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

Abstract

Background: A systematic search was conducted of the literature addressing suicidality after traumatic brain injury (TBI). Results from population-based studies found that people with TBI have an increased risk of death by suicide (3–4 times greater than for the general population), as well as significantly higher levels of suicide attempts and suicide ideation. Clinical studies have also reported high levels of suicide attempts (18%) and clinically significant suicide ideation (21–22%) in TBI samples.

Methods and Results: In reviewing risk factors, two prognostic studies using multivariate analysis were identified. Adjusted risk statistics from these studies found an elevated risk of suicide for people with severe TBI in comparison to concussion (hazard ratio 1.4, 95% CI 1.15–1.75) and an elevated risk of suicide attempts among people displaying post-injury suicide ideation (adjusted odds ratio 4.9, 95% CI 1.79–13.17) and psychiatric/emotional distress (adjusted odds ratio 7.8, 95% CI 2.11–29.04).

Conclusions: To date, little evidence exists for the role of pre-morbid psychopathology, neuropathology, neuropsychological impairments or post-injury psychosocial factors as major risk factors for post-injury suicidality. Finally, there has been little empirical examination of approaches to suicide prevention. Therefore, current best practice is based on clinical judgement and the untested extrapolation of prevention approaches from other clinical populations.

• Traumatic brain injury
• suicide
• suicide attempts
• suicide ideation
• review

Notes

Notes

[1] Suicidality in this review refers to death by suicide, suicide attempts and suicide ideation, defined using the nomenclature outlined by O’Carroll et al. ([13], pp. 246–247). Suicide: Death from injury, poisoning or suffocation where there is evidence (either explicit or implicit) that the injury was self-inflicted and that the decedent intended to kill himself/herself; Attempted suicide: A potentially self-injurious behaviour with a non-fatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some level to kill himself/herself. A suicide attempt may or may not result in injuries; Suicide ideation: Any self-reported thoughts of engaging in suicide-related behaviour.

[2] The DSM-IV criterion reads ‘recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide’ ([45], p. 327).

[3] Criteria as applied to this review: (i) contained empirical data; (ii) a defined sample with a primary diagnosis of TBI (i.e. no single case studies); (iii) a defined outcome variable for completed suicide, suicide attempt or suicide ideation (e.g. a diagnostic code, a standardized measure or item, entry in a state death registry); (iv) prognostic variables that were fully defined and for which data was reported (e.g. frequencies or percentages, means, standard deviations, survival rates, etc.) and (v) the variables were tested in a multivariate analysis.

[4] The authors defined suicide ideation using the Beck Depression Inventory (BDI [69]) suicide ideation item. For the risk estimate calculation, participants who endorsed the level ‘No suicidal thoughts’ were classified as ‘No ideation’. Respondents endorsing any of the other three levels on the BDI item (Suicidal thoughts, Would like to kill self, Would kill self if had the chance) were counted as expressing suicide ideation.