Suicide in Veterans with Post-Traumatic Headache: An Analysis of Health Systems Data
Sarah E. Anthony, M.Sc.1, Manali A. Phadke, M.S.2, Richard B. Lipton, M.D.3, X. Michelle Androulakis, M.D.4, Hamada H. Altalib, D.O., M.P.H.5, Brenda Fenton, Ph.D.6, Jason J. Sico, M.D., M.H.S.7, Elizabeth K. Seng, Ph.D.8
1Veterans Health Administration Headache Centers of Excellence (HCoE), Department of Veterans Affairs, Orange, CT USA; Department of Neurology, Yale School of Medicine, New Haven, CT USA, 2Yale Center for Analytical Sciences, Yale University, New Haven, CT USA; Yale School of Public Health, New Haven, CT USA, 3Albert Einstein College of Medicine, Bronx, NY USA; Montefiore Medical Center, Bronx, NY USA, 4Columbia VA Health Care System, Columbia, SC USA, 5Department of Neurology, Yale School of Medicine, New Haven, CT USA; Neurology Service, VA Connecticut Healthcare System, West Haven, CT USA, 6Veterans Health Administration Headache Centers of Excellence (HCoE), Department of Veterans Affairs, Orange, CT USA; Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT USA, 7Veterans Health Administration Headache Centers of Excellence (HCoE), Department of Veterans Affairs, Orange, CT USA; Department of Neurology, Yale School of Medicine, New Haven, CT USA; Neurology Service, VA Connecticut Healthcare System, West Haven, CT USA; Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT USA; Center for Neuroepidemiological and Clinical Neurological Research, Yale School of Medicine, New Haven, CT USA; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT USA, 8Veterans Health Administration Headache Centers of Excellence (HCoE), Department of Veterans Affairs, Orange, CT USA; Albert Einstein College of Medicine, Bronx, NY USA; Montefiore Medical Center, Bronx, NY USA; Yeshiva University, Bronx, NY USA
Objective:
Evaluate the association of post-traumatic headache (PTH) with suicide-related behaviors (SRBs) compared to matched controls and explore psychiatric diagnoses and headache disease severity as mediators.
Background:
While PTH and SRB risk factors are prevalent among Veterans, whether PTH is associated with increased risk of SRBs is unclear.
Design/Methods:
This study extracted data from Veterans Health Administration (VHA) electronic health record data sources. Veterans diagnosed with PTH by a physician or APRN during the study period (fiscal years 2008-2020) were included. Non-headache controls were matched on gender, race/ethnicity, age (+/- 5 years), and year and point of care. Logistic regression evaluated differences in SRBs between the PTH group and matched controls. Diagnoses of major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and insomnia, and headache disease severity (operationalized as neurology consultation), were explored separately as potential mediators between PTH and SRBs.
Results:
Out of 51,755 Veterans diagnosed with PTH, 6,447 (12.5%) reported any SRB compared to 5,150 matched controls (5%). The PTH group was predominantly White, Non-Hispanic (64.5%) male (89.4%) with an average age of 41 (interquartile Range= 30 – 56). Veterans with PTH had increased odds of any SRB (OR = 2.72, 95% confidence interval [CI] 2.62, 2.82) compared to controls. Results remained significant (OR= 1.80, 95% CI 1.72, 1.87) after adjusting for age, substance use disorders, and the Charlson Comorbidity Index. Significant mediation was observed; the percentages mediated were as follows: MDD (49.4%), PTSD (41.0%), headache disease severity (15.8%), and insomnia (11.8%).
Conclusions:
PTH was significantly associated with SRBs; mental health diagnoses and headache disease severity contributed to this relationship. Suicide risk mitigation strategies must be integrated into clinical practice for clinicians treating PTH patients, including addressing headache disease severity and comorbid mental health concerns, particularly MDD and PTSD.