# Inequities in Neuropsychiatric Outcomes After Brain Trauma in the All of Us Database

## TL;DR

Black individuals are more likely than White individuals to be diagnosed with certain neuropsychiatric conditions after traumatic brain injury, highlighting racial disparities in outcomes.

## Contribution

The study reveals racial disparities in neuropsychiatric diagnoses after TBI and emphasizes the role of social determinants in these differences.

## Key findings

- White participants had lower risks of psychotic, PTSD, substance use, and headache disorders compared to Black participants.
- Higher social deprivation was linked to lower likelihoods of mood and anxiety disorders but higher likelihoods of sleep disorders.
- Accounting for selection bias confirmed lower probabilities of psychotic and headache disorders in White participants.

## Abstract

What is the association of neuropsychiatric diagnosis incidence following traumatic brain injury (TBI) with racial disparities?

In a cohort study of 8714 participants with a history of TBI in the National Institutes of Health All of Us database, White participants were less likely than Black or African American participants to be diagnosed with psychotic, posttraumatic stress, substance use, or headache disorders. Accounting for sample selection bias, White participants had a lower probability of being diagnosed with psychotic or headache disorders.

These findings suggest that there are substantial racial disparities in neuropsychiatric outcomes following TBI, underscoring the importance of accounting for psychosocial and environmental modifiers that may alter TBI outcome trajectories.

This cohort study examines the incidence of neuropsychiatric diagnoses following traumatic brain injury among All of Us Research Program participants and the factors associated with racial and social deprivation differences.

Traumatic brain injury (TBI) is an important public health concern, with disparities in post-TBI neuropsychiatric diagnoses (NPDs) observed across Black or African American and White populations.

To examine the incidence of NPDs following TBI in the US and assess how socioecologic factors are associated with population-level differences.

This retrospective cohort study used data from the All of Us Research Program, version 7, including available electronic health record data from participants aged 18 years or older enrolled between May 6, 2018, and July 1, 2022, with an established TBI diagnosis based on diagnostic codes and criteria from the Centers for Disease Control and Prevention, Department of Defense, and clinical expertise. Data were analyzed between June 24, 2024, and January 23, 2025.

Social and structural determinants of health.

The primary outcomes assessed were incident NPDs following TBI grouped into 10 diagnostic clusters according to phecode categories. Competing-risk models (subdistribution hazard ratio [HR] with 95% CI) and Heckman-type selection models (β [SE]) were used.

The study included 8714 participants (mean [SD] age, 49.0 [17.9] years; 4700 women [54.5%]) with TBI and was limited to participants self-identifying as Black or African American (hereafter, Black) (2192 [25.2%]) or White (6522 [74.8%]) race. White participants had a lower adjusted risk of schizophrenia or other psychotic disorders (adjusted HR [AHR], 0.49 [95% CI, 0.35-0.69]), posttraumatic stress disorder (AHR, 0.67 [95% CI, 0.52-0.86]), substance use disorders (AHR, 0.51 [95% CI, 0.42-0.62]), and headache disorders (AHR, 0.78 [95% CI, 0.67-0.91]) compared with Black participants. Models accounting for selection bias revealed a lower adjusted likelihood of schizophrenia or other psychotic disorders (β [SE], −0.24 [0.07]) and headache disorders (β [SE], −0.10 [0.03]) in White participants. Higher social deprivation was associated with a lower likelihood of mood disorders (β [SE], −0.65 [0.14]), anxiety disorders (β [SE], −0.85 [0.13]), posttraumatic stress disorder (β [SE], −1.06 [0.22]), any dementia (β [SE], −1.03 [0.22]), and headache disorders (β [SE], −0.52 [0.14]) but a higher likelihood of sleep disorders (β [SE], 0.34 [0.08]).

This cohort study found that post-TBI NPDs varied across populations, with a higher likelihood of psychotic and headache disorders among Black All of Us participants. These findings highlight the utility of social determinants of health for better understanding disparities in post-TBI outcomes, underscoring the need for additional efforts to address these disparities.