Exploring the link between suicide and TBI

Earlier this year, the Pentagon reported an extremely grim statistic: In the first months of the year, a soldier was more likely to die from suicide than from war injuries. From early January to early May 2012, the suicide rate averaged nearly one per day among active-duty troops — an 18 percent increase from last year. Suicide rates among veterans are equally daunting. According to an estimate from the Department of Veterans Affairs (VA), a veteran dies by suicide every 80 minutes.

In August, President Barack Obama signed an executive order that strengthened suicide prevention efforts for service members and veterans. Among the many efforts being funded and watched by the Department of Defense (DoD) are those of Lisa Brenner, PhD, who is working with colleagues to adapt a civilian suicide prevention intervention for military personnel and veterans with traumatic brain injury (TBI).

Brenner directs the VA's Mental Illness Research, Education and Clinical Center (MIRECC) in Denver and Salt Lake City, one of 10 such VA centers designed to be incubators of innovative research and treatment. Each center has a specific mission; in Denver, Brenner and her colleagues study ways to prevent suicide among veterans. They have about 30 ongoing research projects. Funding is from the VA, DoD, and non-federal sources including the State of Colorado TBI Trust Fund.

One project explored whether a history of TBI increases suicide risk among veterans and service personnel. "We're just beginning to figure that out," she says.

Brenner led a study examining suicide risk in 49,626 VA patients with a history of TBI. The team's findings show that, overall, veterans with TBI have an increased risk of dying by suicide compared with veterans without brain injuries. This is consistent with findings among members of the general population. The analysis was published in the July/August 2011 issue of the Journal of Head Trauma Rehabilitation.

Brenner is quick to note that more severe brain injury doesn't necessarily correlate with an increased suicide risk. "The really important point is that TBI is a very heterogeneous condition," she says. "In terms of death by suicide, research in the field is beginning to suggest that mild TBI is a very different condition than moderate to severe TBI. We're trying to explore key factors for those with mild or moderate to severe TBIs. We hope that looking at them separately will help us create appropriate intervention."

Evidence-based interventions for those with TBI are needed, Brenner adds. That's where her work with Grahame Simpson, PhD, of the Liverpool Hospital/Ingham Institute of Applied Medical Research in Sydney, Australia, comes in. He developed the Window to Hope program, which focuses on relieving feelings of hopelessness among patients with TBI. Previous research has shown that hopelessness is a stronger predictor of eventual suicide than depression. Based on the principles of cognitive behavioral therapy (CBT), the intervention consists of 10 two-hour sessions aimed at building patients' problem-solving abilities and feelings of hope and self-esteem.

In a randomized, controlled pilot study of 17 civilian patients with severe TBI, the intervention reduced feelings of hopelessness to a similar extent as CBT in earlier studies of depressed patients without TBI. The study is believed to be the first to examine an intervention that's tailored to address elevated suicide risk among brain-injured patients (Journal of Head Trauma Rehabilitation, July/August, 2011).

With Simpson's input, Brenner and her team have adapted Window to Hope for military personnel and veterans. The Department of Defense's Military Suicide Research Consortium (MSRC) is now funding a randomized clinical trial of the intervention within the VA.

Brenner's Window to Hope collaboration is an innovative research approach for the VA, says Peter Gutierrez, PhD, a clinical/research psychologist at the VA's MIRECC in Denver and co-director of the MSRC. "This is a much faster way to do treatment development," he says. "A big chunk of the work is already done, so that allows you to start testing things out much more rapidly."

Recognizing opportunities for collaboration is another of Brenner's strengths as a researcher, Gutierrez adds. "She meets someone at a conference and realizes a shared interest they have," he says. "Before you know it, they're putting in a grant application together."

Her dedication to helping brain-injured veterans earned Brenner the Special Contribution Award from the Association of VA Psychologists, presented at the APA's 2012 Annual Convention in Orlando, Fla. "So far, this has really been a rich career," she says, "but there is still much work to be done."

Rebecca Voelker is a writer in Chicago.