Psychology Chartered

Suicide and Traumatic Brain Injury – an area under-researched and under-valued.

Posted by Richard Maddicks

14th July 2023

Written by Olivia Fretwell, Assistant Psychologist.

In honour of Samaritan’s annual ‘Talk to Us’ campaign throughout July, this blog will discuss the heart-breaking and complex issue of suicidality in our population, whilst remaining focused on those who have experienced a traumatic brain injury (TBI).

As defined by Headway, TBI is trauma to the brain, caused for example by a road traffic accident, a fall at home, or an accident at work. They can range from mild in severity to severe in terms of symptom presentation / functional impact. Data from Headway shows that every 90 seconds, someone is admitted to hospital with a brain injury (Headway, 2023).

The number of documented suicides in England in 2021 was 5,219 (3,852 males and 1,367 females) and the overall rate was 10.5 per 100,000 (Samaritans, 2023). Research suggests that those with a TBI are at a heightened risk for suicidality (ideation and behaviour) compared to the general population. The figures are variable, however one population based study showed a 2.23x higher risk in individuals with a TBI compared to the general population (Lu et al., 2020).

Risk Factors.

Individuals who have experienced a more severe brain injury, as well as those remaining in hospital for longer periods and individuals in the first six months of discharge all face greater risk of suicidality (Madsen, 2018). Comorbid psychiatric pathology, specifically depression and post-traumatic stress disorder as well as comorbid substance abuse disorder have also been associated with an increased risk (Simpson & Tate, 2005; McIntire et al., (2021). Previous suicide attempts and suicidal ideation have been shown to also increase an individual’s risk of future suicide (McIntire et al., 2021). It is important to highlight that compared to the general population, individuals serving in the military are at an increased risk of TBI and subsequent suicidal behaviours (Brenner, Ignacio, & Blow, 2011; Hostetter et al., 2019). This is due to the high incidence rate of blunt-force traumatic brain injury (Bhattrai, Irimia, & Van Horn, 2019) and repetitive exposure to concussive injuries resulting from explosions or other combat-related factors (Bryan, & Clemans, 2013). Likewise, the development of mental health problems e.g., post-traumatic stress disorder, and discharge from the military i.e., becoming a veteran and adjustment to civilian life, can significantly increase risk of suicidal behaviour (Ramchand, 2021).

Simpson & Tate (2002) describe a four-area model which can be used when identifying risk in individuals. The first area to consider is pre-injury suicide risk factors i.e., psychiatric morbidity and/or substance abuse. The second area is post-injury factors, which could include psychiatric morbidity and/or substance abuse, but also emotional disturbance i.e., levels of hopelessness, and level of disability post-injury. Aetiology of the TBI is also crucial to consider, for example the injury may have been due to a suicidal attempt and thus increasing future risk (Simpson & Tate, 2009). Also, despite there being an increase rate of suicide in those with severe traumatic brain injury due to subsequent injury sequalae (Simpson & Tate, 2007), those also who have experienced concussion/cranial injuries may be at an increased risk due to comorbid psychosocial factors associated with the injury (Teasdale and Engberg, 2001). Lastly, demographic characteristics must be considered, like age and gender, as these can lead to an increased risk (Simpson & Tate, 2002).

Why are those with a brain injury at an increased risk?

There are a number of factors which increase individuals’ risk of suicidal ideation and behaviour post TBI. In the vast majority of TBI cases, the brain injury has suddenly occurred, likewise the onset of disability. Significant adjustment is therefore required which can be incredibly difficult, as one has adjust to a completely new life, and with this have to process substantive changes to their self-identity (Simpson & Tate, 2002). This can have significant negative impact on their mental health and psychological wellbeing (Ownsworth, 2014). Some individuals may experience significant physical adjustment (e.g., severe injuries, like the loss of a limb), psychosocial adjustment (e.g., unemployment, social isolation), emotional changes (e.g., development of post-traumatic stress disorder), behavioural changes (e.g., impulsivity, aggression) and cognitive adjustments (e.g., reduced problem-solving ability), making rehabilitation extremely challenging (Simpson & Tate, 2002; 2007). These are some examples of the sobering consequences of traumatic brain injuries.

Crisis Intervention.

Safety planning is a type of structured crisis intervention, which helps to stop an individual acting on their suicidal feelings when in future crisis. A safety plan is mutually created by the individual and a mental health professional.

Please see a 6-step example below (Stanley and Brown, 2012; O’Connor, 2021).

STEP 1: Warning signs for onset of crisis (thoughts, images, mood, situation, behaviour).

1) e.g., the thought: “I am completely useless.”

2) e.g., feeling: hopeless, trapped, numb.

3) e.g., behaviour: withdrawing, self-neglect, self-isolation.

STEP 2: Internal Coping Strategies.

1) e.g., listening to my favourite music.

2) e.g., watching TV.

3) e.g., drawing.

STEP 3: People and social settings which provide distractions.

1) e.g., being around family/friends.

2) e.g., visiting the library.

3) e.g., going to a place of worship.

STEP 4: People who I can ask for help – someone who I trust and is a safe place.

1) e.g., friend.

2) e.g., work colleague.

3) e.g., sibling.

STEP 5: Professionals/Organisations I can contact during a crisis.

1) e.g., crisis helpline – SHOUT, Samaritans, 111, Emergency services.

2) e.g., GP.

3) e.g., social worker.

STEP 6: Making the environment safe – needs to be done in agreement and collaboratively.

1) e.g., removal of large quantities of prescription drugs.

2) e.g., store medication in a locked box.

3) e.g., take a different route home to avoid the area of concern.

It is critical not only to plan the above, but also to consider the individual in the context of their brain injury. Based on an assessment of neurocognitive change, it is important to consider what is unique to the individual and their post-injury presentation which may increase their risk. This could include, but is not limited to, executive dysfunction, black & white thinking, rigidity or impulsivity. Likewise, some of these factors could be argued to be protective in some cases, but adopting an individual, person-centered approach and understanding is critical.

Future.

A review of the literature indicates that this topic is under-researched, and methodological issues such as small sample sizes, restrict this area’s development.

There needs to be more systematic reviews of existing literature, and the development of new research studies with larger samples, in order to substantiate the existing, somewhat limited, portfolio. Specifically, the focus of research could shift to the neuropsychological/neuropathological mechanisms which are involved i.e., the link between damage to frontal lobes and subsequent cognitive/behavioural changes like increased impulsivity, which may help to identify individuals who perhaps do not present as immediately high risk (Teasdale and Engberg, 2001; Simpson and Tate 2007). The heterogenous nature of traumatic brain injuries needs to be taken into consideration (Teasdale and Engberg, 2001; Simpson and Tate 2007).

Aside from focusing on the individual, it is also important to take a more holistic approach. Research by Townsend & Norman (2018) highlighted a need to focus on the secondary impact of TBI on family and friends, and also their response and understanding of the injury and associated changes. This is important to consider in terms of suicide risk management and prevention. Other research highlights the silo that individuals experience post-injury when being discharged from hospital and upon accessing community rehabilitation (Odumuyiwa et al., 2019; Norman et al., 2020). As mentioned above, this is a critical time period in terms of reducing risk for suicidal ideation/behaviour. Ensuring adequate service provision and treatment for individuals with a traumatic brain injury should therefore be a focus for both future research and change.

Please visit our FREE online training course, available here. This course will help to develop your knowledge, competence and confidence in a number of topics that we have put together related to suicide risk, management and prevention.

We welcome any feedback, so please don’t hesitate to get in touch:

 

References

  • Bhattrai, A., Irimia, A., & Van Horn, J. D. (2019a). Neuroimaging of traumatic brain injury in military personnel: An overview. Journal of Clinical Neuroscience, 70, 1–10. https://doi.org/10.1016/j.jocn.2019.07.001
  • Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2011). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration Services. Journal of Head Trauma Rehabilitation, 26(4), 257–264. https://doi.org/10.1097/htr.0b013e31821fdb6e
  • Bryan, C. J., & Clemans, T. A. (2013). Repetitive traumatic brain injury, psychological symptoms, and suicide risk in a clinical sample of deployed military personnel. JAMA Psychiatry, 70(7), 686. https://doi.org/10.1001/jamapsychiatry.2013.1093
  • Headway, 2023 – https://www.headway.org.uk
  • Hostetter, T. A., Hoffmire, C. A., Forster, J. E., Adams, R. S., Stearns-Yoder, K. A., & Brenner, L. A. (2019). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services between Fiscal Years 2006 and 2015.Journal of Head Trauma Rehabilitation, 34(5).https://doi.org/10.1097/htr.0000000000000489
  • Lu, Y.-C., Wu, M.-K., Zhang, L., Zhang, C.-L., Lu, Y.-Y., & Wu, C.-H. (2020). Association between suicide risk and traumatic brain injury in adults: A population based Cohort Study. Postgraduate Medical Journal, 96(1142), 747–752. https://doi.org/10.1136/postgradmedj-2019-136860
  • Madsen, T., Erlangsen, A., Orlovska, S., Mofaddy, R., Nordentoft, M., & Benros, M. E. (2018). Association between traumatic brain injury and risk of suicide. JAMA, 320(6), 580. https://doi.org/10.1001/jama.2018.10211
  • McIntire, K. L., Crawford, K. M., Perrin, P. B., Sestak, J. L., Aman, K., Walter, L. A., Page, D. B., Wen, H., Randolph, B. O., Brunner, R. C., Novack, T. L., & Niemeier, J. P. (2021). Factors increasing risk of suicide after traumatic brain injury: A state-of-the-science review of military and civilian studies. Brain Injury, 35(2), 151–163. https://doi.org/10.1080/02699052.2020.1861656
  • Norman, A., Holloway, M., Odumuyiwa, T., Kennedy, M., Forrest, H., Suffield, F., & Dicks, H. (2020). Accepting what we do not know: A need to improve professional understanding of brain injury in the UK. Health & Social Care in the Community, 28(6), 2037–2049. https://doi.org/10.1111/hsc.13015
  • O’Connor, R. C. (2021). When it is darkest: Why people die by suicide and what we can do to prevent it(1st ed.). Vermilion, an imprint of Ebury Publishing, Penguin Random House UK.
  • Odumuyiwa, T., Kennedy, M., Norman, A., Holloway, M., Suffield, F., Forrest, H., & Dicks, H. (2019). Improving access to social care services following acquired Brain Injury: A needs analysis. Journal of Long-Term Care, 0(2019), 164.
  • https://doi.org/10.31389/jltc.6
  • Ownsworth, T. (2014). Self-identity after Brain Injury. Taylor and Francis.
  • Ramchand R. (2022). Suicide Among Veterans: Veterans’ Issues in Focus.Rand health quarterly, 9(3), 21.
  • Samaritans, 2023 – https://www.samaritans.org
  • Simpson, G., & Tate, R. (2002). Suicidality after traumatic brain injury: Demographic, injury and clinical correlates. Psychological Medicine, 32(4), 687–697. https://doi.org/10.1017/s0033291702005561
  • Simpson, G., & Tate, R. (2005). Clinical features of suicide attempts after traumatic brain injury. The Journal of Nervous and Mental Disease, 193(10), 680–685. https://doi.org/10.1097/01.nmd.0000180743.65943.c8
  • Simpson, G., & Tate, R. (2007). Suicidality in people surviving a traumatic brain injury: Prevalence, risk factors and implications for clinical management. Brain Injury, 21(13–14), 1335–1351. https://doi.org/10.1080/02699050701785542
  • Stanley, B., & Brown, G.K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive & Behavioural Practice, 19, 256-64.
  • Teasdale, T. W. (2001). Suicide after traumatic brain injury: A population study. Journal of Neurology, Neurosurgery & Psychiatry, 71(4), 436–440. https://doi.org/10.1136/jnnp.71.4.436
  • Townshend, J., & Norman, A. (2018). The secondary impact of Traumatic Brain Injury. The Family Journal, 26(1), 77–85. https://doi.org/10.1177/1066480717752905
Subscribe to RSS

Categories