Concussion is Associated With a 2x Higher Risk of Suicide

December 28, 2018
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A meta-analysis shows people who have experienced concussion and/or mild traumatic brain injury are more likely to attempt suicide and to have suicidal ideation than people who have not experienced the injuries.

Much of the attention on traumatic brain injury (TBI) and suicide has focused on severe TBI, or on the rare cases of professional athletes with concussion histories who have died by suicide. Studies that have explored the larger connection between concussion (or relatively mild TBI) and suicide have been heterogeneous and difficult to base overall conclusions on.

But a recent meta-analysis in JAMA Neurology has brought that disparate research together and found an overall two-fold increase in suicide risk for people who have experienced concussion and/or mild TBI. The authors also found that the literature consistently demonstrated higher risk of suicide attempts and suicidal thought after concussion or mild TBI.

"This is a large-scale wake-up call. We're not just talking about professional football here. We're talking about your friend ... who gets in a car crash, your buddy who served in Iraq or your high school student who was hit hard in hockey. This is something that could happen to anyone." – Todd Karsies, MD, MPH

“This is a large-scale wake-up call,” says Todd J. Karsies, MD, MPH, a Critical Care physician at Nationwide Children’s Hospital and senior author of the study. “We’re not just talking about professional football here. We’re talking about your friend down the street who gets in a car crash, your buddy who served in Iraq or your high school student who was hit hard in hockey. This is something that could impact anyone.”

The research considered 17 total publications that had originally studied general population cohorts along with more discrete populations, including military veterans, patients with depression, the homeless, middle and high school students and people admitted to a trauma unit. The meta-analysis pooled those publications, statistically accounting for the differences between studies with study design, population and reported results.

While there was high statistical heterogeneity, the authors quantified the pooled increase in suicide because it is such a clear outcome. They found a general increase in the risk of suicide attempts or ideation, but they did not pool these results because of the variable ways these outcomes were identified across studies.

A number of very important findings simply couldn’t be made because of the way the data was originally collected or because of the eras of collection, says Dr. Karsies, who is also an assistant professor of Clinical Pediatrics at The Ohio State University College of Medicine. For example, the analysis could not capture the effect of “Return-to-Play” protocols or other concussion management strategies that have become increasingly prevalent in the last decade.

No study, in fact, has analyzed the association of young athletes and suicide, though one ongoing prospective registry in Texas for high school athletes who sustain concussions, and another ongoing prospective registry for college athletes, may ultimately provide some answers.

To be sure, more than 99 percent of people who have a concussion will have no suicide-related outcome. What this study does, however, is highlight to every provider that suicide is a possible outcome of concussion in a small subset of the population, says Dr. Karsies. It should also push more researchers to study this outcome across different populations, including more precisely identifying the subset who may experience suicidality.

“Places and providers that see concussion must begin thinking about the most serious long-term behavioral health outcomes. We need to have a real sense of urgency about this,” Dr. Karsies says. “Should we be conducting extra screening for depression or other suicide risk factors for people who experience concussion? It certainly affects how I think about this as an intensive care physician, and it should for any other provider who sees these patients.”


Fralick M, Sy E, Hassan A, Burke MJ, Mostofsky E, Karsies T. Association of concussion with the risk of suicide: a systematic review and meta-analysis. JAMA Neurology. 2018 Nov 12. [Epub ahead of print]


Photo credit: Nationwide Children’s