Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Letters

Concussions and suicide

Francis X. Speidel
CMAJ May 17, 2016 188 (8) 605; DOI: https://doi.org/10.1503/cmaj.1150101
Francis X. Speidel
Drexel University, Philadelphia, Penn.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Responses
  • Metrics
  • PDF
Loading

Fralick and colleagues1 report a suicide rate three times the population norm for concussions that occur on weekdays and four times the norm for those that occur on weekends. The conclusion was based on a 20-year longitudinal study that used vital statistics from Canada’s Office of the Registrar General for the general population and physician claims for ICD-9 code 850, for concussion, for the cohort.

The authors excluded patients under 17 years of age “because most suicide deaths occur in adults.” Was a similar exclusion applied to the general population? If not, the exclusion of those less likely for suicide would seem to bias the cohort for a higher rate of suicide.

In stating “This code [850] has been validated with high specificity (99%) and mid-range sensitivity (22%–76%),” the authors cite three references. In one, the authors conclude, “The identification of mild TBI [traumatic brain injury] patients using retrospectively assigned ICD-9 codes appears to be inaccurate. These codes are associated with a significant number of false-positive and false-negative code assignments.”2

In another, the authors conclude, “ICD-9-CM codes were sensitive for the presence of any severe TBI, but further classification of specific types of TBI was limited by variable sensitivity/specificity. Use of these codes should be supplemented by other methodology.”3

These cited observations do not seem to promote comfort with Fralick and colleagues’ use of retrospective ICD-9 code (850) for defining the cohort.

Nor should this surprise many who have experience with acute closed head trauma. Using the 850 code puts into the same category patients who complain of feeling “out of it” for a few seconds after striking their head while denying a loss of consciousness (850.0) with those who have documented unresponsiveness for more than an hour with no memory of the preceding events (850.4). This indiscriminate comingling of disparate presentations invites skepticism of the predictive power of ICD-9 code 850. The authors appear to attempt to mitigate the broadness of the concussion diagnosis by excluding patients admitted immediately or within two days after initial assessment, thereby creating an ambulatory subset of ICD-9 code 850.

The article by Fralick and colleagues invites consideration of the NIOSH (National Institute for Occupational Safety and Health) report by Baron and associates.4 The cohort for this study was 3439 former National Football League (NFL) players with five years or more credited playing seasons between 1959 and 1988. The mortality for this cohort was compared with the general mortality for the US population. No consideration for a history of concussion was made in this study. The authors report that the number of suicides occurred at a substantially lower rate (standardized mortality ratio 0.41) than that in the general population. If this study is considered in light of the Fralick report of a suicide rate for those who have had a concussion three times higher than that in the general population, one must infer that those who have played five or more years of NFL have experienced concussions at a rate one-sixth that of the general US population.

References

  1. ↵
    1. Fralick M,
    2. Thiruchelvam D,
    3. Tien HC,
    4. et al
    . Risk of suicide after a concussion. CMAJ 2016;188:497–504.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Bazarian JJ,
    2. Veazie P,
    3. Mookerjee S,
    4. et al
    . Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes. Acad Emerg Med 2006;13:31–8.3
    OpenUrlCrossRefPubMed
  3. ↵
    1. Carroll CP,
    2. Cochran JA,
    3. Guse CE,
    4. et al
    . Are we underestimating the burden of traumatic brain injury? Surveillance of severe traumatic brain injury using Centers for Disease Control International Classification of Disease, ninth revision, clinical modification, traumatic brain injury codes. Neurosurgery 2012;71:1064–70.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Baron SL,
    2. Hein MJ,
    3. Lehman E,
    4. et al
    . Body mass index, playing position, race, and the cardiovascular mortality of retired professional football players. Am J Cardiol 2012;109:889–96.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 188 (8)
CMAJ
Vol. 188, Issue 8
17 May 2016
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Concussions and suicide
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Concussions and suicide
Francis X. Speidel
CMAJ May 2016, 188 (8) 605; DOI: 10.1503/cmaj.1150101

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Concussions and suicide
Francis X. Speidel
CMAJ May 2016, 188 (8) 605; DOI: 10.1503/cmaj.1150101
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • References
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Concussions and suicide
  • Google Scholar

More in this TOC Section

  • Coexisting failures do not diminish the stature of a giant
  • Dare we hope
  • Highlighting obesity as a risk factor for endometrial cancer
Show more Letters

Similar Articles

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire