The importance of mental health considerations for critical care burns patients.

Abstract

Mental health issues for critical care patients have important consequences for care, recovery and follow-up (Kornhaber, Childs, & Cleary, 2017; Kornhaber, Haik, Sayers, Escott, & Cleary, 2017). Burn injuries and treatment can be both physically and psychologically traumatic. Patients are often confronted by adjustments to physical capacity and body image (O'Donnell, Bryant, Creamer, & Carty, 2008), with the distress affecting not only the patient but also their families (Johnson, Taggart, & Gullick, 2016) and even burns clinicians (Haik et al., 2017). Treatments, such as debridement and wound dressings, often add additional pain and distress (McLean, Chen, Kwiet, Vandervord, & Kornhaber, 2017) and the process of recovery can be protracted, intrusive and dehumanizing (Horridge, Cohen, & Gaskell, 2010). The importance of considering mental health in burns care is demonstrated by the prevalence of incidents, with 25–50% of all burns patients experiencing a mental health disorder after burn injury (Mahendraraj, Durgan, & Chamberlain, 2016). For health professionals, such a figure should elicit action to address, mitigate and even prevent such outcomes for burns patients. However, considerable research has shown that the issue is more complex than the simple issue of postburn mental health. This requires equally considerable discussion to better define the problem, the factors that impact upon it and the solutions. These factors include the link between trauma and postburn mental health, pre-existing mental health conditions, self-immolation, alcohol and drug use amongst burns patients, the effect on family, and screening and assessment of mental health disorders. There is a substantial amount of research confirming a strong link between burn injuries and resulting mental health issues, including post-traumatic stress disorder, major depression, substance abuse, sleep disorders, poor body image and anxiety (Bakker, Maertens, Van Son, & Van Loey, 2013; Dahl, Wickman, Bjornhagen, Friberg, & Wengstrom, 2016; Lawrence, Qadri, Cadogan, & Harcourt, 2016; Oster & Sveen, 2014; Palmu, Suominen, Vuola, & Isometsa, 2011). However, as discussed by O'Donnell et al. (2008), while burns injuries vary in severity, it is not the injury severity alone that determines whether the experience of the patients is considered traumatic. Fear, helplessness felt at the time of the injury, the invasiveness of procedures and dealing with the consequences of the injury, such as disability or disfigurement, are all secondary stressors that can create the perception of trauma. It is, therefore, the potential for an injury to be considered as traumatic that will affect the likelihood of mental health issues afterwards and, therefore, the likelihood of screening, assessment and support. Separate to post-injury mental health is the substantial impact of pre-existing mental health conditions amongst burns patients to the point where it can even predispose people to burns (Logsetty et al., 2016) and increase the likelihood and severity of postburn mental health disorders (Oster & Sveen, 2014). Common pre-existing conditions include substance abuse, affective disorder, psychotic disorder and personality disorder (Logsetty et al., 2016) and the reported prevalence of pre-burn psychiatric morbidity ranges from 28% to 75% (Palmu et al., 2011). The existence of a mental health condition prior to injury can further complicate management through poor compliance with medications, procedures and rehabilitation (Caine, Tan, Barnes, & Dziewulski, 2016) and longer hospital stays, higher incidence of complication and increased morbidity (Mahendraraj et al., 2016). In burns patients, there is an increased prevalence of self-immolation, or self-inflicted burns, which can have different causes and implications for treatment. Some studies have drawn a significant link between previous diagnosis of a psychiatric disorder and self-inflicted burns (Caine et al., 2016). However, another found low rates of mental illness amongst self-immolators in Iran, where is constitutes approximately 25% of all suicides, compared with approximately 96% of self-immolators in Europe and North America having a mental illness (Parvareh et al., 2017). Self-immolation has significant impacts on the treatment of burns due to the longer resulting hospital stay, larger body surface areas being burned and higher mortality than non-intentional injuries (Caine et al., 2016). Causal mechanisms exist linking pre-existing mental disorders and burns injuries via increased risk-taking behaviours. There is a demonstrated link between alcohol and drug use with both mental health disorders and burns risk. Alcohol-related burns account for up to 50% of admissions (Palmu, Partonen, Suominen, Vuola, & Isometsa, 2017) and 20% of acute burns admissions (Holmes, Hold, & James, 2010). Alcohol and drug use is one of the most common disorders amongst burns patients (Holmes et al., 2010; Oster & Sveen, 2014) and a significantly higher prevalence of mental disorders has been found amongst patients who were under the influence of alcohol or drugs at the time of their burn injury (Palmu et al., 2017). Alcohol use also impacts burns recovery, with longer hospital stays, higher cigarette smoking rates, poorer compliance with care, increased complications and assaults on staff as a consequence of alcohol withdrawal (Holmes et al., 2010). Burn injuries have a wider mental health impact on family member's mental health, and clinicians. Bakker et al. (2013) observed high rates of maternal depression and anxiety in mothers, which could often persist for years. Horridge et al. (2010) found that parents proceeded through stages of guilt, anxiety and anger after a child's burn injury, and that mothers blamed themselves for the injury, causing subsequent anxiety and low mood. This has strong implications for burns treatment as both Bakker et al. (2013) and Horridge et al. (2010) confirmed that family support or conflict has considerable impact on the child's capacity to adjust to their injuries, adopt coping mechanisms and improve their quality of life. Therefore, the capacity to monitor parental mental health becomes directly important to the treatment of the child. There is the significant body of research that suggests that burns patients who are pre-symptomatic, at high risk or otherwise likely to benefit from an assessment, of a mental health disorder are often not receiving screening and support in a timely manner or not receiving this at all. This lies at the crux of the issue of appropriate treatment and support of burns patients with pre-existing or risk factors for mental health disorders. Whilst the factors impacting on mental health of burns patients may be understood, the response of health systems often fails to translate this knowledge into well-targeted and appropriate responses. Caine et al. (2016) described a tendency for psychological well-being to be neglected at the time of presentation when the burn injury itself takes priority. In a survey of US hospitals, 27% stated there was no psychologist available at their hospital and 28% of UK respondents stated there was no social worker (Lawrence et al., 2016). Furthermore, between 64% and 79% of the US patients were not screened for psychological issues after discharge (Lawrence et al., 2016; Mahendraraj et al., 2016). This figure was even higher in a study by Palmu et al. (2011). Financial barriers evident in user-pay systems such as the US could exacerbate this, making access to mental health services after discharge problematic. When discussing self-inflicted burns injuries Caine et al. (2016) noted that although guidelines existed in Australia that stated emergency staff should urgently establish the likelihood of physical and mental risk to the patient, only 7% had been seen by the psychology team at the emergency department. This figure did rise to 82% once admitted to the burns ICU, but outside of the first 24 hr deemed appropriate under the guidelines. The authors stated that sedation, mechanical ventilation, palliation, and the difficulty in getting weekend and outside hours psychiatric reviews were all likely causes of the delay in assessment. Early assessment of problems and symptoms is integral to getting the right patients the right level of support in the right timeframe (Dahl et al., 2016; Kornhaber et al., 2017) and the hospital setting provides this brief window of opportunity start the process of proper assessment (O'Donnell et al., 2008). This assessment needs to consider the injury and its many impacts holistically, including pre- and postmental health risks, family support, self-infliction, substance abuse and, importantly, how the patient themselves views the trauma of their burn experience. Health professionals need to reach beyond the physical recovery that confronts patients and plan from the first instances for the emotional and psychological needs of the patient, their family and those impacted by the injury. This involves a multi-pronged approach, including clear and well-understood standards and guidelines, early assessment and screening, structured follow-up, understanding of pre-symptomatic risk factors, continuous contact from burns care staff, and appropriate referral to support groups. Authors declare that there is no conflict of interest. Improving Mental and Critical Care Health (MaCCH)—UT as funding awarded under the UTAS Research Themes: Better Health Research Development Grant Scheme, supported by the Office of the Deputy Vice-Chancellor and FoH (C0025653).