Psychiatric comorbidities in adult survivors of major trauma: Findings from the Midland Trauma Registry Network Spijker E, Jones K, Duijff JW, Smith A, & Christey GR.

The Problem: Psycho-social needs of adult trauma survivors are poorly understood 10-39% of trauma survivors experience PSTD Those affected face 2-6-fold risks for developing psychiatric comorbidities Common reports of diminished functioning, poor quality of life, hospitalisation, use of medical care, unemployment, and poverty No national guidelines for psychiatric treatment of trauma survivors

Aim: What is the scope of the problem in NZ? Enhance understanding of the nature of psychiatric comorbidities in the first year of recovery Identify factors associated with poor outcomes Survey of a retrospective, regional cohort of 65 adult (>15 yrs) major trauma survivors in the Waikato district (MTRS data) 01 June 2010 to 01 July 2011

Sample Mean age at injury 46.3 years (21.2) Male 42 (64.6%) Ethnicity Maori 10 (15.4%) Non-Maori 54 (83.0) Marital status Married 37 (56.9%) Single/widow/divorced 27 (41.6%) Higher education 9 (13.8) Injury mechanism Motor vehicle 23 (35.3%) Fall 16 (24.6%) Motorbike 8 (12.3%) Psychiatric history 10 (15.0%)

Measures EuroQol (EQ-5D-3L) assesses health-related QOL in five domains affected by injury (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) Posttraumatic Stress Disorder Checklist (PTSD checklist) – specifically aligns with DSM-IV criteria for PTSD, assessing three main syndromes: re-experiencing, avoidance, and hyperarousal. The 21-item Beck Depression Inventory (BDI) screens for depression symptoms in the past two weeks (i.e. sense of failure, pessimism, guilt). The Visual Analogue Scale for Pain is a single-item scale using a 10-cm vertical line. Ranging from 0 = ‘no pain’ and 10 = ‘worst possible pain’, participants indicate their pain level during the last 3-months. The 10-item Alcohol Use Disorders Identification Test screens for harmful alcohol use.

Potential person and injury factors associated with outcomes Education Age Gender Ethnicity Marital status Psychiatric history TBI ICU Days in hospital Injury mechanism ICD-10 codes Injury Severity Score (ISS)

Proportion of adults meeting criteria Results Research Themes Proportion of adults meeting criteria

Proportion of adults meeting criteria Results Research Themes Proportion of adults meeting criteria

Total number (%) of criteria met Results Research Themes Patterns of comorbidity Total number (%) of criteria met N = 65 9 (13.8) 1 19 (29.2) 2 20 (30.8) 3 4 6 (9.2) 5 2 (3.1)

Factors associated with meeting criteria Results Research Themes Factors associated with meeting criteria ICU admission** >10 days hospitalisation* ICU admission* Younger age (16-50 yrs)** Depression Harmful alcohol use Psychiatric history** Younger age (16-50 yrs)** Substance use* Younger age (16-50 yrs)* P<.01**, p<.05*

Impaired QoL associated with… Results Research Themes Impaired QoL associated with… Time since trauma ≤ 6-months* >10-days hospitalisation** No associations between any outcomes and gender, ethnicity, marital status, education, injury mechanism, ISS score.

Discussion Nearly half of adult survivors of major trauma experienced PTSD symptoms in first year after injury (similar to previous overseas reports) Around one quarter reported harmful alcohol use and/or moderate- severe pain 1 in 5 adults reported 2 or more psychiatric comorbidities Important for primary care and community health workers to be aware of increased risks and to consider ways to identify those at risk

Where to now? A key challenge in hospitals is distinguishing between transient distress and risk for subsequent psychiatric disorder One option – standardised review of patient records for known risk factors prior to discharge (i.e. Injured Trauma Survivor Screen, Post-traumatic Adjustment Scales) Status indicated in discharge summaries to flag follow-up in primary care and prompt systematic provision of trauma patient- specific information at discharge Primary care could use of predictive screeners (i.e. My Mood Monitor Checklist) and a trauma survivor template in electronic patient management systems Those who screen positive can be engaged in further discussion and potential follow-up (i.e. psychological assessment) Significant improvements in well-being and careful allocation of costly and limited mental health resources