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Traumatic Brain Injury 

and risk for suicidal 

thoughts and behaviors

Craig J. Bryan, PsyD, ABPP

National Center for Veterans Studies & The University of Utah

Tracy A. Clemans, PsyD and Lisa Brenner, PhD, ABPP

VISN 19 MIRECC & University of Colorado School of Medicine

1 
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Audience Question

What is your primary role within the VA? 

Please select one: 

 * Student, trainee, or fellow 

 * Clinician

 * Researcher

 * Manager or policy-maker

 * Other
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Agenda 

• Overview of TBI and suicide

• Risk factors and protective factors with TBI 

patients 

• Fluid vulnerability theory of suicide

• Recent findings regarding multiple TBIs & 

suicide risk

• Implications for clinical practice

• Discussion and questions
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TBI and Suicide

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TBI and Suicide

• First dedicated systematic review of suicidality and TBI 

(Simpson & Tate, 2007)

• Individuals with TBI 2.7 to 4 times greater risk for 

suicide compared to general population (Teasdale & 

Engberg, 2001; Harris & Barraclough, 1997)

• Higher lifetime history of suicide attempts (8.1% TBI 

versus 1.9% general population) (Silver et al., 2001)
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TBI and Suicide

• Higher levels of suicidal ideation in a large community 

survey in Australia (Anstey et al., 2004) 

• Elevated rates in all of these studies were significant

after adjusting for a range of covariates
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TBI and Suicide

• Recent systematic review of current evidence of 

prevalence/ risk of suicide deaths, and suicidal ideation 

and attempts post-TBI (Bahraini et al., 2013). 

• Review examined literature published from 2007 to 

2012

• Out of 1,104 abstracts, 16 studies met inclusion criteria

• Review included information about the risk of bias for 

each study
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Suicidal Ideation

Study Sample Sample 

Size 

Injury 

Severity 

Source of 

Ideation 

Time 

PostInjury

Prevalence 

of SI

28.3%

Risk 

of 

Bias 

Tsaousides 

et al 2011 

US 

Civilian, 

52% 

male, 

Age M 

(SD):

44.5 

(15.2) 

yrs

N = 356 

community

dwelling, 

 diverse 

Mild: 

37.6% 

Mod -

Sev: 

62.4% 

SI item 

on BDI-II 

last 2 

weeks 

M (SD) = 

5.9 

(9.2) yrs

LOW

(Bahraini et al., 2013) 
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Suicide Attempts

Prevalence 

of SA

7.1%

27.3%

Study Sample Sample 

Size 

TBI 

Severity 

Source of 

Attempt

Time 

PostInjury

Risk 

of 

Bias 

Breshears et 

al 2010

US 

Veteran, 

97% male, 

Age M

(SD): 30.3 

(11.57)

n=154 

archival data 

of TBI team 

evals

Mild: n=42; Mod: 

n=44; Sev: n=68

Medical

record review, 

clinical 

determination 

of SA post-TBI

14 yrs Mod

Gutierrez et 

al 2008

US 

Veteran, 

95% male, 

Age Med:

51, range 

38-65 yrs

n=22 attended 

TBI team, 

archival data 

of all w psych

IPU

Mild: n=1; Mod: 

n=11; Sev: n=10

Documented 

SA in psych 

discharge 

summaries 

post-TBI

median = 

15 yrs

Mod

(Bahraini et al., 2013) 
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Study Sample Sample 

Size

TBI 

Severity

Observed 

Suicides

Reference

Population

SMR or OR 

Overall: 1.55 (1.24, 1.92); 

Mild: 1.98 (1.39, 2.82); 

Mod - Sev : 1.34 (1.09, 1.64)

Overall: 2.95 

Risk 

of 

Bias

Brenner et 

al 2011

US Veteran, 

2001-2006

n=49,626 VHA 

users with TBI

Concussion: 

n=12,159

Contusion/ 

TIH: 39,623

n=105 5% random 

sample of VHA 

users without TBI, 

n=389,583

Low

HarrisonFelix et al 

2009

US Civilian, 

1961-2003

n=1678 TBI 

patients admitted

to rehab hosp 

and survived >1 

year

No LOC: 

n=129; <1 

day: n=495; 2-

7days: n=360; 

8-129 days: 

n=568

n=10, n=3.39 

expected

US Federal 

mortality rates by 

age, sex, race (1.42, 5.43)

Mod

Himanen 

et al 2011

Finland 

Civilian, 1950-

1971

n=192 neuro 

referrals to univ

hosp

Mild: n=65; 

Mod: n=68; 

Sev: n=53

Very Sev: n=5

3/75 deaths = 

4.2%

General

population

NR Mod

Mainio et 

al 2007

Finland 

Civilian, 1988-

2004

n=1877 general 

pop suicides in 

province

Concussion:

n=83; Lesion: 

n=20

103/1877 = 

5.5%

Subset of n=1877 

suicides with no 

TBI

NA Mod

Skopp et al 

2012

US Military, 

2001-2009

n=1764 suicides 

in US active 

military

Mild: n=97; 

Mod: n=25; 

Sev: n=5

Uncl: n=2

129/1764 = 

7.3%

Random selection 

matched 4:1 to 

cases by multiple 

demographics

Mild (OR): 1.1 (0.88, 

1.42), ns

Mod

Death by Suicide

(Bahraini et al., 2013) 
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TBI and Suicide

• Bahraini and colleagues (2013) systematic review found 

new robust evidence of the association between TBI 

and elevated risk for suicide

• Contributes to the debate about whether there is an 

elevated risk of suicide post-TBI, as some previous 

studies did not find a significant association
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Risk & Protective Factors 

with TBI patients

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Why is their an increased risk?

• Dysfunction of frontal lobes and frontal-subcortical circuits often 

associated with aggression, impulsivity, and poor decision making 

(Dyer et al., 2006; Powell & Voeller, 2004).

• Mann et al (1999) found that lifetime, externally directed aggression 

and impulsivity distinguished past suicide attempters from nonattempters. This study resulted in evidence for a link between 

executive dysfunction and suicide risk.

• A study by Oguendo and colleagues (2004) found that having a TBI 

increased pre-existing risk factors (e.g., aggression) for self-harm 

behavior, which increases risk post-TBI.
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Risk Factors for Suicide

• The presence of substance misuse was associated 

with increased risk in those with a history of TBI who 

died by suicide (Teasdale & Engberg, 2001) 

• Individuals with comorbid post-injury histories of 

psychiatric and emotional disturbance and 

substance abuse were 21 times more likely to have 

made a post-TBI suicide attempt than those without 

such histories (Simpson & Tate, 2005)
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Qualitative data- risk factors

• Loss of self after TBI associated with decreased sense 

of masculinity & increased sense of burdensomeness

(Brenner et al., 2009)

• Cognitive difficulties were “embarrassing and 

depressing.” Difficult to track warning signs, use coping 

skills, or consider alternatives to suicidal behavior 

(Brenner et al., 2009)

• Psychiatric and emotional disturbances (depression, 

worthlessness, anger, hopelessness, burdensomeness)

 (Brenner et al., 2009)
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Qualitative data- protective factors

• Social support

• Sense of purpose and hopefulness regarding future

• Religion/ spirituality

• Employment/ volunteerism

• Mental health treatment (Brenner et al., 2009) 
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Risk Factors- mTBI

• (a) 133 military personnel and 4 civilian contractors referred to 

outpatient TBI clinic in Iraq and (b) 55 military personnel selfreferred to outpatient mental health clinic in Iraq

• Evaluated the interpersonal-psychological theory of suicidal 

behaviors within these 2 samples

• In both samples, perceived burdensomeness demonstrated a 

significant relationship with suicidality above and beyond the effects 

of other risk factors for suicide

• Acquired capability was associated with suicidality, however only 

among TBI patients (Bryan, Clemans, & Hernandez, 2012)
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Risk factors- mTBI

• 158 military personnel referred to an outpatient TBI 

clinic in Iraq; 135 (85.4%) had a diagnosis of mTBI

• Increased suicidality was significantly associated with 

depression and the interaction of depression with

posttraumatic stress disorder symptoms

• Longer duration of loss of consciousness was 

associated with decreased likelihood for any suicidality 

 (Bryan, Clemans, Hernandez, & Rudd, 2012)
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Fluid vulnerability theory 

of suicide

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Fluid vulnerability theory 

Fundamental Assumptions: 

• Baseline risk varies from individual to individual

• Baseline risk is determined by static factors

• Baseline risk is higher and endures longer for 

multiple attempters (2 or more attempts)

• Risk is elevated by aggravating factors

• Severity of risk is dependent on baseline level and 

severity of aggravating factors

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(Rudd, 2006)
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Fluid vulnerability theory 

Fundamental Assumptions (cont’d):

• Risk is elevated by aggravating factors for limited 

periods of time (hours, days, weeks), and resolves 

when risk factors are effectively targeted

• Risk returns to baseline level only

• Risk is reduced by protective factors

• Multiple attempters have fewer available protective 

factors (support, interpersonal resources, 

coping/problem-solving skills, etc.)

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(Rudd, 2006)
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Time

Mild Zero attempter

Acute crisis

Risk level

Extreme

Multiple attempter
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Predispositions

Prior suicide attempts

Abuse history

Impulsivity

Genetic vulnerabilities

Physiology

Agitation

Sleep disturbance

Concentration problems

Physical pain

Emotion

Shame

Guilt

Anger

Anxiety

Depression

Behavior

Substance abuse

Social withdrawal

Nonsuicidal self-injury

Rehearsal behaviors

Cognition

“I’m a terrible person.”

“I’m a burden on others.”

“I can never be forgiven.”

“I can’t take this anymore.”

“Things will never get better.”

Trigger

Job loss

Relationship problem

Financial stress

Suicidal

Mode

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Multiple TBIs and Suicide Risk:

Recent Findings

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Sample Demographics
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Procedures 

• Patients referred to outpatient TBI Clinic in Iraq for 

evaluation / treatment of suspected TBI

• Patients completed standardized intake procedures:

– Self-report symptom and demographics measures

– Self-report concussion symptoms and history

– Clinical interview by psychologist

– Physical examination by physician

– Neurocognitive testing 
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TBIs & Psychiatric Symptoms
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Multiple TBIs and Suicide Risk

• Lifetime incidence suicide ideation (χ2 = 9.524, p = .009)

– Zero TBIs: 0%

– One TBI: 6.9%

– Multiple TBIs: 21.7%

• Past year incidence suicide ideation (χ2 = 5.276, p = .040)

– Zero TBIs: 0%

– One TBI: 3.4%

– Multiple TBIs: 12.0%

 (Bryan & Clemans, 2013)
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Multiple TBIs and Suicide Risk
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Multiple TBIs and Suicide Risk
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Limitations 

• Limited information about past head injuries (e.g., no 

information about previous LOC)

• Data collected in combat zone

• Small clinical sample, predominantly male

• Cross-sectional data only
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Predispositions

Prior suicide attempts

Abuse history

Impulsivity

Genetic vulnerabilities

Traumatic brain injury

Physiology

Agitation

Sleep disturbance

Concentration problems

Physical pain

Emotion

Shame

Guilt

Anger

Anxiety

Depression

Behavior

Substance abuse

Social withdrawal

Nonsuicidal self-injury

Rehearsal behaviors

Cognition

“I’m a terrible person.”

“I’m a burden on others.”

“I can never be forgiven.”

“I can’t take this anymore.”

“Things will never get better.”

Trigger

Job loss

Relationship problem

Financial stress

Suicidal

Mode

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Clinical Implications

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Clinical Implications

• Assess for substance misuse/abuse and psychiatric 

disorders (depression, PTSD) & increase access to 

mental health/substance abuse treatment (Brenner et, 2009)

• Assess for cognitive dysfunction and associated 

functional impairment (Brenner et al., 2009)

• Assess for suicide risk– suicide attempt history is the 

most reliable & robust predictor of current/ future 

suicidal behaviors (Bryan & Rudd, 2006)
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Clinical Implications

• How long should clinicians assess for suicide risk for 

TBI patients? Answer is forever! 

 Why?

TBI patients were followed for 15 years with no 

particular period of “greatest risk” identified (Teasdale & 

Engberg, 2001)

The mean period of post-injury suicide attempts was 

5 years (Simpson & Tate, 2002)
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Clinical Implications

• Implement coping and compensatory strategies as part 

of treatment (Brenner et al., 2009)

• Initiate safety planning (Brenner et al., 2009)

• Utilize empirically-supported interventions for conditions 

associated with the acquired capability for suicide, such 

as prolonged exposure or cognitive processing therapy 

for PTSD as they can prevent the eventual onset or 

worsening of suicidal ideation (Bryan, Clemans, & Hernandez, in 

press) 
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Clinical Implications

• Directly work to reduce the Veterans’ desire for suicide 

by targeting their maladaptive belief systems, including 

perceived burdensomeness and thwarted 

belongingness. (Rudd, 2012)

• Facilitate the use of religious/spiritual support, 

vocational/volunteer activities, social support, and family 

focused intervention (Brenner et al., 2009; Dausch & Saliman, 2009)
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Clinical Implications

• Restriction of access to lethal means for suicide (e.g., 

firearms, medications) is another strategy designed to 

directly target the acquired capability for suicide. 

• Engaging the Veteran and their friends/ family in 

assisting with the restriction of lethal means can 

significantly reduce the likelihood of an adverse 

outcome during a suicidal crisis (Bryan, Stone, & Rudd, 2012)
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Suicide Risk Management

Consultation Program
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Discussion

40
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Questions ?

 Craig J. Bryan, PsyD, ABPP craig.bryan@psych.utah.edu

 Tracy A. Clemans, PsyD tracy.clemans@va.gov

Lisa Brenner, PhD, ABPP lisa.brenner@va.gov

41
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References • Anstey, K.J., Butterworth, P., Jorm, A.F., Christensen, H., Rodgers, B., & Windsor, T.D. (2004). A population 

survey found an association between self-reports of traumatic brain injury and increased psychiatric symptoms. 

Journal of Clinical Epidemiology, 57(11), 1202-1209.

• Bahraini, N.H., Simpson, G.K., Brenner, L.A., Hoffberg, A.S., & Schneider, A.L. (2013). Suicidal ideation and 

behaviours after traumatic brain injury: A systematic review. Brain Impairment. 1-21.

• Brenner, L.A., Homaifar, B.Y., Adler, L.E., Wolfman, J.H., & Kemp, J. (2009) Suicidality and veterans with a 

history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies. Rehabilitation 

Psychology, 54(4), 290-397.

• Brenner, L. A., Gutierrez, P. M., Cornett, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A 

qualitative study of potential suicide risk factors in returning combat Veterans. Journal of Mental Health 

Counseling, 30, 211–225. 

• Brenner, L.A., Ignacio, R.V., & Blow, F.C. (2011). Suicide and traumatic brain injury among individuals seeking 

veterans health administration services. Journal of Head Trauma Rehabilitation, 26(4), 257-264.

• Bryan, C.J., & Clemans, T.A. (in press). Repetitive traumatic brain injury, psychological symptoms, and suicide 

risk in a clinical sample of deployed military personnel. JAMA Psychiatry. 

• Bryan, C.J., Stone, S., & Rudd, M.D. (2011). A practical, evidence-based approach for means restriction 

counseling with suicidal patients. Professional Psychology: Research and Practice, 42, 339-346.

• Bryan, C.J., Hernandez, A.M., Allison, S., & Clemans, T. (2013). Loss of consciousness, depression, 

posttraumatic stress disorder, and suicide risk among deployed service members with mild traumatic brain injury 

(mTBI). Journal of Head Trauma Rehabilitation, 28, 13-20. 
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References • Bryan, C.J., Hernandez, A.M., Allison, S., & Clemans, T. (2013). Combat exposure and suicidality in two samples 

of military personnel. Journal of Clinical Psychology, 69, 64-77

• Bryan, C.J., Clemans, T.A., & Hernandez, A.M. (2012). Perceived burdensomeness, fearlessness of death, and 

suicidality among deployed military personnel. Personality and Individual Differences, 52, 374-379

• Clemans, T.A., Bryan, C.J., & Hernandez, A.M. (in press). Combat experience and the acquired capability for 

suicide. In G. Sullivan, L. James, & B. Bongar (Eds.), The Oxford Handbook of Suicide in Military and Veteran 

Populations. New York, NY: Oxford University Press. 

• Dausch, B. M., & Saliman, S. (2009). Use of family focused therapy in rehabilitation for Veterans with traumatic 

brain injury. Rehabilitation Psychology, 54, 279–287.

• Dyer, K.F., Bell, R., McCann, J., (2006). Aggression after traumatic brain injury: analysing socially desirable 

responses and the nature of aggressive traits. Brain Injury, 20:11, 1163-1173.

• Mann, J. J., Waternaux, C., Haas, G. L., et al. (1999). Toward a clinical model of suicidal behavior

• in psychiatric patients. The American Journal of Psychiatry, 156, 181–189.

• Oguendo, M.A., Friedman, J.H., Grunebaum, M.F., Burke, A., Silver, J.M., & Mann, J.J. (2004). Suicidal behavior 

and mild traumatic brain injury in major depression. Journal of Nervous Mental Disorders, 192(6), 430-434.

• Powell, K. B. & Voeller, K. K. S. (2004). Prefrontal executive function syndromes in children. Journal of Child 

Neurology, 10, 785–797.

• Rudd, M.D. (2012). Brief cognitive behavioral therapy for suicidality in military populations. Journal of Military 

Psychology, 24 (6), 592-603.
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References • Rudd, M.d. (2006). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and 

chronic suicide risk. In T.E. Ellis (Ed.), Cognition and Suicide (p.355-368). Washington, DC: American 

Psychological Association.

• Silver, J. M., Kramer, R., Greenwald, S., & Weissman, M. (2001). The association between head injuries and 

psychiatric disorders: Findings from the New Haven NIMH Epidemiological Catchment Area Study. Brain Injury, 

15, 935–945. 

• Simpson, G., & Tate, R. (2005). Clinical features of suicide attempts after traumatic brain injury. The Journal of 

Nervous and Mental Disease, 193, 680–685.

• Simpson, G., & Tate, R. (2007). Suicidality in people surviving a traumatic brain injury: Prevalence, risk factors, 

and implications for clinical management. Brain Injury, 21, 1335–1351.

• Teasdale, T.W., & Engberg, A.W. (2001). Suicide after traumatic brain injury: A population study. Journal of 

Neurology, Neurosurgery and Psychiatry, 71, 436–440.