TRAUMATIC BRAIN INJURY (TBI) has long been

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1 J Head Trauma Rehabil Vol. 22, No. 6, pp Copyright c 2007 Wolters Kluwer Health Lippincott Williams & Wilkins Screening Substance Abuse Treatment Clients for Traumatic Brain Injury: Prevalence and Characteristics Robert Walker, MSW, LCSW; Jennifer E. Cole, MSW; TK Logan, PhD; John D. Corrigan, PhD Objectives: To examine clinical characteristics of clients in state-funded substance abuse treatment who report traumatic brain injury with loss of consciousness (TBI-LOC). Participants: Adult clients (N = 7784) entering state-funded substance abuse treatment in a rural state during a 12-month period. Measurement tools: Substance use and mental health problems were measured using the federal Substance Abuse and Mental Health Services Administration (SAMHSA) adaptation of the Addiction Severity index (ASI). A brain injury screening question was used to determine the number of TBI-LOCs in a client s lifetime. Design: Cross-sectional study of intake characteristics as part of a state-mandated treatment outcome study. Results: Almost one-third (31.7%) of substance abuse treatment clients reported 1 or more TBI-LOCs. The clients reporting 2 or more TBI-LOCs were more likely than clients with none or 1 TBI-LOC to have serious mental health problems (ie, depression, anxiety, hallucinations, and suicidal thoughts and attempts), trouble controlling violent behavior, trouble concentrating or remembering, and more months of use of most substances. When depression and anxiety were held constant, and controlling for race and gender, clients with TBI-LOC had more months of marijuana and tranquilizer use. Conclusions: Findings suggest that treatment providers may need to be attentive to the complex conditions that co-occur with TBI-LOC. Future research should examine whether there are differences in treatment outcome for clients reporting TBI-LOC. Keywords: traumatic brain injury, substance abuse, screening TRAUMATIC BRAIN INJURY (TBI) has long been associated with alcohol and drug use both prior to the injury and as a complicating factor in outcomes including neurobehavioral impairments that have wideranging effects. 1 3 There is some evidence that preinjury substance use negatively affects neurobehavioral outcomes, 3,4 and it can also be difficult to disentangle the distinct and separate contributions of substance use and brain injury, particularly mild brain injury, to neurobehavioral outcomes. 5 While several studies have shown decreased drinking and other substance use after brain injury, individuals eventually return to preinjury levels of substance use. 6 8 There is, however, substantial evidence that brain injury and substance use are associated. Corrigan 9 found, from a review of 6 studies, that between 38% and 63% of substance abuse treatment clients reported brain injuries. Two of these studies used an extensive brain injury screen, the Brain Injury From the Center on Drug and Alcohol Research (Mr Walker and Ms Cole) and the Department of Behavioral Science (Dr Logan), College of Medicine, University of Kentucky, Lexington; and the Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus (Dr Corrigan) Corresponding author: Robert Walker, MSW, Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY Screening Questionnaire (BISQ), and 1 assessed specific characteristics of brain injury such as time unconscious, use of an emergency department, or hospitalization after the injury. 9 One study found that individuals who drank alcohol had a 4 times greater risk of brain injury than those who did not drink alcohol. 10 Other studies suggest that individuals with preinjury substance use disorders are likely to be heavy substance users postinjury, thus incurring added health, mental health, and injury risk. 8 Identifying TBI among clients in a substance abuse treatment setting raises several challenges. One potential goal of screening and assessing for TBI is to identify clinical characteristics among those with TBI that suggest a need for treatment accommodations or different approaches. However, the identification of clinical problems distinctly associated with TBI is not a simple matter. Both TBI and substance use can cause neurobehavioral problems, which include cognitive difficulties and behavioral disinhibition. Neurobehavioral problems can also be due to co-occurring mental health problems, as well as congenital or other sources of central nervous system compromise. Methods of screening for TBI that depend heavily on affective or behavioral symptoms can result in false positives when used in substance abuse treatment settings, if not elsewhere. For

2 Screening Substance Abuse Treatment Clients for Traumatic Brain Injury: Prevalence and Characteristics 361 example, the Brain Injury Screening Questionnaire contains 100 symptoms or behavioral problems that are intended to help validate the self-report of brain injury. However, 79 of the items are also symptoms of depression, anxiety, other affective disorders, thought disorders, or Axis II traits that can exist independent of brain injury. Indeed, the overlap between symptoms of psychiatric conditions and TBI makes it critical to consider multiple sources of problems when studying whether there are clinically relevant differences between substance abuse clients with and without TBI. This article builds on a previous study of head injury among substance abusers that found significant substance use differences between prison inmates with and without self-reported head injuries. 11 Since prison populations likely differ from other substance abusing populations, this article examines findings from a TBI screen used in assessment with clients in community substance abuse treatment. A TBI screening question was embedded in a state-mandated substance abuse treatment outcome study that focused primarily on substance use and related behaviors. A screening question about the number of self-reported injuries with loss of consciousness was asked by clinicians in the context of a substance abuse assessment process. The overall goal of adding this screening question was to identify special clinical characteristics of clients with TBI to inform substance abuse treatment and the state substance abuse services planning authority. METHOD Participants The sample used for analyses comprised 7784 adults who had entered substance abuse treatment in statefunded facilities in the Commonwealth of Kentucky during a 12-month period (July 1, 2005 to June 30, 2006). Only those clients who reported their race as white or African American were included in the analyses. Consistent with Kentucky s rural population, only a small proportion of participants reported a race other than white or African American (1.9%). The final sample represented 98% of the total number of clients entering state-funded substance abuse facilities and completing a baseline interview. The programs at which subjects sought treatment included outpatient, intensive outpatient, case management, and residential settings in urban and very rural areas of the state. Respondents were mostly men (64.9%), and non-hispanic whites (86.3%). Only 23.5% were married, while 42.5% were never married and 35.4% were separated or divorced. Fortythree percent had less than 12 years of education and 38% were employed full or part time. Measures TBI with loss of consciousness Clients were asked to report the number of lifetime head injuries that resulted in being knocked out or kept in a hospital at least 1 night. This wording was chosen to minimize stigma ( head versus brain injury) and to maximize concrete indices of serious effects (thus knocked out or hospitalized). This screening question identified relatively more severe injuries, but was likely to miss less severe TBIs that did not involve loss of consciousness. In the remainder of this report, a positive screen will be referred to as TBI with loss of consciousness (TBI-LOC) reflecting our presumption that the screening is only sensitive to this subset of TBIs. Substance use Substance use measures were taken from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center on Substance Abuse Treatment (CSAT) GPRA (Government Performance and Results Act) data-collection tool, which has been used to examine treatment outcomes among Treatment Capacity Expansion and other CSAT grant-funded programs. 12 The CSAT GPRA is based on the Addiction Severity Index (ASI) 13 and it measures substance use, criminal activity, employment, and other related behaviors in the past 30 days and the past 12 months and lifetime. Clients were asked if they had ever used each class of substance (eg, alcohol, any illicit drug, marijuana, opiates, tranquilizers, cocaine, and stimulants), and if so, how many months in the past 12 months they had used each class of substance. Mental health problems The mental health measures were taken from the ASI. 13 Groups based on clients self-reported depression and anxiety in the 12 months before the intake interview were formed to be included in the multivariate analysis to control for the effect of depression and anxiety on substance use, while examining the relationship between TBI-LOC and substance use. This composite measure was necessitated by the high prevalence of cooccurrence in the sample. More than one third of clients reported that they had not experienced depression or anxiety (37.7%, n = 2937), 18.7% (n = 1455) reported either depression or anxiety, and 43.6% (n = 3392) reported both depression and anxiety. Procedures In Kentucky, all state-funded substance abuse treatment programs participate in a statutory treatment outcome study each year. Substance abuse clinicians in

3 362 JOURNAL OF HEAD TRAUMA REHABILITATION/NOVEMBER DECEMBER 2007 TABLE 1 Sociodemographic factors by traumatic brain injury with loss of consciousness (TBI-LOC) group No lifetime 1 lifetime 2 or more TBI-LOC TBI-LOC lifetime TBI-LOCs (n = 5319) (n = 1541) (n = 924) Gender (% men) 62.4 a,b 68.3 a,c 74.1 b,c Race (%) White 86.3 a,b 89.9 a,c 93.8 b,c Black 13.7 a,b 10.1 a,c 6.2 b,c Age 32.7 a,b 33.9 a 34.3 b Marital status (%) Never married 44.0 a,b 40.3 a 36.7 b Married 21.6 a 18.4 a 17.9 Separated/divorced 32.7 a,b 39.4 a 44.4 b Widowed Less than 12 years of education (%) Employment status (%) Unemployed 59.4 a,b 64.8 a 69.2 b Employed 40.6 a,b 35.2 a 30.8 b Income from all reported sources in the past 30 days ($) Values sharing the same subscript differ at P <.01. P <.001. outpatient, intensive outpatient, and residential settings collect baseline data on clients during the intake and assessment phase of services. The data for the treatment outcome study are collected electronically from clients during assessment interviews using a personal digital assistant (PDA) that presents 1 question per screen. Minimal data are missing because the PDA program will not move to the next question without a response to each item. The data are synchronized via modem on a regular basis to the University of Kentucky Center on Drug and Alcohol Research (CDAR) for analysis, and CDAR develops reports on baseline characteristics of clients in treatment. CDAR reports annually on baseline-tofollow-up comparisons to examine treatment outcomes and cost benefits of treatment expenditures. All data are client self-reports. Data analysis Bivariate analyses were conducted to describe the sample by the TBI-LOC groups, and to inform the selection of variables to be included in the multivariate analysis. It was hypothesized that more clients with TBI would be men, white, report depression and anxiety, and clients with TBI would be older than clients without TBI. Bivariate associations were examined by chi-square tests for categorical variables and 1-way analysis of variance (ANOVA) for continuous variables between TBI-LOC and (a) sociodemographic variables, (b) substance use variables, and (c) mental health problems. Two-way (3 3) analyses of covariance (ANCOVAs) were conducted with TBI-LOC and depression/anxiety as independent variables, with the mean number of months clients used various substances in the 12 months before intake as dependent variables. Control variables included gender, race, age, and other substance use. Stimulant use was dropped from this analysis because too few clients reported its use in the 12 months before intake (17.7%). It was hypothesized that clients with TBI would report more months of substance use reflecting a more sustained pattern of substance use. A nominal number of cases were dropped from specific analyses because of missing values on key variables: (1) number of months of cocaine use, n = 1; (2) number of months of tranquilizer use, n = 14; (3) maximum number of months of illicit drug use, n = 3; (4) number of months of use of drugs other than marijuana, (5) number of months of drug use other than cocaine, n = 1; (6) number of months of use of drugs other than opiates, n = 1, and (7) 3 cases had missing values on all the variables of number of months of other substance use. RESULTS Bivariate analysis The majority of clients reported no lifetime TBI-LOC (68.3%, n = 5319), about 1 out of 5 reported 1 lifetime TBI-LOC (19.8%, n = 1541), and the remainder reported 2 or more lifetime head TBI-LOCs (11.9%, n = 924). The results of bivariate analysis of lifetime TBI- LOC group (no lifetime TBI-LOC, 1 lifetime TBI-LOC, and 2 or more TBI-LOCs) and sociodemographic factors

4 Screening Substance Abuse Treatment Clients for Traumatic Brain Injury: Prevalence and Characteristics 363 TABLE 2 Substance use in the past 12 months by traumatic brain injury with loss of consciousness (TBI-LOC) group, No lifetime TBI-LOC 1 lifetime TBI-LOC 2 or more lifetime TBI-LOCs (n = 5319) (n = 1541) (n = 924) Alcohol Any illicit drugs 5.6 a,b 6.0 a 6.3 b Marijuana 3.2 a a Opiates 2.3 a 2.6 b 3.1 a,b Tranquilizers 1.7 a,b 2.2 a,c 2.7 b,c Cocaine Values indicate mean no. of months of substance use in the past 12 months. Values sharing the same subscript differ at P <.01. P <.01. P <.001. are presented in Table 1. Significant differences between all the groups were found in gender, race, and employment status, with significantly more individuals with 2 or more lifetime TBI-LOCs being men, white, and unemployed, than were individuals with 1 lifetime TBI-LOC and individuals with no lifetime TBI-LOC. Significantly more individuals with 1 TBI-LOC were men, white, and unemployed than were individuals with no lifetime TBI- LOC. Significantly more individuals who had never had a TBI-LOC were black than were individuals in the other 2 groups. Individuals with no TBI-LOC were significantly younger than individuals who reported any TBI- LOC (1 and 2 or more). Significantly more individuals with no TBI-LOC had never been married than were individuals with 2 or more TBI-LOCs. More individuals with no TBI-LOC reported that they were currently married than did individuals with 1 TBI-LOC. Fewer individuals with no TBI-LOC were separated or divorced than were individuals with any TBI-LOC (1 and 2 or more). No significant differences were found in education or recent income by TBI-LOC group. When number of months of use of substances was examined by TBI-LOC group, no significant differences were found in the mean number of months of alcohol or cocaine use (see Table 2). The no lifetime TBI-LOC group had a significantly lower mean number of months of any illicit drug use than that of the 1 lifetime TBI- LOC group and the 2 or more lifetime TBI-LOC s group. The 2 or more lifetime TBI-LOCs group had a significantly higher mean for the number of months of marijuana use than that of the no lifetime TBI-LOC group. Individuals with 2 or more TBI-LOCs reported significantly more months of opiate use than did individuals with 1 TBI- LOC and individuals with no TBI-LOC. Tranquilizer use was significantly different between all the groups, with the 2 or more lifetime TBI-LOCs group reporting the greatest number of months of use, followed by the 1 lifetime TBI-LOC group, and with the no lifetime TBI- LOC group reporting the fewest number of months of use. Table 3 shows the significant differences in psychological problems in the past 12 months that were found between all the groups, with more individuals with 2 or more TBI-LOCs experiencing serious depression, serious anxiety, hallucinations, trouble remembering or concentrating, trouble controlling violent behavior, suicidal thoughts, and suicide attempts than did individuals with 1 TBI-LOC and individuals with no TBI-LOC. Furthermore, significantly more individuals with 1 TBI-LOC experienced psychological problems than did individuals with no TBI-LOC. Additionally, a sizeable minority of individuals (44.8%) with 2 or more TBI-LOCs had taken psychotropic medication in the past 12 months, which was a significantly higher percent than was found in the 1 lifetime TBI-LOC group and the no lifetime TBI- LOC group. Multivariate analysis A series of 3 3 (TBI-LOC and depression/anxiety) ANCOVAs was conducted to examine main effects of those 2 factors on the number of months clients used specific classes of substances (eg, alcohol, any illicit drugs, marijuana, opiates, tranquilizers, and cocaine). The first factor, TBI-LOC group, had 3 levels: (1) no lifetime TBI-LOC, n = 5319, (2) 1 lifetime TBI-LOC, n = 1541, and (3) 2 or more lifetime TBI-LOCs, n = 924. The second factor, depression/anxiety, also had 3 levels: (1) neither depression nor anxiety, n = 2937; (2) either depression or anxiety, n = 1455; and (3) both depression and anxiety, n = Interaction terms (TBI- LOC Depression/anxiety) were entered into each ANCOVA as well as covariates (gender, race, age, and number of months of other substance use in the 12 months before entry into treatment). Because of the large

5 364 JOURNAL OF HEAD TRAUMA REHABILITATION/NOVEMBER DECEMBER 2007 TABLE 3 Mental health problems in the past 12 months by TBI-LOC group, No lifetime 1 lifetime 2 or more TBI-LOC TBI-LOC lifetime TBI-LOCs (n = 5319) (n = 1541) (n = 924) Serious depression 45.5 a,b 55.7 a,c 67.4 b,c Serious anxiety 50.2 a,b 63.6 a,c 74.5 b,c Hallucinations 8.6 a,b 13.6 a,c 21.5 b,c Trouble understanding, concentrating, or remembering 43.7 a,b 58.0 a,c 65.7 b,c Trouble controlling violent behavior 18.5 a,b 28.1 a,c 34.5 b,c Suicidal thoughts 13.9 a,b 21.4 a,c 27.8 b,c Attempted suicide 5.9 a,b 8.2 a,c 12.9 b,c Took prescribed medication for mental health problems 28.5 a,b 36.5 a,c 44.8 b,c Values indicate the percent of clients reporting mental health problems in the past 12 months. Values sharing the same subscript differ at P <.01. P <.001. sample size, alpha was set at P <.01. Table 4 summarizes the results of the ANCOVA analyses by presenting the main effects for TBI-LOC and the main effects for depression/anxiety side-by-side as adjusted means for the number of months specific substances were used in the past 12 months. There were no significant interactions terms; thus these are not discussed further. As shown in Table 4, no significant main effect for TBI-LOC was found for number of months of alcohol use, after controlling for gender, race, age, and number of months of illicit drug use, F (2,7768) = 0.035, P >.01. Thus, lifetime TBI-LOC was not significantly associated with the number of months individuals used alcohol in the past 12 months. However, a main effect for the depression/anxiety index was found, F (2,7768)(THROUGHOUT) = 9.859, P <.001, with individuals in the 2 or more lifetime TBI-LOCs group reporting significantly more months of alcohol use than did individuals in the other 2 groups. No main effect for TBI-LOC was found on number of months of overall illicit drug use, after controlling for gender, race, age, and number of months of alcohol use in the past 12 months, F (2,7768) = 3.122, P >.01. A main effect was found for the depression/anxiety index, F (2,7768) = , P <.001. Specifically, clients with neither depression nor anxiety reported significantly fewer months of illicit drug use than did clients with either depression or anxiety and clients with both depression and anxiety. Also, clients with either depression or anxiety reported more months of illicit drug use than did clients with neither depression nor anxiety. TABLE 4 Adjusted means for past 12-month substance use by 2 factors, lifetime TBI-LOC and depression/anxiety, adjusting for gender, race, age, and other substance use, Lifetime TBI-LOC Independent variables Depression/anxiety 1 lifetime 2 or more Neither Either Both No TBI-LOC TBI-LOC TBI-LOCs depression depression depression Dependent group group group nor anxiety or anxiety and anxiety variables (n = 5319) (n = 1541) (n = 924) (n = 2937) (n = 1455) (n = 3392) Alcohol (0.067) (0.123) (0.174) a (0.137) b (0.153) a,b (0.092) Any illicit drug (0.068) (0.125) (0.178) a,b (0.139) a,c (0.156) b,c (0.092) Marijuana a (0.059) (0.109) a (0.154) (0.121) (0.136) (0.081) Opiate (0.056) (0.103) (0.146) a (0.115) b (0.129) a,b (0.077) Tranquilizer a,b (0.049) a (0.090) b (0.128) a,b (0.100) a (0.112) b (0.067) Cocaine (0.048) (0.089) (0.126) a,b (0.099) a,c (0.111) b,c (0.066) Groups sharing the same subscript significantly differ at P <.01. Values in parentheses are standard errors. P <.001. P <.01.

6 Screening Substance Abuse Treatment Clients for Traumatic Brain Injury: Prevalence and Characteristics 365 A main effect for TBI-LOC was found for number of months of marijuana use, after controlling for gender, race, age, number of months of alcohol use, and number of months of use of illicit drugs other than marijuana, F (2,7764) = 5.674, P <.01. Clients with 2 or more TBI- LOCs reported significantly more months of marijuana use than did clients with no lifetime TBI-LOC. No main effect for depression/anxiety was found on number of months of marijuana use, F (2,7764) = 4.295, P >.01. A main effect for TBI-LOC was found for number of months of tranquilizer use, after controlling for gender, race, age, number of months of alcohol use, and number of months of use of illicit drugs other than tranquilizers, F (2,7753) = , P <.001. Clients with no lifetime TBI-LOC reported fewer months of tranquilizer use in the past 12 months than did clients with 1 lifetime TBI- LOC and clients with 2 or more lifetime TBI-LOCs. In addition, a significant main effect was found for depression/anxiety on number of months of tranquilizer use, F (2,7753) = , P <.001. Clients who reported neither depression nor anxiety used tranquilizers significantly fewer months than did clients with either depression or anxiety and clients with both depression and anxiety. No main effect for TBI-LOC was found for number of months opiates [F (2,7766) = 0.990, P >.01], and cocaine [F (2,7765) = 0.133, P >.01] were used in the past 12 months, after controlling for gender, race, age, and number of months of use of other substances. However, a main effect was found for depression/anxiety for number of months opiates [F (2,7766) = , P <.001] and cocaine were used [F (2,7765) = , P >.001]. Specifically, there was a linear pattern in months of use of opiates and cocaine by the depression/anxiety groups, with clients with depression and anxiety reporting more months of use than the other 2 groups, and clients with either depression or anxiety reporting more months of use than clients with neither depression nor anxiety. DISCUSSION This study highlights several important considerations in screening for TBI among substance abuse clients. First, substance abuse treatment clients with a greater number of TBI-LOCs are significantly more likely to report mental health problems and the prevalence of mental health problems increases with the number of reported TBI-LOCs. Given the extensive literature on the occurrence of depression following TBI, this should not be surprising. 14,15 Second, given the associations of TBI- LOC with depression and anxiety, and the further associations of depression and anxiety with substance abuse, it may be clinically important to consider the 3 problem areas concurrently. In addition, these findings suggest that a preliminary screen for TBI-LOC, controlling for mental health conditions, identifies differences in substance use with those with TBI-LOC reporting greater months of marijuana and tranquilizer use. The use of marijuana and tranquilizers suggests a coherent pattern of seeking an emotionally dampening experience; however, it is interesting that months of alcohol use was not significantly associated with TBI-LOC. In addition, the combined presentation of TBI-LOC, depression and/or anxiety should form a marker for clinical complexity that needs special attention in treatment given the negative impact of depression on abstinence outcomes. 16 The considerable overlap of depression, anxiety, and TBI-LOC begs the question of which comes first. Unfortunately, in this limited cross-sectional examination of intake substance abuse assessment, the onset dates of these problems were not available. It is possible that the group reporting depression, anxiety, and other mental health problems plus TBI-LOC is composed of clients whose mental health problems either were the result of TBI-LOC or were exacerbated by TBI-LOC. The literature is clear about the relationship of earlier injury on subsequent depression as well as on increased neurocognitive difficulties when both conditions are present The linear trend toward more mental health complaints among those with greater number of TBI-LOCs in this study suggests the complexity of this co-occurrence. The co-occurrence of TBI-LOC with depression and anxiety also suggests a need for substance abuse treatment approaches that focus on stabilizing mood and affect rather than simply seeing these complaints as effects of substance withdrawal. At a minimum, this study suggests that the combined factors of TBI-LOC and depression and anxiety represent a far more clinically complex population deserving closer assessment and treatment attention. The findings from this study may also suggest a need for more medically managed recovery approaches. Given the reported association of marijuana and tranquilizers with TBI-LOC, the specific drug use expectations among those with TBI-LOC may need to be explored in order to inform interventions. It remains unclear whether clients with TBI-LOC are in fact exhibiting self-medication practices in selecting the emotion dampening effects of marijuana and tranquilizers. This study is perhaps one of the first to begin a routine clinical screening for TBI-LOC among a large population of individuals during the assessment for substance abuse problems in publicly funded treatment facilities. While many studies of TBI and substance abuse have featured small samples, often of convenience, this project has included all clients who were assessed for substance abuse as part of their participation in either residential, intensive outpatient, or outpatient treatment in a 12-month period in 1 state. The large sample size contributes to the broader understanding of the prevalence of TBI-LOC among persons entering publicly funded substance abuse treatment. It is also possible that by

7 366 JOURNAL OF HEAD TRAUMA REHABILITATION/NOVEMBER DECEMBER 2007 using the TBI-LOC question during assessment, clinicians will follow-up with more detailed assessment of neurobehavioral problems and thus adjust their clients treatment plans accordingly. Part of the goal for beginning the use of TBI-LOC screening was to better sensitize substance abuse treatment clinicians about the prevalence and clinical problems of clients with TBI- LOC histories. The prevalence estimates from this study are lower than those of some studies, but the percent of clients with TBI-LOC is sizeable within the statewide substance treatment population. There were several limitations to this study. First, all data were client self-reports and the data were collected by clinicians in publicly funded treatment settings with a wide range of training and clinical experience. However, the reliability and validity of self-reports about alcohol and drug use have been substantiated. 22,23 While the PDA data system prevents contradictory responses or missing fields, it does not protect against other sources of inaccurate response. In addition, clinicians vary widely in their knowledge and understanding of TBI and its implications for treatment. Also, the limited, cross-sectional nature of the instrument, and the fact that the questions for TBI-LOC are designed only for screening, not assessment purposes, precludes interpretations of which problems predate each other, including TBI-LOC, depression and anxiety. Most importantly, the study did not ascertain the dates of TBI or other associated problems and thus cannot claim more than associations of TBI with other problems. However, even with these limitations, this study is perhaps the first to begin a systematic screening for TBI- LOC among a large number of substance abuse treatment clients in publicly funded programs. The study used a careful analysis to more fully examine the specific contribution of TBI-LOC history to the substance abuse clinical presentation while controlling for depression and anxiety as well as gender, age, and race, among clients in publicly funded treatment. While the findings suggest a difference in substance use for 2 substances among clients with TBI-LOC, the associations between TBI-LOC and depression and anxiety are of great clinical importance and call for more focused research to help understand the specific relationship between all 3 conditions. Funding agencies in state and federal government may need to consider TBI-LOC as a co-occurring condition (along with mental disorders) that needs special attention in funding allocations and in research. Future research might examine whether depression and anxiety resulting from TBI-LOC results in greater risk for substance abuse than does TBI-LOC only. Also, it remains to be seen whether the history of TBI-LOC at intake predicts any significant differences in treatment outcome 12 months after entering treatment. This issue is of paramount importance for treatment providers and should be examined by future research. REFERENCES 1. Taylor LA, Kreutzer JS, Demm SR, Meade MA. Traumatic brain injury and substance abuse: a review and analysis of the literature. Neuropsychol Rehabil. 2003;13: Corrigan JD, Rust E, Lamb-Hart GL. The nature and extent of substance abuse problems in persons with traumatic brain injury. J Head Trauma Rehabil. 1995;10: Parry-Jones BL, Vaughn FL, Cox WM. Traumatic brain injury and substance misuse: a systematic review of prevalence and outcomes research ( ). Neuropsychol Rehabil. 2006;16: Kelly MP, Johnson CT, Knoller N, Drubach DA, Winslow MM. 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