ORIGINAL ARTICLE

Functioning, Disability, and Social Adaptation Six Months After Burn Injury Raimo Palmu, MD, PhD,*† Timo Partonen, MD, PhD,† Kirsi Suominen, MD, PhD,†‡ Jyrki Vuola, MD, PhD,§ Erkki Isometsä, MD, PhD*†

Major injuries commonly cause long-standing functional impairment. The authors investigated the levels of and predictors for functioning, disability, and social adaptation 6 months after a burn injury. The overall level of functioning at 6 months postburn was assessed among 87 (81%) of the 107 consecutive acute adult burn patients (mean TBSA 9.7%) admitted to the Helsinki Burn Centre during an 18-month period. Social and Occupational Functioning Assessment Scale (SOFAS) was used to evaluate functioning overall, and Sheehan Disability Scale (SDS) to assess the domains of working capacity, social life, and family life. Social Adaptation SelfEvaluation Scale (SASS) was used to measure social adaptation. Structured clinical interview was used to assess mental disorders at baseline and 6 months after injury. The mean SOFAS score was 69.7 (SD = 20.8), indicating some impairment in social and occupational functioning. The strongest independent predictors of SOFAS were mental disorders during follow-up (P < .001), particularly major depressive disorder (P < .001) and delirium (P = .016), but also length of stay (P = .004) and hand burn (P = .012). Concerning disability (SDS), the authors found mild impairment in all three domains, the most in SDS work (mean 3.59, SD = 3.46). The strongest predictor of SDS was major depressive disorder during follow-up (P < .001) and of SASS personality disorders (P = .007). Six months after a burn injury, some difficulties in social and occupational functioning remained. Level of functioning was predicted strongly and consistently by mental disorders, particularly depression. Length of stay and hand burns also predicted functioning, more in a clinician’s evaluation (SOFAS) than in self-reported measures (SDS and SASS). (J Burn Care Res 2016;37:e234–e243)

Functional outcome after burn injury has been a major focus of interest, with most of the literature concentrating on physical outcomes and results of rehabilitation. As early as the 1990’s Xiao and Cai1 found that also patients surviving massive burns may function without obvious limitations and return to work. Van Baar et al2 reviewed 50 studies using the International Classification of Functioning, Disability and Health. In these studies, the variables From the *Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland; †Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland; ‡Department of Psychiatry, City of Helsinki, Department of Social Services and Health care, Helsinki, Finland; and §Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland. Address correspondence to Raimo Palmu, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, P.O. Box 590, FI-00029 HUS, Helsinki, Finland. Email: [email protected] hus.fi. Copyright © 2015 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000258

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analyzed included age, body function by age, body functions (including mental function), body structures, activities participation, and environmental factors, and noted problems with appearance (43%) among inpatients with minor burns. Problems with work were reported by 21 to 50% of adult patients. However, they found no studies comprehensive enough to adequately estimate the functional consequences of burns, and recommended that a standard core set of measures for reporting functional outcome after burns. In medicine overall, mental disorders are a central determinant of functioning. In a systematic analysis for the WHO Global Burden of Disease Study 2010, Vos et al3 investigated years lived with disability for 1160 sequelae of 289 diseases and injuries in 1990 to 2010, finding that the largest contributor to global years lived with disability were mental and behavioral disorders, followed by musculoskeletal, endocrine, and neurological disorders. Given the result that the prevalence of mental disorders among injured is high,4–6 such findings

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Journal of Burn Care & Research Volume 37, Number 3

give a rationale for investigating the effect of mental disorders among injured. However, clinical-epidemiological studies concerning the impact of mental disorders on functioning among injured are scarce. In a review using the International Classification of Functioning, Disability and Health, Wasiak et al7 identified 151 outcome measures in 132 studies. Frequently used measures in the assessment of burn outcomes included both burn-specific (eg, Burn-Specific Health Scale) and generic measures (eg, Medical Outcome Study 36-item Short Form, SF-36; Beck Depression Inventory, BDI; Impact of Event Scale, IES). However, despite extensive efforts in investigating functional outcome of injured, including studies with questionnaires covering psychological symptoms (eg, BDI), no studies have focused on mental disorders diagnosed by a psychiatrist as predictor of functioning and social adaptation after burn injury. Only a few studies exist with appropriate methods for assessing mental disorders among injured.4–6,8 Burn severity and mental disorders are related in a complex way. For instance, suicidal or psychotic patients can be predisposed to burns, but severe burns also predispose to mental disorders.4–6,8–10 Both burn severity and mental disorders can influence recovery and rehabilitation, having an impact on the final level of functioning and adaptation. Determination of how mental disorders and burn severity influence social and occupational functioning, disability, and social adaptation is important for improving burn rehabilitation services.11 In a previous prospective cohort study of acute hospitalized burn patients, we found 55% of patients to suffer from at least one mental disorder during a 6-month follow-up.8 This prevalence increased as burn injury exposure (%TBSA) increased. The relation was statistically significant with regard to Axis I disorders overall, and specifically with anxiety disorders and disorders due to general medical condition. In earlier studies that excluded minor burns, such a relation was not observed, probably because the variation in severity of burns was limited.5,6 The aim of this study was to investigate the level and predictors for functioning, disability, and social adaptation at 6 months after acute burn injury. In particular, we examined the predictive roles of characteristics of the burn injuries and mental disorders before and after the burn.

METHODS Participants The Helsinki Burn Centre is a tertiary unit in Helsinki University Central Hospital that treats all the most

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severe burn injuries and approximately two-thirds of all burn injuries in Finland, a country with a population of 5.4 million. We included into this prospective cohort study4,8 all consecutive Finnish-speaking patients admitted to the Helsinki Burn Centre, who were at least 18 years old, between May 5, 2006 and October 31, 2007. Of all the 156 consecutive acute injured, 19 (12.1%) died, and 10 patients (6.4%) were transferred to another hospital after immediate care at the Burn Centre; one patient refused, and one aborted his participation to the study. We excluded patients who could not participate because of poor understanding of Finnish, or poor cognitive or sensory capacity (eg, dementia, brain damage, or deafness), altogether 18 patients (11.5%). Eighty-six percent (N = 92) of the cohort (N = 107) participated the 6-month followup.8 The study protocol was approved by the Ethics Committee of Helsinki University Central Hospital. The methodology and procedure of the study have been described in detail elsewhere.4,8

Assessment and Prevalence of Mental Disorders at the Baseline Phase For the assessment of mental disorders, patients were examined with the Clinical Version of the Structured Clinical Interview for DSM-IV-TR (SCID-CV) for Axis I mental disorders,12 and with SCID-II for personality disorders.13 The same experienced psychiatrist (R.P.) interviewed all participants at baseline and at 6 months. Mental disorders were assessed for five different time frames. The diagnostic procedure has been described in detail in our previous articles.4,8,14 The percentage of TBSA (%TBSA) was the measure used for assessing the severity of burn injuries. As previously reported,4 we assessed mental disorders in three different time-frames at baseline: 1) during their lifetime before the burn, 2) during the final month before the burn, and 3) during acute care in hospital. During lifetime before the burn almost two-thirds, during the final month 40%, and during acute care 48% of the subjects had at least one Axis I mental disorder.4 During lifetime before burn, 27% had any mood and 20% anxiety, 10% psychotic, and 47% substance-related disorders. More specifically, 15% met the criteria for major depressive disorder (MDD) and 7.5% posttraumatic stress disorder (PTSD). Of those 43 patients (40%), who had a disorder during the final preburn month, 5.6% had mood, 14% anxiety, 6.5% psychotic, and 32.7% substance-related disorders. During acute care in hospital 5% had mood, 16% anxiety, 7% psychotic, 33% substance-related disorders, and 13% disorder due to General medical condition (delirium).4

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Follow-Up at 6 Months and %TBSA Ninety-two subjects (86% of cohort) participated in the 6-month follow-up, findings from which are the focus of this study. The majority of these subjects were middle-aged men with a low level of education; their mean age was 46.3 years (SD = 16.5) and 70% had only elementary level of education. Many had a history of mental disorder, psychiatric hospitalization, or suicide attempt before the injury. The other sociodemographic variables included in analyses are shown in Table 1. The average %TBSA was 9.7, and 40% of severely injured (%TBSA of >20) still had outpatient visits at the Burn Centre at 6 months. Hand burns were common (N = 39) among those who participated in the follow-up. The other clinical variables included in analyses are presented in Table 2. More than three-fourths of the injured who had been working or studying at baseline had returned to work at 6 months. Patients who dropped out (n = 15) during follow-up did not differ significantly from the interviewed subjects (n = 92) in gender, age, civil or working status, %TBSA, or preburn psychiatric hospitalization, but they had more often a history of suicidal acts (33.3 vs 9.8%; P = .012) before burn than participants.8

Mental Disorders During the 6-Month Follow-Up More than half (55%) of the participants had some Axis I disorder during the 6 months after burn injury (Table 3). Substance use-related disorders were most common (27%), following by anxiety and mood disorders (22 and 15%) and disorders due to general medical condition (16%). The majority of patients with PTSD (11% altogether) not had symptoms of PTSD before the burn. More than one-third of those with no preburn mental disorder had at least one Axis I disorder during the follow-up. Furthermore, 37% of the injured had comorbid Axis I mental disorder during the 6-month follow-up. These descriptive findings have been previously published elsewhere in detail,8,14 but are summarized here because of their role as predictors for functioning, disability, and social adaptation.

Measures of Functioning, Disability, and Social Adaptation At 6 months, the patients filled in the following three widely used and well-validated measures of level of functioning: The Social and Occupational Functioning Assessment Scale (SOFAS), the Sheehan Disability Scale (SDS), and the Social Adaptation

Table 1. Sociodemographic and psychiatric background of 92 acute injured in a 6-month follow-up Men N 64 Mean age (SD)* Marital status  Single  Married or cohabiting  Divorced  Widowed Level of education  None  Elementary  Gymnasium Social assistance recipient†  None  Occasionally  As principal income Earlier serious injury‡ Treatment of psychiatric illness‡ Psychiatric hospitalization‡ History of suicide attempt‡

45.1

Women % 69.6 (16.0)

N 28 49.0

Total % 30.4 (17.6)

N 92

% 100

46.3

(16.5)

14 40 8 2

21.9 62.5 12.5 3.1

5 10 6 7

17.9 35.7 21.4 25.0

19 50 14 9

20.7 54.3 15.2 9.8

0 45 19

0 70.3 29.7

0 19 9

0 67.9 32.1

0 64 28

0 69.6 30.4

55 5 4 45 15 6 4

85.9 7.8 6.3 71.4 23.4 9.4 6.3

19 8 1 18 11 3 5

67.9 28.6 3.6 64.3 39.3 10.7 17.9

74 13 5 63 26 9 9

80.4 14.1 5.4 69.2 28.3 9.8 9.8

*t test. †Need for socioeconomic support in the 12 months before burn. ‡Before burn injury; the variables were tested one by one.

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Table 2. Burn-related clinical characteristics of 92 acute injured Men

Type of burn  Flame  Liquid  Electrical  Other %TBSA  0–5  >5–10  >10–20  >20 Part of body burned  Head  Hand  Genital area  Other Length of stay  1 day or less  2–7 days  8–30 days  31 days Treatment at burn unit  Intensive care unit  Floor Outpatient visits  0  1  2–5   ≥6 Sick leave  0 days  1–7 days  8–30 days  1–6 months  >6 months

Women

Total

N

%

N

%

N

%

64

69.6

28

30.4

92

100

29 10 5 20

45.3 15.6 7.8 31.3

11 12 0 5

39.3 42.9 0 17.9

40 22 5 25

43.5 23.9 5.4 27.2*

29 11 13 11

45.3 17.2 20.3 17.2

15 5 4 4

53.6 17.9 14.3 14.3

44 16 17 15

47.8 17.4 18.5 16.3

22 30 6 55

34.4 46.9 9.4 85.9

12 9 1 19

42.9 32.1 3.6 67.9

34 39 7 74

37.0 42.4 7.6 80.4

5 22 29 8

7.8 34.4 45.3 12.5

2 8 15 3

7.1 28.6 53.6 10.7

7 30 44 11

7.6 32.6 47.8 12.0

19 45

29.7 70.3

7 21

25.0 75.0

26 66

28.3 71.7

3 9 38 14

4.7 14.1 59.4 21.9

1 3 14 10

3.6 10.7 50.0 35.7

4 12 52 24

4.3 13.0 56.5 26.1

0 0 8 24 5

0 0 21.6 64.9 13.5

0 0 1 5 3

0 0 11.1 55.6 33.3

0 0 9 29 8

0 0 19.6 63.0 17.4

*Including several types of burns, each occurring rarely.

Self-evaluation Scale (SASS). To the best of our knowledge, they have not been used earlier in surgical patients. The psychometric properties and validation of these instruments have been described in more detail elsewhere.15 The SOFAS is rated by a clinician who uses information from any clinical source (eg, clinical evaluation of the patient, a reliable informant, or a case record). It focuses exclusively on the level of social and occupational functioning irrespective of causes. It does not measure symptoms. It includes impairments in functioning due to physical limitations, as well as those due to mental impairments. The SOFAS is used to estimate functioning for the

current period. The range is 0 to 100, with a score of 80 to 90 referring to normal function and a score of below 40 being typical of patients in psychiatric hospitals.16,17 The joint reliability of this instrument has been found excellent.18 The SDS is a brief, self-rated, widely used, measure of disability and impairment.19–22 The total score range is 0 to 30, consisting of three domains, each scored 0 to 10. These three domains comprise Work/ School, Social Adaptation, and Family life/Home responsibilities. If symptoms have not disrupted the patient at all the score of the domain is 0, with scores 1 to 3 referring to mildly, 4 to 6 moderately, 7 to 9 markedly, and 10 extremely impaired abilities. It is a

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Table 3. Mental disorders among 92 patients during the 6 months after burn injury N (%) 92 (100) Axis I disorders  Any mood disorder   Major depressive disorder  Any anxiety disorder    PTSD   Acute stress disorder    Panic disorder  Any psychotic disorder    Schizophrenia   Psychotic disorder NOS  Any substance-related disorder    Alcohol dependence    Drug dependence  Disorders due to GMC    Delirium NOS Personality disorder (=Axis II)

51 (55.4) 14 (15.2) 12 (13.0) 20 (21.7) 10 (10.9) 5 (5.4) 4 (4.3) 7 (7.6) 3 (3.3) 2 (2.2) 25 (27.2) 21 (22.8) 5 (5.4) 15 (16.3) 15 (16.3) 19 (20.7)

GMC, general medical condition; NOS, not otherwise defined; PTSD, post-traumatic stress disorder.

visual-analog scale and has been used in evaluation of mental and physical disorders.21–26 The SDS has shown adequate internal reliability (internal consistency and factor analyses) and construct/criterionrelated validity,22 and we also found the internal consistency excellent (Cronbach’s α = 0.89). The SASS measures social functioning. SASS is a 21-item self-assessment questionnaire developed for measuring social functioning in patients with depression. The questionnaire covers four broad areas of social functioning: work, spare time, family, and ability to organize and cope with the environment. Patients are asked complementary questions to evaluate their motivation, self-perception, and interest and satisfaction in the different roles they have in their everyday life, eg, being a parent, partner, work colleague, and friend.27 The responses are scored 0 to 3 and the total score range is 0 to 60 (questions 1 and 2 are mutually exclusive). SASS has been validated in a survey of more than 3000 individuals in the general population in France and in 496 patients with depression. The “normal” score range, ie, that of 80% of the population, was found to be 35 to 52 and social maladjustment was defined as a total score of less than 25. The test was found to be sensitive to change, both in the total score and in individual items, in patients with depression.27 It has high internal consistency (mean Cronbach´s alpha, r = .74) and test–retest stability across 2-week period (mean coefficient, r = .80). Cronbach’s α in our study was 0.89.

In addition, both at baseline and at 6 months, the subjects answered a single question on a four-point Likert-scale (excellent/good/moderate/poor) concerning their social coping in life during the month prior the burn and during 6 months after the burn.

Statistical Analysis The Student’s t-test and χ2 test were used as appropriate. To examine the independent effects of sociodemographic, burn-related, and psychiatric (preburn and postburn mental disorders) factors, linear regression models were used. First, all variables in Table 1 (sociodemographic) and Table 2 (clinical, burn-related) were calculated in univariate linear regression (Stage I). In addition, the univariate analyses included preburn severe somatic diseases, and the Likert-scale contained questions concerning cosmetic discomfort, discomfort of functioning due to the burn injury in different fields of life (work, leisure time, hobbies, sex life), and the level of limitation of functioning due to the scar. The statistically significant variables of the first stage were then tested together in a multivariate model, variables of Tables 1 and 2 separately (Stage II). Mental disorders were tested in a univariate model at three levels of hierarchy: Axis I and II disorders, subgroups of disorders (eg, any anxiety disorders) and specific disorders (eg, MDD). These were tested in both lifetime and 6-month follow-up time frames. The statistically significant variables of each group of variables (sociodemographic, clinical, and mental disorder variables) were collected to formulate the final multivariate model (Table 5). The overall measure of burn severity, %TBSA, as a clinically important variable was included in this final model, although it did not independently predict at a significant level any of the outcome measures (SOFAS, SDS, and SASS) in multivariate analysis (Stage II, Table 2). Nonstandardized coefficient (B) and P values were used for reporting the results. The data were analyzed with IBM SPSS Statistics 21 software.

RESULTS Descriptive Data of Functioning, Disability, and Adaptation Mean score on SOFAS was 69.7 (SD = 20.8), indicating some difficulty in social and occupational functioning (Table 4). The level of functioning was worse in women than in men (P = .013). The SOFAS scores of those with MDD in follow-up indicated markedly more impairment in social and occupational functioning than among those without (mean 52.9 ± SD

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Table 4. Self-assessment of functioning, disability, and social adaptation at 6 months postburn

SOFAS* SDS total*  Work  Social life  Family life SASS†

Men

Women

Total

Mean (SD)

Mean (SD)

Mean (SD)

P

73.47 (19.10) 7.11 (8.04) 3.06 (3.31) 2.03 (2.60) 2.02 (2.60) 43.15 (8.12)

61.79 (22.25) 11.92 (8.50) 4.88 (3.56) 3.04 (2.88) 4.00 (3.29) 40.72 (10.52)

69.71 (20.78) 8.49 (8.41) 3.59 (3.46) 2.32 (2.70) 2.59 (2.94) 42.44 (8.90)

.013 .013 .026 .116 .004 .253

SASS, social adaptation self-evaluation scale; SOFAS, social and occupational functioning assessment scale; SDS, Sheehan disability scale. Statistically significant P values are presented in bold. *n = 87. †n = 85.

12.5 vs 72.4 ± 20.6; P = .006). Patients with schizophrenia had remarkably lower scores compared with those without (27.5 ± 10.6 vs 70.7 ± 19.9; P = .003). The SOFAS score of those with delirium during follow-up was lower than among those without delirium (51.1 ± 19.1 vs 73.3 ± 19.2; P < .001). Patients who had received economical support as social assistance recipients during the 12 months preburn had lower SOFAS scores than those who did not (56.9 ± 21.3 vs 72.6 ± 19.7; P = .006). The mean SOFAS score of the patients with hand burns was generally higher than among patients with mental disorders (66.8 ± 18.0). Patients with length of stay (LOS) more than 7 days had lower scores than those who stayed 1 week or less (63.0 ± 19.4 vs 78.8 ± 19.3). In the SDS (total score = 8.49, SD = 8.41), we found mild impairment in all three areas of life, with the greatest impairment in work domain (3.59, SD = 3.46). Injured females were more disabled than men in the work and family life subscales of SDS (P values of .004 to .026). The score of SDS total and scores of all three subdomains indicated stronger disability among those patients with MDD in follow-up than those without MDD; SDS total (mean 17.8 ± SD 8.6 vs 7.1 ± SD 7.5; P < .001), SDS work (7.2 ± 2.7 vs 3.1 ± 3.2; P < .001), SDS social (4.8 ± 3.5 vs 1.9 ± 2.4; P = .001), and SDS family (5.8 ± 3.4 vs 2.1 ± 2.6; P < .001). The mean SDS work score indicated more disability in patients with alcohol dependence than among those without alcohol dependence (4.8 ± 3.3 vs 3.0 ± 3.4; P = .026). Patients with LOS more than 7 days had higher SDS scores at 6 months than those who stayed only 1 week or less in hospital; SDS total (10.3 ± 7.2 vs 6.2 ± 9.4; P = .027), SDS work (4.5 ± 3.1 vs 2.4 ± 3.6; P = .004), and SDS family (3.2 ± 2.8 vs 1.9 ± 3.0; P = .043). The mean score in SASS was 42.44 (SD = 8.90). Sex differences were not statistically significant. MDD

during follow-up lowered social adaptation (SASS mean 35.5 ± 9.4 vs 43.4 ± 8.4; P = .005). Personality disorders clearly weakened social adaptation (34.2 ± 9.0 vs 44.3 ± 7.7; P < .001). Patients who needed social assistance recipient preburn had poorer social adaptation at 6 months postburn than subjects who did not need this support (36.6 ± 11.0 vs 43.8 ± 7.8; P = .003). According to the Likert-scale evaluation by survivors themselves, social coping by acute injured at 6 months postburn was at least moderate, with the exception of one patient. More than 80% of the patients scored their level of social coping as good or better while two-thirds (67%) evaluated it as high during the month preceding the burn.

Variables Predicting Functioning, Disability, and Adaptation The sociodemographic and clinical predictors of SOFAS in univariate analyses were history of psychiatric hospitalization (P = .006), need for social assistance recipient (P = .007), length of sick leave due to treatment (P < .001), LOS in hospital (P < .001), and %TBSA (P = .008). There were no strong predictors of SDS total, SDS work, SDS social (history of treatment of preburn psychiatric illness; P = .049) and SDS family among variables in Table 1. Of the variables analyzed and presented in Table 2, the length of sick leave was the strongest predictor of SDS total (P < .001), SDS work (P = .004), SDS social (P < .001), and SDS family (P < .001). %TBSA predicted also SDS total (P = .016), SDS work (P = .003), and SDS family (P = .037) and LOS predicted SDS total (P = .016), SDS work (P = .001), and SDS family (P = .030). Predictors of SASS in the univariate model were need for social assistance recipient (P < .001), and number of outpatient visits after acute treatment in hospital (P = .004).

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e240  Palmu et al

In Stage II with, multivariate analyses of Tables 1 and 2 separately, significant predictive variables for SOFAS were history of psychiatric hospitalization (P = .024), need for social assistance recipient (P = .007), hand burn injury (P = .049), LOS (P = .001), number of outpatient visits (P = .020), and sick leave (P = .005). The other outcome measures were not predictive variables in Table 1, however, in Table 2, LOS (P < .001) and the number of outpatient visits (P = .004) predicted significantly SOFAS and the latter also SASS (P = .005). In multivariate analyses of variables significant in univariate analyses of Table 2 (Stage I), no predictors for SDS were found. In univariate analyses, the lifetime pre-burn Axis I mental disorders overall (P values of

Functioning, Disability, and Social Adaptation Six Months After Burn Injury.

Major injuries commonly cause long-standing functional impairment. The authors investigated the levels of and predictors for functioning, disability, ...
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