Post-9/11 military veterans with mild to severe traumatic brain injuries (TBIs) face a higher mortality burden from multiple causes of death across the total US population, despite historically low combat fatality rates having been reported in Iraq and Afghanistan, according to an analysis published in JAMA Network.
Previous research has found TBI to be associated with a significant increase in the risk of mental health issues, including post-traumatic stress disorder, depression, anxiety, and dementia, including cardiovascular disease and premature death. Yet, the effect of TBI exposure on all-cause and cause-specific deaths among post-9/11 military veterans remains unknown. The objective of the current study was to evaluate the mortality rates, and to estimate the number of all-cause and cause-specific deaths among veterans who served after the 9/11 terrorist attacks with and without exposure to TBI.
A cohort study of all-cause and cause-specific mortality rates for military veterans who had served active duty in the United States following September 11, 2001, and received care in the Department of Defense Military Health System (MHS) with or without care in the Veterans Health Administration (VHA), was conducted.
Administrative and military data were analyzed between January 1, 2002, and December 31, 2018, among a cohort of US veterans who had served active military duty after September 11 with 3 years or more of care in the MHS, or had 3 years or less of care in the MHS and 2 years or less of care in the VHA. The Centers for Disease Control and Prevention WONDER database was used to compare rates among the veterans with those in the total US population. The data analysis occurred between June 16 and September 8, 2021.
Among a total of 2,516,189 post–September 11 military veterans, 17.5% had mild TBI and 3.0% had moderate to severe TBI. A total of 30, 564 deaths were reported. Overall, 86.2% of the veterans evaluated were male; 64.4% were non-Hispanic white, 15,4% were non-Hispanic Black, 10.3% were Hispanic, 6.4% were Asian/Pacific Islander, 1.8% were American Indian/Alaska Native, and 1.7% were of unknown ethnicity.
Study findings showed that adjusted, age-specific mortality rates were higher among post-9/11 veterans than among those in the total US population, increasing with the severity of TBI.
An estimated 3858 (95% CI, 1225 to 6490) excess deaths were reported among all post-9/11 military veterans. Among these, an estimated 275 (95% CI, –1435 to 1985) were not exposed to TBI; 2285 (95% CI, 1637 to 2933) had mild TBI; and 1298 (95% CI, 1023 to 1572) had moderate to severe TBI. The estimated excess deaths were mainly from suicides in 4218 (95% CI, 3621 to 4816) participants and accidents in 2631 (95% CI, 1929 to 2333) participants. Veterans who had experienced moderate to severe TBI accounted for 33.6% of the total excess deaths reported—an 11-fold higher rate than would otherwise have been expected.
Study limitations include the exclusion of individuals who left military service without care in 3 years to and the reliance of approximations of TBI diagnoses and severity levels, which the researchers noted may not entirely be representative of exposure to or severity of injuries.
“These results suggest that a focus on what puts veterans at risk for accelerated aging and increased mortality is warranted,” the researchers concluded.
Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Howard JT, Stewart IJ, Amuan M, Janak JC, Pugh MJ. Association of traumatic brain injury with mortality among military veterans serving after September 11, 2001. JAMA Netw Open. Published online February 11, 2022. doi:10.1001/jamanetworkopen.2021.48150