Are Mental Health Issues a Precursor or a Consequence of Injury?

This prospective cohort study of 1084 injured patients from 4 major (unidentified) Australian trauma hospitals were recruited over a 23 month period from 2004-6 and followed up for 3 and 12 months respectively. The injuries ranged from minimum to critical based on Injury Severity Score. They were assessed for the prevalence of psychiatric disorders, quality of life, mental health service use and lifetime axis 1 psychiatric disorders. At 12 months after injury the authors found that 31% reported a psychiatric disorder and 22% developed a new psychiatric disorder.

The most common new psychiatric disorders were depression (9%), generalised anxiety disorder (9%), posttraumatic stress disorder (PTSD) (6%) and agoraphobia ( 6%). They also found that patients were more likely to develop PTSD and agoraphobia if they suffered mild traumatic brain injury. Participants were more likely to develop a psychiatric disorder at 12 months if they had physical, psychological, social or environmental impairment in function at 3 months.

These findings differ from previous studies which have shown rates of PTSD and depression in survivors of major traumatic injury to be 10-20% and 9-15% respectively. Although PTSD is the predominant disorder after traumatic events that involve significant violence, it appears that a broader range of disorders affect people after traumatic injury in general. Although there was a lack of a non-trauma-exposed comparison group, the risk of development of psychiatric illness in the trauma exposed group is five times greater than the point prevalence rate in the general Australian population.

Another interesting finding was that contrary to other studies, the rate of development of psychiatric illness did not decrease between 3 and 12 months post-traumatic injury. They found that more than half of the patients with either an anxiety or a depressive disorder at 12 months did not have the disorder at 3 months and only 33% with a psychiatric disorder sought mental health treatment before the 12 month assessment. A potential weakness of the study is that the patients were limited to weekday admissions but the overall follow-up rate of 86% and 75% at 3 and 12 months respectively was quite good.

The authors conclude that significant mental health needs are experienced by about one-third of survivors of traumatic injury and there is a need for significant public health initiatives to address the significant mental health burden associated with these injuries. The challenge for those of us who treat these patients is how to identify those with new psychiatric disorders associated with trauma and what interventions will facilitate optimum recovery from these psychiatric disorders.

The Psychiatric Sequelae of Traumatic Injury.
Bryant RA, O’Donnell ML, Creamer M et al. Am J of Psychiatry 2010;167: 312-320

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