Strategies for Preventing Suicide in TBI Patients

1
Strategies for Preventing Suicide in TBI Patients

• Janet E. Kemp, RN, PhD
• Lisa A. Brenner, PhD, ABPP
• Beeta Y. Homaifar, PhD
• VA Eastern Colorado Health Care System
• VISN 19 Mental Illness Research, Education, and
  Clinical Center (MIRECC)

2
Acknowledgments

• VISN 19 MIRECC
• Colorado Traumatic Brain Injury Trust Fund
  Program Education Grant

3
Relevance

• As of March 31, 2006, DOD reported that 1,179
  individuals have sustained a traumatic brain
  injury (TBI) during OIF/OEF.

4
TBI - Definition

• A bolt or jolt to the head or a penetrating head
  injury that disrupts the function of the brain.
  Not all blows or jolts to the head result in a
  TBI. The severity of such an injury may range
  from mild (i.e. a brief change in mental
  status or consciousness) to severe (i.e. an
  extended period of unconsciousness or amnesia
  after the injury). A TBI can result in short or
  long-term problems with independent function.
•  

5
Leading Causes of Brain Injury

• Falls (28)
• Transportation related events (20)
• Assaults (11)
•  Blasts
•  

6
TBI-Related Sequelae

• Sensory deficits
• Motor disturbances
• Psychiatric symptoms anxiety, depression,
  psychosis, personality changes
• Cognitive dysfunction attention, concentration,
  processing speed, memory, language and
  communication, problem solving, concept
  formation, judgment, initiation

7
Background TBI and Suicide

• Studies have shown that significant numbers of
  TBI patients endorse a post-injury history of
  suicidal ideation (Simpson and Tate, 2002).
• In comparison to the general population, people
  with a history of traumatic brain injury (TBI)
  have both a higher lifetime prevalence rate of
  suicide attempts (Silver et al., 2001 Simpson
  and Tate, 2005) and a significant increased risk
  of death by suicide (Teasdale and Engberg, 2001).

8
Objectives

• Because suicide is a significant issue for
  individuals with a history of traumatic brain
  injury (TBI), and since TBI aware suicide
  resources are limited
• A qualitative, interview-based study was
  conducted in a veteran population to clarify the
  needs of TBI survivors and their families.

9
Strategies for Preventing Suicide in TBI
Patients Background

• Replication study
• The Acquired Brain Injury Outreach Service
  (ABIOS) in Australia. (Kupier and Lancaster,
  2000).
• Findings
• Knowledge regarding interface between TBI/Suicide
• Increased coordination of services
• Individual education
• Discrepancy between needs of clients/family

10
Strategies for Preventing Suicide in TBI
Patients Recruitment

• Patients were recruited into the study if they
  met the following criteria
• Having received care from members of the ECHCS
  TBI Interdisciplinary Team
• Diagnosis of TBI and a history of suicidal
  behavior (ideation, self-harm, nonfatal attempts)
• Ability to provide informed consent and
  adequately respond to questions regarding the
  informed consent procedure
• Age 18-74
• 17 participants
• (13 TBI survivors and 4 family members)

11
Strategies for Preventing Suicide in TBI
Patients Methods

• Interviews were phenomenological in nature, and
  subsequent questions were based on the responses
  to open ended questions.

12
Strategies for Preventing Suicide in TBI
Patients Survivor Questions

• Have you ever felt really down or even thought
  about taking your life?
• What stopped you or what might have stopped you?
• Who did you turn to for help or what did you do
  and how helpful was this?
• If you got really down in the future where would
  you get help or who would you turn to?
• What do you think would be the best way to help a
  person with TBI who might be depressed or
  suicidal?
• How do you think your military experience has
  affected your feelings about taking your life or
  how you feel?

13
Strategies for Preventing Suicide in TBI
Patients Family Questions

• In general, what do you think would be the most
  effective way of preventing suicide among people
  with TBI?
• Who do you think a person with TBI might turn to
  for help if they were considering suicide?
• What do you think would be the most effective way
  of getting a message across to a person with TBI,
  who might be at risk of suicide?
• What is your relationship to the patient we are
  interviewing?

14
Strategies for Preventing Suicide in TBI
Patients Analysis

• Interviews tape recorded, transcribed and
  analyzed
• General and specific themes
• Comments outside specific questions
• All 13 patients had attempted suicide or had
  serious thoughts/plans
• Attempts and ideation ranged from 1-30 years
  post-TBI

15
Strategies for Preventing Suicide in TBI
Patients Findings

• Precipitating Themes
• Lack of connection
• Others/themselves
• Isolated, loneliness, being alone on the
  holidays, limited support from others, and social
  anxiety
• Loss of self lack of purpose in their lives.
• Frustration, anger regarding sequelae
• Hopelessness

16
Strategies for Preventing Suicide in TBI
Patients Findings

• Precipitating Themes

I think it took awhile before I realized and
then when I started thinking about things and
realizing that I was going to be like this for
the rest of my life, it gives me a really down
feeling and it makes me think likewhy should I
be around like this for the rest of my life? -
TBI Survivor
17
Strategies for Preventing Suicide in TBI
Patients Findings

• Preventative Factors
• Family and other significant relationships
• Children, spouses, parents, friends and pets.
• Sense of responsibility
• Professional help
• Medication, psychotherapy, support groups
• Active listening, clarifying questions, patience,
  talking slowly, repeating instructions several
  times
• Spiritual orientation
• Distraction

18
Strategies for Preventing Suicide in TBI
Patients Findings

• Family members
• Caregiver burnout
• Professionals need to know about TBI and enduring
  sequelae
• Conversations about the possibility of their
  family member becoming suicidal
• Involving them in treatment planning
• Assistance with resources and ongoing support
• Medication
• Case managers
• Somone to go to for help

19
Strategies for Preventing Suicide in TBI
Patients Findings

• Family members

The doctors need to know that the caregiver has
no idea what to expect. I dont know if they
just dont know that much about it or they just
dont get it.   - A TBI Survivors Wife
 
20
Strategies for Preventing Suicide in TBI
Patients Findings

• Common themes expressed by both patients and
  family members
• Continued support in the face of no functional
  improvement
• Provide hope while telling us the truth

21
Strategies for Preventing Suicide in TBI
Patients Warning Signs 

• Be aware of what can precipitate suicidal
  thoughts in people with TBI
• Loneliness
• Lack of connection
• Holiday times
• Lack of support
• Job/employment issues
• Lack of resources
• Frustration over tasks
• Bad news about prognosis

• I had my heart set on it, and for three days I
  just sat in my room and contemplated how to do
  this. And finally it got to the point where I
  tried.
• - A TBI Survivor
•  

22
Strategies for Preventing Suicide in TBI
Patients Limitations

• Cognitive deficits
• Small population size
• Saturation reached
• Limited to Denver area

23
Strategies for Preventing Suicide in TBI
Patients The Next Steps

• Receive feedback from participants
• Receive feedback from providers
• Continued study replication in other geographic
  areas

24
Take Home Message

• The fact that individuals continued to endorse
  suicidal behaviors up to 30 years post-TBI
  suggests that this is a problem that requires
  professional attention over the course of a
  lifetime

25
VISN 19 MIRECC 1055 Clermont St. Denver, CO 80220
Traumatic Brain Injury and Suicide
An information manual for clinicians
Introduction There is a need for more resources
that are specifically targeted toward Traumatic
Brain Injury (TBI) survivors who may be
considering suicide. Based upon this need,
researchers at the VISN 19 MIRECC applied for a
Colorado TBI Trust Fund Education Grant in order
to 1. Develop a resource manual and brochure
regarding TBI and suicide prevention aimed at
meeting the needs of Colorado State veterans. 2.
Make this material available to the state-wide
community of providers who work with brain
injured individuals.
Background Information 2 Suicide and TBI 8
Suicide Warning Signs 11 Provider Tips
13 Treatment-Literature 15 Our Study 16
Findings 17 Resources 18 References
24
26
VISN 19 MIRECC 1055 Clermont St. Denver, CO 80220
27
References

•  
• Ahmed, I., Fujii D. (1998). Posttraumatic
  psychosis. Seminar in Clinical Neuropsychiatry,
  3, 23-33.
• Alderfer, B., Arcinegas, D.B., Silver, J.M.
  (2005). Treatment of Depression Following
  Traumatic Brain Injury. Journal Of Head Trauma
  Rehabilitation, 20, 6, 544-562.
• American Association of Suicidology (2005).
  Resource Sheet 4 Basic Terms. Clinical Core
  Competencies Draft Curriculum.
• Centers for Disease Control and Prevention.
  (2005). WISQARS website and Fatal injury reports.
  Retrieved from http//www.cdc.gov/ncipc/wisqars/
  February 7, 2006.
• Cocoran, C., McAllister, T.W., and Malaspina, D.
  Psychotic Disorders. In Silver JM, McAllister
  TW, Yudofsky SC, editors. Textbook of Traumatic
  Brain Injury. Arlington, VA American Psychiatric
  Publishing 2005. 213-229.
• Fann, J.R., Burington, B., Leonetti, A., Jaffe,
  K, Katon, W., Thompson, R.S. (2004). Psychiatric
  Illness Following Traumatic Brain Injury in an
  Adult Health Maintenance Organization Population.
  Archives of General Psychiatry, 61, 53-61.
• Hibbard, M.R., Ashman, T.A., Spielman, L.A.,
  Chun, D. Charatz, H.J., Melvin, S. (2004)
  Relationship Between Depression and Psychosocial
  Functioning After Traumatic Brain Injury.
  Archives of Physical Medicine and Rehabilitation,
  85, 2, S43-S53.
• Hornstein, A. Social Issues. Textbook of
  Traumatic Brain Injury. Arlington, VA American
  Psychiatric Publishing 2005. 571-581.
• Jorge, R.E., Robinson, R.G., Arndt, S.V. (1993).
  Depression Following Traumatic Brain Injury.
  Journal of Affective Disorders, 27, 233-243.

28
References (cont.)

• Kraus, J.F. and Chu, L.D. Epidemiology. In
  Silver JM, McAllister TW, Yudofsky SC, editors.
  Textbook of Traumatic Brain Injury. Arlington,
  VA American Psychiatric Publishing 2005. 3-26.
• Langlois JA, Rutland-Brown W, Thomas KE.
  Traumatic brain injury in the United States
  Emergency department visits, hospitalizations,
  and deaths. Atlanta, GA Centers for Disease
  Control and Prevention, National Center for
  Injury Prevention and Control 2006.
• Maris, R.W., Berman, A.L., Silverman, M.M.
  (2000). Comprehensive Textbook of Suicidology.
  The Guilford Press New York.
• McCullagh S, Feinstein A. Cognitive changes. In
  Silver JM, McAllister TW, Yudofsky SC, editors.
  Textbook of Traumatic Brain Injury. Arlington,
  VA American Psychiatric Publishing 2005. p
  321-35.
• McIntosh, J. (2006). USA suicide 2003 Official
  final data. Fact sheet developed by the American
  Association of Suicidology from National Center
  Health Statistics. www.suicidology.org.
• National Center for Health Statistics (1998).
  Vital Statistics of the United States, 1996 Vol.
  II. Mortality, Part A. Washington, D.C. US
  Government Printing Office.
• Robinson, R.G. and Jorge, R.E. Mood Disorders.
  In Silver JM, McAllister TW, Yudofsky SC,
  editors. Textbook of Traumatic Brain Injury.
  Arlington, VA American Psychiatric Publishing
  2005. 201-212.
• Silver, J.M., Kramer, R., Greenwald, S.,
  Weissman, M. The association between head
  injuries and psychiatric disorders findings from
  the New Haven NIMH Epidemiological Catchment Area
  Study. Brain Injury, 15, 11, 935-945.