Suicide After Traumatic Brain Injury: Just the Tip of the Iceberg
Information sourced from NEJM Journal Watch:
Suicide After TBI: Just the Tip of the Iceberg
Traumatic brain injury increased the risk for suicide, but psychiatric disorders and self-harm in this TBI population were exceptionally common.
A wealth of research over the past 20 years has demonstrated that traumatic brain injury (TBI) of all severities is associated with later psychiatric disorders. Other studies have documented post-TBI increases in suicide attempts. These findings might arise from the TBI itself or from the circumstances of, or reaction to, the injury (e.g., accidents, post-traumatic stress disorder). Focusing on suicide, researchers analyzed 1980–2014 data from a Danish registry of >7 million individuals.
The researchers categorized TBI as mild skull fracture without documented TBI or severe fracture with evidence of structural injury, making use of International Classification of Diseases codes but not standard TBI severity definitions. Analyses controlled for medical contacts for TBI, days of TBI treatment, orthopedic fractures, epilepsy, psychiatric illnesses, episodes of deliberate self-harm, and demographics.
Overall, 567,823 people received a TBI diagnosis, 3536 of whom died by suicide (mean age, 52; rate, 41/100,000 person-years vs. 20/100,000 person-years in non-TBI individuals). Risk increased with TBI-related hospitalization, greater TBI severity, pre- and postinjury diagnoses of (unspecified) psychological illness, and self-harm. Pre-TBI psychiatric disorders and deliberate self-harm were common (47,405 and 14,941, respectively), as were new post-TBI psychiatric disorders and self-harm (72,504 and 18,161).
We can debate the authors’ categorization of TBI severity (not based on duration of loss of consciousness or Glasgow Coma Scale), but the significantly higher suicide rate with TBI is concerning. However, this rate (91/100,000 person-years in the highest-risk group) is only the tip of the iceberg. The absolute number pales compared with the prevalence of psychiatric disorders and self-harm, both before and after TBI. Preventing suicide is important; education of clinicians regarding assessment and treatment of common neuropsychiatric disorders in people with TBI would have even greater impact.
Jonathan Silver, MD reviewing Madsen T et al. JAMA 2018 Aug 14
Madsen T et al. Association between traumatic brain injury and risk of suicide. JAMA 2018 Aug 14; 320:580.
Goldstein L and Diaz-Arrastia R. Traumatic brain injury and risk of suicide. JAMA 2018 Aug 14; 320:554.
[JAMA editorial preview]
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