Evidence-Based Mental Health Services for Distressed Post-9/11 Military Family Caregivers

Background: Traumatic brain injury (TBI) is considered the "signature injury" of recent
conflicts in Iraq and Afghanistan, with 22% of returning troops experiencing a TBI. After
receiving acute and rehabilitative healthcare services, Veterans with TBI are typically cared
for at home, by their female (79%) parent (62%, 32% spouses), and the majority (60%) of these
caregivers receive little or no help from others with their caregiving responsibilities. Not
only is TBI a well-documented risk factor for dementia of the Alzheimer's type (AD) later in
life, noteworthy similarities exist between the experiences of family caregivers of Veterans
with TBI and caregivers of civilians with AD. Symptoms of TBI are very similar to AD and
include cognitive impairment (deficits in memory, language, attention, and/or planning),
difficulty communicating, poor impulse control, and poor emotion regulation. Both conditions
necessitate adaptation to emotional and behavioral changes in the injured family member, and
personality changes may result in relationship strain between the injured person and his or
her family caregiver. Similar to AD, symptoms of TBI do not lessen over time, are often
perceived as burdensome, and are associated with negative mental health outcomes in their
family caregivers. Similarly, both AD and TBI family caregivers report additional stressors
(e.g., continuous monitoring for unpredictable behaviors and their consequences) when
cohabitating with the impaired or injured family member for an extended period of time.

Objective/Hypotheses: To improve the mental health of family caregivers of Veterans with TBI,
the proposed study is designed to evaluate the efficacy of an evidence-based, short-term (9,
60-mintue session), solution-focused, self- management intervention utilizing problem-solving
therapy (PST) to lessen burden and depression levels, and improve the quality of life (QOL)
in co-residing family caregivers of Veterans with TBI (military family caregivers). PST is
based on the premise that real-life problem-solving plays an important role as a mediator of
the relationship between stressful life events and negative mental health outcomes. When
deficits in problem-solving lead to ineffective coping attempts, under high levels of stress
exposure, burden and depression is likely to ensue. Building on our previous work with
caregivers of civilians with mild cognitive impairment (a proposed precursor for AD) and
early-stage AD, it is hypothesized that military family caregivers receiving PST training
will endorse lower levels of caregiving burden and depression, and improved mental health
QOL, at each follow-up assessment, than caregivers in the comparison (usual care) group.

Specific Aims: The primary aim of the proposed study is to assess the efficacy of PST for
positively impacting distressed military family caregiver's burden, and depression levels,
ultimately enhancing their mental health QOL (primary outcomes). Data will also be collected
to characterize physical and social stressors for these caregivers such as illness that
limits the caregiver's activities, new household management and caregiving responsibilities,
satisfaction with social roles and activities, lifestyle constraints, the quality of the
marital relationship, perceived social support, and demographic factors. A secondary aim of
the proposed study is to determine which of a series of key caregiver sociodemographic
factors moderate PST- intervention efficacy for caregiving burden and mental health QOL
outcomes.

Study Design: A randomized controlled trail design (intention-to-treat model) will be used to
evaluate the effects of an individualized PST-based intervention on burden, mental health,
and well-being outcomes in family caregivers of Veterans with TBI. We expect to enroll and
randomize 100 family caregivers of Veterans with TBI from the Joint Forces Explosive Ordnance
Disposal (the disarming and disposal of bombs) Warrior Foundation and Boulder Crest Retreat
for Wounded Warriors family caregiver websites. Caregivers assigned to the PST group will
receive nine PST training sessions (each approximately 60 minutes) delivered face-to-face
every two weeks (to allow time for problem solving efforts and scheduling conflicts) using
study-specific webcams (part of the Study Welcome Kit). Software will be utilized that
permits recording and saving of intervention sessions for review (to ensure treatment
fidelity over time). Outcomes will be collected through the Internet (to enhance the study's
sustainability and scalability) and measured baseline, and at 1-, 3-, 6-, and 12-mos.
post-intervention.

Study Relevance: Since family caregivers constitute the largest group of adult care providers
in the United States and the market value of family caregiving exceeds that spent on formal
health and nursing home care, the mental health and well-being of family caregivers of
Veterans with TBI - and their subsequent ability to assist wounded Veterans at home (e.g.,
prevent institutionalization of injured/impaired Veterans) - is of paramount importance. If
the PST-based intervention reduces burden levels and improves mental health aspects of QOL in
military family caregivers, the data will be used to lay the foundation for offering PST-
based mental health services for distressed family caregivers of Veterans with TBI through
the VA Program of Comprehensive Assistance for Family Caregivers.

Study inclusion criteria are that the participant:

1. screens positive for caregiving burden,

2. lives with a post-9/11 Veteran or Service Member with a diagnosis of a TBI,

3. can communicate using the English language, and

4. are 18 years or older.