Violent Death Rates Increased After Traumatic Brain Injury

Bill (William) Yates, M.D.
Brain Post

July 30 / 2014

Anecdotal reports have linked traumatic brain injury with later violent death including death by suicide.

Few large epidemiological studies have been published on this association.

However, a recent Swedish population study published in JAMA Psychiatry provides valuable insight into this issue.

Seena Fazel and colleagues from the University of Oxford, University College London and the Karolinksa Institute examined a large database of over 200,000 patients with TBI.

Cases of TBI were identified from all Swedish persons born in or after 1954 who received a ICD diagnosis of TBI.  These diagnoses were assigned by physicians treating hospitalized or clinic patients.

TBI cases were then examined for cause of death using the Swedish National Cause-of-Death Register. Death rates for TBI were compared to two control groups in the period at least six months following TBI. One control group was an age and sex-matched general population group without a TBI diagnosis.

A second control group was comprised of siblings of the TBI group who themselves had not suffered a TBI. This type of control group is helpful in controlling for important sociodemographic variables.

The key findings from the study included:

• TBI cases had significantly higher rates of death during follow up with odds ratios estimates of 2.6 using sib controls and 3.2 using population controls
• Violent death causes were key contributors to increased mortality in TBI including (sib OR, population control OR)
• motor vehicle accidents (2.5, 3.2)
• non-motor vehicle accidents (3.4, 5.2)
• assault (2.7, 3.9)
• suicide (2.3, 3.3)

The research team examined potential mortality co-factors including pre-existing and post-TBI depression diagnosis, alcohol abuse and drug abuse. Additionally they examined effects of sex, TBI severity, brain imaging abnormalities and presence of concussion.

TBI cases had higher rates compared to controls for pre-existing any psychiatric diagnosis, depression, alcohol abuse and drug abuse.

TBI cases also had higher rates for a new diagnosis of any psychiatric diagnosis, depression, alcohol abuse and drug abuse.

In the TBI sample with premature mortality, 61% had a lifetime diagnosis of a psychiatric or substance abuse diagnosis.

Medical factors contributing to violent death including suicide were presence of a TBI-related brain imaging abnormality (edema, focal changes, hemorrhage), more severe TBI and presence of concussion.

This study confirms that TBI is an independent contributor to increased premature violent death including suicide. However, pre-existing psychiatric and substance abuse problems may contribute both to risk of TBI and risk of premature violent death. Additionally, the increased rate for developing a post-TBI depression, alcohol abuse or drug abuse may also contribute to violent death risk.

The highest rates for suicide were those with TBI and depression as well as for those with TBI and substance abuse.

The take home message here is pretty clear. Clinicians treating and following TBI populations need to monitor closely for co-occurring psychiatric illness, depression and substance abuse.

Close monitoring and intervention for these co-occurring disorders may reduce premature mortality due to suicide and other violent death in TBI.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below.

Photo of osprey is from the author's files.

Follow the author on Twitter WRY999.

Fazel S, Wolf A, Pillas D, Lichtenstein P, & Långström N (2014). Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study. JAMA psychiatry, 71 (3), 326-33 PMID: 24430827

See the original article:

Violent Death Rates Increased
After Traumatic Brain Injury

in

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