suicide prevention after traumatic brain injury

a public health approach to suicide prevention after TBI

Risk Reduction & Health Promotion

Translational Neuroscience Conference September 27, 2013

Learning Objectives 1.  Gain information about the public health significance of TBI and

suicide 2.  Gain an understanding of how risk reduction and health promotion

are two distinct but complementary approaches within the field of public health

3.  Learn how both approaches can be applied to guide suicide

prevention efforts for those with TBI 4.  Learn how a comprehensive suicide prevention strategy for

individuals with TBI will include approaches to risk reduction and health promotion that moves beyond individual behavior

Overview

1 2

4 3

Proposed Solution

Significance of the Problem

Breaking it Down

Putting it All Together

significance of the problem

one

The Impact of TBI

•  Each year, approximately 1.5 million Americans survive a traumatic brain injury

•  An estimated 5.3 million U.S. citizens are

living with disability as a result of a TBI

CDC, 2010

Potential Sequelae of TBI

cognitive deficits

mood and behavioral issues

sensory and motor impairments

sleep disturbance and pain

seizures

Psychiatric Illness Following TBI

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1 2 3 4 5 6

mild

mod-‐sev

mild psy

mod-‐sev psy

TBI of all severity levels associated with increased risk of psychiatric illness

Fann et al.,2009

TBI in the Post 9-11 Era

•  Reported rates of TBI in deployed OEF/OIF service members have ranged from 15.2% to 22.8%

•  Majority of TBIs sustained are mild TBI

•  Veterans with TBI, particularly mTBI at increased RISK for developing PTSD

Hoge et al. 2008; Terrio et al., 2009

Potential Reasons

•  Impaired emotional regulation resulting from damage to the medial pre-frontal cortex

•  Additional stressors that occur after mTBI

Bryant et al. 2009

Does More Equal More?

Veterans with both conditions are at greater risk for PC symptoms than those with either PTSD, mTBI, or neither

Brenner et al., 2009

PC Symptom Reporting


PTSD only = 82 (7%) mTBI only = 555 (45%) PTSD + mTBI = 323 (26%) None = 287 (23%)

N= 1247 OEF/OIF soldiers

Any PC Symptom (n = 389)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

No mTBI & no PTSD

Had PTSD but no mTBI

Had mTBI but no PTSD

Had mTBI & PTSD

1.00

2.74

4.03

6.27

Adjus

teda (P

R)


Total no. of soldiers (N = 1247)

Adjusted for age, gender, education, rank, and MOS

Symptom: Headache (n=204)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

No mTBI & no PTSD



Had mTBI & PTSD

1.00

2.79

4.26

5.91

Adjus

teda (P

R)



Symptom: Dizziness (n = 51)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

No mTBI & no PTSD



Had mTBI & PTSD

1.00

4.37

3.00

6.48

Adjus

teda (P

R)



Symptom: Memory (n=154)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

No mTBI & no PTSD



Had mTBI & PTSD

1.00

4.00

6.22

12.70

Adjus

teda (P

R)



Symptom: Balance (n = 62)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

No mTBI & no PTSD



Had mTBI & PTSD

1.00

5.316.04

12.91

Adjus

teda (P

R)



Symptom: Irritability (n = 215)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

No mTBI & no PTSD



Had mTBI & PTSD

1.00

3.19 3.45

6.61

Adjus

teda (P

R)



Impact on Functioning

ratings of general health

sick call visits

missed workdays

physical symptoms

PTSD significantly associated with

Hoge et al. 2007

Suicidal Self Directed Violence After TBI

Individuals at TBI are at increased risk for Suicidal Ideation Suicide Attempts Suicide

Bahraini et al 2013; Simpson & Tate, 2002

Shared Risk Factors

TBI Suicide

Age

Gender

Substance Use

Psychiatric Illness

Aggression

TBI Specific Risk Factors for Suicide

•  Psychiatric/Emotional Disturbance

•  Substance Abuse

•  Problem solving deficits •  Psychosocial stressors •  Loss of self, lack of purpose •  Social isolaOon, loneliness

Other risk factors related to the injury

TBI is a “Disease Process”

For some, TBI is a lifelong process that may be both disease

and

Masel & DeWiR, 2010

Optimal Health Trajectory

Suicide Risk Trajectory

TBI Shifts the Health Trajectory

Time



TBI Shifts the Health Trajectory

Time

TBI



Timing Matters

Time

TBI

the proposed solution

two

Suicide Prevention Across the Lifespan

Focus on op<mal health trajectories

Pathways to Optimal Health

•  Risk Reduction •  Reduce exposure to and cumulative

impact of health risks after TBI

•  Health Promotion •  Increase positive health outcomes and

protective factors in those with TBI

The Overarching Goal

Mitigate the impact of TBI on health trajectory and prevent the

downward pressure towards suicide risk

Op<mal Health Trajectory


Shifting Towards Optimal Health

Time




Time

TBI




RR

Time

TBI HP




Time




Time

TBI




Time

TBI RR HP

breaking it down three

Proposed Framework

When? Timing of Prevention Who? Populations and Sub-groups

Where? Contexts and settings

What? Intervention Targets

when to promote, prevent, & treat?

Prevention

To PREVENT means “to keep something from happening”

The Current State of Suicide Prevention

•  Weighted towards crisis intervention “cliff-edge”

approach

•  Current evidence- based interventions designed to prevent re-attempts (none specific to TBI)

•  Less research on interventions that prevent the onset of suicidal SDV behavior



Shifting the Focus Upstream

Time

Traditional Prevention Model

Onset of a disorder or condition

Primary Prevention

Secondary Prevention

Tertiary Prevention

Severity of a disorder or condition

Disability associated with a disorder or condition

BEFORE

AFTER

Public Health

Prevention

Populations

Socio-cultural

Medical Treatment Individuals Biological/ Behavioral

The Need for an Integrated Model

Prevention

Treatment

Maintenance

Before the onset of suicidal SDV behavior

Once suicidal SDV behavior that is not fatal has occurred

Preventing repeated acts of suicidal SDV, fatal and non-fatal

THE IOM Healthcare Continuum

Suicide Prevention

IntervenOons, policies, and acOons that prevent suicidal SDV behavior from iniOally occurring

Treatment and Maintenance

Occurs after suicidal SDV has initially occurred, non-fatal

–  Reduce associated injury and disability

–  Prevent repeated acts of suicidal SDV

–  Treat other factors contributing to suicide risk (e.g., hopelessness)

Prevention Treatment

Can include the treatment of precursors of suicide risk— depression, substance abuse, hopelessness Targeting hopelessness to prevent re-attempt or CBT for suicide prevention

When Is Treatment Still Prevention?

The Role of Health Promotion

•  Emphasis on enhancing well-being rather than prevention of disease or illness

•  Increases protective factors, an area that has

been vastly understudied •  Applies to all individuals regardless of disease

or illness status, history or current risk level

Comprehensive Strategy

Reduce rates of SUICIDE MORTALITY in a given population

Promotion

Prevention

Treatment

Maintenance

who to intervene with?

Universal ALL MEMBERS of a given population regardless of risk

Selected Sub-populations who may be AT ELEVATED RISK

Indicated Members of a given population with SPECIFIC RISK CONDITIONS

Levels of Prevention

Application to TBI

•  What do we know about our population? •  Who are most vulnerable? •  What are their characteristics? •  What risks/behaviors are present in their

lives?

ALL INDIVIDUALS in a given TBI population regardless of risk level

Universal Prevention

TBI POPULATIONS who may be at greater risk for suicidal SDV

Selected Prevention

TBI SUB-POPULATIONS with identified risk conditions

Indicated Prevention

which setting or context?

Suicide is Multifaceted

Suicide is an individual act; however, it results from a complex interaction of biological, genetic, psychological, SOCIOLOGICAL and environmental factors

Socio-Ecological Model of Prevention 4th LEVEL 3rd LEVEL

I

2nd LEVEL

Individual

1st LEVEL

Community & Institutional Interpersonal Socio-political

Dahlberg & Krug 2002

Individual

Personal Characteristics Biological Factors Behavior

Psychiatric hx

Social Skills

Cognitive deficits

Substance use

Hopelessness

Interactions between two or more individuals

Interpersonal

Family Communication

Social Support

Parent-Child Interactions

Intimate Partner Violence

Community & Institutional

Settings and institutions in which social relationships take place

Schools (K-12)

Colleges/Universities

Workplace

Healthcare Institutions

Neighborhoods

Community Centers

Socio-political

Larger, macro-level factors that contribute

to disparities among groups of people and/or environmental factors that influence risk for suicidal SDV

Societal norms

Socioeconomic status

Economic policies

Geographical location

Access to healthcare

Unemployment rates

What factors to Target?

Proposed Intervention Targets?

modifiable RISK and PROTECTIVE

factors for suicide or PRE-CURSORS to

suicidal behavior in those with TBI

Multiple Targets

Prevention interventions may be more effective when they target MULTIPLE

risk and protective factors rather than just one

High Impact Targets

Psychiatric Illness Substance Abuse Hopelessness

Social Connectedness Problem Solving Physical Activity

four putting it all together

Multicomponent Interventions

Prevention efforts can be maximized by interventions that simultaneously address risk and protective factors across the socio-ecological domains

Maton et al. 2004; Sandler et al. 2004

Single Component Evidence-based psychological interventions for depression for individuals with TBI

Approach: Risk Reduction Target: Depression Level: Indicated Domain: Individual

Multiple Component Tele-health or computerized delivery of evidence-based psychological interventions for depression for individuals with TBI living in rural areas

Approach: Risk Reduction Target: Depression and Treatment Access Level: Indicated Domain: Individual and Societal

Combining HP and RR Internet based Family Problem Solving Intervention for emotional and behavioral disturbance after Pediatric TBI Targets: Emotional and Behavioral Disturbance;

Parent–Child Interactions; Problem-solving skills, Access to Care

Level: Selected or Indicated Domains: Individual, Interpersonal, and Societal

Substance Use An educational DVD for providers to facilitate patient and family education regarding the risk of substance use after TBI Approach: Risk Reduction Targets: Substance use, Patient-Provider Communication Level: Universal or Selected Domain: Individual and Institutional

Promising Interventions Peer-Mentoring Programs to increase Social Integration for Persons With Traumatic Brain Injury (Struchen et al., 2011)

Window to Hope: A psychological intervention for hopelessness (Simpson et al., 2011)

Physical Exercise for post-TBI depression, cognitive deficits Complementary and alternative and integrative medicine

Research Considerations

•  “Practical” science •  Collaborating across systems/contexts •  Community partnered research •  Dissemination and Implementation of

evidence based practices

Questions?

Nazanin Bahraini, PhD Director of Education, VISN 19 MIRECC

Assistant Professor of Psychiatry

University of Colorado Anschutz Medical Campus

http://www.mirecc.va.gov/visn19/

suicide prevention after traumatic brain injury

Health & Medicine

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