Psychiatric disorders after accidents burns and other trauma

Methodological issues

There are few systematic studies of the prevalence of persistent (more than 1 year) psychiatric disorders in random samples of accident victims, and even fewer studies of the long-term effects on children. Most studies have a 3- to 12-month perspective. The severity and type of physical injuries are often not addressed. Patients are often highly selected (e.g. from tertiary trauma centres). Estimates are often based on patient-endorsed questionnaires with no control over attribution or concurrent psychiatric disorders. Life events during the follow-up period are seldom controlled for. Furthermore, many studies rely on research interviewers with no experience of assessing trauma patients.

The time of the interview is important. Within the first 48 h, psychological defences are less rigid. Interviews at this time may reveal valuable information about pre-accident problems and current distress. Within the next 3 to 5 days, most patients become more defensive. During this period, they may deny problems existing before the accident. With very few exceptions,(4) research on psychiatric disorders associated with accidents has been conducted 4 to 7 days after the accident. Such studies regularly underestimate pre-accident problems.

The prevalence rates of PTSD depend on the research criteria adopted. Studies using DSM-IV criteria report higher rates that those using ICD-10 criteria. Prevalence of psychiatric disorders

The main psychological consequences are listed in Table.3. To date, there has been no study of the long-term outcome in a random sample of 15 per cent of the population involved in accidents each year. Studies of subgroups coming to medical attention suggest an incidence of non-organic mental disorders of about 17 per cent after 6 months and 9 per cent after 2 years.(!3) After motor vehicle accidents, the prevalence has been estimated at about 25 per cent.

Table 3 Main emotional and behavioural consequences of accidents

Depressive symptoms and disorders are most frequent, followed by specific accident-related phobias and post-traumatic disorder, but prevalence data vary greatly across study populations. In a prospective study of 211 trauma survivors, of whom 84 per cent were victims of motor vehicle accidents, 14 per cent were depressed 4 months after the accident.(6) In another study(13) of mostly minor accidental injuries, 21.4 per cent had some depressive symptoms after 2 to 3 years (MADRS score greater than 12), but they were clinically significant (MADRS score greater than 20) in only 5 per cent; 3 per cent had a dysthymic disorder.

The 1-year prevalence of PTSD after accidents in a random sample of the population is probably no more than 1 to 5 per cent. (!3) Among motor vehicle accident survivors brought to medical attention the estimates vary from 4 to 12 per cent.(! J..5 Women are at greater risk than men. Similar figures have been reported for children/1.® The 6-month prevalence of PTSD is about 1 per cent, and the lifetime incidence is about 5 per cent in males and 10 per cent in females. In fact, sudden unexpected death of a loved one and violent assault lead to higher rates of PTSD than accidents. Head injury with retrograde amnesia for the accident seems to reduce the rate of long-term PTSD. Brain injuries are discussed in Chapte.L.4.1.11.

Chronic pain is quite frequent following accidental injury. Victims with high PTSD symptoms reported higher pain scores and more affective disturbance, (17) and complaints of chronic pain are common among wounded soldiers with PTSD. These findings emphasize the role of comorbidity for disability and functional impairment. The prevalence and incidence of long-term pain and psychiatric problems after whiplash injury are debatable. About 15 per cent report extended periods of significant pain/18 and 5 to 10 per cent may develop long-term disability. Risk factors reported are persistent and severe neck symptoms after 4 weeks, a greater variety of subjective complaints, more problems with focused attention, older age, and early complaint of sleep disturbances. None of these studies have controlled for treatment. The finding that subjects treated with a collar or rest, or who have been given sick leave, have a poorer outcome (192,9 suggests that some of the findings from follow-up studies are due to the treatment and not the natural course of neck pain.

The greater the comorbidity, the greater is the functional impairment. All studies addressing the psychological and physical outcomes simultaneously have found a strong association between psychological and physical outcomes in accident studies, in particular among patients with PTSD and those seeking treatment. The more severe the PTSD, the more depressive symptoms are reported, and those with marked depression report more intrusive symptoms. In patients with PTSD after accidents, the comorbidity rates for significant depressive symptoms have been estimated to range from 40 to 100 per cent. Estimated comorbidity rates are 0.5 to 0.7 for somatization (e.g. pain), 0.3 to 0.5 for substance abuse as a result of the accident, and 0.3 or less for aggressive behaviour.

Disasters may create special long-term problems/!0,21 After disasters, family members may suffer from significant post-traumatic symptoms, without reaching the cut-off level for a psychiatric disorder, more than 5 years after the event.(22) Accidents may also have long-term effects on normal behaviour and attitudes without causing psychiatric disorders.(1)

Predictors of long-term psychiatric disorders

Several variables show a strong statistical association with the long-term outcome, but none is a useful predictor in daily practice. The clinician should also take account of the clinical response in the first hours to days after the accident,(4) in particular panic, severe anxiety, severe depression, and excessive pain. Repeated use of the General Health Questionnaire or another scale of distress reliably identifies cases and may help to predict complications.

Risk factors include threat to life, horrifying visual images, severity of injury, length of hospital stay, loss of loved ones and friends, damage to property, degree of helplessness, length of time in the the accident situation, and negative psychological consequences. These findings are quite robust across studies and do not depend solely on the individual's perception of the impact. Similar factors have also been found in rescue personnel and non-injured survivors of disasters. The psychological impact of the accident has predictive importance even when injury severity is controlled for.

Pre- and post-accident risk factors

The more complex the clinical picture, the more important are variables not directly related to the accident. In a study of 130 victims of motor vehicle accidents, only those who attributed responsibility for the accident to others were still distressed 6 to 12 months after the accident. (23)

Pre-accident social and emotional problems are risk factors for post-accident distress and psychopathology. (5.,1 14 and 1,21,24) A prior psychiatric diagnosis and 'neuroticism' (as defined by Eysenck) predict later PTSD and other mental problems. Data from the United States National Comorbidity study of 5877 respondents showed that, after adjustment for individual types of trauma, only one risk factor (history of affective disorder) predicted PTSD in women, and two (history of anxiety disorder and parental mental disorder) predicted PTSD in men. (25> Similarly, only familial variables of mental disorders distinguished PTSD in male military veterans from other proband groups. Previous trauma or childhood behavioural problems also increases the risk for long-term problems. Level of education, family factors, treatment-related variables, and secondary events may also influence long-term adjustment.(91 1 ^.l,26

The longer the time since the accident, the more important are such variables. Prior major depression predicts 1-year outcome. (6,.l 24) Fear of dying in a motor vehicle accident, extent of physical injury, and whether litigation has been initiated also predict outcome. Other predictors are alcohol abuse, Axis II disorder at the time of the accident, and the level of hyperarousal and avoidance symptoms in the first few weeks after the accident.

Studies of differential outcomes in men and women have had mixed results. Women seem to be at higher risk for anxiety and depression, and men more at risk for substance abuse and antisocial behaviour. Some studies suggest that middle-aged subjects are most at risk for psychological problems. Only a few studies have adequately examined and controlled for pre-existing conditions and injury severity.

There is some evidence that adverse mental health effects persist longer after accidents caused by humans than after technological accidents. Blaming others may bring the post-accident psychological process to a standstill.

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