Shelley A. Wiechman

Rates, trends, and severity of depression after burn injuries

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

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.

Post-traumatic stress symptoms and distress 1 year after burn injury.

The occurrence and predictors of post-traumatic stress symptoms 1 year after a burn injury were assessed in a large prospective sample (N = 172). Participants completed a self-report post-traumatic stress symptom checklist at 3 time points: within 24 hours of admission to a burn center, 1 month after the injury, and 1 year after the injury. A notable number of participants had a range of post-traumatic stress symptoms both at 1 month and at 1 year after the burn injury. More than half of the sample reported recurrent intrusive recollections of the burn injury at 1 month and at 1 year. Other commonly endorsed symptoms were sleep disturbance, avoidance of thoughts or feelings associated with the burn, and distress at reminders of the burn. The number of post-traumatic stress symptoms endorsed at 1 month was the only significant predictor of post-traumatic stress symptoms at 1 year. These results suggest that it is common for patients to have some post-traumatic symptoms 1 year after a burn injury and that early experiences of post-traumatic stress symptoms may be associated with the development or maintenance of post-traumatic stress disorder. We recommend that burn care professionals identify and intervene with patients who have clinically significant distress as a result of their burn injuries.

Psychological distress after major burn injury

Objective: To track the prevalence and stability of clinically significant psychological distress and to identify potentially modifiable inhospital symptoms predictive of long-term distress (physical, psychological, and social impairment). Method: We obtained data from the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The Brief Symptom Inventory (BSI) was used to assess symptoms in-hospital (n = 1232) and at 6 (n = 790), 12 (n = 645), and 24 (n = 433) months post burn. Distress was examined dimensionally (BSI’s Global Severity Index (GSI)) and categorically (groups formed by dichotomizing GSI: T score ≥63). Attrition was unrelated to in-hospital GSI score. Results: Significant in-hospital psychological distress occurred in 34% of the patients, and clinically significant and reliable change in symptom severity by follow-up visits occurred infrequently. Principal components analysis of in-hospital distress symptoms demonstrated “alienation” and “anxiety” factors that robustly predicted distress at 6, 12, and 24 months, controlling for correlates of baseline distress. Conclusions: This is the largest prospective, multisite, cohort study of patients with major burn injury. We found that clinically significant in-hospital psychological distress was common and tends to persist. Two structural components of in-hospital distress seemed particularly predictive of long-term distress. Research is needed to determine if early recognition and treatment of patients with in-hospital psychological distress can improve long-term outcomes. TBSA = total body surface area; BMS = burn model systems; PTSD = posttraumatic stress disorder; ASD = acute stress disorder; BSI = Brief Symptom Inventory; ROM = range of motion; GSI = Global Severity Index (of the BSI); OR = odds ratio; RCI = Reliable Change Index; SD = standard deviation; CI = confidence interval.

Sleep onset insomnia symptoms during hospitalization for major burn injury predict chronic pain.

&NA; Both cross‐sectional studies of chronic pain and sleep deprivation experiments suggest a bi‐directional relationship between sleep and pain. Few longitudinal studies, however, have assessed whether acute insomnia following traumatic injury predicts the development of persistent pain. We sought to evaluate (1) whether in‐hospital insomnia independently predicts long‐term pain after burn injury and (2) whether in‐hospital pain predicts future insomnia symptoms. We analyzed data on 333 subjects hospitalized for major burn injury (72.7% male; mean age = 41.1 ± 14.5 years) who were participating in the multi‐site, Burn Model System project. Subjects completed measures of health, function (SF‐36), and psychological distress (Brief Symptom Inventory) while in hospital, at 6, 12, and 24 months after discharge. Participants were categorized as either having or not having sleep onset insomnia at discharge. Linear mixed effects analyses revealed that persons reporting insomnia at discharge (40.5%) had significantly decreased improvement in pain and increased pain severity during long‐term follow‐up (p < 0.001). More severe pain during the week preceding hospital discharge, time from injury, lack of college education and older age also contributed independent effects on chronic pain (p < 0.05). In a reciprocal model (N = 299), more severe pain during the week preceding discharge predicted increased rates of long‐term sleep onset insomnia. In‐hospital insomnia and pre‐burn mental health symptoms were also highly significant predictors of insomnia. This study provides support for a long‐term, prospective and reciprocal interaction between insomnia and pain. Future work should ascertain whether treatment of insomnia and pain during acute injury can prevent or minimize chronic pain.

Hypnosis Delivered Through Immersive Virtual Reality for Burn Pain: A Clinical Case Series

Abstract This study is the first to use virtual-reality technology on a series of clinical patients to make hypnotic analgesia less effortful for patients and to increase the efficiency of hypnosis by eliminating the need for the presence of a trained clinician. This technologically based hypnotic induction was used to deliver hypnotic analgesia to burn-injury patients undergoing painful wound-care procedures. Pre- and postprocedure measures were collected on 13 patients with burn injuries across 3 days. In an uncontrolled series of cases, there was a decrease in reported pain and anxiety, and the need for opioid medication was cut in half. The results support additional research on the utility and efficacy of hypnotic analgesia provided by virtual reality hypnosis. The technology involved in virtual reality hypnosis was primarily developed through Hunter Hoffman, Ph.D. This project was supported by funding from NIH grants R01 GM42725-09A1 and 1 R21 HD40954-01 as well as the Paul Allen and Scandinavian Design Foundations.

Pruritus in adult burn survivors: Postburn prevalence and risk factors associated with increased intensity

Pruritus (itching) is a common and distressing complaint after injury. The purpose of this study was to investigate self-reported postburn pruritus in a large, multisite cohort study of adult burn survivors. Descriptive statistics, general linear regression, and mixed model repeated measures analyses were employed to test statistical significance. Two cohorts of adult burn survivors were studied. Group 1 participants (n = 637) were injured from 2006 to 2010 and were followed up prospectively for 2 years from the time of injury. Prevalence and severity of pruritus were compared across multiple subgroups. Prevalence of pruritus at discharge, 6, 12, and 24 months following injury were 93, 86, 83, and 73%, respectively. Regression results established that %TBSA-burn and %TBSA-grafted were correlated to itch intensity values. Group 2 participants (n = 336) were injured 4 to 10 years before an assessment using the validated 5-D Itch Scale. Many patients (44.4%) reported itching in the area of the burn, graft, or donor site. Within this group, 76% reported itching for <6 hours/day, and 52 and 29% considered itch intensity to be mild or moderate, respectively. This study confirms that the prevalence of burn pruritus is high, initially affecting >90% and persisting for >40% of long-term burn survivors. New predictors for postburn itch were identified to include younger age, dry skin, and raised/thick scars. Characterization of the impact of postburn pruritus on leisure, vocation, and sleep are quantified for those long-term survivors suffering from postburn pruritus.

Post-traumatic stress symptoms and distress following acute burn injury

The occurrence and predictors of acute post-traumatic stress symptoms were assessed in a large, prospective sample of persons with new burn injuries (N = 172). Participants completed a self-report post-traumatic stress symptom checklist, pain ratings, and a premorbid mental health inventory within 24 h of admission to a burn center (Day 1). Over half of the sample reported sleep disturbance and recurrent, intrusive recollections of the burn injury on Day 1. Other commonly endorsed symptoms were difficulties concentrating, avoidance of thoughts/feelings associated with the burn, flashbacks, and exaggerated startle response. Persons with less favorable premorbid mental health and larger burns reported a greater number of stress symptoms on Day 1. These results suggest that experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal. It is recommended that burn care professionals identify and intervene with patients who are suffering clinically significant distress early in the hospitalization.

VIRTUAL REALITY HYPNOSIS FOR PAIN ASSOCIATED WITH RECOVERY FROM PHYSICAL TRAUMA

Abstract Pain following traumatic injuries is common, can impair injury recovery and is often inadequately treated. In particular, the role of adjunctive nonpharmacologic analgesic techniques is unclear. The authors report a randomized, controlled study of 21 hospitalized trauma patients to assess the analgesic efficacy of virtual reality hypnosis (VRH)—hypnotic induction and analgesic suggestion delivered by customized virtual reality (VR) hardware/software. Subjective pain ratings were obtained immediately and 8 hours after VRH (used as an adjunct to standard analgesic care) and compared to both adjunctive VR without hypnosis and standard care alone. VRH patients reported less pain intensity and less pain unpleasantness compared to control groups. These preliminary findings suggest that VRH analgesia is a novel technology worthy of further study, both to improve pain management and to increase availability of hypnotic analgesia to populations without access to therapist-provided hypnosis and suggestion.

Premorbid mental health status of adult burn patients: comparison with a normative sample.

The presence of psychiatric problems in burn patients has been found to have an impact on their burn care and long-term adjustment. This study investigated rates of previous mental health symptoms in a sample of 199 hospitalized burn patients screened for previous psychiatric diagnoses. Patients were instructed to fill out a questionnaire about their mental health functioning on the Rand Inventory for the month preceding their burn injury. Scores compared with a national normative sample on the Rand Mental Health Inventory revealed that burn patients scored higher on psychological distress, anxiety, depression, and loss of behavioral and emotional control. These results reflect other studies in the literature, indicating that burn patients are premorbidly more psychologically vulnerable than the general population, a factor that likely contributes to many of them sustaining their injuries.