Barriers and facilitators to the management of mental health complications after mild traumatic brain injury

Background: Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI. Methods & results: Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains. Conclusion: Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

. Theoretical Domains Framework-based interview questions.

Theoretical domains Example questions
Knowledge How common do you think mental health problems are after a concussion? How much do they influence recovery from concussion?
How strong is the scientific evidence for mental health treatments in patients with concussions? How helpful is the evidence for guiding you to take one action versus another?
Skill Which skills are most important for a family physician to have in managing post-concussion mental health problems?
Social/professional role What role should the family physician play in managing mental health problems after concussion?
Beliefs about capabilities How confident do you feel in your ability to identify when your patient has significant depression or anxiety after concussion?
How confident do you feel in your ability to initiate treatment for depression or anxiety after concussion?
Beliefs about consequences What difference does it make to a patient's long-term outcome from concussion when a family physician takes action to address mental health problems?

Memory, attention and decision process
To what extent do you remember to screen for mental health issues after concussion?

Environmental context and resources
To what extent do you use any clinical practice guidelines or expert consensus statements to help you manage a patient with concussion? Which one(s)? How do you use them? How are they helpful (or not)?
How available is counseling or psychological treatment for your patients with concussion?
What other resources do you use to help you manage a patient with concussion who is presenting with mental health problems?

Social influences
To what extent do patients with concussion expect you to ask about their mental health or want to talk about their mental health problems?

Emotion
To what extent are there certain patients with concussion that make you more concerned or worried?
Behavioral regulation What might help you to consistently screen patients for mental health problems after concussion?
Goals What do you hope to achieve by screening for mental health problems after concussion?

Reinforcement
What kind of experiences have you had in the past that influence your management of post-concussion mental health problems today?

Intention
To what extent do you intend to be more attentive to potential mental health problems after concussion?

Optimism
To what extent do you expect that screening and initiating treatment for mental health problems after concussion will lead to better patient outcomes?

Procedure
The authors conducted a qualitative study with semi-structured interviews. The interview guide the authors developed was structured using the TDF and revolved around participants' experiences with management of mTBI, specifically with mental health complications. Example questions are found in Table 1. The more colloquial term 'concussion' was used in the interviews to refer to mTBI. Interviews occurred either in person at a location of the participant's choice or over the telephone using a secure web-based teleconference service (OpenVoice). Participants were sent a written consent form and asked to return a signed copy before the interview session. The session began by verbally reconfirming eligibility and consent, asking the participants standardized questions about their demographic and clinical practice characteristics, and then proceeded with the TDF-based interview. Interviews were completed by family medicine residents (one female, two male) who were members of the research team. Training was provided for the interviewers through mock interviews by personnel with experience in qualitative interviews. Interviewers' initial audio recordings were also reviewed by members of the team with qualitative interviewing experience, and feedback was given regarding strategies for developing rapport with the participants before starting the formal interview, facilitating a conversational discussion, and using follow-up probes for participants to elaborate on their initial answers. The interviews occurred between February and April 2019 and were audio recorded and transcribed verbatim by a professional transcription service. Interviews lasted between 19 and 49 min (mean = 27; standard deviation = 8).

Participants
Participants were eligible for the study if they were fully licensed FPs, had a practice located within the Greater Vancouver area, had been in independent practice for at least 1 year, and devoted at least 50% of their time to an outpatient general practice. Participants were selected using a purposive sampling strategy with the aid of the College of Physicians and Surgeons of British Columbia's public registry to identify and recruit FPs who Number of years practicing post-residency 12  Estimated number of mTBI patients seen in past year 12.5  Estimated number of mTBI patients seen in past month 2.5 (0-10) † n = 10 because demographic data were missing for one participant as a result of administrative error.
were eligible for the study. The authors identified a pseudorandom selection of 167 potential participants. These physicians, who appeared to meet the study eligibility criteria (based on information available in the College of Physicians and Surgeons of British Columbia's website directory), were sent a letter of initial contact inviting them to contact the authors' team. Potential participants who did not contact the authors' team within 10 days were telephoned by a research team member and invited to participate in the study. Purposive recruitment was supplemented by snowball sampling (outreach to potential participants through referrals from FP participants) and convenience sampling (referrals from study team members). The authors were unable to collect data on reasons for nonparticipation. No FPs replied to the letter of invitation to express interest but not proceed with enrollment. Of the FPs identified through snowball sampling, a minority (n = 4) expressed interest but did not respond to scheduling requests.

Data analysis
Interview transcripts were imported into the qualitative data analysis software NVivo. Recommendations for the application of the TDF to identify implementation problems [18] were followed using directed content analysis [24] to deductively code the participants' accounts along the domains of the TDF. In-depth data familiarization was achieved by reading the entire data set several times and highlighting all meaning units (manifest and latent) that were deemed relevant to barriers and facilitators to the identification and initiation of treatment for post-mTBI mental health complications. To increase reliability, two researchers (T Otamendi and A MacLellan) independently engaged in the process and met several times to refine coding procedures and ensure consistency for the analyses. For example, they conferred after independently coding the first four interviews, which resulted in an agreement of 84% [18,25]. The researchers resolved any differences through discussion, further analysis and consensus. The remaining differences were discussed with an additional member of the research team (ND Silverberg), who assisted with the final decisions. Through this approach, relevant barriers and facilitators within the TDF domains were identified by their prominence in the transcripts (i.e., frequency and presence of strong beliefs) [18]. Participants' direct quotations were used to supplement the findings. The consolidated criteria for reporting qualitative research [26] were used to ensure that relevant aspects of qualitative research were reported. A copy of the checklist is provided in Supplementary File 1.

Results
The final sample consisted of 11 FPs, with characteristics summarized in Table 2. An administrative error resulted in missing demographic data for one participant. Participants had regular but infrequent (∼1/month) experience caring for patients with mTBI. Using directed content analysis, the authors identified the following five prevalent TDF domains: professional role and identity, environmental context and resources, knowledge, beliefs and consequences, and beliefs about capabilities. Within these domains, the barriers and facilitators identified were: perceived role in post-mTBI mental health care, positive outcome expectancies, challenges within the healthcare system, need for consolidated and concise material resources, knowledge of condition based on clinical experience, barriers to patient engagement, and diagnostic ambiguity.

Professional role & identity
Perceived role in post-mTBI mental health care FPs firmly believed that they should have an integral role in managing mTBI, including associated mental health complications: "I think the role as family physician is crucial because we are the ones with long-term, longitudinal relationships with these patients, and so we see them month after month, and they have to feel supported by their family doctor month after month." (Participant 10) That said, the nature of the role FPs should play was less defined. Whereas some participants perceived themselves to be competent to screen for and diagnose anxiety and depression in mTBI, others were less certain that they had the knowledge and resources to treat these conditions. In general, FPs perceived blurred professional boundaries in the treatment of post-mTBI mental health conditions and preferred to have the option of referring to specialized or allied healthcare practitioners: "I think the details and intricacies of therapy might be the realm of another profession. For example, more indepth counseling that might take an hour visit might be better done by a counselor or psychologist. Then therapies, like looking at return to school or work, might be better done by an occupational therapist." (Participant 2) Because of their broad role in management, FPs often felt obligated to initiate treatment for mental health complications following mTBI but experienced limitations, such as lack of training and/or lack of time. FPs expressed that better defined roles could allow them to focus on what they consider the most appropriate tasks for an FP: screening for mental health problems, coordinating care, and providing education to patients about the potential involvement of mental health complications in mTBI recovery.

Beliefs about consequences Positive outcome expectancies
FPs were motivated to screen for mental health problems because of their expectation that proactively implementing care would lead to better patient outcomes: "I would expect that both screening, identifying and potentially treating mental health issues in the context of concussion would potentially help them to get better faster, both from the mental health perspective and, in theory, from the concussion elements." (Participant 7) Based on their clinical experience, FPs also perceived that the earlier the problems were addressed, the more manageable they would be: In all, FPs perceived that a lack of structured support in post-mTBI mental health care was a significant obstacle to providing optimal care.

Need for consolidated & concise material resources
During appointments with mTBI patients, FPs perceived to have helpful material resources to separately assess mental health and to guide a return to activity as symptoms allowed. Specific resources mentioned by name included the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 to screen for depression and anxiety, the Sport Assessment Concussion Tool-5 to track mTBI symptoms, and Parachute Canada's Return to Play/Activity guidelines to guide patients in their return to sports and other activities. However, FPs were not aware of consolidated tools to facilitate intervention for mental health complications after mTBI: Finally, FPs perceived some of these existing materials to be long and not easily implementable in an FP office practice: "The problem is that these are long guidelines that are not distilled down for primary care. If they were distilled down for primary care and had templates to be practically used in practice, it would be very useful." (Participant 4) FPs mentioned their preference for brief (one page) print or digital materials that consolidated mTBI and mental health information and were readily accessible to themselves and their patients.

Knowledge based on clinical experience
When asked how common they perceived post-mTBI mental health complications to be, FPs answered that they were quite common, providing estimates that ranged between 25 and 50% of mTBI patients. This understanding was based mostly on their clinical experience: "I mean, I've had the experience of seeing hundreds of patients and watching them recover or not recover, sometimes over years." (Participant 8) FPs acknowledged that they were not up to date on current scientific literature and therefore could not comment on the supporting evidence of post-mTBI mental health management: FPs talked about reluctantly having to rely on their intuition rather than existing guidelines to guide practice.

Beliefs about capabilities Barriers to patient engagement
FPs identified certain patient characteristics (e.g., premorbid personality pathology, lack of awareness of potential post-mTBI mental health complications) and contextual stressors (e.g., medicolegal involvement) that may limit the effectiveness of mental health treatment in the primary care setting:

"I think of patients I know who are just barely getting by, struggling with family issues prior to a concussion, and then have a concussion kind of just tip them over the edge. When I see those patients, I feel like a treatment plan has to be a bit more comprehensive and sometimes beyond what I can do just in the office." (Participant 2)
FPs also suggested that a patient's lack of awareness that mental health is involved in their recovery could pose a barrier to accepting treatment:

"I don't think they really have an expectation of that. I don't think most of them are really aware that concussion causes that. Most patients know that concussion causes headache and dizziness and inability to work and things like that, but I don't think most patients really understand that it can cause depression, anxiety, long-term mental health problems." (Participant 8)
In some cases, this lack of awareness became more troublesome when patients resisted the idea that mental health could be involved in their recovery. Although FPs did not explicitly mention it, this presumably added yet another step to the treatment process, as patients would have to be persuaded of the involvement of mental health in recovery: " Certain patient characteristics and contextual situations were perceived to diminish the already limited confidence FPs had in their capabilities to address these complications.

Diagnostic ambiguity
Although FPs were aware that mTBI and mental health disorders commonly co-occur, certain characteristics made them difficult to assess, differentiate and manage. For example, an important source of confusion seemed to be the nonspecific nature of mTBI and mental health symptoms as well as the overlap between them:

"Again, because lots of the cognitive effects of concussions have challenges that can sometimes mimic or look similar to depression, it's oftentimes very difficult. Unless they have a fairly established baseline of mental illness, it makes the diagnostics quite challenging." (Participant 7)
They perceived that diagnostic clarity was even more challenging to achieve when certain patients were motivated to downplay or exaggerate symptoms, introducing uncertainty about the results of their assessments: "I guess just really trying not to miss people who might be having mental health issues who aren't as forthcoming about it." (Participant 9) Furthermore, patients' focus on physical symptoms during consultations as well as the potential late onset of mental health symptoms made it challenging to determine which patients to proactively intervene with: In all, ambiguity surrounding mTBI and mental health diagnoses and treatment was perceived by the FPs as a challenge to their own capability to correctly detect and manage these injury complications. They expressed concern that mental health complications could go undiagnosed in the early stages of recovery and manifest as larger problems in the long-term.

Discussion
A deductive qualitative analysis rooted in the TDF led the authors to identify multiple barriers and facilitators to implementing early management of mental health complications following mTBI in primary care. FPs generally perceived themselves to have a prominent role in post-mTBI care (professional role and identity), specifically screening for mental health problems, providing education about mTBI, and coordinating care. Additionally, FPs believed that managing post-mTBI complications facilitated better patient outcomes (beliefs about consequences), motivating them to intervene. These facilitators are likely offset by significant barriers, including not having a clearly defined role in the treatment of mental health vis-à-vis other mental health professionals (professional role and identity). FPs were generally not aware of evidence-based guidelines or tools to guide their practice (knowledge). As such, they hesitantly relied on general mental health screening tools and attempted to refer to specialized mental health practitioners for support, but encountered difficulties in finding accessible referral streams (environmental context and resources). Finally, FPs described the process of diagnosing mental health conditions after mTBI as challenging, explaining that certain patient factors (e.g., premorbid personality) and contextual factors (e.g., injury compensation seeking), as well as the subjective and nonspecific nature of symptoms, decreased their confidence in detecting and treating mental health complications (beliefs about capabilities). FPs' limited familiarity with evidence-based and expert consensus recommendations for identifying and managing mental health problems after mTBI is consistent with research reporting low uptake of clinical practice guidelines in general [27][28][29][30], including mTBI-specific guidelines [31][32][33][34][35]. Reasons for the limited incorporation of these tools in primary practice may be multifaceted. Individual-level barriers are regularly reported in the literature [35]. For example, the lack of awareness of the existence of clinical care guidelines reported by the FPs in this study is a common finding [36][37][38]. Previous research has reported that practitioners' comfort using 'knowledge in practice' to guide clinical judgment [39,40] and resistance to the 'cookie-cutter' approach to care [40,41] may serve as obstacles to seeking published guidelines. FPs' perception of having an integral role in post-mTBI mental health care and positive expectations of proactive management, together with their self-awareness of knowledge gaps, motivated them to pursue learning opportunities regarding mTBI and mental health. For instance, they sought confirmation that it was reasonable to use standard mental health screening measures (e.g., Patient Health Questionnaire-9 for depression) in patients with mTBI, which practice guidelines recommend [10] based on evidence that such measures perform similarly in mTBI [42][43][44][45]. Limited beliefs in their abilities may stem from FPs' relatively infrequent exposure to mTBI patients. Previous research has reported that the majority of FPs see less than ten mTBI patients per year [46], a figure similar to that seen in the present study. This might prevent them from maintaining knowledge of best practice and confidence in managing these patients [19,47]. This study suggests that FPs are motivated and open to incorporating evidence-based knowledge into their management of post-mTBI mental health care but experience barriers to accessing such information.
Passive dissemination of guidelines (i.e., through publication) rarely leads to sustained changes in clinical practice [38,48]. This may be due to an overload of information that is not readily applied in practice and is consistent with the FPs' perceptions that existing knowledge is likely not distilled down for primary care. Thus, this study supports recommendations that mTBI guidelines should be more 'implementable' (e.g., adaptable, usable, easily communicated) [49] and disseminated through active knowledge transfer strategies, such as tailored recommendations, decision support tools, or interactive education sessions [38,50,51].
Guideline implementation tools alone may not be enough to achieve optimal care for post-mTBI mental health problems. In accordance with guidelines [8,9], FPs will need to be able to refer patients with mTBI to mental health specialists in situations of diagnostic uncertainty, complex symptom presentations, or if initial treatment is not effective. FPs reported encountering limited options and long wait lists in the public healthcare system, as well as prohibitive costs for patients and referral rejections in the private healthcare system. Therefore, organizational interventions may be necessary to implement structured referral processes and involve specialists in the dissemination of best care practices [52].

Limitations
The number of participants interviewed was limited pragmatically by the training program-dictated timeline for the involvement of family medicine residents on the authors' research team. It is possible that interviewing additional FPs would have enhanced the richness of the data and allowed conflicting opinions to emerge, but the sample size was enough to achieve thematic saturation, which was reached by the eighth interview. Therefore, the authors' sample size seemed adequate for the relatively homogeneous population and study objectives. Although the interviewers of the research team received training, their limited experience in qualitative interviewing may have also impacted the depth of the data collected. This weakness is weighed against the strength of having family medicine residents do the interviewing, which may have helped with FP participant engagement. Selection bias was likely, due to the sampling strategies used and the volunteer nature of the study, where FPs who agreed to participate may have had an above average awareness of and interest in the topic of post-mTBI mental health. Using the TDF to inform the interview guide allowed for a theoretical basis to the study but may also have biased answers toward those associated with TDF domains rather than ones naturally reported. Finally, the authors did not observe marked differences between male and female participants because of the sample size, which did not allow adequate exploration of potential sex and gender differences. This is an important avenue for future research.

Conclusion
To our knowledge, this is the first study to investigate potential barriers and facilitators to implementing clinical practice guidelines regarding screening and initiating treatment for mental health complications after mTBI in primary care. This study can inform future interventions to improve implementation. The results suggest that addressing FP knowledge of evidence-based post-mTBI mental health management guidelines, introducing tailored implementation tools that highlight specific actions the FP could consider, and building accessible referral pathways to mental health specialists may be most impactful. Timely treatment for mental health complications following mTBI would improve patient outcomes from mTBI.

Future perspective
Mental health conditions are increasingly being recognized as barriers to recovery from mTBI. Considering that evidence-based recommendations for post-mTBI mental health conditions are not consistently applied, we expect that implementation efforts will address this knowledge-care gap in the next decade. The findings from this study can inform such efforts. Along with other pillars of evidence-based mTBI management, such as encouraging a prompt return to activity and multidisciplinary treatment, we expect that the implementation of mental healthcare guidelines will decrease the burden of chronic disability after mTBI. conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research
The study protocol was approved by the University of British Columbia Behavioral Research Ethics Board (#H18-03352). Participants were sent a written consent form and asked to return a signed copy before their interview session.

Open access
This work is licensed under the Creative Commons Attribution 4.0 License. To view a copy of this license, visit http://creativecomm ons.org/licenses/by/4.0/

Summary points
• Clinical practice guidelines for mild traumatic brain injury management recommend screening and initiating treatment for mental health complications in primary care, but passive dissemination of guidelines has not led to sustained changes in clinical practice. • Family physicians experience barriers to guideline implementation, such as lack of role clarity in managing post-mild traumatic brain injury mental health care, lack of awareness of existing knowledge and tools to guide their practice, and difficulties in finding accessible referral streams to mental health specialists. • Family physicians could benefit from active guideline implementation strategies, such as providing succinct knowledge and accessible tools for post-mild traumatic brain injury mental health management, tailored treatment recommendations, and formalization of referral processes to mental health specialists.