Longitudinal Study of Suicide After Traumatic Injury

Association of substance use with suicide mortality: An updated systematic review and meta-analysis

Background

Rates of suicide mortality and substance use have increased globally. We updated and extended existing systematic reviews of the association between substance use and suicide.

Methods

This systematic review and meta-analysis explored the association between substance use and suicide mortality in peer reviewed, longitudinal cohort studies published from 2003 through 2024. Risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled data were analyzed using a quality effects model. Meta-regression was used to assess the effect of moderation by study quality. Asymmetry in funnel plots and Doi plots were used to detect reporting bias.

Findings

The analysis involved 47 studies from 12 countries. Substance misuse (SMR: 5.58, 95 % CI: 3.63-8.57, I2: 99 %) was significantly associated with risk for suicide. Alcohol (SMR: 65.39, 95 % CI: 3.02-19.62, I2: 99 %), tobacco (SMR: 1.83, 95 % CI: 1.20-2.79, I2: 83 %), opioid (SMR: 5.46, 95 % CI: 3.66-8.15, I2: 96 %), cannabis (SMR 3.31, 95 % CI: 1.42-7.70, I2: 95 %), and amphetamine (SMR 11.97, 95 % CI: 3.13-45.74, I2: 99 %) misuse were each linked to higher rates of suicide mortality. The association between substance misuse and suicide was stronger for females (SMR: 12.37, 95 % CI: 7.07-21.63, I2: 98 %) than males (SMR: 5.21, 95 % CI: 3.09-8.78, I2: 99 %) overall and in analyses of specific substances. Further disaggregated data were not available to sufficiently explore for potential health inequities across social factors.

Conclusions

This meta-analysis highlights that substance misuse remains a significant suicide risk factor. It underscores the need for universal and targeted prevention and equitable access to effective interventions.

Lower Extremity Trauma is Associated With an Increased Rate of New Mental Disorder Diagnosis and Suicide Attempt

OBJECTIVES

To evaluate the risk of developing a new mental disorder diagnosis within 2 years of lower extremity fracture.

METHODS

DESIGN

Retrospective cohort study.

SETTING

National insurance claims database.

PATIENT SELECTION CRITERIA

Patients between 18 and 65 years with lower extremity, pelvis, and acetabular fractures without prior mental disorders as defined using International Classification of Diseases, 9th and 10th revision diagnosis codes were included. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, posttraumatic stress disorder, and suicide attempt.

OUTCOME MEASURES AND COMPARISONS

The individual lower extremity fracture cohorts were matched 1:4 with nonfracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within 2 years were compared using multivariable logistic regression.

RESULTS

Overall, the 263,988 patient-fracture group was 57.2% female with an average age of 46.6 years. Compared with controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significantly increased risk of being diagnosed with a queried mental disorder within 2 years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures [OR: 1.51, 95% confidence interval (CI): 1.39-1.64] and proximal femur fractures [odds ratio (OR): 1.36, 95% CI: 1.26-1.47], demonstrated greater risk of developing any of the queried mental disorders compared with fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients with patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients sustaining a Lisfranc fracture.

CONCLUSIONS

There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared with matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried greater risk compared with more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared with patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospital Patients: Formative Acceptability Evaluation of an eLearning Continuing Education Training

BACKGROUND

Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance.

OBJECTIVE

This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively.

METHODS

Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses' performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor.

RESULTS

A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (≥14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7).

CONCLUSIONS

Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33695.

Alcohol use and death by suicide: A meta-analysis of 33 studies

INTRODUCTION

Decades of research show an association between alcohol use and death by suicide. However, findings on the temporal link between alcohol use and death by suicide are unclear. In the most comprehensive meta-analysis on the topic to date, we analyzed data from longitudinal studies to determine if alcohol use is a risk for death by suicide. We also explored moderators to uncover conditions where the alcohol use-suicide link is strengthened/weakened.

METHODS

Our literature search of six databases yielded 33 eligible studies involving 10,253,101 participants (community, psychiatric, and military samples).

RESULTS

Alcohol use was associated with a 94% increase in the risk of death by suicide. Specifically, random-effects meta-analysis revealed alcohol use displayed small-to-large significant risk and odds ratios with suicide for quantity of alcohol use and alcohol use diagnosis/alcohol-related problems. Meta-regression generally indicated larger effect sizes for studies with a higher percentage of women, younger age, unadjusted estimates, longer follow-up periods, military samples, and higher frequencies and quantities of alcohol use (relative to drinker/non-drinker status).

CONCLUSION

Our study highlights alcohol use as a substantive risk factor for death by suicide and underscores the importance of monitoring alcohol use among suicidal individuals and screening for suicidality among heavier alcohol users.

Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death

Purpose of Review

This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers.

Recent Findings

The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide.

Summary

Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

Determinants of long-term unplanned readmission and mortality following self-inflicted and non-self-inflicted major injury: a retrospective cohort study

PURPOSE

To describe the characteristics of major injury and identify determinants of long-term unplanned readmission and mortality after self-inflicted and non-self-inflicted injury to inform potential readmission screening.

METHOD

A retrospective cohort study of 11,269 individuals aged ≥ 15 years hospitalised for a major injury during 2013-2017 in New South Wales, Australia. Unplanned readmission and mortality up to 27-month post-injury were examined. Logistic regression was used to examine predictors of unplanned readmission.

RESULTS

During the 27-month follow-up, 2700 (24.8%) individuals with non-self-inflicted and 98 (26.1%) with self-inflicted injuries had an unplanned readmission. Individuals with an anxiety-related disorder and a non-self-inflicted injury who were discharged home were three times more likely (OR: 3.27; 95%CI 2.28-4.69) or if they were discharged to a psychiatric facility were four times more likely (OR: 4.11; 95%CI 1.07-15.80) to be readmitted. Compared to individuals aged 15-24 years, individuals aged ≥ 65 years were 3 times more likely to be readmitted (OR 3.12; 95%CI 2.62-3.70). Individuals with one (OR 1.60; 95%CI 1.39-1.84) or ≥ 2 (OR 1.88; 95%CI 1.52-2.32) comorbidities, or who had a drug-related dependence (OR 1.88; 95%CI 1.52-2.31) were more likely to be readmitted. The post-discharge age-adjusted mortality rate following a self-inflicted injury (35.6%; 95%CI 29.9-41.8) was higher than for individuals with a non-self-inflicted injury (11.0%; 95%CI 10.4-11.8).

CONCLUSIONS

Unplanned readmission after injury is associated with injury intent, age, and comorbid health. Screening for anxiety and drug-related dependence after major injury, accompanied by service referrals and post-discharge follow-up, has potential to prevent readmission.

Evaluating the Cross-Sectional and Longitudinal Relationships Predicting Suicidal Ideation Following Traumatic Brain Injury

OBJECTIVE

Characterize relationships among substance misuse, depression, employment, and suicidal ideation (SI) following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Inpatient rehabilitation centers with telephone follow-up; level I/II trauma centers in the United States.

PARTICIPANTS

Individuals with moderate to severe TBI with data in both the National Trauma Data Bank and the Traumatic Brain Injury Model Systems National Database, aged 18 to 59 years, with SI data at year 1 or year 2 postinjury (N = 1377).

MAIN OUTCOME MEASURE

Primary outcome of SI, with secondary employment, substance misuse, and depression outcomes at years 1 and 2 postinjury.

RESULTS

Cross-lagged structural equation modeling analysis showed that year 1 unemployment and substance misuse were associated with a higher prevalence of year 1 depression. Depression was associated with concurrent SI at years 1 and 2. Older adults and women had a greater likelihood of year 1 depression. More severe overall injury (injury severity score) was associated with a greater likelihood of year 1 SI, and year 1 SI was associated with a greater likelihood of year 2 SI.

CONCLUSIONS

Substance misuse, unemployment, depression, and greater extracranial injury burden independently contributed to year 1 SI; in turn, year 1 SI and year 2 depression contributed to year 2 SI. Older age and female sex were associated with year 1 depression. Understanding and mitigating these risk factors are crucial for effectively managing post-TBI SI to prevent postinjury suicide.

The Trauma and Suicide Potential Index-5: Psychometric Evaluation in College Samples

We provide a brief description of the development of the Trauma and Suicide Potential Index-5 (TSPI-5) and report on the psychometric properties of scores from the new instrument. The TSPI-5 is designed to assess an individual's desire to attempt suicide due to experiencing a trauma. We examined the structure of the instrument in two independent undergraduate samples. Study 1 (N = 415) examined the structure of the TSPI-5 using exploratory structural equation modeling. Study 2 (N = 538) reexamined the instrument structure using the same modeling strategy and also examined other validity estimates. Study 1 demonstrated an adequate fit to the sample data (χ2 [1, N = 415] = 215.99, p < .001, comparative fit index (CFI ) = .969, Tucker-Lewis non-normed fit index (TLI) = .939, root mean squared error of approximation (RMSEA) = .319 [90% confidence interval (CI) = .283, .356], p < .001) and suggested evidence for unidimensionality. Study 2 confirmed the unidimensionality of the TSPI-5 as shown by acceptable fit estimates to the sample data, χ2 (5, N = 538) = 80.45, p < .001, CFI = .996, TLI = .99, RMSEA = .17 (90% CI = .140, .200), p < .001. Scale reliability estimates for the TSPI-5 were good in Study 1 (omega = .94) and Study 2 (omega = .96). The TSPI-5 is a brief unidimensional instrument and its scores demonstrated good reliability and validity for assessing suicide-related behaviors due to experiencing a trauma in undergraduate samples.

Determining suicide risk in trauma patients using a universal screening program

BACKGROUND

Trauma patients may be at elevated risk for subsequent suicide; however, it is unclear whether patients at risk can be identified during their initial presentation following injury. The objectives of this study were to evaluate the use of a standardized clinical decision support system for suicide risk screening developed by our hospital system and to determine the incidence of positive suicide screenings in our trauma population.

METHODS

Adult trauma patient screenings were performed by nursing staff during the triage process using the Columbia Suicide Severity Rating Scale, Clinical Practice Screener, Recent (C-SSRS). Adult trauma patients who had a suicide risk screening completed from February 2015 to November 2015 were evaluated retrospectively. Patients were divided into cohorts consisting of those with positive and negative screening assessments. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and a χ test where appropriate.

RESULTS

Overall, 3,623 of 3,712 patients (98%) completed a suicide risk screening during the study period. Those who went unscreened were not evaluated due to altered mental status/intubation/emergent surgery (97%), death (1%), or an unwillingness to cooperate (2%). The suicide risk screening result was positive in 161 of 3,623 patients (4%) in the study cohort. On univariate analysis, patients with a positive suicide risk screen result were more likely to be white (43% vs 32%; p = 0.01), identify English as their primary language (91% vs 73%; p < 0.01), have insurance coverage (48% vs 28%; p < 0.01), and were more likely to initiate a low-level trauma activation (27% vs 16%; p <0.01) than those who had a negative screening result. A positive suicide risk assessment result was moderately associated with patients of white race (odds ratio, 1.83; 95% confidence interval, 1.27-2.65) on multivariable logistic regression.

CONCLUSION

Our universal suicide screening process identifies an at-risk subpopulation of trauma patients.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic, level IV.

Risk Factors Associated With Attempted Suicide Among US Army Soldiers Without a History of Mental Health Diagnosis

IMPORTANCE

The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis.

OBJECTIVE

To examine risk factors for suicide attempt among soldiers without a previous MH-Dx.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective longitudinal cohort study using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), person-month records were identified for all active-duty Regular Army enlisted soldiers who had a medically documented suicide attempt from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis in our study was from September 16, 2017, to June 6, 2018. In a stratified sample, it was examined whether risk factors for suicide attempt varied by history of MH-Dx.

MAIN OUTCOMES AND MEASURES

Suicide attempts were identified using Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E95 × diagnostic codes. Mental health diagnoses and related codes, as well as sociodemographic, service-related, physical health care, injury, subjection to crime, crime perpetration, and family violence variables, were constructed from Army personnel, medical, legal, and family services records.

RESULTS

Among 9650 enlisted soldiers with a documented suicide attempt (74.8% male), 3507 (36.3%) did not have a previous MH-Dx. Among soldiers with no previous diagnosis, the highest adjusted odds of suicide attempt were for the following: female sex (odds ratio [OR], 2.6; 95% CI, 2.4-2.8), less than high school education (OR, 1.9; 95% CI, 1.8-2.0), first year of service (OR, 6.0; 95% CI, 4.7-7.7), previously deployed (OR, 2.4; 95% CI, 2.1-2.8), promotion delayed 2 months or less (OR, 2.1; 95% CI, 1.7-2.6), past-year demotion (OR, 1.6; 95% CI, 1.3-1.8), 8 or more outpatient physical health care visits in the past 2 months (OR, 3.3; 95% CI, 2.9-3.8), past-month injury-related outpatient (OR, 3.0; 95% CI, 2.8-3.3) and inpatient (OR, 3.8; 95% CI, 2.3-6.3) health care visits, previous combat injury (OR, 1.6; 95% CI, 1.0-2.4), subjection to minor violent crime (OR, 1.6; 95% CI, 1.1-2.4), major violent crime perpetration (OR, 2.0; 95% CI, 1.3-3.0), and family violence (OR, 2.9; 95% CI, 1.9-4.4). Most of these variables were also associated with suicide attempts among soldiers with a previous MH-Dx, although the strength of associations differed.

CONCLUSIONS AND RELEVANCE

Suicide attempt risk among soldiers with unrecognized mental health problems is a significant and important challenge. Administrative records from personnel, medical, legal, and family services systems can assist in identifying soldiers at risk.

Continuing Trauma: The Unmet Needs of Trauma Patients in the Postacute Care Setting

Trauma care has traditionally focused on prehospital and hospital settings, yet many injured patients report emotional distress in the postacute care setting, which is known to impair recovery. The objective of this study was to assess postdischarge emotional recovery and communication preferences. An observational cohort of 100 adult patients from our Level 1 Trauma Center was surveyed one to two months postdischarge. Among those employed preinjury, 44 per cent had not returned to work. Nearly half screened positive for emotional issues (posttraumatic stress disorder, depression, and/or psychological distress); of these, only 35 per cent considered getting professional help and only 10 per cent received help. The barrier most cited (58%) was cost; 42 per cent did not know how or where to get help. Most participants responded “no” or “I don't know” when asked if they had received information about coping with negative emotions after injury and how to seek help from a doctor to address these emotions. Two-thirds preferred to receive such information via phone call from a health care provider or by text. Eighty-nine per cent owned a cellphone. Our trauma systems are failing to provide comprehensive care or look at the ultimate outcomes of our patients, yet modern technology could provide needed resources to patients in novel ways.

Suicide Risk Among Wounded U.S. Service Members

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

Is the Digital Divide for Orthopaedic Trauma Patients a Myth? Prospective Cohort Study on Use of a Custom Internet Site

OBJECTIVES

Some have proposed that a so-called digital divide exists for orthopaedic trauma patients and that the clinical usefulness of the Internet for these patients is limited. No studies to date have confirmed this or whether patients would use a provided web resource. The hypotheses of this study were (1) a larger than expected percentage of trauma patients have access to the Internet and (2) if given access to a custom site, patients will use it.

DESIGN

Prospective cohort.

SETTING

Level 1 regional trauma center.

PATIENTS

Patients who were 18 years or older with acute operative fractures participated in this study. Enrollment was initiated either before discharge or at initial outpatient follow-up.

INTERVENTION

We conducted a survey of demographics, Internet usage, device type, eHealth Literacy, and intent to use the web site. Participants received a keychain containing the web address and a unique access code to our custom orthopaedic trauma web site.

MAIN OUTCOME MEASUREMENTS

Percentage of patients with Internet access and percentage of patients who visited the web site.

RESULTS

One hundred twelve patients were enrolled. Ninety-three percent (104/112) reported having Internet access (P < 0.0001). Only increasing age predicted lack of access (P < 0.015; odds ratio, 0.95). Most (95%, 106/112) planned to visit our site; however, only 11% (P < 0.001) accessed it.

CONCLUSIONS

The digital divide is a myth in orthopaedic trauma. Despite widespread access and enthusiasm for our web site, few patients visited. This cautions against the allocation of resources for patient-specific web sites for orthopaedic trauma until a rationale for use can be better delineated.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute Trauma Factor Associations With Suicidality Across the First 5 Years After Traumatic Brain Injury

OBJECTIVE

To determine whether severity of head and extracranial injuries (ECI) is associated with suicidal ideation (SI) or suicide attempt (SA) after traumatic brain injury (TBI).

DESIGN

Factors associated with SI and SA were assessed in this inception cohort study using data collected 1, 2, and 5 years post-TBI from the National Trauma Data Bank and Traumatic Brain Injury Model Systems (TBIMS) databases.

SETTING

Level I trauma centers, inpatient rehabilitation centers, and the community.

PARTICIPANTS

Participants with TBI from 15 TBIMS Centers with linked National Trauma Data Bank trauma data (N=3575).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

SI was measured via the Patient Health Questionnaire 9 (question 9). SA in the last year was assessed via interview. ECI was measured by the Injury Severity Scale (nonhead) and categorized as none, mild, moderate, or severe.

RESULTS

There were 293 (8.2%) participants who had SI without SA and 109 (3.0%) who had SA at least once in the first 5 years postinjury. Random effects logit modeling showed a higher likelihood of SI when ECI was severe (odds ratio=2.73; 95% confidence interval, 1.55-4.82; P=.001). Drug use at time of injury was also associated with SI (odds ratio=1.69; 95% confidence interval, 1.11-2.86; P=.015). Severity of ECI was not associated with SA.

CONCLUSIONS

Severe ECI carried a nearly 3-fold increase in the odds of SI after TBI, but it was not related to SA. Head injury severity and less severe ECI were not associated with SI or SA. These findings warrant additional work to identify factors associated with severe ECI that make individuals more susceptible to SI after TBI.

Correlates of suicidal ideation in physically injured trauma survivors

Epidemiologic studies have documented that injury survivors are at increased risk for suicide. We evaluated 206 trauma survivors to examine demographic, clinical, and injury characteristics associated with suicidal ideation during hospitalization and across 1 year. Results indicate that mental health functioning, depression symptoms, and history of mental health services were associated with suicidal ideation in the hospital; being a parent was a protective factor. Pre-injury posttraumatic stress disorder symptoms, assaultive injury mechanism, injury-related legal proceedings, and physical pain were significantly associated with suicidal ideation across 1 year. Readily identifiable risk factors early after traumatic injury may inform hospital-based screening and intervention procedures.

Differences Between Suicide Victims Who Leave Notes and Those Who Do Not

Background: Whether differences exist between those who do leave a suicide note and those who do not has not yet been comprehensively answered. Leaving a suicide note is not a random phenomenon: A minority, varying between 3–42%, of all suicide victims leave a note. Aims: To compare the group of suicide victims who leave notes with the ones who do not, using data from the Athens Department of Forensic Medicine, the largest in Greece. Methods: We examined sex, age, nationality, religious beliefs, marital and residential status, history of prior psychiatric disorder and psychiatric attempt(s), suicide method, physical disease, recent hospitalization, and existence of suicide notes. We completed psychological autopsy questionnaires after phone interviews with relatives of the suicide victims of a 2-year period (November 2007–October 2009). Results: Note writers, 26.1% of our sample, differed in the following: they died by hanging or shooting (p = .007), had no history of psychiatric illness (p < .001) or recent (i.e., within 12 months of the suicide) psychiatric hospitalization (p = .005). Conclusions: Our study showed that there are indeed differences between suicide victims who leave a note and those who do not. We also suggest some explanations for these differences, which could represent a valuable starting point for future research on this topic.

Predictors for suicidal ideation after occupational injury

Risk of suicide has been associated with trauma and negative life events in several studies. Our aim was to investigate the prevalence and risk factors of suicidal ideation, and the population attributable risk among workers after occupational injuries. We investigated workers who had been hospitalized for ≧3 days after occupational injuries between February 1 and August 31, 2009. A self-reported questionnaire including demographic data, injury condition, and the question of suicidal ideation was sent to 4498 workers at 3 months after their occupational injury. A total of 2001 workers (45.5%) completed the questionnaires and were included in final analysis. The prevalence of reporting suicidal ideation was 8.3%. After mutual adjustment, significant risk factors for suicidal ideation higher than "serious" in a self-rated severity scale (adjusted odds ratio, aOR=2.31; adjusted population attributable risk, aPAR=34.7%), total hospital stay for 8 days or longer (OR=1.98; aPAR=20.5%), intracranial injury (OR=2.30; aPAR=10.2%), and marriage status of being divorced/separated/widowed (OR=2.70; aPAR=10.0%). Three months after occupational injury, a significant proportion of workers suffered from suicidal ideation. Significant predictors of suicidal ideation after occupational injury included broken marriage, intracranial injury, injury severity, and total hospital stay. Identification of high risk subjects for early intervention is warranted.

Impulsive or depressive personality traits do not impede behavioral change after brief alcohol interventions

The authors investigated whether impulsivity and depression affect the success of interventions to reduce alcohol use. Unadjusted and adjusted regression models were constructed to analyze the effect of impulsivity and depression on 12-month outcomes of participants of a trauma center based randomized trial of brief personalized motivational interventions versus information and advice. Of 497 problem drinkers enrolled in the program, 248 completed the 12-month follow-up. Impulsivity, male gender, being older than 35, and intentional mechanism of injury had a direct association with drinking. After interventions, a decrease in drinking was found that was unaffected by the presence of impulsivity or depression indicators.

Predicting the future development of depression or PTSD after injury

OBJECTIVE

The objective was to develop a predictive screener that when given soon after injury will accurately differentiate those who will later develop depression or posttraumatic stress disorder (PTSD) from those who will not.

METHOD

This study used a prospective, longitudinal cohort design. Subjects were randomly selected from all injured patients in the emergency department; the majority was assessed within 1 week postinjury with a short predictive screener, followed with in-person interviews after 3 and 6 months to determine the emergence of depression or PTSD within 6 months after injury.

RESULTS

A total of 192 completed a risk factor survey at baseline; 165 were assessed over 6 months. Twenty-six subjects [15.8%, 95% confidence interval (CI) 10.2-21.3] were diagnosed with depression, four (2.4%, 95% CI 0.7-5.9) with PTSD and one with both. The final eight-item predictive screener was derived; optimal cutoff scores were ≥2 (of 4) depression risk items and ≥3 (of 5) PTSD risk items. The final screener demonstrated excellent sensitivity and moderate specificity both for clinically significant symptoms and for the diagnoses of depression and PTSD.

CONCLUSIONS

A simple screener that can help identify those patients at highest risk for future development of PTSD and depression postinjury allows the judicious allocation of costly mental health resources.

The impact of trauma mechanism on outcome: a follow-up study on health-related quality of life after major trauma

OBJECTIVES

To relate the trauma mechanism in a trauma population to health-related quality of life outcomes and mortality rates.

METHODS

A consecutive series of patients (>15 years old) with major injuries [Injury Severity Score (ISS) ≥10] treated during a 2-year period at a general hospital in a city area were included (n = 458). Baseline data were collected from medical records, and patients were followed up 12 months post injury. Outcome was measured by health-related quality of life (HRQoL) according to the SF-36 and musculoskeletal function according to the short musculoskeletal function assessment (SMFA). Mortality rates were collected during 7 years.

RESULTS

Of all patients, 86.9% had an unintentional injury, 4.4% had a self-inflicted injury, and 8.7% had been assaulted. The mortality rate during the acute phase and at 7 years post trauma did not differ between the groups with different trauma mechanisms. At 12 months, patients with unintentional injuries and assault victims had SF-36 ratings comparable to the general population, while patients with self-inflicted injuries had worse ratings in all SF-36 domains except physical function and general health. There were no differences between the groups regarding SMFA results.

CONCLUSION

Even though the follow-up rate was only 53%, this study showed that, at 12 months, patients with self-inflicted injuries had significantly lower HRQoL ratings. There was no difference in mortality with regard to trauma mechanism. Cooperation between emergency service and psychiatric care early in the acute phase could provide a golden opportunity to reach this patient group.