Wednesday, November 14, 2018

Concussion, mild TBI double suicide risk

Fralick M, Sy E, Hassan A, Burke MJ, Mostofsky E, Karsies T. Association of
Concussion With the Risk of Suicide: A Systematic Review and Meta-Analysis. JAMA
Neurol. 2018 Nov 12. doi: 10.1001/jamaneurol.2018.3487. [Epub ahead of print]

Concussion is the most common form of traumatic brain injury (TBI). While most patients fully recover within 1 week of injury, a subset of patients might be at a higher risk of suicide.

To assess the risk of suicide after concussion.

We performed a systematic search of Medline (PubMed), Embase, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS) from 1963 to May 1, 2017. We also searched Google Scholar and conference proceedings and contacted experts in the field to seek additional studies.

Studies that quantified the risk of suicide, suicide attempt, or suicidal ideation after a concussion and/or mild TBI were included. Studies that included children and adults, including military and nonmilitary personnel, were included. Two authors independently reviewed all titles and abstracts to determine study eligibility.

Study characteristics were extracted independently by 2 trained investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Study data were pooled using random-effects meta-analysis.

The primary exposure was concussion and/or mild TBI, and the primary outcome was suicide. Secondary outcomes were suicide attempt and suicidal ideation.

Data were extracted from 10 cohort studies (n = 713 706 individuals diagnosed and 6 236 010 individuals not diagnosed with concussion and/or mild TBI), 5 cross-sectional studies (n = 4420 individuals diagnosed and 11 275 individuals not diagnosed with concussion and/or mild TBI), and 2 case-control studies (n = 446 individuals diagnosed and 8267 individuals not diagnosed with concussion and/or mild TBI). Experiencing concussion and/or mild TBI was associated with a 2-fold higher risk of suicide (relative risk, 2.03 [95% CI, 1.47-2.80]; I2 = 96%; P < .001). In 2 studies that provided estimates with a median follow-up of approximately 4 years, 1664 of 333 118 individuals (0.50%) and 750 of 126 114 individuals (0.59%) diagnosed with concussion and/or mild TBI died by suicide. Concussion was also associated with a higher risk of suicide attempt and suicide ideation. The heightened risk of suicide outcomes after concussion was evident in studies with and without military personnel.

Experiencing concussion and/or mild TBI was associated with a higher risk of suicide. Future studies are needed to identify and develop strategies to decrease this risk.

Concussion, mild TBI double suicide risk
Source: JAMA Neurol
Curated by: Susan London
November 13, 2018

Suicide risk was twice as high for individuals who had experienced concussion and/or mild traumatic brain injury (TBI).

Why this matters

Roughly 4 million concussions occur each year in United States.
It is unclear whether elevated suicide risk after severe TBI extends to mild TBI.

Key results

Relative to unaffected counterparts, individuals who had experienced concussion and/or mild TBI had a doubling of suicide risk (relative risk, 2.03; P<.001).
2 studies with median follow-up ~3.6 years and ~4 years found incidence was 0.50% and 0.59%, respectively, after concussion/mild TBI.
Most studies found concussion/mild TBI was also associated with higher risk for:
Suicide attempt (odds or probability ratios, 1.22-19.1).
Suicide ideation (odds or probability ratios, 1.24-2.59).
Elevated risk for suicide after concussion/mild TBI was evident in studies:
With military personnel (relative risk, 1.46; P<.01).
Without military personnel (relative risk, 2.36; P<.01).

Expert comment

In an editorial, Donald A. Redelmeier, MD, MSHR, and Junaid A. Bhatti, MMB, PhD, write, "Neurologists need to be aware of the suicide risks and consider screening patients with a concussion for additional factors, including substance use, mood disorders, and past suicide attempts. Psychiatrists should also consider a concussion history when judging an individual patient’s suicide risk."

Study design

Meta-analysis of 17 studies:
10 cohort (713,706 with, 6,236,010 without concussion/mild TBI),
5 cross-sectional (4420 with, 11,275 without concussion/mild TBI), and
2 case-control (446 with, 8267 without concussion/TBI).

Main outcome: suicide.
Funding: None disclosed.

Absolute risks seldom reported.
Most studies retrospective, lacked active comparator.

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