Suicide, Fatal Injuries, and Other Causes of Premature Mortality in Patients With Traumatic Brain Injury

Abstract

IMPORTANCE Longer-term mortality in individuals who have survived a traumatic brain injury (TBI) is not known. OBJECTIVES To examine the relationship between TBI and premature mortality, particularly by external causes, and determine the role of psychiatric comorbidity. DESIGN, SETTING, AND PATIENTS We studied all persons born in 1954 or later in Sweden who received inpatient and outpatient International Classification of Diseases-based diagnoses of TBI from 1969 to 2009 (n = 218 300). We compared mortality rates 6 months or more after TBI to general population controls matched on age and sex (n = 2 163 190) and to unaffected siblings of patients with TBI (n = 150 513). Furthermore, we specifically examined external causes of death (suicide, injury, or assault). We conducted sensitivity analyses to investigate whether mortality rates differed by sex, age at death, severity (including concussion), and different follow-up times after diagnosis. MAIN OUTCOMES AND MEASURES Adjusted odds ratios (AORs) of premature death by external causes in patients with TBI compared with general population controls. RESULTS Among those who survived 6 months after TBI, we found a 3-fold increased odds of mortality (AOR, 3.2; 95% CI, 3.0-3.4) compared with general population controls and an adjusted increased odds of mortality of 2.6 (95% CI, 2.3-2.8) compared with unaffected siblings. Risks of mortality from external causes were elevated, including for suicide (AOR, 3.3; 95% CI, 2.9-3.7), injuries (AOR, 4.3; 95% CI, 3.8-4.8), and assault (AOR, 3.9; 95% CI, 2.7-5.7). Among those with TBI, absolute rates of death were high in those with any psychiatric or substance abuse comorbidity (3.8% died prematurely) and those with solely substance abuse (6.2%) compared with those without comorbidity (0.5%). CONCLUSIONS AND RELEVANCE Traumatic brain injury is associated with substantially elevated risks of premature mortality, particularly for suicide, injuries, and assaults, even after adjustment for sociodemographic and familial factors. Current clinical guidelines may need revision to reduce mortality risks beyond the first few months after injury and address high rates of psychiatric comorbidity and substance abuse.

A critical review of chronic traumatic encephalopathy

“…TBI is also a risk factor for suicide. In a longitudinal epidemiological study of 218,300 individuals who sustained a TBI, the injury was independently related to increased risk for completed suicide, the risk was greater in those Page 37 of 82 A c c e p t e d M a n u s c r i p t 37 with moderate or severe TBIs compared to those with MTBIs, and those with depression or substance abuse were at the greatest risk (Fazel et al, 2014). In terms of absolute numbers, the rate of suicide was as follows: general population (0.03%), TBI and no psychiatric disorder (0.1%), TBI and a psychiatric disorder (1%), TBI and depression (1.5%), and TBI and substance abuse (1.6%).…”

Risk of suicide after a concussion

“…8,16 Severe head trauma resulting in admission to hospital has also been associated with an increased risk of suicide, whereas mild concussion in ambulatory adults is an uncertain risk factor. [17][18][19][20] The aim of this study was to determine whether concussion was associated with an increased long-term risk of suicide and, if so, whether the day of the concussion (weekend v. weekday) could be used to identify patients at further increased risk. The severity and mechanism of injury may differ by day of the week because recreational injuries are more common on weekends and occupational injuries are more common on weekdays.…”

Cranial vault trauma and selective mortality in medieval to early modern Denmark

“…That is much like today where people who suffer head trauma leading to brain injuries also have a higher risk of dying (34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45). Modern figures vary according to injury severity; where and when the data were collected; sample composition, especially the patient age distribution and inclusion criteria; and posttrauma study duration.…”

“…Modern figures vary according to injury severity; where and when the data were collected; sample composition, especially the patient age distribution and inclusion criteria; and posttrauma study duration. Nevertheless, today people with traumatic brain injuries experience roughly two to four times the risk of dying than uninjured people (37,38,(40)(41)(42)(43)(44)(45).…”