Session III - Polytrauma

Psychological Distress among Patients with a Severe Lower Limb Injury

Melissa L. McCarthy, ScD; Ellen J. MacKenzie, PhD; David Edwin, PhD; Michael J. Bosse, MD; Renan C. Castillo, MS; Adam J. Starr, MD; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Purpose: The results of previous studies of general trauma patients suggest that patients who sustain a moderate to severe injury are vulnerable to serious psychological morbidity. The purpose of this study was to document the psychological distress among patients with a severe lower limb injury and to identify correlates of poor psychological outcome.

Methods: Patients, 16 to 69 years of age, who were admitted to one of eight level-1 trauma centers over a 40-month period for treatment of one of the following injuries were eligible for the study: 1) traumatic amputations, 2) Gustilo-Anderson type III tibia fractures, 3) dysvascular limbs, 4) major soft tissue injuries to the tibia, and 5) severe foot injuries. Patients were enrolled and interviewed during their initial hospitalization. The baseline interview obtained background information on the patients and their health status prior to the injury. In addition, the attending orthopaedic surgeon documented the nature and severity of the limb injury as well as all treatment received.

Patients were contacted again at 3, 6, 12, and 24 months after the injury for follow-up assessments. As part of each follow-up evaluation, patients completed the Brief Symptom Inventory (BSI) and the Sickness Impact Profile (SIP). The BSI is a 53-item, self-reported measure of psychological distress that consists of nine symptom scales and three global scales and takes 5 to 10 minutes to complete. Normative data on the BSI are available. A BSI total score of 63 on the global severity scale or a total score of 63 on at least two out of the nine symptom scales is considered a positive case: a patient who is likely to have a psychological disorder and should receive a mental health evaluation.

The relationship between patient characteristics (socio-demographic traits, pre-injury health and health habits, personality traits, and social support), injury severity, form of treatment (amputation vs. reconstruction) and physical function (as measured by the physical health subscore of the SIP) on psychological outcome were examined. Longitudinal logistic regression techniques were used to model positive case status (likely to have a psychological disorder) as a function of patient, injury and treatment characteristics.

Results: Of the 569 patients enrolled, 545 (96%) completed at least one BSI and 67% completed all four. The mean age of the study sample was 36 years. Most patients were male (75%), white (75%), and had completed high school (74%). The most common types of injuries sustained among patients in the study group were grade IIIB tibia fractures (36%) and severe foot injuries (24%). At the time of hospital discharge, 73% of the limbs were reconstructed and 27% amputated.

The proportion of patients who screened positive for a likely psychological disorder was 48% at 3 months after the injury and did not improve significantly by 24 months (42%). Two years after the injury, almost one-fifth of the study patients reported severe phobic anxiety (20%) or depression (19%) or both. Although these two subscales reflected the highest prevalence of severe psychological distress, none of the BSI subscales reflected the prevalence expected from a normal population sample (2 to 3%).

A number of factors were significantly correlated to screening positive for a likely psychological disorder. Patients with a physical SIP score of 10 (significant dysfunction) were 1.7 times more likely to screen positive compared with patients with a score of 1 (little to no dysfunction) (95% C.I. 1.5, 1.9). Younger patients, age 24 to 54 years of age, were 6 times more likely to screen positive for a psychological disorder compared with patients 55 years of age or older (95% C.I. 3.1, 11.8). Non-white patients and poor patients were significantly more likely to screen positive compared with white patients or non-poor patients (OR = 1.5 and 1.4, respectively). Patients with a likely drinking problem, a high degree of neuroticism, or relatively low self-efficacy were also significantly more likely to screen positive for a psychological disorder compared with patients without a drinking problem, with low to average neuroticism, and a strong sense of self-efficacy (OR = 1.4, 1.4 and 1.5, respectively). Finally, patients who reported poor to average social support were 1.9 times more likely to screen positive compared with patients who reported the availability of good social support (95% C.I. 1.4, 2.5). The severity of the limb injury and the treatment type were not associated with psychological outcome.

Discussion: A high proportion of patients who sustained a severe lower limb injury reported significant psychological distress up to 2 years after injury. Furthermore, psychological morbidity did not improve over time. Even after controlling for patients' physical health, a number of patient characteristics such as age, race, poverty status, sense of self-efficacy, availability of social support, likelihood of a drinking problem, and extent of neuroticism were significantly associated with poor psychological outcome. Despite the high proportion who screened positive for a psychological disorder, relatively few reported receiving any mental health services following their injury (12% at 3 months and 22% at 24 months post injury).

Conclusion: The psychological health of patients who sustain a severe lower limb injury is largely being ignored.