Suicide Attempts Following Traumatic Brain Injury

1. Suicide Attempts Following Traumatic Brain Injury From Risk Identification to Prevention Rolf B. Gainer, Ph.D. Neurologic Rehabilitation Institute of OntarioNeurologic Rehabilitation Institute atBrookhaven Hospital

2. Learning Objectives • Identify psychiatric and psychological issues associated with suicidal behavior following TBI • Identify risk factors related to suicide • Develop an understanding of a multi-axial approach to assessment • Identify methods to reduce risk and address suicidality

3. by the numbers: • 32,000 deaths per year, over 1 million attempts • 8.3 million seriously considered suicide this past year • Men are 4 times as likely to die by suicide than women • Veterans are 2 times as likely to die by suicide than nonveterans • Younger and older veterans at a higher risk than middle-aged vets

4. the geography of suicide risk • living in rural Nevada, Wyoming, Idaho, Oregon, New Mexico, Oklahoma, Montana, Alaska • 11.6/100,000 in Rhode Island, New Jersey, Massachusetts • 67.0/100,000 in Nevada • being American Indian or Alaskan Native, youth or middle-aged

5. factors which set the stage for suicide • isolated from others • history of abuse • history of trauma • socio-cultural losses • domestic violence

6. Confluence of negative feelings and self-directed anger Thinking about “the end” Developing plans Selecting method Implementation phase Why Live?

7. Depression/ despair/ hopelessness Pre-existing and co-morbid psychiatric diagnosis History of previous attempts Family history of suicide Substance abuse / addiction history Individuals with neurobehavioral syndrome or seizure disorder at “enhanced risk” The TBI Factors

8. bringing a TBI home • PTSD • Physical and cognitive disability • Physical illness, ongoing medical care • Exposure to suicide by others • Relationship changes • Job loss/ financial problems

9. a personal life in turmoil • lack of social support network • isolation • barriers to accessing care • stigma of asking for help

10. Depression over loss of self and functional changes Experience of despair Feelings of worthlessness History of ideation and previous attempts, both pre- and post- TBI Setting the Stage

11. enhancing the risk • impulsive behaviors, limited self regulation • failed sense of belonging • perceived burden on others • loss of fear of death and pain

12. “The Process” of Suicide

13. Depression & Despair

14. Life Not Worth Living

15. Loss of Self

16. Disconnecting

17. Creating “The Plan”

18. The Act: Lethal Impulse

19. Ready Aim Fire A Different Model for Suicide • Ready • Fire • Aim • Role of impulsive behaviors • Executive Dysfunction • Thinking, planning, decision making problems • Role of Mood state instability

20. “Thinking about thinking” Unable to withstand impulse “Getting stuck” Suicide and Cognition

21. A Model for Understanding Suicide • Self worth vs. worthlessness • Hopelessness/depression/despair • Anger/Hostility • Plan • Method • Access • Previous history of suicidal thoughts and attempts • Capacity to act on plan • Social withdrawal • In TBI cases, impulsivity is an important factor

22. Prevalence & Risk • 17% of individuals with TBI report suicidal thoughts, plans and attempts in first 5 years (Teasdale, 2000) • Majority are males ages 25-35 at the greatest risk • Feelings of hopelessness a key factor • Comorbidity with psychiatric or substance abuse diagnosis • Role of identity crisis and social disruption (Klonoff and Tate, 1995) • Risk remains high for a 15 year period following first attempt

23. The Research • Social Withdrawal Syndrome (Sugarman, 1999) • Role of Affective Disorders (Morton and Wehman, 1995) • Awareness of deficits (Prigatano, 1996) • Disinhibition Syndrome (Shulman, 1997) • TBI as a stressful life event (Frey, 1995) • Increased risk associated with Mild TBI, psychiatric diagnosis and psychosocial disadvantage (Teasdale and Engberg, 2000)

24. The Perfect Storm: TBI and Suicide • High rate of depression within 1 year of injury (53.1%) • Cognitive deficits affect problem solving • Impaired self-regulation • Loss of social role • Loss of social connections • Disconnect from “rhythm of life” • Substance abuse

25. A Better Storm: TBI + PTSD • Co-occurrence rate of 44-47% • PTSD rate increases with physical injury • PTSD rate increases with multiple injuries • Concussion group had 27% PTSD rate • TBI with Loss of Consciousness had a 44% PTSD rate

26. Second Suicide Attempt: Greater Risk • Unipolar or bipolar depression and schizophrenia diagnosis have the highest risk for up to 31 years following the first attempt (Tidemalm, Swedish Cohort Study, BMJ 2008, DOI:10)

27. Understanding the Second Attempt • 11.8% of first attempters die by suicide, 87% within 1 year of the first attempt • Majority used the same methodology • Methods with highest later risk: hanging; drowning; jumping; cutting; poisoning • 84% of psychotic individuals who attempted suicide, died in a subsequent attempt

28. Aggression Trigger/Life Event Perception of Attack/Injury/Threat Anger Impulsivity External Aggressive Act Suicidal Act Depression following TBI Perception of Depression and Suicidal Ideation Suicidal Planning Impulsivity Suicidal Act Aggression and Suicide (Mann, The Neurobiology of Suicide and Aggression, 2000)

29. Issues of Diagnosis and Suicide Potential • Depression • Bipolar Disease/Manic Depression • Psychosis/Thinking disorder • Personality Disorders/Borderline Personality • Seizure Disorders/Pre and Post-Ictal Changes • Impulse Control Problems • Drug/alcohol abuse and addiction • Anger/Rage problems/ Episodic Explosive Disorder • Relationship of suicidal act to other aggressive acts

30. Brain Injury and Suicide Risk: Issues • History of prior attempts, pre- and post injury • History of psychiatric illness, pre and post injury • History of suicide in other family members • Passive ideation without an active plan • Role of disinhibition, including medication related problems • Anger/emotional dysregulation

31. Brain Injury Accelerates Psychiatric Conditions • Thinking problems • Emotional response to injury and disability • Difficulties with impulse control and self-regulation • Role of memory problems • Compliance with treatment • Social withdrawal • Social role changes • Perceived failure

32. Mood State and Behavioral Changes • Pre-injury psychiatric problems exacerbated by TBI • Emergence of new psychiatric symptoms post-injury • Effect of psychosocial stressors • Response to disability • Effectiveness of medication

33. Impulse Control Issues • Limited ability to self-manage mood state • Self-regulation of behavior is impaired • Problems in selecting behavioral alternatives • “Stuck” or repetitive quality of behavior • Difficulty in expressing feeling/mood problems to others • Anger management • Family and social role issues • Seizure related events, possible “kindling”

34. Trigger Events • Humiliation • Shame • Despair • Real or anticipated loss of relationship • Real or anticipated change in financial status • Real or anticipated change in health status

35. A Four Axis Approach to Evaluating Suicide Risk • Suicide Probability Scale (SPS) John Cull and Wayne Gill, 1988 • SPS uses a four axis system • Hopelessness • Suicide Ideation • Negative self-evaluation • Hostility

36. Hopeless Indicators • Loneliness • Inability to change life • Problems doing things, initiation • Not important to others • Unable to meet expectations • Few friends • No future/no improvement • Perceived disapproval by others • Feeling tired/listless • Can’t find happiness

37. Suicidal Ideation Indicators • Punish others by suicide • Punish self • “Better off dead” • “Less painful to die then living this way” • Thought of a plan/method • Think of suicide

38. Negative Self Evaluation Indicators • Not feeling like a worthwhile person • Not feeling appreciated by others • Not missed by others if dead • Things don’t go well • Not close to mother • Not close to father • Not close to significant other

39. Hostility Indicators • Anger/rage control, “gets mad easily” • Impulsive acts • Angry feelings towards others • Feels isolated from others • Senses anger from others • Can’t find a job/activity that I like

40. Practical Aspects of the SPS • Establishes scores in four domains • Compares score to “average” and standard deviation • Combines raw score data into a weighted T-score to define “probability” • Ranks probability risk from mild to severe • Considers major stressors/upsets over last two years, including past attempts in assessing risk potential

41. Suicide Probability Scale (SPS) • Predicts risk potential based on self-report of the individual to questions • The four axis model provides relationship to dimensions of suicide • Clinical importance/relevance of questions relates to risk factors • Limited bias caused by age, gender or ethnicity • Can be re-administered without practice learning bias • Current mood state dependent

42. Suicide Probability Scale (SPS) • Axial approach provides an opportunity to assess potential for suicidal thinking, planning and acting • Risk potential is assigned using data from the four domains of the scale • Test questions relate to current emotional state • Instrument supports, but does not replace a clinical interview and assessment • Specific questions/response trigger “risk”

43. Applying the Suicide Probability Scale to TBI • Cognitive issues must be considered • Reading and comprehension support may be required • The role of denial may effect score and obscure certain risk factors • Impulsive behaviour(s) will accelerate risk potential • Planning of suicide, including access and method may be poorly organized, but risk potential may be high • Passive issues may be significant to risk

44. History of prior attempts, pre- and post-injury History of psychiatric illness, pre- and post-injury Suicide in other family members Passive ideation without plan Role of disinhibition Substance abuse, prescription drug reaction Anger/emotional dysregulation The Past, Present, and the Future

45. Risk Assessment Process • Clinical assessment based on presentation of suicidal thoughts and plan and the individual’s current mental state • Assessment must include current psychological/psychiatric issues and diseases, past history and psychological stressors • Use of an assessment instrument will highlight issues, but cannot be used solely without a further assessment • Current behavioral risk issues must be evaluated • Prevalence of impulsive behaviors in individuals with TBI will enhance risk potential • Lack of planning due to cognitive deficits does not exclude the individual from risk assignment • Mood state issues must be considered

46. Risk Assessment • Current stressors and/or life changes • Medication and its effects • Substance use/abuse • Specific problem(s) that the individual cannot solve • Engagement in other self-harmful behavior(s)

47. TBI and Suicide: Shared Risk Factors • Age • Gender • Substance Use • Psychiatric Disorder • Aggressive Behavior

48. a clear and present danger • Threatening to hurt or kill self • Looking for ways to kill self • Seeking access to pills, weapons • Talking or writing about death, dying or suicide

49. Watch for the warning signs • Feeling hopeless • Trapped, no alternatives • Increased drug/alcohol use • Dramatic mood change • Withdrawal • Anxiety, agitation • Sleep problems, too little or too much • Rage, anger, revenge • Reckless actions • Lost purpose for living

50. Risk Identification Leads to Prevention • Is there evidence of suicidal thinking or self-harm? • Has the person experienced a loss of self-worth related to their disability? • Is there evidence of depression, including vegetative symptoms? • Is there a plan and/or method for the act? • Is there a passive component? • Is there a past history of suicide attempts? • Has anger or hostility increased in response to internal or external events?