ReviewMental health following traumatic physical injury: An integrative literature review
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:
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Establish what is known about the relationship between traumatic physical injury and mental health;
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Determine the frequency of depression, anxiety, and post-traumatic stress following traumatic physical injury;
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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.
Section snippets
Results
The 41 papers were grouped into five categories according to the findings of the analysis: Acute Stress Disorder and physical injury; Post-traumatic stress disorder (PTSD) and physical injury; Anxiety and physical injury, Depression and physical injury, and subjective experiences of physical injury. Pre-injury mental health status was not identified in many of these studies. Summary findings of the papers are provided in Table 1. The majority of studies (35/41) used quantitative methods;
Discussion
Literature investigating the relationship between traumatic physical injury and mental health was predominantly empirical in nature; hence knowledge of mental health of patients with traumatic physical injury is primarily quantitative. However, the findings of both quantitative and qualitative studies were generally supportive of each other. The majority of studies highlighted the need for further investigation into mental health problems associated with traumatic physical injury, particularly
Implications for clinicians
There are some key implications for clinicians caring for the traumatically injured patient arising from this review. Van Horn3 emphasised the importance of case management for mental health screening in traumatically injured patients. While trauma case management during the acute hospitalisation phase has been demonstrated to improve time to allied health intervention, decrease patient morbidity and reduce hospital length of stay,48 this review indicates there is a need for mental health
Conclusion
Traumatic physical injury is strongly associated with subsequent mental health problems. If these problems are identified early, the associated morbidity can be reduced. However there is a distinct lack of translation of existing research findings in clinical practice, including the use of routine mental health screening post traumatic injury. This review has identified that routine mental health screening in this patient cohort could enable identification, early referral and intervention in
Funding statement
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical approval
Nil ethics approval has been sought as the paper is a review of literature.
Conflict of interest
No conflict of interest has been declared by the authors.
Acknowledgments
Nil.
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