One of the challenges facing trauma surgeons and administrators of trauma systems is to better understand the consequences of injury. Numerous outcome studies have focused on measures of physical recovery, complications, mortality, and cost. Because the ultimate beneficiary of our trauma system is the society it serves, we question whether there are other outcomes not routinely measured that interest our patients and their families.
The American College of Surgeons Committee on Trauma states that “An ideal trauma system would include all the components identified with optimal trauma care.”1 On the basis of the repeated observation that our injured patients complained of unmet social and emotional needs during the convalescent phase of their care, we questioned whether we had identified all of the components needed to provide optimal care. In the early 1990s, increasing findings in the trauma literature suggested that there were “unmet medical needs”2 of trauma patients and important but nebulous psychosocial components to trauma recovery and return to function. 3–6 Several investigators characterized the nature and incidence of these psychosocial outcomes. 7–9
Our goal was to identify aspects of this morbidity 10 and to link them with recognized functional outcomes. 11 To evaluate the impact of injury-related mental distress on the subtle outcomes of patient productivity, general health, and satisfaction after discharge from the hospital, we have conducted a prospective, multidisciplinary study of adults sustaining moderate to severe injury.
PATIENTS AND METHODS
During 1997, patients older than 18 years of age who were admitted for more than 24 hours to a university Level I trauma center and regional burn center were approached for consent to participate in the study. Inclusion criteria were the following: (1) a trauma mechanism (ICD-9 code 800.0–957.9) as primary diagnosis for admission, (2) the absence of a spinal cord injury with neurologic deficit, and (3) a Glasgow Coma Scale score of 15 within 24 hours of admission or extubation. Patients were excluded because they had neurologic injury sufficient to make the survey instrument invalid, had amputations, had a history of psychosis or self-inflicted injuries, were mentally retarded, or were in prison. All patients were admitted either directly from the scene of injury or as interhospital transfers within hours of injury. Patients who were admitted more than 12 hours from the time of injury and those who had received operative interventions before transfer were excluded. The Human Institutional Review Board of the University of Michigan approved all aspects of this protocol.
Baseline data were gathered from a variety of sources. Clinical data were obtained from the Trauma Registry (Trauma One, Lancet Technology, Inc. Cambridge, Mass), and by review of the medical chart. The hospital’s cost-accounting system (Transition Systems, Inc., [TSI] Boston, Mass) provided patient medical insurance and some financial data.
The majority of the general health, psychological, and socioeconomic information was determined in structured face-to-face interviews conducted by trained interviewers early in the patient’s hospital stay. These interviews were conducted in private and required approximately 45 minutes to complete.
Patient and Injury Characteristics
Demographic data included age, race, gender, and level of education. Injury-specific data obtained from the Registry included Injury Severity Score (ISS), region of injury, and Abbreviated Injury Score (AIS). Mechanism of injury was coded as blunt force, penetrating, or burn, and injuries were categorized as intentional (assault) or unintentional. Patients with orthopedic injuries were identified and evaluated in additional subgroup analyses. Admission blood alcohol level and length of stay in the hospital were also obtained from the Trauma Registry. Admission blood alcohol levels were recorded in mg/dL (the legal limit for operating a motor vehicle in Michigan is 100 mg/dL).
Insurance status, derived from the TSI database, was evaluated for payer class and dichotomized by the presence or absence of insurance. Hospital costs were also extracted from the TSI system, and this database was used to verify demographic data acquired from the Registry and the charts. Further financial data obtained during the interviews included self-reported income, employment status and occupation, and additional sources of income.
Health and Functional Status
The interviewers used validated instruments designed to assess general health status, the presence and severity of psychological symptoms, and standardized social questionnaires.
General health status was measured with the Short Form 36 (SF36), 12 a widely used instrument that measures self-reported health status in a number of domains, including general health, mental health, and physical function. The SF36 subscales are standardized to a 100-point scale, with higher scores representing better function. A low score on the general health scale indicates that the patient has the perception of poor personal health and the belief that it is likely to get worse (Table 1). On the mental health scale, a low score measures feelings of nervousness and depression (Table 2). The physical functioning scale evaluates limitations in performing all physical activities. Each of the subscales is composed of separate questions, and their scores are not mathematically linked.
The Sickness Impact Profile (SIP) 13 work scale provides quantifiable information regarding work status and function that is not available with the SF36 (Table 3). For the SIP work score, standardized to a 100-point scale, lower numbers represent better employment status.
For the SF36 and the SIP work scale, the patients were asked to describe their status during the 30 days preceding the injury event for which they were hospitalized.
The Brief Symptom Inventory (BSI), 14 used to assess the presence and severity of psychological distress symptoms, consists of 53 questions and has both global severity indices and specific subscales such as depression and anxiety. The BSI depression scale is widely accepted and demonstrates a high convergence with the Minnesota Multiphasic Personality Inventory (MMPI, National Computer Systems, Inc., Eden Prairie, Minn) 15 a more lengthy and well-known measure of psychological function. The BSI is scored on a 100-point scale, with high values representing increasing distress. As with the baseline measures of the SF36 and the SIP work scale, patients were asked respond to the BSI items on the basis of their status in the 30 days before injury. Patients also competed a questionnaire that measured the frequency of their use of alcohol and other drugs.
Social and Spiritual Status
A standard questionnaire was used to quantify the patient’s social support group size and their satisfaction with their perceived level of social support. A series of questions was also used to independently rate the importance, frequency, and coping value of religion and spiritual practices to the individual.
Follow-up Assessment Methods
Six and 12 months after the injury, patients were contacted by mail with a cover letter, a packet of survey instruments, a self-addressed stamped return envelope, and a $10 payment for completing the surveys. Patients who failed to return the papers within 10 working days received a second mailing without the $10. If they did not respond to either mailing, they were contacted by telephone, and when possible, the survey was completed by phone interview. If the patient had not completed the survey by a second phone contact, or could not be reached within 1 month of the 6- or 12-month anniversary, they were considered lost to follow-up. No follows-up were completed by proxy.
The follow-up assessments included the BSI, the SF36, the SIP work scale, and the Civilian Mississippi Scale for Posttraumatic Stress Disorder (PTSD), 16 and we asked the patient for information regarding current financial, disability, and legal status, satisfaction, substance use, social and spiritual status, and domestic status.
The Mississippi PTSD scale, a widely used 30-item evaluation, measures the symptoms of PTSD in four key domains: intrusion, arousal, avoidance, and impairment. Scores on the Mississippi PTSD scale were totaled to yield a continuous variable and scored to create a dichotomous variable for the presence of PTSD. Identification as a PTSD case required that the individual’s Mississippi scale results meet DSM-IV 17 criteria for the diagnosis of PTSD. Specifically, the patient had to demonstrate at least one intrusive, three avoidance, and two arousal symptoms as well as impairment.
Follow-up surveys included questions that evaluated the presence of workers’ compensation, active or historical injury-related litigation, and perceived financial difficulty. Patients were also asked if they had increased their consumption of alcohol and other drugs. We included the patient’s use of pharmaceutical analgesics in excess of the prescribed amount in the database. Finally, patients were asked to rate their level of satisfaction with their overall recovery, as well as to rate again their social support and religious and spiritual status. Figure 1 illustrates a timeline of the evaluations.
A commercial statistical package (SPSS Inc., Chicago, Ill) was used for all analyses. Univariate evaluations were conducted by independent samples t test for continuous variables and by χ2 test for categorical variables. Factors related to SIP work score were also evaluated after controlling for ISS.
Regression analysis was performed to evaluate factors related to the 12-month outcome variables of SF36 general health, SIP work status, and satisfaction with recovery. In each case, baseline functional status and SF36 mental health, ISS, and 12-month SF36 physical function were entered before analyzing the role of 12-month mental health on outcome. For general health and SIP work status, linear regression was used, and for satisfaction, logistic regression was conducted. The SF36 was used to measure both baseline status and outcome mental health for the satisfaction and general health evaluations. For work status at 12 months, baseline was measured with the preinjury SIP work score, and mental health outcome with the BSI depression score.
The SF36 mental health scale was used to quantify overall mental health because it provides a generic measure of self-reported status. Univariate methods were then used to identify factors associated with outcome SF36 mental health score. A model of the independent factors associated with outcome mental health was built by linear regression. The independent role of each specific mental health component could be identified despite the high degree of correlation between these measures. Results are presented as the mean ± SEM or percent (%). Regressions are presented with the standardized β, the change (Δ) in R2, and the p value for each step. Statistical significance is defined at the 95% confidence level (p < 0.05).
Subgroup analyses evaluating a variety of factors were also performed by splitting the cohort on the basis of loss to follow-up, orthopedic injury, intentional injury, injury-related litigation, and gender. With the exception of those lost to follow-up, the subgroups were assessed for impact on the components of outcome.
The study population was composed of 247 patients enrolled during 1997. Follow-up data were available for 75% of the patients at 6 months and for 51% at 12 months. The patients’ mean age was 37.2 ± 0.9 years, and 73% were male. Patients had a mean of 12.9 ± 0.16 years of education, earned $42,950 ± 3020/year, and 92.6% had some form of insurance. Occupationally, 72% of the patients were employed, 3% were students, 1.5% were full-time homemakers, 8% were retired, 6.5% were disabled, and only 9% were unemployed.
The mechanisms of injury were blunt force in 70%, penetrating in 13.5%, and 16.5% were burned (mean total body surface area, 13.3 ± 1.5%). Injury was intentional for 15% of the patients. The mean ISS for all patients was 13.9 ± 0.6, and the average hospital length of stay was 10.1 ± 0.5 days. Orthopedic injury was present in 47% of the population, with a mean orthopedic AIS of 2.48 ± 0.56.
Baseline measures on the SF36 were not statistically different from those reported for an age-matched healthy national norm (Fig. 2). The use of alcohol and other drugs was prevalent. Drugs were used for nonmedical reasons by 26% of the patients before injury, and alcohol by 67.2%. The mean blood alcohol at admission was 66.8 ± 6.9 mg/dL. Overall, 17% of the patients had blood alcohol levels above the legal limit. Diagnostic level symptoms of depression were identified in 19% of the patients (Fig. 3).
The majority of the patients engaged in religious and spiritual practices before injury. Religion was important to 79% of the respondents and helpful for coping to 76%. The frequency of religious practice was at least weekly for 33.9%. Spiritual practice was not further defined and was left to the interpretation of the respondent. Given this latitude, spiritual practice was important to 74% of respondents and helpful in coping for 77%. The frequency of spiritual practice was at least weekly for 32.8%.
The patients lost to follow-up were more likely to be male (81 patients vs. 63.6, p = 0.002), to have less education (12.6 ± 2.3 vs. 13.3 ± 2.24 years, p = 0.032), and to have been injured by an intentional mechanism (20.7 vs. 8%, p = 0.006). No other studied variable differentiated those lost to follow-up from those who completed the 12-month survey.
The SF36 demonstrated a progressive return toward baseline on all subscales from 6 to 12 months after injury (Fig. 2). The factors that remained the most impaired and showed the least improvement between 6 and 12 months were role-physical and physical function, both measures of physical recovery. This was particularly true concerning those with orthopedic injuries. Patients with extremity fractures were more impaired in physical function, role-physical, and bodily pain at both 6 and 12 months than those with nonorthopedic injuries (all with p < 0.001, Fig. 4). Full recovery was not in evidence in any domain of the SF36 for any subgroup by the 12-month follow-up, and, in addition, SIP work score did not recover to baseline (Fig. 5).
Twelve months after injury, 64% of the patients had returned to work and 22.9% were on workers’ compensation or disability relief. Financial difficulty was reported by 47%, and 30.3% acknowledged a decrease in their level of income. One year after injury, 31.6% of the patients were involved in injury-related litigation, 79% as plaintiffs and 21% as defendants. The majority of the cases were civil, although 21% were criminal proceedings. Among our patients, 8.5% of those involved in litigation were defendants in criminal cases.
Factors associated with outcome SIP work score after controlling for ISS are listed in Table 4. Because the various scales are different regarding the significance of a high value, the direction of association with good function at work is also listed.
Increased drug use after injury was described by 47.1% of the patients. This increase was attributable to alcohol only in 33%, illicit drugs (not including analgesics or alcohol) in 27.7%, and multiple substances in 17.7%. Use of analgesic pharmaceuticals in excess of the prescribed amount or duration was reported by 20.2%. Although the patients abusing analgesics reported more pain and lower mental health and physical function scores at 12 months, they did not have higher ISS, hospital length of stay, or AIS in any region, including orthopedic. They did, however, have higher blood alcohol levels at admission (124.2 ± 30.9 vs. 45.3 ± 12.2, p = 0.037) and more frequent illicit drug use before injury (37.7 vs. 16.9%, p = 0.024).
The only findings regarding spiritual and religious practices were that more patients felt that these practices were important for coping with stress 1 year after injury (spirituality, 35–44.5%; religion, 38.5–46.5%), and that the frequency of spiritual practice was associated with good mental health at 12 months (p = 0.005).
Follow-up mental health was associated with each dependent outcome in regression. First, baseline functional status and mental health, ISS, and outcome SF36 physical function were controlled by regression techniques. Then, 12-month mental health was evaluated in each regression model. The regression analyses are shown for SF36 general health outcome (Table 5), SIP work score (Table 6), and overall satisfaction with recovery (Table 7). Given the controls described, mental health was found to be a significant and independent factor in all three outcomes. The regression models identified about 40% of the variance, or statistical explanation, for each outcome. Mental health, as measured by the SF36 1 year after injury, was found to be associated with outcome SF36 general health score (ΔR2 = 0.085, p < 0.001), and satisfaction with recovery (p = 0.005). Outcome mental health, as measured by the BSI depression scale, was inversely related to the SIP work score at 12 months (ΔR2 = 0.107, p = 0.007).
To evaluate the independent components of the 12-month SF36 mental health score, a regression model (Table 8) was developed that explained 61.6% of the variance (adjusted R2 = 0.616). This methodology statistically takes into account the correlation between the various baseline and outcome mental health measures and thereby provides an evaluation of the independent contribution of each to the 12-month SF36 mental health score. Outcome SF36 mental health was related to baseline SF36 mental health score (ΔR2 = 0.221, p = 0.003), 12-month Mississippi PTSD score (ΔR2 = 0.252, p = 0.016), the 12-month BSI depression score (ΔR2 = 0.116, p = 0.002), increased use of alcohol and other drugs at 12 months (ΔR2 = 0.028, p = 0.005), and the 12-month SF36 bodily pain score (ΔR2 = 0.015, p = 0.039). At the 12-month follow-up, diagnostic level symptoms of PTSD were present in 38% of the patients and depression in 42% (Fig. 3). This incidence was reduced from the levels noted at 6 months (depression, 40%; PTSD, 41.3%) and was still elevated relative to baseline measured (depression, 18.6%).
To expand on traditional surgical endpoints of morbidity, mortality, physical disability, and simple return to work, we selected outcomes related to general wellness, function at work, and overall satisfaction with recovery. We chose these outcomes because they have meaning for the patient and our community as well as trauma surgeons. Each of our selected measures was based on patient self-report and consequently represents outcome status from the patient’s perspective. We have previously shown that return to work 11 and general health 18 in the early postinjury period are associated with outcome mental health. This work demonstrates both the pervasiveness of the effects of mental distress and their duration.
This study is the extension of questions raised by two seemingly independent sets of observations we have made while seeing patients in the trauma clinic weeks to months after their injury. First, it became apparent that many of the complaints we faced were not physical in nature, yet were extremely common and disturbing to the patients. Many complaints fell into the broad category of socioeconomic distress related to insurance, financial, legal, and work-related issues. The second category of complaint seemed to be emotional in nature. The patients frequently described problems with chronic pain, depression, sleep disturbance, deterioration in relationships, substance abuse, and depression. There also seemed to be a recurrent theme involving constellation of anxiety-provoking thoughts related to the injury event itself. Because these problems seemed to defy objective evaluation and there were no obvious surgical treatments or even reasonable referrals to make, both the patients and physicians were left feeling vaguely dissatisfied with the completeness of convalescent care. Consequently, it became apparent that the trauma surgeon’s estimation of successful outcomes did not match the patient’s expected and necessary functional goals during the posthospital recovery phase.
To address this concern, we began spending more time asking the patients what was bothering them and started to focus more on what we could not fix than what we could. From these discussions, which evolved into exploratory focus groups, we developed a taxonomy of outcome after trauma that was more general in nature. We designed a study to evaluate trauma outcome in relation to mental, physical, spiritual, economic, and social factors. Although our pilot study revealed a number of logistic and administrative difficulties with this type of work, it also illustrated a clear relationship between psychosocial and functional outcomes. 11 We undertook this study to expand on that work in scope, scale, and duration of follow-up.
Trauma care is expensive. But the cost of injury to our society characterized by delay or incomplete return to function is dramatically more expensive 19 and difficult to measure. There can be no savings to society if the injured individual is not returned to productivity.
The factors identified as important for trauma patient return to productivity include level of education, occupational status, the presence of insurance and compensation, the absence of litigation, chronic pain, and the presence of orthopedic injuries. 2–4,20–25 After controlling for injury severity, we found that baseline level of function was as important for work status as were nonphysical outcomes. Patients with higher levels of education and better baseline general health had better 12-month SIP work scores. Those with orthopedic injury, longer hospital stays, and socioeconomic issues at 12 months had relatively poor work status after injury. Financial difficulty, compensation, and litigation were all negatively associated with work status, as were pain, compromised mental health, and overall satisfaction. These findings are consistent with and add to the previous work done in this area, and by controlling for ISS before evaluating each factor, we have added a measure of validity to these conclusions.
Psychological distress after trauma has always been recognized, but its significance has been less certain. During this century, the phenomenon known as shell shock evolved into combat fatigue, which ultimately became labeled posttraumatic stress disorder. The work of trauma outcomes investigators in public health and surgery has evolved in parallel with that of psychologists and psychiatrists, but with a different focus. We have tried to bridge that gap by placing psychosocial morbidities into the context of broader functional outcomes.
Antecedent work by MacKenzie et al., 3,22 Morris et al., 2 Jurkovich et al., 6 and others 4,7,8,26 has demonstrated that psychosocial distress may complicate return to function after injury. We built on that foundation by more specifically evaluating the nature of these psychosocial morbidities and by carefully controlling for the potentially confounding effects of preinjury status, injury severity, and physical outcome. We believe it is essential to control for baseline status, injury severity, and physical recovery before confidently stating that mental health issues have an independent effect on outcome. Our goal, by applying similar regression models to each outcome, was to demonstrate that certain factors are consistently important, and that mental health outcome in particular has an impact on a variety of outcomes.
We have identified 60% of the variance, or statistical explanation, for the SF36 mental health score 12 months after injury. It is not surprising that baseline mental health status is related to outcome mental health, but after controlling for this relationship, PTSD, depression, and increased abuse of alcohol and other drugs were prevalent and compromising. PTSD and depression have been prospectively evaluated in injured patients 27 and found to interact to increase both distress and dysfunction after trauma. Initial concerns with the high degree of comorbidity found in these patients have given way to the realization that PTSD and major depression are independent but reinforcing psychological responses to injury. 28,29 Holbrook et al., in the Trauma Recovery Project, 30 has shown that quality of well being is a general health outcome that is affected independently by depression, PTSD, intensive care unit length of stay, and orthopedic injury. These results are consistent with and reinforce our conclusions regarding general health, work status, and patient satisfaction.
Increased use of alcohol and drugs is the third component of psychological distress present in our cohort 12 months after injury. Intoxication is a major factor in the epidemiology of trauma, but to observe the exacerbation of this pathology among individuals under the care of the trauma system is disturbing. PTSD, depression, and the abuse of alcohol and other drugs are prevalent, interrelated, and important factors that impede recovery from trauma. Clearly, further work could be done to provide treatment protocols for these psychological morbidities as an integrated component of our trauma system.
This study has several limitations and specific considerations. First, the patients lost to follow-up constitute 50% of the initial cohort and were significantly different from the reported population in several ways. Because they did complete the initial assessment however, we are able to state with confidence that although they were younger, more likely to be male, and injured by violence more frequently, they were not different with regard to any other reported measures of social, financial, physical, psychological, or functional status. Second, another limitation is the method we used to assess baseline status. During the initial evaluations, patients described their preinjury levels of function, although these interviews took place shortly after their trauma admission. This situation raises the possibility of both recall bias and situational bias. In fact, it is evident statistically (and from Fig. 1) that the baseline responses to the SF36 were no different to national norms of uninjured patients. The ability of the patients to provide essentially normal responses to a variety of survey items despite their acute injury adds some validity to this methodology. Third, the patients had a fairly homogeneous moderate injury severity and were treated at a single trauma center. Logistic limitations existed because some patients were minimally injured and discharged quickly, and the most severely injured were not available for interview. Also, the demographics of this cohort, in particular regarding financial and educational status, may differ from other trauma populations. To increase the generalizability of our findings, similar work could be replicated in a multi-institutional protocol and include evaluation of patients with less severe injury. Lastly, all of the follow-up measures were self-reported by the patients. This was designed to evaluate outcome from the patient’s perspective, but raises the possibility of systematic underreporting of socially undesirable factors such as defendant status in litigation and substance abuse. For this reason we evaluated only an increase in substance abuse compared with the level of use reported by the patients during their initial assessment. By doing this, the patients served as their own controls.
This study demonstrates that outcome can be assessed from the patients’ perspective, and that in their eyes, mental health is an essential element of satisfaction, work function, and general health status after trauma. This association persists after controlling for measured baseline status, injury severity, and physical recovery. The mental distress after trauma is related to a lower level of baseline mental health, the development of symptoms of PTSD and depression, an increase in substance abuse, and pain. These symptoms persist and continue to compromise the patients for at least a year after injury.
Trauma surgeons have witnessed great strides in patient care delivery, prehospital care, resuscitative and diagnostic methods, operative techniques, and critical care. Because of many socioeconomic factors, trauma patients discharged from hospitals are frequently “lost to follow-up” and many are functionally lost to society. We, on the basis of these data, suggest that trauma centers and trauma systems look beyond the acute hospital phase of trauma care and make greater political, financial, contractual, and academic efforts to provide care and support to our patients until optimal return to function is achieved.
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Dr. C. James Carrico (Dallas, Texas): I would like to thank Dr. Michaels for delving into the difficult areas of the soft sciences of human behavior and outcome. I would also like to thank him for sending me the manuscript well in advance and for his careful preparation of that excellent manuscript.
The study was designed to determine the impact of injury on general health, work status, and patient satisfaction. It has a number of strengths. The most outstanding of these are: (1) evaluating outcome from the patient’s perspective as opposed to our perspective; and (2) using quantifiable measurements that have been tested and validated in a variety of conditions or situations.
There are some weaknesses. There are a relatively small number of patients. Particularly after the 50% attrition during follow-up, we are down to about 120 patients. The small number is compounded by the wide variety of injury mechanisms and environments: burns; intentional violence; unintentional injury; some patients impaired; some patients not impaired; some injured at work; some injured not at work. Intuitively, those conditions and environments must have varying impacts on some of the outcomes being evaluated. Furthermore, because of the small numbers, these patients are not stratified, so that we are dealing with a broad look rather than at specifics.
I would like to ask Dr. Michaels a couple of questions about the measurements used. In using the in-hospital SF36 and other interviews, the patients were asked to retrospectively evaluate their health status. We saw that that meets the national norm, but the question is, was there some overestimation in the patient’s mind of their preexisting health status? Was the SF-36, in fact, lower than the national norm, but elevated by the patient’s perception? The other is the validity of the mailed SF36. Was the response pattern impacted by the fact that the people who chose to respond might be very different from those who did not.
I would like you to comment on the exclusions. You excluded people with amputations and severe nervous system injury. You also excluded patients who were transferred in more than 12 hours after their injury and who had previous operations. I would like you to comment on why you did that and what difference that might have made.
Despite some of these questions, the study shows that work status and satisfaction 12 months after injury is not as good as it was before the injury, at least in the patient’s perception.
There are major associations with a number of factors, and Dr. Michaels emphasized the patient’s postoperative mental health. I would simply point out that there was also a correlation with the preoperative mental health. The question is, which is the chicken or the egg? Are these patients not as functional because of their reaction to their injury or because of their preinjury status?
Despite those reservations, this is an excellent study. We clearly have a responsibility (and a goal) to help our patients return to society and to decrease risk-taking behavior. So, I guess my last question to Dr. Michaels is: since we have identified the patients who have preexisting problems of mental health, drug and ethanol dependency, and social integration, what should we be doing—what should we change—to more effectively impact on the outcome of these patients?
Dr. C. William Schwab (Philadelphia, Pennsylvania): I would like to commend the authors and the Association for the placement of this paper on the program.
Therese Richmond, PhD, RN, a functional outcome researcher in the School of Nursing at the University of Pennsylvania, reported in The Journal of Trauma (1998;44(4):635–642) a similar study and found very similar findings. What was interesting is that she had better compliance with follow-up, and I think that is an important thing to address here.
In those people that are questionnaire-ologists, there is a certain science of how one administers the questionnaire and the steps you take to get maximum compliance. Did you inform the patient or the family that you would be doing this study during the acute phase of care so as to mentally alert them, that this follow-up would occur at a future date?
Explain to us why you did mailing with incentives, another mailing, and then phone follow-up, as opposed to earlier phone follow-ups to perhaps recruit more people and recruit them for the long term.
When I initially read this abstract, I was hoping that what you were going to do is to show us how to identify a patient at risk for prolonged mental or physical disability. Perhaps what you could do in closing is give us what you think is a profile of that “patient at risk” to better help us mobilize forces to take better long-term care of these patients.
Dr. Robert Fulton (Louisville, Kentucky): Several years ago, we tried to do a similar study. Our premise was twofold. Patients who got in car accidents were frequently not only immediately drunk, but were in fact alcoholic. I believe some 43% of the patients in car accidents who were intoxicated were in fact alcoholic.
Second, our other premise was that if we could perhaps intervene in the alcoholism, we could prevent trauma. We have not done that.
I think this is a very important study, and I would like to ask the authors, did you correct for alcoholism? Because I don’t think you did. First off, depression is a very easy illness to confuse with alcoholism, and I suspect the same thing is true of posttraumatic stress disorder.
Dr. Ronald I. Gross (Bridgeport, Connecticut): I thought the paper was excellent, and the concept was excellent as well.
I would like to agree with Dr. Fulton, and I think that we need to pay attention to two things. First, regarding the preinjury psychological status, I do not think that there is a psychiatrist or psychologist in the world that would state to us that if we have the means and we live in the nice neighborhoods, that we can certainly compensate, if not cope, for our underlying mental disease. That is the kind of stuff that we need to unmask, because it becomes unmasked in the posttraumatic setting.
The other question I have for the authors is are they now going to take this concept and examine the more violently injured patients and see how their preoperative mental status is affected by their postoutcome stress disorders?
Dr. Janice A. Mendelson (San Antonio, Texas): The outcome from injury is influenced by the type of injury, the patient’s occupation and motivation, and whether physical and rehabilitation therapy is started early.
It is important to differentiate between those who may benefit financially from compensation or disability payments and those who are financially required to return to work promptly. It is also important to know whether the patient’s work requires strong physical ability or is mostly sedentary.
Early physical and rehabilitation therapy procedures help to develop optimism and progress for further recovery.
Have these factors been included in your study?
Dr. Andrew J. Michaels (closing): I would like to thank Dr. Carrico and the others for their kind comments and important questions.
Dr. Carrico, you are right. This was a small study, and not well-funded. It was funded internally and was administered with a lot of volunteer help. It was a labor of love from a number of people I did not have the opportunity to thank. To do this properly, as many of you know, including Dr. Schwab, with your work with Dr. Richmond, and Dr. Holbrook, who has done a tremendous job with Dr. Hoyt in San Diego, this is a very expensive type of research, and the issue really is in terms of follow-up.
A number of questions are related to that, and I think I will address them first. Dr. Schwab, you asked about compliance. Yes, we did go speak with the patients. We also spoke with their families. We explained to them that it was going to be difficult for them, that we were going to be talking to them again and again over the course of the next year.
We also did do a shorter-term follow-up at 1 month with some other instruments that are not reported in this study. You can just see a linear decline in compliance. When we spoke on the phone to those who had failed to respond to the mailings, not one of them said, “Well, I will send back the $10.” I think that we must expect that from some people, and although I feel very badly about it, I do not think that offering more money would have helped.
But when you talk to Dr. Holbrook, who really did do a great job of follow-up, they had a whole staff and they would focus specifically on each patient. They would go to their homes, sit outside their cars, do whatever was needed. I think that approach is going to be necessary.
Dr. Carrico, you asked about the exclusions. Basically, this was designed to be an outcome study, so we excluded people a priori who I did not think would have the opportunity for an optimal outcome. Bad brain injuries, spinal cord injuries, and amputations fell into that group.
We also did some other work with this population in terms of their immediate perceptions to the injury event itself. First, we wanted to get at them while those perceptions were still fresh. Second, we wanted to have a kind of injury-transport-hospital sequence of events to look at, so prehospital transfers and treatment at another facility were going to complicate that tremendously.
Regarding the broad spectrum of the patients, a number of people asked about that. It is true that it does make things a little bit more heterogeneous. We have a real power issue here, but when we do put patients into subgroups, we find that assault patients are very different than unintentional injury patients. They are very different in terms of their psychological outcomes as well as their baseline status.
We recently presented a path analysis for PTSD at the Western Trauma Association annual meeting. The analysis showed that one of the strongest risk factors was to get injured by an intentional mechanism. In fact, it is almost universal. So I think that that is very important to know.
Interestingly, a finding that we have not presented yet, and which I am going to communicate to the American Burn Association, is the observation that burn patients do not seem to get PTSD nearly as much. Although this has been observed before, I would like to investigate this with a much bigger population and really pay attention to the subgrouping.
Who is at risk, Dr. Schwab? I think I answered that a little bit in terms of talking about the injury violence, and I would add that the other risk factors are poor baseline mental health, peritraumatic dissociation, youth, and female gender.
Alcohol is a big problem. Premorbid psychological pathology is a big problem. We all know that these really are not normal people that are filling our trauma centers. I agree that alcohol and depression look a lot alike in terms of psychological assessment if you are not very careful, but it is really quite different from PTSD. We did try and control and correct for alcoholism, and that is why we used their self-reported level of usage as the control.
We also did CAGE studies and found that we had tremendous rates of impairment, which is not surprising.
What do we do for these patients downstream? A couple of years ago at the EAST meeting, we presented a paper that showed a big regression when we looked at recidivism. We only found two factors that were related, and one of them was alcohol at the time of admission.
The second factor, interestingly, was whether the patients had friends who were injured patients as well, not in the same event, but within the previous 5 years, implying that there is a kind of social cohort in which there is a norm of bad decision-making combined with substance abuse. From an injury prevention perspective, these subtle personal and social judgment and behavior issues seem to be important.
To answer the thousand-dollar question from Dr. Mendelson “What can we do about all of this, and how can we go about addressing it?” Well, I think first we need to do a better job of treating their pain. Second, we clearly need to address their alcohol and other drug issues. Third, we need to really get serious about this mental health problem.
I don’t know the right answer. I don’t know that anybody knows the right answer of how we treat acute and posttraumatic stress disorder. So the first thing we need to do is a randomized control trial of treatments, which would be easy to get through the IRB because the current standard of care is no treatment. There are many treatment options but no large, well funded, early intervention trial.
Finally, regarding early rehabilitation, actually we do very early rehabilitation at our center. The issue is not if we do the rehabilitation, but what is the appropriate scope of that rehabilitation. That is really the issue that I am trying to address with this whole area of investigation. Again, I would like to thank you all very much.