**Transcript of Cyberseminar**

**Timely Topics of Interest**

**Traumatic Brain Injury and risk for suicidal thoughts and behaviors**

**Presenters:  Craig J. Bryan, PsyD, ABPP; Tracy A. Clemans, PsyD; Lisa Brenner, PhD, ABPP**

**July 2, 2013**

**Traumatic Brain Injury and risk for suicidal thoughts and behaviors**

**July 2, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:  lisa.brenner@va.gov; tracy.clemans@va.gov; craig.bryan@utah.edu.*

Moderator:And we are at the top of the hour, so at this time I’m going to turn it over to Dr. Ralph DePalma who’ll introduce our speakers today.

Palmer:Thank you very much Molly and it’s a great pleasure today to have several mental health professionals who’re working with our Veterans who will present the association between traumatic brain injury and risk for suicidal thoughts and behaviors. Craig Bryan at the National Center for Veterans at Utah, Tracy Clemans with him at the same institution and Lisa Brenner will be the discussion; she is the Director at VISN 19 MIRECC at Colorado. Tracy will open the discussion, then Craig, then Tracy and then Lisa. Thank you very much.

Moderator: During the conference...

Tracy:Thank you to Dr. Palmer and at this time I’m going to ask Dr. Clemans are you ready to share your screen?

[crosstalk]

Moderator: Thanks Tracy we can see your slide, go ahead and pickup the handset and we’re to go.

Clemans: Okay Craig: Thank you so much Dr. Palmer for the very nice introduction. We’re certainly very happy to be here today to discuss the really important topic uh-huh about the impact of traumatic brain injury on the risk for suicidal thoughts and behaviors among our Veterans and before we begin the presentation, I would like to ask if you could just take a minute to answer the pool question, there on your screen about your primary wall within the VA, and if you feel like doing this, this is going to help us guide our discussion today. So I’ll just give you a minute for those of you who would like to answer that question?

Moderator: Thank you Dr. Clemans, so far attendees as you can see you do have a pool question which is up on your screen at this time. Please click the circle next to the answer which best describes your primary role within the VA and press submit. It looks like we’ve already had 70% of our audiences vote so that’s great. The answers are still streaming in, so I’m going to go ahead and give people a just a few more seconds. Well I’ve your undivided attention and I’m going to remind our attendees that I’ll not unmute you, so please do not use the hand raising function icon. Thank you so much. All right and it looks like 80% have voted so I’m going to go ahead and close the pool and I’m going to share the results. So Dr. Clemans you should be able to see those on your screen, if you would like to talk through them real quick.

Clemans: Okay yes, it looks like the majority of our audience members today are clinicians and we’ve about 11% of researchers, 5% are student or trainees or solos and 8% are managers or policy makers. So thank you for doing that, I appreciate that, that really just helps us guide our discussion. So we can go ahead and go forward Molly.

Moderator:You should see the pop up there you go. 

Clemans: Okay so as far as our gender today, I’m going to be talking about literature base that is out there on TBI and suicide including risk and protective factors within TBI patient, Dr. Bryan is going to be speaking about the Fluid vulnerability theory of suicide and recent findings from a study regarding multiple TBIs and suicide risks. I’m going to end our presentation today talking about the implications for clinical practice and then Dr. Brenner is going to lead us in discussion of this really important topic and we’ll make sure we leave time at the end for people’s question so, so regarding the literature base that is out there [telephone ringing sound], so very first, review of suicidality and TBI was conducted by [telephone ringing sound] and then 7, this, this systematic review looks at [telephone ringing sound] internal articles from 1960.

Moderator:I’m sorry I apologize [telephone ringing sound]. Presenters can you please [buzzer sound] mute your audio and for our attendees your audio should be muted. Sorry about that Dr. Clemans go ahead.

Clemans:Among the most robust of these studies were three population studies and one meta analysis. One in particular by Teasdale & Engberg with the first population based evidence of elevated suicide rates and civilians after a TBI and they looked at individuals who had been admitted to Danish hospitals from 1979 to 1973 who had a primary or secondary diagnosis of TBI and their total number of subjects was almost a 150,000 and what they found was those individuals with a TBI were 2.7 to 4 times at greater risk for suicide compared to the general population. They actually follow these subjects up to 15 years and found no particular period of greatest risk for these individuals, which is really important for clinicians to keep in mind and will discuss this a little more later.

Another study by Silver and colleagues was a probability sample of participants who were part of the Epidemiological Catchment Area Study and within their study the rate of TBI was 8.5% and they found that those of TBI were significantly more likely to have had a lifetime history of a suicide attempt. So you can see that on your screen at 8.1% in the TBI group versus 1.9% in the general population and I want you to keep in mind that this risk was significant after the authors adjusted for different variables such as demographics and alcohol abuse and psychiatric disorders. I need to go back here just one second, sorry about that. Okay on our next slide there, we found that there were higher levels of suicidal ideation in a large community survey that was conducted in Australia and their participants they followed for over a total of 20 years.

Of the total sample of about 6% reported a history of TBI and this was an average of 22 years after their injury. They found out within in the TBI group, they were more likely to report that life was hardly worth living; they had thoughts that they would really be better off dead, and had thoughts of taking their own life. So as you can see the Simpson & Tate review that they did really contributed to this debate that whether there is actually this elevated risk of suicide after TBI and so has been a couple of studies that did not find this association. So although this review from since an intake was super helpful to the field it was a bit limited by the fact that there were a small number of TBI studies that existed prior to 2007. So Bahraini and colleagues completed a very recent systematic review and they worked at the literature from 2007 to 2012, looked at approximately a 1000 abstracts and 16 of the studies actually met their inclusion criteria.

One of the things that’s really noteworthy about this systematic review is that they included the global rating of risk of bias for each observational studies that they looked at and what this means is a low risk of bias means that the study had results that were valid, moderate bias means that the results are valid but the study still was susceptible to some bias and high bias meaning that the study had significant flaws making the results of the study invalid. So of the 16 studies that they worked at only three have this low risk of bias and I’m going to talk about a couple of those here right now. You can see in this chart here, one of the first studies that I want to talk about is among a sample of civilian adults who are living in the community who had mild‐to‐severe TBIs and they found a prevalence rate of suicidal ideation among the sample at 28% which was really similar to the rates found in the Simpson and Tate review I mentioned earlier.

So this study along with some of the studies in the Simpson and Tate reviews found that significant levels of suicidal ideation is present in patients with the TBI at the chronic state and so really a level of distress among TBI survivors can continue to the extent even several years after their injury. The next two studies I want to highlight are regarding suicide attempts. The first one there that you can see looked at archival data of 154 Veterans who had sustained TBIs between 1954 and 2005. They found that 7% of their sample had a history of suicide attempt after the TBI and almost half of these individuals had been in more than one attempt and that’s really important for clinicians to know and Dr. Bryan is going to get into that in a minute because a really significant risk factor for suicide are those the individuals that have had multiple suicide attempts. The second study listed there in the table with Guttierez and colleagues and they looked at data from 114 acute psychiatric admissions among 22 Veterans that had a history of TBI.

They only looked at those records of Veterans after they sustained a TBI. In this sample 24, I’m sorry, 27% of this sample made a total of 14 suicide attempts with half of these attempts requiring medical attention; which is really noteworthy because they indicate that their attempt was of higher lethality. Can I go back here once? In this table so the second time I’m just going to focus on the first two studies and this is regarding look at death by suicide among TBI patients. The first one was Brenner and colleagues and what they did is they looked at the history of TBI diagnosis and death by suicide among Veterans who are receiving care within the VA between 2001 and 2006 and they found that the Veterans with the TBI were 1.55 times more likely to die by suicide than those without a history of TBI. They also looked their injury severity of the TBI and so in the mild group, they found that the mild TBI Veterans were almost two times more likely to die by suicide and the moderate-to-severe TBI Veterans were 1.34 times more likely to die by suicide. You can see that all the way to the right on the chart is the risk of bias being low which really suggest that the results of this study were valid.

The second study on this chart I want to highlight was by Harrison Felix and colleagues. They reviewed medical records of about 1700 civilian individual who had been admitted to a Rehab Hospital between the years 1961 and 2002 and they found that the individuals with the TBI were almost three times more likely who have died by suicide compared to individuals in the general population who were matched for other demographics like age, race, and sex.

Okay so in regards to the very noteworthy systematic review of Bahraini and colleagues they found this new robust evidence of this association between TBI and the elevated risk for suicide and so again this really adds a lot to our research and contributes to this debate whether this elevated risk of suicide after a TBI actually exist. As I mentioned before there have been some previous studies that did not find a significant association and it’s important to note that when nonsignificant findings from these studies when I looked through them some of them had a very small sample size. Some of them didn’t have a comparison group and so with a comparison group and if you are just comparing to the general population, we don’t really know that within the general population which of those individuals may have actually had a history of TBI.

So now I would like talk a minute about risk and protective factors within TBI patients. It’s certainly we know at this point that there is an increased risk and the next logical question is why is there an increased risk? One possibility for the increased risk for suicide is that there is a neuropsychiatric mechanism which underlies those acquisitions of the TBI and the risks for engaging in suicidal behavior and that’s called executive dysfunction. So this area of the brain the lateral prefrontal cortex is believed to be responsible for higher levels of cognitive functioning. For example processing of emotions and planning. So when the dysfunction of these frontal lobes we often find an association with aggression, impulsivity, and poor decision making which are all factors that really can contribute to suicidal behaviors. One study that actually provided us empirical evidence for this link between executive dysfunction and suicide risk was by Mann and colleagues. They found that lifetime externally directed aggression and impulsivity distinguish those individuals who had a history of suicide attempts versus those who did not have the same history.  Additionally Oguendo and colleagues looked at the relationships and depressed patients. So they found out that those with a mild TBI had much larger increases in adult aggression scores when they compared these same individuals to their childhood aggression scores.

So this finding suggested that those with a history of TBI may...  their aggression may have contributed to later suicidal behaviors. Also something that’s important to keep in mind with regard to risk is substance use. In the Danish study that I talked about earlier the presence of substance misuse was associated with increased risk and those again with a history of TBI who died by suicide and another study found within the individual who were outpatient in Australia those with a comorbid postinjury history of psychiatric or emotional disturbances like depression and also had substance abuse they were 21 more times likely to have made a suicide attempt after their injury compared to those without a history. They also, these authors also found that high levels of hopelessness was most significantly associated with suicidal ideation and higher levels of suicidal ideation along with these emotional disturbances I mentioned like depression were more significantly associated with suicide attempt after their injury.

So we’ve definitely gotten a very good picture of the data in regards to quantitative date in order to make this picture much more rich with a very complex issue of TBI and suicide, I want to talk about some really important qualitative data regarding risk and protective factors. There was one study that collected qualitative data from 13 Veterans who had a history of TBI and a history of clinically significant suicidal ideation or behaviors. When they talked to these Veterans, what they found out was that a lot of the Veterans had a change in their self concept after their TBI and this was associated with a sense of loss. These Veterans talked about how prior to their injuries, they were providers and caregivers and that this was a major transition from them after their injury because all of a sudden, they’re dependent on other people. They talked about being a burden on others and so this concept of being a burden is something I am going to get into here in a minute.  I also wanted to point out that Veterans in the study talked about how for them their cognitive difficulties were embarrassing. It was often difficult for them to track warning signs for suicidal behavior. It was hard for them to use coping strategies or they even be able to see alternatives to their suicidal behavior.

Veterans in the study talked about how feelings like depression and anger and hopelessness really emerged from them for them after they were discharged from acute rehabilitation. They, this, these feelings also emerged once they became more aware of their own deficits. One of the things I really want to point out about this qualitative data is the concept of being a burden and so there is a suicidologist by the name of Thomas Joiner who has a serious suicidal behavior and it’s called the interpersonal psychological theory of suicidal behavior. One of these concepts is called perceived burdensomeness and this is when a suicidal individual perceives himself as being a burden on others such as their family or friends or society. When a person is experiencing this burdensomeness, there, they have an increased risk because their desire for suicide has increased. Within this same study, they found the same qualitative data that they collected, they also asked about protective factors which are factors that would keep an individual from committing suicide or engaging in suicidal behaviors.

So those things were things like social support, they talked about support from family or friends, peers, even pets being very protective for them that they feel as though this gave them more of a sense of responsibility. Veterans talked about the importance of volunteering for them, having a job, helping others, or even participating in hobbies. Those individuals in this study who describes having a sense of purpose or much more hopeful about their future and lastly mental health treatment. So Veterans talked about how having access to mental health providers and psychiatric medications for them was very protective against suicide. I want to highlight two studies that were among active duty personnel and talking about risk factors and so this first one was data that was collected in a combat zone, it was 133 active duty military personnel and 4 civilian contractors. The second thing above within the same study was 35 military personnel who were self referred to an Outpatient Mental Health Clinic. Both happened in Iraq and the first group were those individuals who are referred to an outpatient TBI Clinic.

The purpose of this study was to look at that, that theory I mentioned earlier, Thomas Joiner’s theory, which is interpersonal psychological theory of suicidal behavior, when we looked at that within both of these samples, what we found was that perceived burdensomeness what demonstrated a significant relationship with suicidality above and beyond the effects of other risk factors for suicide. So when we controlled for things like gender and age, PTSD symptoms, depression, we found that this relationship still existed and was significant. Also in regards to the theory I had mentioned to you earlier, another essential component of Joiner’s theory is this concept of acquired capability and that’s a degree to which an individual can endure the fear or pain associated with a lethal suicide attempt. We naturally are afraid of pain and so this theory says that individual who can acquire pain tolerance and fearlessness are more capable of suicide and so you can see how this is really relevant to our military personnel and to Veterans who are routinely exposed to fear and pain inducing situations.

When you think about things like training exercises and combat exposure, re-experiencing symptoms of PTSD. So going back to acquired capability within this study, we found it was associated with suicidality; however, this was only among those TBI patients. A second study I want to highlight again took place in a combat zone. This was a 158 military personnel again referred to an Outpatient TBI Clinic. About 85% had a diagnosis of mild TBI and what we found was that increased suicidality was significantly associated with depression. This isn’t surprising given that depressions are well known risk factor for suicide. We also found that increased suicidality was associated with interaction of depression and PTSD symptoms and this is well known within literature with Veterans and civilians too. One thing I want to point out that if I mean that was a little contr., was contradictory to previous literature, is that longer duration of loss of consciousness was associated with the decreased likelihood for any suicidality.

I want to point out that this sample got within the combat zone. About three quarters of the sample were evaluated within seven, seven days of their TBI and so we don’t know that the impact of this, they have been collected in the combat zone and then the amount of time that they were evaluated and how this impacted this last finding as really the preponderance of TBI research out there is much later than seven days after the TBI. So now I would like to handle it over to Dr. Bryan who is going to talk about the Fluid vulnerability theory of suicide.

Moderator: Thank you. Dr. Bryan are you ready to show your screen?

Dr. Bryan: Yeah.

Moderator: There you go.

Dr. Bryan: Okay. Are we good to go?

Moderator: OK.

Dr. Bryan: Okay. What I’m going to do is introduce to you the theory of suicide that my research lab has based most of it to work on with respect to suicide in the military and amongst Veterans. The Fluid vulnerability theory was actually first introduced and proposed by David Rudd about a decade ago now and some of the fundamental of function of this particular theory is that we have to consider suicide risk from two different dimensions. Most of us only think about suicide and which is compared to dementia low risk or the high risk, but Rudd argued with that we also need to take into consideration with baseline risk. Baseline risk is a sort of the set point of the propensity of the life because that somebody will engage suicidal behaviors even when they are not encouraged to or even when they are relatively calm and for those who are to work with suicidal patients if you can show respect upon your experiences, you can certainly think about patients who were more likely if you were little more nervous about even when things are going reasonably well we would say they’re more likely who engage in suicidal behaviors than others and just something about them that increases their set point of risk. The set point base line risk is determined by static risk factors like gender and race. Genetic vulnerabilities are biochemical factors etc.

Moderator:  Dr. Bryan?

Dr. Bryan: Yeah.

Moderator: Dr. Bryan.

Dr. Bryan: Yes.

Moderator: Dr. Bryan.

Dr. Bryan: Yes.

Moderator: I apologize for interrupting. Can you please speak up just a little bit or increase the volume on your phone?

Dr. Bryan: Sure.

Moderator: Thank you.

Dr. Bryan: Sure, sure no problem. Okay. So the, the baseline risk is determined by static factors. One of the clearest indicators of increased baseline risk in suicide, suicidal patients is the presence of multiple suicide attempts. So those who have tried to kill themselves two or more times and when we know amongst multiple attempters that they tend to have more frequent suicidal crisis and when they’re suicidal, those crisis tend to last longer and it’s harder for them to return back to stabilization state and so the severity of risk than you have to take into consideration both the baseline as well as acute aggravating factors such as life stressors, depression, trauma, short-term psychiatric symptomatology etc. Another essential piece of information about this theory is that suicide risk returns the base line level only. Why that’s important is because if you had some individuals who are chronically at elevated risk for suicide by their very nature, they are only going to return back to their unique setpoint.  So zero risk might not be their setpoint and so this plans an important role for clinical management overtime especially amongst multiple of the doctors.

So I have going through of the graphic of how this sort of works? This first line here this green line indicates someone who has never attempted suicide. They have their baseline risk level, they experience an acute crisis, they become acutely suicidal that causes results and they return back to their individual baseline setpoint. Then we have the multiple suicide attempts. It was a higher baseline to begin with. They hit an acute crisis and you can see that their acute suicidal state appears worse. It appears more dangerous overall and that’s because they have a higher setpoint to begin with and it takes some long to return back to their individual setpoint. They never return to a level that matches or gets down as little as zero chapter. Within this notion of Fluid vulnerability theory in bed of the concept of the suicidal note.

The suicidal note is sort of how we, is a cognitive behavior of conceptualization of suicide risk and so we start up with this notion of predisposition, which are those baseline risk factors, gender, age, history of abuse, trauma exposure, impulsivity, etc. In the presence of the triggering event or life stressor typically some kind of a perceived loss kind of a of relationship failure financial stress. We have an activation of what we call the suicide. This is the suicidal crisis and the suicidal note contains several components that interact with each other. So for instance, suicidal individuals tend to abuse substances more often. They withdraw from others and they engage in other self injurious behaviors and they practice rehearse of suicidal behavior. Physiologically, they will report agitation, insomnia, concentration problems, pain, emotionally will see things like shame, guilt, anger, and depression and then cognitively we see very specific thought process that is associated with suicidal crisis such like I’m worthless, I’m terrible, I’m no good. This proceed burdens and affects the rate with talking about and there is a notion that I can’t take it anymore and I have to do something about it now.

This if you keep this model in mind as we’re talking about the relationship of traumatic brain injury, I mean if you go over the results of a study that was just recently published in JAMA Psychiatry and I will explain how we’re conceptualizing the role of traumatic brain injury with suicide risk? So this is the sample demographics from this recent study. You can see that about 90% of the sample was male in terms of ratio distribution of about 70% white. We had predominance of army personnel followed by Air Force and Marines and we had a number of civilian contractors. Rank was generally junior enlisted to non commissioned officer. What we did in the study is, patients were referred to an outpatient TBI Clinic in Iraq for the evaluation treatment suspected TBI. In most cases, they were aeronautically evacuated directly from the battle field to the hospital.

In other cases, they were referred by a battalion or brigade surgeon basically like a primary care provider in that sense located at a forward operating based on another outpost you know service member comes in and says, yeah I’m having headaches, I’m having these problems like I have got blown up a couple of days ago and they might have been sent down to us for an evaluation. Once I arrived at the clinic, all patients complete the standardized intake procedures including self-report symptoms, measures, concussion symptoms, participating in clinical interview by psychologist, physical exam by physician as well as neurocognitive testing, but what we found in terms of results was we looked at the number of lifetime traumatic brain injuries that was reported by each of the patients and so during that clinical interview and in addition to outstanding information about the recent index event that brought them in to treatment well, so asked have you ever experienced a head injury in the past even knocked unconscious etc. and then we did a test or review of those other reported incident.

So many of these guys were reporting football injuries from high school, accidents where they slip and fall in the shower, trip over in the steps etc. but many of them were also reporting combat related injuries like multiple blasts, motor vehicle accident etc. What we did is, based on the total number of traumatic brain injury experienced during their life, and separated them in to these three groups. So no history of TBI they had one single TBI during their entire life or they had multiple TBIs and this first graph shows what we found in terms of psychiatric symptoms. So on the left hand side; these were the number of concussion symptoms that they reported. So balance problems, dizziness you know coordination difficulties and as you can see with greater history of traumatic brain injury, more and more concussion symptoms were reported. In the mid of this kind of hard to see because of scale only runs from zero to four but we saw more severe depression symptoms and then finally on the right hand side, PTSD symptoms as this was measured with PTSD checklist and then we saw get increasing severity of PTSD symptoms as the number of TBIs.

We had the suicide behavior questionnaire revised measured to assess lifetime and recent incidence of suicidal ideation behaviors.  In the sample of 161 participants only two personnel reported a history of suicide attempts and we looked at suicidal ideation within the study. What we found was that in terms of lifetime incident of suicidal ideation basically having thoughts of suicide at any point in their as the participants recorded a greater number of TBIs, the likelihood of them experience suicidal ideation at some point increased dramatically with the biggest difference occurring amongst the multiple TBI group.  We don’t work that more recent suicidal ideation as well, we found the same pattern. About 12% of those who had sustained two or more TBIs during their life reported that they had considered suicide within the past year relative to only 3% with the single TBI and 0% of those who had never experienced TBI.

We then conducted a regression analysis to look at how strongly is the number of TBI associated with suicidality and when we’re taking into account other thing that contribute to suicidality such as depression and PTSD. As Tracy mentioned earlier we know these are risk factors of suicidality in general and we have demonstrated that their risk factors for suicidality amongst TBI cases as well. In model 1 on the left hand side, what this is showing is yes, indeed those who have sustained more traumatic brain injuries do report higher levels of suicidality even with controlling of depression, posttraumatic stress, and concussion something severity.

In model 2 on the right hand, we also looked at the interaction of number of TBIs with depression severity but we actually looked at the interaction of TBI group with all of the other covariates of PTSD and concussion symptoms but those were not significant. The only significant finding was interaction of depression with TBI group. What this is suggesting is that depression is more strongly associated with suicidality as number of TBI increased. So in other words thinking of volume increases or the depression becomes more dangerous as the number of TBIs in a lifetime increases. This is just a sort of graphic display of that interaction and you can see there is dotted line at the top that is relationship of depression with suicidality amongst those who have multiple TBI as you can see as the depression gets worse, the suicidality gets worse and it is more much pronounced relative to those who have a single TBI and those who have no history of TBI.

Some of the limitations of the study, first is that we had overall limited information about past head injuries. So although during the clinical interview, we were asking you know when you got knocked out in high school or when you got, when you tripped and fell you know two years ago during a training exercise you lose consciousness, did you have altered mental status etc. we did not code that within the database so we don’t necessarily know someone finds it reporting five previous traumatic brain injuries what the portion of those were lost consciousness or what were not, etc. Another significant limitation reports the data clubbed in the combat zone which is not exactly the pristine research conditions that were most of us would necessarily like, we did receive about 75% of the patients were evaluated within about three days of their entry so with extremely acute much more acute stage injury than we see in the research. Another limitation, we only had 161 personnel 93% of which were male and so is there a gender differences we really cannot pass that out if there’re possible differential risk factors amongst females or unless it is males. And then of course cross sectional data we need additional studies that track the TBI patients over time to see how these different trajectories e merge from the incidents of TBI, suicidality later on especially among the accumulated TBI.

How in other what sort of it has been that repeated exposure, repeated injury confir increased risk over time. And so kind of sum up if we go back to the conceptualization of the suicidal mode what the results of this most recent study suggest is that TBI especially repetitive TBI probably serves as a pre disposition for suicide risk and as Tracy indicated before, there does not seem to be identifiable high risk period so to speak where some one with a traumatic brain injury is that increased risk for suicide suggesting that traumatic brain injuries might elevate a person’s base line risk of propensity for suicide in the future. This is also supported by the findings of significant in our action between TBI group with depression suggesting that there is vulnerability amongst those who has experienced one TBI and even multiple TBI they are more sensitized and more vulnerable to the emotional components of the suicidal crisis. Right and we will switch back over to Tracy now. 

Moderator:Thank you so much and Dr. Clemans are you sure you are ready to share your screen again?

Clemans: I am thank you. Okay. This is going to put through these quick. Looks like the power point got stuck where I left off. Sorry about this folks. Okay so obviously we talked about quite a bit today and since the majority of our audience today are clinicians we’re going to spend some time talking about how was this information has implications for your practice. Most importantly one of the most important thing to start with this is that really for clinicians to have the good understanding of this existing relationship between psychiatric and emotional disturbance and substance misuse and abuse so ongoing assessment of these issues is really paramount also within Veterans assessing for cognitive dysfunction and any associated functional impairment can really help facilitate treatment planning and then reduce risks among our Veteran.  One of the most things obviously since we know that there is no greatest risk.

Period for suicide or suicidal behaviors in Veterans assessing for suicide risk is extremely important and so for providers that means evaluating the extent and intensity of things like suicidal thoughts the desire for suicide their intention and specific plans along with assessing risk and protecting factors and knowing that these factors can change over time is really important so for example a Veteran, who would say has been sober for 20 years, who all of a sudden starts drinking alcohol all of the sudden they have an added risk factors that they didn’t have previously. Then you could have another Veteran who let’s say had a protective factor of a significant relationship and let’s say through law, of that relationship all of a sudden that protective factor transition in to a risk factor and so knowing that ongoing assessment of these and that they can change over time is really important. So one of the questions is how long should we assess for the suicide risk of TBI patients and the easy answer is for ever.

We really don’t know again this greatest risk period. The different studies that I looked at we had one study that documented that the suicide of the 25 years after a TBI so we really just have to look at this TBI is a chronic risk factor for suicide and so the answer is we should assess forever until we know more collect more information about this particular topic. Other implications that are important are implementing coping and compensatory strategies with Veterans so this can be, one way to specifically do this is their safety planning which really give the Veteran an alternative to suicidal behavior. And so working with a Veteran collaboratively and initiating safety planning that is unique for them and helping the Veteran to identify their warning signs. So what are those signs that they are in a suicidal crisis. Identifying their external support to family and friends who they can call is there a crisis, identifying their internal coping skills so things that they can do in order to decrease their suicidal crisis at that time and then obviously additional resources so Veterans to have suicide hotline zone numbers the number to their mental health clinic and the providers is really important.

Another thing that I want to point out is that utilizing and carefully supported interventions for conditions that we know are associated with acquired capability for suicide is really important. That was the concept I talked about earlier and one of the things that we found is that even among experiencing symptoms and PTSD we found that this is associated with acquired capability for suicide and so for clinicians to use their base for PTSD such as prolong exposure or cognitive processing therapy what can happen inside we can prevent or at least decrease the worsening of suicidal ideation. We have recent data from some clinical trials being conducted with active duty military personnel who have the PTSD and suicidal ideation as an onset of treatment who within these military personnel they receive prolonged exposure and cognitive processing therapy obviously one or the other what we found was that the reductions in suicidal ideation once treatment began within these personnel. Clinicians directly working to reduce the Veterans desire for suicide so targeting maladaptive systems so those thoughts about I am better off dead, thoughts about I’m a burden to everyone and my family and friends and I don’t belong to any group, I am not connected to any one so really targeting those maladaptive belief symptoms can be super helpful. And then also facilitating religious and spiritual support,, talking to the friends about what are their, what are possibilities of vocational or volunteer activities helping them talk about think about what is their support system and even family focused intervention.

So family focused therapy was something that has been modified for use with military personnel with a history of TBI and this can be really something that helps with things like communication and problems and you can see where this is done within the family unit, the Veteran may experience the decrease and the sense of being a burden on their family and may increase the sense of their belongingness. And then lastly obviously restriction of access to lethal  means and we know that means restriction is one of the only effective methods for preventing that by suicide and this can be successfully accomplished with Veterans and so engaging Veterans and their family and friends and support system and helping the provider and the Veteran restrict lethal means such as firearms or guns in the home, talking to them about how they can manage with potentially refill means like medication and how may be family and support system can help with this can really significantly reduce the likelihood of an adverse outcome for Veterans during a suicidal crisis.

And before I hand it over to Dr. Brenner I want to really highlight a wonderful resource for clinicians that just got started with us two of my colleagues here at the VISN 19 MIRECC created suicidal risk management consultation program and this is for VA clinicians who are working with Veterans who have suicide risk assessment management issues and so if that if providers are interested you can call this number and schedule complication and they will assist you in coming up with ways to successfully or better manage Veterans with suicidal behaviors. So now I’m going to hand this over to Dr. Lisa Brenner for discussion.

Dr. Lisa Brenner:Hi, first of all I want to thank Dr. Clemans and Dr. Bryan for this excellent contribution for literature and we’re really excited to see the article and learn more about it. Because it does seem to fall in line with the number of the papers we read here recently that has been organized around the idea of cumulative disadvantage. Or the idea of the cumulative impact of adversities the results in negative psychiatric outcome. And this theory of cumulative disadvantage actually was introduced in the academic world there was a researcher named Morton who identified early disparities between clear trajectories and find this to be early advantages including good mentoring first it shows that did not and then look at this clear trajectories over time and realize that this extra support at the beginning made it a huge difference at the end. In turn this theory has been used to look at long term outcome in those with TBI and those with suicide so the idea being as you go along your life time and accumulate adversities, those adversities that pile up early in life can really impact the trajectory and change the life course in a way so you have negative psychiatric outcomes like suicide.

And some very interesting work has been done both in the world of suicide prevention looking at health promotion and importance of addressing adversities in childhood to prevent adult suicide as well as in the TBI world. One of our great VA scientists and clinicians Dr. Ruth wrote about the cumulative model in post concussive disorder obviously back in 1996 before the current conflict and said that difficulties with physical emotional cognitive and psychosocial and occasional financial and recreational functioning are viewed as the stressors that should be considered together and then can exacerbate the morbid factors that results in negative outcome. One other examples how we have seen this kind of cumulative cascade of events, one of our researchers here Jennifer Olson-Madden published in paper in 2010 in which she looked at the relationship between TBIs and psychiatric disorders inthose receiving substance abuse treatment and what Jen found was that for each additional TBI sustained there was an estimated 9% increase in the number of psychiatric diagnoses documented. At the same time for each additional documented psychiatric diagnosis there was an estimated increase of a 11% in the number of future TBI sustained.

So again this kind of cascading relationship between psychiatric symptoms and diagnoses brain injury and then negative psychiatric outcomes, suicide being the most serious of those.  Because we have been kind advocating for a while that this history information regarding predisposing factors as Craig talked about and this accumulation of predisposing factors is really important in  a recent response to letters to the editor, Dr. Bahraini and myself spoke about some potential changes that could occur within the VA using current screening, currently the screening strategies is you’d screen positive for OEF/OIF Veterans if you have a history of TBI, had symptoms of the kind of injury and then have persistent and continuing symptoms, which is great. It does identify those who need treatment for persistent post concussive symptoms, but it doesn’t really allow us to do some of this accumulated risk work. It doesn’t let us know lifetime TBIs for people. Those TBIs are not counted in terms of screening with current practices in the VA.

So, really this idea that we could use some of our practices and data that we have and change things a bit to help us understand what this accumulated risk might be. Turning a bit towards suicide and TBI literature on whole and ongoing challenges, in the recent review by Dr. Bahraini and as Dr. Clemans also noted, both Tracy and Nazi spoke about challenges associated with doing this kind of research and it is really quite challenging and one of this things that was so important that Nazi identified in this review was how few studies actually were conducted with this question at the fore. Most of the studies that were conducted were secondary analyses that people conducted after the fact with the existing data which is great. It does lay the ground work, but it does create challenges associated with looking at the data. Just some very basic things to think about in terms of doing this kind of research, you know we think about exposure which is TBI and TBI history which everybody has spent a lot of time thinking about and trying to help us better understand how to get history of TBI particularly mild TBI, particularly mild TBI in a combat zone. How do you get in accurate reported that overtime which is very, very challenging and then how do you assess outcomes of interest in this case is suicide related thoughts or behaviors.

First of all we need to figure out if we’re interested in ideation or interested in behaviors? Are we interested in risk? Are we interested in death? And then how are we going to look at the relationship between those things, the relationship between the exposure and the outcome. So this idea that you know did the TBI start before the suicidal ideation? Did the ideation start before the TBI and then how do you begin to understand the accumulated risk of those two things together over time. Unfortunately, you know, I think some of the clearest researches can be conducted in those who already died by suicide because the outcome is very clear or clear than the other outcomes in terms of death by suicide, but to do studies like that you need huge databases that we’re very lucky to work with our colleagues at the SMITREC and we looked at over eight million cases in VA records to be able to identify the relationship between TBI and suicide as an outcome.

So, that definitely highlights how important it is for us to be working together and be collecting data in the manner that we can look cross studies to begin to class data.  I would also like to say that you know, we are continuing to work on identifying measures that are really good at letting us identify ideation and attempts over time and how do we assess those particularly in populations that have challenges, cognitive challenges like those with TBI. Dr. Bryan also highlighted the importance of the relationship between depression and TBI in this case and that again is, it fits very well with the work that has been done in this area, there’re very high rates of psychiatric disorders and psychiatric symptoms in those with TBI, which creates challenges I think in terms of ferreting out, which symptoms are TBI related, which symptoms are unique psychiatric disorders and then how do we measure those in individuals, particularly individuals where they may be experiencing acute symptoms post TBI having very, you know, significant challenges with things like concentration by post or mild TBI, but we also ascribe concentration as a symptom of depression. So, then which category does I go under or does it go under both. Finally, I just want to highlight again.

Moderator: Dr. Brenner?

Moderator: Oh, yes. I apologize, I just want to know, you know that we do have about half a dozen pending questions.

Moderator: Okay.

Moderator: So let us get to that shortly, I apologize.

Moderator: No, no. no problem, that was my last comment on, on discussing and let’s get to the questions.

Moderator: Thank you very much. Can you advance to the next slide and then put it up in slideshow mode just we have something to look at while I moderate the questions.

Moderator: Why don’t we put it up to this?

Moderator:  The consult service or the questions.

Moderator: Oh, yeah that sounds good either one.

Moderator: For the consult service, I would like to point that resource.

Moderator: Yeah and if you can feel free to put it on speaker phone and we’ll get right to it. So, this one came in early on during Dr. Clemans’ presentation. Has there been a correlation between length of time between suicide attempts and date of TBI?

Moderator: Length of time between a suicide attempt and TBI, so how, how quickly after the onset of a TBI that would come first is their, is the suicide attempt is that the question? I think it is. You know when I think that we have better data around death. Unfortunately, the last really comprehensive study that has been done around suicide attempt, it was done by Silver in 2001, but like I was suggesting and see timing here Tracy or Craig, that, that we are in need of further study around this and to begin to look at the relationship between an injury and attempts. We do know that for death by suicide, it does appear that it is sustained risk over the course of brain injuries, lifetime, not just right after postacute injury.

Moderator: Thank you Dr. Bryan or Lisa would you like to contribute to that?

Dr. Bryan: No, I think that’s a great summary. I don’t have anything to add.

Moderator: Okay. Thank you.

Moderator: Another one for Dr. Clemans. Can you please explain again the possible reason for decreased likelihood of suicidality with a longer loss of consciousness?

Dr. Clemans: So I would need pick up the phone here. Yeah, this is obviously a finding that really has contradicted previous literature. One of the things that, that we talked about in our paper was you know we were trying to make sense of this finding. One thing to keep in mind is that about 75% of our samples were evaluated within seven days of the TBI. Also, this occurred in a combat zone and when we look at the preponderance of TBI research out there, the majority of research is not collected in a combat zone, the majority of researches collected months or years post TBI and where our participants were evaluated within that seven-day period, the majority of them were anyway. Another possibility that we considered is that all the participants in this sample had a mild TBI first is moderate or severe TBI and again the majority of the research out there, regarding TBI are participants that have the more severe brain injuries versus mild.

You know another thing that we discussed and put in our paper was that, the longer duration of loss of consciousness you know, it may have served as protective buffer against suicidality, in it such as the traumatic material was not as easily accessed in those who had a shorter loss of consciousness, so for e.g. the access to traumatic material for e.g. remembering the blast injuries or seen others injured that could have been more likely to result in depression and PTSD symptoms that are correlated with suicidality so really you know just made some suggestions as to this findings, we clearly don’t know the exact reason and more research needs to be done to investigate this particular finding.

Moderator: Thank you for that reply. We do have five pending questions so we will get right to them. How does a PCP assess for suicide risk? And this came in I believe during Craig’s portion.

Dr. Bryan: Sure,  so in general for a primary care provider, you’re typically going to be looking at many of the same risk factors that we would recommend for a mental health professional, we are truly doing a number of projects within primary care, focused on improving risk assessment in the settings,  the reason being that in fact 60-67% individuals who are screened for suicide risk in primary care by asking them, are you thinking about killing yourself will say no, and then kill themselves within a year and so what we are finding in some of our pilot researches is that asking about things like perceived burdensomeness in the sense of I can’t take this any longer, things aren’t getting any better. This thought process is associated with the suicidal stage, seems to do a better job of detecting those at risk and the reason for that is if we go back to the Fluid vulnerability theory, we have some individuals who are most likely to attempt suicide or die by suicide have these chronic beliefs and chronic identity based notions about how horrible, worthless and terrible they are and they will report those and they will say yes, I’m a terrible, horrible person, even when they’re not suicidal and these sort of thought processes seems to do a better job and so I encourage all primary care providers in addition to asking about suicidal thoughts and behaviors who also ask their patients do you feel like people will be better off without you, do you feel that things are so bad that you just can’t take it anymore.

Moderator: Thank you for that reply, my next question, if a Veteran is experiencing something due to a TBI or concussion while overseas and hasn’t seen a clinician yet, but is out of the military do you have suggestions as where to that individual can get services? And this person also kindly said that you can answer them off line, if you would like.

Dr. Bryan: Lisa do you have suggestions for that? I am assuming that their meaning a Veteran is no longer in service or they referring to a service member stationed in a military base overseas?

Moderator: Uh-huh I’m not sure, will that attendee please write in further clarification while we wait for that.

Dr. Bryan: Yeah.

Moderator: We’ll move onto the next question, they say no longer in service now a Veteran.

Dr. Bryan: Okay, what thoughts do you have Lisa for Veterans no longer in service, I’m more familiar with the DOD side than I’m with the VA side.

Moderator: Let me find Tracy or I’m muted...okay, we may have lost their audio or they may be on mute uh-huh while I work with them, we can move onto the next question.

Dr. Bryan:Okay.

Moderator:  I have done review of the religion and spirituality literature, as protective and the mechanisms were by protection operates, if any are unclear. Furthermore, the inclusion of pastoral providers in care for standard or routine is not tested empirically. Can you comment on that?

Dr. Bryan: Yes sure, I actually have comment on that, yet that the research on the relationship between spirituality and psychiatric distress in general, but specific to suicidality is actually quite interesting and there is some more recent work there including that we had a presentation at conference just this past year on a newer study and we’re doing some study at the National Center as well on this, the protective benefits of faith and religion seemed to be conferred by the engagement in social activities with people who care about you, who express concern and compassion, there also seems to be mediational effect to proceed meaning and purpose in life so interestingly enough the science seems to suggest it’s more “secular” aspects of spirituality that really seems to explain the relationship and so if viewed from a clinical perspective, so when I have patients coming in who are suicidal and they cite as a reason for living not only because of my religious belief and the follow up options that I always ask you the last time you went to worship service for you, you know went to a bible study with you know friends or something like that to assess what is their social connectedness with others, because when you tease apart the belief system by itself you actually do not see a protective effect, but it's the engagement and purposeful meaningful activities with other people, who care about the effect and you definitely see a protective effect there.

Moderator: Thank you for that reply, we do have just few questions pending are you guys able to stay on and continue answering those?

Dr. Bryan: I can certainly stay on for a while.

Moderator: [laughing] Thank you, giving your study of multiple TBIs, can you relate your findings to chronic traumatic encephalopathy?

Dr. Bryan: I would say that I’m not very familiar with the literature on encephalopathy so I don’t think I would be able to give a very informed response to that question unfortunately.

Moderator: Not a problem, okay let’s see, we do have two more questions and just so everybody knows that this recording, this session has been recorded, if you can, you will receive a follow up e-mail with a link to the archive recording. This one is for Tracy, but we lost her audio, so I will move on to the next one.

Dr. Bryan: If you want I can try and answer it myself but I’ll do my best.

Moderator: Tracy. Are ongoing studies that show actual long term reduction of suicide per se available if not are there plans for future research?

Dr. Bryan: Yeah, actually so there’re, so actually we’ve been doing this study right now at Fort Carson, Colorado Treatment Study. We’re looking at reducing suicide attempt so we’re not sufficiently powered to reduce death by suicide, we’re looking at suicide attempts and we’ve finished enrolling and are doing followup right now and what we’ve found thus far is that, the soldiers who are receiving the active treatment condition are 50% less likely to attempt suicide within the two years follow in therapy and that’s actually the findings that has been replicated in other studies or mostly in civilian studies and so there are number of studies underway right now by the Research Consortium which is actually affiliated with the MIRECC, it’s funding a number of treatments in intervention studies to reduce long term effects so we do have some preliminary evidence and more studies are underway, to find more and more ways to prevent suicide including those amongst the patient with TBI.

Moderator: Thank you for that reply and we’re getting right through these. Next question that we have is how does this relate to domestic violence if at all?

Dr. Bryan: So we just published the study, I would say a few months ago with an air force sample through which we found that domestic violence was associated with increased risk of suicidality and interestingly enough domestic violence in this air force sample was the sort of traumatic event in the form of interpersonal violence that was riskiest so to speak and we’re finding some replication of that in some other research that we’re doing, and so not only do you have controlled risk factor of interpersonal trauma associated with increased risk, but if the victimization was so severe that the person sustained significant physical injury or traumatic brain injury, my guess is that we would see sort of an accumulated effect like we talked before where is the number of convergence of these different issues, different entries, and different life events that seem to confer increased baseline risk that persists overtime even during you know periods of relative calm or you know lack of emotional distress.

Moderator: Thank you very much, I did just get a note, from Dr. Clemans and Dr. Brenner that they did get disconnected and I don’t think they’re currently on audio, but they do apology for getting cutoff those last two seconds. Lisa can you hear me?

Dr. Brenner: We are in here, can you hear us?

Moderator: Oh, we can, welcome back.

Moderator: Oh, good, good, good, sorry about that.

Moderator: [laughing] No problem.

Moderator: It’s okay. So actually had a nationwide failure earlier so we’re lucky that we even got to have the session, we do still have a large portion of our audience and I would just like to give each of you opportunity to give any concluding comments I guess we can go and order of appearance, do you want to start Dr. Clemans?

Moderator: Sure, just want to thank everyone for getting on the call today, you know we all are very excited to be able to talk about obviously a very important topic, and excited to see you know from what I found in Dr. Brenner systematic review, just increase in research on this topic of TBI and suicide both together and both separately and hopefully hope that this leaves us in a good direction with beginning to get more answers than having questions, so just want to thank everyone for being here and hope that, the for all the clinicians, which it sounds like is the majority of our audience that the clinical implications and suggestions were helpful, feel free to e-mail myself or Dr. Brenner or Dr. Bryan with any questions that you know we’ll be glad to answer and get information or resources for you, so thank you for having me.

Dr. Bryan: Good. I think the, the only concluding comment I would have is, I think it’s always important to keep in mind when we’re talking about research related to suicide is that, as in this case although what we’re talking about is increased risk for suicidal thoughts and behaviors associated with traumatic brain injury especially cumulative brain injury. The focus of the point is that means the vast majority of TBI victims do not think about suicide and do not attempt suicide and do not die by suicide, and I think it’s important at least for the clinician to convey that sense of hope for patients especially in wide of some of the evidence that were finding now on our treatment study is that we would reduce emotional distress extremely affectively and reduce the likelihood of suicide attempts and that I think these patients need to understand that things can get better and treatment does work and it’s important and behold on upon us clinicians to make sure that we are offering those best treatments to our patients.

Moderator: Thank you, Dr. Brenner, would you like to say anything?

Dr. Brenner: Again thank you for allowing me to be part of this discussion and just I’m encouraged that there is more work and interest in this area, I think one, just piggybacking on Dr. Bryan’s comments. Unfortunately in the latest systematic review there are only one RCT to look at preventing suicide with TBI with a total sample of under 20, so although we have really identified this is a problem, we’ve not done very much work in terms of modifying treatments existing, evidence based treatment, so we’re using evidence informed practices to prevent suicide in this really high risk population so I encourage everybody who is interested to kind of really look into that and may be reach out to us and kind of help us figure out next steps on that.

Moderator: Well, I would like to thank each of you for presenting to the field, they’re very appreciative and we have had a lot of people right in saying thank you bravo this was wonderful, we do have a couple of people that I’m encouraged to contact you all off line, ask their questions either just came in just now and we’re ready to wrap up or it was clearly a one-on-one question, for our attendees thank you so much for joining us which really appreciated and as you exit today’s session, please wait just a second and a survey will pop up, we do appreciate your feedback, it is your responses that guide where we go with this program, and well I have a captive audience I do want to promote our next TBI session, which will be taking place on September 16th, 2:00-3:00 PM EST, and that is on the diagnosis and treatment of vestibular disorders and mild TBI, so please go to the cyber seminar registration catalogue and join us for that or any other sessions, so thanks again to everybody for joining us and please enjoy the rest of your day.

Moderator: Thank you very much, have a great day, Bye!

Moderator: Bye!

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