533836 research-article2014
ANP0010.1177/0004867414533836Australian & New Zealand Journal of PsychiatryHolmes et al.
Research
Persistent disability is a risk factor for late-onset mental disorder after serious injury
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(12) 1143–1149 DOI: 10.1177/0004867414533836 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alex CN Holmes1,2, Meaghan L O’Donnell3, Owen Williamson4, Malcolm Hogg5 and Carolyn Arnold6
Abstract Background: Most of what we know about the psychiatric consequences of injury is limited to the first year. Determining the prevalence of and risk factors for psychiatric morbidity beyond one year will aid service development and facilitate timely diagnosis and treatment. The aim of this prognostic study was to determine the prevalence of mental disorders in the three years following serious injury and to identify risk factors for the onset of new disorders after 1 year. Methods: Of 272 patients assessed in hospital following serious injury, 196 (72.1%) were reassessed at 3 years. Assessment involved gold standard semi-structured interviews for psychiatric diagnoses, risk factors for mental disorder, injury measures and pain scores. Results: More than a quarter of all patients were diagnosed with at least one mood or anxiety disorder at some stage during the three years following their injury. The most common diagnoses were major depression (20.0%), generalised anxiety disorder (6.7%) and panic disorder (6.7%). For a third of these patients, the disorder appeared after 12 months, for which persistent physical disability was an independent risk factor. Conclusion: Although there is a necessary focus on the early detection and treatment of mental disorders after injury, attention to later onset disorders is also required for those with persistent pain and physical disability. Keywords Disability, injury, mental, risk
Introduction Serious injury makes its significant contribution to the global burden of disease through both physical and psychological mechanisms (World Health Organization, 2008). Psychiatric morbidity after injury impairs long-term function (O’Donnell et al., 2013) and reduces quality of life (O’Donnell et al., 2005). Most of what we know about the psychiatric consequences of injury, however, is limited to the first year post injury, despite the common clinical experience of problems continuing well beyond this time. We do not know, for example, what proportions of patients’ disorders are persistent, which types of disorders persist and whether new disorders arise. Furthermore, we do not know the risk factors for persistence or late onset – a necessary step in determining whether they are modifiable. The most comprehensive prospective study of psychiatric disorder after injury was conducted on almost 1000 patients admitted to level 1 trauma hospitals Australia wide
(Bryant et al., 2010). At 12 months, 11.6% of patients described major depression, 9.7% post-traumatic disorder (PTSD), 9.5% generalised anxiety disorder and 6% 1Department
of Psychiatry, University of Melbourne, Melbourne, Australia 2Consultation-liaison Psychiatry Service, Royal Melbourne Hospital, Melbourne, Australia 3Australian Centre for Post Traumatic Mental Health, University of Melbourne, Melbourne, Australia 4Department of Clinical Epidemiology, Monash University, Melbourne, Australia 5Pain Service, Royal Melbourne Hospital, Melbourne, Australia 6Pain Management Service, Alfred Health, Melbourne, Australia Corresponding author: Alex CN Holmes, Level 5 Centre, Main Building, Royal Melbourne Hospital, Grattan St, Parkville, VIC 3050, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(12)
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Table 1. Risk factors for psychiatric disorder post injury. Pre
Peri
Post
Major depression
ETOH (O’Donnell et al., 2004a)a Psychiatric history (O’Donnell et al., 2004a)a Life events (O’Donnell et al., 2004a)a
Event severity (O’Donnell et al., 2004a) Anticipated effect of injury (O’Donnell et al., 2004a)a Re-experiencing (O’Donnell et al., 2004a)a
Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010)
PTSD
Psychiatric history (Bryant et al., 2010; Shalev et al., 1998) ETOH (O’Donnell et al., 2004a)a Life events (O’Donnell et al., 2004a)
Event severity (O’Donnell et al., 2004a) Psychological symptoms (Mayou and Bryant, 2001; O’Donnell et al., 2004a)
Pain (Bryant et al., 2010) Physical symptoms (Mayou and Bryant, 2001) Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010) Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010)
Anxiety disordersb
ETOH: alcohol abuse; TBI: traumatic brain injury; PTSD: post-traumatic stress disorder. aCo-morbid PTSD and major depression. bPanic disorder, agoraphobia, simple phobia, social phobia.
agoraphobia – findings consistent with earlier studies (O’Donnell et al., 2004b; Shalev et al., 1998; Zatzick et al., 2002). Psychiatric co-morbidity (O’Donnell et al., 2004a) is common, with major depression and PTSD more likely to occur together than in isolation. The diagnostic status of an individual can also change, with only half of those reporting major depression at 12 months having done so at 3 months (Bryant et al., 2010). Little is known about psychiatric disorder beyond 12 months. One indication of its persistence is found in a study by Malt et al. (1988), which used a rating scale to make diagnoses 28 months after injury, and reported the prevalence of PTSD and major depression to be 2.8% and 0.9%, respectively. Risk factors for psychiatric disorder after serious injury have been identified in the pre-injury, peri-injury and postinjury periods (Table 1). Pre-existing risk factors identified in the general population – age (Barkow et al., 2003), sex (Merikangas et al., 1985) and marital status (Sargeant et al., 1990) – do not necessarily apply to injury patients. Others – family history (Sullivan et al., 2000) and poor social support (Wade and Kendler, 2000) – have not been studied. Post injury, pain (Liedl et al., 2010), persistent medical problems (Mayou and Bryant, 2001) and mild traumatic brain injury (Bryant et al., 2010) all correlate with the development of PTSD. In addition, Bryant et al. (2010) found that functional impairment present 3 months after injury was associated with psychiatric disorder at 12 months. This paper describes a prospective cohort study of patients following serious injury in which the presence of psychiatric disorder was determined at index, and 1 and 3 years. Patients with head injury were not included. The aim of the study was
to determine the prevalence of new psychiatric disorders emerging in the 3 years after serious injury, to determine the degree to which disorders persisted or new disorders emerged after 1 year, and to identify unique risk factors associated with the delayed emergence of new disorders.
Methods Subjects Patients were recruited from sequential admissions to two level 1 trauma centres in Melbourne, Australia. Patients were eligible for the study if they were between 18 and 70 years of age; were admitted for more than 24 hours; scored two or more on the Abbreviated Injury Scale (AIS; Association for the Advancement of Automotive Medicine, 1998); had adequate English; and could be assessed within 30 days of injury. Individuals were excluded if their injury was due to a non-height fall; had a head injury or pre-existing cognitive impairment; or were known to be psychotic or suicidal. Candidates (n=272) undertook an interview and completed questionnaires when deemed able to provide consent and to engage in the initial assessment. The mean age of the sample was 38.4 years (standard deviation (SD) = 13.0) and 73.0% were male. The mean Injury Severity Score (Baker et al., 1974) was 12.0 (SD=8.4). The most common causes of injury were transport accidents (60.3%), falls (23.1%) and assaults (5.9%). Participants spent an average of 10.0 (SD=9.8) days in hospital. One ninety six (72.1% of original cohort) were reassessed at 3 years. Those who were not able to be reviewed (n=78) were no different in terms of age, sex, marital status, work, injury severity, pain or socioeconomic status (SES) .
Australian & New Zealand Journal of Psychiatry, 48(12) Downloaded from anp.sagepub.com at Purdue University on June 16, 2015
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Holmes et al.
Mental disorder Current and past psychiatric disorder was determined using the Structured Clinical Interview for DSM-IV disorders (SCID) (Spitzer et al., 1996). The SCID was administered by trained and experienced practitioners during the index admission and again at 1 and 3 years. At the index assessment, the presence of current or past psychiatric disorder was determined. At subsequent assessments, for each mental disorder, a determination was made as to whether it was currently present or an episode had occurred since the last assessment.
Risk factors The risk factors for mental disorder were determined with reference to the literature on major depression and PTSD in the general population (Baker et al., 1974; Brewin, 2005) and following injury (Bryant et al., 2010; Mayou and Bryant, 2001; O’Donnell et al., 2004a). Pre-injury and injury data were collected during the index admission whilst post-injury factors were collected at 1 and 3 years. Pre-injury Demographic: Age, sex, marital status (single/partnered), living status (alone/shared) and income (greater or less than $90,000). Social support: The Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1990) was completed in relation to the time prior to the injury. The MSPSS is a 10-item self-report questionnaire that informs three subscales of support from family, friends and significant others. Physical function: The Physical Function subscale of the SF-36 version 2 (Ware and Sherbourne, 1992) was used to assess limitation in function due to physical illness. The SF-36 is a self-report questionnaire used to describe function in the 4 weeks prior to assessment. Family history: A family history of major depression and psychiatric disorder was assessed using questions requiring ‘yes/no’ answers. Past psychological distress: Statements requiring answers using an 11-point numerical rating scale (NRS) (0=not at all, 10=totally) were used to measure past depression (‘feeling low or sad has impacted on my life in the past’), anxiety (‘feeling anxious or nervous has impacted on my life in the past’), past psychiatric help (‘I have needed professional help to deal with emotional problems in the past’) and life events (‘previously traumatic events have impacted negatively on my life in the past’). Injury Injury severity: Each individual injury was scored using the AIS (Association for the Advancement of Automotive Medicine, 1998). Severity is rated on a scale of 1 to 6,
where 1 is equivalent of a superficial cut, 3 a fracture, and 6 an injury incompatible with life. The AIS scores are used to generate the Injury Severity Score (Baker et al., 1974). Pain severity: Current and 24-hour pain severity was measured at the time of the initial assessment using an 11-point NRS (0=no pain, 10=the worst pain imaginable). Peri-injury Anxiety and depression: The severity of anxiety and depression symptoms following the injury was measured using the Hospital Anxiety and Depression rating scale (Zigmond and Snaith, 1983). Subjective event severity: The answer to ‘During the event, I thought I was about to die’ was rated on an 11-point NRS. Re-experiencing: The answer to ‘I have sweated, trembled or noticed my heart beating faster when I am reminded about the event’ in the time following the injury was rated on an 11-point NRS. Anticipated effect of injury: The answer to ‘I am confident that I will fully recover from my injuries’ in the time following the injury was rated on an 11-point NRS. Post injury Physical disability: Limitation in function due to injury in the 4 weeks prior to assessment was measured with the Physical Function subscale of the SF-36 version 2. Pain severity: Pain severity was measured using an 11-point numerical rating scale (NRS) in response to ‘How severe was your pain on average over the past 24 hours?’. Social support: The MSPSS. Compensation: The injury was deemed compensable if it was eligible for either the work-based or transport no-fault compensation schemes.
Analysis Data were entered into the IBM SPSS (Statistical Package for the Social Sciences) for Windows, v.19, 2010 (IBM Corp., Armonk, NY, USA). For each episode of mental disorder, it was determined if it occurred: (1) prior to the injury; (2) in the first 12 months following the injury (early); or (3) in the second and third years after the injury (late). Logistic regression analysis was conducted in order to determine the risk factors associated with the onset of mental disorder (not including alcohol or substance abuse disorders). Separate analyses were conducted for new episodes of mental disorder occurring early and late after injury. In the first step, a bivariate analysis was conducted to determine the association between each risk factor and the presence of mental disorder. Pearson correlation was used for continuous variables and analysis of variance (ANOVA) for categorical independent variables. All factors with p-scores
ANP0010.1177/0004867414533836Australian & New Zealand Journal of PsychiatryHolmes et al.
Research
Persistent disability is a risk factor for late-onset mental disorder after serious injury
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(12) 1143–1149 DOI: 10.1177/0004867414533836 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alex CN Holmes1,2, Meaghan L O’Donnell3, Owen Williamson4, Malcolm Hogg5 and Carolyn Arnold6
Abstract Background: Most of what we know about the psychiatric consequences of injury is limited to the first year. Determining the prevalence of and risk factors for psychiatric morbidity beyond one year will aid service development and facilitate timely diagnosis and treatment. The aim of this prognostic study was to determine the prevalence of mental disorders in the three years following serious injury and to identify risk factors for the onset of new disorders after 1 year. Methods: Of 272 patients assessed in hospital following serious injury, 196 (72.1%) were reassessed at 3 years. Assessment involved gold standard semi-structured interviews for psychiatric diagnoses, risk factors for mental disorder, injury measures and pain scores. Results: More than a quarter of all patients were diagnosed with at least one mood or anxiety disorder at some stage during the three years following their injury. The most common diagnoses were major depression (20.0%), generalised anxiety disorder (6.7%) and panic disorder (6.7%). For a third of these patients, the disorder appeared after 12 months, for which persistent physical disability was an independent risk factor. Conclusion: Although there is a necessary focus on the early detection and treatment of mental disorders after injury, attention to later onset disorders is also required for those with persistent pain and physical disability. Keywords Disability, injury, mental, risk
Introduction Serious injury makes its significant contribution to the global burden of disease through both physical and psychological mechanisms (World Health Organization, 2008). Psychiatric morbidity after injury impairs long-term function (O’Donnell et al., 2013) and reduces quality of life (O’Donnell et al., 2005). Most of what we know about the psychiatric consequences of injury, however, is limited to the first year post injury, despite the common clinical experience of problems continuing well beyond this time. We do not know, for example, what proportions of patients’ disorders are persistent, which types of disorders persist and whether new disorders arise. Furthermore, we do not know the risk factors for persistence or late onset – a necessary step in determining whether they are modifiable. The most comprehensive prospective study of psychiatric disorder after injury was conducted on almost 1000 patients admitted to level 1 trauma hospitals Australia wide
(Bryant et al., 2010). At 12 months, 11.6% of patients described major depression, 9.7% post-traumatic disorder (PTSD), 9.5% generalised anxiety disorder and 6% 1Department
of Psychiatry, University of Melbourne, Melbourne, Australia 2Consultation-liaison Psychiatry Service, Royal Melbourne Hospital, Melbourne, Australia 3Australian Centre for Post Traumatic Mental Health, University of Melbourne, Melbourne, Australia 4Department of Clinical Epidemiology, Monash University, Melbourne, Australia 5Pain Service, Royal Melbourne Hospital, Melbourne, Australia 6Pain Management Service, Alfred Health, Melbourne, Australia Corresponding author: Alex CN Holmes, Level 5 Centre, Main Building, Royal Melbourne Hospital, Grattan St, Parkville, VIC 3050, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(12)
Downloaded from anp.sagepub.com at Purdue University on June 16, 2015
1144
ANZJP Articles
Table 1. Risk factors for psychiatric disorder post injury. Pre
Peri
Post
Major depression
ETOH (O’Donnell et al., 2004a)a Psychiatric history (O’Donnell et al., 2004a)a Life events (O’Donnell et al., 2004a)a
Event severity (O’Donnell et al., 2004a) Anticipated effect of injury (O’Donnell et al., 2004a)a Re-experiencing (O’Donnell et al., 2004a)a
Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010)
PTSD
Psychiatric history (Bryant et al., 2010; Shalev et al., 1998) ETOH (O’Donnell et al., 2004a)a Life events (O’Donnell et al., 2004a)
Event severity (O’Donnell et al., 2004a) Psychological symptoms (Mayou and Bryant, 2001; O’Donnell et al., 2004a)
Pain (Bryant et al., 2010) Physical symptoms (Mayou and Bryant, 2001) Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010) Mild TBI (Bryant et al., 2010) Functional impairment (Bryant et al., 2010)
Anxiety disordersb
ETOH: alcohol abuse; TBI: traumatic brain injury; PTSD: post-traumatic stress disorder. aCo-morbid PTSD and major depression. bPanic disorder, agoraphobia, simple phobia, social phobia.
agoraphobia – findings consistent with earlier studies (O’Donnell et al., 2004b; Shalev et al., 1998; Zatzick et al., 2002). Psychiatric co-morbidity (O’Donnell et al., 2004a) is common, with major depression and PTSD more likely to occur together than in isolation. The diagnostic status of an individual can also change, with only half of those reporting major depression at 12 months having done so at 3 months (Bryant et al., 2010). Little is known about psychiatric disorder beyond 12 months. One indication of its persistence is found in a study by Malt et al. (1988), which used a rating scale to make diagnoses 28 months after injury, and reported the prevalence of PTSD and major depression to be 2.8% and 0.9%, respectively. Risk factors for psychiatric disorder after serious injury have been identified in the pre-injury, peri-injury and postinjury periods (Table 1). Pre-existing risk factors identified in the general population – age (Barkow et al., 2003), sex (Merikangas et al., 1985) and marital status (Sargeant et al., 1990) – do not necessarily apply to injury patients. Others – family history (Sullivan et al., 2000) and poor social support (Wade and Kendler, 2000) – have not been studied. Post injury, pain (Liedl et al., 2010), persistent medical problems (Mayou and Bryant, 2001) and mild traumatic brain injury (Bryant et al., 2010) all correlate with the development of PTSD. In addition, Bryant et al. (2010) found that functional impairment present 3 months after injury was associated with psychiatric disorder at 12 months. This paper describes a prospective cohort study of patients following serious injury in which the presence of psychiatric disorder was determined at index, and 1 and 3 years. Patients with head injury were not included. The aim of the study was
to determine the prevalence of new psychiatric disorders emerging in the 3 years after serious injury, to determine the degree to which disorders persisted or new disorders emerged after 1 year, and to identify unique risk factors associated with the delayed emergence of new disorders.
Methods Subjects Patients were recruited from sequential admissions to two level 1 trauma centres in Melbourne, Australia. Patients were eligible for the study if they were between 18 and 70 years of age; were admitted for more than 24 hours; scored two or more on the Abbreviated Injury Scale (AIS; Association for the Advancement of Automotive Medicine, 1998); had adequate English; and could be assessed within 30 days of injury. Individuals were excluded if their injury was due to a non-height fall; had a head injury or pre-existing cognitive impairment; or were known to be psychotic or suicidal. Candidates (n=272) undertook an interview and completed questionnaires when deemed able to provide consent and to engage in the initial assessment. The mean age of the sample was 38.4 years (standard deviation (SD) = 13.0) and 73.0% were male. The mean Injury Severity Score (Baker et al., 1974) was 12.0 (SD=8.4). The most common causes of injury were transport accidents (60.3%), falls (23.1%) and assaults (5.9%). Participants spent an average of 10.0 (SD=9.8) days in hospital. One ninety six (72.1% of original cohort) were reassessed at 3 years. Those who were not able to be reviewed (n=78) were no different in terms of age, sex, marital status, work, injury severity, pain or socioeconomic status (SES) .
Australian & New Zealand Journal of Psychiatry, 48(12) Downloaded from anp.sagepub.com at Purdue University on June 16, 2015
1145
Holmes et al.
Mental disorder Current and past psychiatric disorder was determined using the Structured Clinical Interview for DSM-IV disorders (SCID) (Spitzer et al., 1996). The SCID was administered by trained and experienced practitioners during the index admission and again at 1 and 3 years. At the index assessment, the presence of current or past psychiatric disorder was determined. At subsequent assessments, for each mental disorder, a determination was made as to whether it was currently present or an episode had occurred since the last assessment.
Risk factors The risk factors for mental disorder were determined with reference to the literature on major depression and PTSD in the general population (Baker et al., 1974; Brewin, 2005) and following injury (Bryant et al., 2010; Mayou and Bryant, 2001; O’Donnell et al., 2004a). Pre-injury and injury data were collected during the index admission whilst post-injury factors were collected at 1 and 3 years. Pre-injury Demographic: Age, sex, marital status (single/partnered), living status (alone/shared) and income (greater or less than $90,000). Social support: The Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1990) was completed in relation to the time prior to the injury. The MSPSS is a 10-item self-report questionnaire that informs three subscales of support from family, friends and significant others. Physical function: The Physical Function subscale of the SF-36 version 2 (Ware and Sherbourne, 1992) was used to assess limitation in function due to physical illness. The SF-36 is a self-report questionnaire used to describe function in the 4 weeks prior to assessment. Family history: A family history of major depression and psychiatric disorder was assessed using questions requiring ‘yes/no’ answers. Past psychological distress: Statements requiring answers using an 11-point numerical rating scale (NRS) (0=not at all, 10=totally) were used to measure past depression (‘feeling low or sad has impacted on my life in the past’), anxiety (‘feeling anxious or nervous has impacted on my life in the past’), past psychiatric help (‘I have needed professional help to deal with emotional problems in the past’) and life events (‘previously traumatic events have impacted negatively on my life in the past’). Injury Injury severity: Each individual injury was scored using the AIS (Association for the Advancement of Automotive Medicine, 1998). Severity is rated on a scale of 1 to 6,
where 1 is equivalent of a superficial cut, 3 a fracture, and 6 an injury incompatible with life. The AIS scores are used to generate the Injury Severity Score (Baker et al., 1974). Pain severity: Current and 24-hour pain severity was measured at the time of the initial assessment using an 11-point NRS (0=no pain, 10=the worst pain imaginable). Peri-injury Anxiety and depression: The severity of anxiety and depression symptoms following the injury was measured using the Hospital Anxiety and Depression rating scale (Zigmond and Snaith, 1983). Subjective event severity: The answer to ‘During the event, I thought I was about to die’ was rated on an 11-point NRS. Re-experiencing: The answer to ‘I have sweated, trembled or noticed my heart beating faster when I am reminded about the event’ in the time following the injury was rated on an 11-point NRS. Anticipated effect of injury: The answer to ‘I am confident that I will fully recover from my injuries’ in the time following the injury was rated on an 11-point NRS. Post injury Physical disability: Limitation in function due to injury in the 4 weeks prior to assessment was measured with the Physical Function subscale of the SF-36 version 2. Pain severity: Pain severity was measured using an 11-point numerical rating scale (NRS) in response to ‘How severe was your pain on average over the past 24 hours?’. Social support: The MSPSS. Compensation: The injury was deemed compensable if it was eligible for either the work-based or transport no-fault compensation schemes.
Analysis Data were entered into the IBM SPSS (Statistical Package for the Social Sciences) for Windows, v.19, 2010 (IBM Corp., Armonk, NY, USA). For each episode of mental disorder, it was determined if it occurred: (1) prior to the injury; (2) in the first 12 months following the injury (early); or (3) in the second and third years after the injury (late). Logistic regression analysis was conducted in order to determine the risk factors associated with the onset of mental disorder (not including alcohol or substance abuse disorders). Separate analyses were conducted for new episodes of mental disorder occurring early and late after injury. In the first step, a bivariate analysis was conducted to determine the association between each risk factor and the presence of mental disorder. Pearson correlation was used for continuous variables and analysis of variance (ANOVA) for categorical independent variables. All factors with p-scores
