Inpatient depression in persons with burns

Correlation of Sociodemographic Factors, Characteristics of Burns, and Neutrophil-to-Lymphocyte Ratio with the Level of Depression in Patients with Burn injuries

Background

The most common psychological impact experienced by patients with burn injuries is depression. Several significant risk factors influence depression, including sociodemographic factors (gender, employment status, socioeconomic status, and marital status) and burn characteristics (burn depth, burn area, and total burn surface area). Neutrophil-to-lymphocyte ratio (NLR) was discovered as a new biomarker for depression detection. The purpose of this study was to investigate the correlation of sociodemographic factors, burn characteristics, and NLR with the severity of depression in patients with burn injuries.

Methods

This analytic descriptive study was conducted at Dr. Hasan Sadikin General Hospital from June 2022 to April 2023. Samples were assessed by a psychiatrist using the Hamilton Depression Rating Scale instrument, and a differential white blood count was calculated to obtain the NLR value.

Results

The study sample consisted of 32 patients, including 27 males and 6 females. There was no correlation of sociodemographic factors and burn wound characteristics with the level of depression. NLR in patients with burn injuries who had no depression, mild depression, and moderate depression was 5.78 ± 2.23, 7.4 ± 1.77, and 13.04 ± 6.25, respectively. NLR was statistically significantly associated with the level of depression in patients with burn injuries (p = 0.001).

Conclusion

There was no correlation of sociodemographic factors and burn characteristics with the level of depression. There was a significant correlation between NLR and the level of depression in patients with burn injuries at Dr. Hasan Sadikin General Hospital.

Predictors of post-traumatic growth in young adult burn survivors

Although burns most often result in negative psychological consequences, some studies have identified self-reported, positive psychological growth after such injuries. Post-traumatic growth is a positive psychological change in which an individual develops stronger functioning, beliefs, and values following a trauma. To date, no quantitative analysis has been done of post-traumatic growth in young adult burn survivors. The present study aims: (1) to delineate the overall level of post-traumatic growth among Korean young adult burn survivors, and (2) to investigate the factors that influence the post-traumatic growth. To accomplish this, data for 221 burn survivors in a burn hospital and self-help groups were analyzed. Young adult burn survivors were found to have experienced post-traumatic growth, although to a lesser degree than previous research would suggest (36.86 ± 31.16). Results of the hierarchical multiple regression analysis indicated that change in a family relationship after the burn experience, treatment situation, and level of interpersonal relationship skills, were statistically significant in young adult burn survivors' post-traumatic growth. Results support good interpersonal relationship skills and positive family relationships appear to facilitate the positive growth after burn experience. Clinical implications are presented in the discussion.

Psychological aspects in early adjustment after severe burn injury

Burn injury is one of the most serious traumatic events with possible psychological and psychosocial consequences. Health status perception is one of the main health outcomes. The severity of psychological symptoms does not always correlate with that of the burn injury, suggesting that early screening for psychological vulnerabilities may be beneficial. The aim of our study was to identify the personality, clinical, and sociodemographic characteristics related to patient´s subjective perception of health, depression, and anxiety, in a sample of 52 adult patients with severe burn injury shortly before discharge from specialty Burn clinic. Subjective health perception was predicted by depression (β = -.143, t(47) = -3.94, P < .001) and neuroticism (β = -.106, t(43) = -4.83, P < .001), and it correlated positively with extraversion (r = .2858, P = .0465) and conscientiousness (r = .3663, P = .0096). Depression was predicted by neuroticism (F(1,49) = 18.4; P < .001) and correlated with attachment avoidance (r = .29, P = .0383) and negatively with extraversion (r = -.32, P = .0220). Anxiety was related to attachment anxiety (F(1,49) = 4.25; P = .045), neuroticism (F(1,49) = 15.75; P < .001), and agreeableness (r = -.36, p = .0101). Unemployed patients experienced higher levels of depression and anxiety. This research suggests that personality traits and adult attachment may play an important role in the acute phase of the recovery from a severe burn injury. These findings can be relevant for early intervention and holistic rehabilitation.

Three Years After Black Saturday: Long-Term Psychosocial Adjustment of Burns Patients as a Result of a Major Bushfire

Despite increasing evidence that burn injuries can result in multiple psychological sequelae, little is known about the long-term psychosocial adjustment to burns sustained in a major bushfire. The aim of the present study was to assess long-term psychological distress and health-related quality of life in Australian burns patients as a result of the 2009 Black Saturday bushfires. Eight male and five female burns patients with a mean age of 53.92 (SD = 11.82) years who received treatment at a statewide burns service participated in the study. A battery of standardized questionnaires was administered to assess general psychological distress, burns-specific and generic health-related quality of life, alcohol use, and specific psychological symptoms of posttraumatic stress disorder, depression, and anxiety. The results revealed that more than 3 years after Black Saturday 33% of the burns patients still suffered "high" to "very high" levels of general distress, whereas 58% fulfilled partial or full criteria for posttraumatic stress disorder. Furthermore, participants still experienced significantly impaired physical health functioning as compared to their preinjury status including limitations in work-based activities, increased bodily pain, and lower vitality overall. The trajectory of distress varied for participants. Some individuals experienced little distress overall, whereas others displayed a decline in their stress levels over time. Notwithstanding, some patients maintained high levels of distress throughout or experienced an increase in distress at a later stage of recovery. The results point to the importance of psychosocial screening to identify distress early. Follow-up assessments are crucial to diagnose individuals with chronic or late onset of distress.

Psychiatric aspects of burn

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. The psychological aspects of burn injury have been researched in different parts of the world, producing different outcomes. Studies have shown that greater levels of acute pain are associated with negative long-term psychological effects such as acute stress disorder, depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychological outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

Mice treated with a benzodiazepine had an improved survival rate following Pseudomonas aeruginosa infection

Psychological stress has a high incidence after burn injury, therefore, anxiolytic drugs are often prescribed. Unfortunately, to date, no burn study has investigated the effects of anxiolytic drugs on the ability to fight infection. This study was undertaken to determine if psychological stress, anxiety-modulating drugs, or both, alter survival following an infection. On day 0, 7-week-old male C57Bl/6 mice either received a 15% full-thickness flame burn or were sham treated (anesthesia and shaved), whereas controls received no treatment. Mice received midazolam (1 mg/kg intraperitoneally) or saline daily and were stressed by exposure to rat in a guinea pig cage or placed in an empty cage for 1 hour a day, beginning on postburn day 1. For the survival experiments, mice either received bacteria after 2 or 8 consecutive days of predator exposure and drug treatment, which continued daily for 7 days after inoculation. In a separate set of experiments, after eight daily injections of midazolam, mice were given lipopolysaccharide, bacteria, or saline and were killed 12 hours later. Mice that received midazolam had improved survival rates when compared with their saline-treated counterparts, and the protective effect was more significant the more days they received the drug. For most of the cytokines, the bacteria-induced increase was significantly attenuated by midazolam as was the amount of bacteria in the liver. The protective effect seems to be independent of the drug's anxiolytic activity as there were no significant differences in survival between the predator-stressed and the nonstressed mice. The mechanisms responsible for the protective effect remain to be elucidated.

Bench-to-bedside review: Burn-induced cerebral inflammation--a neglected entity?

Severe burn injury remains a major burden on patients and healthcare systems. Following severe burns, the injured tissues mount a local inflammatory response aiming to restore homeostasis. With excessive burn load, the immune response becomes disproportionate and patients may develop an overshooting systemic inflammatory response, compromising multiple physiological barriers in the lung, kidney, liver, and brain. If the blood–brain barrier is breached, systemic inflammatory molecules and phagocytes readily enter the brain and activate sessile cells of the central nervous system. Copious amounts of reactive oxygen species, reactive nitrogen species, proteases, cytokines/chemokines, and complement proteins are being released by these inflammatory cells, resulting in additional neuronal damage and life-threatening cerebral edema. Despite the correlation between cerebral complications in severe burn victims with mortality, burn-induced neuroinflammation continues to fly under the radar as an underestimated entity in the critically ill burn patient. In this paper, we illustrate the molecular events leading to blood–brain barrier breakdown, with a focus on the subsequent neuroinflammatory changes leading to cerebral edema in patients with severe burns.

The risk factors of psychosocial problems for burn patients

Many burn patients experience psychosocial problems such as personality change, post-traumatic stress disorder, family trouble, and financial burden. The purpose of this study was to identify the risk factors of these psychosocial problems that prevented burn patients from developing appropriate adjustments after burn. Six hundred eighty-six adult burn inpatients were interviewed. Most of them suffered from burns less than 10% of total body surface area. They were asked to fill in a questionnaire for this study, which was a psychosocial problem checklist of 17 items. Descriptive analysis, factor analysis, Chi-square test, and multiple logistic regression analysis were used to analyze the results. Lack of family support and living expense burden were the two significant risk factors for psychosocial problems including, burn treatment problems, rehabilitation problems, and welfare information problems on both acute and chronic burn patients. Medical expense burden was the risk factor among chronic burn patients. These findings suggested that active interventions by the burn team including mental health professionals (psychologist, psychiatrist or social worker) might reduce psychosocial problems of burn patients and encourage social rehabilitation.

Burn rehabilitation: an overview

Burn injuries result in significant physical and psychologic complications that require comprehensive rehabilitation treatment and coordination with the acute care burn team. This interdisciplinary rehabilitation treatment is focused on preventing long-term problems with scarring, contractures, and other problems that limit physical function. Adequate pain management and recognition of psychologic issues are important components of treatment after burn injuries. Burn injuries present significant barriers to community integration, but many people can successfully return to work and other activities.

Use of the Beck Depression Inventory for assessing depression in patients hospitalized with severe burn Disentangling symptoms of depression from injury and treatment factors

The objective of this study was to assess whether scores on the Beck Depression Inventory (BDI) are biased by injury severity among hospitalized survivors of burn (N=262). A confirmatory factor analysis (CFA) model was developed with a general depression factor that loaded on all items and somatic and cognitive factors that were orthogonal to the general factor and to each other. The model fit the data well and substantially better than an alternative three-factor model with correlated factors. Percent total body surface area burned (TBSA) was significantly associated with the general depression factor (p=.04), but also with the orthogonal somatic factor (p<.001), suggesting biased measurement due to overlap between somatic symptoms of depression and the severity of the burn injury. Analysis of item communalities, however, suggested that only approximately 2% of total predicted item variance was associated with bias related to injury severity. It was concluded that, despite a small amount of bias, the BDI is a reasonably accurate clinical tool even in the context of severe burn. Appropriate adjustments for bias, however, should be made in research with the BDI among patients with acute burn.

Burn injuries

PURPOSE OF REVIEW

To summarize new advances and research findings that relate to the treatment of burn victims.

RECENT FINDINGS

Recent advances in burn resuscitation and critical care reflect a better understanding of the acute phase pathophysiology of severe burns. Aggressive management of the unstable burn airway is always the most important clinical priority. Emphasis has been placed on the early identification of inhalation injury and its impact on fluid resuscitation, as well as on a protective lung strategy to reduce the development of pulmonary edema, acute lung injury and pneumonia, and to reduce the risk of barotrauma. New blood markers, such as serum cholinesterase and inflammatory cytokines, have been introduced to assist in the prognosis of morbidity and mortality, beyond the traditional vital signs. At this time, however, these are available only for research purposes. Finally, early burn wound excision and coverage with new biodegradable materials results in less pain and more rapid healing for the patient.

SUMMARY

The combination of innovative approaches and a dedicated burn team is expected to continue to improve survival in the next few years even in the most severe cases.

Psychological distress after major burn injury

OBJECTIVE

To track the prevalence and stability of clinically significant psychological distress and to identify potentially modifiable in-hospital symptoms predictive of long-term distress (physical, psychological, and social impairment).

METHOD

We obtained data from the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The Brief Symptom Inventory (BSI) was used to assess symptoms in-hospital (n = 1232) and at 6 (n = 790), 12 (n = 645), and 24 (n = 433) months post burn. Distress was examined dimensionally (BSI's Global Severity Index (GSI)) and categorically (groups formed by dichotomizing GSI: T score > or =63). Attrition was unrelated to in-hospital GSI score.

RESULTS

Significant in-hospital psychological distress occurred in 34% of the patients, and clinically significant and reliable change in symptom severity by follow-up visits occurred infrequently. Principal components analysis of in-hospital distress symptoms demonstrated "alienation" and "anxiety" factors that robustly predicted distress at 6, 12, and 24 months, controlling for correlates of baseline distress.

CONCLUSIONS

This is the largest prospective, multisite, cohort study of patients with major burn injury. We found that clinically significant in-hospital psychological distress was common and tends to persist. Two structural components of in-hospital distress seemed particularly predictive of long-term distress. Research is needed to determine if early recognition and treatment of patients with in-hospital psychological distress can improve long-term outcomes.

Symptoms of depression predict change in physical health after burn injury

This study investigated the prevalence of symptoms of depression in patients hospitalized with severe burns and the association of symptoms of depression in the hospital with physical health 2 months after discharge, controlling for pre-burn physical health as measured by the SF-36 physical composite score. Survivors of acute burns were evaluated during the hospitalization (N=262) and at 1 week (N=165) and 2 months (N=100) after discharge. The prevalence of at least mild to moderate symptoms of depression (Beck Depression Inventory > or = 10) ranged from 23% to 26%. In-hospital symptoms of depression predicted change in physical health from pre-burn to 2 months post-discharge (p=.02), controlling for patient demographics, burn severity, and symptoms of PTSD. These results suggest that patients should be screened for depression, both in-hospital and during rehabilitation after discharge.

Assessing potential suicide risk of young adults burned as children

This study examines potential for suicide risk among young adults burned as children and examines characteristics associated with potential risk. Eighty-five young adults were administered the Suicide Probability Scale, which contains four clinical subscales: suicide ideation, hopelessness, negative self-evaluation, and hostility; the 16 Personality Factor Questionnaire; and the Family Environment Scale. Burn survivors reported more feelings of hopelessness in comparison to the reference group. High anxiety was positively associated with hopelessness, suicide ideation, hostility and negative self-evaluation whereas high extroversion was inversely related with hopelessness, negative self-evaluation, and hostility. Multiple regression analyses revealed emotional stability explained 29% of the variance, self-reliance 17% of the variance, and both 38% of the variance in relation to Suicide Probability Scale scores; and increased family conflict 12% of the variance. Results suggest that high anxiety, emotional reactivity, and family conflict correlate with increased potential suicide risk; whereas, extroversion correlates with decreased risk.

Self-reports of anxiety in burn-injured hospitalized adults during routine wound care

The purpose of this investigation was to examine the amount of anxiety patients believed tolerable and the amount of anxiety experienced during routine burn wound care. Participants included 47 hospitalized adults who provided data for four consecutive assessment periods. Patients (mean TBSA, 16%; range, 2-70%) were primarily Caucasian (87%) and had an average hospital stays of 23 days (range, 11-130). Reports of what level of anxiety they would be able to tolerate and what level of anxiety had been experienced were assessed using 10-point Graphic Rating Scales. The use of anxiolytic was recorded, and patient suggestions for reducing anxiety were obtained. The single most commonly endorsed anxiety treatment goal was 0, although 53% consistently chose a treatment goal other than 0 (range, 1-6). Two repeated-measure analyses of variance indicated that the amount of anxiety patients could tolerate and the amount they reported experiencing did not change over the course of time. Paired t-tests revealed that patients routinely reported more anxiety than they considered tolerable. Analyses of anxiety reports of patients treated with anxiolytics (n = 6) vs patients receiving no anxiolytics (n = 41) revealed inconsistent differences in actual anxiety and treatment goals across time. In general, patient suggestions for lessening anxiety included requests for education, communication, additional medications, and manipulation of the hospital environment. Anxiety for burn-injured, hospitalized adults remains a concern. Our findings are consistent with the literature indicating that adult patients hospitalized for burn wound care report appreciable anxiety, over and above what they consider "tolerable." Continued research is needed and should include investigations into the relationship between pain and anxiety during routine wound care.

Burns as a result of assault: associated risk factors, injury characteristics, and outcomes

The purpose of this study was to identify specific premorbid factors and injury characteristics associated with intentional burn injuries and to compare outcomes for individuals injured by assault and those with unintentional injuries. Participants sustaining major burns from May 1994 to August 2005 and consenting to a multisite, prospective, longitudinal outcome study were included. Etiology of the injury was classified as intentional (i.e., assault) or unintentional. Subjects <18 years old or with self-inflicted burns were excluded. Statistical analysis was performed with t-tests, chi2 tests, and analysis of variance. Eighty patients sustained intentional burn injuries and 1982 subjects sustained nonintentional burn injuries. Compared to patients with nonintentional burns, those with burns related to assault were more likely to be female, black, and unemployed and to have higher rates of premorbid substance use. Between the groups, there were no significant differences in preinjury living situation, education level, history of psychiatric treatment, or hospital length of stay. The intentional-burn group had larger burns and a greater in-hospital mortality rate, and these patients were less likely to be discharged to home. They also demonstrated significantly greater levels of psychological distress during the acute hospitalization but not at follow-up. Understanding the unique characteristics and needs of patients with intentional burn injuries is important because these individuals are less likely to have a steady income and more likely to rely on community social services. Affordable and accessible community-based health services are necessary in order to improve their outcomes.

Depression in survivors of burn injury: a systematic review

BACKGROUND

The objective of this study was to systematically review the prevalence, persistence, and risk factors for depression postburn injury.

METHODS

A search of the MEDLINE, CINAHL, and PsycINFO databases was conducted in June 2006 to identify studies that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals and references of identified articles and reviews.

RESULTS

Major depression was identified in 4% to 10% of adult patients using structured interviews in hospital and in the year following discharge. The prevalence of significant depressive symptoms in studies that used the depression subscale of the Hospital Anxiety and Depression Scale post discharge was 4% to 13%, whereas studies that used the Beck Depression Inventory generally produced substantially higher rates: between 13% and 26% for "moderate to severe" symptoms and between 22% and 54% for at least "mild" symptoms.

CONCLUSIONS

The general low quality of studies reviewed suggests the need for future studies using larger sample sizes to adequately assess prevalence rates and risk factors. No existing studies have addressed the persistence of depression in burn survivors; there are no treatment studies; and there are no recent studies of children.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

Trends in Burn Research as Reflected in American Burn Association Presentations, 1998 to 2003

The American Burn Association (ABA) mission promotes burn care, research, rehabilitation, teaching, and prevention. Therefore, we sought to determine recent burn research trends by reviewing 1595 accepted abstracts from the Proceedings of the American Burn Association from 1998 to 2003. This study encompassed a retrospective, descriptive audit of ABA abstracts accepted for presentation, including topic, institution, accreditation status, and presentation. Overall, Shriners Hospitals for Children (SH) provided 31%, non-Shriners burn centers (N-S) provided 53%, international and nonburn center hospitals provided 13%, and multicenter ventures provided 2% of the abstracts. Abstract topics addressed most frequently in this time period were cell biology 271 (17%), general care 240 (15%), and pain 235 (15%). Multicenter trials were negligible from the period of 1998 to 2000 but increased to 3% to 4% annually since 2001. In 2003, 39 of 128 (30%) of U.S. burn centers were accredited and delivered 67% of the presentations. SH abstracts increased from 26% in 1998 to 35% in 2003, whereas the N-S decreased from 61% to 48%. Thirty-seven percent of the abstracts reported prospective studies, 28% retrospective, and basic research abstracts comprised 18%. Four SH and 91 N-S (U.S.) hospitals primarily shared the podium, although N-S presentations decreased annually since 1998. On the basis of 2003 ABA/ACS accreditation data, there was an association between accreditation and research activity. SH and N-S collaborative studies for better patient care are the trend for the future as burn centers pool data and resources.

Treating Sleep Problems in Patients with Burn Injuries: Practical Considerations

Sleep disorders are a frequent but under-addressed complication of burn injuries. Burn injuries can potentially disrupt sleep for a variety of reasons, including the physiological effects of trauma as well as ramifications of treatment (ie, intensive care unit environment, pain, itching, medications). The literature on sleep disorders and burn injuries is reviewed, and suggestions for treatment are provided. Treatment is divided into two major types: nonpharmacologic and pharmacologic. Nonpharmacologic treatment, also referred to as behavioral techniques, may include any one or combination of the following: sleep hygiene, stimulus control, sleep restriction, relaxation techniques, cognitive, and light therapy. Pharmacologic therapies may include hypnotics (benzodiazepine, nonbenzodiazepine, or benzodiazepine receptor agonists), antidepressants, over-the-counter preparations, hormone replacement therapy, herbs, and melatonin.

Psychopathology and psychological problems in patients with burn scars: epidemiology and management

Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses. Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13-23% and 13-45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury. Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life.In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.

Partial-thickness burns: identification and management

PURPOSE

To provide an overview of the appropriate evaluation and management of partial-thickness burns.

TARGET AUDIENCE

This continuing-education activity is intended for physicians and nurses with an interest in learning about burn wound care.

LEARNING OBJECTIVES

After reading the article and taking the test, the participant will be able to: 1. Describe the classification of burn wounds. 2. Identify characteristics of burn wounds and the clinical techniques for diagnosing burn wound depth. 3. Identify the treatment options for partial-thickness burns.