James A. Fauerbach

Even minimal symptoms of Depression increase mortality risk after acute myocardial infarction

Mild to moderate levels of depressive symptoms as characterized by Beck Depression Inventory (BDI) scores of > or =10 are associated with decreased survival after acute myocardial infarction (AMI). We investigated whether lower levels of depressive symptoms are also associated with increased mortality risk after AMI. We prospectively studied 285 patients with AMI who survived to discharge for evidence, at the time of hospitalization, of a DSM-IIIR mood disorder (using a structured clinical interview) and for symptoms of depression (using the BDI). The overall mortality rate at 4 months was 6.7%. Multiple logistic regression (chi-square 35.79, p < or =0.001) revealed that the independent predictors of mortality were: age > or =65 years, left ventricular ejection fraction <35%, diabetes mellitus, and any depression (DSM-IIIR mood disorder or BDI > or =10) present at the time of AMI. Among patients > or =65 years old with left ventricular ejection fraction <35%, the 4-month mortality was 12%. However, in this same group, those with any depression at the time of AMI had a 4-month mortality of 50% (relative risk 4.1, p = 0.01). Among patients aged > or =65 years, the mortality according to BDI scale grouping 0 to 3, 4 to 9, and 10+ was 2.6%, 17.1%, and 23.3%, respectively (p <0.002). Highest mortality rates were observed in patients with most severe depressive symptoms. However, compared with those without depression, higher mortality was also observed at very low levels of depressive symptoms (BDI 4 to 9) not generally considered clinically significant and below the level usually considered predictive of increased post-AMI mortality.

Prevalence of depression in survivors of acute myocardial infarction.

OBJECTIVES: To assess the prevalence and persistence of depression in patients with acute myocardial infarction (AMI) and the relationship between assessment modality and prevalence.DATA SOURCES: MEDLINE®, Cochrane, CINAHL®, PsycINFO®, and EMBASE®.REVIEW METHODS: A comprehensive search was conducted in March 2004 to identify original research studies published since 1980 that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals from October 2003 through April 2004 and references of identified articles and reviews. Studies were excluded if only an abstract was provided, if not in English, or if depression was not measured by a validated method.RESULTS: Major depression was identified in 19.8% (95% confidence interval [CI] 19.1% to 20.6%) of patients using structured interviews (N=10,785, 8 studies). The prevalence of significant depressive symptoms based on a Beck Depression Inventory score ≥10 was 31.1% (CI 29.2% to 33.0%; N=2,273, 6 studies), using a Hospital Anxiety and Depression Scale (HADS) score ≥8%, 15.5% (CI 13.2% to 18.0%; N=863, 4 studies), and with a HADS score ≥11%, 7.3% (CI 5.5% to 9.3%; N=830, 4 studies). Although a significant proportion of patients continued to be depressed in the year after discharge, the limited number of studies and variable follow-up times precluded specification of prevalence rates at given time points.CONCLUSIONS: Depression is common and persistent in AMI survivors. Prevalence varies depending on assessment method, likely reflecting treatment of somatic symptoms.

Personality predictors of injury-related posttraumatic stress disorder

This longitudinal, cohort study examined the effect of personality traits on the emergence of posttraumatic stress disorder (PTSD) in a recently traumatized, civilian, mixed-gender sample with significant injuries. Burn survivors (N = 70) were administered the NEO-Personality Inventory (NEO-PI) and the Structured Clinical Interview for DSM III-R (SCID) at hospital discharge and readministered the SCID 4 and 12 months later. Overall, the sample of burn survivors scored significantly higher on neuroticism and extraversion and lower on openness, agreeableness, and conscientiousness relative to a normative national sample. Furthermore, multivariate analysis of variance revealed that PTSD symptom severity groups (i.e., single symptom, multiple symptoms, subthreshold PTSD, PTSD) were differentially related to neuroticism and extraversion. Planned comparisons indicated that neuroticism was higher and extraversion was lower in those who developed PTSD compared with those who did not develop PTSD.

Visible vs hidden scars and their relation to body esteem

This study examined the relationship among burn scarring, severity and visibility, and body esteem. Previous work addressing this question has relied on case studies and small samples. We mailed a survey to 2500 members of a national burn survivor support group. Survivors were asked to complete and

Effect of early body image dissatisfaction on subsequent psychological and physical adjustment after disfiguring injury.

Objective The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (ie, injury, distress, and preburn quality of life). Methods The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2–3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed. Results Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61;p < .01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78;p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment. Conclusions Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

The Significance of Depression in Older Patients After Myocardial Infarction

OBJECTIVES: Depression is common in patients recovering from a myocardial infarction (MI) and is an independent risk factor for early mortality. Although most patients with MI are aged 65 and older, there is little information about post‐MI depression in this age group. This study was performed to determine the significance of post‐MI depression in individuals aged 65 and older.

Preburn psychiatric history affects posttrauma morbidity.

A sample of inpatient, burn-injured adults (N = 95) were assessed upon discharge, and 4 and 12 months later with a structured interview and DSM-III-R criteria. The prevalence of disorder in this sample was contrasted with published data on a representative national community-dwelling comparison group in the National Comorbidity Study. The prevalence of lifetime affective, alcohol, and substance use disorders was significantly higher, and lifetime anxiety disorders significantly lower, in the burn-injured sample. The 12-month postburn prevalences of alcohol, and substance use disorders were significantly greater in the burn-injured sample. The risk of postburn disorder was significantly greater for the subjects who had a preburn history of affective, alcohol, or substance use disorder. The risk for developing posttraumatic stress disorder (PTSD) was elevated in the subjects with a preburn affective disorder but not preburn anxiety disorder. Finally, postburn PTSD was associated with a greater length of stay, and greater preburn comorbidity predicted preburn employment status and tended to lengthen hospitalization.

Personality, coping, chronic stress, social support and PTSD symptoms among adult burn survivors: a path analysis.

This paper presents a longitudinal study of the relationship between personality, coping, chronic stress, social support and posttraumatic stress disorder (PTSD). A hypothesized model of the relationship between the predictor variables and PTSD symptoms was proposed. Path analyses was completed to test the model. One hundred fifty-eight adult burn survivors completed questionnaires measuring each of the variables in the hospital. Of those 124 and 94 completed the PTSD measure at 1 month and 6 months postdischarge, respectively. The hypothesized model fit the data at each time point with slight variations. The model accounted for 46 and 29% of the variance of PTSD symptoms at hospitalization and 1 month. Neuroticism was the most important personality dimension in predicting PTSD. Avoidant Coping and Social Support mediated a high percentage of the relationship between Neuroticism and PTSD. The best predictor of PTSD symptoms at 1 and 6 months was PTSD symptoms at hospitalization.

Burden of burn: A norm-based inquiry into the influence of burn size and distress on recovery of physical and psychosocial function

This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.

Development and Validation of the Satisfaction with Appearance Scale: Assessing Body Image among Burn-Injured Patients.

The Satisfaction With Appearance Scale (SWAP) is a 14-item questionnaire, assessing both the subjective appraisal and social-behavioral components of body image among burn survivors. Burn survivors requiring hospitalization (n = 165) completed a packet of psychometric instruments, including the SWAP at 1-week postdischarge. The SWAP demonstrated a high level of intemal consistency (Cronbachs alpha, r a = .87; the mean interitem correlation, r ii = .32, the mean item-total correlation, r ii = .53). Eighty-four participants were retested approximately 2 months after the initial assessment to evaluate test-retest reliability (r ii , = .59). A principal-components analysis with a varimax rotation yielded 4 easily interpretable factors accounting for 66% of the total variance. The correlations of the SWAP total score with other selected psychometric measures provided evidence for both convergent and discriminant validity. This initial evaluation of the SWAP suggests that it is both a reliable and valid measure of body image for a burn-injured population.