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Original Investigation
November 12, 2018

Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 2Now with Eliot Phillipson Clinician Scientist Training Program, Department of Medicine, University of Toronto, Ontario, Canada
  • 3College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
  • 4Department of Critical Care, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
  • 5Antiviral Research Center, Department of Medicine, University of California, San Diego
  • 6Cognitive Neurology Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 7Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 8Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 9Division of Critical Care, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
JAMA Neurol. 2019;76(2):144-151. doi:10.1001/jamaneurol.2018.3487
Key Points

Question  Is concussion and/or mild traumatic brain injury (TBI) associated with a higher risk of suicide?

Findings  This systematic review and meta-analysis found a 2-fold higher risk of subsequent suicide among more than 700 000 patients diagnosed with concussion and/or mild TBI, compared with more than 6.2 million individuals who had not been so diagnosed. Experiencing concussion and/or mild TBI was also associated with a higher risk of suicide attempt and suicidal ideation.

Meaning  These results suggest that experiencing concussion and/or mild TBI is associated with an increased risk of suicide.

Abstract

Importance  Concussion is the most common form of traumatic brain injury (TBI). While most patients fully recover within 1 week of injury, a subset of patients might be at a higher risk of suicide.

Objective  To assess the risk of suicide after concussion.

Data Sources  We performed a systematic search of Medline (PubMed), Embase, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS) from 1963 to May 1, 2017. We also searched Google Scholar and conference proceedings and contacted experts in the field to seek additional studies.

Study Selection  Studies that quantified the risk of suicide, suicide attempt, or suicidal ideation after a concussion and/or mild TBI were included. Studies that included children and adults, including military and nonmilitary personnel, were included. Two authors independently reviewed all titles and abstracts to determine study eligibility.

Data Extraction and Synthesis  Study characteristics were extracted independently by 2 trained investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Study data were pooled using random-effects meta-analysis.

Main Outcomes and Measures  The primary exposure was concussion and/or mild TBI, and the primary outcome was suicide. Secondary outcomes were suicide attempt and suicidal ideation.

Results  Data were extracted from 10 cohort studies (n = 713 706 individuals diagnosed and 6 236 010 individuals not diagnosed with concussion and/or mild TBI), 5 cross-sectional studies (n = 4420 individuals diagnosed and 11 275 individuals not diagnosed with concussion and/or mild TBI), and 2 case-control studies (n = 446 individuals diagnosed and 8267 individuals not diagnosed with concussion and/or mild TBI). Experiencing concussion and/or mild TBI was associated with a 2-fold higher risk of suicide (relative risk, 2.03 [95% CI, 1.47-2.80]; I2 = 96%; P < .001). In 2 studies that provided estimates with a median follow-up of approximately 4 years, 1664 of 333 118 individuals (0.50%) and 750 of 126 114 individuals (0.59%) diagnosed with concussion and/or mild TBI died by suicide. Concussion was also associated with a higher risk of suicide attempt and suicide ideation. The heightened risk of suicide outcomes after concussion was evident in studies with and without military personnel.

Conclusions and Relevance  Experiencing concussion and/or mild TBI was associated with a higher risk of suicide. Future studies are needed to identify and develop strategies to decrease this risk.

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