Concussion in Youth a Suicide Risk Factor?

Damian McNamara

December 05, 2019

Sports-related concussion in youth is tied to a marked increase in risk for subsequent suicide risk factors, including depression, suicidal ideation, and suicide attempts, new research shows.

In the first study to examine the relationship between sports-related concussion in youth and suicide risk factors in a nationally representative sample, investigators found that high school students who reported having had a concussion were 60% more likely to attempt suicide and were 135%, or more than twice as likely, to require medical treatment related to a suicide attempt.

"Our findings...demonstrate the relationship between concussions and suicidal behavior was even stronger than anticipated," lead author Dale S. Mantey, a predoctoral fellow at the University of Texas School of Public Health, Austin, told Medscape Medical News.

The study was published online November 11 in the Journal of Affective Disorders.

Research Gap

Suicide is the third leading cause of death among US teens. Although previous research has shown that concussion is a risk factor for suicide in adults, few studies have examined this link in youth, which represents "a substantial gap in the public health literature," the investigators note.

Data show that every year, 1.5 million US adolescents experience a concussion related to physical activity or sports participation.

To learn more, the researchers assessed data for 13,353 participants in the Youth Risk Behavior Surveillance Survey – United States, 2017. They found that 15% of adolescents self-reported a history of concussion during the previous 12 months.

The survey also asked participants about feelings of sadness or hopelessness, suicidal ideation, making a suicide plan, attempting suicide, or a suicide attempt treated by a physician or nurse. The investigators controlled for factors that are widely accepted as increaseing risk for suicide in this age group, including sexual orientation and being the victim of in-person bullying or cyberbullying.

Thirty-two percent of high school students reported feeling sad or hopeless; 18% reported having suicidal thoughts; 14% reported making a suicide plan; 7% reported making a suicide attempt; and a little more than 2% reported making a suicide attempt that required treatment by a physician or nurse.

Table. Risks Among Those Reporting Recent Concussion

  Odds Ratio* 95% Confidence Interval
Feeling sad or hopeless 1.20 1.02 – 1.42
Suicidal ideation 1.25 1.02 – 1.55
Suicide attempt 1.60 1.31 – 1.96
Sought medical treatment 2.35 1.68 – 3.29
*Adjusted for sex, race/ethnicity, grade level, sexual orientation, and history of bullying victimization.

 

Greater Risk in Males

A higher proportion of males reported a history of sports-related concussion, at 17%, vs 13% in females – a difference that was statistically significant (P < .001).

Some suicide factors were different between boys and girls as well. Males who reported having a concussion in the previous 12 months had a greater likelihood of a suicide attempt (adjusted odds ratio [aOR], 2.04; 95% confidence interval [CI], 1.19 – 3.49). This group also was more likely to be treated by a physician or nurse after a suicide attempt (aOR, 3.27; 95% CI, 1.85 – 5.78).

In contrast, girls had a higher risk for all five suicide-related factors. Females who reported having concussion were more likely to feel sad or hopeless (aOR, 1.26; 95% CI, 1.06 – 1.49); to have reported suicidal thoughts (aOR, 1.37; 95% CI, 1.08 – 1.73); to have planned a suicide attempt (aOR, 1.39; 95% CI, 1.08 – 1.79); to have attempted suicide (aOR, 1.40; 95% CI, 1.08 – 1.80); and to have made a suicide attempt that required treatment by a physician or nurse (aOR, 1.97; 95% CI, 1.24 – 3.14).

The researchers also found that the prevalence of concussion was almost 20% higher among participants who reported a history of bullying victimization. This finding was statistically significant in comparison with participants who did not report such bullying (P < .001).

The investigators point out that the study findings do not show causality and that the self-reporting in the study means that the results are subject to bias. "Despite these limitations, this study has substantial public health implications," the investigators note.

They add that although more research is needed to further explore the relationship between concussion and suicide risk, the results "suggest a critical need for expanded education, awareness, monitoring and treatment of sports-related concussions. Furthermore, suicide prevention programs should consider incorporating concussions as a risk factor for suicide completion among youth, particularly among boys."

"Physicians should inform parents and guardians of the risks that come with concussions and should advise them to monitor changes in mood or behavior, as these may be warning signs of depression and/or suicidal ideation," Mantey said.

The researchers are currently expanding their research to explore the same relationship in younger athletes who sustain concussions during middle school. They also plan to explore behavioral and psychological risk factors that may further explain the link between concussions and depression or suicide.

Going forward, the investigators hope to create "a social and behavioral science perspective that compliments the incredible clinical research being done on traumatic brain injury," Mantey said.

"We hope our research can inform educational programs and other interventions aimed at reducing the short- and long-term consequences of brain injuries suffered by adolescents," he added.

"Timely Data"

Commenting on the findings for Medscape Medical News, Michael Fralick, MD, PhD, a general internist at Sinai Health System and assistant professor at the University of Toronto, said the study provides "timely data" on the potential link between concussion and suicide in high school students.

"While it is challenging to draw causal conclusions from this cross-sectional study, their results are in line with prior research that suggests concussion is a risk factor for suicide," said Fralick, principal investigator of a meta-analysis that showed a twofold risk for suicide associated with mild traumatic brain injury.

"Additional research is required to understand what can be done to identify individuals, both young and old, at risk of suicide following concussion and to develop strategies to mitigate this risk," he added.

Also commenting on the findings, Amanda Clacy, PhD, a postdoctoral research fellow in suicide prevention, University of the Sunshine Coast, Birtinya, Australia, said the study makes a significant contribution to the growing discussion about the impact of sports-related concussion on emotional functioning.

Many concussion management practices across different sports prescribe varying levels of physical and cognitive rest, she noted.

"While this is fundamental and imperative for neurobiological recovery, it also presents psychosocial stressors that may negatively impact emotional functioning through disengagement and disconnection, which are two of the leading risk factors associated with suicidality," Clacy told Medscape Medical News.

"It is also important to note that sport participation has been shown to offer protection against the onset of depression and suicidality ― and this fact should not be forgotten as we further explore this complex issue," added Clacy, who was lead author of a September 2019 position statement entitled "Concussion Risk and Suicide Prevention: Balancing the Risks and Benefits of Youth Sport."

Mantey, Fralick, and Clacy have disclosed no relevant financial relationships.

J Affect Disord. Published online November 11, 2019. Abstract

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