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

IMPORTANCE 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. OBJECTIVE To examine the incidence of NPDs following TBI in the US and assess how socioecologic factors are associated with population-level differences. DESIGN, SETTING, AND PARTICIPANTS 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. EXPOSURE Social and structural determinants of health. MAIN OUTCOMES AND MEASURES 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. RESULTS 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]). CONCLUSIONS AND RELEVANCE 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.