PTSD, TBI, and Suicide Risk: Awareness Is Not Enough

September is Suicide Prevention Month.

Awareness matters. But awareness without understanding does not give families, teammates, clinicians, or veterans enough to work with.

For military and veteran populations in particular, two conditions deserve careful attention when we talk about suicide risk: posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI).

They are different conditions. They can also occur together, share symptoms, and interact with depression, sleep disruption, substance use, chronic pain, relationship problems, and difficulty adjusting to life after injury or service.

Understanding that complexity matters.

PTSD and Suicide Risk

PTSD is more than remembering something terrible that happened.

It can affect sleep, threat perception, emotional regulation, concentration, relationships, and the ability to feel safe even when the immediate danger has passed.

Research consistently demonstrates an association between PTSD and suicidal thoughts and behaviors.

A systematic review and meta-analysis found that PTSD was associated with approximately twice the relative risk of death by suicide, with an even stronger association observed among combat-veteran samples (Fox et al., 2023).

More recently, Cenkner et al. (2025) conducted a systematic review and three meta-analyses specifically examining active-duty service members and veterans. PTSD symptom severity was significantly associated with suicidal ideation, suicide attempts, and overall suicide risk.

This does not mean that someone with PTSD will become suicidal.

It means PTSD should be taken seriously as part of a comprehensive assessment of suicide risk.

TBI Changes the Conversation

Traumatic brain injury deserves similar attention.

TBI can affect far more than memory.

Depending on the individual and the injury, persistent symptoms may include:

• impulsivity

• irritability

• emotional dysregulation

• sleep disturbance

• difficulty concentrating

• cognitive fatigue

• depression

• changes in relationships or functioning

Research involving Veterans Health Administration patients found that veterans with a history of TBI had a significantly greater risk of death by suicide than veterans without a TBI history (Brenner et al., 2011).

More recent evidence continues to identify an association between TBI and suicidal thoughts and behaviors, particularly when other factors such as depression, PTSD, substance misuse, and persistent post-injury symptoms are present.

The Department of Veterans Affairs’ 2025 National Veteran Suicide Prevention Annual Report provides an especially important contemporary snapshot. Among recent Veteran VHA users in 2023, the suicide rate among those with a recent TBI diagnosis was 77.6 per 100,000, compared with 39.9 per 100,000 among those without a recent TBI diagnosis.

That does not establish that TBI alone caused those deaths.

It tells us that TBI history is clinically important information that should not be ignored when evaluating the whole person.

When PTSD and TBI Overlap

This is where suicide prevention needs to become more sophisticated.

A veteran may be experiencing PTSD. They may also have a history of blast exposure, concussion, or TBI. They may not be sleeping. They may be drinking more. They may be increasingly irritable or impulsive. Their relationships may be deteriorating.

They may feel disconnected from the identity, team, mission, and sense of purpose they once had.

None of those factors alone tells us that someone will attempt suicide.

Together, however, they tell us something important: Look deeper.

Suicide rarely has one simple explanation.

Effective prevention requires us to understand the individual rather than reducing the problem to a diagnosis.

Suicide Prevention Has to Be More Than Awareness

A social media graphic telling someone to “reach out” is not enough.

We need to recognize changes. Ask direct questions. Take statements about suicide seriously. Understand someone’s trauma and brain-injury history. Address sleep, substance use, depression, pain, isolation, impulsivity, and deteriorating functioning. Create safety plans when appropriate. And connect people with qualified care before the situation becomes an emergency. Most importantly, asking directly about suicide does not put the idea into someone’s head.

Sometimes the most useful question is also the simplest:

“Are you thinking about killing yourself?”

Then listen to the answer.

Our Approach at Brain Treatment Center NoVA

At Brain Treatment Center NoVA, we work extensively with veterans, military personnel, first responders, and their families.

Our model is built around a simple principle: Look at the whole person.

Depending on individual needs, our multidisciplinary approach may incorporate mental health therapy, qEEG brain mapping, neuromodulation, occupational therapy and nervous-system regulation, integrative psychiatry, and functional health evaluation.

No single modality is a substitute for appropriate suicide-risk assessment, emergency intervention, or evidence-based mental health care.

But prevention becomes stronger when we stop looking at symptoms in isolation.

PTSD matters.

TBI matters.

Sleep matters.

Substance use matters.

Relationships matter.

Purpose matters.

Brain health matters.

Suicide Prevention Month should not simply make us more aware of suicide.

It should make us better at recognizing risk, asking the right questions, and helping people earlier.

If someone is in immediate danger or experiencing a suicidal crisis, call or text 988. Veterans and service members can call 988 and Press 1 to reach the Veterans Crisis Line or text 838255.

Brain Treatment Center NoVAWe Can Help.BTCNVA.com | 703-857-2560

References

Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2011). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services. Journal of Head Trauma Rehabilitation, 26(4), 257–264. https://doi.org/10.1097/HTR.0b013e31821fdb6e

Cenkner, D. P., Dent, A. L., Zhou, A., Wislocki, K. E., Stevens, S. K., Lee, S., Amindari, K., Sereno, M., Lu, D., Chang, M., Uwadia, H., Smith, E. G., Woo, R., Nip, H., Serrano, B. N., & Zalta, A. K. (2025). Posttraumatic stress disorder symptoms and suicide ideation, attempt, and risk among active-duty service members and veterans: A systematic review with three meta-analyses of associations and moderators. Clinical Psychology Review, 122, 102652. https://doi.org/10.1016/j.cpr.2025.102652

Fox, V., Dalman, C., Dal, H., Hollander, A.-C., Kirkbride, J. B., & Pitman, A. (2023). Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden. Journal of Affective Disorders, 279, 609–616.

Greer, N., Sayer, N. A., Spoont, M., Taylor, B. C., Ackland, P. E., MacDonald, R., McKenzie, L., Rosebush, C., & Wilt, T. J. (2020). Prevalence and severity of psychiatric disorders and suicidal behavior in service members and veterans with and without traumatic brain injury: Systematic review. Journal of Head Trauma Rehabilitation, 35(1), 1–13. https://doi.org/10.1097/HTR.0000000000000478

U.S. Department of Veterans Affairs. (2025). 2025 National Veteran Suicide Prevention Annual Report: Part 2, report findings. Office of Mental Health and Suicide Prevention.