Original Investigation |

Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel

Craig J. Bryan, PsyD, ABPP1; Tracy A. Clemans, PsyD2
[+] Author Affiliations
1National Center for Veterans Studies, Salt Lake City, Utah
2VA VISN 19 Mental Illness Research Education Clinical Center, Denver, Colorado
JAMA Psychiatry. 2013;70(7):686-691. doi:10.1001/jamapsychiatry.2013.1093.
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Importance  Traumatic brain injury (TBI) is believed to be one factor contributing to rising suicide rates among military personnel and veterans. This study investigated the association of cumulative TBIs with suicide risk in a clinical sample of deployed military personnel referred for a TBI evaluation.

Objective  To determine whether suicide risk is more frequent and heightened among military personnel with multiple lifetime TBIs than among those with no TBIs or a single TBI.

Design  Patients completed standardized self-report measures of depression, posttraumatic stress disorder (PTSD), and suicidal thoughts and behaviors; clinical interview; and physical examination. Group comparisons of symptom scores according to number of lifetime TBIs were made, and generalized regression analyses were used to determine the association of cumulative TBIs with suicide risk.

Participants  Patients included 161 military personnel referred for evaluation and treatment of suspected head injury at a military hospital’s TBI clinic in Iraq.

Main Outcomes and Measures  Behavioral Health Measure depression subscale, PTSD Checklist–Military Version, concussion symptoms, and Suicide Behaviors Questionnaire–Revised.

Results  Depression, PTSD, and TBI symptom severity significantly increased with the number of TBIs. An increased incidence of lifetime suicidal thoughts or behaviors was associated with the number of TBIs (no TBIs, 0%; single TBI, 6.9%; and multiple TBIs, 21.7%; P = .009), as was suicidal ideation within the past year (0%, 3.4%, and 12.0%, respectively; P = .04). The number of TBIs was associated with greater suicide risk (β [SE] = .214 [.098]; P = .03) when the effects of depression, PTSD, and TBI symptom severity were controlled for. A significant interaction between depression and cumulative TBIs was also found (β  = .580 [.283]; P = .04).

Conclusions and Relevance  Suicide risk is higher among military personnel with more lifetime TBIs, even after controlling for clinical symptom severity. Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide.

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Figure 1.
Traumatic Brain Injury (TBI) Groups

Mean symptom scores with 95% CIs by TBI group. For all scales, pairwise comparisons with Bonferroni corrections revealed significant differences in scores (P < .05) between the no-TBI and single-TBI groups and between the single- and multiple-TBI groups. PTSD indicates posttraumatic stress disorder.

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Figure 2.
Depression, Suicide Risk, and Traumatic Brain Injury (TBI)

Suicide risk as a function of the interaction between depression severity and TBI group. SBQ-R indicates Suicidal Behaviors Questionnaire–Revised.

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