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Aaronson AL, Smith B, Krese K, Barnhart M, Adamson M, de Wit H, Philip NS, Brenner LA, Bender-Pape T, Herrold AA. Impulsivity and Psychiatric Diagnoses as Mediators of Suicidal Ideation and Suicide Attempts Among Veterans With Traumatic Brain Injury. J Neuropsychiatry Clin Neurosci 2024; 36:125-133. [PMID: 38192217 PMCID: PMC11018458 DOI: 10.1176/appi.neuropsych.20230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a risk factor for suicide, but questions related to mechanisms remain unanswered. Impulsivity is a risk factor for suicide and is a common sequela of TBI. The authors explored the relationships between TBI and both suicidal ideation and suicide attempts and explored whether impulsivity and comorbid psychiatric diagnoses mediate these relationships. METHODS This cross-sectional retrospective chart review study included 164 veterans enrolled in a previous study. Sixty-nine veterans had no TBI history, and 95 had a TBI history (mild, N=44; moderate, N=13; severe, N=12; and unclear severity, N=26). To examine the associations between TBI and suicidal ideation or suicide attempts, as well as potential mediators of these relationships, chi-square tests, t tests, and logistic regression models were used. RESULTS Unadjusted analyses indicated that veterans with TBI were more likely to report suicidal ideation; however, in analyses controlling for mediators, this relationship was no longer significant. Among veterans with TBI, suicidal ideation was related most strongly to high impulsivity (odds ratio=15.35, 95% CI=2.43-96.79), followed by depression (odds ratio=5.73, 95% CI=2.53-12.99) and posttraumatic stress disorder (odds ratio=2.57, 95% CI=1.03-6.42). TBI was not related to suicide attempts, yet suicide attempts were related to high impulsivity (odds ratio=6.95, 95% CI=1.24-38.75) and depression (odds ratio=3.89, 95% CI=1.56-9.40). CONCLUSIONS These findings suggest that impulsivity, followed by psychiatric diagnoses, most strongly mediate the relationships between TBI and both suicidal ideation and suicide attempts. Impulsivity may be mechanistically related to, and serve as a future treatment target for, suicidality among veterans with TBI.
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Affiliation(s)
- Alexandra L Aaronson
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Bridget Smith
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Kelly Krese
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Meghan Barnhart
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Maheen Adamson
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Harriet de Wit
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Noah S Philip
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Lisa A Brenner
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Theresa Bender-Pape
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
| | - Amy A Herrold
- Mental Health Service Line (Aaronson) and Research Service Line (Smith, Bender-Pape, Herrold), Edward J. Hines Veterans Administration Hospital, Hines, Ill.; Department of Psychiatry, University of Illinois, Chicago (Aaronson); Brain Innovation Center, Shirley Ryan AbilityLab, Chicago (Krese); Chicago Association for Research and Education in Science, Hines, Ill. (Krese); Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colo. (Barnhart, Brenner); Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora (Barnhart, Brenner); Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (Adamson); Department of Neurosurgery, Stanford University, Stanford, Calif. (Adamson); Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (de Wit); Center for Neurorestoration and Neurotechnology, Veterans Affairs Providence Health Care System, Providence, R.I. (Philip); Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, R.I. (Philip); Departments of Physical Medicine and Rehabilitation (Bender-Pape) and Psychiatry and Behavioral Sciences (Herrold), Northwestern University, Chicago
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Brenner LA, Forster JE, Gradus JL, Hostetter TA, Hoffmire CA, Walsh CG, Larson MJ, Stearns-Yoder KA, Adams RS. Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk. JAMA Netw Open 2023; 6:e2326296. [PMID: 37523186 PMCID: PMC10391302 DOI: 10.1001/jamanetworkopen.2023.26296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/09/2023] [Indexed: 08/01/2023] Open
Abstract
Importance Research to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges. Objective To identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide. Design, Setting, and Participants This retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022. Exposures Military-related TBI. Main Outcomes and Measures The outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit. Results The study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI. Conclusions and Relevance In this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.
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Affiliation(s)
- Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora
| | - Jaimie L. Gradus
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Trisha A. Hostetter
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
| | - Claire A. Hoffmire
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora
| | - Colin G. Walsh
- Departments of Biomedical Informatics, Medicine, and Psychiatry, Vanderbilt University Medical Center, Durham, North Carolina
| | - Mary Jo Larson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Kelly A. Stearns-Yoder
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora
| | - Rachel Sayko Adams
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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