Psychiatric Morbidity Following Injury
O’Donnell ML, Creamer M, Pattison P and Atkin C;
Commented by , 25 Mar 2004
Aims of the study
To assess the prevalence and nature of psychopathological consequences i.e. psychiatric disorders in subjects admitted to a trauma service over a period of 12 months following a severe injury.
Method
363 patients consecutively admitted to a trauma service for a severe injury (excluding moderate and severe brain injuries) were assessed for the presence of anxiety disorders (including in particular acute stress disorder and post-traumatic stress disorder or PTSD), depressive disorders and substance use disorders.
Patients were assessed just before discharge, and again three and 12 months after the injury, using the Clinician-Administered PTSD Scale or CAPSE, the relevant sections of the Structured Clinical Interview for DSM-IV or SCID, the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory (BDI).
To assess the presence of psychiatric disorders prior to the injury, patients were asked about the duration of any mental disorder that met DSM-IV criteria according to the SCID. Disorders that had been present for more than three months at the three-month assessment were considered to have been present before the injury.
Results
During the initial assessment, the incidence of acute stress disorder was low (1%), but a significant proportion of patients reported moderate to high levels of anxiety (score of > or = 19 on the BAI) and depression (score of > or = 15 on the BDI). At the 12 months assessment, 10.4% of the patients met criteria for PTSD, 20.5% met diagnostic criteria for at least one psychiatric diagnosis (vs. 12.2% before the injury), 10.1% for major depression (vs. 2.4 before the injury), and 6.5% for substance abuse (vs. 5.3% before the injury). On the whole, PTSD and depressive disorders accounted for 53% of the diagnoses at the 12 months assessment.
Discussion
The low incidence of acute stress disorder could be attributed to the fact that only a few patients met criteria for dissociation (the DSM-IV criterion B for acute stress disorder requires the presence of three dissociative symptoms from a list of five such symptoms). The fact that a higher proportion of patients went on to develop PTSD suggests that either the presence of acute stress disorder is not be a reliable predictor of PTSD or that the current diagnostic criteria for acute stress disorder (in particular the requirement for three dissociative symptoms) are not adequate to predict the occurrence of PTSD.
The fact that one-fifth of the patients met diagnostic criteria for at least one psychiatric disorder 12 months after the injury has major implications for health care systems involved in the treatment of traumatically injured patients. In particular, health care providers should look out for early signs of PTSD and depression in this population and provide psychiatric intervention at an early stage for psychiatric disorders that may develop in the months following a physical injury.
The review has a number of limitations, concerning in particular the fact that the presence of psychiatric disorders before the injury was determined using assessments made after the injury. In addition the results may have been blurred by the exclusion (for various reasons) of a high proportion of patients.
In spite of these limitations, this is a highly interesting study. It shows that physical injury is frequently and persistently followed by the occurrence of psychiatric disorders and that there is a need for early identification and treatment of these disorders.