Quality of life in Burn Injury Patients

Transcription

1 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012 Original Article Quality of life in Burn Injury Patients 1 Prerna Malik, 2 Rajinder Garg, 3 Kuldip C. Sharma, 4 Purushotam Jangid, 5 Anil Gulia 1,4,5 Department of Psychiatry, PGIMS, Rohtak, Haryana 2 Department of Psychiatry, Gian Sagar Medical College & Hospital, Banur. 3 Department of Psychiatry, Government Medical College, Patiala. Abstract Objectives: The study was planned to assess quality of life and factors affecting it in patients with burn injury. Methods: This is hospital based cross sectional study which involves 70 burn patients hospitalized to the department of surgery and plastic surgery of Rajindra Hospital, Government. Medical College, Patiala between May 07 and Aug 08. Details of burns were taken on semi-structured proforma. All patients underwent detailed psychiatric assessment using International Classification of Disease-10 (ICD-10) and divided into two groups. Group A contains burn patients with psychiatric morbidity and remaining burn patients without psychiatric morbidity were included in Group B. Further, both groups were subjected to Quality Of Life Scale (QOL) to assess quality of life. Results: Quality of life was poor in burn injured patients and was affected by severity of burn injury. Psychiatric morbidity was found to be significant factor affecting quality of life in burn injury patients. Conclusion: The quality of life following burns must be assessed at every stage of their treatment for better adjustment. Keywords: Quality of life, Burns, Psychiatric morbidity. Introduction Burn scars after dermal injury are cosmetically disfiguring and forced the scarred person to deal with an alteration in body image or appearance. Also the traumatic nature of the burn accident and the painful treatment induce psychopathological responses. Problems in mental area are more disabling than physical problems. Social problems include difficulties in sexual life and social interactions. Mediating variables such as low social support, avoiding coping styles and personality traits such as neuroticism and low extroversion negatively affect adjustment after burn injury. Quality of life is initially lower in burn patients compared to general population but it improves over a period of many years. 1 Long term squeals of burn injury indicated that many burn survivors achieve a quality of life that was satisfying to them. A retrospective study to determine the duration of disability in burn patients found that 79 % of the patients were able to return to work or school, 45 % required a change in work and 25 % were not able to continue with their peer group in school. The average time of disability was 6 months. 2 The previous literature shows that only 30 % of any given sample of adult burn survivors consistently demonstrate moderate to severe psychological and/or social difficulties. 3 Also in each sample, % of the subjects experience mild to moderate difficulties with adjustment. 4 A cr itical factor in the successful or unsuccessful life adjustment of the badly burned patient is his family s reaction to his chronic problem, their ability to support and help him to pursue the long course of treatment and also to help him to adjust in the social world. So, it is vital to deal effectively in the sustained manner to assess the type of emotional disturbances which exist in these families at very higher rate. 5 Another study shows that many burn victims are socioeconomically disadvantaged and have poor support systems, which further contribute to poor functional outcomes. 6 Other study assessed the emotional distress as 308 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society

2 OCTOBER 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 well as psychosocial resources in 55 patients with burn injury. They demonstrated the importance of routine screening of psychological symptoms as early identification of at risk patients, allow appropriate psychotherapeutic interventions and can thus help to improve the quality of life and general well being of burn patients on a long term basis. 7 The rationale behind the current study was to evaluate the quality of life that the patients with burns sustain as an after math of the psychological trauma they undergo following disfigurement and disability out of burns and the assessment of factors affecting quality of life in burn patients. The study was undertaken at a tertiary centre of northern India as there was paucity of literature on quality of life in burn patients. Material and Methods After obtaining due permission from departmental ethics committee of the Department of Psychiatry, 70 hospitalized consecutive and consenting patients with burn injury at the Department of surgery and plastic surgery of Rajindra Hospital, Govt. Medical College, Patiala between may 07 to Aug 08 were studied. 10 patients were excluded from the study either due to chronic medical illness, epilepsy, mental retardation or previous psychiatric disorder. 60 patients were found to fulfil the inclusion criterion of the study. Based on a detailed clinical interview, psychiatric diagnosis was established by using ICD -10 criteria. 30 patients found to have significant psychiatric morbidity were included in group A. The remaining patients who did not have any significant psychiatric morbidity were grouped in group B. Quality of life was further assessed in both groups by Quality Of Life Scale. Instruments 1. Semi structured Performa to record sociodemographic details of the patients, presenting complaints, history of illness, circumstances of burn injury, time since burn injury, local examination of burn injury and percentage of burn injury. 2. Clinical interview for diagnosis of psychiatric disorders made as per ICD-10 criteria Quality of Life Scale 9 (QOLS): The QOLS is a valid instrument for measuring quality of life across patient groups and cultures and is conceptually distinct from health status or other causal indicators of quality of life. Use in chronic illness populations, including a small group of cancer patients with ostomies has been validated. The QOLS measures domains that diverse patient groups with chronic illness define as quality of life and has low to moderate correlations with physical health status and disease measures. It measures 3 conceptual domains of quality of life- (a) Relationships and material well-being (b) Personal, social and community commitment (c) Health and functioning Item Scaling : A 7-point delighted-terrible scale has been used to measure satisfaction with each item for a broad range of affective responses to QOL items. The seven responses were delighted (7), pleased (6), mostly satisfied (5), mixed (4), mostly dissatisfied (3), unhappy (2), terrible (1). The QOLS is scored by adding up the score on each item to yield a total score for the instrument. Scores can range from 16 to 112. The QOLS scores are summed so that a higher score indicates higher quality of life. Average total score for healthy populations is about 90. Statistical methods The data collected was subjected to statistical analysis. Descriptive statistics (frequencies, means, standard deviations, and percentages) were used to characterize the sample and inferences using t tests for two groups and Chi-square for proportion were applied to test the statistical significance of the various factors that affected quality of life. Chi square was applied for frequencies less than 5 by applying Yate s correction. Further, QOLS scores were statistically analyzed for the two groups using t-test. Statistical significance was set at P < 0.05 (significant) and P < 0.01 (highly significant). Results The table-1 shows sociodemographic attributes of burn injury patients. Majority of the patients in both groups were females and most of these were Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society 309

3 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012 housewives. Almost equal percentage of subjects came from urban as well as rural background. Further, the groups did not differ significantly (p > 0.05) for marital status and education status. The details can be seen from Table-1. Table-5 shows the psychiatric diagnosis of group A patients according to ICD-10 criteria. Depression (33.33%) was most common diagnosis followed by post traumatic stress disorder (PTSD) (26.67%). Remaining patients had adjustment Table - 1 : Socio-Demoghraphic attributes of Patients Socio-demographic attributes Group A Group B Statistics No. %age No. %age Sex Male 6 20% % 2 = 0.09 p = Female 24 80% % (p > 0.05) Marital Status Married % 24 80% 2 = 0.09 Single/ p = divorced/ % 6 20% (p > 0.05) Widowed Education Illiterate 6 20% % 2 = 1.23 Under Matric % % p = th class % % (p > 0.05) Graduate 3 10% % Domicile Urban 12 40% % 2 = 0.07 Rural 18 60% % p = (p > 0.05) Occupation Unemployed 3 10% % 2 = 1.3 Semi skilled % 6 20% p = Skilled % 3 10% (p > 0.05) Housewives % % *Not Significant It can be seen from table-2 that majority of patients in both groups were in age group of years and their mean age did not differ significantly (p > 0.05). This suggests that the burn injuries are more common in reproductive age group. The table-3 shows that both group did not differ significantly (p>0.05) regarding causes of burn injury. However, it can be seen that majority of the patients of burn injury in group A (63.33%) and group B (86.67%) had accidental burn injury. Most of the patients in group A (60%) and group B (53.33%) had burns that were thermal in nature. In both group, the cause of burn injury was mostly related to stove accidents (group A [40%] and group B [33.33%]). Through table-4, it can be observed that majority (76.67%) of the patients with psychiatric morbidity in group A had higher percentage and higher degree of burn injury as compared to group B patients and this difference is statistically significant (p < 0.05) % patients in group A had second degree burns and 40% patients had third degree burns. In group A, majority of the patients (66.67%) have burn injury involving the face with other parts of the body while in group B, 60% of patients have burn injury of other parts of the body without involvement of face. Duration of burn injury was significantly shorter in patients with psychiatric morbidity as compared to other group having no psychiatric morbidity, where duration of burn was more than one year. The details can be seen from Table Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society

4 OCTOBER 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 Table - 2. Age of Patients Age group (in yrs) Group (n = 30) Group B (n = 30) No. % age No. % age < % 0 0% % 3 10% % % % % % % > % % Range (yrs) Mean ± SD ± ± Df 58 t and p value t = , P > 0.05 Significance *Not Significant Table - 3. Various Causes of Burn Injury Causes Group A (n = 30) Group B (n = 30) Statistics No. % age No. % age Medicolegal Cause Accidental % % 2 = 3.20 Non Accidental % % p > 0.05 Nature Thermal Burn 18 60% % 2 = 2.60 Electric Burn % % p > 0.05 Chemical Burn % % Df = 2 Cause Stove Accidents 12 40% % 2 = 3.47 Electricity % % p > 0.05 Hot Liquid Spill 6 20% 9 30% Df = 4 Acid Spill % % Fire with Open 3 10% % Flames *Not Significant Table - 4. Variables of Burn Injury Variables Group A (n = 30) Group B (n = 30) Statistics No. %age No. %age Percentage < % % c 2 = > % % p < 0.05 S # Degree 1st Degree % % c 2 = nd Degree % % p < rd Degree 12 40% % Df = 3 4th Degree 6 20% % S # Site Face with other % 12 40% c 2 = 4.29 parts of body p <0.05 Other parts of body S # without face % 18 60% Duration < 1 year % 6 20% c 2 = > 1 year % 24 80% p < 0.05 S # # Significant Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society 311

5 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012 Table - 5. Psychiatric Diagnosis according to ICD-10 Criteria ICD-10 Diagnosis Group A No. % Depression % Post traumatic stress disorder % Adjustment Disorder % Substance use disorder % Acute stress reaction % Phobic anxiety disorder % Somatoform disorder % disorder, substance use disorders, phobic anxiety disorder and somatoform disorder. Table-6 shows quality of life scale scores in both groups. In the Group with psychiatric morbidity (group A) quality of life was found to have a mean value of ranging from while in Group B, mean value was found to be ranging from It can be seen from table that most of the items of quality of life scale in group A was lower than group B. In group A, the items with the lowest rate of satisfaction were Socializing, Participating in active recreation, Participating in public affairs. The difference between the two groups was found to be highly significant (p < 0.01). Disscussion The present study was carried out with the aim of assessing the quality of life among patients of burn injury. Effects of burn variables on quality of life were also assessed. We examined whether presence of psychiatric morbidity affected the quality of life in these patients. It was observed in our study that gender, different age groups, marital status, education, occupation, residence and cause of burn injury in group A and group B did not differ significantly on quality of life and on psychiatric morbidity in two groups. But burn itself declines the quality of life of the person by limiting his/her functions. A study evaluated post-burn employment in 48 Table - 6. Quality of Life Scale (QOLS) Scores Items Group A Group B (Mean ± SD) (Mean ± SD) 1. Material comforts home, food, conveniences, financial security ± Health - being physically fit and vigorous 4.66 ± ± Relationships with parents, siblings & other relatives- communicating, 4.76 ± ± 1.2 visiting, helping 4. Having and rearing children 3.64 ± ± Close relationships with spouse or significant other 4.79 ± ± Close friends 5.39 ± ± Helping and encouraging others, volunteering, giving advice 4.23 ± ± Participating in organizations and public affairs 3.63 ± ± Learning- attending school, improving understanding, getting 4.75 ± ± 1.6 additional knowledge 10. Understanding yourself - knowing your assets and limitations ± ± 1.1 knowing what life is about 11. Work - job or in home 3.66 ± ± Expressing yourself creatively 4.85 ± ± Socializing - meeting other people, doing things, parties, etc 2.76 ± ± Reading, listening to music, or observing entertainment 4.53 ± ± Participating in active recreation 2.94 ± ± Independence, doing for yourself 3.50 ± ± 1.4 Mean ± SD of total scores ± ± 12.6 (Range) (35-73) (40-89) Df 58 t value 7.32 p value p<0.05 Significance S # # Significant 312 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society

6 OCTOBER 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 patients on average 3.8 years after the burn. 31% patients had not returned to work. Those who did not work had low health related quality of life and poor er tr auma r elated physical and psychological health. 10 Another study assessed 26 burn patients and suggested that the electrical burn patients had the limited ability to return to work and overall poor quality of life. Emotional distress is the dominant feature influencing long term outcome in these patients. 11 In current study, it was observed that patients in group A had more percentage of burn injury, of severe degree mostly involving face and other regions. It was also seen that group A patients had poor quality of life as compared to group B. In a follow up study of 70 burn adults after 3-13 years of burn, it was observed that patients with severe injuries had more psychosocial problems (44%) than patients with minor injuries (16%). A combination of variables describing the length of the hospital stay, presence of scars, premorbid psychopathology and deviant behaviour during the hospital stay were found to be the better predictors of the negative psychosocial outcome. 12 Another study examined functional and psychological outcome of 38 severely burn patients after 2 years of burn and observed that the mobility and self care were significantly altered when the burn injury was more than 20%. 13 In a recent study of patients hospitalized for burn injury, 66% of patients returned to work within six months of their injury and 81% had returned by one year. Patients who sustained larger burns took longer time to return to work. About half of the patients required some change in job status. 14 There are two important factors related to psychological and social adjustment. The enduring quality of family support received by the patient and the willingness on the part of the patient to take social risks appear to play critical roles in the adaptation process. The factors associated with poor prognosis for psychosocial adjustment includes social shyness of the individual, an acceptance within the family of dependence, lack of family cohesion and high conflict within the family. So, the burn care of the whole person including early and continued attention to the psychosocial aspects of the patient s life can facilitate positive psychological adaptation to the challenges of traumatic injury, painful treatment and permanent disfigurement. 15 In our study, it was found that quality of life was poor in burn patients and the most common areas affected by burn injury were participation in active recreation and social events. These findings were consistent with previous follow up study which suggest that patients perceiving more social support (friends more than family) had more positive body images (p < 0.01), greater self-esteem (p < 0.01) and less depression (p < 0.01). 16 The variance in psychosocial adjustment in adults was related to unemployment, loss of occupational status, avoidance coping and little involvement in recreational activities. While in children, it depends on their mother adjustment and method of coping. 17 Another survey on psychological needs of burn patients by comparing 68 burn injured patients with 44 patients having other types of traumatic injuries suggested that burn injured individuals lack psychological support and made suggestions for support services that may have been beneficial. These findings supported the need for a comprehensive follow-up service that would make specialist physical and psychological support more accessible to burn injured patients post-hospitalization. 18 However, another study demonstrated that burn patients enjoyed a quality of life comparable to that of the control subjects although they perceive some deterioration in their general health. 19 Although quality of life was poor in burn patients but it was observed in our study that it worsens if psychiatric morbidity supervened. The assessment and early treatment of both depressive and anxiety symptoms may help to improve a broad range of long term pain related outcomes following burn injury. A two years follow up study assessed the prospective effects of anxiety and depression on pain and functional outcome following burn injury and they observed that both anxiety and depression were strong prospective predictors of greater pain, more fatigue and physical dysfunction. 20 Another study found that sleep disturbances were significantly negatively correlated with all aspects of quality of life. 21 Another study assessed the health related quality of life, PTSD and associations between these Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society 313

7 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012 in 43 burn survivors of 7-16 years age and found that severity of PTSD was significantly associated with physical, cognitive and emotional dimensions of health related quality of life. Most dimensions of health related quality of life were within normal limits except social functioning which was impaired. Children with PTSD report an impaired overall health related quality of life and limited physical and emotional functioning. 22 Assessing quality of life in burn patients has many implications as it might affect the treatment compliance and causes overall poor quality of life. This study emphasizes that there must be more awareness and sensitization among health care providers regarding need of assessing quality of life in post-burn patients which may help in their rehabilitation. Limitations Though the present study was conducted using sound methodology and strict inclusion criteria, there are certain limitations. The study was cross sectional. The sample size was lesser than some of the previous similar studies. The sampling done was non-randomized because of which the finding of the study can only be representative of the study population and cannot be extrapolated to the community at large. Longitudinal studies involving larger samples selected by systematic sampling methods would be needed further for better assessment in these patients. Conclusion Quality of life in burn injured patients was affected by severity of burn injury. Psychiatric morbidity was found to be significant factor affecting quality of life in burn injury patients. So, this study also enlighten that psychiatric care must be included at every stage of their treatment for the better adjustment and quality of life in burn injury patients. The eventual outcome for burn patient is related to injury severity, individual physical characteristics of patients, motivation of patient, quality of treatment and after care support. Burn patients often require years of supervised rehabilitation, reconstruction and psychosocial support. The quality of burn care is no longer measured only by survival but also by long term function and appearance. 314 References Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society 1. Loey NEV, Son MJV. Psychopathology and psychological problems in patients with burn scars: epidemiology and management. Am J Clin Dermatol 2003; 4(4) : Chang FC, Herzog B. Burn Morbidity: A Followup Study of Physical and Psychological Disability. Ann Surg Jan 1976; 183 (1) : Andreasen NJ, Norris AS. Long term adjustment and adaptation mechanisms in severly burned adults. J Nerv Ment Dis 1972; 154(5) : Blakeney P, Herndon DN, Desai MH, et al. Long term psychosocial adjustment following burn injury. J Burn Care Rehabil 1988; 9(6) : Cahners SS, Bernstein NR. Rehabilitating families with burned children. Scand J Plast Reconstr Surg 1979; 13(1) : Jones JD, Barber B, Engraw L. Alcohol use and burn injury. J Burn Care Rehabil 1991; 12 : Wallis H, Renneberg B, Ripper S, et al. Emotional distress and psychosocial resources in patients recovering from severe burn injury. J Burn Care Res 2006 Sep-Oct; 27(5) : World Health Organization. The ICD-10 classification of Mental and Behavioural Disorders:Clinical Description and Diagnostic Guidelines. World Health Organization, Geneva; Burckhardt CS, Anderson KL, Archenholtz B, Hagg O. The Quality of Life Scale (QOLS): Reliability, Validity, and Utilization. Health and Quality of Life Outcomes 2003; 1 : Dyster-Aas J, Kidlal M, Willebrand M. Return of work and health related quality of life after burn injury. J Rehabil Med 2007 Jan; 39(1) : Noble J, Gomez M, Fish JS. Quality of life and return to work following electrical burns. Burns 2006; 32(2) : Malt UF, Ugland OM. A long-term psychosocial follow-up study of burned adults. Acta Psychiatr Scand Suppl 1989; 355 : Druery M, Brown TL, Brown TLH, Muller M. Long term functional outcomes and quality of life following severe burn injury. Burns Sep; 31(6) :

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