The Long Shadow: Traumatic Brain Injury in America’s Veterans Secrets of Survival (S.O.S.) Traumatic brain injury (TBI) is often called the signature injury of America’s post-9/11 wars—but its imprint stretches far beyond the battlefield. In this episode of Secrets of Survival, Dr. Susan Rashid examines the enduring consequences of TBI in veterans, weaving together insights from neuroscience, clinical medicine, and public health. From the blast overpressure of improvised explosive devices to the subtle shearing of axons invisible on routine scans, the episode traces how TBI alters the brain in ways that reverberate for decades. Listeners will hear how chronic pain, psychiatric comorbidities like PTSD, and long-term risks of dementia, epilepsy, and suicide shape the lives of those who served. The discussion expands beyond the clinic to confront social realities, including the heightened risk of homelessness among veterans with TBI—underscoring the injury’s profound impact on both individual and societal health. Grounded in leading scientific research and policy guidelines, this episode outlines the clinical imperatives: screen with rigor, treat pain and psychiatric illness comprehensively, guard against opioid misuse, and plan for the long horizon of neurological and social outcomes. Just as importantly, it highlights the structural responsibilities—ensuring that veterans have access to housing, rehabilitation, and mental health services as essential components of recovery. The Long Shadow: Traumatic Brain Injury in America’s Veterans is not simply about injury—it is about responsibility. With science that is precise, medicine that is integrated, and care that honors dignity and resilience, the shadow of TBI of our veterans can be transformed into a pathway of survival and strength.
Traumatic brain injury (TBI) is often called the signature injury of America’s post-9/11 wars—but its imprint stretches far beyond the battlefield. In this episode of Secrets of Survival, Dr. Susan Rashid examines the enduring consequences of TBI in veterans, weaving together insights from neuroscience, clinical medicine, and public health.
From the blast overpressure of improvised explosive devices to the subtle shearing of axons invisible on routine scans, the episode traces how TBI alters the brain in ways that reverberate for decades. Listeners will hear how chronic pain, psychiatric comorbidities like PTSD, and long-term risks of dementia, epilepsy, and suicide shape the lives of those who served. The discussion expands beyond the clinic to confront social realities, including the heightened risk of homelessness among veterans with TBI—underscoring the injury’s profound impact on both individual and societal health.
Grounded in leading scientific research and policy guidelines, this episode outlines the clinical imperatives: screen with rigor, treat pain and psychiatric illness comprehensively, guard against opioid misuse, and plan for the long horizon of neurological and social outcomes. Just as importantly, it highlights the structural responsibilities—ensuring that veterans have access to housing, rehabilitation, and mental health services as essential components of recovery.
The Long Shadow: Traumatic Brain Injury in America’s Veterans is not simply about injury—it is about responsibility. With science that is precise, medicine that is integrated, and care that honors dignity and resilience, the shadow of TBI of our veterans can be transformed into a pathway of survival and strength.
🎙️ Podcast Title: Secrets of Survival (S.O.S.)
🎧 Episode Title: "The Long Shadow: Traumatic Brain Injury In America's Veterans
🩺 Written and Narrated by Dr. Susan Rashid
🎓 Tone: Scholarly
NARRATOR:
Welcome to Secrets of Survival (SOS)—a podcast that illuminates the systems, stories, and science shaping the health of our nation.
In today’s episode—‘The Long Shadow: Traumatic Brain Injury in America’s Veterans’—we confront the neurological signature of modern war. From the concussive force of blasts to the burden of chronic pain, from the entanglement of PTSD to the heightened risk of dementia, we examine how traumatic brain injury alters lives long after the battlefield has grown silent.
Drawing on clinical research, epidemiology, and public health policy, this episode traces what we know, where science continues to evolve, and how medicine strives to meet the enduring needs of those who served.
Guiding us is Dr. Susan Rashid—a physician and public health scholar who brings a clinically grounded and policy-informed perspective to the complex intersections of neurology, military service, and health equity.
This is Secrets of Survival (SOS). Let us begin.
Dr. Susan Rashid: Traumatic brain injury, TBI, is the hidden scar of modern war. Since the year 2000, more than 450,000 American service members have sustained a TBI, many during deployments to Iraq and Afghanistan (Traumatic Brain Injury Center of Excellence). Though most are labeled ‘mild,’ the impact is anything but. Headaches that persist for months, memory lapses that alter daily life, mood changes that strain families, and long-term risks of dementia and epilepsy—all shadow our veterans well beyond the battlefield.
But what exactly is a traumatic brain injury? At its core, TBI is the result of biomechanical forces applied to the brain—whether from a direct blow to the head, a rapid acceleration or deceleration of the skull, or the invisible force of blast overpressure. These forces stretch and shear delicate axons, disrupt neural networks, and trigger a cascade of inflammation, excitotoxicity, and metabolic dysfunction. Even when conventional imaging appears normal, the microscopic injury to white matter tracts can reverberate through cognition, mood, and function for years to come (Cernak and Noble-Haeusslein 255; Bigler and Maxwell 391).
Why is TBI so common in veterans? The answer lies in the nature of modern warfare. Improvised explosive devices, rocket-propelled grenades, and heavy artillery produce powerful blast waves that sweep through the brain in milliseconds. Military service members also sustain TBIs through falls, vehicle crashes, and training accidents. Unlike the civilian population—where motor vehicle collisions and sports are leading causes—combat settings multiply both the risk and the intensity of exposure. Blast injuries are uniquely complex: when they occur in enclosed spaces such as vehicles or buildings, shock waves can reflect multiple times, amplifying their destructive effect (Goldstein 2145; Hoge et al. 453).
The clinical reality is that these so-called ‘mild’ injuries are cumulative. A soldier with repeated concussions may experience slowed reaction time, difficulty concentrating, chronic insomnia, or irritability. And when layered with the psychological toll of deployment, pain syndromes, and the stresses of reintegration into civilian life, the burden of TBI extends far beyond the walls of neurology clinics. It becomes a public health concern, a policy challenge, and, most of all, a lifelong struggle for those who carried the battle into their bodies.
Bigler, Erin D., and William L. Maxwell. “Neuropathology of Mild Traumatic Brain Injury: Relationship to Neuroimaging Findings.” Brain Imaging and Behavior, vol. 6, no. 2, 2012, pp. 108–136.
Cernak, Ibolja, and Linda J. Noble-Haeusslein. “Traumatic Brain Injury: An Overview of Pathobiology with Emphasis on Military Populations.” Journal of Cerebral Blood Flow & Metabolism, vol. 30, no. 2, 2010, pp. 255–66.
Goldstein, Lee E., et al. “Chronic Traumatic Encephalopathy in Blast-Exposed Military Veterans and a Blast Neurotrauma Mouse Model.” Science Translational Medicine, vol. 4, no. 134, 2012, p. 134ra60.
Hoge, Charles W., et al. “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq.” New England Journal of Medicine, vol. 358, no. 5, 2008, pp. 453–463.
Traumatic Brain Injury Center of Excellence (TBICoE). “DoD TBI Worldwide Numbers (2000–2024 Q4).” Defense Health Agency, 2025.
Dr. Susan Rashid: Traumatic brain injury in veterans arises primarily through three well-documented mechanisms: direct impact, rapid acceleration or deceleration of the head, and exposure to blast overpressure. Each mechanism produces its own neuropathological signature. Direct impact may cause skull fractures, contusions, and focal hemorrhages. Acceleration and deceleration forces disrupt axonal integrity through shearing and stretching, leading to diffuse axonal injury—often invisible to conventional neuroimaging but demonstrable on diffusion tensor imaging (Bigler and Maxwell 391).
Blast-related TBI, however, remains the most complex and defining mechanism of modern warfare. The initial shockwave—traveling at supersonic speeds—induces abrupt changes in intracranial pressure, producing barotrauma to delicate neural and vascular structures. Secondary blast injuries result from shrapnel and debris striking the body, while tertiary injuries occur when service members are physically displaced by the force of the blast. Quaternary injuries add further layers of complexity, including burns, toxic inhalation, and systemic inflammatory responses (Cernak and Noble-Haeusslein 255).
If a blast occurs in an enclosed space—such as an armored vehicle or building—the intensity is amplified. Multiple reflections and reverberations of the blast wave magnify intracranial stress, compounding the risk of structural and metabolic injury (Taber et al. 276). These biomechanical forces disrupt neural membranes, alter calcium homeostasis, impair mitochondrial function, and set off neuroinflammatory cascades that can persist long after the acute event has ended (Goldstein et al. 134).
The clinical manifestations are equally concerning. Veterans with blast-related mild TBI report persistent somatic pain syndromes: more than 40 percent endorse chronic back pain; nearly 70 percent report head, neck, or spinal pain; and late-onset headaches appear in up to 42 percent of cases, sometimes weeks or months after the initial exposure (Iverson et al. 164). These data underscore a critical point: the absence of visible injury does not equate to the absence of disease. Careful inquiry into the mechanism of injury and the timing of symptom onset is essential to accurate diagnosis and effective treatment.
Bigler, Erin D., and William L. Maxwell. “Neuropathology of Mild Traumatic Brain Injury: Relationship to Neuroimaging Findings.” Brain Imaging and Behavior, vol. 6, no. 2, 2012, pp. 108–136.
Cernak, Ibolja, and Linda J. Noble-Haeusslein. “Traumatic Brain Injury: An Overview of Pathobiology with Emphasis on Military Populations.” Journal of Cerebral Blood Flow & Metabolism, vol. 30, no. 2, 2010, pp. 255–66.
Goldstein, Lee E., et al. “Chronic Traumatic Encephalopathy in Blast-Exposed Military Veterans and a Blast Neurotrauma Mouse Model.” Science Translational Medicine, vol. 4, no. 134, 2012, p. 134ra60.
Iverson, Grant L., et al. “Chronic Pain in Veterans with Mild Traumatic Brain Injury.” Journal of Head Trauma Rehabilitation, vol. 34, no. 3, 2019, pp. 162–170.
Taber, Katherine H., et al. “Blast-Related Traumatic Brain Injury: What Is Known? What Is Needed?” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 18, no. 2, 2006, pp. 141–145.
Dr. Susan Rashid: The scope of traumatic brain injury in American veterans is vast. According to the Defense Health Agency, more than 450,000 service members have been diagnosed with a TBI since the year 2000 (Traumatic Brain Injury Center of Excellence). Of these, approximately 80 to 85 percent are classified as mild, or concussion-level injuries, with the remainder ranging from moderate to severe. The term ‘mild,’ however, often misleads. Even these concussive injuries can produce disabling symptoms when repeated, unrecognized, or layered with psychological stressors.
The epidemiology tells the story of modern warfare. In civilian life, the leading causes of TBI are falls, sports injuries, and motor vehicle crashes. For military populations, by contrast, the leading mechanism has been blast exposure—particularly improvised explosive devices during operations in Iraq and Afghanistan (Hoge et al. 453). In this context, TBI became known as the ‘signature injury’ of the post-9/11 conflicts, in the same way that lung injury was once synonymous with World War I’s chemical warfare and amputations with the Civil War (Tanielian and Jaycox 61).
The clinical burden is intensified by repetition. Many service members sustain more than one concussion during deployment. Studies show that multiple concussions compound cognitive deficits, extend recovery times, and heighten the risk of developing chronic symptoms (Iverson et al. 167). Beyond the acute stage, the long-term outcomes include sleep disturbance, persistent headache, impaired memory, mood instability, and increased vulnerability to neurodegenerative disease.
Since 2007, the Department of Veterans Affairs has mandated screening for TBI in all post-9/11 combat veterans seeking care, using a standardized four-question instrument (U.S. Department of Veterans Affairs). This national program reflects recognition of the injury’s scale, but also of its subtlety: without deliberate screening, many cases would remain undiagnosed. The mandatory screening also underscores the reality that TBI is not simply a neurological problem—it is a systems problem, one that requires coordination between medicine, rehabilitation, behavioral health, and long-term policy planning.
Hoge, Charles W., et al. “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq.” New England Journal of Medicine, vol. 358, no. 5, 2008, pp. 453–63.
Iverson, Grant L., et al. “Chronic Pain in Veterans with Mild Traumatic Brain Injury.” Journal of Head Trauma Rehabilitation, vol. 34, no. 3, 2019, pp. 162–170.
Tanielian, Terri, and Lisa H. Jaycox, editors. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. RAND Corporation, 2008.
Traumatic Brain Injury Center of Excellence (TBICoE). “DoD TBI Worldwide Numbers (2000–2024 Q4).” Defense Health Agency, 2025.
U.S. Department of Veterans Affairs. “TBI Screening Program for Post-9/11 Veterans.” 2024.
Dr. Susan Rashid: Chronic pain is among the most disabling long-term consequences of deployment-related traumatic brain injury. Estimates vary, but studies consistently show that between 30 and 90 percent of veterans with TBI experience persistent pain syndromes—including headaches, cervical and lumbar pain, musculoskeletal injuries, and neuropathic pain states (Nampiaparampil 60). Compared with their uninjured peers, veterans with TBI are five to seven times more likely to report enduring pain, often persisting for five years or more after deployment (Otis et al. 216).
The underlying mechanisms are multifactorial. Traumatic brain injury triggers neuroinflammatory cascades and alters pain modulation pathways within the thalamus and cortex, producing heightened pain sensitivity. Concurrent musculoskeletal injuries sustained during blast exposures, falls, or rapid acceleration-deceleration further complicate the clinical picture. Pain is also magnified by comorbid conditions common among veterans with TBI—such as PTSD, depression, and sleep disturbance—which reinforce one another in a cycle of suffering (Lew et al. 701).
Management must be both comprehensive and individualized. Nonpharmacologic therapies are the foundation of care. Physical therapy restores mobility and prevents deconditioning. Aerobic and resistance exercise reduce systemic inflammation and improve quality of life. Cognitive-behavioral therapy addresses the psychological dimensions of pain, helping veterans regain control and adapt to persistent symptoms (Cifu et al. 1046).
When medications are needed, clinicians are advised to begin with acetaminophen or nonsteroidal anti-inflammatory drugs. If pain persists, tricyclic antidepressants, SSRIs, or SNRIs may be added—agents that target both mood and pain. For neuropathic pain or spasticity, gabapentin or baclofen may be useful, though they require careful monitoring to avoid cognitive or sedative side effects (American Academy of Family Physicians 2021).
Opioid therapy is the exception, not the rule. While opioids may provide temporary relief, their risks are especially pronounced in TBI populations, where cognitive impairment and psychiatric comorbidity increase the dangers of dependence, misuse, and adverse events. The VA/DoD Clinical Practice Guideline advises that opioids be considered only when all other options fail, and even then with strict monitoring and a plan for tapering (VA/DoD 2017).
For veterans with TBI, chronic pain is rarely an isolated complaint. It interacts with mood, cognition, and sleep, shaping the overall clinical trajectory. Effective treatment therefore demands an interdisciplinary approach—linking neurology, pain medicine, behavioral health, and rehabilitation to address the full burden of injury.
American Academy of Family Physicians. “Traumatic Brain Injury: Diagnosis and Management.” American Family Physician, vol. 104, no. 6, 1 Dec. 2021, pp. 655–663.
Cifu, David X., et al. “Chronic Pain in Military Service Members with Traumatic Brain Injury.” American Journal of Physical Medicine & Rehabilitation, vol. 92, no. 12, Dec. 2013, pp. 1046–1053.
Lew, Henry L., et al. “Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OEF/OIF Veterans: Polytrauma Clinical Triad.” Journal of Rehabilitation Research and Development, vol. 46, no. 6, 2009, pp. 697–702.
Nampiaparampil, Maya A. “Prevalence of Chronic Pain After Traumatic Brain Injury: A Systematic Review.” JAMA, vol. 300, no. 6, 13 Aug. 2008, pp. 711–719.
Otis, John D., et al. “An Examination of the Co-Morbidity Between Chronic Pain and Posttraumatic Stress Disorder on U.S. Veterans.” Psychiatric Annals, vol. 39, no. 3, Mar. 2009, pp. 216–222.
U.S. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Version 3.0, 2017.
Dr. Susan Rashid: Traumatic brain injury does not occur in isolation. It is often accompanied by psychiatric comorbidities that shape both the course of recovery and the quality of life for veterans. Among these, posttraumatic stress disorder is the most pervasive. Research demonstrates that veterans with a history of TBI are three times more likely to develop PTSD compared with their peers without brain injury (Lew et al. 701). This interaction between neurological injury and psychological trauma complicates diagnosis and treatment, creating what clinicians sometimes call the ‘polytrauma clinical triad’—the overlapping presence of pain, PTSD, and persistent post-concussive symptoms.
The mechanisms underlying this relationship are multifaceted. Neuroimaging and neuroendocrine studies suggest that TBI alters the amygdala, hippocampus, and prefrontal cortex, regions that also mediate fear, memory, and emotional regulation. Damage in these circuits may increase vulnerability to PTSD, intensify symptom severity, and prolong recovery (Stein and McAllister 1309). Veterans with both TBI and PTSD frequently experience heightened arousal, intrusive memories, irritability, and insomnia, which amplify cognitive complaints and impair daily functioning (Vasterling and Bryant 201).
Treatment is correspondingly complex. Cognitive-behavioral therapy remains first-line for PTSD, but the presence of TBI can reduce therapeutic response by nearly 50 percent due to cognitive slowing, memory deficits, and impaired executive functioning (Stein and McAllister 1310). Clinicians must adapt psychotherapy accordingly—using shorter, more structured sessions, incorporating memory aids, and pacing interventions more gradually.
Pharmacologic management assumes greater weight in these cases. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered first-line therapies, given their efficacy for both PTSD and comorbid depression. Mirtazapine may be used when insomnia or appetite loss dominate, while prazosin has demonstrated utility in reducing trauma-related nightmares and improving sleep quality (Raskind et al. 563). Tricyclic antidepressants, nefazodone, and monoamine oxidase inhibitors, however, must be approached with caution in TBI populations because of their anticholinergic side effects, potential cardiac risks, and limited data supporting efficacy (Management of Concussion/mTBI Working Group 2016).
Treatment must be deliberate: begin with single agents, start at lower doses, titrate slowly, and allow extended trial periods to properly evaluate effectiveness. Ultimately, psychiatric comorbidities are not peripheral to the problem of traumatic brain injury—they are central to it. Effective care requires integration of neurology, psychiatry, and rehabilitation, with careful tailoring to the unique vulnerabilities of veterans living with both TBI and PTSD.
Dr. Susan Rashid: The long arc of traumatic brain injury extends far beyond the acute phase. Its consequences ripple forward in time, reshaping health trajectories decades after the original event.
One of the most concerning risks is dementia. Large cohort studies within the Veterans Health Administration have shown that even mild TBI—whether or not associated with loss of consciousness—is linked to a more than twofold increase in the risk of developing dementia later in life (Barnes et al. 1058). This association persists after controlling for psychiatric comorbidities and vascular risk factors, underscoring TBI itself as an independent contributor. Neuropathological studies suggest that axonal injury and chronic neuroinflammation may accelerate neurodegenerative processes, leading to conditions such as Alzheimer’s disease or chronic traumatic encephalopathy (Goldstein et al. 134).
Another long-term complication is post-traumatic epilepsy (PTE). Epilepsy may develop months, years, or even decades after the initial insult. A landmark longitudinal study—the Vietnam Head Injury Study (VHIS)—followed veterans with penetrating head trauma for over 30 years. It revealed a striking prevalence: 44 percent of these veterans developed epilepsy, with 13 percent reporting late-onset seizures more than 14 years after their injury (Raymont et al. 1242). Risk factors included left parietal lobe lesions, retained metallic fragments, larger lesion size, and greater overall brain volume loss. These findings underscore that PTE is not merely an acute or subacute risk but a lifelong vulnerability that demands ongoing medical surveillance for veterans who sustained penetrating injuries.
Perhaps most troubling is the association between TBI and suicide. Analyses of post-9/11 veterans reveal that suicide risk rises significantly with the presence of TBI, and the risk increases with the number and severity of injuries. Veterans with moderate or severe TBI have the highest risk, but even those with mild concussions face elevated rates compared to non-injured peers (Howard et al. 649). This relationship is mediated not only by neurobiological changes but also by comorbid pain, depression, PTSD, and functional disability. These findings demand systematic suicide risk screening, lethal-means safety counseling, and integration of behavioral health into long-term TBI care (Bryan and Clemans 129).
The lesson is clear: TBI is not a discrete event. It is a lifelong condition with neurological, psychiatric, and social implications. To care for veterans with TBI is to plan decades ahead—to anticipate dementia risk, to remain vigilant for seizures, and to actively guard against suicide. These responsibilities extend far beyond neurology clinics; they are part of the collective obligation we bear to those who carried war within their bodies.
Barnes, Deborah E., et al. “Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in U.S. Military Veterans.” JAMA Neurology, vol. 75, no. 9, 2018, pp. 1055–61.
Bryan, Craig J., and Tracy A. Clemans. “Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel.” Journal of the American Medical Association Psychiatry, vol. 70, no. 7, 2013, pp. 686–693.
Goldstein, Lee E., et al. “Chronic Traumatic Encephalopathy in Blast-Exposed Military Veterans and a Blast Neurotrauma Mouse Model.” Science Translational Medicine, vol. 4, no. 134, 2012, p. 134ra60.
Howard, John T., et al. “Suicide Rates Among Post-9/11 U.S. Military Veterans With and Without Traumatic Brain Injury, 2006–2020.” JAMA Neurology, vol. 80, no. 6, 2023, pp. 648–56.
Raymont, Vanessa, et al. “Correlates of Post-Traumatic Epilepsy 35 Years Following Traumatic Brain Injury.” Epilepsia, vol. 51, no. 7, 2010, pp. 1241–1248.
Dr. Susan Rashid: Traumatic brain injury is not only a clinical disorder—it is also a public health concern. One of the most sobering intersections lies between TBI and homelessness. Research has consistently shown that veterans with a history of TBI are significantly more likely to experience homelessness than their uninjured peers (Adams et al. 7).
The prevalence is striking. Studies report that nearly 50 percent of homeless veterans have sustained at least one traumatic brain injury, a rate far higher than that seen in the general veteran population, where estimates range from 20 to 25 percent (Frieden et al. S133). In many cases, the injury predates the loss of housing, suggesting that TBI may increase vulnerability to homelessness by undermining employability, social stability, and mental health (Brenner et al. 1636).
The mechanisms are multifactorial. Cognitive impairments following TBI—such as deficits in attention, memory, and executive function—make it more difficult to hold steady employment, manage finances, and navigate bureaucratic systems for benefits or housing support. Psychiatric comorbidities including PTSD, depression, and substance use disorders compound these risks, magnifying social instability (Petrakis et al. 174). Chronic pain and functional disability further erode resilience, while involvement with the criminal justice system—a documented risk among veterans with TBI—can interrupt employment and housing stability, creating an additional pathway into homelessness (Kemp et al. 486).
The public health implications are profound. Homelessness itself worsens health outcomes, increases emergency department utilization, and accelerates morbidity and mortality. For veterans with TBI, living without stable shelter exacerbates vulnerability to further injury, untreated seizures, substance use relapse, and psychiatric crises. Thus, TBI is both a cause and a consequence of homelessness: the injury predisposes veterans to instability, while homelessness heightens exposure to violence, accidents, and further brain injury (Adams et al. 12).
Policy responses have begun to recognize this overlap. The Department of Veterans Affairs has integrated TBI screening into its Homeless Programs Office, ensuring that veterans experiencing homelessness are assessed for brain injury and referred for appropriate rehabilitation. Housing-first models, coupled with specialized medical and psychiatric support, have shown promise in stabilizing veterans with complex comorbidities. Yet the persistence of high rates of TBI among homeless veterans highlights the need for coordinated care models that bridge neurology, mental health, pain management, and social services.
Ultimately, the intersection of TBI and homelessness illustrates that war’s injuries extend beyond the clinic and into the social fabric. Addressing brain injury in veterans requires not only medical vigilance but also structural commitment—policies that recognize stable housing as a form of healthcare and a prerequisite for recovery.
Adams, Rachel S., et al. “Traumatic Brain Injury Among Homeless Veterans: Prevalence and Associated Risks.” Journal of Head Trauma Rehabilitation, vol. 33, no. 1, 2018, pp. 7–13.
Brenner, Lisa A., et al. “Traumatic Brain Injury, Neuropsychiatric Symptoms, and Homelessness Among Veterans.” Psychiatric Services, vol. 64, no. 2, 2013, pp. 1636–1642.
Frieden, Lex L., et al. “Homeless Veterans and Traumatic Brain Injury.” Journal of Rehabilitation Research & Development, vol. 50, no. 7, 2013, pp. S131–S142.
Kemp, Jason, et al. “Traumatic Brain Injury and Homelessness.” Brain Injury, vol. 33, no. 4, 2019, pp. 482–490.
Petrakis, Ilsa L., et al. “Comorbidity of Alcoholism and Psychiatric Disorders: An Overview.” Alcohol Research & Health, vol. 26, no. 2, 2002, pp. 81–89.
Dr. Susan Rashid: For family physicians, neurologists, psychiatrists, and rehabilitation specialists alike, the clinical imperatives are clear.
First, always ask about deployment and blast exposure. The mechanism of injury—whether from direct impact, acceleration-deceleration, or blast wave—shapes both immediate and long-term outcomes.
Second, screen systematically for TBI and its comorbidities. The Veterans Health Administration mandates TBI screening for all post-9/11 veterans, but the responsibility extends to every clinical encounter. Standardized tools such as the Military Acute Concussion Evaluation (MACE-2) and VA/DoD protocols improve detection, while structured follow-up ensures that cognitive, psychiatric, and neurological sequelae are not missed (VA/DoD 2021).
Third, treat chronic pain with tiered strategies. Nonpharmacologic modalities—physical therapy, exercise, cognitive-behavioral therapy—form the foundation of care, supplemented when necessary by judicious pharmacotherapy. NSAIDs, acetaminophen, tricyclic antidepressants, SSRIs, and SNRIs may be considered, while opioids should remain the exception, reserved only for refractory cases with strict adherence to VA/DoD guidelines (Cifu et al. 1047; VA/DoD 2017).
Fourth, integrate psychiatric care as an inseparable part of TBI management. PTSD, depression, anxiety, and insomnia are not peripheral—they are intrinsic to the injury’s impact. Evidence-based therapies such as trauma-focused CBT must be adapted for cognitive impairments, while SSRIs, SNRIs, mirtazapine, or prazosin may serve as first-line pharmacologic supports (Stein and McAllister 1310; Raskind et al. 929).
Fifth, plan for the long horizon. Dementia, post-traumatic epilepsy, and suicide are not distant hypotheticals; they are well-documented long-term consequences. Clinicians should counsel patients and families accordingly, maintain vigilance for late-onset seizures, and incorporate suicide risk screening into routine care (Barnes et al. 1058; Raymont et al. 1243; Howard et al. 650).
Finally, be mindful of the social determinants of health, particularly homelessness. Veterans with TBI face markedly higher rates of housing instability and homelessness, driven by the combined effects of cognitive impairment, psychiatric comorbidity, chronic pain, and unemployment (Adams et al. 7; Brenner et al. 1637). Addressing these risks requires coordinated care that bridges neurology, psychiatry, primary care, and social services—recognizing that stable housing is itself a form of medical treatment.
The central truth is this: traumatic brain injury is more than a battlefield wound. It is a lifelong medical and social condition requiring precision, compassion, and commitment. For our veterans, survival is not simply the absence of death. It is the presence and understanding of dignity, function, and hope.
[Music swells and fades.]
Adams, Rachel S., et al. “Traumatic Brain Injury Among Homeless Veterans: Prevalence and Associated Risks.” Journal of Head Trauma Rehabilitation, vol. 33, no. 1, 2018, pp. 7–13.
Barnes, Deborah E., et al. “Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in U.S. Military Veterans.” JAMA Neurology, vol. 75, no. 9, 2018, pp. 1055–61.
Brenner, Lisa A., et al. “Traumatic Brain Injury, Neuropsychiatric Symptoms, and Homelessness Among Veterans.” Psychiatric Services, vol. 64, no. 2, 2013, pp. 1636–42.
Cernak, Ibolja, and Linda J. Noble-Haeusslein. “Traumatic Brain Injury: An Overview of Pathobiology with Emphasis on Military Populations.” Journal of Cerebral Blood Flow & Metabolism, vol. 30, no. 2, 2010, pp. 255–66.
Cifu, David X., et al. “Chronic Pain in Military Service Members with Traumatic Brain Injury.” American Journal of Physical Medicine & Rehabilitation, vol. 92, no. 12, 2013, pp. 1046–53.
Howard, John T., et al. “Suicide Rates Among Post-9/11 U.S. Military Veterans With and Without Traumatic Brain Injury, 2006–2020.” JAMA Neurology, vol. 80, no. 6, 2023, pp. 648–56.
Raskind, Murray A., et al. “A Parallel Group Placebo Controlled Study of Prazosin for Trauma Nightmares and Sleep Disturbance in Combat Veterans with Post-Traumatic Stress Disorder.” Biological Psychiatry, vol. 61, no. 8, 2007, pp. 928–34.
Raymont, Vanessa, et al. “Correlates of Post-Traumatic Epilepsy 35 Years Following Traumatic Brain Injury: A Vietnam Head Injury Study.” Epilepsia, vol. 51, no. 7, 2010, pp. 1241–48.
Stein, Murray B., and Thomas W. McAllister. “Exploring the Convergence of Posttraumatic Stress Disorder and Mild Traumatic Brain Injury.” American Journal of Psychiatry, vol. 166, no. 7, 2009, pp. 768–76.
U.S. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Version 3.0, 2017.
U.S. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury. Version 3.0, 2021.
Dr. Susan Rashid: Traumatic brain injury is not a chapter of war that closes when the guns fall silent. It is an injury that follows our veterans home—into their families, their work, their sleep, and their futures. We have seen how blast waves alter brain chemistry in milliseconds, how pain lingers for years, how psychiatric wounds entwine with neurological scars, and how dementia, epilepsy, and even homelessness can emerge decades later.
The story of TBI is therefore not only a clinical one. It is a story of systems—medical, social, and political—that must adapt to meet the needs of those who served. For clinicians, that means vigilance: ask the question, screen with rigor, and treat with compassion across specialties. For policymakers, it means recognizing that housing, rehabilitation, and mental health services are medical necessities. And for society, it means refusing to let invisible injuries remain unseen.
The long shadow of traumatic brain injury will not lift easily. But with science that is precise, medicine that is integrated, and care that honors both dignity and resilience, it is possible to turn that shadow into a path of survival.
This has been Secrets of Survival (S.O.S.). I’m Dr. Susan Rashid. Until next time—let us carry forward the work of turning survival into strength, and service into lasting health.
[Outro music swells—solemn, steady, then fades.]
American Academy of Family Physicians. “Traumatic Brain Injury: Diagnosis and Management.” American Family Physician, vol. 104, no. 6, 2021, pp. 655–663.
Barnes, Deborah E., et al. “Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in U.S. Military Veterans.” JAMA Neurology, vol. 75, no. 9, 2018, pp. 1055–61.
Cernak, Ibolja, and Linda J. Noble-Haeusslein. “Traumatic Brain Injury: An Overview of Pathobiology with Emphasis on Military Populations.” Journal of Cerebral Blood Flow & Metabolism, vol. 30, no. 2, 2010, pp. 255–66.
Howard, John T., et al. “Suicide Rates Among Post-9/11 U.S. Military Veterans With and Without Traumatic Brain Injury, 2006–2020.” JAMA Neurology, vol. 80, no. 6, 2023, pp. 648–56.
Iverson, Grant L., et al. “Chronic Pain in Veterans with Mild Traumatic Brain Injury.” Journal of Head Trauma Rehabilitation, vol. 34, no. 3, 2019, pp. 162–170.
Lew, Henry L., et al. “Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OEF/OIF Veterans.” Journal of Rehabilitation Research and Development, vol. 46, no. 6, 2009, pp. 697–702.
Management of Concussion/mTBI Working Group. VA/DoD Clinical Practice Guideline for the Management of Concussion/mild Traumatic Brain Injury. Department of Veterans Affairs, Department of Defense, 2016.
Nampiaparampil, Maya. “Prevalence of Chronic Pain After Traumatic Brain Injury: A Systematic Review.” JAMA, vol. 300, no. 6, 2008, pp. 711–719.
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