Annotated Abstracts of Journal Articles
2014, 1st Quarter


Annotations by Kemuel Philbrick, MD, FAPM
March 2014

  1. The effects of involuntary job loss on suicide and suicide attempts among young adults: Evidence from a matched case-control study
  2. Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study

PUBLICATION #1 — Suicide
The effects of involuntary job loss on suicide and suicide attempts among young adults: Evidence from a matched case-control study

Milner A, Page A, Morrell S, Hobbs C, Carter G, Dudley M, et al
Aust N Z J Psychiatry 2014 Apr; 48(4):333-40

ANNOTATION (Kemuel Philbrick)

The Finding: Proximate (within 12 months) job loss was associated with a near doubling in the odds ratio (1.82) of suicide attempts and completions but this did not achieve statistical significance (p=0.058) as compared with the statistically significant risks associated with low socio-economic status (OR=3.80), diagnosis of either an affective or anxiety disorder (OR=7.87), and relationship status (single OR=3.49 and separated OR=3.97).

Strengths and Weaknesses: This was a population-based case-control study focusing on the potential effect of recent job loss as opposed to simple unemployment. It deliberately included both urban and rural areas and limited the scope of its study to young adults aged 18-34. Suicide attempts and completions were aggregated, as were both sexes, to enable sufficient statistical power for meaningful analysis. It was not possible to determine whether mental disorders preceded or followed the involuntary job loss, rendering the heightened risk an observation of association rather than causation. It was also not possible to ascertain additional details of possible relevance such as availability of alternative employment, previous episodes of job loss, or the duration of time between job loss and the suicide or attempt.

Relevance: The challenging financial and employment climate in developed countries presents continuing stresses for young adults. In the absence of robust economic growth and opportunity, job loss is an additional burden on individuals who present for medical and psychiatric evaluation, and may signal a heightened risk for suicide.


Objective: To assess the influence of involuntary job loss on suicide and attempted suicide in young adults.

Method: A population-based case-control study of young adults (18-34 years) was conducted in New South Wales, Australia. Cases included both suicides (n=84) and attempts (n=101). A structured interview was conducted with next of kin (for suicide cases) and suicide attempters admitted to hospital. Controls selected from the general population were matched to cases by age and sex. Job dismissal or redundancy (involuntary job loss) in the 12 months before suicide or attempt was the main study variable of interest. Suicide and attempts were modelled separately and in combination as outcomes using conditional logistic regression modelling. The analysis was also adjusted for marital status, socio-economic status and diagnosis of an affective or anxiety disorder.

Results: Following adjustment for other variables, involuntary job loss was associated with an odds ratio of 1.82 for suicide and attempted suicide (combined) (95% CI 0.98 to 3.37; p=0.058). Low socio-economic status was associated with an odds ratio of 3.80 for suicide and attempted suicide (95% CI 2.16 to 6.67; p<0.001) compared to high socio-economic status (after adjustment). Diagnosis of a mental disorder was associated with a 7.87 (95% CI 5.16 to 12.01; p<0.001) odds ratio of suicide and attempted suicide compared to no diagnosis (after adjustment). Involuntary job loss was associated with increased odds of suicide and attempts when these were modelled separately, but results did not reach statistical significance.

Conclusions: Involuntary job loss was associated with increased odds of suicide and attempted suicide. The strength of this relationship was attenuated after adjustment for socio-economic status and mental disorders, which indicates that these may have a stronger influence on suicide than job loss.

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PUBLICATION #2 — Suicide
Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study

Fazel S, Wolf A, Pillas D, Lichtenstein P, Långström N
JAMA Psychiatry 2014 Mar 1; 71(3):326-33

ANNOTATION (Kemuel Philbrick)

The Finding: Drawing on extended longitudinal follow-up (four to >40 years) of more than 218K Swedish individuals who suffered a TBI, this study indicates that persons who survive 6 months or more beyond a TBI are three times more likely to die prematurely from suicide, assault, or other injuries. Of particular interest to psychiatrists, post-TBI patients are twice as likely to die by suicide compared to their uninjured siblings.

Strengths and Weaknesses: This study relies on impressive numbers and extensive longitudinal data, taking advantage of comprehensive nationwide population-based registers in Sweden which also allowed comparison to general population controls and a substantial number (>237K) of uninjured siblings; this extensive database enabled uncommon statistical power to examine relatively infrequent events. Unfortunately, the study was not able to specify either the type of TBI or quantify the severity of the TBI.

Relevance: This study underscores the utility of regarding post-TBI patients as having a chronic medical problem that deserves ongoing attention, perhaps particularly those who are also prone to impulsivity, risk-taking behaviors, or substance abuse. Returning veterans, youth involved in contact sports, and individuals who live in environments where assaults are more common comprise a population at increased risk of having suffered a TBI and may invite psychiatric attention when they pursue medical attention.


Importance: Longer-term mortality in individuals who have survived a traumatic brain injury (TBI) is not known.

Objectives To examine the relationship between TBI and premature mortality, particularly by external causes, and determine the role of psychiatric comorbidity.

Design, Setting, and Patients: We studied all persons born in 1954 or later in Sweden who received inpatient and outpatient International Classification of Diseases-based diagnoses of TBI from 1969 to 2009 (n=218 300). We compared mortality rates 6 months or more after TBI to general population controls matched on age and sex (n=2 163 190) and to unaffected siblings of patients with TBI (n=150 513). Furthermore, we specifically examined external causes of death (suicide, injury, or assault). We conducted sensitivity analyses to investigate whether mortality rates differed by sex, age at death, severity (including concussion), and different follow-up times after diagnosis.

Main Outcomes and Measures: Adjusted odds ratios (AORs) of premature death by external causes in patients with TBI compared with general population controls.

Results: Among those who survived 6 months after TBI, we found a 3-fold increased odds of mortality (AOR, 3.2; 95% CI, 3.0-3.4) compared with general population controls and an adjusted increased odds of mortality of 2.6 (95% CI, 2.3-2.8) compared with unaffected siblings. Risks of mortality from external causes were elevated, including for suicide (AOR, 3.3; 95% CI, 2.9-3.7), injuries (AOR, 4.3; 95% CI, 3.8-4.8), and assault (AOR, 3.9; 95% CI, 2.7-5.7). Among those with TBI, absolute rates of death were high in those with any psychiatric or substance abuse comorbidity (3.8% died prematurely) and those with solely substance abuse (6.2%) compared with those without comorbidity (0.5%).

Conclusions and Relevance: Traumatic brain injury is associated with substantially elevated risks of premature mortality, particularly for suicide, injuries, and assaults, even after adjustment for sociodemographic and familial factors. Current clinical guidelines may need revision to reduce mortality risks beyond the first few months after injury and address high rates of psychiatric comorbidity and substance abuse.


Comment on this article:
Limb M: Traumatic brain injury carries long term health risks, finds study
BMJ 2014; 348:g294

Robinson RG: Mortality in patients with traumatic brain injury
JAMA Psychiatry 2014 Mar 1; 71(3):234-5

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