March 8, 2023 – Previous studies have reported high rates of death by suicide and drug overdose – including opioid overdose – in military service members with a history of mild traumatic brain injury (mTBI). A new study finds that those risks are highest among military members with mTBI who identify their racial/ethnic status as "Other," as opposed to standard racial/ethnic categories, reports the March/April issue of the Journal of Head Trauma Rehabilitation (JHTR). The official journal of the Brain Injury Association of America, JHTR is published in the Lippincott portfolio by Wolters Kluwer.
"In our study of military members with mTBI, mortality rates for suicide and drug and opioid overdose were consistently higher among those who self-identified as 'Other' – a category often selected by multiracial or other individuals who do not see themselves as fitting into White, Black, Hispanic, or other standard racial/ethnic categories," comments lead author Nazanin Bahraini, PhD, of VA Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention and University of Colorado Anschutz Medical Campus, Aurora.
Racial/ethnic disparities in suicide and overdose deaths among military members with mTBI
In military as well as civilian populations, mTBI is a documented risk factor for suicide and death from drug overdose. "Among military service members, disparities in external causes of death, such as suicide and drug overdose associated with TBI, may be further compounded for members of minoritized groups," Dr. Bahraini and coauthors write.
Using Department of Defense databases, the researchers identified 356,514 service members diagnosed with mTBI during military service between 1999 and 2019. Most served during the conflicts in Iraq and Afghanistan.
Based on data from the National Death Index, 1,105 of the military members with mTBI died of suicide (0.31% of the study population) and 886 died from drug overdose (0.25%), of which 595 were from opioid overdose (0.17%). More than half of deaths from these three causes occurred in members who were between 18 to 24 years old at the time of their mTBI.
Rates of all three causes of death were highest in the "Other" racial/ethnic category. Although military members in the "Other" group made up only 7.38% of the study sample, they accounted for 17.83% of suicides, 21.44% of drug overdose deaths, and 21.01% of opioid overdose deaths.
After accounting for the effect of age, rates of all three outcomes remained higher among service members who identified their race/ethnicity as "Other," compared to individuals who identified with the five more traditionally categorized racial/ethnic groups, with the exception of service members in the American Indian/Alaska Native category, who comprised 1.48% of the study sample. Relative risk of suicide in the "Other" group was about twice as high as in White/non-Hispanic military members and five times higher than in Black/non-Hispanic members.
'Perfect storm' of TBI, opioids, and other risk factors for overdose and suicide
Military service members in the "Other" category also had a higher relative risk of death from drug overdose. Age-adjusted risk of drug overdose death was more than three times higher than for White/non-Hispanic military members, five times higher than for Hispanic or Asian American/Pacific Islander members, and 11 times higher than for Black/non-Hispanic members. Opioid overdose deaths were up to 3.5 times more common than for members of the five traditional racial/ethnic categories.
These findings add to previous evidence that people with TBI are more likely to receive prescription opioids and to have other risk factors – creating a "perfect storm" of risk factors for opioid misuse and related consequences. "[A]mong military members with mTBI, over two-thirds of drug-overdose deaths involved an opioid," Dr. Bahraini and coauthors note.
This study highlights the importance of examining racial/ethnic disparities in suicide and drug overdose mortality rates in military members with mTBI," the researchers conclude. "[B]ecause choices for race/ethnicity were constrained to a single choice with no category options for multiple races, the racial and ethnic identities of military members in this higher-risk group remain unclear."
Dr Bahraini comments: "Race and ethnicity are social constructs that are continually evolving, yet current data collection methods do not account for the significant heterogeneity within groups. We could gain a clearer picture if we were able to examine more detailed subgroups, including those who self-identify with multiple race and ethnicity groups as well as subgroups differentiated by national origin. More importantly, we need to better understand how the different experiences of these subgroups – for example, discrimination – may contribute to health disparities."
