Suicide After Brain Injury

Major Concerns with Suicide After Brain Injury

Suicide after brain injury is a serious concern as emotional centers may have suffered discrete physical damage causing depression and anxiety, but the added burden of dealing with disability and deficits can severely tax the injured mind.

By Rebecca Martin

Navigating our modern world is a difficult task for the most capable of us. We deal with stressors in our lives which would make the average person from 1950’s America throw their hands up and yell “stop!” We all hoped technology would make our lives easier and less complicated.

Suicide after brain injury is a topic that we of the Brain Injury Law Group have been concerned about for more than a generation. Rebecca Martin illustrated this story of the struggles to adapt of her fictional Sue nearly 25 years ago.

These days, however, a simple question about a phone bill can entail hours of maneuvering through automated voice systems with the slim hope that eventually a human will appear to listen and assist with a simple problem. In many ways our voices have been muffled as technology takes over. Increasing feelings of powerlessness and isolation are often the result. I often wonder while navigating modern day to day life, how are people with compromised coping abilities able to navigate modern life? And the answer is that, in many instances, they are not able to successfully map out a road to a successful existence in our new societal dynamics. Depression is often the outcome and suicides continue to trend upward for the last two decades.

Many years ago when I was working on the brain injury support page waiting.com I was struck by the fact that due to advances in automobile engineering and medical technology more people were surviving with brain injuries. We were beginning to understand how even so-called “mild” brain injuries could exhibit far reaching long term deficits that could ultimately derail the most resilient among us. And we were beginning to understand the interplay of depression and brain injury and the increased risk of suicide among survivors.

Society places an almost criminal connotation on suicide. The term “commit suicide” in itself denotes a criminal intent to do violence to one’s self and carries a burden of guilt. This alone has driven those struggling with suicidal thoughts into hiding. In the medical profession, intake questionnaires for any type of significant treatment often include questions regarding depression and suicidal ideation. Medical records themselves label attempts as “successful”, the person succeeded in the suicide attempt or, “failed”, the person did not succeed. Even when desperation has driven someone to the brink of suicide, to have failed is labeled as a failure. This nomenclature has effectively made depression and suicide taboo subjects for discussion.

Suicide after Brain Injury Starts with Depression

Brain injury is now acknowledged as a leading indicator in the potential for depression and suicide. For more on brain damage after carbon monoxide poisoning, click here.  Let’s examine a hypothetical instance to study the dynamics of how brain injury can impact an individual. We have a basic understanding that it is often the type A personality which is at greatest risk for compromise from an acquired brain injury. A person has worked hard and intelligently to establish a lifestyle which is a delicate balance of seeking new challenges and goals, accomplishing those challenges and goals and ultimately balancing those challenges and goals with personal satisfaction in the way of relationships, family life and recreational time. They have established an identity which is able to rationally accept defeats without being defeated. But what happens when we introduce a brain injury?

First of all, brain injury is not immediately evident in the outward appearance of the survivor. Often the reactions of those around them are limited to the endless observations of “you are so lucky to be alive” or “it could’ve been so much worse, how fortunate for you.” This is obviously not the same reaction people might have to say, a severed limb or other outward sign of injury. Yet with a brain injury the person is experiencing problems with thinking, judgement, emotions, coping and prioritizing skills, concentration, flexibility and much more. These deficits begin to impact relationships, family dynamics and work. The person is very likely to feel an increasing isolation and sense of helplessness which ultimately can lead to depression. This withdrawal from social arenas where once the person was functioning in an acceptable manner becomes a spiral which grows worse over time.

Although it is very difficult to have accurate insight into one’s deficits when the facilities for that introspection are damaged, survivors are often affected by a disturbing sense that things are not as they should be. Even if they are able to vocalize what seems to be occurring, it is human nature to minimize such complaints.

Loss of Self Esteem Contributes to Suicide After Brain Injury

I compare it personally to the period of time I was experiencing the dreaded “chemo brain” after cancer treatment which affects memory and concentration much like brain injury. I would express concerns about not being able to remember events or directions to familiar destinations and the response would often be “oh, I forget all the time too”. Those words I searched for or memories I struggled to find became huge roadblocks in my functioning which shook my confidence to the core. Medical professionals glossed over my concerns with promises that it was temporary. But for those with brain injury, it’s not going away. And that makes it worse. But the inclination to minimize those deficits is the same. And it leads to the same type of self-doubt that leads to a constant state of second guessing our ability to accurately assess or assume our place in the world. And when those deficits are the result of physical injury to those parts of the brain, trying harder is not going to make it better.

When one is working so hard to just live up to former levels of functioning, the entire process becomes exhausting. The brain is working overtime to accomplish simple tasks. Focusing on one’s work, concentrating on the task at hand, decreased confidence in our ability to accomplish a task correctly–many of these things can create a confusing scenario. Changes can be due to physical changes in the brain which damage areas specifically involved in emotional responses. Emotional changes can result from the ensuing struggle to deal with the changes after an injury. And there may be genetic, family history or other factors which exacerbate our ability to cope with brain injury. And this can lead to depression.

According to msktc.org

“Depression is a common problem after TBI. About half of all people with TBI are affected by depression within the first year after injury. Even more (nearly two-thirds) are affected within seven years after injury. In the general population, the rate of depression is much lower, affecting fewer than one person in 10 over a one-year period. More than half of the people with TBI who are depressed also have significant anxiety.”

Depression Comes from Both Organic and Emotional Damage

Across the board it is widely recognized that depression is a common outcome of a brain injury. Depression can lead to an increase in thoughts of death or suicide. We wrote previously of the functions of the basal ganglia which was not only responsible for promoting functions to accomplish tasks but also to control inhibitions that might counteract those actions. And that it is now understood that deficits in this area could affect judgement. When you throw depression into the mix you may now have a cocktail of negative thoughts with inappropriate inhibitions on those thoughts meant to rationalize behaviors and ultimately preserve life. Those feelings of worthlessness, a decreased self-confidence, fatigue and interrupted sleep and rest patterns, increased social isolation–all of these things may contribute to an increasing perseveration with thoughts of suicide.

The severity of injury may play a role in the prevention of depression as well, but often in an inverse relationship to the severity of injury. If one is hospitalized for treatment of a brain injury, it is more likely that a course of treatment to address depression will be implemented. Often in the case of a more “mild” brain injury, the rising symptoms of depression may be written off as symptoms of the brain injury itself. In this case, the depression may not be addressed as actively and can escalate. And unfortunately, a misguided approach to treatment for depression specific to brain injury may contribute to an escalation of suicidal thoughts through improper medication or an inadequate intervention.

In a 2020 Medscape article authored by Percival H. Pangilinan, Jr, MD and associates, it is estimated that 40% of patients hospitalized for TBI have been found to suffer from depression and further, with cognitive decline. Cognitive decline includes “…anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts.” See more at https://www.medscape.com/answers/326643-121901/how-is-depression-treated-in-traumatic-brain-injury-tbi

Further findings by Whitnall L, McMillan TM, Murray GD, et al reported “that persistent disability (5-7 years after TBI) was strongly associated with depression and anxiety, and that it was more poorly associated with initial severity or persistent cognitive impairments.”

Need for More Research on Suicide after Brain Injury in Mild Cases

Many studies point to increased rates of suicide after brain injury amongst those who previously suffered a moderate/severe brain injury. However, an increase in the rate of suicide extends to all levels of brain injury. As I pointed out earlier, those who might be more likely to be impacted by a mild brain injury show a direct correlation to personality type with a high achieving individual being the most at risk. And not because they are predisposed to the impact, but because a mild brain injury is going to have the most impact on someone juggling the difficulties of modern life and thus more likely to result in causing the whole stack of cards to fall. Failure is often not an option in these cases. This is not to discount other personality factors that may lead to increased risks for depression but our focus is on those who functioned in an acceptable societal norm prior to injury and were unable to function at those levels post injury.

We are likely to have more research which links prior mild brain injury to suicide as patients with mild brain injuries were not typically followed up with prior to 1995. as noted in the Danish Study which established a definite connection between brain injury and depression/suicide. Even so, this study found that

“Even people who had milder brain injuries like concussions without any evidence of fracture were still 81 percent more likely to commit suicide than individuals without a history of TBI.”

The Danish study was the largest study done to date. Dr. Ramon Diaz-Arrastia summed up the findings of the study.

“The take-home message here is that mood and affect are commonly impacted by TBI, and that it is part of the organic brain injury, and need to be taken seriously,”

Treatment for Depression Must be Explored

One point that everyone is agreed upon is that ongoing treatment for the psychological impact of brain injury, in all categories of severity, is both needed and under-utilized. Treatment needs to be targeted to deal with specific areas of damage in the brain and could include pharmaceutical, behavioral or rehabilitation techniques. And as the greatest risk is present in the first year following injury, a treatment program should be put in place from the onset of the injury and continued as a long term plan. It is noted in many articles that early onset of depression or suicidal ideation can continue for many years without any decrease in intensity so ongoing treatment remains important. Family members and associates should be educated as to the warning signs that intervention is needed. There is a good article on this at https://www.sprc.org/sites/default/files/migrate/library/TBI_Suicide.pdf if you have suffered a brain injury and have suicidal thoughts, help should be sought immediately.

Another factor we must consider is prevention of brain injury. Whether it is through education about the risks of carbon monoxide poisoning, helmet safety, seatbelt use, to reducing risks associated with falls–prevention ultimately is the most important way to avoid brain injury. Remember, once a person has had a brain injury, they are three times more likely to have a second brain injury.

The National Suicide Prevention Lifeline is 800-273-8255