Suicide and Suicide Prevention After Brain Injury
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Suicide and Suicide Prevention After Brain Injury

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Suicide and Suicide Prevention After Brain Injury

Neuropsychiatric disorders frequently occur following brain injuries and are often diagnosed within a year of the injury.1,2 Mood disorders, especially major depressive disorder (MDD), are the most commonly diagnosed disorders DSM-5 Mental disorders following brain injury.3 Mood disorders can develop independently of pre-traumatic mental health conditions and may increase the risk of suicidal thoughts.1-4

MDD after brain injury

Prospective studies using structured clinical interviews indicate that the rate of depression in the first year following mild traumatic brain injury ranges from 13.9% to 23.2%.3 Reported rates of MDD across a broader range of injury severity are higher, ranging from 15.3% to 33%.5 Risk factors for MDD include pretraumatic depression, focal lateral and left frontal lesions, and psychosocial stressors including social isolation and maladaptive coping. MDD following brain injury was associated with comorbid anxiety and self-rated lower quality of life at 1 year postinjury.6

Suicide Risk and Suicidal Tendency

Research indicates an increased risk of suicidal thoughts, suicide attempts, and even suicide following a brain injury.4,7-9 Makelprang followed a group of adults with traumatic brain injury (TBI) for a year after discharge from the hospital and found that 25% of the study participants experienced suicidal thoughts within the first year of their injury.4 The strongest predictors of suicidal ideation after traumatic brain injury were a prior history of attempted suicide, a neuropsychiatric diagnosis (depression, bipolar disorder), and less than a high school education. Simpson and Tate reported a lifetime prevalence rate of attempted suicide of 26.2% in an outpatient sample with TBI.9 They also examined the clinical characteristics of suicide attempts after TBI in an outpatient cohort followed for 24 months. Their dataset included 43 patients who made a total of 80 suicide attempts; 30% of attempts occurred before the injury and 70% after the injury. More than 55% of the attempts made one attempt, 25.6% made two attempts, and 18.6% made three or more attempts. Of those who made three or more attempts, a second attempt occurred within 13 months of the index attempt, and more than one third of those who made multiple attempts used the same method. Excessive alcohol consumption in the previous 24 hours, psychological stress from previous stressors (arguments, loss of an important relationship, negative feedback, etc.), and hopelessness combined with severe suicidal ideation were associated with suicide attempts after TBI.

Treatment and prevention

Preventive and treatment measures for suicidal ideation and attempts may include pharmacological and psychosocial approaches, substance abuse treatment, environmental changes, and, if necessary, acute intervention.10,11 Given the multiple and complex challenges associated with this patient population, physicians are encouraged to tailor and individualize treatment and prevention approaches.11

In terms of pharmacological intervention, SSRIs, and sertraline in particular, have been shown to be an effective first-line treatment for depression.12 In addition to treating symptoms of depression, SSRIs can also alleviate other commonly reported symptoms of TBI, such as irritability, aggression, and poor impulse control. A conservative approach to dosing (i.e., “low and slow”) is recommended when prescribing medications after TBI, because people with TBI may be sensitive and susceptible to adverse drug reactions.13

Psychosocial interventions such as support groups, strengthening family relationships, and engaging patients in social skills training have been shown to be effective in reducing feelings of loneliness and isolation.10 In a controlled trial, Simpson et al. randomly assigned a group of adults with severe traumatic brain injury and severe hopelessness or suicidal ideation to either an intervention group (n=8) or a wait-list control group (n=9).14 Participants in the intervention group received a 20-hour, automated cognitive behavioral therapy program. The interventions helped participants maintain a positive lifestyle by promoting the expression of thoughts and feelings, reframing/reappraising distressing situations, acquiring adaptive coping skills (i.e., problem-solving, asking for help, etc.), and promoting posttraumatic growth by making meaning of the brain injury. The treatment group showed significant reductions in hopelessness, and this effect was maintained at 3-month follow-up in 75% of participants.

Given that substance abuse, especially alcohol, is a risk factor for suicide attempts, substance abuse treatment can be an important component of a suicide prevention plan.9,10 Environmental changes, such as limiting access to sharp instruments, weapons, toxic chemicals, and other means of self-harm, have been shown to be effective in reducing suicide rates.10

The use of “no harm agreements” may be an appropriate intervention for patients with brain injury. A no harm agreement is an intervention designed to prevent self-harm.15 It is a written agreement between a doctor and a patient (i.e., the person receiving psychotherapy or mental health services) in which the patient promises not to harm themselves. Reviewers of the literature on the effectiveness of No Harm contracts argue that there is a lack of quantitative evidence to support the use of such contracts.16 Conceptual and ethical issues related to the use of no-harm contracts include:

  • Possibility of coercion by a physician in order to ensure his/her own protection (i.e. legal protection)
  • Patients who agree to such contracts are still at high risk of suicide.
  • Contracts can falsely reassure physicians, which may result in reduced attention and concern about the patient’s risk of suicide
  • A significant percentage of patients who signed the contract attempted or committed suicide.

However, alternatives to No Harm Contracts have shown limited or questionable utility. Some clinicians believe that the lack of extensive research on the effectiveness of contracts in preventing suicide should not be used to conclude that contracts have no therapeutic benefit or utility in treating patients with suicidal ideation.17 Potential benefits may include:

  • The patient’s willingness to enter into a contract may be a useful tool in assessing suicidal tendencies.
  • The agreement gives the doctor the opportunity to express sincere care and commitment to the patient, which can strengthen the therapeutic relationship.
  • Emphasizing a common goal can increase the bond between therapist and patient and provide a calming effect
  • The agreement can also provide the patient with the opportunity to safely explore self-destructive feelings and the meaning of life and death.

Like all therapeutic interventions and techniques, those addressing suicidal tendencies must be tailored to the individual patient.

Dr. Seale is the Regional Director of Clinical Services for the Center for Neuro Skills, which provides acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a psychologist with an independent practice and is a Certified Brain Injury Specialist Trainer. He holds a clinical appointment at the University of Texas Medical Branch (UTMB) at Galveston in the Department of Rehabilitation Sciences.

Bibliography

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