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Suicidal Behavior among Veterans with TBI and PTSD

Like individuals from previous Veteran cohorts, military personnel serving in Iraq and Afghanistan are being exposed to physical and psychological traumas that place them at risk for traumatic brain injury (TBI) and/or post-traumatic stress disorder (PTSD). Both of these conditions are associated with negative outcomes. Recent research suggests that Veterans with TBI and/or PTSD may be at risk for self-directed violence (SDV) such as suicide attempts and death by suicide.

Death by Suicide among Those with TBI¹

Although previous studies supported the relationship between history of TBI and suicide in the general population, no research had been conducted to explore TBI as a risk factor for SDV among those seeking care at Veterans Health Administration (VHA) facilities. Using data from VHA electronic medical records and the National Death Index (NDI), we examined the relationship between history of TBI and death by suicide among individuals who had sought VHA care between 2001 and 2006. Analyses included all individuals with a history of TBI (n = 49,626) plus a 5 percent random sample of patients without TBI (n = 389,053). VHA users with a history of TBI were 1.55 times more likely to die by suicide than those without a history of TBI. The increased risk was not explained by the presence of psychiatric disorders or demographic factors. This finding suggests that history of TBI had an independent influence; thereby highlighting the possibility that injury-specific factors such as cognitive dysfunction or TBI-related psychosocial stressors (e.g., loss of employment, marital discord) may contribute to risk.

Moreover, among individuals whose data were included in the study, significant differences were identified in the rate of all psychiatric diagnoses (e.g., PTSD) between those who died by suicide and those who did not. In addition, the rate of PTSD was significantly greater (p< .0001) among those with TBI who died by suicide (21.9 percent) versus those with TBI who did not die by suicide (9.81 percent). This suggests that a diagnosis of PTSD may increase risk for death by suicide among those with a history of TBI.

PTSD and Suicide Attempt History among Those with and without TBI²

We also looked at the relationship between PTSD and suicide attempt history in those with and without TBI who were using VHA mental health services. Electronic medical records were used to identify history of TBI, PTSD, and/or suicide attempt. Findings suggested that a history of PTSD was associated with suicidal behavior among those with and without a history of TBI. Specifically, the odds of a suicide attempt for those with a history of PTSD were 2.8 times that of the odds for those without PTSD. Similarly, for those with both PTSD and TBI the likelihood of a suicide attempt was 3.3 times greater than for those with a TBI alone.

Recommendations for Clinical Practice

Findings from the presented studies suggest that continued research is needed to increase understanding regarding the complex relationship between TBI, PTSD, and suicidal behaviors. It is likely that factors associated with increased risk (e.g., history of risky behavior, executive dysfunction) vary by TBI severity (i.e., mild, moderate, severe) and are exacerbated by PTSD symptoms. Mild TBI versus moderate/severe TBI are distinct conditions. Knowledge regarding differences associated with TBI severity will allow clinicians to appropriately conceptualize the degree to which the injury sustained would be expected to impact functioning. Regardless of injury severity, the focus of treatment should be rehabilitation/ recovery oriented.

Based on the presented results, sufficient data exist to: 1) support screening for TBI among those with PTSD; 2) support screening for PTSD among those with TBI; and 3) consider PTSD and/or TBI as potential risk factors for suicidal behavior. For more recent Veterans, TBI screening procedures are in place; however, further work is required to identify psychometrically sound screening strategies for Veterans from previous cohorts. If a history of TBI is identified, clinicians are encouraged to evaluate for injury-related factors that may be contributing to increased risk. Those with moderate to severe injury often face challenges both at home and at work. Job loss and divorce are common. In addition, organic injury may contribute to increased impulsivity and aggression, and poor decisionmaking--all risk factors for suicidal behavior. Development of safety and treatment plans with these contributors in mind is recommended. For educational materials and information about current VISN 19 Mental Illness Research, Education and Clinical Center (MIRECC) research regarding TBI, PTSD, and suicide please visit www.mirecc. va.gov/visn19/.

References

1. Brenner, L.A. et al. "Suicide and Traumatic Brain Injury among Individuals Seeking VHA Services," Journal Head Trauma Rehabilitation 2011; 26(4):257-64.
2. Brenner, L.A. et al. "Post-traumatic Stress Disorder, Traumatic Brain Injury, and Suicide Attempt History among Veterans Receiving Mental Health Services," Suicide and Life-Threatening Behavior 2011; 41(4):416-23.