a public health approach to suicide prevention after TBI
Risk Reduction & Health Promotion
Translational Neuroscience Conference September 27, 2013
Learning Objectives 1. Gain information about the public health significance of TBI and
suicide 2. Gain an understanding of how risk reduction and health promotion
are two distinct but complementary approaches within the field of public health
3. Learn how both approaches can be applied to guide suicide
prevention efforts for those with TBI 4. Learn how a comprehensive suicide prevention strategy for
individuals with TBI will include approaches to risk reduction and health promotion that moves beyond individual behavior
Overview
1 2
4 3
Proposed Solution
Significance of the Problem
Breaking it Down
Putting it All Together
significance of the problem
one
The Impact of TBI
• Each year, approximately 1.5 million Americans survive a traumatic brain injury
• An estimated 5.3 million U.S. citizens are
living with disability as a result of a TBI
CDC, 2010
Potential Sequelae of TBI
cognitive deficits
mood and behavioral issues
sensory and motor impairments
sleep disturbance and pain
seizures
Psychiatric Illness Following TBI
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1 2 3 4 5 6
mild
mod-‐sev
mild psy
mod-‐sev psy
TBI of all severity levels associated with increased risk of psychiatric illness
Fann et al.,2009
TBI in the Post 9-11 Era
• Reported rates of TBI in deployed OEF/OIF service members have ranged from 15.2% to 22.8%
• Majority of TBIs sustained are mild TBI
• Veterans with TBI, particularly mTBI at increased RISK for developing PTSD
Hoge et al. 2008; Terrio et al., 2009
Potential Reasons
• Impaired emotional regulation resulting from damage to the medial pre-frontal cortex
• Additional stressors that occur after mTBI
Bryant et al. 2009
Does More Equal More?
Veterans with both conditions are at greater risk for PC symptoms than those with either PTSD, mTBI, or neither
Brenner et al., 2009
PC Symptom Reporting
Brenner et al., 2009
PTSD only = 82 (7%) mTBI only = 555 (45%) PTSD + mTBI = 323 (26%) None = 287 (23%)
N= 1247 OEF/OIF soldiers
Any PC Symptom (n = 389)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
2.74
4.03
6.27
Adjus
teda (P
R)
Brenner et al., 2009
Total no. of soldiers (N = 1247)
Adjusted for age, gender, education, rank, and MOS
Symptom: Headache (n=204)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
2.79
4.26
5.91
Adjus
teda (P
R)
Brenner et al., 2009
Adjusted for age, gender, education, rank, and MOS
Symptom: Dizziness (n = 51)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
4.37
3.00
6.48
Adjus
teda (P
R)
Brenner et al., 2009
Adjusted for age, gender, education, rank, and MOS
Symptom: Memory (n=154)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
4.00
6.22
12.70
Adjus
teda (P
R)
Brenner et al., 2009
Adjusted for age, gender, education, rank, and MOS
Symptom: Balance (n = 62)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
5.316.04
12.91
Adjus
teda (P
R)
Brenner et al., 2009
Adjusted for age, gender, education, rank, and MOS
Symptom: Irritability (n = 215)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
No mTBI & no PTSD
Had PTSD but no mTBI
Had mTBI but no PTSD
Had mTBI & PTSD
1.00
3.19 3.45
6.61
Adjus
teda (P
R)
Brenner et al., 2009
Adjusted for age, gender, education, rank, and MOS
Impact on Functioning
ratings of general health
sick call visits
missed workdays
physical symptoms
PTSD significantly associated with
Hoge et al. 2007
Suicidal Self Directed Violence After TBI
Individuals at TBI are at increased risk for Suicidal Ideation Suicide Attempts Suicide
Bahraini et al 2013; Simpson & Tate, 2002
Shared Risk Factors
TBI Suicide
Age
Gender
Substance Use
Psychiatric Illness
Aggression
TBI Specific Risk Factors for Suicide
• Psychiatric/Emotional Disturbance
• Substance Abuse
• Problem solving deficits • Psychosocial stressors • Loss of self, lack of purpose • Social isolaOon, loneliness
Other risk factors related to the injury
TBI is a “Disease Process”
For some, TBI is a lifelong process that may be both disease
and
Masel & DeWiR, 2010
Optimal Health Trajectory
Suicide Risk Trajectory
TBI Shifts the Health Trajectory
Time
Optimal Health Trajectory
Suicide Risk Trajectory
TBI Shifts the Health Trajectory
Time
TBI
Optimal Health Trajectory
Suicide Risk Trajectory
TBI Shifts the Health Trajectory
Time
TBI
Optimal Health Trajectory
Suicide Risk Trajectory
Timing Matters
Time
TBI
Optimal Health Trajectory
Suicide Risk Trajectory
Timing Matters
Time
TBI
Optimal Health Trajectory
Suicide Risk Trajectory
Timing Matters
Time
TBI
the proposed solution
two
Suicide Prevention Across the Lifespan
Focus on op<mal health trajectories
Pathways to Optimal Health
• Risk Reduction • Reduce exposure to and cumulative
impact of health risks after TBI
• Health Promotion • Increase positive health outcomes and
protective factors in those with TBI
The Overarching Goal
Mitigate the impact of TBI on health trajectory and prevent the
downward pressure towards suicide risk
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
TBI
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
RR
Time
TBI HP
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
RR
Time
TBI HP
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
TBI
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
TBI RR HP
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting Towards Optimal Health
Time
TBI RR HP
breaking it down three
Proposed Framework
When? Timing of Prevention Who? Populations and Sub-groups
Where? Contexts and settings
What? Intervention Targets
when to promote, prevent, & treat?
Prevention
To PREVENT means “to keep something from happening”
The Current State of Suicide Prevention
• Weighted towards crisis intervention “cliff-edge”
approach
• Current evidence- based interventions designed to prevent re-attempts (none specific to TBI)
• Less research on interventions that prevent the onset of suicidal SDV behavior
Op<mal Health Trajectory
Suicide Risk Trajectory
Shifting the Focus Upstream
Time
Traditional Prevention Model
Onset of a disorder or condition
Primary Prevention
Secondary Prevention
Tertiary Prevention
Severity of a disorder or condition
Disability associated with a disorder or condition
BEFORE
AFTER
Public Health
Prevention
Populations
Socio-cultural
Medical Treatment Individuals Biological/ Behavioral
The Need for an Integrated Model
Prevention
Treatment
Maintenance
Before the onset of suicidal SDV behavior
Once suicidal SDV behavior that is not fatal has occurred
Preventing repeated acts of suicidal SDV, fatal and non-fatal
THE IOM Healthcare Continuum
Suicide Prevention
IntervenOons, policies, and acOons that prevent suicidal SDV behavior from iniOally occurring
Treatment and Maintenance
Occurs after suicidal SDV has initially occurred, non-fatal
– Reduce associated injury and disability
– Prevent repeated acts of suicidal SDV
– Treat other factors contributing to suicide risk (e.g., hopelessness)
Prevention Treatment
Can include the treatment of precursors of suicide risk— depression, substance abuse, hopelessness Targeting hopelessness to prevent re-attempt or CBT for suicide prevention
When Is Treatment Still Prevention?
The Role of Health Promotion
• Emphasis on enhancing well-being rather than prevention of disease or illness
• Increases protective factors, an area that has
been vastly understudied • Applies to all individuals regardless of disease
or illness status, history or current risk level
Comprehensive Strategy
Reduce rates of SUICIDE MORTALITY in a given population
Promotion
Prevention
Treatment
Maintenance
who to intervene with?
Universal ALL MEMBERS of a given population regardless of risk
Selected Sub-populations who may be AT ELEVATED RISK
Indicated Members of a given population with SPECIFIC RISK CONDITIONS
Levels of Prevention
Application to TBI
• What do we know about our population? • Who are most vulnerable? • What are their characteristics? • What risks/behaviors are present in their
lives?
ALL INDIVIDUALS in a given TBI population regardless of risk level
Universal Prevention
TBI POPULATIONS who may be at greater risk for suicidal SDV
Selected Prevention
TBI SUB-POPULATIONS with identified risk conditions
Indicated Prevention
which setting or context?
Suicide is Multifaceted
Suicide is an individual act; however, it results from a complex interaction of biological, genetic, psychological, SOCIOLOGICAL and environmental factors
Socio-Ecological Model of Prevention 4th LEVEL 3rd LEVEL
I
2nd LEVEL
Individual
1st LEVEL
Community & Institutional Interpersonal Socio-political
Dahlberg & Krug 2002
Individual
Personal Characteristics Biological Factors Behavior
Psychiatric hx
Social Skills
Cognitive deficits
Substance use
Hopelessness
Interactions between two or more individuals
Interpersonal
Family Communication
Social Support
Parent-Child Interactions
Intimate Partner Violence
Community & Institutional
Settings and institutions in which social relationships take place
Schools (K-12)
Colleges/Universities
Workplace
Healthcare Institutions
Neighborhoods
Community Centers
Socio-political
Larger, macro-level factors that contribute
to disparities among groups of people and/or environmental factors that influence risk for suicidal SDV
Societal norms
Socioeconomic status
Economic policies
Geographical location
Access to healthcare
Unemployment rates
What factors to Target?
Proposed Intervention Targets?
modifiable RISK and PROTECTIVE
factors for suicide or PRE-CURSORS to
suicidal behavior in those with TBI
Multiple Targets
Prevention interventions may be more effective when they target MULTIPLE
risk and protective factors rather than just one
High Impact Targets
Psychiatric Illness Substance Abuse Hopelessness
Social Connectedness Problem Solving Physical Activity
four putting it all together
Multicomponent Interventions
Prevention efforts can be maximized by interventions that simultaneously address risk and protective factors across the socio-ecological domains
Maton et al. 2004; Sandler et al. 2004
Single Component Evidence-based psychological interventions for depression for individuals with TBI
Approach: Risk Reduction Target: Depression Level: Indicated Domain: Individual
Multiple Component Tele-health or computerized delivery of evidence-based psychological interventions for depression for individuals with TBI living in rural areas
Approach: Risk Reduction Target: Depression and Treatment Access Level: Indicated Domain: Individual and Societal
Combining HP and RR Internet based Family Problem Solving Intervention for emotional and behavioral disturbance after Pediatric TBI Targets: Emotional and Behavioral Disturbance;
Parent–Child Interactions; Problem-solving skills, Access to Care
Level: Selected or Indicated Domains: Individual, Interpersonal, and Societal
Substance Use An educational DVD for providers to facilitate patient and family education regarding the risk of substance use after TBI Approach: Risk Reduction Targets: Substance use, Patient-Provider Communication Level: Universal or Selected Domain: Individual and Institutional
Promising Interventions Peer-Mentoring Programs to increase Social Integration for Persons With Traumatic Brain Injury (Struchen et al., 2011)
Window to Hope: A psychological intervention for hopelessness (Simpson et al., 2011)
Physical Exercise for post-TBI depression, cognitive deficits Complementary and alternative and integrative medicine
Research Considerations
• “Practical” science • Collaborating across systems/contexts • Community partnered research • Dissemination and Implementation of
evidence based practices
Questions?
Nazanin Bahraini, PhD Director of Education, VISN 19 MIRECC
Assistant Professor of Psychiatry
University of Colorado Anschutz Medical Campus
http://www.mirecc.va.gov/visn19/