Psyched out: Trauma patients with major psychiatric comorbidities

Over the past year, the public and providers alike have shown increasing interest in the effect of a preexisting diagnosis of a major psychiatric illness on trauma patients. Recent publications have focused on the prevalence of these diagnoses and which of these disorders are most common in the trauma population. The most recently published data find that approximately 18 percent of Americans will experience a psychiatric illness at one time during a year. These data also indicate that 44 percent of patients with unintended traumatic injuries will have a comorbid major psychiatric diagnosis. The most common diagnoses were divided into age groups, with patients younger than 18 years old much more likely to have a neurodevelopment disorder, whereas patients 18–64 years of age commonly had a substance abuse diagnosis. For patients ages 65 and older, dementia was most common.¹

Other studies have focused on psychological stress measured using validated inventories rather than patients with known psychiatric illness² and compared these measures with the occurrence of unintentional trauma. In these studies, patients still have twice the risk of experiencing unintentional trauma, even a year after a major psychiatric event. They also endure longer lengths of stay and have higher general complication rates.

A dangerous comorbidity

Some research focuses on specific common psychiatric illnesses, such as major depressive episodes, and have examined the effect of these individual diagnoses on trauma patients.^3,4 Finally, other researchers are looking at outcome measures, such as length of stay, morbidity and mortality, recidivism rates, and volume of patients who are sent to a skilled nursing facility.^2,5,6,7

To examine the occurrence of patients with psychiatric comorbidities and traumatic injuries in the National Trauma Data Bank^® (NTDB^®) research admission year 2016, medical records were searched using the comorbid conditions DG-01 field value of 27 (major psychiatric illness). A total of 90,855 records were found. Of these records, 79,057 contained a discharge status, including 45,039 patients discharged to home, 12,047 to acute care/rehab, 16,156 to skilled nursing facilities, and 3,742 discharged to a psychiatric hospital/unit; 2,073 died (see Figure 1). Most of these patients (53 percent) were women, on average 55.3 years of age, had an average hospital length of stay of 6.1 days, an intensive care unit length of stay of 5.3 days, an average injury severity score of 9.9, and were on the ventilator for an average of 5.9 days. Of the patients tested, 32 percent (13,233 out of 41,922) tested positive for alcohol.

Figure 1. Hospital discharge status

In this research year dataset, which includes both intentional and unintentional injury, almost 10 percent of records contain a comorbidity relating to a major psychiatric illness. With close to one in five adults in the U.S. experiencing a major psychiatric illness yearly, we should not be psyched out by the number of trauma patients presenting with a preexisting major psychiatric illness. This comorbidity is a significant issue in our nation’s trauma population and requires a multidisciplinary approach above and beyond the treatment of their specific physical injuries.

Throughout the year, we will be highlighting these data through brief reports that will be found monthly in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file. In addition, information is available on our website about how to obtain NTDB data for more detailed study. To submit your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.

Acknowledgment

Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.

References

1. Townsend LL, Esquivel MM, Uribe-Leitz T, et al. The prevalence of psychiatric diagnoses and associated mortality in hospitalized U.S. trauma patients. J Surg Res. 2017; 213:171-176.
2. McAninch J, Greene C, Sorkin JD, Lavoie MC, Smith GS. Higher psychological distress is associated with unintentional injuries in U.S. adults. Inj Prev. 2014;20(4):258-265.
3. Hung CI, Liu CY, Yang CH. Unintentional injuries among psychiatric outpatients with major depressive disorder. PLoS One. 2016;11(12): e0168202.
4. Inder KJ, Holliday EG, Handley TE, et al. Depression and risk of unintentional injury in rural communities—a longitudinal analysis of the Australian rural mental health study. Int J Environ Res Public Health. 2017;14(9):E1080.
5. Adlam M, Feehan A, Metaxa V. Prevalence of psychiatric disorders in trauma patients: Results from a major trauma unit. Critical Care. 2015;19(Suppl 1): P477.
6. Zatzick DF, Rowhani-Rahbar A, Wang J, et al. The cumulative burden of mental, substance use, and general medical disorders and rehospitalization and mortality after an injury. Psychiatr Serv. 2017;68(6):596-602.
7. Falsgraf E, Inaba K, de Roulet A, et al. Outcomes after traumatic injury in patients with preexisting psychiatric illness. J Trauma Acute Care Surg. 2017;83(5):882-887.