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Original Investigation
August 14, 2018

Association Between Traumatic Brain Injury and Risk of Suicide

Author Affiliations
  • 1Danish Research Institute of Suicide Prevention, Mental Health Centre Copenhagen, Capital Region of Denmark, Copenhagen, Denmark
  • 2Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
  • 3Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4iPSYCH – The Lundbeck Foundation Initiative for Integrated Psychiatric Research, Aarhus, Denmark
  • 5Center of Mental Health Research, Australian National University, Canberra, Australia
JAMA. 2018;320(6):580-588. doi:10.1001/jama.2018.10211
Key Points

Question  What is the association between medical contact for traumatic brain injury (TBI) and risk of suicide?

Findings  In this registry-based retrospective cohort study from Denmark that included 34 529 deaths by suicide over 35 years, individuals with medical contact for traumatic brain injury, compared with the general population without traumatic brain injury, had an increased risk of suicide, incident rate ratio of 1.90.

Meaning  Traumatic brain injury may be associated with increased risk of suicide.


Importance  Traumatic brain injuries (TBIs) can have serious long-term consequences, including psychiatric disorders. However, few studies have assessed the association between TBI and risk of suicide.

Objective  To examine the association between TBI and subsequent suicide.

Design, Setting, and Participants  Retrospective cohort study using nationwide registers covering 7 418 391 individuals (≥10 years) living in Denmark (1980-2014) with 164 265 624 person-years’ follow-up; 567 823 (7.6%) had a medical contact for TBI. Data were analyzed using Poisson regression adjusted for relevant covariates, including fractures not involving the skull, psychiatric diagnoses, and deliberate self-harm.

Exposure  Medical contacts for TBI recorded in the National Patient Register (1977-2014) as mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injuries with evidence of structural brain injury).

Main Outcomes and Measures  Suicide recorded in the Danish Cause of Death register until December 31, 2014.

Results  Of 34 529 individuals who died by suicide (mean age, 52 years [SD, 18 years]; 32.7% women; absolute rate 21 per 100 000 person-years [95% CI, 20.8-21.2]), 3536 (10.2%) had medical contact: 2701 with mild TBI, 174 with skull fracture without documented TBI, and 661 with severe TBI. The absolute suicide rate was 41 per 100 000 person-years (95% CI, 39.2-41.9) among those with TBI vs 20 per 100 000 person-years (95% CI, 19.7-20.1) among those with no diagnosis of TBI. The adjusted incidence rate ratio (IRR) was 1.90 (95% CI, 1.83-1.97). Compared with those without TBI, severe TBI (absolute rate, 50.8 per 100 000 person-years; 95% CI, 46.9-54.6) was associated with an IRR of 2.38 (95% CI, 2.20-2.58), whereas mild TBI (absolute rate, 38.6 per 100 000 person-years; 95% CI, 37.1-40.0), and skull fracture without documented TBI (absolute rate, 42.4 per 100 000 person-years; 95% CI, 36.1-48.7) had an IRR of 1.81 (95% CI, 1.74-1.88) and an IRR of 2.01 (95% CI, 1.73-2.34), respectively. Suicide risk was associated with number of medical contacts for TBI compared with those with no TBI contacts: 1 TBI contact, absolute rate, 34.3 per 100 000 person-years (95% CI, 33.0-35.7; IRR, 1.75; 95% CI, 1.68-1.83); 2 TBI contacts, absolute rate, 59.8 per 100 000 person-years (95% CI, 55.1-64.6; IRR, 2.31; 95% CI, 2.13-2.51); and 3 or more TBI contacts, absolute rate, 90.6 per 100 000 person-years (95% CI, 82.3-98.9; IRR, 2.59; 95% CI, 2.35-2.85; all P < .001 for the IRR’s). Compared with the general population, temporal proximity since the last medical contact for TBI was associated with risk of suicide (P<.001), with an IRR of 3.67 (95% CI, 3.33-4.04) within the first 6 months and an incidence IRR of 1.76 (95% CI, 1.67-1.86) after 7 years.

Conclusions and Relevance  In this nationwide registry-based retrospective cohort study individuals with medical contact for TBI, compared with the general population without TBI, had increased suicide risk.