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CMAJ Research CMAJ Research Risk of suicide after a concussion Michael Fralick MD BScH, Deva Thiruchelvam MSc, Homer C. Tien MD MSc, Donald A. Redelmeier MD MS(HSR) CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/150790-res Abstract Competing interests: Background: Head injuries have been associated equivalent to 31 deaths per 100 000 patients None declared. with subsequent suicide among military person- annually or 3 times the population norm. This article has been peer nel, but outcomes after a concussion in the com- Weekend concussions were associated with a reviewed. munity are uncertain. We assessed the long-term one-third further increased risk of suicide com- Accepted: Nov. 26, 2015 risk of suicide after concussions occurring on pared with weekday concussions (relative risk Online: Feb. 8, 2016 weekends or weekdays in the community. 1.36, 95% confidence interval 1.14–1.64). The increased risk applied regardless of patients’ Correspondence to: Methods: We performed a longitudinal cohort Donald A. Redelmeier, demographic characteristics, was independent [email protected] analysis of adults with diagnosis of a concus- of past psychiatric conditions, became accentu- sion in Ontario, Canada, from Apr. 1, 1992, to ated with time and exceeded the risk among CMAJ 2016. DOI:10.1503 /cmaj.150790 Mar. 31, 2012 (a 20-yr period), excluding severe military personnel. Half of these patients had cases that resulted in hospital admission. The pri- visited a physician in the last week of life. mary outcome was the long-term risk of suicide after a weekend or weekday concussion. Interpretation: Adults with a diagnosis of con- cussion had an increased long-term risk of Results: We identified 235 110 patients with a suicide, particularly after concussions on week- concussion. Their mean age was 41 years, 52% ends. Greater attention to the long-term care were men, and most (86%) lived in an urban of patients after a concussion in the community location. A total of 667 subsequent suicides might save lives because deaths from suicide occurred over a median follow-up of 9.3 years, can be prevented. uicide is a leading cause of death in both protracted course.13 However, the frequency of military and community settings.1 During depression after concussion can be high,14,15 and 2010, 3951 suicide deaths occurred in Can- traumatic brain injury in the military has been S2 3 8,16 ada and 38 364 in the United States. The fre- associated with subsequent suicide. Severe quency of attempted suicide is about 25 times head trauma resulting in admission to hospital has higher, and the financial costs in the US equate to also been associated with an increased risk of sui- about US$40 billion annually.4 The losses from cide, whereas mild concussion in ambulatory suicide in Canada are comparable to those in other adults is an uncertain risk factor.17–20 countries when adjusted for population size.5 Sui- The aim of this study was to determine cide deaths can be devastating to surviving family whether concussion was associated with an and friends.6 Suicide in the community is almost increased long-term risk of suicide and, if so, always related to a psychi atric illness (e.g., depres- whether the day of the concussion (weekend v. sion, substance abuse), whereas suicide in the mili- weekday) could be used to identify patients at tary is sometimes linked to a concussion from further increased risk. The severity and mecha- combat injury.7–10 nism of injury may differ by day of the week Concussion is the most common brain injury because recreational injuries are more common in young adults and is defined as a transient dis- on weekends and occupational injuries are more turbance of mental function caused by acute common on weekdays.21–27 The risk of a second trauma.11 About 4 million concussion cases occur concussion, use of protective safeguards, pro- in the US each year, equivalent to a rate of about pensity to seek care, subsequent oversight, sense 1 per 1000 adults annually;12 direct Can adian data of responsibility and other nuances may also dif- are not available. The majority lead to self-limited fer for concussions acquired from weekend rec- symptoms, and only a small proportion have a reation rather than weekday work.28–31 Medical ©2016 8872147 Canada Inc. or its licensors CMAJ, April 19, 2016, 188(7) 497 Research care on weekends may also be limited because standardized concussion assessment scores were of shortfalls in staffing.32 not available.53 Similarly, information was not available on cases that did not lead to medical Methods attention or on whether day of the week was an imperfect proxy for concussion circumstances. Patient selection The official demographic registry provided data We conducted a longitudinal cohort analysis of on patient age, sex and home location (urban or adults with a diagnosis of a concussion in rural).34 Socioeconomic status was based on neigh- Ontario, Canada, from Apr. 1, 1992, to Mar. 31, bourhood income quintile and was determined 2012 (20 yr), based on vital statistics data avail- through the validated Statistics Canada algo- able through the Office of the Registrar General rithm.54–56 The health care services databases pro- database.33 Ontario is Canada’s most populous vided data on hospital admissions, outpatient con- province, with 12 259 564 individuals in 2003 tacts and diagnoses in the previous year.57,58 Prior (study midpoint).34 During the study period, the psychiatric conditions (schizophrenia, depression, annual suicide rate in Ontario was about 9 per bipolar disorder, suicide attempt, anxiety, sub- 100 000,35 somewhat lower than the global sui- stance abuse) were determined from physician cide rate of 11 per 100 00036 and the rate among diagnostic data for the full year before injury.59 former military personnel of 14 per 100 000.37,38 The available databases contained no information During the study period, Ontario health insur- on social stress, life events, employment status, ance covered primary, emergency and hospital race or ethnicity, sexual orientation, immigration care with no out-of-pocket costs to patients.39,40 status, borderline personality disorder, childhood The project was approved by the Research Eth- abuse, eating disorders, suicidal ideation, novel ics Board of Sunnybrook Health Sciences Cen- biomarkers or other suicide risks.60–62 tre; the approval included a waiver of the need for informed consent. Outcome identification We identified patients with a diagnosis of a We determined the cause of death from official concussion by screening physician claims data death certificates encompassing definite or prob- using the International Classification of Dis- able suicide, as investigated by the responsible eases, 9th revision (ICD-9) diagnostic criteria for coroner. All coroners were licensed physicians concussion (code 850) from the Ontario Health in Ontario, and suicidal death investigations Insurance Plan database.41,42 This code has been have an interrater agreement of about 70% in validated with high specificity (99%) and mid- this setting.63 We identified definite cases of sui- range sensitivity (22%–76%).43–45 Patients who cide by ICD-9 codes (E950–E959) or Interna- were admitted to hospital immediately or within tional Statistical Classification of Diseases and 2 days of injury were excluded because such Related Health Problems, 10th revision (ICD- cases tend to reflect severe brain injury (a known 10)64 codes (X60–X84) and probable cases of risk factor for suicide) and do not represent suicide by ICD-9 codes (E980–E987, E989) or ambulatory patients with concussion.46,47 Patients ICD-10 codes (Y10–Y32, Y34), as validated in under 17 years of age were excluded because past research.65 The database for death certifi- most suicide deaths occur in adults.48,49 Other- cates has been validated previously and is the wise, the selection criteria were fully compre- official source for vital statistics reporting, as hensive and included all patients seeking care well as the authoritative file for population-based whose diagnosis was made by a physician. analyses of suicides.59,66,67 For each case, we recorded the forensic cer- Data collection tainty and mechanism of suicide from the death We distinguished each case as a weekend concus- certificate. We calculated age at death and elapsed sion (midnight Friday to midnight Sunday) or a time from index concussion from the same source, weekday concussion (remaining 5 days and nights coded to the exact day. Similarly, we recorded the of the week).50 Differentiating a weekend from a time since the last visit with a physician by linking weekday concussion was based on the date of med- to the physician care database. We also recorded ical care, which closely corresponds to the date of the reason for the last visit, classified as a psychiat- injury.51,52 For patients with multiple concussions, ric, neurologic, medical or miscellaneous diagno- we used the date of the first concussion, such that sis along with the physician’s specialty.68 The each person was counted once in the analyses; available databases did not have information on repeat concussions were tracked for separate sec- pathology reports, toxicology reports, psychologi- ondary analyses. Further data on duration of amne- cal scores, presence of a suicide note, litigation sia, loss of consciousness, mechanism of injury, involvement, seniority of the investigating coroner severity of symptoms, delays in seeking care and or findings from a psychiatric autopsy.69 498 CMAJ, April 19, 2016, 188(7) Research Statistical analysis In the prespecified primary analysis, we assessed Table 1: Characteristics of patients with diagnosis of concussion in Ontario, Canada cumulative incidence rates (accounting for cen- soring and deaths) to estimate the probability of Timing of concussion; suicide after concussions on weekends and week- no.
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