Soldiers with a traumatic brain injury are about one and a half times more likely to die by suicide than those without a TBI, according to a study done by Veterans Affairs in 2011. (Note: the terms TBI and concussion are used interchangeably.)

Our most common types of concussion in recent years have occurred during combat deployment when there is an exposure to a blast from an improvised explosive device, a rocket-propelled grenade, a mortar or a rocket. Some concussions come from VBIEDs, or vehicle-borne improvised explosive devices, and these tend to be more severe than the other types of concussion because of the force of the blast, although a lot depends on one's proximity and head position relative to the blast.

Concussions in combat also are caused by falls from tactical vehicles or down cliffs, or from vehicle rollovers. A surprising number of concussions come when the hatch on a vehicle comes falling down on one's head, Kevlar or not.

Noncombat concussions, which we are seeing more of these days, are caused by sports injuries, combatives, motor vehicle accidents, syncopal episodes (getting dizzy, falling to the ground and hitting one's head), slipping on the ice, and physical assaults.

Think about what happens when a Soldier has a concussion. Many think that it's the shock wave from a blast that causes the concussion, but this is not necessarily true. The shock wave travels at an enormous speed and passes through the body, the brain, everything in its radius. Many Soldiers experience this blast wave without having a concussion at all. It all depends on the position of the brain relative to the wave. The concussion occurs when the brain twists and turns within the skull cage. Neurons are pulled and stretched. Parts of the brain may be bruised; swelling occurs.

Immediately after the concussion there is a sense of disbelief and confusion. There may be an adrenaline rush and perhaps a feeling of anger. There may be dust everywhere and darkness, even in the daylight.

It's common for the Soldier to report a tremendous headache and perhaps tinnitus (a high-pitched sound in the ears). They may "see stars." Some experience nausea and may throw up. They get wobbly on their feet and may try to walk around in circles.

Many people get over a concussion within seven to 10 days. The Army standard for healing is three months, and we see this in about 90 percent of the cases.

This uncomplicated healing can happen when proper procedures are instituted to facilitate the healing process. For example, we know now that the TBI victim needs a period of brain rest following the event. Go on quarters, stay in the dark, sleep a lot, avoid use of laptops and other electronics as well as stressful conversations. (Contrast this to the old myth that said that a concussion victim should not go to sleep -- slap the face to keep them awake lest they fall into a coma and never wake up!) This period of rest allows the brain to heal.

A great many Soldiers we see today are well past the three-month healing stage, yet they retain post-concussive symptoms, which can be exacerbated by living with continual stress / anxiety:

* We see headaches, often migraines that began when the concussion occurred and are still happening years later on a daily basis (anywhere from 2 to 10 on the pain scale).

* Their sleep patterns are impaired. It is not uncommon for a Soldier to report getting from two to five hours of sleep per night on average. They may stay fatigued throughout the day.

* Their short-term memory functioning -- and this includes concentration, ability to focus and attention -- is deficient. They can't keep track of conversations or what they intended to do.

* They get irritable easily, and their angry episodes get them into trouble, both at work and at home.

* They may have vision problems (eyes jumping, inability to converge), or they still have balance problems, dizziness or periods of vertigo.

We work with Soldiers at the TBI Clinic at Fort Drum on all of these issues using an interdisciplinary, treatment team approach.

One thing to keep in mind is that Soldiers with a history of TBI frequently also have post-traumatic stress disorder or generalized anxiety, depression, self-medication with alcohol, and domestic issues.

Everyone develops a schema -- our way of organizing our world and making sense of it. The person without a TBI has a schema that allows for gaining a sense of past, present and future, and putting them all into perspective. We learn how to read the world, including other people, and to make appropriate responses to our environment.

But look at what happens to the schema of one who suffers daily from post-concussive symptoms. There is little thought given to the past or to the future. Everything gets shrunk to the present. How do I get through the day with this headache, when I haven't slept enough last night, I can't keep track of anything, I'm blowing up at people -- including my family -- so that I don't even trust being around anyone, and I'm stumbling all over the place?

Stress can prolong post-concussive symptoms. The symptoms remain a prominent part of the Soldier's everyday life even though it has been years since he or she had a concussion. This state of affairs can generate feelings of loss and depression. The victim may abuse alcohol to cope with things. The outlook appears hopeless, and the sufferer feels helpless in the face of the enormity of his or her problems. One's thoughts are seldom reality-tested, and it's just the dark thoughts that prevail. There is no community out there to offer support, feedback or motivation to ignite the spark within to start the healing process.

Here are some factors that increase the risk of suicide: gender (women are more likely to attempt suicide, while men are more likely to complete suicide); family or friend history of suicide; impulsivity; history of abuse; chronic pain; current or past suicidal thoughts or behaviors or self-harm behaviors; limited social support; depression or other behavioral health conditions; substance abuse; occupational or financial stressors.

If you or someone you know is considering suicide, there are numerous ways to seek help. For life-threatening emergencies, call 911 and/or go to the nearest medical emergency department. The National Suicide Prevention Lifeline is available 24/7 at 800-273-TALK (8255).

The Fort Drum MEDDAC Department of Behavioral Health also offers triage clinics within each of its locations during duty hours for anyone with an urgent behavioral health concern. Contact us at (315) 772-0215. Let's work together to prevent suicide!