Suicidality in people surviving a traumatic brain injury: Prevalence, risk factors and implications for clinical management

Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017

BACKGROUND

Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury.

OBJECTIVE

To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk.

METHODS

Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression.

RESULTS

Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk.

CONCLUSIONS

Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

Suicide Attempts and Ideation Among Veterans/Service Members and Non-Veterans Over 5 Years Following Traumatic Brain Injury: A Combined NIDILRR and VA TBI Model Systems Study

OBJECTIVE

This study compared rates of suicide attempt (SA) and suicidal ideation (SI) during the first 5 years after traumatic brain injury (TBI) among veterans and service members (V/SMs) in the Veterans Affairs (VA) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Model Systems National Databases to each other and to non-veterans (non-Vs) in the NIDILRR database.

SETTING

Twenty-one NIDILRR and 5 VA TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States.

PARTICIPANTS

Participants with TBI were discharged from rehabilitation alive, had a known military status recorded (either non-V or history of military service), and successful 1-, 2-, and/or 5-year follow-up interviews completed between 2009 and 2021. The year 1 cohort included 8737 unique participants (8347 with SA data and 3987 with SI data); the year 2 (7628 participants) and year 5 (4837 participants) cohorts both had similar demographic characteristics to the year 1 cohort.

DESIGN

Longitudinal design with data collected across TBIMS centers at 1, 2, and 5 years post-injury.

MAIN OUTCOMES AND MEASURES

History of SA in past year and SI in past 2 weeks assessed by the Patient Health Questionnaire-9 (PHQ-9). Patient demographics, injury characteristics, and rehabilitation outcomes were also assessed.

RESULTS

Full sample rates of SA were 1.9%, 1.5%, and 1.6%, and rates of SI were 9.6%, 10.1%, and 8.7% (respectively at years 1, 2, and 5). There were significant differences among groups based on demographic, injury-related, mental/behavioral health, and functional outcome variables. Characteristics predicting SA/SI related to mental health history, substance use, younger age, lower functional independence, and greater levels of disability.

CONCLUSIONS

Compared with participants with TBI in the NIDILRR system, higher rates of SI among V/SMs with TBI in the VA system appear associated with risk factors observed within this group, including mental/behavioral health characteristics and overall levels of disability.

The role of spirituality and identity formation in personal recovery from traumatic brain injury: A qualitative analysis through the personal experiences of survivors

Traumatic brain injury (TBI) is a type of acquired brain injury (ABI) that happens when a sudden, external, physical assault damages the brain. TBI can cause long-term cognitive impairments and other lifestyle changes that may affect psychological wellbeing. Among the psychological challenges people recovering from TBI often face is the subjective loss of their pre-injury identity. Quantitative and qualitative research suggests that spirituality can play a positive role in recovery from TBI, increasing the quality of life and overall mental health. However, thus far, the research into this topic has not directly addressed the relationship between identity and spirituality after TBI. The present study sought to do this by thematically analyzing 22 public podcasts featuring interviews of people recovering from TBI telling their stories. The authors review the spiritual themes discussed in the podcasts and then propose a hypothesis about how, through a sense of connection to something self-transcendent, spirituality may enable people to test new meanings and identities, relatively free from the consequences of discrepancy in meaning and identity after TBI.

The psychological autopsy: An overview of its utility and methodology

Objectives

The objective of this study is to provide an overview of the psychological autopsy (PA) research method, including its methodology, uses, limitations, and ethical considerations.

Materials and Methods

The study conducted a PA investigation on 35 cases of suicide. Information was collected from multiple sources and reliable informants, including family members, friends, medical and mental health professionals, and other relevant individuals. Qualitative and quantitative research methods were used to analyze the collected information.

Results

The results indicated that several factors were associated with suicide, including mental health problems, life stressors, interpersonal conflicts, substance abuse, and history of previous suicide attempts. The findings have important implications for suicide prevention strategies, emphasizing the significance of addressing mental health issues and providing social support.

Conclusion

The PA is a valuable research method for investigating and understanding suicide. Despite challenges such as recall biases and methodological limitations, it provides insights into the psychological factors associated with suicide and informs suicide prevention strategies. However, conducting psychological autopsies requires careful consideration of ethical issues. Further research is needed to replicate and extend the findings of this study.

Understanding TBI as a Risk Factor Versus a Means of Suicide Death Using Electronic Health Record Data

OBJECTIVE

The aim of this research was to examine predictors and characterize causes of suicide death in people with traumatic brain injury (TBI) and conduct sensitivity analyses with and without people whose first diagnosis of TBI occurred within 3 days of their suicide death.

METHODS

This case-control study examined suicide risk for people with TBI in eight Mental Health Research Network-affiliated healthcare systems. Sample 1 included 61 persons with TBI who died by suicide and their 75 matched controls with TBI who did not die by suicide between January 1, 2000, and December 31, 2013. Sample 2 excluded the 34 persons with TBI whose first TBI diagnosis occurred within 3 days of their suicide death and their 46 matched controls. Descriptive statistics characterized the sample stratified by cases and controls, while conditional logistic regression models estimated the adjusted odds of suicide.

RESULTS

Over half of suicide deaths occurred within 3 days of a person's first diagnosis of TBI in the larger sample. After excluding these persons, people with TBI were 2.84 (95% confidence interval [CI]: 2.15-2.73) times more likely to die by suicide than were people without TBI. Among those with TBI, men were 16.39 times (95% CI: 1.89-142.15) more likely to die by suicide than were women.

CONCLUSIONS

Accounting for TBI as a potential consequence of suicide attenuates the association between TBI and suicide, but a robust association persists-especially among men. Ultimately, all people with TBI should be carefully screened and monitored for suicide risk.HIGHLIGHTSPeople with traumatic brain injury (TBI) were at considerably elevated risk for suicide deathMen with TBI had significantly increased risk of suicide death compared to women with TBITBI timing suggests confusion of risk factors for and consequences of suicide.

Patient-Centered Approaches to Cognitive Assessment in Acute TBI

PURPOSE OF THE REVIEW

The purpose of this article is to help clinicians understand how underlying pathophysiologies and medical comorbidities associated with acute traumatic brain injury (TBI) can impact assessment of cognition during the initial stages of recovery. Clinicians can use information from this article to develop assessment plans rooted in patient-centered care.

RECENT FINDINGS

The authors conducted a review of the literature related to the assessment of cognition in acute TBI, focusing on pathophysiology, medical comorbidities, and assessment approaches. Results indicated that TBI pathophysiologies associated with white and gray matter changes make many patients vulnerable to cognitive deficits. Acute comorbidities such as psychological and pain status influence cognitive abilities as well. The current approaches to cognitive assessment can be limited in many ways, though by using the patient's neuropathological profile, noted comorbidities, and other patient specific factors, clinicians can potentially improve the effectiveness of assessment.

A Case Series of 39 United States Veterans with Mild Traumatic Brain Injury Treated with Hyperbaric Oxygen Therapy

Importance: The Defense and Veterans Brain Injury Center reported 358,088 mild traumatic brain injury (mTBI) among U.S. service members worldwide between the years 2000 and 2020. Veterans with mTBI have higher rates of Post-Traumatic Stress Disorder (PTSD), depressive disorder, substance use disorder, anxiety disorder, and suicide than their healthy counterparts. Currently, there is no effective treatment for mTBI. Objective: To assess the efficacy of hyperbaric oxygen therapy (HBOT) as a treatment option for mTBI. Design, Setting, Participants: This is a case series of 39 U.S. Veterans diagnosed with mTBI and treated with HBOT. Of these participants, 36 were men and 3 women, and their ages ranged between 28 and 69. The treatment was administered by The 22 Project (a veteran-centered nonprofit organization) using monoplace hyperbaric chambers located in Delray Beach, Florida. Neuroimaging using Single Photon Emission Computer Tomography (SPECT) brain scans performed pre- and post-HBOT were made available for secondary analysis. Nilearn Python Library was utilized to visualize the corresponding neuroimaging data. A two-sided paired t-test in R was used to compare the pre- and post-treatment results. Intervention: A full treatment of HBOT involved 40 sessions. Each session consisted of the administration of 100% oxygen at 1.5 atmospheres for 90 min, twice a day, for 20 days, Mondays to Fridays only. Main Outcome and Measure: Perfusion in the brain’s Brodmann Areas (BA) comparing pre- and post-HBOT using NeuroGam software analysis from brain SPECT scan neuroimaging and multi-symptom self-reports. Results: A comparison between the pre- and post-HBOT brain scans showed significant improvement in the brain perfusion, and the difference was statistically significant (p < 0.001). Separately, participants reported reduced pain, improved mood, and better sleep, an outcome that translated into an average of about 46.6% improvement in the measured symptoms. Conclusions and Relevance: This series demonstrated that HBOT could be a useful treatment for mTBI in U.S. veterans. The participants in the study showed marked improvement in both brain perfusion measured on SPECT scan imaging and measured mTBI symptoms. This is the first study to use brain SPECT scans with quantitative numerical measurements to demonstrate improvement in brain perfusion in veterans with mild TBI treated with HBOT and measured mTBI symptoms. Future research studies are currently being done to validate these important findings.

Developing a method to assess fidelity to a complex vocational rehabilitation intervention in the FRESH trial: a feasibility study

Background

Determining whether complex rehabilitation interventions are delivered with fidelity is important. Implementation fidelity can differ between sites, therapists delivering interventions and, over time, threatening trial outcomes and increasing the risk of type II and III errors. This study aimed to develop a method of assessing occupational therapists’ fidelity to deliver a complex, individually tailored vocational rehabilitation (VR) intervention to people with traumatic brain injury (TBI) and assess the feasibility of its use in a randomised controlled trial.

Methods

Using mixed methods and drawing on the intervention logic model, we developed data collection tools to measure fidelity to early specialist TBI VR (ESTVR). Fidelity was measured quantitatively using intervention case report forms (CRF), fidelity checklists and clinical records. Qualitative data from mentoring records, interviews with intervention therapists, participants with TBI, employers and NHS staff at trial sites explored moderators of implementation fidelity. The conceptual framework of implementation fidelity (CFIF) guided measurement and analysis of and factors affecting fidelity. Data were triangulated and benchmarked against an earlier cohort study.

Results

Fidelity to a complex individually tailored VR intervention could be measured. Overall, OTs delivered ESTVR with fidelity. Different fidelity measures answered different questions, offering unique insights into fidelity. Fidelity was best assessed using a fidelity checklist, intervention CRFs and clinical notes. The OT clinical notes and mentoring records were best at identifying fidelity moderating factors. Interviews added little insight into fidelity moderating factors over and above mentoring or clinical records. Data triangulation offered a comprehensive assessment of fidelity, highlighting limitations of measurement methods and learning for future trials but was resource intensive. Interviews, fidelity visits and analysing clinical notes were also resource intense. Comparing fidelity data to a benchmark and using CFIF as a framework for organising the fidelity assessment helped.

Conclusions

OTs delivered the VR intervention with fidelity. A fidelity checklist and benchmark plus mentoring may offer a practical and effective way of measuring fidelity and identifying fidelity moderating factors in trials of complex individually-tailored rehabilitation interventions. Mentoring provided real-time indicators of and reasons for fidelity deviations. These methods require further evaluation.

Trial registration

ISRCTN Registry, ISRCTN38581822 (Registered: 02/01/2014).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01111-2.

Prevalence of suicidal ideation and suicide attempt among patients with traumatic brain injury: A meta-analysis

BACKGROUND

Suicidality is common among patients with traumatic brain injury (TBI). This meta-analysis aimed to assess the prevalence of suicidal ideation (SI) and suicide attempt (SA) in TBI patients.

METHODS

Databases including PubMed, Cochrane Library, Embase, CINAHL, Web of Science, PsycINFO, China National Knowledge Infrastructure (CNKI), VIP, WanFang Data, and Chinese Biomedical Literature Database (CBM) were searched for relevant literature from inception to 9th January 2021. Random effects models were used to estimate the prevalence of SI and SA. The methodological quality of the included studies was assessed using the modified Newcastle-Ottawa Scale. Subgroup analysis was performed based on the geographical location of the institutions.

RESULTS

A total of 16 studies involving 1,146,271 patients with TBI were included in our meta-analysis. The prevalence of SI and SA were 19.1% (95% CI 13.6-24.6%) and 2.1% (95% CI 1.8-2.4%), respectively, while the prevalence of SA in Asian and non-Asian countries were 2.0% (95% CI 0.3-3.7%) and 2.0% (95% CI 1.6-2.3%). Meta-regression analyses revealed that the publication year and age were positively associated, while the geographical location of the institution and sample size were negatively associated with the pooled prevalence of SI. On the other hand, the geographical location of the institution, sample size and age were negatively associated with the pooled prevalence of SA.

LIMITATIONS

The overall heterogeneity between studies was high.

CONCLUSION

SI and SA are common among TBI patients. Therefore, targeted preventive measures are paramount to manage TBI-related suicide.

Suicidal ideation in people with tinnitus: a systematic review and meta-analysis

OBJECTIVE

Tinnitus is associated with a variety of cognitive, psychosocial and psychiatric disorders, and may contribute to suicidality. However, the prevalence of suicidal ideation (SI) in tinnitus populations has not previously been systematically reviewed.

METHOD

Medline, Embase and PsychInfo were searched in August 2020 to identify studies that assessed suicidal ideation in people aged 16 years and above with subjective tinnitus.

RESULTS

Six cross-sectional studies were included, representing 7192 tinnitus sufferers across 4 countries. The pooled prevalence of suicidal ideation in tinnitus populations was 20.6 per cent (95 per cent confidence interval, 10.8-30.3 per cent; I2 = 88 per cent). Two studies included a control population, in which the prevalence of suicidal ideation was significantly lower. The quality of included studies was variable.

CONCLUSION

It is not possible to arrive at any reasonable conclusion given the lack of quality studies, meaning the pooled prevalence should be interpreted very cautiously. Suicidal ideation may be more prevalent in tinnitus populations. Further large-scale epidemiological research investigating this relationship is needed, which may help psychiatric risk stratification.

Relations among Suicidal Ideation, Depressive Symptoms, and Functional Independence during the Ten Years after Traumatic Brain Injury: A Model Systems Study

OBJECTIVE

To investigate relative causality in relations among suicidal ideation (SI), depressive symptoms, and functional independence over the first 10 years after traumatic brain injury (TBI).

DESIGN

Prospective longitudinal design with data collected through the TBI Model Systems (TBIMS) network at acute rehabilitation hospitalization, as well as 1, 2, 5, and 10 years after injury.

SETTING

United States Level I/II trauma centers and inpatient rehabilitation centers with telephone follow-up.

PARTICIPANTS

Individuals enrolled into the TBIMS National Database (N=9539) with at least one SI score at any follow-up data collection (72.1% male, mean age = 39.39 years).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 and Functional Independence Measure at years 1, 2, 5, and 10 post-injury.

RESULTS

A cross-lagged panel structural equation model (SEM), which is meant to indirectly infer causality through longitudinal correlational data, suggested that SI, depressive symptoms, and functional independence each significantly predicted themselves over time. Within the model, bivariate correlations among variables were all significant within each time point. Between years 1 and 2 and between years 2 and 5, depressive symptoms had a larger effect on SI than SI had on depressive symptoms. Between years 5 and 10, there was reciprocal causality between the two variables. Functional independence more strongly predicted depressive symptoms than the reverse between years 1 and 2 as well as years 2 and 5, but its unique effects on SI over time were extremely marginal or absent after controlling for depressive symptoms.

CONCLUSIONS

A primary goal for rehabilitation and mental health providers should be to monitor and address elevated symptoms of depression as quickly as possible before they translate into SI, particularly for individuals with TBI who have reduced functional independence. Doing so may be a key to breaking the connection between low functional independence and SI.

Readmission Following Hospitalization for Traumatic Brain Injury: A Nationwide Study

OBJECTIVE

To determine whether sociodemographic and clinical factors were associated with nonelective readmission within 30 days of hospitalization for traumatic brain injury (TBI). Secondary objectives were to examine the effects of TBI severity on readmission and characterize primary reasons for readmission.

SETTING

Hospitalized patients in the United States, using the 2014 Nationwide Readmission Database.

PARTICIPANTS

All patients hospitalized with a primary diagnosis of TBI between January 1, 2014, and November 30, 2014. We excluded patients (1) with a missing or invalid length of stay or admission date, (2) who were nonresidents, and 3) who died during their index hospitalization.

DESIGN

Observational study; cohort study.

MAIN MEASURES

Survey weighting was used to compute national estimates of TBI hospitalization and nonelective 30-day readmission. Associations between sociodemographic and clinical factors with readmission were assessed using unconditional logistic regression with and without adjustment for suspected confounders.

RESULTS

There were 135 542 individuals who were hospitalized for TBI; 8.9% of patients were readmitted within 30 days of discharge. Age (strongest association for 65-74 years vs 18-24 years: adjusted odds ratio [AOR], 2.57; 95% CI: 2.02-3.27), documentation of a fall (AOR, 1.24; 95% CI: 1.13-1.35), and intentional self-injury (AOR, 3.13; 95% CI: 1.88-5.21) at the index admission were positively associated with readmission. Conversely, history of a motor vehicle (AOR, 0.69; 95% CI: 0.62-0.78) or cycling (AOR, 0.56; 95% CI: 0.40-0.77) accident was negatively associated with readmission. Females were also less likely to be readmitted following hospitalization for a TBI (AOR, 0.87; 95% CI: 0.82-0.92).

CONCLUSIONS

Many sociodemographic and clinical factors were found to be associated with acute readmission following hospitalizations for TBI. Future studies are needed to determine the extent to which readmissions following TBI hospitalizations are preventable.

Factors Increasing Risk of Suicide after Traumatic Brain Injury: A State-of-the-Science Review of Military and Civilian Studies

Primary Objective: Survey TBI literature to identify evidence of risk for post-injury suicide.Literature Selection: Search terms ((traumatic brain injury OR TBI) AND (suicidality OR suicidal behaviour OR suicidal ideation)) entered in PubMed, OVID Medline, PsychInfo, and Web of Science for papers published in print 01/01/1997 to 06/30/2019.Analysis of Literature: Authors screened abstracts, excluding duplicates and articles not meeting inclusion/exclusion criteria. Full papers were reviewed to make final exclusions. Data were extracted from 40 papers included co- and premorbid disorders, demographics, injury-related and psychological factors.Results: Persons with TBI have a higher risk for suicide than the general population. Reviewed articles reported comorbid depression and/or PTSD as risk factors for post-TBI suicide. Co- or premorbid substance misuse, sex, and sleep disturbance moderate risk. Quality of the literature was limited by sample size, the predominance of male participants, and inconsistency in reporting of findings.Conclusions: Comorbid depression and PTSD are significant post-TBI risk factors for suicide. Several variables combine to moderate or mediate TBI's connection with suicide. Civilian and military clinician cross-talk and consistent reporting of results from reproducible studies of post-TBI suicide risk factors could improve prevention and treatment efforts in veterans and civilians.

Risk Factors for Suicidal Ideation Following Mild Traumatic Brain Injury: A TRACK-TBI Study

OBJECTIVE

To identify risk factors for suicidal ideation (SI) following mild traumatic brain injury (mTBI).

SETTING

Eleven US level 1 trauma centers.

PARTICIPANTS

A total of 1158 emergency department patients with mTBI (Glasgow Coma Scale score = 13-15) enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study.

DESIGN

Prospective observational study; weights-adjusted multivariable logistic regression models (n's = 727-883) estimated associations of baseline factors and post-TBI symptoms with SI at 2 weeks and 3, 6, and 12 months postinjury.

MAIN MEASURES

Patient Health Questionnaire, Rivermead Post-Concussion Symptoms Questionnaire.

RESULTS

Preinjury psychiatric history predicted SI at all follow-ups (adjusted odds ratios [AORs] = 2.26-6.33, P values <.05) and history of prior TBI predicted SI at 2 weeks (AOR = 2.36, 95% confidence interval [CI] = 1.16-4.81, P = .018), 3 months (AOR = 2.62, 95% CI = 1.33-5.16, P = .005), and 6 months postinjury (AOR = 2.54, 95% CI = 1.19-5.42, P = .016). Adjusting for these baseline factors, post-TBI symptoms were strongly associated with SI at concurrent (AORs = 1.91-2.88 per standard deviation unit increase in Rivermead Post-Concussion Symptoms Questionnaire score; P values <.0005) and subsequent follow-up visits (AORs = 1.68-2.53; P values <.005). Most of the associations between post-TBI symptoms and SI were statistically explained by co-occurring depression.

CONCLUSION

Screening for psychiatric and prior TBI history may help identify patients at risk for SI following mTBI. Awareness of the strong associations of post-TBI symptoms with SI may facilitate interventions to prevent suicide-related outcomes in patients with mTBI.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Deployment and Psychological Correlates of Suicide Ideation: A Prospective, Longitudinal Study of Risk and Resilience Among Combat Veterans

INTRODUCTION

Suicide rates among military personnel have risen in part due to war zone deployments. Yet, the degree to which deployment-related stressors, in combination with preexisting and co-occurring psychiatric symptoms and individual resilience factors, contribute to suicide ideation (SI) remains unclear. The current study leverages prospective, longitudinal data to examine both risk and protective factors associated with SI in deployed service members.

MATERIALS AND METHODS

Participants were 1,805 active duty enlisted Marines and Navy service members assessed before and after a 7-month deployment for SI, preexisting and concurrent symptoms of depression, post-traumatic stress disorder (PTSD), alcohol consumption, as well as prior and deployment-related traumatic brain injury (TBI). Current self-reported psychological resilience and social support were analyzed as potential protective factors.

RESULTS

Rates of SI were 7.3% and 3.9% before and after deployment, respectively. Of those with post-deployment SI, 68.6% were new-onset cases. Multivariate regression revealed that concurrent mild depression was the strongest risk factor (odds ratio [OR] = 10.03, 95% CI 5.28-19.07). Other significant risk factors included prior SI (OR = 3.36, 95% CI 1.60-7.05), prior subthreshold PTSD (OR = 2.10, 95% CI 1.10-3.99), and deployment TBI (OR = 1.84, 95% CI 1.03-3.28). Controlling for clinical symptoms and TBI, the risk of SI was reduced for those with moderate (OR = 0.50, 95% CI 0.27-0.93) and high psychological resilience scores (OR = 0.25, 95% CI 0.08-0.79) after deployment.

CONCLUSIONS

Results indicate that even mild symptoms of depression and PTSD may increase the risk of SI. Screening for subthreshold clinical symptoms and TBI while incorporating psychological resilience training would allow for a more multidimensional approach to suicide risk assessment.

Effect of an in-home, family-inclusive rehabilitation programme on depressive symptoms in veterans with traumatic brain injury and its mediation by activity engagement

Background/Aims

Depression, the most common psychiatric sequela of traumatic brain injury in both civilians and veterans, produces serious and wide-ranging problems. Although medication and cognitive behavioural therapy are the most common treatments, some rehabilitation approaches designed to enhance functioning and/or community reintegration may decrease depression by facilitating active engagement in life – the key component of some depression therapies. The present secondary analysis of a community reintegration-focused rehabilitation programme for veterans with traumatic brain injury posed two questions: Did the programme affect depressive symptoms? If so, was this effect mediated by engagement in activities?

Methods

A secondary analysis was undertaken of an intervention study of 83 former members of the United States Armed Forces (veterans) with traumatic brain injury, who were interviewed in their homes. Depressive symptoms were assessed using the short-form Centre for Epidemiological Studies-Depression Scale, activity engagement using an 8-item subscale derived from the Community Reintegration of Injured Service Members Scale, and physical and emotional functioning using the SF-36V. Sociodemographic, medical and military characteristics were elicited during the first interview, and medical and military characteristics were identified through a medical chart review.

Results

Depressive symptoms significantly decreased among the veterans in the treatment group. That effect was mediated by activity engagement. Thus, the intervention's impact on depressive symptoms was attributable to the increased activity that it produced.

Conclusions

Research on rehabilitation that enhances engagement in activities should examine its possible benefits for improving mood.

Contributions of posttraumatic stress disorder (PTSD) and mild TBI (mTBI) history to suicidality in the INTRuST consortium

OBJECTIVE

Mild TBI (mTBI) and posttraumatic stress disorder (PTSD) are independent risk factors for suicidal behaviour (SB). Further, co-occurring mTBI and PTSD increase one's risk for negative health and psychiatric outcomes. However, little research has examined the role of comorbid mTBI and PTSD on suicide risk.

METHODS

The present study utilized data from the Injury and TRaUmatic STress (INTRuST) Consortium to examine the prevalence of suicidal ideation (SI) and behaviours among four groups: 1) comorbid mTBI+PTSD, 2) PTSD only, 3) mTBI only, and 4) healthy controls.

RESULTS

Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI+PTSD was 40%, 25%, and 19%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with PTSD only was 29%, 11%, and 11%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI only was 14%, 1%, and 2%, respectively. Group comparisons showed that individuals with mTBI alone experienced elevated rates of lifetime SI compared to healthy controls. History of mTBI did not add significantly to risk for suicidal ideation and behaviour beyond what is accounted for by PTSD.

CONCLUSION

Findings suggest that PTSD seems to be driving risk for suicidal behaviour.

Living with suicidality following traumatic brain injury: a qualitative study

PURPOSE

Numbers of traumatic brain injury (TBI) are increasing, and with suicidality post-injury presenting at 3-4 times higher than in the general population, understanding this is crucial in reducing a devastating outcome. Given the lack of literature, this study investigated the experiences of living with suicidality after TBI.

METHODS

Interview data from nineteen participants with TBI from a Brain Injury Rehabilitation Unit (BIRU) in New South Wales (NSW), Australia were collected and thematically analyzed.

FINDINGS

The participants (predominantly male) sustained extremely severe injuries (median PTA 60 [IQR 81.0] days) and were in the chronic phase post-injury (median 8.0 [IQR 9.0] years). Six main themes were identified; Loss of sense of self, TBI as a hidden disability, Chronic but transient suicidality, Reliance, Protective factors, and Hope. Tentative relationships between themes and subthemes were identified.

CONCLUSION

Chronic suicidality after TBI was demonstrated consistently regardless of receiving long-term support. However, their engagement with protective factors such as social support, spirituality and positive personal qualities was identified. Implementing these as coping strategies during long-term rehabilitation may reduce the levels of suicidal distress. Implications, methodological considerations and future research were discussed, with the aim of improving experiences of individuals with TBI to reduce suicidality.

Association between suicide risk and traumatic brain injury in adults: a population based cohort study

Background

Traumatic brain injury (TBI) is a major cause of death and disability worldwide, and its treatment is potentially a heavy economic burden. Suicide is another global public health problem and the second leading cause of death in young adults. Patients with TBI are known to have higher than normal rates of non-fatal deliberate self-harm, suicide and all-cause mortality. The aim of this study was to explore the association between TBI and suicide risk in a Chinese cohort.

Method

This study analysed data contained in the Taiwan National Health Insurance Research Database for 17 504 subjects with TBI and for 70 016 subjects without TBI matched for age and gender at a ratio of 1 to 4. Cox proportional hazard regression analysis was used to estimate subsequent suicide attempts in the TBI group. Probability of attempted suicide was determined by Kaplan-Meier method.

Results

The overall risk of suicide attempts was 2.23 times higher in the TBI group compared with the non-TBI group (0.98 vs 0.29 per 1000 person-years, respectively) after adjustment for covariates. Regardless of gender, age or comorbidity, the TBI group tended to have more suicide attempts, and the risk attempted suicide increased with the severity of TBI. Depression and alcohol attributed disease also increased the risk of attempted suicide in the TBI group.

Conclusion

Suicide is preventable if risk factors are recognised. Hence, TBI patients require special attention to minimise their risk of attempted suicide.

Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis

Importance

Concussion is the most common form of traumatic brain injury (TBI). While most patients fully recover within 1 week of injury, a subset of patients might be at a higher risk of suicide.

Objective

To assess the risk of suicide after concussion.

Data Sources

We performed a systematic search of Medline (PubMed), Embase, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS) from 1963 to May 1, 2017. We also searched Google Scholar and conference proceedings and contacted experts in the field to seek additional studies.

Study Selection

Studies that quantified the risk of suicide, suicide attempt, or suicidal ideation after a concussion and/or mild TBI were included. Studies that included children and adults, including military and nonmilitary personnel, were included. Two authors independently reviewed all titles and abstracts to determine study eligibility.

Data Extraction and Synthesis

Study characteristics were extracted independently by 2 trained investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Study data were pooled using random-effects meta-analysis.

Main Outcomes and Measures

The primary exposure was concussion and/or mild TBI, and the primary outcome was suicide. Secondary outcomes were suicide attempt and suicidal ideation.

Results

Data were extracted from 10 cohort studies (n = 713 706 individuals diagnosed and 6 236 010 individuals not diagnosed with concussion and/or mild TBI), 5 cross-sectional studies (n = 4420 individuals diagnosed and 11 275 individuals not diagnosed with concussion and/or mild TBI), and 2 case-control studies (n = 446 individuals diagnosed and 8267 individuals not diagnosed with concussion and/or mild TBI). Experiencing concussion and/or mild TBI was associated with a 2-fold higher risk of suicide (relative risk, 2.03 [95% CI, 1.47-2.80]; I2 = 96%; P < .001). In 2 studies that provided estimates with a median follow-up of approximately 4 years, 1664 of 333 118 individuals (0.50%) and 750 of 126 114 individuals (0.59%) diagnosed with concussion and/or mild TBI died by suicide. Concussion was also associated with a higher risk of suicide attempt and suicide ideation. The heightened risk of suicide outcomes after concussion was evident in studies with and without military personnel.

Conclusions and Relevance

Experiencing concussion and/or mild TBI was associated with a higher risk of suicide. Future studies are needed to identify and develop strategies to decrease this risk.

Attempted suicide leading to acquired brain injury: a scoping review

Objective: Conduct a scoping review of literature surrounding acquired brain injury (ABI) sustained secondary to a suicide attempt to establish the current body of research on injury outcomes and rehabilitative needs for this population.Methods: A systematic search of the literature was conducted. Searches were conducted using terms relating to this injury etiology and search results with original or secondary data on individuals with an ABI were included for review.Results: Thirty-two articles were reviewed. Limited data characterizing this population exists in the literature. Findings indicate that this population have generally poorer injury outcomes compared with ABI sustained through other means. Rehabilitative needs are rarely addressed, but limited commentary suggests that extensive pre-morbid conditions, severity of injuries and psychosocial support needs of this population present implications for rehabilitative supports.Conclusion: There is a relative dearth of research examining ABI sustained secondary to a suicide attempt. Collated findings suggest these individuals are rarely recognized in the literature as a distinct ABI population with rehabilitative needs specific to this etiology. Future research should aim to address the gaps identified in the literature, including characterizing the population, establishing pre-morbid conditions and developing tailored rehabilitative support to address complex needs.

Early, specialist vocational rehabilitation to facilitate return to work after traumatic brain injury: the FRESH feasibility RCT

BACKGROUND

Up to 160,000 people incur traumatic brain injury (TBI) each year in the UK. TBI can have profound effects on many areas of human functioning, including participation in work. There is limited evidence of the clinical effectiveness and cost-effectiveness of vocational rehabilitation (VR) after injury to promote early return to work (RTW) following TBI.

OBJECTIVE

To assess the feasibility of a definitive, multicentre, randomised controlled trial (RCT) of the clinical effectiveness and cost-effectiveness of early, specialist VR plus usual care (UC) compared with UC alone on work retention 12 months post TBI.

DESIGN

A multicentre, feasibility, parallel-group RCT with a feasibility economic evaluation and an embedded mixed-methods process evaluation. Randomisation was by remote computer-generated allocation.

SETTING

Three NHS major trauma centres (MTCs) in England.

PARTICIPANTS

Adults with TBI admitted for > 48 hours and working or studying prior to injury.

INTERVENTIONS

Early specialist TBI VR delivered by occupational therapists (OTs) in the community using a case co-ordination model.

MAIN OUTCOME MEASURES

Self-reported RTW 12 months post randomisation, mood, functional ability, participation, work self-efficacy, quality of life and work ability. Feasibility outcomes included recruitment and retention rates. Follow-up was by postal questionnaires in two centres and face to face in one centre. Those collecting data were blind to treatment allocation.

RESULTS

Out of 102 target participants, 78 were recruited (39 randomised to each arm), representing 39% of those eligible and 5% of those screened. Approximately 2.2 patients were recruited per site per month. Of those, 56% had mild injuries, 18% had moderate injuries and 26% had severe injuries. A total of 32 out of 45 nominated carers were recruited. A total of 52 out of 78 (67%) TBI participants responded at 12 months (UC, n = 23; intervention, n = 29), completing 90% of the work questions; 21 out of 23 (91%) UC respondents and 20 out of 29 (69%) intervention participants returned to work at 12 months. Two participants disengaged from the intervention. Face-to-face follow-up was no more effective than postal follow-up. RTW was most strongly related to social participation and work self-efficacy. It is feasible to assess the cost-effectiveness of VR. Intervention was delivered as intended and valued by participants. Factors likely to affect a definitive trial include deploying experienced OTs, no clear TBI definition or TBI registers, and repatriation of more severe TBI from MTCs, affecting recruitment of those most likely to benefit/least likely to drop out.

LIMITATIONS

Target recruitment was not reached, but mechanisms to achieve this in future studies were identified. Retention was lower than expected, particularly in UC, potentially biasing estimates of the 12-month RTW rate.

CONCLUSIONS

This study met most feasibility objectives. The intervention was delivered with high fidelity. When objectives were not met, strategies to ensure feasibility of a full trial were identified. Future work should test two-stage recruitment and include resources to recruit from 'spokes'. A broader measure covering work ability, self-efficacy and participation may be a more sensitive outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38581822.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 33. See the NIHR Journals Library website for further project information.

Mild Traumatic Brain Injury Burden Moderates the Relationship Between Cognitive Functioning and Suicidality in Iraq/Afghanistan-Era Veterans

OBJECTIVES

Suicidal ideation (SI) is highly prevalent in Iraq/Afghanistan-era veterans with a history of mild traumatic brain injury (mTBI), and multiple mTBIs impart even greater risk for poorer neuropsychological functioning and suicidality. However, little is known about the cognitive mechanisms that may confer increased risk of suicidality in this population. Thus, we examined relationships between neuropsychological functioning and suicidality and specifically whether lifetime mTBI burden would moderate relationships between cognitive functioning and suicidal ideation.

METHODS

Iraq/Afghanistan-era Veterans with a history of mTBI seeking outpatient services (N = 282) completed a clinical neuropsychological assessment and psychiatric and postconcussive symptom questionnaires.

RESULTS

Individuals who endorsed SI reported more severe post-traumatic stress disorder (PTSD), depression, and postconcussive symptoms and exhibited significantly worse memory performance compared to those who denied SI. Furthermore, mTBI burden interacted with both attention/processing speed and memory, such that poorer performance in these domains was associated with greater likelihood of SI in individuals with a history of three or more mTBIs. The pattern of results remained consistent when controlling for PTSD, depression, and postconcussive symptoms.

CONCLUSIONS

Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and SI in veterans with three or more mTBIs. Results have the potential to better inform treatment decisions for veterans with history of multiple mTBIs. (JINS, 2019, 25, 79-89).

Association Between Traumatic Brain Injury and Risk of Suicide

IMPORTANCE

Traumatic brain injuries (TBIs) can have serious long-term consequences, including psychiatric disorders. However, few studies have assessed the association between TBI and risk of suicide.

OBJECTIVE

To examine the association between TBI and subsequent suicide.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using nationwide registers covering 7 418 391 individuals (≥10 years) living in Denmark (1980-2014) with 164 265 624 person-years' follow-up; 567 823 (7.6%) had a medical contact for TBI. Data were analyzed using Poisson regression adjusted for relevant covariates, including fractures not involving the skull, psychiatric diagnoses, and deliberate self-harm.

EXPOSURE

Medical contacts for TBI recorded in the National Patient Register (1977-2014) as mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injuries with evidence of structural brain injury).

MAIN OUTCOMES AND MEASURES

Suicide recorded in the Danish Cause of Death register until December 31, 2014.

RESULTS

Of 34 529 individuals who died by suicide (mean age, 52 years [SD, 18 years]; 32.7% women; absolute rate 21 per 100 000 person-years [95% CI, 20.8-21.2]), 3536 (10.2%) had medical contact: 2701 with mild TBI, 174 with skull fracture without documented TBI, and 661 with severe TBI. The absolute suicide rate was 41 per 100 000 person-years (95% CI, 39.2-41.9) among those with TBI vs 20 per 100 000 person-years (95% CI, 19.7-20.1) among those with no diagnosis of TBI. The adjusted incidence rate ratio (IRR) was 1.90 (95% CI, 1.83-1.97). Compared with those without TBI, severe TBI (absolute rate, 50.8 per 100 000 person-years; 95% CI, 46.9-54.6) was associated with an IRR of 2.38 (95% CI, 2.20-2.58), whereas mild TBI (absolute rate, 38.6 per 100 000 person-years; 95% CI, 37.1-40.0), and skull fracture without documented TBI (absolute rate, 42.4 per 100 000 person-years; 95% CI, 36.1-48.7) had an IRR of 1.81 (95% CI, 1.74-1.88) and an IRR of 2.01 (95% CI, 1.73-2.34), respectively. Suicide risk was associated with number of medical contacts for TBI compared with those with no TBI contacts: 1 TBI contact, absolute rate, 34.3 per 100 000 person-years (95% CI, 33.0-35.7; IRR, 1.75; 95% CI, 1.68-1.83); 2 TBI contacts, absolute rate, 59.8 per 100 000 person-years (95% CI, 55.1-64.6; IRR, 2.31; 95% CI, 2.13-2.51); and 3 or more TBI contacts, absolute rate, 90.6 per 100 000 person-years (95% CI, 82.3-98.9; IRR, 2.59; 95% CI, 2.35-2.85; all P < .001 for the IRR's). Compared with the general population, temporal proximity since the last medical contact for TBI was associated with risk of suicide (P<.001), with an IRR of 3.67 (95% CI, 3.33-4.04) within the first 6 months and an incidence IRR of 1.76 (95% CI, 1.67-1.86) after 7 years.

CONCLUSIONS AND RELEVANCE

In this nationwide registry-based retrospective cohort study individuals with medical contact for TBI, compared with the general population without TBI, had increased suicide risk.

Gender Differences in Suicidal Behaviors: Mediation Role of Psychological Distress Between Alcohol Abuse/Dependence and Suicidal Behaviors

Suicide is the second leading cause of death among emerging adults ages 18 to 25.

AIMS

To examine gender differences on the mediation effect of psychological distress between alcohol abuse or dependence (AAD) and suicidal behaviors (ideation, plan, and attempt).

METHOD

The current study used the 2014 NSDUH public use data. Young adults aged 18 to 25 years (M = 21.02) old were selected as study participants. The three outcome variables were suicide ideation, plan, and attempt. AAD was an independent variable. As a mediation variable, psychological distress was used to test the research questions. The mediation effect was tested by using bootstrapping methods with the SPSS version of the macro (PROCESS version 2.16) developed by Preacher and Hayes.

RESULTS

Six separate mediation analyses (three for a male and three for a female group) were conducted for different types of suicidal behaviors including ideation, plan, and attempt. Overall, psychological distress mediated the association between AAD and suicidal behaviors, except the relationship between AAD and suicide attempts among the male young adults group.

CONCLUSIONS

The findings of the current study provide specific directions for practitioners to reduce suicide rates among young adults who are at risk for suicidal behavior.

Social work-generated evidence in traumatic brain injury from 1975 to 2014: A systematic scoping review

The International Network for Social Workers in Acquired Brain Injury (INSWABI) commissioned a systematic scoping review to ascertain the social work-generated evidence base on people with traumatic brain injury (TBI) of working age. The review aimed to identify the output, impact and quality of publications authored by social workers on this topic. Study quality was evaluated through assessment frameworks drawn from the United Kingdom National Service Framework for Long-Term Conditions. In the 40-year period from 1975 to 2014, 115 items were published that met the search criteria (intervention studies, n = 10; observational studies, n = 52; literature reviews, n = 6; expert opinion or policy analysis, n = 39; and others, n = 8). The publications could be grouped into five major fields of practice: families, social inclusion, military, inequalities and psychological adjustment. There was a significant increase in the number of publications over each decade. Impact was demonstrated in that the great majority of publications had been cited at least once (80.6%, 103/115). Articles published in rehabilitation journals were cited significantly more often than articles published in social work journals. A significant improvement in publication quality was observed across the four decades, with the majority of studies in the last decade rated as high quality.

Suicidal Ideation After Mild Traumatic Brain Injury: A Consecutive Canadian Sample

This study aims to elucidate psychosocial and injury features contributing to SI following concussion or mild traumatic brain injury (mTBI) and the time course for its development. Between 1998 and 2012, a sample of 871 patients referred to a follow-up clinic after concussion treatment in an urban tertiary care ED were consecutively offered enrollment at 3 months post injury. Data from psychiatric and social-demographic assessments were consecutively collected at 2 visits (3 and 6 months after injury) respectively. Chi-square and t-tests were performed to identify associations between variables related with SI. Logistic regression analysis was performed to identify factors independently associated. During the enrolment period, 2,296 patients with mTBI presented to the ED. 871 adults completed psychiatric and social demographic clinic assessments at 3 months, and 500 returned at 6 months. Suicidal ideation was expressed by 6.3% at 3 months and 8.2% at 6 months. Regression models showed SI independently associated with: speaking English as a second language (ESL) and injury mechanism (MVC passenger) at 3 and 6 months; and history of depression and marital status at 3 months only. SI is common 3 months after mTBI, and appears more at 6 month follow up. These findings suggest earlier screening for predisposing factors and closer monitoring of those at risk for suicidality.

Traumatic Brain Injury, Sleep Quality, and Suicidal Ideation in Iraq/Afghanistan Era Veterans

The objective of this study was to test the hypothesis that sleep quality mediates the association between traumatic brain injury (TBI) history and current suicidal ideation. Measures of TBI history, sleep quality, and suicidal ideation were administered to 130 Iraq/Afghanistan veterans. As expected, sleep quality mediated the effect of TBI history on current suicidal ideation (indirect effect, 0.0082; 95% confidence interval, 0.0019-0.0196), such that history of TBI was associated with worse sleep quality, which was, in turn, associated with increased suicidal ideation. These findings highlight the importance of assessing TBI history and sleep quality during suicide risk assessments for veterans.

A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges

Depression is one of the most common conditions to emerge after traumatic brain injury (TBI), and despite its potentially serious consequences it remains undertreated. Treatment for post-traumatic depression (PTD) is complicated due to the multifactorial etiology of PTD, ranging from biological pathways to psychosocial adjustment. Identifying the unique, personalized factors contributing to the development of PTD could improve long-term treatment and management for individuals with TBI. The purpose of this narrative literature review was to summarize the prevalence and impact of PTD among those with moderate to severe TBI and to discuss current challenges in its management. Overall, PTD has an estimated point prevalence of 30%, with 50% of individuals with moderate to severe TBI experiencing an episode of PTD in the first year after injury alone. PTD has significant implications for health, leading to more hospitalizations and greater caregiver burden, for participation, reducing rates of return to work and affecting social relationships, and for quality of life. PTD may develop directly or indirectly as a result of biological changes after injury, most notably post-injury inflammation, or through psychological and psychosocial factors, including pre injury personal characteristics and post-injury adjustment to disability. Current evidence for effective treatments is limited, although the strongest evidence supports antidepressants and cognitive behavioral interventions. More personalized approaches to treatment and further research into unique therapy combinations may improve the management of PTD and improve the health, functioning, and quality of life for individuals with TBI.

Animal models to improve our understanding and treatment of suicidal behavior

Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.

Suicide Mortality Among Retired National Football League Players Who Played 5 or More Seasons

BACKGROUND

There is current disagreement in the scientific literature about the relationship between playing football and suicide risk, particularly among professional players in the National Football League (NFL). While some research indicates players are at high risk of football-related concussions, which may lead to chronic traumatic encephalopathy and suicide, other research finds such a connection to be speculative and unsupported by methodologically sound research.

PURPOSE

To compare the suicide mortality of a cohort of NFL players to what would be expected in the general population of the United States.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A cohort of 3439 NFL players with at least 5 credited playing seasons between 1959 and 1988 was assembled for statistical analysis. The vital status for this cohort was updated through 2013. Standardized mortality ratios (SMRs), the ratio of observed deaths to expected deaths, and 95% CIs were computed for the cohort; 95% CIs that excluded unity were considered statistically significant. For internal comparison purposes, standardized rate ratios were calculated to compare mortality results between players stratified into speed and nonspeed position types.

RESULTS

Suicide among this cohort of professional football players was significantly less than would be expected in comparison with the United States population (SMR = 0.47; 95% CI, 0.24-0.82). There were no significant differences in suicide mortality between speed and nonspeed position players.

CONCLUSION

There is no indication of elevated suicide risk in this cohort of professional football players with 5 or more credited seasons of play. Because of the unique nature of this cohort, these study results may not be applicable to professional football players who played fewer than 5 years or to college or high school players.

Prevalence of suicidal behaviour following traumatic brain injury: Longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems

OBJECTIVE

This study utilized the Traumatic Brain Injury Model Systems (TBIMS) National Database to examine the prevalence of depression and suicidal behaviour in a large cohort of patients who sustained moderate-to-severe TBI.

METHOD

Participants presented to a TBIMS acute care hospital within 72 hours of injury and received acute care and comprehensive rehabilitation in a TBIMS designated brain injury inpatient rehabilitation programme. Depression and suicidal ideation were measured with the Patient Health Questionnaire (PHQ-9). Self-reported suicide attempts during the past year were recorded at each follow-up examination, at 1, 2, 3, 10, 15 and 20 years post-injury.

RESULTS

Throughout the 20 years of follow-up, rates of depression ranged from 24.8-28.1%, suicidal ideation ranged from 7.0-10.1% and suicide attempts (past year) ranged from 0.8-1.7%. Participants who endorsed depression and/or suicidal behaviour at year 1 demonstrated consistently elevated rates of depression and suicidal behaviour 5 years after TBI.

CONCLUSION

Compared to the general population, individuals with TBI are at greater risk for depression and suicidal behaviour many years after TBI. The significant psychiatric symptoms evidenced by individuals with TBI highlight the need for routine screening and mental health treatment in this population.

Contemporary Perspectives on Social Work in Acquired Brain Injury: An Introduction

This special issue of the Journal of Social Work in Disability and Rehabilitation, "Contemporary Perspectives on Social Work in Acquired Brain Injury," has been initiated and coordinated by the International Network of Social Workers in Acquired Brain Injury (INSWABI). In introducing the issue, some space is allocated for providing definitions of traumatic brain injury (TBI) and acquired brain injury (ABI), outlining the epidemiology and global costs, and detailing the impairments and psychosocial impacts for both the person sustaining the injury and his or her family. Finally, an outline of the articles contributing to this special issue are detailed, followed by a brief discussion about the role of the INSWABI network in promoting best practice in social work within this specialty area.

Updates and Current Perspectives of Psychiatric Assessments after Traumatic Brain Injury: A Systematic Review

Neuropsychological and psychiatric disorders represent a major concern and cause of disabilities after the trauma, contributing to worse recovery after traumatic brain injury (TBI). However, the lack of well-defined parameters to evaluate patient's psychiatric disorders leads to a wide range of diagnoses and symptoms. The aim of this study was to perform a review of literature in order to gather data of the most common scales and inventories used to assess and diagnose depression, anxiety, and posttraumatic stress disorder (PTSD) after TBI. We conducted a literature search via MEDLINE, PubMed, and Web of Science. We included reviews, systematic reviews, and meta-analysis studies, and we used the following keywords: "traumatic brain injury OR TBI," "depression OR depressive disorder," "anxiety," and "posttraumatic stress disorder OR PTSD." From 610 titles, a total of 68 systematic reviews or meta-analysis were included in the section "Results" of this review: depression (n = 32), anxiety (n = 9), and PTSD (n = 27). Depression after TBI is a more established condition, with more homogeneous studies. Anxiety and PTSD disorders have been studied in a heterogeneous way, usually as comorbidity with other psychiatric disorders. Some scales and inventories designed for the general community may not be appropriate for patients with TBI.

Self-amputation of the hand: issues in diagnosis and general hospital management

OBJECTIVES

To detail a diagnostic dilemma of intentional hand amputation in a man with a history of substance misuse and associated psychosis, depression and traumatic brain injury and to highlight issues in joint psychiatric and surgical management of such a complex patient in a general hospital setting.

CONCLUSIONS

Deliberate limb self-amputation is a rare event with the majority of reported cases occurring during an episode of psychosis. This case illustrates the diagnostic utility of the literature supporting that a person who has self-inflicted amputation of a limb should be treated as psychotic until proven otherwise. The presence of a traumatic brain injury, with associated cognitive and psychosocial sequelae, affected diagnosis and management. Early and ongoing involvement of consultation-liaison psychiatry collaborating with a multidisciplinary general hospital team may improve mental and physical health outcomes for such patients.

Acute Trauma Factor Associations With Suicidality Across the First 5 Years After Traumatic Brain Injury

OBJECTIVE

To determine whether severity of head and extracranial injuries (ECI) is associated with suicidal ideation (SI) or suicide attempt (SA) after traumatic brain injury (TBI).

DESIGN

Factors associated with SI and SA were assessed in this inception cohort study using data collected 1, 2, and 5 years post-TBI from the National Trauma Data Bank and Traumatic Brain Injury Model Systems (TBIMS) databases.

SETTING

Level I trauma centers, inpatient rehabilitation centers, and the community.

PARTICIPANTS

Participants with TBI from 15 TBIMS Centers with linked National Trauma Data Bank trauma data (N=3575).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

SI was measured via the Patient Health Questionnaire 9 (question 9). SA in the last year was assessed via interview. ECI was measured by the Injury Severity Scale (nonhead) and categorized as none, mild, moderate, or severe.

RESULTS

There were 293 (8.2%) participants who had SI without SA and 109 (3.0%) who had SA at least once in the first 5 years postinjury. Random effects logit modeling showed a higher likelihood of SI when ECI was severe (odds ratio=2.73; 95% confidence interval, 1.55-4.82; P=.001). Drug use at time of injury was also associated with SI (odds ratio=1.69; 95% confidence interval, 1.11-2.86; P=.015). Severity of ECI was not associated with SA.

CONCLUSIONS

Severe ECI carried a nearly 3-fold increase in the odds of SI after TBI, but it was not related to SA. Head injury severity and less severe ECI were not associated with SI or SA. These findings warrant additional work to identify factors associated with severe ECI that make individuals more susceptible to SI after TBI.

The association between traumatic brain injury and suicide: are kids at risk?

Traumatic brain injury (TBI) in late adolescence and adulthood is associated with a higher risk of suicide; however, it is unknown whether this association is also present in people who sustained a TBI during childhood. The purpose of the present study was to determine whether experiencing a TBI during childhood is a risk factor for suicide later in life and to examine whether the risk of suicide differs by sex or injury severity. A cohort of 135,703 children aged 0-17 years was identified from the Quebec population-based physician reimbursement database in 1987, and follow-up was conducted until 2008. Of the children in this cohort, 21,047 had sustained a TBI. Using a survival analysis with time-dependent indicators of TBI, we found a higher risk of suicide for people who sustained a TBI during childhood (hazard ratio (HR) = 1.49, 95% confidence interval (CI): 1.04, 2.14), adolescence (HR = 1.57, 95% CI: 1.09, 2.26), and adulthood (HR = 2.53, 95% CI: 1.79, 3.59). When compared with less severe injuries, such as concussions and cranial fractures, more severe injuries, such as intracranial hemorrhages, were associated with a higher risk of suicide (HR = 2.18 vs. 2.77, respectively). Repeated injuries were associated with higher risks of suicide in all age groups.

Executive function and suicidality: A systematic qualitative review

Deficits in executive function (EF) have been proposed as a possible explanation for the "cognitive rigidity" often observed in suicidal individuals. This article provides a systematic review of the existing literature testing the relations between EF and suicidality, across various diagnostic and demographic populations, using the influential multidimensional model of EF proposed by Miyake and colleagues (2000) as an organizing framework. Forty-three journal articles on this topic published before January of 2014 were reviewed. Collectively, results from these studies provide tentative support for an association between EF deficits and suicidality. However, there is some evidence that this association is moderated by other factors (e.g., suicide attempt lethality). Importantly, this relationship may vary across diagnostic groups. Specifically, more studies that used depressive disorder samples reported some positive findings (75%), followed by mixed diagnostic samples (54%). In contrast, fewer positive findings have emerged from studies with bipolar or psychotic disorder samples (29% and 33% respectively), and some even found that suicidality is associated with better EF in individuals with psychotic disorders. Firm conclusions about relationships between specific dimensions of EF and/or aspects of suicidality are difficult to draw this time. Limitations of the existing literature and corresponding directions for future research are discussed.

Mortality following Traumatic Brain Injury Inpatient Rehabilitation

The aim of this study was to examine the rate and causes of mortality following mild to severe traumatic brain injury (TBI) rehabilitation and to develop a multivariate prognostic model of mortality. We conducted a cohort study of 3341 individuals with mild to severe TBI followed-up from a post-acute inpatient rehabilitation center. Rate of death and survival between one and 26 years following injury were examined using standardized mortality ratios (SMRs) and prognostic models developed using Cox regression. A mortality rate of 9.3% was observed and an overall SMR of 1.04 (95% confidence interval [CI]=1.04-1.05). A statistically significant elevated SMR of 1.20 (95% CI=1.06-1.37) was observed for males, and both males and females had an elevated risk of death from external causes. Females also were found to have a significantly elevated SMR of 5.02 (95% CI=1.36-12.80) for intentional self-harm. Individuals ages 15-44 had a two-fold increase in mortality, compared with the general population. The multivariate Cox model indicated that increased risk of mortality was associated with older age, being male, being unemployed prior to injury, having a history of stroke, alcohol use, mental health issues, and back injury sustained in the accident. Premorbid lifestyle factors exerted a greater influence on mortality following TBI, compared with injury-related factors. This risk was especially prominent for younger individuals, who died primarily due to external causes. These findings highlight the need for interventions that address premorbid issues, such as substance abuse and mental health issues.

Exploring the Relationship Between Mild Traumatic Brain Injury Exposure and the Presence and Severity of Postconcussive Symptoms Among Veterans Deployed to Iraq and Afghanistan

OBJECTIVE

The aim of this study was to describe the association between mild traumatic brain injury (mTBI) and persisting postconcussive symptoms according to symptom category, number, and severity.

DESIGN

The study design was observational.

PARTICIPANTS

The study sample comprised veterans (≥18 years of age) deployed in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts who had not received any treatment for mTBI in the 30 days preceding study enrollment.

METHODS

Veterans were interviewed and completed testing in a single day. The Standard TBI Diagnostic Interview and the Clinician-Administered PTSD Scale were used. Testing included the Neurobehavioral Symptom Inventory and a full neuropsychological battery. Gold standard classification methods were utilized to determine presence/absence of mTBI. For each of the 5 symptom outcomes, an adjusted multiple linear regression model (negative binomial count models) accounting for effects of socio-demographic variables and behavioral health conditions was used.

MAIN OUTCOME MEASURES

Self-report of neurobehavioral symptoms categorized as affective, cognitive, somatic, and vestibular symptoms, in addition to the instruments specified above.

RESULTS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, were observed to have 30% more symptoms overall (P < .001), 34% more somatic symptoms (P < .001), 22% more cognitive symptoms (P = .008), 15% more affective symptoms (P = .017), and 59% more vestibular symptoms (P < .001). For adjusted models, variables significantly related to number of symptoms across all 4 symptom categories were anxiety (all P < .001) and insomnia (all P < .001). For the adjusted models, variables significantly related to symptom severity across all 4 symptom categories were insomnia (all P < .001), depression (P < .001-.05) and anxiety (all, P < .001).

CONCLUSIONS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, have significantly more and significantly more severe persisting symptoms, with vestibular symptoms reported with the greatest frequency. After accounting for behavioral health conditions and socio-demographic factors, OEF/OIF veterans with mTBI compared to veterans without mTBI had significantly more cognitive, affective, vestibular, and somatic symptoms persisting 4.8 years after the mTBI event(s).