Iraq and Afghanistan veterans with multiple traumatic brain injuries (TBI) are about twice as likely to consider suicide compared to those with only one TBI or none, according to a new Veterans Affairs study published online in the journal Psychological Services.
“Suicide is a major concern with veterans,” said Dr. Robert Shura, a neuropsychologist at the W.G. (Bill) Hefner VA Medical Center in North Carolina and study leader.
“Right now, the prime point of intervention is at the level of thinking about suicide. Therefore, identifying characteristics of veterans who are more likely to think about suicide is a high priority.”
The study findings come from interviews with more than 800 veterans who held combat roles in Iraq and Afghanistan. About half of the veterans reported at least one TBI.
The researchers were primarily focused on whether the vets had experienced suicidal thoughts in the past week. The level of suicidal thinking was defined by the Beck Scale for Suicidal Ideation.
According to the findings, nearly 20 percent of vets with a history of multiple TBIs reported recent suicidal ideation, compared with 11 percent with one TBI and 9 percent with no history of a traumatic brain injury.
Veterans with at least one TBI were much younger and more likely to be white and male than those with no brain injuries. The TBI group also reported significantly poorer sleep quality and much higher rates of depression, both of which are risk factors for suicidal ideation.
Of the veterans with at least one brain injury, 18 percent met the criteria for major depressive disorder (MDD), which is characterized by intense and persistent feelings of sadness and loss of interest in activities.
Shura says the findings were consistent with previous research demonstrating a link between multiple TBIs and suicide. “But we need to be careful not to oversimplify things,” he adds. “There are folks with a single TBI in their past who have had suicidal ideation, and there are those with many TBIs who have not.”
However, he found it “somewhat unexpected” that post-traumatic stress disorder (PTSD) wasn’t consistently associated with suicidal ideation in veterans with TBI.
“There’s research suggesting a relationship between PTSD and suicidal ideation,” he said. “Our results are only one piece of a complex puzzle and should not be taken to mean that veterans suffering PTSD do not have suicidal ideation.”
“Suicidal ideation is not a defining symptom for PTSD, but it certainly is for major depressive disorder. Depression was consistently related to suicidal ideation in our sample, due to how we defined the diagnosis. A more interesting and clinically relevant result is that poor sleep quality was related to recent suicidal ideation. Providers probably need to pay more attention to returning veterans who continue to have sleep issues after re-adjustment from deployment.”
Shura isn’t certain why TBI may increase the possibility of suicide. His best guess is that the risk isn’t related primarily to the brain injury, but to the theory that a series of difficult life events can have a cumulative effect on someone.
“For example, during deployment, a service member is exposed to traumatic events, possible stressful situations at home, and chronic sleep deprivation,” he says.
“On returning home, the veteran may struggle with chronic pain, difficulty adjusting, continued sleep issues, depression, and heavy alcohol use. TBI may have little to do with all of that. But those with multiple TBIs may be more likely than others to have that cumulative trajectory and thus thoughts of suicide.”
Another theory was presented in a study published earlier this month in the Journal of the International Neuropsychological Society, by a VA team in San Diego. Based on assessments of 282 Iraq and Afghanistan Veterans with a history of mild TBI, the team linked certain specific cognitive deficits that often occur in TBI to higher rates of suicidal thinking.
They concluded, “Slowed processing speed and/or memory difficulties may make it challenging to access and use past experiences to solve current problems and imagine future outcomes, leading to increases in hopelessness and suicidal ideation in Veterans with three of more mTBIs.”
A number of other VA studies to date have looked at TBI and suicidality, and Shura expects to see yet more research on the subject.
“One or two studies does not tell the whole story,” he says. “Accumulating research from a variety of samples and methodologies is necessary to even begin to understand some of the complex relationships of this topic.”
The new study was funded by VA’s Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC).