Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries.

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.

From survival to socialization: a longitudinal study of body image in survivors of severe burn injury.

OBJECTIVE: Little is known about the course of body image dissatisfaction following disfiguring injury or illness. The objective of this study was to test a proposed framework for understanding the trajectory of body image dissatisfaction among burn survivors and to longitudinally investigate the role of body image in overall psychosocial functioning. METHODS: A sample of 79 survivors of severe burn injuries completed the Satisfaction with Appearance Scale (SWAP), the Importance of Appearance subscale of the Multidimensional Body-Self Relations Questionnaire, and the SF-36 in the hospital and at 6 and 12 months postdischarge (SWAP and SF-36). A repeated-measures analysis of covariance model was used to assess the course of body image dissatisfaction over time, and a path analysis model tested the role of body image dissatisfaction in mediating the relationship between preburn and postburn psychosocial functioning. RESULTS: Female sex (P<.05), total body surface area burned (P<.01), and importance of appearance (P<.01) predicted body image dissatisfaction. From hospitalization to 12 months postdischarge, body image dissatisfaction increased for women (P<.01) and individuals with larger burns (P<.01) compared, respectively, to men and individuals with smaller burns. In the path analysis, body image dissatisfaction was the most salient predictor of psychosocial function at 12 months (beta=.53, P<.01) and mediated the relationship between preburn and 12-month psychosocial function. CONCLUSION: Findings from this study suggest the importance of routine psychological screening for body image distress during hospitalization and after discharge.

Mortality risk and length of stay associated with self-inflicted burn injury: evidence from a national sample of 30,382 adult patients.

OBJECTIVE: Existing studies report contradictory findings regarding characteristics and outcomes of patients admitted with self-inflicted burn injuries. The objective of this study was to report demographic and medical characteristics of patients admitted to burn centers with self-inflicted burn injuries and to assess mortality risk and length of stay compared with patients whose injuries were not self-inflicted. DESIGN: Retrospective, cohort study. SETTING: A total of 70 burn centers from the United States that contributed data to the American Burn Association National Burn Repository. PATIENTS: A total of 30,382 adult patients (593 with self-inflicted injuries) who were admitted with a thermal injury from 1995 through 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, comorbidities, burn injury severity variables (total body surface area burned [TBSA], TBSA burned third degree, inhalation injury), hospital mortality, intensive care length of stay, and total hospital length of stay were ascertained. Patients with self-inflicted injuries had larger TBSA burned (32.0% vs. 12.8%, p < .01) and larger third-degree TBSA burned (20.6% vs. 4.9%, p < .01) and were more likely to incur an inhalation injury (37.3% vs. 12.8%, p < .01). Before matching, patients with self-inflicted injuries were at greater risk of mortality (23.6% vs. 6.8%, p < .01) and required longer intensive care (median of 4 days vs. 0 days, p < .01) and total hospital stays (median of 23 days vs. 8 days, p < .01). After propensity score matching on demographic, medical, and burn injury variables, they were not more likely to die of their injuries (23.6% vs. 23.1%, p = .84), did not require longer intensive care stays (4 days vs. 3 days, p = .75), and did not require longer total hospital stays (23 days vs. 18 days, p = .50). CONCLUSIONS: Compared with patients with similar demographic, health, and injury characteristics whose injuries are not self-inflicted, patients with self-inflicted burn injuries are not at greater risk of mortality and do not require longer durations of intensive care or total hospitalization.

Augmented exercise in the treatment of deconditioning from major burn injury.

OBJECTIVE: To investigate the efficacy of a 12-week exercise program in producing greater improvement in aerobic capacity in adult burn survivors, relative to usual care. DESIGN: Randomized, controlled, double-blinded trial. SETTING: Burn center. PARTICIPANTS: A population-based sample of 35 adult patients admitted to a burn center for treatment of a serious burn injury. INTERVENTION: A 12-week, 36-session, aerobic treadmill exercise program where work to quota (WTQ) participants intensified their exercise according to preset quotas and work to tolerance (WTT) participants continued to their tolerance. Participants completed a maximal stress test at baseline and 12 weeks to measure physical fitness. MAIN OUTCOME MEASURE: Maximal aerobic capacity. RESULTS: The WTT and the WTQ exercise groups both made significant improvements in aerobic capacity from baseline to 12 weeks (t=-3.60, P< or =.01; t=-3.17, P< or =.01, respectively). The control group did not (t=-1.39, P=.19). WTT and WTQ participants demonstrated significantly greater improvements in aerobic capacity in comparison to the control group members (F=4.6, P< or =.05). The WTT and WTQ groups did not differ significantly from each other with regard to their respective improvements in aerobic capacity (F=.014, P=.907). CONCLUSIONS: The aerobic capacity of adult burn survivors can be improved with participation in a structured, 12-week exercise program after injury.

Who attempts suicide by burning? An analysis of age patterns of mortality by self-inflicted burning in the United States.

OBJECTIVE: The objective of this study was to compare age patterns of completed suicide by burning in the USA to age patterns in suicide by all methods as an indicator of whether suicide by burning may be a phenomenon related to altered mental status (psychosis and/or intoxication). METHODS: Analysis of three national databases: Fatal injury data from the U.S. National Vital Statistics System, estimates of nonfatal injury data from the U.S. National Electronic Injury Surveillance System All-Injury Program and mortality data from the American Burn Association National Burn Repository. RESULTS: Risk of suicide by burning is highest between 30 and 59 years (odds by decile of age compared to 18-29 years, 1.47 to 1.82), whereas risk by all methods is highest for ages 70 and older (odds, 1.26 to 1.55). Of patients admitted to burn centers with large self-inflicted burns (total body surface area > or =20%), 58.6% live. Among those with specified psychiatric or substance abuse/dependence disorders, 69.2% had either a disorder that included psychosis and/or a substance abuse/dependence disorder. CONCLUSIONS: Age patterns of suicide by burning suggest that psychotic and/or substance-related disorders may be present in a substantial proportion of victims. Further research is needed, however, to document the psychiatric characteristics of these patients.

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.

Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function.

OBJECTIVE: This study investigated the prevalence and the clinical correlates of symptoms of depression among burn reconstruction patients. METHOD: A sample of 224 burn reconstruction patients completed the Beck Depression Inventory (BDI), the SF-36 Health Survey and the Satisfaction with Appearance Scale. RESULTS: The prevalence of at least mild to moderate symptoms of depression (BDI > or =10) was 46%. Female patients were disproportionately represented in this burn reconstruction population (46%) compared to all survivors from the burn center (29%; P<.001) and compared to a national sample of burn survivors (27%; P<.001). Compared to males, female patients presented for consultation much longer after a burn injury (P<.001), tended to have smaller burns (P=.06) and were less likely to have facial burns (P=.08). Depressive symptoms were largely predicted by body image dissatisfaction (beta=.58; P<.001), with additional variance predicted by physical function (beta=-.13; P=.07). The effect of patient and burn injury variables on depressive symptoms was mediated by body image dissatisfaction and physical function. CONCLUSION: The high prevalence of significant symptoms of depression in burn reconstruction patients and their relationship with body image suggest the importance of the routine psychological screening of patients seeking reconstruction services.

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.