Running Head: COMPLICATIONS FOLLOWING TBI

The Incidence of Mental Illness and Suicide in Patients with Traumatic Brain Injury

Jessica Crish, Eleni Skiffey, Alexis Stutz, Sarah Wiscott

04/07/2021

NURS 3749: Nursing Research

Dr. Valerie O’Dell

Running Head: COMPLICATIONS FOLLOWING TBI 2

The purpose of this research was to look at the relationship between mental illness and suicide in

patients who have had traumatic brain injuries versus those with no occurrence of traumatic brain

injury. The information gathered was on mental health, predictors of suicide, occurrence and risk

factors of TBI related to suicide, and suicide post-TBI. Research shows there is significant evi-

dence supporting that there is a higher risk for suicide among people who suffered from a TBI.

There is no specific timespan of when patients begin to develop these mental health disorders or

how long they can last. Also, there is sufficient evidence as to which race and gender is most at

risk. Overall, the research provided showed that patients who suffered from TBI are at risk for

developing mental health issues, which could then lead to suicide.

The Incidence of Mental Illness and Suicide in Patients with Traumatic Brain Injury
Running Head: COMPLICATIONS FOLLOWING TBI 3

Traumatic Brain Injury related emergency department visits, hospitalizations, and deaths

have been on the rise in recent years. Medical professionals are becoming more aware of the in-

creasing long-term effects TBI can have on a person. These patients require an intense past his-

tory, close monitoring, and frequent mental health exams post-injury. Many short and long-term

studies have been done to provide more information about the risk factors for TBI as well as

post-injury adverse effects. Mental illness, suicide ideation, and suicide attempts are common re-

actions to TBI. If this can be proven undisputedly, this will assure that TBI patients receive the

proper care they need to assure quality of life and safety. Due to this correlation, the following

question was researched: What is the incidence of mental illness and suicide in adult patients

who have had multiple Traumatic Brain Injury as opposed to those with no occurrence of Trau-

matic Brain Injury?

Literature Review

Introduction

The incidence of Traumatic Brain Injury and its correlation with mental illness and sui-

cide is a relationship that has been extensively studied. According to the Centers for Disease

Control and Prevention (CDC) (2020), a Traumatic Brain Injury is defined as “a disruption in the

normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrat-

ing head injury” (p. 1). TBI can range from mild to severe and affect different areas of the skull

and brain. Data from a 2014 study estimates there were approximately 2.87 million TBI-related

hospital visits that year (p. 3). Effects from an injury like this can last weeks to years after the in-

cident. In this review, accredited research sources were gathered from databases like CINAHL

Database, MEDLINE, and Proquest Nursing & Allied Health Database. Throughout this paper

six studies regarding TBI, mental illness, and suicide are reviewed. Demographics of TBI, occur-
Running Head: COMPLICATIONS FOLLOWING TBI 4

rences of TBI-related suicide, suicide and mental illness predictors after a TBI, suicide ideation

post-injury, and mental illness post-injury will be discussed.

Demographics

Traumatic Brain Injury is the leading cause of death and lifelong disability in the United

States. Demographics of people who sustained a TBI and deaths have been studied for many

years. According to the CDC, each year an estimated 1.5 million Americans sustain a TBI. As a

consequence of these injuries, 50,000 people die (Thurman et al., 2016). While any age group is

able to suffer a head injury, the risk is greatest among adolescents, young adults, and people

older than 75. This is due to motor vehicle accidents, suicidal behavior, and the elderly being

susceptible to falls. The risk of having a TBI among males is twice the risk among females. Re-

searchers determined that lower levels of education, African-Americans, and anyone with a his-

tory of mental illness had an increased risk (McMakin, 2019).

Occurrences and risk factors of TBI related to suicide

There is a strong relationship between the occurrence of suicide after acquiring a trau-

matic brain injury. Research indicates the correlation between the occurrence of severe TBI ver-

sus the occurrence of a mild TBI and the suicide rates that follow. A study was conducted in

which patients in Danish hospitals who had mild to severe traumatic brain injuries were observed

and followed for 14 years after their injury. The study concluded that those sustaining more se-

vere injuries showed more difficulty in social capabilities and thinking processes in conjunction

with increased suicidal thoughts. This further contributed to low self-esteem, depression, and at-

tempts of suicide (Teasdale, 2001, p.2). Another risk factor that increases the chances of suicidal

ideations after the occurrence of a TBI is the presence of a psychological disorder prior to the in-
Running Head: COMPLICATIONS FOLLOWING TBI 5

jury. A study conducted by (Fisher, 2020) was completed on multiple populations of patients

who had PTSD and then after acquired a traumatic brain injury and found the following:

The prevalence of lifetime suicidal ideations, current suicidal ideations, and lifetime sui-

cidal behaviors for individuals with PTSD only was 29%, 11%, and 11%, respectively.

Prevalence of lifetime suicidal ideations, current suicidal ideations, and lifetime suicidal

behaviors for individuals with a TBI only was 14%, 1%, and 2%, respectively.

Prevalence of lifetime suicidal ideations, current suicidal ideations, and lifetime suicidal

behaviors for individuals with PTSD and TBI was 33%, 13%, and 8%, respectively. (p.

2)

Overall the risk of suicide for patients with PTSD and a history of traumatic brain injury is

slightly higher than the risk with just TBI or PSTD alone. The occurrence of suicide after a TBI

can also be linked to severity and time spent in the healthcare setting. The study calculated this

by examining patients who spent more time in the hospital for their injuries. Research (Teasdale,

2001) concluded that there was a tendency among patients with cerebral contusions or traumatic

intracranial hemorrhages for suicide risk to increase with the duration of their hospital stay. The

study analyzed patients of both genders in order to determine the occurrence of suicide for fe-

males versus males. In all diagnosis groups, the ratios were higher for males than for females,

and lower for patients injured before the age of 21 or after the age of 60 (p. 2). Overall this study

concluded that those at highest risk for suicide after a TBI are those of male gender between the

age of 21 and 60 and those who have acquired a more severe TBI. Another study conducted by

The Division of Injury Prevention, National Center for Injury Prevention and Control analyzed

the prevalence of death related to TBI in all races, ethnicities, and genders. It determined that

those most at risk were non-hispanic whites, accounting for a 32% increase in TBI-related sui-
Running Head: COMPLICATIONS FOLLOWING TBI 6

cide deaths. It also concluded that TBI-related deaths were significantly higher among males and

persons who were American Indians and Alaskan Natives than among all other groups across all

years (Daugherty et al., 2019, p.1). Overall, the findings of these studies concluded that suicide

death resulting from traumatic brain injury is seen more frequently in males. This information is

crucial and can impact the world of health in regard to patient care from a physical and psycho-

logical standpoint.

Predictors of Suicide After a TBI

After sustaining a traumatic brain injury the chances of dying due to suicide dramatically

increases, especially within the first year following the injury. Many studies have been done to

observe the correlation between suicide following a TBI and determining what factors make a

person more susceptible to committing suicide. In an Australian study including outpatients who

had a history of suffering from TBI, the majority had no pre-injury history of suicide. Suicide at-

tempts were reported by 17.4% (30 of 172) of the sample over a 5-year period (Mackelprang et

al., 2014). Also, in relation to the patients attempting suicide, many of them had multiple at-

tempts. Although this study favored the theory behind TBI increasing the chances of suicide

amongst people who have suffered from them, some studies believe there is not enough data to

determine if that theory holds true. In an effort to eliminate doubt between whether or not there is

a true correlation and to prove that many factors can increase a person's chance of having suicide

ideation, an extensive study consisting of 559 participants that completed at least one interview

was done. This study emphasized the importance of different predictors and factors that can in-

crease a persons chance of committing suicide. Suicide ideation throughout the study ranged

from 7% to 10% with it being the highest during the first two to eight months post-injury. This

study concluded that the following factors of having Medicaid insurance (relative to commercial
Running Head: COMPLICATIONS FOLLOWING TBI 7

or private), having a higher score on the first PHQ-8 after injury, bipolar disorder or other anxi-

ety disorder, and prior suicide attempt(s) or psychiatric hospitalization (Mackelprang et al.,

2014) were significantly associated with having suicidal ideation. Overall, the strongest predictor

that had the highest correlation between a TBI and having suicidal ideation during the first year

post-injury was the first PHQ-8 score. Other compelling predictors involving multiple variables

that present there is a strong relationship between suicidal ideation following a TBI during the

first year is a history of prior suicide attempts, a history of bipolar disorder, having less than a

high school education, and the interaction between PHQ-8 score and pre-injury suicide attempt

(Mackelprang et al., 2014). As a result from the 559 participants, 421 people displayed negative

characteristics and predictors for suicidal ideation and 138 people displayed positive characteris-

tics and predictors of suicidal ideation.

Suicide Post-TBI

Suicide as a reaction to one or multiple TBI has been a controversial area of study. Due to

media outlets emphasizing the importance of care and monitoring after TBI, more data has be-

come available. Hospitalizations and emergency department visits related to TBI have increased

over the past decade. Theories have proposed that pre-existing mental illness alone precedes sui-

cide ideations. However, according to Bryson (2017), TBI was robustly associated with suicide

even when pre-existing suicide risk factors were taken into account. Suicidal behaviors require

the “desire to die by suicide” as well as the wish to overcome the need to live (p.400). Groups

with no history of TBI had increasingly lower suicidal risk factors than post-TBI groups. A

small scale study indicated that suicide ideation was increased among TBI patients as a result of

post-injury emotional disturbances ( Simpson, 2002). Risk factors for suicide prior to TBI did

not have any relationship to levels of suicide ideation post-TBI. Emotional disturbance brought
Running Head: COMPLICATIONS FOLLOWING TBI 8

on by the traumatic injury is the greatest factor in suicide risk. Aspects of risk for suicide include

“hopelessness, suicide ideation, and suicide attempts” (p.687). There is a relationship between

suffering from TBI and showing signs of increased risk for suicide and increased suicide at-

tempts. There is no concluded risk period after a sustained brain injury. It is suggested that sui-

cide risk is constant for 15 years post-injury ( Teasdale, 2001). The concept that death by suicide

is unreported due to “social and religious disapprobation of suicide” (p.430) is an issue in regard

to this study. Deaths can be ruled as accidental and therefore not reported as suicide. Studies also

speculate that TBI can be the result of a suicide attempt. Regardless of these possible limitations,

large and small scale studies have concluded that there is a relationship between TBI and suicide

ideation as well as suicide attempts. There is a great effort to explain the correlation between TBI

and suicidal behaviors. In 2002, Simpson’s study attempted to explain why TBI and suicide

ideation go together:

They [TBI] include the suddenness of the onset of a disability in previously healthy

young males, the often global negative effects of disability on the person’s life, the diffi-

cult and painful process of grieving the loss of a valued pre-injury lifestyle, a growing re-

alization of the level of effort involved in maintaining levels of functioning as well as re-

duced neuropsychological resources to cope with the stresses of everyday living… (p.

688)

This attributes changes in everyday life to emotional disturbances which lead to suicidal thoughts

and behaviors.

Mental Health Disorders

Traumatic brain injuries cause individuals to have different emotions. Follow-up care af-

ter a severe injury to the head is extremely important due to the fact that individuals may experi-
Running Head: COMPLICATIONS FOLLOWING TBI 9

ence mental health symptoms up to six months after the impact. Patients that have a TBI are

likely to develop post traumatic stress disorder (PTSD) or major depressive disorder. Individuals

with PTSD have been shown to have a higher suicide rate due to trauma, anger, and poor control

of impulses. Furthermore, people who have major depressive disorder also have an increased risk

for suicide because of poor coping mechanisms, such as hiding their feelings.

A study done at the University of California San Diego investigated mental health outcomes in

1,155 people who had experienced a mild TBI and were treated at the emergency room. At three,

six, and 12 months after injury, study participants completed questionnaires related to various

mental health disorders. The researchers had a comparison group who were surveyed regarding

their orthopedic traumatic injuries, such as broken legs, but did not have any head injuries. The

results showed that at three and six months following the injury, people who experienced a mild

traumatic brain injury were more likely than orthopedic trauma patients to report symptoms of

PTSD and/or major depressive disorder. For example, three months after injury, 20 percent of

TBI patients reported mental health symptoms compared to 8.7 percent of orthopedic trauma pa-

tients. At six months after injury, 21.2 percent who had experienced head trauma and 12.1 per-

cent of orthopedic trauma patients reported symptoms (McMakin, 2019). Due to the research re-

sults, it is shown that patients who experienced a TBI are more likely to show mental health

symptoms.

Conclusion

The dispute on whether there is any correlation between mental illnesses and suicidal

ideation with the incidence of a traumatic brain injury is still ongoing. Although, numerous stud-

ies have made a valiant effort in proving there is, in fact, a strong correlation between them.

Many of the above studies emphasized that after a TBI the chances of the person having suicidal
Running Head: COMPLICATIONS FOLLOWING TBI 10

ideation or committing the act of suicide itself to be strong. Also, the studies recognized the im-

portance of certain predictors that predispose certain demographics of people more so than others

to having suicidal ideations. Furthermore, other studies demonstrated that people with mental ill-

nesses who have suffered from a TBI are also at a greater risk for experiencing suicidal ideations

or committing suicide. Under these circumstances, it is vital that more studies are done to prove

that there is a strong relationship between mental illnesses and suicidal ideations following the

occurrence of TBI so people have the help and resources available to them to prevent suicide.

References

Bryson, C. N., Cramer, R. J., & Schmidt, A. T. (2017). Traumatic brain injury and lifetime
suicidality: Applying the interpersonal-psychological theory perspective. Death Studies,
41(7), 399–405. https://doi-org.eps.cc.ysu.edu/10.1080/07481187.2017.1320340

Daugherty, J. (2019, November 22). Traumatic Brain Injury-Related Deaths by Race/Ethnicity,

Running Head: COMPLICATIONS FOLLOWING TBI 11

Sex, Intent, and Mechanism of Injury - United States, 2000–2017. PubMed. https://
pubmed.ncbi.nlm.nih.gov/31751321/

Mackelprang, J. L., Bombardier, C. H., Fann, J. R., Temkin, N. R., Barber, J. K., & Dikmen, S.
S. (2014). Rates and Predictors of Suicidal Ideation During the First Year After Trau-
matic Brain Injury. American Journal of Public Health, 104(7), e100–e107. https://doi-
org.eps.cc.ysu.edu/10.2105/AJPH.2013.301794

McMakin, B. (2019). Mental Health Disorders Common Following Mild Head Injury. National

Institutes of Health, U.S. Department of Health and Human Services. www.nih.gov/

news-events/news-releases/mental-health-disorders-common-following-mild-head-injury.

Simpson, G., & Tate, R. (2002). Suicidality after traumatic brain injury: Demographic, injury
and clinical correlates. Psychological Medicine, 32(4), 687-97.
doi:http://dx.doi.org.eps.cc.ysu.edu/10.1017/S0033291702005561

TBI: Get the Facts | Concussion | Traumatic Brain Injury | CDC Injury Center. (2020). Centers
for Disease Control and Prevention (CDC). https://www.cdc.gov/traumaticbraininjury/
get_the_facts.html

Teasdale, T. W., & Engberg, A. W. (2001). Suicide after traumatic brain injury: a population
study. Journal of neurology, neurosurgery, and psychiatry, 71(4), 436–440. https://
doi.org/10.1136/jnnp.71.4.436

Thurman, D., Alverson, C., Browne, D., Dunn, K. A., Guerrero, J., Johnson, R., Johnson, V.,

Langlois, J., Pilkey, D., Sniezek, J. E., Toal, S. (2016). Report to Congress: Traumatic
Brain Injury in the United States. Centers for Disease Control and Prevention (CDC).
www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html#:~:text=Each
%20year%20an%20estimated%201.5,50%2C000%20people%20die.