In Reply Dr Fleminger and Ms Fleminger suggest that both the TBI itself and also constitutional factors, such as prior deliberate self-harm, may be responsible for the high suicide rates after TBI found in our study.1 Our study showed that the incidence rate ratio of suicide was increased by 1.90 times after adjusting for relevant covariates, including fractures not involving the skull, chronic medical diseases, socioeconomic status, and preinjury factors such as prior mental illness and deliberate self-harm. We adjusted our estimates for confounding effects more rigorously than prior studies that have yielded higher risk estimates after TBI; thus, our estimates were more conservative. Moreover, the suicide rate associated with TBI was found to be 1.73 times higher than for other fractures not involving the skull, which was a way of taking accident proneness due to constitutional factors into account.
Madsen T, Nordentoft M, Benros ME. Self-harm, Traumatic Brain Injury, and Suicide—Reply. JAMA. 2018;320(23):2485. doi:10.1001/jama.2018.17562
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