Psychiatry and Primary CarePredicting the future development of depression or PTSD after injury☆
Introduction
Thirty-seven percent to 56% of injured patients admitted to a trauma service experience depression [1], [2], [3]. Up to 38% of injured patients are depressed by 6 months, with similar rates of depression observed 1 year after injury [4], [5]. Posttraumatic stress disorder (PTSD) is also common after injury, with 10% to 22% of injured patients meeting diagnostic criteria for PTSD [6], [7]. Injured patients are more likely to commit suicide than the general population, an extreme indicator of the impact of depression and psychiatric comorbidity [8].
Injury events can generate feelings of helplessness, horror and a belief that the world is no longer safe. Mental health consequences of injury pose serious health care problems, and depression and PTSD interfere in daily activities [9], [10], [11]. Thus, it should not be surprising that injured patients who develop depression or PTSD have higher levels of functional impairment. Depression and PTSD exert a significant, independent and persistent effect on general health, work status, somatic symptoms, adjustment to illness and function after injury [2], [12]. Even subdiagnostic depression or PTSD is associated with lost wages, use of temporary workers, sick time, an inability to fully function and increased cost [13].
Physical injury is experienced as life-threatening and engenders a response of fear, helplessness or horror, such that the event may cause a traumatic stress response [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR)] [14]. Therefore, PTSD is a potential psychiatric consequence of injury. Cognitive processing in the posttraumatic setting contributes to development of PTSD and may also influence an individual's negative core schemas (e.g., I'm worthless, I'm unlovable). This can contribute to depression, a second potential consequence of injury [15]. A consistent finding, however, is that the objective severity of physical injury is not related to the occurrence or severity of postinjury psychological consequences; even minor injuries can lead to traumatic stress responses [16].
Early intervention models are designed to mediate the damaging effects of potentially traumatic events. These models require reliable predictors of risk for the development of psychological consequences in order to allow interventions to be targeted to those most in need [17]. The challenge is to identify those injured patients at highest risk for the future development of depression or PTSD. Studies over the past decade suggest that there are identifiable risk factors for the development of postinjury psychological disorders. Factors associated with an increased likelihood of depression or PTSD include acute stress symptoms [11], previous treatment for depression [11], previous trauma exposures [18], [19], limited financial and social resources [20], history of maladaptive coping responses (e.g., substance abuse) [17], concerns related to injury [21] and appraisal of acute stress reactions [22].
Several predictive screeners have been developed and tested in the UK and Australia, one focused on the prediction of the future development of PTSD (UK) [23], one with the intent to predict the future development of depression after motor vehicle crash (Australia) [24] and one to predict depression and PTSD postinjury (Australia) [25]. To our knowledge, no predictive screeners for the future development of depression or PTSD postinjury in adults have been developed in the United States.
Therefore, we report on our initial work to develop a predictive screener that when given soon after injury will accurately predict who, in the future, will develop a diagnosis of depression or PTSD. In this study, we build on the seminal work of Winston and colleagues in predicting PTSD in pediatric injury patients after motor vehicle crashes [26]. This predictive screener has been integrated into clinical care in a number of pediatric settings to help guide decisions about psychological support during and after acute care for pediatric injury. We model their approach to develop a theoretically derived and empirically validated predictive screener in the adult injury population and extend the predictive screener to also include depression. This study is an important first step in identifying those individuals at highest risk for developing these disorders in order to target appropriate resources to this vulnerable group.
Section snippets
Materials and methods
The current study was part of a prospective, longitudinal cohort study whose primary aim was to determine the emergence of depression and PTSD in the year after injury and to examine the contribution of these psychiatric disorders to the return to preinjury function; these findings have been reported elsewhere. The earlier report showed that those who developed postinjury depression did not return to their preinjury level of function [27]. This study was approved by the appropriate human
Results
One hundred and sixty-five of the 192 participants enrolled were available for the 6-month outcome assessment. Of this group, 30 [18.2%, 95% confidence interval (CI) 12.3–24.1] participants had significant symptoms of depression, and 26 participants (15.8%, 95% CI 10.2–21.3) were diagnosed with depression. Also in this group, 26 (15.8%, 95% CI 10.2–21.3) participants had significant symptoms of posttraumatic stress, and 4 (2.4%, 95% CI 0.7–-5.9) were diagnosed with PTSD. One participant had
Discussion
In the United States, approximately 30 million Americans seek care for injury in the ED annually [38]. The frequency of injury and the prevalence of postinjury psychological sequelae provide the impetus to develop clinically relevant mechanisms to identify those patients at highest risk for depression and PTSD. The final screener is brief and includes only information that is readily available from the medical record, patient or family so that it is easily administered and scored by clinicians
Summary
The findings of this study indicate that it is possible to identify a subset of injured patients who are likely to develop depression or PTSD in the 6 months after hospital discharge. By differentiating those who will develop depression or PTSD from those who will not, clinicians can focus limited resources to follow, diagnose and treat those most likely to experience problematic psychological sequelae from injury.
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Cited by (0)
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Funding: National Institute of Mental Health R01MH63818 to Dr. Richmond.