|Year : 2012 | Volume
| Issue : 1 | Page : 57-61
Assessment of psychological status and quality of life in patients with facial burn scars
Anshumali Misra1, Deepti Munshi Thussu2, Karoon Agrawal1
1 Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjang Hospital, New Delhi, India
2 Department of Psychiatry, Base Hospital, New Delhi, India
|Date of Web Publication||13-May-2013|
J3/63 DDA Flats, Alaknanda Kalkaji, New Delhi - 110 019
Introduction : This study was carried out in the Department of Burns, Plastic and Maxillofacial Surgery, Safdarjang Hospital, New Delhi. Aim : The aim of this study was to assess the psychological status of patients with facial burn scars and to assess the quality of life (QOL) of these patients. Materials and Methods : The study was performed on 20 patients who were interviewed to assess depression (psychological status) and QOL. The assessment of depression was carried out using Beck's depression inventory, which has been translated into Hindi for use. The depression based on this questionnaire was graded into present or absent and further into mild, moderate and severe if present. QOL was assessed using the World Health Organization (WHO) QOL index questionnaire. The QOL was assessed to determine the environmental well being, adjustment to social relations, psychological well being and physical health and level of independence. The assessment of the patients was compared with the general population of similar socioeconomic strata. Results : The study showed presence of depression in all the studied subjects, with more females in the moderate and severe group of depression and more males in the mild group of depression. QOL assessment revealed significant derangement of psychological well being and social interaction in all subjects, but the physical abilities and environmental interaction were comparable to the normal subjects. Further, it is concluded to carry out larger and well-designed studies in burn and trauma patients to establish a protocol for assessment and management of post-traumatic stress disorders.
Keywords: Burn scars, depression, quality of life
|How to cite this article:|
Misra A, Thussu DM, Agrawal K. Assessment of psychological status and quality of life in patients with facial burn scars. Indian J Burns 2012;20:57-61
|How to cite this URL:|
Misra A, Thussu DM, Agrawal K. Assessment of psychological status and quality of life in patients with facial burn scars. Indian J Burns [serial online] 2012 [cited 2014 Dec 19];20:57-61. Available from: http://www.ijburns.com/text.asp?2012/20/1/57/111787
| Introduction|| |
Burn injuries are a major cause of mortality and morbidity in our country. Every year, an estimated 6-7 million people in our country suffer burn injuries. Of these, nearly 10% require admission and approximately 1-1.5 lakh people are crippled every year. 
Such is the magnitude of the situation that any reference to burn injuries highlights only the physical damage that is caused by this phenomenon, more so in a populous country like ours where resources are limited and optimal utilization is the key.
With advancements in medical research and development of new products such as artificial dermis, negative pressure therapy, limited access dressing, collagen dressings and silver impregnated dressings, the survival rates of burn patients are bound to improve. This makes the smooth and functional amalgamation of the burn survivor in the society, a final desired outcome. However, in the present scenario, especially in India, most of the burn care community is oblivious to the psychosocial requirements of the burn victim. The need for psychological support in all stages of burn care is usually overlooked.
Burn survivors experience a series of traumatic assaults to the body and mind that present extraordinary challenges to psychological resilience. Of any given sample of adult burn survivors most subjects demonstrate psychological/social difficulties. 
Facial and body disfigurement as a result of burns are known causes of profound shame, stigmatization and isolation. Deep burns frequently result in damage or loss of functionally and cosmetically important body parts. Many of these burn victims suffer long-term morbidity as a result of functional impairment and severe facial defects.  Also among the burn patients, facial burn survivors reported low psychosocial scores compared with those with no facial burns.  Facial burns are also considered an important factor in the development of post-traumatic stress disorder.
Thus, all burn afflicted individuals need help and many require psychiatric consultation; their psychiatric care is as challenging as their surgical care. 
Proper assessment and intervention at the right time may prove very valuable for such patients. One of the methods for comprehensive evaluation of a patient's health status is quality of life assessment, which is an individual's perception of his position in life, in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.
Considering the effect of facial disfigurement on self-esteem and perceived social rejection, the consequent QOL impairment is another indicator to the morbidity experienced by these patients.
Considering these, we planned this study to assess the quantum of psychological problems (depression) and the consequent QOL impairment in facial burn survivors. A comparison on these parameters between patients with and without facial deformity was also performed. The results would help in identifying and focusing in the much neglected direction of psychological care in burn survivors.
| Materials and Methods|| |
A questionnaire-based study was conducted in the Department of Burns, Plastic and Maxillofacial Surgery, Safdarjang Hospital, New Delhi, to study the presence and level of depression and to assess the QOL of patients with facial burn scars.
A total of 20 patients were included in the study, of which eight were males and 12 were females. All patients included in the study were more than 18 years of age. Only thermal burn patients were included. The 20 patients were divided into two groups:
All the patients had sustained burns at least 6 months from the time of interview to a maximum of 5 years. Informed consent was obtained from each participant for participating in the study.
- Group 1: Patients with facial burns without deformity of the face, and
- Group 2: Patients with facial burns with deformity of the face.
Patients with deformities of any other part of the body coupled with facial burns, pediatric patients and patients with comorbid conditions and previous history of any psychiatric illness were excluded from the study.
Beck's depression inventory (World Health Organization [WHO] prescribed) was used for assessment of the psychological profile of the patient. The 21 question format (Hindi version) was used for assessment.
The grading was as follows 
Patients were familiarized with the questionnaire format prior to actual assessment by explaining the format in the native language.
- 0-9 - no depression
- 10-15 - mild depression
- 16-23 - moderate depression.
- 24 and above - severe depression
QOL was assessed by using the WHO Quality of Life questionnaire - brief (Hindi version). The QOL was assessed under the following parameters:
These were categorized as domains. Scores were given for these domains labeled as raw scores, which were then converted to transformed scores based on standard tables. The questionnaire had questions in random order for all the domains to reduce predictability of response. Comparison of these scores was done with scores of 20 subjects from the general population randomly selected but matched for age, sex and socioeconomic status. P value was then calculated for the scores using the paired t-test, and the level of significance was P < 0.05.
- Physical health and level of independence
- Psychological well being
- Social relationships and
- Environmental adjustability.
A single interview was conducted for the study in which the patient was assessed on both the questionnaires.
| Results|| |
Male and female participants and their groups are as shown in [Table 1].
Of the eight male patients, six patients had scores in the range of 10-15, and were graded into the mild depression group (approximately 80%). Two patients had scores of 16 and above, and were grouped in the moderate depression group. No male patient was found to have severe depression. No difference was found in the scores of group 1 and group 2 patients [Figure 1].
Of the 12 female patients, six patients had scores of 24 and above, and were graded into severe depression group; six patients had scores of 16 and above and were grouped in the moderate depression group. No female patient was found to have mild depression. No difference was found in the scores of group 1 and group 2 patients [Figure 2].
Quality of life
The assessment of QOL was done by assigning scores in each of the four domains listed. The score that each participant achieved was termed as the raw score. This score was then converted to a transformed score using standard tables in which the 0-100 series was used [Figure 3]. 
|Figure 3: The values for conversion of raw scores into transformed scores for the quality of life questionnaire|
Click here to view
Domain 1:- Physical health and level of independence:- In this group, the study group had a transformed score of 68.9 whereas the control group had a score of 84.5. The calculated P value was 0.333, which was not significant.
Domain 2:- Psychological well being:- Of a total of 100, the mean study group-transformed score in this group was 35.1 and the mean score of the control group was 81.4. The calculated P value was 0.0006, which was highly significant.
Domain 3:- Social relationships:- This domain had a mean study group score of 28.5 and mean control group score of 77.5. The P value deduced was 0.001, which was statistically significant.
Domain 4:- Environmental Adjustability:- In this domain, the mean study group score was 51.3 and that of the control group was 72.4. This difference was not found to be statistically significant as the P value was 0.108 [Table 2].
| Discussion|| |
Depression is a very important aspect of the milieu of sickness, and is probably a component of all conditions requiring prolonged duration of treatment. Burns is one such condition where it is not only the physical pain but also the financial losses and the domestic and social burden on the victim and the family that has a major role to play in the final outcome of the disease process. Burn accident survivors are constantly grappling with the problems of scars, contractures and a multitude of other deformities, having a profound impact on their daily life. All this is theoretically plausible and possible but what actually is the quantum of the problem? Does depression exist in burn wound survivors? Does it affect their daily life and have an impact on their physical abilities and interpersonal and environmental relationships? An effort was made to answer these questions with this study, where patients with facial burns were taken who were otherwise clinically healthy and were able to carry out their day-to-day activities normally.
The study showed an equivocal presence of depression in all the burn scar patients, irrespective of their gender. In a study by Thombs BD et al.,  conducted on 224 patients, mild to moderate depression was found in at least 46% of the cases. In another study by Stubbs, TK  conducted on burn-afflicted children for health-related QOL, teenagers between the ages of 11-18 years, who had sustained facial burns during their childhood, were found to have significantly low psychosocial scores as compared with the patients who had burns in hidden parts of the body. In another study by Tedstone JE and Tarrier N  it was found that patients with burn injuries as less as 1% also experienced clinically significant levels of psychological difficulties post-burn.
The present study highlighted the gender variation of post-burn depression, which has not been previously dealt with in burn survivors. Men were found to have a lower degree of depression as compared with women. None of the women in the study were found to have mild depression as compared with the men, 80% of whom had mild depression. Also, while 50% of women had severe depression, this was absent in the male group. One possible explanation for this phenomenon in the Indian setup could be the fact that men are traditionally the bread winners of the family and hence are forced to step out in the society to work and earn. Acceptance by the colleagues and the society with the scars may be a determinant in reducing the psychosocial burden in the male population. As this study takes into consideration only the facial burn scars, and because beauty is a feminine attribute, it has a higher importance for women thus adding extra pressure in the female mindset.
The physical abilities and social and interpersonal relationships of the above-discussed group were put to test by the QOL questionnaire. As was expected, none of the patients had any problem in physical work (P value = 0.33). Environmental adjustability was also found to be similar to the control population probably due to the absence of physical deformities. But, comparison of the test and control groups in the categories of psychological well being and social relationships showed marked difference between the two groups, with P values of 0.0006 and 0.001, respectively. In their study, Rossi LA et al. concluded that for burn patients, QOL is associated with the concept of normality, the satisfactory performance of social roles in the context of family life and the social world. In another study by Von Loey NE et al., they emphasized that both injury severity and psychological problems play a pivotal role in reduced health-related QOL, and the speed of recovery in burn patients and routine screening for the traumatic stress disorder was suggested by the authors. The above findings highlight the impact of burn injury on the psychological well being of the patient, and, in turn, the changes brought in the overall QOL, although definitive recommendations cannot be made due to a small sample size. The small sample size is due to the fact that pure facial burns are few in number and inclusion of burns of any other parts of the body would have confounded the results of this study.
| Conclusion|| |
Trauma in any form has a profound impact on the mind of the victim and brings about changes in the whole personality of the patient. This fact has to be understood and acted upon. As suggested by the findings of this study, all patients had post-burn depression that had previously not been documented. The authors would like to suggest that post-burn depression is an entity to reckon with and a standard protocol for evaluation and management of this entity should be formulated and implemented in all centers dealing with burn injuries.
| References|| |
|1.||Gupta JL, Makhija LK, Bajaj SP. National programme for prevention of burn injuries. Indian J Plast Surg 2010;43:S6-10. |
|2.||Faber A, Klasen H, Sauer E, Vuister F. Psychological and social problems in burn patients after discharge: A follow-up study. Scand J Plast Reconstr Surg 1987;21:307-9. |
|3.||Patterson C, Everett J, Bombardier C, Questad K, Lee V, Marvin J. Psychological effects of severe burn injuries. Psychol Bull 1993;113:362-78. |
|4.||Madianos MG, Papaghelis M, Ioannovich J, Dafni R. Psychiatric disorders in burn patients: A follow-up study. Psychother Psychosom 2001;70:30-7. |
|5.||Stoddard FJ. Care of Infants, children and adolescents with burn injuries. In: Lewis M, editor. Child and adolescent psychiatry: A comprehensive textbook. 3 rd ed. Baltimore: Williams and Willkins; 2002. p. 1188-208. |
|6.||Beck AT. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71. |
|7.||WHOQOL Group. Measuring Quality of Life: The development of the World Health Organization Quality of Life Instrument (WHOQOL). Geneva: World Health Organization; 1993. |
|8.||Thombs BD, Haines JM, Bresnick MG, Magyar-Russell G, Fauerbach JA, Spence RJ. Depression in burn reconstruction patients: Symptom prevalence and association with body image dissatisfaction and physical function. Gen Hosp Psychiatry 2007;29:14-20. |
|9.||Stubbs TK, James LE, Daugherty MB, Epperson K, Barajaz KA, Blakeney P, et al. Psychosocial impact of childhood face burns: A multicenter, prospective, longitudinal study of 390 children and adolescents. Burns 2011;37:387-94. |
|10.||Tedstone JE, Tarrier N. An investigation of the prevalence of psychological morbidity in burn-injured patients. Burns 1997;23:550-4. |
|11.||Rossi LA, Costa MC, Dantas RS, Ciofi-Silva CL, Lopes LM. Cultural meaning of quality of life: Perspectives of Brazilian burn patients . Disabil Rehabil 2009;31:712-9. |
|12.||Van Loey NE, van Beeck EF, Faber BW, van de Schoot R, Bremer M. Health-related quality of life after burns: A prospective multicenter cohort study with 18 months follow-up. J Trauma Acute Care Surg 2012;72:513-20. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]