Suicidality and Suicide Prevention Following Brain Injury

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Neuropsychiatric disorders regularly occur following brain injury and are often diagnosed within a year of the injury.^1,2 Mood disorders, particularly major depressive disorder (MDD), are the most frequently diagnosed DSM-5 psychiatric disorders after brain injury.³ Mood disorders can develop with or without a preinjury history of psychiatric disorder, and can increase risk for suicidal thoughts.^1-4

MDD Following Brain Injury

Prospective studies using structured clinical interviews report rates of depression between 13.9% and 23.2% within the first year of injury for mild brain injury.³ Reported rates of MDD for a wider range of injury severity are higher, ranging from 15.3% to 33%.⁵ Risk factors for MDD include preinjury depression, focal lateral lesions and left anterior lesions, and psychosocial stressors including social isolation and maladaptive coping. MDD following brain injury was associated with comorbid anxiety and self-reported lower quality of life at 1 year after the injury.⁶

Suicide Risk and Suicidality

Studies report an increased risk for suicidal thoughts, suicide attempts, and even death by suicide following brain injury.^4,7-9 Makelprang followed a cohort of adults with traumatic brain injury (TBI) for 1 year after discharge from the hospital, and found that 25% of the sample reported suicidal ideation within the first year of injury.⁴ The strongest predictors of suicidal ideation after brain injury included prior history of suicide attempt, neuropsychiatric diagnosis (depression, bipolar disorder), and less than a high school education. Simpson and Tate reported a lifetime prevalence rate of 26.2% for suicide attempt in an outpatient sample with TBI.⁹ They also examined the clinical features of suicide attempts after TBI in an outpatient cohort followed over a 24-month period. Their data set included 43 patients who made a total of 80 suicide attempts; 30% of the attempts were preinjury and 70% postinjury. Over 55% of the sample made a single attempt, 25.6% made 2 attempts, and 18.6% made 3 or more attempts. Of those that made 3 or more attempts, the repeat attempts occurred within 13 months of the index attempt, and over one third making multiple attempts used the same method. Excessive alcohol intake within the prior 24 hours, psychological distress brought on by antecedent stressors (arguments, loss of a significant relationship, negative feedback, etc), and hopelessness combined with high suicidal ideation, were associated with suicide attempt after TBI.

Treatment and Prevention

Prevention and treatment interventions for suicidal ideation and attempt can include pharmacological and psychosocial approaches, substance misuse treatment, environmental modifications, and when necessary, emergency intervention.^10,11 Given the multiple and complex challenges associated with this population, practitioners are encouraged to adapt and individualize treatment and prevention practices.¹¹

In terms of pharmacological intervention, SSRIs, namely sertraline, have been found to be effective an first line treatment for depression.¹² In addition to treating depressive symptoms, SSRIs may also improve other frequently reported TBI symptoms, such as irritability, aggression and poor impulse control. When prescribing medications following TBI, a conservative, approach to dosing (ie, “low and slow”) is recommended as individuals with TBI may be sensitive and susceptible to medication adverse effects.¹³

Psychosocial interventions, such as support groups, strengthening family relationships, and involving patients in social skills training have been effective in decreasing feelings of loneliness and isolation.¹⁰ In a controlled trial, Simpson et al randomized a group of adults with severe TBI and severe hopelessness or suicidal ideation to either an intervention group (n=8) or a wait list control group (n=9).¹⁴ The participants in the intervention group received a 20-hour, manualized cognitive behavior therapy program. Interventions assisted participants to live a positive lifestyle by promoting expression of thoughts and feelings, reframing/reappraising disturbing situations, acquire adaptive coping skills (ie, problem-solving, asking for help, etc), and promoting posttraumatic growth by making meaning of the brain injury. The treatment group demonstrated a significant reduction in hopelessness, and this effect was maintained at 3-month follow-up for 75% of participants.

Given that substance abuse, particularly alcohol abuse, is a risk factor for suicide attempt, substance abuse treatment can be an important component in a suicide prevention plan.^9,10 Environmental modifications, such as restricting access to sharps, guns, toxic chemicals, and other means of self-harm, has been shown to be effective in reducing suicide.10

Use of “No Harm Contracts” could be an appropriate intervention for patients with brain injury. A no harm contract is an intervention intended to prevent self-harm.¹⁵ It is a written agreement between a clinician and a patient (ie, person receiving psychotherapy or mental health services) whereby the patient promises not to harm themself. Reviewers of the literature on the efficacy of No Harm Contracts argue a lack of quantitative evidence to support the use of such contracts.¹⁶ Conceptual and ethical issues related to the use of No Harm Contracts include:

• Potential for coercion from the clinician for their own protection (ie, legal protection)
• Patients who agree to such contracts remain at high risk for suicide
• Contracts can falsely reassure clinicians which may result in decreased attention and concern about a patient’s suicide risk
• A significant percentage of patients that signed a contract either attempted or completed suicide

However, alternatives to No Harm Contracts have shown limited or questionable utility. Some clinicians believe that the absence of extensive research concerning the efficacy of contracts in the prevention of suicide should not be used to conclude that contracts have no therapeutic benefit or usefulness in treating suicidal patients.¹⁷ Some potential benefits could include:

• A patient’s willingness to engage in a contract can be a useful tool in assessing suicidality
• A contract allows the clinician an opportunity to express genuine concern and commitment to the patient which may bolster the therapeutic relationship
• Emphasizing a shared common goal may increase the connection between therapist and patient and provide a calming effect
• The contract may also provide an opportunity for the patient to safely explore self-destructive feelings and meanings of life and death.

Like all therapeutic interventions and techniques, those that address suicidality must be tailored to each patient.

Dr Seale is the Regional Director of Clinical Services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a psychological associate with independent practice, and is a Certified Brain Injury Specialist Trainer. He holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

References

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