A-132 Long-Term Vocational Outcomes Following Cognitive Rehabilitation for Mild Traumatic Brain Injury (mTBI): 5-Year Follow-Up of a Cohort from the SCORE Randomized Clinical Trial

Objective Vocational functioning was examined in a cohort of military service members 5 years after completing a randomized, 4-arm controlled trial (RCT) exploring the efficacy of cognitive rehabilitation (CR) for persistent cognitive symptoms following mTBI. Methods Inception cohort design included 69 of the 103 participants (67%) who completed both the study intervention and a 6-week follow-up, contacted by phone at 5-year follow-up. Outcome measures included post-concussive symptoms, emotional distress, functional cognitive complaints, and occupational status. Participants were dichotomized into good and poor occupational outcome groups (Good — returned to duty or retired at the end of the term of service; Poor — medically retired or found unfit for duty by a medical evaluation board). Results Results of a 2X4 contingency table analysis (good/poor occupational outcome by CR treatment group) found 44% of the sample had good occupational outcomes at 5 years. Good outcomes did not significantly differ by CR treatment arm: psychoeducation 56%, computer-directed 18%, therapist-directed 43%, therapist-directed plus psychotherapeutic intervention 50%, χ2(3) = 4.213, p = 0.239. Logistic regression predicting occupational outcome by CR treatment arm found no significant findings of treatment arm (Computer vs. Psychoeducation β = −1.755, p = 0.059; Therapist-directed vs Psychoeducation β = −0.514, p = 0.434; Integrated vs. Psychoeducation β = −0.251, p = 0.716). Psychoeducation treatment arm was coded as the reference group. Conclusions Contrary to our hypotheses, long-term vocational outcomes were lower than expected, despite reductions in overall post-concussive complaints, functional cognitive difficulties, and emotional distress, underscoring the complexity of vocational functioning in post-deployment service members.

Recovery from Borderline Personality Disorder

As important as our findings concerning the high rates of symptomatic remission and low rates of symptomatic recurrence are, the rates of recovery are even more important. This is so because we defined “recovery” as concurrent symptomatic remission and good social and good full-time vocational functioning. After 10 years of prospective follow-up, 50% of borderline patients achieved this important goal. After 16 years of prospective follow-up, 60% of borderline patients achieved this key outcome. In general, recovery is more difficult to achieve and maintain than remission. Two vignettes are presented in this chapter. The first deals with a patient who remitted but never recovered, and the second deals with a patient who both remitted and recovered.

Predictors of Time-to-Remission and Recovery

This chapter reports on the bivariate and multivariate predictors of two of our most important outcomes—remission and recovery. In terms of time-to-remission, seven variables that span five areas of prediction were found to be significant in multivariate analyses. These areas were: lack of chronicity, good premorbid vocational functioning, no history of childhood sexual abuse, no family history of substance abuse, and three aspects of temperament. In terms of time-to-recovery, five variables that span three areas of prediction were found to be significant in multivariate analyses. These areas were: lack of chronicity, competence, and temperament. The clinical implications of these significant models and the significant bivariate predictors that did not end up in these models are discussed in detail.

Psychosocial Functioning over Time

Social and vocational functioning are extremely important outcomes. This chapter details the findings of four sub-studies concerning this area. In all of these studies, borderline patients showed areas of strength. However, remitted borderline patients functioned better than non-remitted borderline patients at six-year follow-up, while the borderline patients on disability functioned more poorly than borderline patients never on disability at 10-year follow-up. Believing that we had been too optimistic about the psychosocial functioning of borderline patients early in the study, we changed the definition to include full-time work or school at 10-year follow-up. This change resulted in 60% rather than 82% achieving this goal. Finally, we compared the rates of marriage and being a parent of recovered and non-recovered borderline patients at 16-year follow-up, finding that recovered borderline patients were more likely to achieve stability in these areas.