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Cited by 198Suicide and Self-Harm StudiesTraumatic Brain Injury ResearchTraumatic Brain Injury and Neurovascular Disturbances

Association Between Traumatic Brain Injury and Risk of Suicide

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Madsen, Trine, Erlangsen, Annette, Orlovska, Sonja, Mofaddy, Ramy, Nordentoft, Merete, Benros, Michael E.·2018·JAMA
DOI 10.1001/jama.2018.10211PMC PMC6142987
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Abstract

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.

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  • Co-occurring suicide and injury risk factors-mental illness, violence exposure, substance abuse-plus elevated risk after injury, especially TBI, SCI, and assault, make adolescent trauma patients very high risk for suicide.

    “The co-occurring risk factors for suicide and injury including mental illness, exposures to violence, and substance abuse, in addition to the elevated risk after injury, especially in specific injuries such as TBI, SCI, and assault, all contribute to making the adolescent trauma patient population very high risk for suicide [8•, 38, 40, 41, 42, 43••].”

    From Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death (2022) · cites this paper as [38]

    The Abstract reports a higher suicide rate after TBI, and the Results include analyses by age at first TBI, including adolescent ages. The paper does not establish that adolescent trauma patients as a group are at very high risk, or address the claimed risks after spinal cord injury or assault and the full set of co-occurring factors. No page numbers are supplied for these passages in our copy. (LLM, conf=0.88)

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  • TBI suicide risk increases with TBI severity, long hospitalizations, and frequent medical encounters.

    “Suicide risk is well established for traumatic brain injury in children and adults, as suicide rates among individuals with a history of TBI are twice that of those who have not experienced TBI, and the risk is increased with TBI severity, long hospitalizations, and frequent medical encounters [38].”

    From Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death (2022) · cites this paper as [38]

  • Suicide rates among individuals with a history of TBI are twice those of individuals without TBI.

    “Suicide risk is well established for traumatic brain injury in children and adults, as suicide rates among individuals with a history of TBI are twice that of those who have not experienced TBI, and the risk is increased with TBI severity, long hospitalizations, and frequent medical encounters [38].”

    From Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death (2022) · cites this paper as [38]

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Research works printed but not linked: 2

  1. [28]28. Hawton K, van Heeringen K. Suicide. Lancet. 2009;373(9672):1372-1381.
  2. [29]29. Clayton D, Hills M. Statistical Models in Epidemiology. Oxford, United Kingdom: Oxford University Press USA-OSO; 2013.

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Authors
Madsen, T., Erlangsen, A., Orlovska, S., Mofaddy, R., Nordentoft, M., & Benros, M. E.
Affiliations
  • Copenhagen University Hospital (DK)
  • Australian National University (AU)
  • Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
Corresponding author
Madsen, Trine
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2018-08-14
Volume
320
Issue
6
Pages
580
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2018.10211
PMC
PMC6142987
OpenAlex
W2887210733
Cited by
198
References
37
Citations by year
2026: 21 · 2025: 23 · 2024: 29 · 2023: 18 · 2022: 26 · 2021: 23 · 2020: 31 · 2019: 20 · 2018: 7
FWCI
23.80
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • ANU Open Research (Australian National University) (submittedVersion)
  • Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
Funders
Lundbeckfonden (R268-2016–3925, R155-2014-1724, R248‐2017‐2003)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
  • Health Sciences › Medicine › Neurology › Traumatic Brain Injury and Neurovascular Disturbances
Keywords
traumatic brain injury, suicide, suicide risk, mild traumatic brain injury, concussion, severe traumatic brain injury, skull fracture, mental illness, psychiatric hospitalization, suicide attempts, suicide risk factors, incidence rate ratio, relative excess risk due to interaction, attributable fraction
MeSH terms
Brain Injuries, Traumatic, Adult, Aged, Denmark, Female, Health Services, Humans, Male, Middle Aged, Registries, Retrospective Studies, Risk, Skull Fractures, Suicide, Bias, Confounding Factors, Epidemiologic, Incidence

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