Mental health following traumatic physical injury: An integrative literature review

Abstract

Aim

To investigate the state of knowledge on the relationship between physical trauma and mental health in patients admitted to hospital with traumatic physical injury.

Background

Adults who sustain traumatic physical injury can experience a range of mental health problems related to the injury and subsequent changes in physical health and function. However early screening and identification of mental health problems after traumatic physical injury is inconsistent and not routine during the hospital admission process for the physically injured patient.

Methods

Integrative review methods were used. Data were sourced for the period 1995–2010 from EMBASE, CINAHL, MEDLINE and PsycINFO and hand searching of key references. Abstracts were screened by 3 researchers against inclusion/exclusion criteria. Forty-one papers met the inclusion criteria. Data were retrieved, appraised for quality, analysed, and synthesised into 5 main categories.

Results

Forty-one primary research papers on the relationship between mental health and traumatic physical injury were reviewed. Studies showed that post-traumatic stress disorder, depression and anxiety were frequent sequelae associated with traumatic physical injury. However, these conditions were poorly identified and treated in the acute hospital phase despite their effect on physical health.

Conclusion

There is limited understanding of the experience of traumatic physical injury, particularly in relation to mental health. Greater translation of research findings to practice is needed in order to promote routine screening, early identification and referral to treatment for mental health problems in this patient group.

Introduction

Traumatic (physical) injury accounts for 11% of global mortality and is a leading cause of significant physical and psychological disability across all ages.¹ Trauma exerts a multi-dimensional influence on physical health, resulting in changes in employment, subsequent financial status and return to work.2, 3 The personal impact of physical injury on the survivor can have such an extensive effect that it is reported to impinge on all aspects of the person's physical functioning, including sexual function, fatigue levels and ability to carry out general physical activities.⁴

Traumatic physical injury can also lead to a range of mental health problems relating to the injury and associated changes in physical health and functioning. Post-traumatic stress disorder (PTSD), depression and anxiety are increasingly recognised post-injury, however there is a lack of systematic identification and prompt treatment for these conditions.3, 5 Despite knowledge that mental health is an integral aspect in the physically injured patient's recovery and quality of life,⁵ there remains a lack of consistent policy for routine assessment of mental health in traumatically injured patients in Australian hospitals. No previous syntheses of research on the relationship between mental health and traumatic physical injury have been conducted and this review was undertaken to synthesise and report the knowledge base on their co-association and inform clinical practice.

To investigate the state of knowledge on mental health following traumatic physical injury in patients admitted to hospital with traumatic physical injury.

Specifically, the study objectives were to:

• Establish what is known about the relationship between traumatic physical injury and mental health;

• Determine the frequency of depression, anxiety, and post-traumatic stress following traumatic physical injury;

• Identify the subjective experience of traumatic physical injury

An integrative review method was chosen to summarise and synthesise findings from literature. A key difference between this type of review and other rigorous review methods is that the integrative review is inclusive of diverse methodologies.⁶ Given the perceived complexity of the relationship between traumatic physical injury and mental health this method was considered the most appropriate for the present review. The review process involved problem identification, search of current literature, evaluation of recovered data, and analysis.⁷

Four electronic databases EMBASE, CINAHL, MEDLINE and PsycINFO were searched from 1995 to 2010 using combinations of the terms ‘trauma’, ‘mental health’, ‘depression’, ‘anxiety’ and ‘stress’. Further refinement of searching included addition of the term ‘injury’. Key references were also hand searched. The outlined time period was selected as this was inclusive of major advances in knowledge on the relationship between traumatic physical injury and mental health.

The initial search resulted in a total of 197 abstracts following the removal of duplicates. Three reviewers assessed the titles and available abstracts according to inclusion and exclusion criteria. After initial screening, full text articles were retrieved and assessed against inclusion/exclusion criteria. Any disparity between reviewers’ rating were discussed and group consensus reached based on the inclusion/exclusion criteria. Articles published in English that were primary quantitative and/or qualitative research reports on aspects of mental health with admissions to hospital as a result of traumatic injury were included. In the case of reports on injury, this needed to be physical in nature rather than psychological to qualify for inclusion. Therefore, papers which addressed emotional trauma and injury; included participants who were below 16 years of age; were not primary (original) research reports; and/or where participants had not been admitted to hospital, were excluded. Following a rigorous selection process 30 articles were included for review. A further 11 references identified by hand-searching of key articles were included, resulting in a total of 41 papers for review (Fig. 1). Data were extracted from each study according to: research design, sample type and size, data collection tools used, setting, methods, and appraised for quality as per criteria recommended by Polit and Beck.⁸ The 41 studies were read and re-read several times, and in an iterative process findings were compared and contrasted and then synthesised and clustered into emergent and then final categories.