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Rates and Predictors of Suicidal Ideation During the First
Year After Traumatic Brain Injury
Jessica L. Mackelprang, PhD, Charles H. Bombardier, PhD, Jesse R. Fann, MD, MPH, Nancy R. Temkin, PhD,
Jason K. Barber, MS, and Sureyya S. Dikmen, PhD
Suicide is a major public health problem among
the 1.7 million people who sustain traumatic
brain injury (TBI) each year in the United
States.1 People with a history of TBI in both
civilian and military populations are 1.55 to
4.05 times more likely to die by suicide than
the general population.2—5 In a study of
Australian outpatients with a history of TBI,
the majority of whom had no preinjury history
of suicide attempts, suicide attempts were
reported by 17.4% (30 of 172) of the sample
over a 5-year period.6 Nearly half of the
individuals who attempted suicide had made
multiple attempts.6,7 The Centers for Disease
Control and Prevention recently called for
investigations of individual-level risk and
protective factors for self-directed violence
among people with TBI as an important com-
ponent of improving long-term outcomes.8
Rates of suicidal ideation (SI) after TB
I
have been found to exceed 20% in some
studies6,9—14; however, in a recent systematic
review of SI and behavior after TBI, Bahraini
et al. highlighted the paucity of research in
this area.15 They concluded that additional
research is needed to determine the prevalence
of SI and behavior after brain injury, as well as
to ascertain patient-level factors that may be
associated with increased suicide risk. Studies
examining whether injury severity predicts
post-TBI suicidality have yielded inconclusive
findings.6,13,16,17 In perhaps the most thorough
study on this topic to date, Tsaousides et al.12
surveyed 356 community-dwelling adults with
a self-reported history of TBI and found that
preinjury substance abuse was the only corre-
late of current SI. Risk factors for SI after TBI
have been underinvestigated. Research in this
area has been limited by reliance on retro-
spective reporting and self-reported history of
TBI,12,18—20 with only a few studies including
objective indicators of TBI severity.6 Most
studies have involved cross-sectional designs
and have included participants whose time
since injury varied from several months to
many years.12,21 Finally, because most existing
studies have included relatively small, poten-
tially biased samples21 recruited from outpa-
tient clinics or TBI survivor programs,6,7,12 they
may not be representative of the population of
people who sustain TBI.
Given these gaps in the existing literature,
our objectives were (1) to investigate rates of SI
during the first year after complicated mild to
severe TBI in a representative sample of adults
who had been admitted to a level I trauma
center and (2) to investigate whether demo-
graphic characteristics, preinjury psychiatric
history, or injury-related factors predicted SI.
METHODS
This study was part of the recruitment phase
of a clinical trial investigating the efficacy of the
antidepressant sertraline for major depressive
disorder after TBI.22 Eligibility criteria were as
follows:
1. admitted to Harborview Medical Center,
a level 1 trauma center in Seattle,
Washington, between June 2001 and
March 2005;
2. at least 18 years old;
3. English speaking;
4. a resident of King, Pierce, Kitsap, Jefferson,
Mason, Thurston, or Snohomish counties;
and
5. radiological or clinical evidence of acute
TBI (i.e., Glasgow Coma Scale [GCS]
score <13 within the first 24 hours after
admission, provided blood alcohol level
was < 200 mg/dL).
For participants whose GCS score at the time
of admission was 13 to 15, radiological evi-
dence was necessary for categorization of
complicated mild TBI. Participants with un-
complicated mild TBIs (GCS sore of 13—1
5
without radiological abnormality) were ex-
cluded. Other exclusion criteria were current
homelessness, incarceration, lack of contact
information, or diagnosis of schizophrenia.
The study team reviewed automatic queries
of electronic medical records and TBI consul-
tation lists on a daily basis to identify eligible
inpatients. Research staff obtained consent
Objectives. We examined rates of suicidal ideation (SI) after traumatic brain
injury (TBI) and investigated whether demographic characteristics, preinjury psy-
chiatric history, or injury-related factors predicted SI during the first year after injury.
Methods. We followed a cohort of 559 adult patients who were admitted to
Harborview Medical Center in Seattle, Washington, with a complicated mild to
severe TBI between June 2001 and March 2005. Participants completed struc-
tured telephone interviews during months 1 through 6, 8, 10, and 12 after injury.
We assessed SI using item 9 of the Patient Health Questionnaire (PHQ-9).
Results. Twenty-five percent of the sample reported SI during 1 or more
assessment points. The strongest predictor of SI was the first PHQ-8 score
(i.e., PHQ-9 with item 9 excluded) after injury. Other significant multivariate
predictors included a history of a prior suicide attempt, a history of bipolar
disorder, and having less than a high school education.
Conclusions. Rates of SI among individuals who have sustained a TBI exceed
those found among the general population. Increased knowledge of risk factors
for SI may assist health care providers in identifying patients who may be
vulnerable to SI after TBI. (Am J Public Health. 2014;104:e100–e107. doi:10.2105/
AJPH.2013.301794)
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from potential participants, who were fully
oriented during their admission prior to dis-
charge. Legal next of kin provided assent to
follow-up for patients who were disoriented at
discharge. Patients who were unable to be
approached during the course of their hospital
stay were contacted after discharge by tele-
phone or via a letter from the attending
neurosurgeon. We followed prospective par-
ticipants who were not oriented at discharge
for 1 year postinjury or until they were ori-
ented and able to consent to participate or to
decline. Prior to consent, all patients completed
a standardized orientation test.23
Measures
Baseline assessment. The study team
extracted medical, radiological, and other
injury-related data (e.g., toxicology reports)
from patients’ electronic medical records and
the Harborview Trauma Registry. The inten-
tionality of the TBI (i.e., unintentional, self-
inflicted, inflicted by someone else) was docu-
mented for 98% of the sample. Demographic
information obtained from those sources was
supplemented by participant interviews, con-
ducted via telephone by trained research staff.
The initial assessment consisted of a structured
interview to assess preinjury psychiatric and
substance use history, as well as prior mental
health treatment. We obtained participants’
history of suicidal behavior, including history
of suicide attempts, number of attempts, date of
most recent attempt, and age at first attempt.
We assessed lifetime history of psychiatric
disorders by inquiring whether participants
had ever been diagnosed with or treated for
any of the following conditions: clinical de-
pression or major depression; bipolar disorder
or manic depression; posttraumatic stress dis-
order; or generalized anxiety disorder, obses-
sive compulsive disorder, panic disorder, or
any phobia. We used the CAGE (cut down,
annoyed, guilty, eye opener) screening tool24 to
assess lifetime history of alcohol dependence.
We defined alcohol intoxication as a blood
alcohol level greater than 79 milligrams per
deciliter, and drug abuse as having a positive
toxicology screen (available on 80% of the
sample) for cocaine or amphetamine upon
admission.
Follow-up assessments. The study team
conducted structured telephone interviews
monthly from months 1 through 6 and bi-
monthly during months 8, 10, and 12.
Follow-up telephone interviews assessed SI;
symptoms of depression, anxiety, mental health
treatment; and other aspects of adjustment
after TBI (e.g., return to employment). We
designed the baseline and follow-up interview
protocols for the purpose of this study, al-
though some components were derived from
previously validated measures. For instance,
we administered at each time point the Patient
Health Questionnaire (PHQ-9),25 a self-report
measure that queries how often in the last 2
weeks respondents have been bothered by the
9 core symptoms of major depressive disorder
(per the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text
Revision26). The PHQ-9 has demonstrated good
psychometric properties among individuals
with TBI.27 We used an abbreviated version of
the PHQ-9, the PHQ-8 (which excludes item 9),
to track depressive symptoms independent of
SI.28,29 We monitored SI using item 9 of the
PHQ-9 (“Thoughts that you would be better off
dead, or of hurting yourself”). The PHQ-9 asks
about the preceding 2 weeks, and responses
are rated on a 4-point Likert scale (“not at all,”
“several days,” “more than half of days,”
“nearly every day”). We utilized additional
modules from the PHQ to assess symptoms of
anxiety.30 When a participant reported SI with
plan or intent at any assessment point, the
study team contacted one of the investigators
(C. H. B. or J. R. F.) immediately, and the par-
ticipant was referred for further evaluation or
treatment, as appropriate.
Statistical Analyses
We classified participants as SI positive if
they reported SI (i.e., item 9 of PHQ-9 was > 0)
at any assessment point and SI negative if they
never reported SI. We estimated prevalence
rates as the proportion of participants inter-
viewed at a given assessment point who
reported SI, regardless of whether it was the
first time, a continuation, or a recurrence. We
calculated cumulative postinjury prevalence as
the proportion of participants who had ever
reported SI since their injury up to that point.
We calculated postinjury incidence as the pro-
portion of participants who reported SI for the
first time since their injury at a given assess-
ment point. First, we used logistic regression to
examine bivariate relationships between SI and
all demographic, preinjury, and injury-related
variables of interest using LogXact version
4.1 (Cytel Software Corp, Cambridge, MA).
We then implemented a forward stepwise
regression procedure to identify independent
predictors of SI during the study period. We
created 2 models. The first model included
variables generally available in a standard
medical record review that were significant
in the bivariate models. Race/ethnicity,
marital status, and cause of injury were also
included. The second model additionally
considered all other variables that were
significant in the bivariate models. Both
models considered total number of inter-
views completed.
RESULTS
During the study period, we identified 108
0
eligible patients, 559 of whom consented to
participate in the study and completed at least
1 interview. Details about participants who
were not enrolled are provided elsewhere.22
Participants were younger (mean age = 42.5
years [SD = 17.9] vs 46.8 years [SD = 21.5]),
more likely to have completed high school
(89% vs 84%), and less likely to have
Medicare insurance (16% vs 25%) than
patients who were not recruited into the
study. Recruited versus nonrecruited groups
did not differ with regard to gender, race/
ethnicity, marital status, cause of injury,
TBI severity, other injury severity, blood
alcohol level, toxicology results, or length of
hospital stay.
The recruited sample was composed pre-
dominantly of non-Hispanic White (86%)
males (71.6%), and most had sustained their
TBI as a result of a vehicular collision (41%;
Tables 1 and 2). Approximately half (52%) of
the brain injuries were categorized as compli-
cated mild (i.e., GCS score of 13—15 with
radiological evidence of acute TBI). Thirty
percent of participants had a positive blood
alcohol level on admission to the hospital.
Toxicology screening indicated that 7% of the
sample used cocaine and 6% used metham-
phetamine around the time of their injury.
Twice as many SI-positive participants
reported receiving mental health treatment
at the time of injury (47% vs 23%). Fewer
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interviews took place during month 1 (n =
289) than at any other assessment point, as
many participants had not yet become eligi-
ble (e.g., pending consent because they were
still not oriented). Participants who were SI
positive completed significantly fewer inter-
views than those who were SI negative (5.6
vs 6.1; P = .04), although participants con-
tinued to be interviewed regardless of their
ideation status.
Rates of Suicidal Ideation and History of
Suicidal Behavior
During the first year after injury, 25% of the
sample reported SI at 1 or more assessment
points. Point prevalence of SI ranged from 7%
to 10% at each assessment point (Figure 1).
Ideation was highest (10%) during months 2
and 8. Sixty percent of those who were SI
positive screened positive during 1 interview
only, whereas 22% reported SI at 3 or more
assessment points. Fifty-three percent of pa-
tients who reported suicidality during their first
year after injury also reported probable de-
pression (PHQ-8 score ‡ 10) at the time of their
first assessment. According to their first PHQ-9
after injury, most SI-positive participants
reported having thoughts that they would be
better off dead or of hurting themselves on
“several days” (37%), but a portion reported
those feelings “more than half the days” (7%)
or “nearly every day” (7%) in the prior 2
weeks.
Concerning prior history of suicidal behav-
ior, 12% of the sample reported a history of 1
or more suicide attempts prior to their TBI
(Table 3). The mean number of prior suicide
attempts was similar for the SI-positive (1.7
[SD = 0.8]) and SI-negative (1.5 [SD = 0.6])
groups. Seven percent of participants who
reported a prior suicide attempt indicated that
they made 5 or more attempts. Relative to
SI-negative participants, SI-positive participants
reported being older the first time they
attempted suicide, (median age = 28 years
[interquartile range = 16—42] and 18 years
[interquartile range = 15—23], respectively;
P = .04). Those with a history of a suicide attempt
were nearly 5 times more likely to report SI
after injury than participants who denied a his-
tory of a suicide attempt (odds ratio = 4.81;
95% confidence interval = 2.83, 8.17). Eight
individuals (1.4%) incurred their TBI as a re-
sult of self-inflicted injury. Of those, half
reported SI during the study period.
Predictors of Suicidal Ideation
On the basis of bivariate relationships, the
following factors were significantly associated
with SI: having Medicaid insurance (relative to
commercial or private); having a higher score
on the first PHQ-8 after injury; a history of
depression, bipolar disorder, or other anxiety
disorder; and prior suicide attempt(s) or psy-
chiatric hospitalization. Older age and retired
status were associated with SI-negative status.
There was a nonsignificant trend (P = .07) for
females to be more likely to report SI. We
created 2 stepwise regression models. In the
first model, which included variables that are
available in a standard medical record review,
being female, having less than a high school
education, and having Medicaid were signifi-
cant predictors of SI in the year after injury
TABLE 1—Demographic Characteristics of the Study Sample, by Presence or Absence of
Postinjury Suicidal Ideation (SI): Seattle, WA,
June
2001–March 2005
Variable
SI Negative
(n = 421),
No. (%)
SI Positive
(n = 138),
No. (%) SI Positive, %
a
OR (95% CI)
Age*
18–29 133 (32) 42 (30) 24 2.31 (1.12, 5.10)
30–44 105 (25) 44 (32) 30 3.06 (1.48, 6.77)
45–59 95 (23) 40 (29) 30 3.07 (1.47, 6.87)
‡ 60 (Ref) 88 (21) 12 (9) 12 1.00
Gender
Male (Ref) 310 (74) 90 (65) 23 1.00
Female 111 (26) 48 (35) 30 1.49 (0.96, 2.29)
Race/ethnicity
Non-Hispanic White (Ref) 363 (87) 114 (84) 24 1.00
Hispanic 17 (4) 7 (5) 29 1.31 (0.45, 3.43)
Non-Hispanic African American 21 (5) 8 (6) 28 1.21 (0.45, 2.94)
Asian/Pacific Islander 12 (3) 5 (4) 29 1.33 (0.36, 4.15)
Other 6 (1) 2 (1) 25 1.06 (0.10, 6.04)
Education*
< high school 34 (8) 24 (17) 41 2.38 (1.29, 4.33)
‡ high school (Ref) 385 (92) 114 (83) 23 1.00
Marital status
Married (Ref) 164 (39) 47 (34) 22 1.00
Never married 175 (42) 54 (39) 24 1.08 (0.67, 1.72)
Divorced, separated, or widowed 82 (19) 37 (27) 31 1.57 (0.92, 2.69)
Preinjury employment status
Working full-time (Ref) 172 (50) 71 (58) 29 1.00
Working part-time 56 (16) 12 (10) 18 0.52 (0.24, 1.06)
Unemployed 38 (11) 18 (15) 32 1.15 (0.58, 2.22)
Retired 54 (16) 7 (6) 11 0.32 (0.12, 0.74)
Other
b
26 (8) 15 (12) 37 1.40 (0.65, 2.93)
Insurance*
Commercial or private (Ref) 245 (58) 71 (51) 22 1.00
Medicaid 100 (24) 53 (38) 35 1.83 (1.17, 2.85)
Medicare 76 (18) 14 (10) 16 0.64 (0.31, 1.22)
Note. CI = confidence interval; OR = odds ratio.
a
Percentage with SI (response ‡ 1 on item 9 of the Patient Health Questionnaire [PHQ-9]) in each variable category.
b
“Other” includes medical leave of absence (n = 2), student (n = 11), homemaker (n = 1), and disabled (n = 24).
*P < .05; P values were determined by the Fisher exact test.
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TABLE 2—Injury Characteristics of the Study Sample, by Presence or Absence of Postinjury Suicidal Ideation (SI): Seattle, WA, June 2001–March 2005
Variable SI Negative (n = 421), No. (%) SI Positive (n = 138), No. (%) SI Positive, %a OR (95% CI)
Cause of injury
Vehicular (e.g., automobile, motorcycle; Ref) 172 (41) 56 (41) 25 1.00
Fall 144 (34) 40 (29) 22 0.85 (0.52, 1.39)
Violence 43 (10) 20 (15) 32 1.43 (0.73, 2.72)
Other or recreational 61 (15) 19 (14) 24 0.96 (0.50, 1.79)
Injuries were intentionally inflicted
No (Ref) 367 (88) 112 (84) 23 1.00
Yes, self-inflicted 4 (1) 4 (3) 50 3.27 (0.60, 17.83)
Yes, inflicted by someone else 44 (11) 18 (13) 29 1.34 (0.70, 2.48)
GCS score
Complicated mild (13–15; Ref)
b
226 (54) 65 (47) 22 1.00
Moderate (9–12) 98 (23) 30 (22) 23 1.06 (0.63, 1.78)
Severe (3–8) 97 (23) 43 (31) 31 1.54 (0.95, 2.48)
Cortical contusions
No (Ref) 294 (70) 101 (74) 26 1.00
Yes 125 (30) 36 (26) 22 0.84 (0.53, 1.32)
Intracerebral hemorrhage
No (Ref) 126 (30) 48 (35) 28 1.00
Yes 293 (70) 89 (65) 23 0.80 (0.52, 1.23)
Injury score,
c
excluding head
0 (Ref) 116 (28) 37 (27) 24 1.00
1–2 151 (36) 41 (30) 21 0.85 (0.50, 1.46)
3–5 152 (36) 60 (43) 28 1.24 (0.75, 2.06)
Length of hospital stay, d
0–3 (Ref) 136 (32) 44 (32) 24 1.00
4–7 92 (22) 26 (19) 22 0.87 (0.48, 1.57)
8–14 99 (24) 28 (20) 22 0.87 (0.49, 1.55)
‡ 15 94 (22) 40 (29) 30 1.31 (0.77, 2.24)
Cocaine intoxication*
No (Ref) 306 (93) 92 (84) 23 1.00
Yes 24 (7) 17 (16) 41 2.35 (1.13, 4.79)
Methamphetamine intoxication
No (Ref) 307 (92) 108 (95) 26 1.00
Yes 26 (8) 6 (5) 19 0.66 (0.22, 1.69)
Alcohol level, mg/dL
0 (Ref) 262 (68) 88 (68) 25 1.00
1–79 28 (7) 8 (6) 22 0.85 (0.32, 2.01)
‡ 80 97 (25) 34 (26) 26 1.04 (0.64, 1.69)
Litigation related to TBI*
No (Ref) 267 (83) 80 (73) 23 1.00
Yes 55 (17) 29 (27) 35 1.76 (1.01, 3.02)
First PHQ-8 score after injury*
< 10 (Ref) 324 (77) 65 (47) 17 1.00
‡ 10 97 (23) 73 (53) 43 3.74 (2.45, 5.73)
Note. CI = confidence interval; GCS = Glasgow Coma Scale; OR = odds ratio; PHQ-8 = Patient Health Questionnaire (PHQ-9) with item 9 excluded; TBI = traumatic brain injury.
aPercentage with SI (response ‡ 1 on item 9 of PHQ-9) in each variable category.
b
Participants with GCS scores of 13 to 15 had radiological evidence of TBI.
c
Calculated as the largest nonhead injury severity score.
31
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(Table 4). In the overall model, the strongest
predictor of SI during the year after TBI was
the first PHQ-8 score after injury (Table 5).
Other significant multivariate predictors in-
cluded a history of a prior suicide attempt,
a history of bipolar disorder, having less than
a high school education, and the interaction
between PHQ-8 score and a preinjury suicide
attempt. With each 1-point increase on the
PHQ-8, participants’ risk of endorsing SI in-
creased by 12% for those without a history of
prior suicide attempts and by 2% for those with
a history.
DISCUSSION
In the current sample, 25% of participants
reported SI at some time during the first year
after TBI, a rate that exceeds the general
population by almost 7 times.32 This finding
aligns with several previous studies that exam-
ined SI after TBI.11—13 Compared with the study
by Tsaousides et al. of patients in the chronic
phase of their TBI recovery,12 our study found
a remarkably similar rate of SI (27.3% vs
24.7%). This is interesting given that their
study included community-based participants
whose history of TBI was based on self-report
and whose average time since injury was 5.93
years, whereas our study included a represen-
tative sample of hospitalized patients with
medically confirmed TBI. In addition, our
participants were followed over the first year
after injury, during which time the point prev-
alence of SI remained fairly consistent. In
a 2007 review of the literature, Simpson and
Tate33 concluded that there is not a circum-
scribed window of risk for suicidality after TBI.
In contrast to suicide risk among individuals
diagnosed with cancer, which is elevated dur-
ing the first 5 years after diagnosis and then
declines,34 SI appears to increase after TBI and
may remain chronically elevated.
Histories of premorbid psychiatric hospital-
ization, mental health diagnoses, and suicide
attempts were more common among this sam-
ple than among the general population. Twelve
percent of our sample reported at least 1
suicide attempt prior to their TBI, whereas
lifetime rates in the general population range
from 1.9% to 8.7%.35 The majority of TBIs
were unintentional, although 1.4% were the
result of a suicide attempt, a finding that
mirrors rates found in the TBI Model Systems
Database.36 Together, these findings align with
the conclusion of Fann et al. that psychiatric
illness may increase one’s risk of TBI.37 Of
those participants who denied a history of prior
suicide attempts (n = 485), 20% reported SI in
the first year after injury. The 12-month prev-
alence of SI among the general population
ranges from 2.1% to 10.0%,35 which suggests
that even among patients who do not have
a prior history of suicidal behavior, rates of SI
are at least double those of the general pop-
ulation. These findings suggest that although
mental illness may be overrepresented among
individuals who sustain a head injury, TBI may
independently increase the risk of SI.
When only those variables that are available
via medical record review were examined,
multivariate analyses demonstrated that being
female, having less than a high school educa-
tion, and having Medicaid were independent
predictors of SI. Together, those variables
accounted for 6.4% of the variability in SI,
compared with the full model, which accounted
for 25.5%. Multivariate analyses revealed that
the independent predictors of SI during the first
year after injury were initial depressive symp-
toms, preinjury psychiatric history (specifically,
a diagnosis of bipolar disorder) and a prior
suicide attempt. Consistent with studies in the
general population,35,38 having less than a high
school education was also associated with in-
creased risk of SI. In the current sample, SI in
people without a high school education was
10
times greater than would be expected among
similarly educated individuals in the general
population.32 Given that TBI may heighten
financial stress and complicate return to
work,39 it is possible that TBI is associated with
greater adjustment difficulties among individ-
uals who may have fewer options or resources
because of limited education. Although the
sequelae of TBI may yield unique vulnerabil-
ities among brain injury survivors, risk factors
for SI among individuals with TBI appear to
align with those that have been identified
among the general population.
Future Research
The body of research investigating the
mental health sequelae of TBI has grown
immensely in recent years; however, there
continue to be notable gaps in the literature.
Further research is necessary to establish the
prevalence of SI and behavior among TBI
survivors.15 Likewise, additional investigation
0
5
10
15
20
25
30
0 2 4 6 8
%
o
f S
am
p
le
W
it
h
P
o
st
in
ju
ry
S
I
Months After Injury
Cumulative
prevalence
Prevalence
Postinjury
incidence
10 12 14
FIGURE 1—Prevalence, cumulative prevalence, and postinjury incidence of suicidal ideation
(SI) at each assessment point during the first year after traumatic brain injury (n = 559):
Seattle, WA, June 2001–March 2005.
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to delineate injury factors (e.g., injury severity)
and postinjury factors (e.g., restriction of lethal
means, provision of social support, return-to-
work status) that may exacerbate or mitigate
risk of suicide is warranted. At present, in-
tervention studies for depression after TBI are
few, and evidence-based treatment guidelines
have not been established.40 Developing in-
terventions to address difficulties with depres-
sion among brain injury survivors should be
a priority, and those interventions should be
tailored to meet the challenges of access to care
(e.g., transportation issues) and concomitant
difficulties often present following TBI (e.g.,
cognitive difficulties). Future studies should
also be mindful in selecting appropriate com-
parison groups. As we are able to better un-
derstand factors associated with self-directed
violence among individuals who have suffered
a TBI, we will be more capable of preventing
lives from being unnecessarily lost to suicide.
Clinical Implications
This study identified several predictors of SI
that are extractable from the medical record.
This information is valuable as it may assist
providers in identifying very early in the in-
patient stay which patients may be at increased
risk for SI later in their recovery. The most
potent predictors, however, were those that
related to depressive symptoms soon after
injury and preinjury psychiatric history. The
challenges that arise in the wake of a brain
injury (e.g., concomitant injuries, financial con-
cerns, return-to-work issues) are many, and
attending to psychiatric well-being along with
competing difficulties is important for optimiz-
ing outcomes. Our findings suggest that in-
dividuals who have serious psychiatric diffi-
culties before sustaining a head injury are likely
to continue to be vulnerable to suicidality
(perhaps even more so) after injury. Assessing
prior psychiatric history should be a routine
component of health assessment. Our findings
also underscore the importance of assessing
mood during the early stages after injury, as
this period may serve as a window of oppor-
tunity to identify patients who are at particular
risk for suicidal behavior later in recovery.
Previous research has suggested that risk for
suicide remains elevated for at least the first 15
years after injury.5 TBI may therefore be
viewed as a chronic health condition,41 and SI
should be monitored long after injury. A
measure of depression integrated into TBI care
would be a useful component of mood assess-
ment and would be feasible in many health
care settings, including those that provide acute
care. Ensuring that health care providers are
sufficiently skilled in suicide assessment is also
critical. Prior research has suggested that
training in suicide assessment and management
TABLE 3—History of Preinjury Suicidal Behavior, Traumatic Brain Injury (TBI), and
Psychiatric Diagnoses, by Presence or Absence of Suicidal Ideation (SI): Seattle, WA,
June 2001–March 2005
Variable
SI Negative (n = 421),
No. (%)
SI Positive (n = 138),
No. (%) SI Positive, %
a
OR (95% CI)
History of suicide attempt(s)*
No (Ref) 386 (93) 99 (73) 20 1.00
Yes 30 (7) 37 (27) 55 4.79 (2.73, 8.47)
History of psychiatric hospitalization*
No (Ref) 395 (95) 117 (85) 23 1.00
Yes 21 (5) 20 (15) 49 3.21 (1.59, 6.46)
History of hospitalization for prior TBI
No (Ref) 374 (90) 120 (87) 24 1.00
Yes 40 (10) 18 (13) 31 1.40 (0.73, 2.61)
Depression history*
No (Ref) 338 (85) 81 (60) 19 1.00
Yes 61 (15) 53 (40) 46 3.61 (2.27, 5.76)
Bipolar or manic depression history*
No (Ref) 407 (98) 112 (82) 22 1.00
Yes 9 (2) 24 (18) 73 9.64 (4.18, 24.26)
PTSD history*
No (Ref) 391 (95) 116 (89) 23 1.00
Yes 22 (5) 14 (11) 39 2.14 (0.98, 4.54)
Other anxiety disorder historyb*
No (Ref) 397 (95) 116 (85) 23 1.00
Yes 19 (5) 20 (15) 51 3.59 (1.75, 7.38)
Lifetime alcohol dependence*
CAGE
c
score 0–1 (Ref) 215 (62) 62 (51) 22 1.00
CAGE score ‡ 2 130 (38) 60 (49) 32 1.60 (1.03, 2.48)
Note. CI = confidence interval; OR = odds ratio; PTSD = posttraumatic stress disorder.
aPercentage with SI (response ‡ 1 on Patient Health Questionnaire [PHQ-9] item 9) in each variable category.
b
Other anxiety disorders included generalized anxiety disorder, panic disorder, obsessive compulsive disorder, and any
phobia.
c
The CAGE (cut down, annoyed, guilty, eye opener) screening tool.
24
*P < .05; P values were determined by the Fisher exact test. TABLE 4—Multivariate Model
Predicting Suicidal Ideation During
the First Year After Traumatic Brain
Injury, Using Variables Available in the
Medical Record: Seattle, WA, June
2001–March 2005
Variable OR (95% CI) P
Male 0.59 (0.37, 0.92) .021
Completed high school 0.47 (0.25, 0.88) .017
Insurance .007
Medicaid vs commercial
or private
1.72 (1.09, 2.72) .019
Medicare vs commercial
or private
0.60 (0.29, 1.17) .149
Note. CI = confidence interval; OR = odds ratio.
Nagelkerke R
2
= 0.06.
RESEARCH AND PRACTICE
July 2014, Vol 104, No. 7 | American Journal of Public Health Mackelprang et al. | Peer Reviewed | Research and Practice | e105
for health and mental health providers is in-
adequate42—45; however, a recent training
program implemented in Australia among re-
habilitation professionals showed sustained
improvements in knowledge and skills in sui-
cide assessment at 6-month follow-up.46 This
topic merits further scrutiny.
Limitations
This study has several limitations that war-
rant discussion. First, we used a single, self-
report question from the PHQ-9 to classify
individuals as having SI. Thus, it relied on
participants’ interpretation of the question,
which does not distinguish explicitly passive
thoughts of death from active suicidality. In
spite of this limitation, item 9 of the PHQ-9 has
been found to have adequate specificity (0.84)
and sensitivity (0.69) compared with interview
measures that target suicidality specifically,47
although some studies have suggested that this
question overestimates rates of SI.48 We also
dichotomized responses on item 9 for the pur-
poses of statistical analyses; thus, relationships
presented do not reflect how frequently (i.e.,
several days, more than half of days, or nearly
every day in the preceding 2 weeks) participants
experienced SI at each assessment point.
SI-positive participants also completed fewer in-
terviews than SI-negative participants, which may
have created conservative bias in the SI preva-
lence rates at each time point. Individuals who
reported suicidality were referred for further
assessment and intervention. It is possible that
this had an impact on the persistence of SI.
This sample, although representative of the
brain-injured patient population served by
a large level 1 trauma center in the Pacific
Northwest, included an overrepresentation of
Medicaid recipients and a relatively small
number of patients from diverse racial/ethnic
backgrounds. Thus, these findings may not
generalize to regions that have a vastly different
socioeconomic or cultural composition. Finally,
we do not have longitudinal data on suicide
attempts or completions that may have occurred
during the study or after the project concluded.
Conclusions
This study adds to the burgeoning body of
literature investigating SI after TBI by identify-
ing risk factors for SI in a representative sample
of adults within the first year after TBI. Identi-
fying key risk factors for SI among patients with
a recent TBI may help health care providers to
determine who among their recently injured
patients may be particularly vulnerable to SI
during the year after TBI. Our findings suggest
that symptoms of depression soon after injury,
prior suicide attempt(s), a diagnosis of bipolar
disorder, and low educational attainment are
particularly salient risk factors. j
About the Authors
Jessica L. Mackelprang is with the Harborview Injury
Prevention and Research Center, Charles H. Bombardier
and Sureyya S. Dikmen are with the Department of
Rehabilitation Medicine, Jesse R. Fann is with the De-
partment of Psychiatry and Behavioral Sciences, and
Nancy R. Temkin and Jason K. Barber are with the
Department of Neurologic Surgery, University of Wash-
ington School of Medicine, Seattle.
Correspondence should be sent to Jessica L. Mackelprang,
PhD, Harborview Injury Prevention & Research Center/
Department of Pediatrics, University of Washington, Seat-
tle, WA 98122 (e-mail: jlmack11@uw.edu). Reprints can
be ordered at http://www.ajph.org by clicking the “Reprints”
link.
This article was accepted November 10, 2013.
Contributors
J. L. Mackelprang, C. H. Bombardier, J. R. Fann, and
J. K. Barber were responsible for drafting the article.
J. L. Mackelprang, C. H. Bombardier, N. R. Temkin, and
J. K. Barber were responsible for statistical analysis and
interpretation of data. C. H. Bombardier, J. R. Fann, N. R.
Temkin, and S. S. Dikmen obtained funding to conduct
the original parent study and were responsible for
acquisition of the data. N. R. Temkin and S. S. Dikmen
provided critical revision of the article for important
intellectual content. All authors were responsible for
conceptualization and design of the study.
Acknowledgments
This study was supported by grants from the National
Center for Medical Rehabilitation Research, the National
Institute of Child Health and Human Development, and
the National Institutes of Health (to C. H. B. and J. R. F.;
R01-HD39415). J. L. Mackelprang received fellowship
support from the National Institute of Child Health and
Human Development (T32-HD057822) during the
preparation of the article.
Note. The contents of this article are solely the
responsibility of the authors and do not necessarily
represent the official views of the National Institutes of
Health.
Human Participant Protection
This study was approved by the University of Washing-
ton Human Subjects Division.
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