1. INTRODUCTION Emotional distress and sense of burden are experienced by many caregivers of persons with traumatic brain injury (TBI). 1-8 Predicting which caregivers will experience distress is critical for developing empirically- based interventions. Researchers have examined injury-related variables and caregiver demographics to predict caregivers’ adjustment following TBI. Injury severity appears to be related to caregiver distress at 3 to 6 months post-injury, but not at longer follow-up intervals. 4, 9-12 Changes in emotional and social functioning in injured persons are strongly related to caregivers’ perceived stress and emotional functioning. 4, 8-10, 13-17 Caregiver demographics: relationship to the injured person has been studied most frequently. Findings have been mixed. Coping styles 18-19 and social support 17, 20, 21 appear to moderate the impact of injury on caregiver perceived burden and distress. Many caregivers have pre-existing difficulties that may predispose them to greater distress following injury, including emotional distress and significant medical illnesses. 4, 22 These variables have the potential to help identify caregivers at risk for developing greater distress after injury. PURPOSE The contribution of pre-injury medical and psychiatric histories to caregiver outcome, above and beyond what can be predicted by other variables, has remained unexplored. Our goal was to examine the relationship of pre- injury caregiver medical and psychiatric histories to perceived burden and emotional distress among caregivers of persons with TBI. Medical and Psychosocial Predictors of Caregiver Functioning After Traumatic Brain Injury Lynne C. Davis, Ph.D., Angelle M. Sander, Ph.D., Margaret A. Struchen, Ph.D., Mark Sherer, Ph.D., Risa Nakase-Richardson, Ph.D., & James F. Malec, Ph.D. METHOD Participants Sample consisted of 114 caregivers of persons with medically documented complicated mild/moderate (35%) or severe (65%) injury, admitted to 1 of 3 participating centers. Of 217 caregivers with baseline data, 114 had follow-up data at 1 year post-injury. Caregivers lost to follow-up did not differ from those with follow-up data with regard to demographics, medical or psychiatric history, or severity of the person with injury. Measures Brief Symptom Inventory (BSI) 24 : 53 items yield 3 global distress indices. Global Severity Index scores were used as an outcome measure of caregiver distress. Modified Caregiver Appraisal Scale (MCAS) 25,26 : used for caregivers of persons with TBI. Perceived Burden Scale scores were used as an outcome measure of perceived burden. Ways of Coping Questionnaire (WOCQ) 27 : used to identify frequently used coping strategies. Escape-Avoidance and Positive Reappraisal subscales were used as predictor variables. Multidimensional Scale of Perceived Social Support (MSPSS) 28 : assesses satisfaction with perceived social support. The total score was used as a predictor variable. Disability Rating Scale (DRS) 29 : rates level of functional ability in 8 areas. The total score was used as a predictor variable. Procedure Caregivers’ demographics, medical history, and psychiatric history were obtained through structured interview. Caregivers completed the BSI, MCAS, WOCQ, and MSPSS at approximately 1 year post- injury. A trained examiner rated the injured person on the DRS at the same time interval. Two multiple linear regression models were constructed, one to predict caregiver perceived burden and one to predict caregiver distress. The models were identical except for the outcome variables. Model 1: Predictors of Caregiver Burden RESULTS Model 1: Predictors of Perceived Burden Model 2: Predictors of Global Distress DISCUSSION Perceived Burden Poorer functional status of persons with injury was associated with greater sense of burden among caregivers. Increased perceived social support was related to decreased sense of burden. Increased use of Escape-Avoidance was associated with elevated caregiver burden. Global Distress Caregivers with reported histories of significant illness(es) reported higher levels of distress. Similarly, caregivers with histories of treatment for psychological problems reported higher levels of distress. Increased use of Escape-Avoidance was associated with elevated distress. CONCLUSIONS After accounting for the functioning of the person with injury and caregiver demographics, pre-injury medical and psychiatric history contributed significantly to overall level of caregiver distress. This suggests that caregiver distress after TBI is not only associated with injury-related variables, but also appears related to pre-existing characteristics of caregivers. Since medical and psychiatric data are readily identifiable at the time of injury, early intervention is possible for caregivers at risk for elevated emotional distress. This relationship was not obtained with respect to caregiver burden. This is likely a function of the inherent differences between the two outcome measures. The BSI Global Severity Index is a general measure of distress that may not necessarily be related to the role of caring for the injured person. In contrast, the Perceived Burden Scale of the MCAS assesses caregivers’ perceptions of stress directly associated with the caregiving role. The relationship between emotion-focused coping (Escape-Avoidance) and caregiver distress and burden is consistent with previous research. Primary limitations: accuracy issues with respect to self- reported medical and psychiatric history data; only single measures of caregiver burden and overall emotional distress were used. *References available on handout Physical Medicine and Rehabilitation