February 27, 2019
This interview originally appeared on Consultant360.
Individuals with traumatic brain injury (TBI) have higher odds of developing psychiatric disorders and related symptoms vs those without TBI, but whether those with TBI have an increased risk of suicide in particular is still unclear.
Trine Madsen, PhD, of the Danish Research Institute for Suicide Prevention at the Mental Health Centre Copenhagen in Denmark, and colleagues sought to examine this potential relationship further. They conducted a large-scale, registry based retrospective cohort study of 7,418,391 Danish individuals aged 10 years or older.1 Of these individuals, 567,823 (7.6%) had a medical contact for TBI.
Study results demonstrated that TBIs of all degrees of severity were tied to an elevated risk for suicide compared with no TBI, indicating that suicide prevention efforts are paramount in this patient population.
Dr Madsen discussed these findings further with Consultant360, highlighting the steps clinicians should take to promote TBI prevention in their patients and suicide prevention in those who have already sustained at least 1 TBI.
How did your study come about? Why did you decide to assess suicide risk among patients with TBI?
In a similar large, register-based nationwide study, our research group previously established an association between TBI and the risk of subsequent psychiatric illness.2 That led us to conduct our present study, where we took it a step further and examined the link between TBI and suicide. Our access to a large, nationwide sample size gave us the opportunity to study the association between TBI and suicide in greater detail than most previous studies have had the power to do.
That said, we are also aware of existing discussions related to veterans who come home from deployment with TBI and their subsequent risk of suicide, as well as the concerns surrounding suicide risk among athletes in contact sports who sustain concussions.
With this in mind, we sought to examine the relationship between suicide and:
- TBI severity
- Number of TBI contacts
- Days in treatment for TBI
- Age at first TBI
- Type of injury
- Time since last TBI
Because of our large sample size, we were also able to take into account many important covariates—including pre-TBI psychiatric illness; pre-TBI deliberate self-harm; social variables such as educational level and employment status; and more.
The results of your study indicated that patients with a diagnosis of TBI had an increased risk of suicide compared with the general population. Why do you think this was the case?
Said our study’s senior author, Michael Eriksen Benros, MD, PhD, “We have previously shown that TBI increases the risk of subsequent psychiatric disorders.”
“Head trauma can affect the brain's functions, which can cause psychological problems and, consequently, increase the risk of suicide,” he added.
In addition, TBI can cause both long-term physical symptoms—such as headache, dizziness, neck pain, etc.— as well as cognitive symptoms—including memory impairment and concentration problems. This may lead to social problems and/or psychiatric symptoms, which can also affect both one's social relations and employment. In combination, these factors may affect TBI patients’ risk of suicide.
How did the risk for suicide vary based on TBI severity?
The link between TBI and suicide was observed for all types of TBI, but was strongest for the most severe TBIs.
We found that individuals with mild TBI, or concussion, requiring hospital contact had an 81% elevated risk of suicide risk, and individuals with skull fracture had a risk that was 2.01 times as high. Individuals with severe TBI had the highest suicide risk, which was 2.38 times that of individuals with no TBI.
How should clinicians apply these findings in practice, especially in terms of suicide risk screening practices among TBI patients?
It is important to note that, even though we found that the relative risk of suicide was almost doubled after sustaining a TBI, the absolute risk of suicide is still low, as suicide is fortunately still a very rare event in this patient population. Out of 567,823 individuals with TBI in our study who had a medical contact for their TBI, a total of 3,536 died by means of suicide.
In order to further prevent suicide risk, we would first and foremost recommend focusing on TBI prevention. This could include promoting the use of protective helmets in traffic, at workplaces like construction sites where head injury and fall risks are higher, and in contact sports like boxing and football.
Patients who sustain a TBI and are admitted to a hospital should be informed by their clinicians prior to discharge regarding an increased risk for developing emotional problems or psychiatric symptoms post-TBI, which can lead to suicidal thoughts, especially if untreated.
Clinicians should advise all patients who experience emotional problems or psychiatric symptoms to seek help or treatment for this in order to prevent potential suicidal ideations or behaviors. This is a recommended action for any patients who experience these symptoms, regardless of TBI status.
What are the next steps in your research?
In terms of future research, it is central to look into ways of optimizing the treatment of serious head injuries in order to minimize the numerous potential psychiatric, cognitive, physical, and social consequences that can tragically lead to suicidal behaviors.
It would also be interesting to carry out a large register-based study examining how TBI might be associated with other social consequences, such as employment status, in the years after a TBI.
1. Madsen T, Erlangsen A, Orlovska S, et al. Association between traumatic brain injury and risk of suicide. JAMA. 2018;320(6):580-588. doi:10.1001/jama.2018.10211.
2. Orlovska S, Skaarup Pedersen M, Benros ME, Mortensen PB, Agerbo E, Nordentoft M. Head injury as risk factor for psychiatric disorders: a nationwide register-based follow-up study of 113,906 persons with head injury. Am J Psychiatry. 2014;171(4):463-469.https://doi.org/10.1176/appi.ajp.2013.13020190