The Current State of the Science and Strategies for Intervention
The association between traumatic brain injury (TBI) and negative psychiatric outcomes, including suicide, has a relatively long history. However, a focus on TBIs sustained by patients who served in recent conflicts in Iraq and Afghanistan, as well as by those who play sports has resulted in a resurgence of interest in acute and post-acute sequelae. According to the Centers for Disease Control and Prevention, a TBI is a “disruption” in normal brain function secondary to “a bump, blow, or jolt to the head.”
The vast majority of TBIs sustained are mild in nature. That is, the disruption of brain functioning at the time of injury is relatively brief (eg, loss of consciousness less than 30 minutes). The severity of injury (mild [concussion], moderate, severe) is determined based on the disruption of brain functioning at the time of injury and is associated with physical and psychological outcomes. Patients with more significant disruptions of brain functioning at the time of injury (eg, loss of consciousness greater than 24 hours) are at increased risk for long-term functional impairment.
Although psychiatrists are intimately familiar with the terms suicidal ideation, suicide attempt, and suicide, clinicians, researchers, and policy makers have long struggled with the lack of universally agreed upon definitions. In light of this, both the Departments of Veterans Affairs and Defense adopted the Self-Directed Violence Classification System (SDVCS).1 Within the system, key terms that are related to the basic clinical phenomena of suicide and suicide-related behaviors are defined. The use of operationalized systems helps to facilitate communication regarding both level of risk and treatment planning.
Seminal epidemiological work in the area of suicide and TBI was conducted by Teasdale and Engberg,2 who used a Danish population register of hospital admissions to determine rates of suicide among those with concussions, cranial fractures, and cerebral contusions/traumatic intracranial hemorrhages. Their findings suggest increased risk among members of all three groups, when compared with members of the general population (3.0, 2.7, 4.1). Of note, the researchers did not adjust for history of psychiatric condition.
A similar study found that history of TBI was associated with an increased risk for death by suicide; however, the hazard ratios identified suggest a more modest relationship (any TBI 1.55, concussion/fracture 1.98, and cerebral contusion/traumatic intracranial hemorrhage 1.34).3 Findings also highlight the key role that co-occurring psychiatric conditions play in increasing risk for suicide among those with a history of TBI.
Using nationwide registries from Denmark, Madsen and colleagues4 found that persons with TBI were at increased risk for suicide compared with the general population. Having access to pre- and post-injury records of all individuals living in Denmark allowed the researchers to examine several key areas. They found that those with a history of severe TBI had a higher risk for suicide than individuals with a mild TBI. In addition, pre- and post-history of psychiatric illness increased risk for death by suicide after a TBI.
Fralick and colleagues5 conducted a systematic review and meta-analysis to examine the risk of post-concussion suicide. Their findings suggest that compared with persons with no history of TBI, sustaining a concussion was associated with a two-fold increased risk for suicide. The authors also highlighted challenges associated with quantifying the “typical” time between injury and suicide, as well as identifying specific cohorts, among those with a history of TBI, who may be at heightened risk for death by suicide.
Dr Brenner is Professor, Departments of Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Neurology and Director of Clinical Research, Marcus Institute for Brain Health, University of Colorado, Anschutz Medical Campus; Mr Grassmeyer is Study Coordinator, Marcus Institute for Brain Health, University of Colorado, Anschutz Medical Campus; and Dr Kelly is Director, Marcus Institute for Brain Health, University of Colorado, Anschutz Medical Campus.
The authors report no conflicts of interest concerning the subject matter of this article.
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