In Reply We appreciate the comments that Lawrence and Hutchinson have provided regarding our recent systematic review and meta-analysis1 that identified a higher rate of suicide among those who received a diagnosis of concussion compared with those who did not. We agree that providing absolute and relative risk estimates is ideal. For this reason, we provided the absolute rate of suicide in both groups when these data were available. However, we did not meta-analyze these results for 2 reasons. First, each study had a different duration of follow-up, which limited our ability to easily pool these results. Based on this, we would caution against the calculation Lawrence and Hutchinson provide because it does not account for the varying durations of follow-up across each study. For example, the study by Fazel et al had a median follow-up of approximately 4 years, whereas the study by Fralick et al had a median of approximately 9 years.2 Second, the studies included in our meta-analysis did not provide adjusted risk differences. Without adjusted risk differences, the estimates do not account for differences in baseline characteristics, in that risk difference measures can be very sensitive to baseline risk.3
Fralick M, Sy E, Karsies T. Absolute Risk Estimates of the Association Between Concussion and Suicide—Reply. JAMA Neurol. Published online June 10, 201976(7):871–872. doi:10.1001/jamaneurol.2019.1452
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