Association between traumatic brain injury and risk of suicide

Trine Madsen; Annette Erlangsen; Sonja Orlovska; Ramy Mofaddy; Merete Nordentoft; Michael E. Benros

doi:10.1001/jama.2018.10211

Association between traumatic brain injury and risk of suicide

Trine Madsen^*, Annette Erlangsen, Sonja Orlovska, Ramy Mofaddy, Merete Nordentoft, Michael E. Benros

^*Corresponding author for this work

Department of Clinical Medicine

54 Citations (Scopus)

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.

Original language	English
Journal	JAMA - Journal of the American Medical Association
Volume	320
Issue number	6
Pages (from-to)	580-588
Number of pages	9
ISSN	0098-7484
DOIs	https://doi.org/10.1001/jama.2018.10211
Publication status	Published - 2018

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@article{527e75a9e3a041dcb744c4c16699714c,

title = "Association between traumatic brain injury and risk of suicide",

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.",

author = "Trine Madsen and Annette Erlangsen and Sonja Orlovska and Ramy Mofaddy and Merete Nordentoft and Benros, {Michael E.}",

year = "2018",

doi = "10.1001/jama.2018.10211",

language = "English",

volume = "320",

pages = "580--588",

journal = "J A M A: The Journal of the American Medical Association",

issn = "0098-7484",

publisher = "American Medical Association",

number = "6",

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TY - JOUR

T1 - Association between traumatic brain injury and risk of suicide

AU - Madsen, Trine

AU - Erlangsen, Annette

AU - Orlovska, Sonja

AU - Mofaddy, Ramy

AU - Nordentoft, Merete

AU - Benros, Michael E.

PY - 2018

Y1 - 2018

N2 - 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.

AB - 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.

U2 - 10.1001/jama.2018.10211

DO - 10.1001/jama.2018.10211

M3 - Journal article

C2 - 30120477

AN - SCOPUS:85051651163

SN - 0098-7484

VL - 320

SP - 580

EP - 588

JO - J A M A: The Journal of the American Medical Association

JF - J A M A: The Journal of the American Medical Association

IS - 6

ER -

Association between traumatic brain injury and risk of suicide

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