Title: Assistant Training Director Fellowship Program
Clinical/Research Psychologist
Contact:
303-355-5886
1055 Clermont Street
Denver, CO 80220 beeta.homaifar@va.gov
Dr. Homaifar has been affiliated with the VISN 19 Mental Illness, Research, Education and Clinical Center (MIRECC) since its inception in 2005. She obtained her doctorate in Counseling Psychology from the University of Iowa in 2005, after which she was accepted into a postdoctoral fellowship program at the VISN 19 MIRECC. She is an Assistant Professor in the Department of Psychiatry at the University of Colorado School of Medicine.
Her primary areas of research interest are TBI, neuropsychological assessment of executive functioning, co-morbid psychiatric disorders, suicide, recovery/resilience, and implementation science. Since 2008 she has served as a reviewer for several rehabilitation, suicide, and general mental health journals and is an associate editor of Frontiers in Neurotrauma. She also serves as a reviewer of grants at the Center for Scientific Review (CSR), National Institute of Health (NIH).
With regard to her clinical background, her areas of expertise are in Rehabilitation Psychology (e.g., TBI, SCI), suicide, neuropsychological/psychological assessment, Acceptance and Commitment Therapy, and Therapeutic Assessment. From 2008-2011 she served as the Director of the VA VISN 19 MIRECC Psychological Consultation Service for Suicidal Veterans.
Additionally, she serves on various local/regional committees including the VA Eastern Colorado Health Care System: Evidence Based Psychotherapy Committee, VA Eastern Colorado Health Care System: Acceptance and Commitment Therapy (ACT) Consultation Peer Group, VA VISN 19 MIRECC: Psychology Postdoctoral Training Committee, and VA VISN 19 MIRECC: Education Committee. Nationally, she has served on the VA Blue Ribbon Panel Workgroup: Suicide Assessment in Primary Care Committee as well as the Health Executive Council (HEC) Psychological Health/Traumatic Brain Injury (PH/TBI) Working Group: Joint VA/DoD Suicide Nomenclature/Data Taskforce.
Research Projects
Clinician Access to Soldier Suicide Information (CASSI)
This study will use VHA data toward the ultimate goal of establishing a mechanism by which VA clinicians could access data on Veterans regarding suicidal thoughts and/or behaviors that occurred when they were on active duty, as documented in the Department of Defense Suicide Event Report (DoDSER).
Military personnel are returning from current conflicts with traumatic brain injury (TBI). Brief and sensitive screening measures are needed to assess TBI in this population. he TBI-4 tool was developed to serve this purpose.
Presentation at the 8th World Congress on Brain Injury (International Brain Injury Association).
Washington DC.
Recent Publications (since 2009)
Bahraini, N.H., Brenner, L.A., Harwood, J.E.F., Homaifar, B.Y., Ladley-O'Brien, S.E., Filley, C.M., Kelly, J.P., & Adler, L.E. (2009). Utility of the Trauma Symptom Inventory for the Assessment of Posttraumatic Stress Symptoms in Veterans with a History of Psychological Trauma and/or Brain Injury. Military Medicine, 174(10), 1005-1009.
Correspondence of three core Trauma Symptom Inventory (TSI) posttraumatic stress disorder (PTSD) scales (Intrusive Experiences, Defensive Avoidance, and Anxious Arousal) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV) PTSD module were examined among 72 veterans with traumatic brain injury (TBI), PTSD, or both conditions. Subjects were classified into PTSD only, TBI only, or co-occurring PTSD and TBI groups based on TBI assessment and SCID-IV PTSD diagnosis. Linear regression was used to model TSI T-Scores as a function of group. Scores on all three scales significantly differed between the TBI and PTSD groups (PTSD only and co-occurring PTSD and TBI) in the expected direction. Study findings indicate that despite the potential overlap of symptoms between PTSD and TBI, the TSI appears to be a useful measure of trauma-related symptoms in veterans who may also have a TBI, particularly mild TBI. Limitations and areas for future research are discussed.
Brenner, L. A., Betthauser, L.M., Homaifar, B. Y., Villarreal, E., Harwood, J. E., Staves, P. J., & Huggins, J. A. (2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among Veterans receiving mental health services. Suicide & Life Threatening Behavior, 41, 416-423.
History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.
OBJECTIVES:: To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury-4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. STUDY DESIGN:: Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. PARTICIPANTS:: The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. MAIN MEASURES:: For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. RESULTS:: The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. CONCLUSIONS:: The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.
Brenner, L.A., Homaifar, B.Y., Wolfman, J.H., Kemp, J., Adler, L.E. (2009). Suicidality and Veterans with a History of Traumatic Brain Injury: Precipitating Events, Protective Factors, and Prevention Strategies. Rehabilitation Psychology, 54(4), 390-397.
OBJECTIVES: To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI). STUDY DESIGN: Qualitative. PARTICIPANTS: Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior. METHOD: In-person interviews were conducted and data were analyzed using a hermeneutic approach. RESULTS: Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals' knowledge regarding TBI, providing more structured treatment). CONCLUSIONS: Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented.
This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.
Homaifar, B. Y., Bahraini, N.H., Silverman, M.M., Brenner, L.A.. (2012). Executive Functioning as a Component of Suicide Risk Assessment: Clarifying its Role in Standard Clinical Applications. Journal of Mental Health Counseling, 34(2), 110-120.
Clinically, because executive dysfunction (e.g., impulsivity, insight, thinking process) is often thought of in the context of those with traumatic brain injuries and other neurologic conditions, its formal assessment has historically been seen as the domain of those who assess and treat patients with neurologic disease. However, mental health counselors (MHCs) could benefit from learning how executive functioning relates to suicide risk assessment and coping strategies. Assessment of executive functions can be incorporated in routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. In fact, during standard clinical assessment, mental health professionals often informally assess components of executive functioning such as impulsivity, insight, and thinking processes. This article highlights aspects of executive functioning with which MHCs may already be familiar and demonstrates their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.
Homaifar BY, Brenner LA, Forster JE, Nagamoto H. Traumatic brain injury, executive functioning, and suicidal behavior: A brief report. Rehabil Psychol. 2012 Nov;57(4):337-41.
Objective: The aim of this pilot study was to explore the relationship between executive dysfunction and suicidal behavior in two groups of participants: (Group 1, n = 18) veterans with traumatic brain injury (TBI) and a history of at least one suicide attempt (SA), and (Group 2, n = 29) veterans with TBI and no history of SA. Controlling for the severity of TBI, it was hypothesized that participants in Group 1 would perform more poorly than those in Group 2 on measures of executive functioning. Design: The primary outcome variable was decision making as assessed by performance on the Iowa Gambling Task (IGT). Secondary outcome variables included laboratory-measured impulsivity as measured by the Immediate and Delayed Memory Test (IMT/DMT), abstract reasoning as measured by the Wisconsin Card Sorting Test (WCST), and aggression as measured by the Lifetime History of Aggression (LHA) scale. Results: Among those in Group 1, time between TBI and first suicide attempt postinjury varied widely (months to nearly 30 years). Only the WCST perseverative errors score differed significantly between individuals with and without histories of one or more suicide attempts (SAs). Conclusion: Suggestions for future study of SA among those with TBI are provided. When working with individuals with TBI, clinicians are encouraged to incorporate suicide risk assessment into their practice. Augmenting this process with a measure of perseveration may be beneficial. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Homaifar, B. Y., Brenner, L. A., Gutierrez, P. M., Harwood, J. E. F., Thompson, C., Filley, C. M., Kelly, J. P., & Adler, L. E. (2009). Sensitivity and specificity of the Beck Depression Inventory-II (BDI-II) in individuals with traumatic brain injury (TBI). Archives of Physical Medicine & Rehabilitation, 90(4):652-6.
OBJECTIVES: Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives. DESIGN: This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI. SETTING: This study was completed at a Veterans Affairs (VA) Medical Center. PARTICIPANTS: Participants were veterans eligible to receive VA health care services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV). RESULTS: We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%). CONCLUSIONS: Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.
Homaifar BY, Harwood JE, Wagner TH, Brenner LA. Description of outpatient
utilization and costs in group of veterans with traumatic brain injury. J Rehabil
Res Dev. 2009;46(8):1003-10.
In an attempt to increase understanding regarding the nonacute healthcare needs of veterans with traumatic brain injury (TBI), we examined the outpatient utilization and cost patterns of 72 patients with TBI who were at least 4 years postinjury. We selected participants from a clinical database of veterans receiving care at a western Department of Veterans Affairs (VA) medical center. We extracted data from national utilization databases maintained by the VA and examined data from primary care and internal medicine, psychiatry and substance use, rehabilitation, and other services (e.g., ancillary, diagnostic, prosthetic, dental, nursing home, and home care). We extracted data for fiscal years 2002 to 2007. In addition to descriptive statistics, we modeled visits per year as a function of time since injury. The data show that this sample of patients with TBI consistently used a wide array of outpatient services over time with considerable variation in cost. Further study regarding economic aspects of care for patients with TBI is warranted.
Swogger MT, Walsh Z, Homaifar BY, Caine ED, Conner KR. Predicting self- and
other-directed violence among discharged psychiatric patients: the roles of anger
and psychopathic traits. Psychol Med. 2011 Jul 18:1-9.
BACKGROUND: We examined the extent to which trait anger and psychopathic traits predicted post-discharge self-directed violence (SDV) and other-directed violence (ODV) among psychiatric patients.MethodParticipants were 851 psychiatric patients sampled from in-patient hospitals for the MacArthur Violence Risk Assessment Study (MVRAS). Participants were administered baseline interviews at the hospital and five follow-up interviews in the community at approximately 10-week intervals. Psychopathy and trait anger were assessed with the Psychopathy Checklist: Screening Version (PSC:SV) and the Novaco Anger Scale (NAS) respectively. SDV was assessed during follow-ups with participants and ODV was assessed during interviews with participants and collateral informants. Psychopathy facets and anger were entered in logistic regression models to predict membership in one of four groups indicating violence status during follow-up: (1) SDV, (2) ODV, (3) co-occurring violence (COV), and (4) no violence. RESULTS: Anger predicted membership in all three violence groups relative to a non-violent reference group. In unadjusted models, all psychopathy facets predicted ODV and COV during follow-up. In adjusted models, interpersonal and antisocial traits of psychopathy predicted membership in the ODV group whereas only antisocial traits predicted membership in the COV group. CONCLUSIONS: Although our results provide evidence for a broad role for trait anger in predicting SDV and ODV among discharged psychiatric patients, they suggest that unique patterns of psychopathic traits differentially predict violence toward self and others. The measurement of anger and facets of psychopathy during discharge planning for psychiatric patients may provide clinicians with information regarding risk for specific types of violence.
Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.
