Multiple TBIs, Chronic Pain Linked to Increased Risk of Military Suicides

by U.S. Medicine

June 8, 2013

By Brenda L. Mooney

SALT LAKE CITY, UT – Two new studies may offer important clues as to why suicide rates are on the increase among military personnel and veterans.

Servicemembers who suffer more than one mild traumatic brain injury (TBI) face a significantly higher risk of suicide, according to research by the National Center for Veterans Studies at the University of Utah.1

Furthermore, the effect appears to last a lifetime, according to the study, based on a survey of 161 military personnel who were stationed in Iraq and evaluated for a possible TBI. Suicide ideation was used as the indicator of suicide risk because too few of the patients had actually made suicide attempts for statistically valid conclusions to be drawn.

Another study, which looked at more than 4 million VA health records, found that chronic back pain, migraine, and psychogenic pain are all associated with greater suicide risk.2

Both reports were published online by JAMA Psychiatry.

The Utah study found that the risk of suicidal thoughts increased significantly in concert with the number of TBIs, even when taking other psychological factors into account.

“Up to now, no one has been able to say if multiple TBIs, which are common among combat veterans, are associated with higher suicide risk or not,” said lead author, Craig J. Bryan, PsyD, assistant professor of psychology at the University of Utah and associate director of the National Center for Veterans Studies. “This study suggests they are, and it provides valuable information for professionals treating wounded combat servicemen and women to help manage the risk of suicide.”

TBI is considered a “signature injury” of the Iraq and Afghanistan conflicts, with  estimated prevalence for deployed troops ranging from 8-20%, according to DoD statistics.

Suicide rates, meanwhile, have been rising unabated. A recent VA study estimated that an average 22 veterans die by suicide every day in the United States. Earlier this year, the Army reported 325 total suicides among active and reserve troops in 2012, an increase over 283 suicides in 2011.

In this study, about 1 in 5 patients, 21.7%, who had ever sustained more than one TBI reported suicidal ideation at any time. For patients experiencing only one TBI, 6.9% reported having suicidal thoughts. None of the study subjects who had avoided a TBI reported suicide ideation, according to the researchers.

Increases were similar when the Iraq-based warriors were questioned about suicidal thoughts during the previous year, as opposed to at any time. Survey responses noted that 12% of those with multiple TBIs had entertained suicidal ideas during the past year, compared with 3.4% with one TBI and 0% for no TBIs.

“That head injury and resulting psychological effects increase the risk of suicide is not new,” Bryan suggested. “But knowing that repetitive TBIs may make patients even more vulnerable provides new insight for attending to military personnel over the long-term, particularly when they are experiencing added emotional distress in their lives.”

Pain and Suicide

To determine the link between chronic pain and suicide risk, Mark A. Ilgen, PhD, of the Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center in Ann Arbor, MI, and colleagues retrospectively examined the associations between clinical diagnosis of noncancer pain conditions and suicide.  

Using data from the National Death Index and VHA treatment records, researchers identified 4,863,036 individuals who received services in fiscal year 2005 and were alive at the start of fiscal year 2006. The data were examined for associations between death by suicide in fiscal years 2006-2008 and baseline clinical diagnoses of pain-related conditions such as arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, as well as psychogenic pain. 

Elevated suicide risks were observed for each pain condition except arthritis and neuropathy, although the association between pain and suicide death were reduced when analyses controlled for accompanying psychiatric conditions. Significant associations remained, however, for back pain, migraine, and psychogenic pain. 

“There is a need for increased awareness of suicide risk in individuals with certain noncancer pain diagnoses, in particular back pain, migraine, and psychogenic pain,” the study concluded.

The TBI study, meanwhile, was initiated during a six-month period in 2009 when 161 patients who received a suspected brain injury while on duty in Iraq were referred to an outpatient TBI clinic at a combat support hospital.

Study subjects — predominantly male, average age of 27, with 6.5 years of military service — were divided into three groups based on the total number of TBIs received during their entire lives– zero, one or multiple (two or more), with the most recent usually having occurred within the days immediately preceding their evaluation and inclusion in the study.

Using standard evaluation tools, patients were surveyed about their symptoms of depression, PTSD and concussions, and their suicidal thoughts and behaviors.

“An important feature of the study is that, by being on the ground in Iraq, we were able to compile a unique data set on active military personnel and head injury,” Bryan recounted. “We collected data on a large number of servicemembers within two days of impact.”

  1. Bryan CJ, Clemans TA. Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel JAMA Psychiatry. 2013 May 15:1-6. doi: 10.1001/jamapsychiatry.2013.1093. [Epub ahead of print]
  2. Ilgen MA, Kleinberg F, Ignacio RV, Bohnert ASB, et. al.  Noncancer Pain Conditions and Risk of Suicide. JAMA Psychiatry. 2013 May 22:1-6. doi:10.1001/jamapsychiatry.2013.908. [Epub ahead of print.]


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