JMIR Publications

ABSTRACT

Background:

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to Veterans without TBI or PTSD.

Objective:

Using administrative data from the United States (US) Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm, among US Veterans who used VHA healthcare between 2008 and 2017.

Methods:

All Veterans with encounters or hospitalizations for intentional self-harm were assigned “index dates” corresponding to the date of first related visit; among those without intentional self-harm, we randomly selected a date from among the Veteran’s healthcare encounters to match the distribution of case index dates over the 10-year period. We then examined prevalence of TBI and PTSD diagnoses within the 5-year period prior to Veterans’ index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases (ICD) diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by Veterans’ average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by Veterans’ prior TBI and PTSD diagnosis status (TBI-only, PTSD-only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs (VA) service-connection status, and Charlson Comorbidity Index scores.

Results:

Across all three VHA utilization strata, prevalence of intentional self-harm diagnoses was higher among Veterans diagnosed with TBI, PTSD, or TBI/PTSD than among Veterans with neither diagnosis. The observed difference was most pronounced among Veterans in the high VHA utilization stratum. Prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (11.63%) than among Veterans with neither TBI nor PTSD (1.92%). Adjusted odds ratios (ORs) suggested that, after accounting for potential confounders, Veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to Veterans without these diagnoses. Among Veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 times more likely to receive diagnoses for intentional self-harm than Veterans with neither diagnosis (95% confidence interval: 4.15-4.38). This pattern was similar for Veterans with low and medium VHA utilization.

Conclusions:

Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among Veterans who used VHA healthcare most frequently. These findings suggest a need for suicide prevention efforts targeted at Veterans with these diagnoses.