
Ethical approval for data collection was completed by Statistics Canada (Government of Canada). Informed consent was obtained by Statistics Canada from all study participants. This study used the public use micro data file collected for the CCHS and the secondary analysis of existing data was exempt from institutional review board review. All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.
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Kureshi, N., Clarke, D.B. & Feng, C. Association between traumatic brain injury and mental health care utilization: evidence from the Canadian Community Health Survey. Inj. Epidemiol. 10, 16 (2023). https://0-doi-org.brum.beds.ac.uk/10.1186/s40621-023-00424-x
- Traumatic brain injury
- Mental health
- Health care utilization