|Year : 2015 | Volume
| Issue : 1 | Page : 37-42
Assessment of the depression and the quality of life in burn patients seeking reconstruction surgery
Akhilesh Jain1, Sunil Rathore2, Rakesh Jain2, Ishwar Dayal Gupta3, Ghisu Lal Choudhary2
1 Department of Psychiatry, SMS Medical College and Hospital, Jaipur, Rajasthan, India
2 Department of Plastic Surgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
3 Department of Psychiatry, ESI Model Hospital, Jaipur, Rajasthan, India
|Date of Web Publication||11-Dec-2015|
Dr. Sunil Rathore
Department of Plastic Surgery, SMS Medical College and Hospital, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background/Purpose: With the remarkable progress in the field of burns treatment, the outcome of extensive burns improved significantly. The increased likelihood of survival of a burn victim heightens concerns for potential psychological morbidity. Our aim of this study was to find out the magnitude of depression in burn patients, quality of life (QOL) in cases as compared to control, the correlation between depression and QOL, and the predictive factors for QOL in burns. Materials and Methods: The study sample comprised of 60 patients with burn between ages of 18 years and 65 years seeking consultation for reconstructive surgery. An equal number of healthy controls of similar age and sex were also enrolled to make a comparison group. Participants were assessed for the presence of depression and QOL by using patient health questionnaire (PHQ-9) and World Health Organization quality of life-BREF scale, respectively. Result: Depression was found statistically significant in burn patients as compared to control. 28.33%-mild, 25%-moderate, 23.33%-severe, and 15%-moderately severe as compared to control, where 86.67% of study sample had no features of depression (P < 0.001). The overall QOL was found significantly lower (32.75 ± 10.33 vs. 69.44 ± 10.87) (P < 0.001). A significant inverse fair correlation existed between the PHQ-9 and QOL. Lower QOL in burn patients positively associated with multiple factors like female patients, the involvement of exposed part, facial burn, etc. Conclusion: The high prevalence of clinically significant depression and lower QOL of in burn reconstruction patients and their relationship with body image suggest the importance of the routine psychological screening and the treatment of patients seeking reconstruction surgeries.
Keywords: burn reconstructive surgeries, patient health questionnaire-9, World Health Organization quality of life-BREF
|How to cite this article:|
Jain A, Rathore S, Jain R, Gupta ID, Choudhary GL. Assessment of the depression and the quality of life in burn patients seeking reconstruction surgery. Indian J Burns 2015;23:37-42
|How to cite this URL:|
Jain A, Rathore S, Jain R, Gupta ID, Choudhary GL. Assessment of the depression and the quality of life in burn patients seeking reconstruction surgery. Indian J Burns [serial online] 2015 [cited 2020 Jan 29];23:37-42. Available from: http://www.ijburns.com/text.asp?2015/23/1/37/171647
| Introduction|| |
Advances in emergency services and burn care in recent years have improved immensely, decreasing the mortality rates substantially, and increasing the number of people living with large scars resulting from burns , related to this, the number of reconstructive surgeries performed as a result of a burn injury has been significantly increased.
The primary reason for undergoing reconstructive surgery is to improve function, comfort, and appearance.  A major burn injury can cause considerable damage to skin integrity and often leads to hypertrophic scarring. Among survivors of burn injuries, both body image dissatisfaction, and functional impairment have been associated with depression 5 years or more after the injury. ,
The estimates of the rate of depression among burn survivors vary widely due to the use of different assessment instruments and cutoffs, small sample sizes, and variations in burn severity across samples. Three studies have used validated questionnaires to assess symptoms of depression in adult burn survivors 12 months after discharge. Ward et al.  reported that 22% of 139 burn survivors had at least mild symptoms of depression as assessed by beck depression inventory (BDI) 1-8 years after burn injury. Wiechman et al.  reported that 34% of 129 survivors scored 8 on the BDI at 12 months and that 45% scored 8 at 2 years after burn injury. Pallua et al.  reported a rate of 18% with severe depressive symptoms among 92 survivors on an average of 5.4 years after injury using the Center for Epidemiological Studies Depression Scale (CES-D). For most burn survivors, average scores on depression indices fall within the mild to moderate range. ,,
Accumulating evidences of different studies suggest that prolonged functional impairment, bad cosmetic appearance, and subsequent psychological distress symptoms have a short- and long-term impact on health, function, and quality of life (QOL). Moreover hypertrophic scarring, which can result in disfigurement coupled with psychological components is devastating that affects QOL of burn victims. Nitescu et al.  in their study assessed the impact of burn scars on the QOL of the survivors using World Health Organization (WHOQOL)-BREF, and concluded that burn scar visibility and severity did have a strong relationship with the QOL in the survivors of a major burn who received allotransplant. Very few studies targeting the psychological consequences and its impact on QOL have been conducted in India. Hence, the present study was designed to assess depression in burn patients seeking reconstructive surgery. This study also aims at exploring the QOL in burn patients and understands the clinical correlation between depression and QOL. Risk factors associated with poor QOL were also addressed in this study.
| Materials and Methods|| |
This cross-sectional study was conducted in Department of Burns and Plastic surgery in a tertiary care super specialty treatment center. The Ethical Committee approval was obtained. The nature and purpose of the study were explained to all the participants, and informed consent was obtained prior to their inclusion in the study sample.
The study sample comprised of 60 patients with burn between ages of 18 years and 65 years seeking consultation for reconstructive surgery. An equal number of healthy controls were also enrolled to make a comparison group. Utmost care was taken to ensure the homogeneity of the sample population by recruiting the close relatives or friends of the patients of nearly same age and sex.
The participants were excluded from the study, if they were known to have current substance abuse disorder using Diagnostic and Statistical Manual, Fourth edition (DSM-IV) criteria, to have current or past psychosis or mania or any other mental disorder using DSM-IV criteria except existing major depressive disorder (MDD) to have major medical or surgical problem other than what may have been caused by burn.
Patients were evaluated in detail, and their clinical, and sociodemographic profile was recorded in a specially designed semi-structured Performa by interviewing the participants and exploring the medical records including investigations. Participants were also assessed for the presence of depression and QOL by using patient health questionnaire (PHQ-9) and WHOQOL-BREF, respectively.
PHQ-9, a self-report version of PRIME-MD11, which assesses the presence of MDD using modified DSM-IV criteria. , In this study, Hindi version of PHQ-9 was used. 
WHOQOL-BREF, questionnaire aims to assess the extent to which significant aspects of a person's life have been affected, rather than what symptoms and disabilities are present. The WHOQOL-BREF was developed by the WHOQOL Group, in 15 international field centers.  It is a self-report questionnaire that contains 26 items. In this study, Hindi version  is used.
Statistical analyses were done using computer software IBM SPSS version 20.0 (trial version) for windows stastical software package (SPSS inc., Chicago, IL, USA). The qualitative data were expressed in proportion and percentages and the quantitative data expressed as mean and standard deviations. The difference in proportion was analyzed by using Chi-square test, and the difference in means were analyzed by using Student's t-test and one-way ANOVA, and linear regression and correlation analyses were performed using Pearson correlation coefficient. A significance level for tests was determined as 95% (P < 0.05).
| Result|| |
The study was conducted on the 60 burn patients and 60 controls. The mean age of the study group and control was 26.95 ± 7.77, 25.34 ± 5.56 (P = 0.19 NS) years, respectively, with the male:female ratio 3:2 in both groups. Among cases 14 (23.3%) patients had burns of <6 months duration, whereas 23 (38.3%) each had a duration of burn between 6 and 12 months and more than 12 months, respectively. The majority of the patients had the flame type of burn (65%) followed by electrical burn (20%); scald burn (11.7%); and chemical burn (3.3%). Almost half of the patients (48.3%) had 20-40% total body surface area (TBSA) involved followed by 40% of the patients with 10-20% TBSA. Fifty-five percent of the burn patient had involvement of exposed parts such as face, neck, and upper extremities, whereas 45% had involvement of nonexposed area of the body. Functional impairment was present in 40 (66.7%) patients. Postburn facial and nonfacial deformity were encountered in 28.3% and 71.7% patients, respectively. According to the type of deformity, scar, contracture, and nonhealing wounds/amputation were in 24 (40%), 29 (48.3%), and 7 (11.3%) patients, respectively [Table 1].
The mean value of the PHQ-9 score in cases was 13.38 ± 6.87 as compared to 0.5 in control. The depression was statistically found very common in burn patients as compared to control. A significant difference was observed among the groups according to PHQ-9 grading of depression. 28.33% cases were in mild type, 25% in moderate, 23.33% in severe type, and 15% in moderately severe as compared to control where 86.67% of study sample had no features of depression, only 6 (10%) were in minimal, and 2 (3.33%) were in mild grade of depression. A significant difference was observed according to PHQ-9 scale among the groups, the severity of depression were more in cases as compared to control (P < 0.001S) [Table 2].
The mean QOL score was significantly lower in cases as compared to controls (32.75 ±10.33 vs. 69.44 ± 10.87) (P < 0.001) [Table 3]. We studied the relationship of all domains of QOL (physical, psychological, social, and environmental) with a demographic profile and burned characteristics. None of the sociodemographic characteristics had statistically significant association with QOL except gender where we found that female patients had poor QOL in psychological domain (D2) as compared to other domains where mean value (33.83 ± 13.67) was significantly higher in male as compared to female (24.21 ± 10.43) (P < 0.05). Among burn characteristics, TBSA had a positive inverse correlation with QOL in respect of all domains. However, the statistical correlation was established with psychological (D2) and environmental (D4) domains (P < 0.05). Similarly, QOL was poor in all domains except D4 among those patients who had a involvement of exposed parts as compared to nonexposed part mean 24.88 vs. 38.48 in D1 (P < 0.001S); 25.30 vs. 35.70 in D2 (P < 0.002S); and 27.52 vs. 37.93 in D3 (P < 0.001S) domain. The functional impairment was also found to have a significant association with poor QOL in D2 and D4 (P < 0.05). All the domain scores were inversely correlated with facial burn deformity. This finding was statistically significant in respect of D1, D2, and D3 (P < 0.05). The type of deformity was found to have a positive correlation with poor QOL in D4 only which scored significantly lower in the nonhealing wound. Likewise, the duration of the burn had a significant association with poor QOL in D3 and D4 (P < 0.05) where score were less with longer duration of the burn. On applying post-hoc test (Turkey Test), it was observed that in nonhealing type/amputation had a significantly lower QOL as compared to scar and 6-12 months duration had a significantly lower QOL as compared to <6 and more than 12 months duration [Table 4].
|Table 4: Association of demographic and burn characteristics with QOL in study sample|
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A significant inverse fair correlation existed between the PHQ-9 and QOL. The patients with high grade of depression had poor QOL (r = 0.306, P = 0.018S) by using Pearson's correlation coefficient. The r2 = 0.093, it means 9.3% of the total variation in QOL was explained by the linear relation with PHQ-9. The relationships between the variables in the patient group were considered by using Pearson's correlation coefficient [Table 5].
| Discussion|| |
This study was unique in a sense that not many studies have been conducted in this subcontinent among burn patients to assess their QOL and its determinants. This study included an equal number of healthy controls to have a distinct and comparative assessment regarding the presence of depression and QOL. The mean age of burn patients in this study was 26.95 ± 7.77 years which corresponds to the commonly afflicted age group as has been reported in other studies.  The higher possibility of sustaining burn injury in this age group may be attributed to several factors like a potential age to remain engage in high-risk work condition. Burn injuries are more common in males than females. Tyson et al. 2013  in his study, has reported similar findings. This may result because that male has more outdoor activities. Furthermore, the addiction is more common in males which lead to accidental injuries, suicide attempts, assault, vehicle blast, and unintentional injury due to alcohol and/or drug abuse. In this study, the most common type of burn was flame burn. In the Indian context, the study of Khan et al. 2015 , also reported flame as a most common type of burn in 46.34% patients. Time since the burn was more than 6 months in most of the patients. Similar observation has been made by van der Wal et al. 2012  in his study, as the burn scar itself takes 6-12 months to attain the maturity before the reconstructive surgery could take place.
This study also explored the presence of depression in burn patients. Depression was strongly associated, 82.33% burn patients reported mood symptoms. However, on applying stringent criteria to identify presence of clinically significant depression, that is, PHQ-9 score 10 or above as has been used in other studies measuring depression,  still 63.33% patients were reported to have clinically significant depression. This rate is substantially higher than the 18% and 34% reported in two long-term studies of burn patients by Pallua et al. 2003  and Loncar et al. 2006  that used standard cutoffs of the BDI and CES-D, respectively, to assess depression. This rate was even higher than 45% prevalence rate reported at 2 years postburn in another study by Wiechman et al. 2001.  Thomas et al., , in their consecutive year series have reported mild depression in 22-54%, moderate depression in 13-26%, and 18% cases with severe depression. The presence of depression in these patients can be well understood on the pretext of undergoing significant stress due to distortion in appearance and disfigurement, functional impairment, social isolation, associated pain, restricted movement all cumulatively leading to development of depression.
We also examined the QOL among burn patients as an important and integral part of this study and analyzed the risk factors associated with poor QOL. In our study, overall QOL was significantly poor (mean value WHOQOL 32.75 in cases as compared to control group WHOQOL 69.44), which is similar to other study by Nitescu et al. 2012  Functional impairment, disability, restricted movements, social isolation, loss of productive work, and financial burden associated with secondary psychological problems are likely to be implicated in contributing toward poor QOL. We observed the correlation of all domains of QOL, that is, physical, psychological, social, and environmental domain with sociodemographic and burn characteristics, that is, total burn surface area involved parts (exposed/nonexposed), functional impairment, postburn deformity (facial/nonfacial), type of deformity (scar/contracture/nonhealing wounds/amputation), and the duration of burns. QOL was poor in females as compared to males, which is a consistent finding with another Indian study by Lal et al. 2006,  and many other studies such as Tahir et al. 2011  and Van Loey and Van Son 2003.  This can be explained as females are poorly entitled to social support, have poor emotional and avoidant coping styles, which negatively affects adjustment after burn injury. The results are equivalent to the study by Dyster-Aas et al. 2007  This finding further gets strengthened with another observation that contracture and limb amputation had a positive correlation with poor QOL as compared to those with other burn deformity like scar and supported by Leblebici et al. 2006.  QOL was inversely proportional to total burn surface area involved. Larger the total burn surface area was involved, greater were the chances of poor QOL. A similar correlation was established by Anzarut et al. 2005.  Larger burns require a longer period to heal, this also imposes more chances of contracture and subsequent disfigurement requiring more reconstructive surgeries and consequential escalation of financial burden influencing the QOL negatively. Burn at the exposed area was positively associated with poor QOL as compared to burn in the nonexposed area. This observation is consistent with the study by Nitescu et al. 2012.  Burn at an exposed parts of face, upper limb, and feet is likely to create more body image dissatisfaction, loss of confidence, loss of interest in outdoor, and social activities and self-reproach. All these factors directly or indirectly affect QOL. Patients with facial burn had poor QOL than those with a nonfacial burn. Misra et al. 2012  have described the analogous report. The face is considered to be a vital component of one's personality and body image. Facial burn has issues accompanied by anxiety and social isolation that ultimately affect QOL. QOL was adversely correlated with a duration of burn as has been reported in the past by Dyster-Aas et al. 2007.  Longer duration of burn was associated with poor QOL. This may have been caused by associated chronic pain, disfigurement, and poor psychosocial adjustment after the lapse of the significant period and patient losing hope to revert back to his earlier look. In the present study, a significant inverse fair correlation existed between the PHQ-9 score and QOL. As the severity of depression increases, QOL becomes poorer. To the best of the author's knowledge, none of the studies in past has attempted to establish a correlation between depression and QOL in burn patients.
| Conclusion|| |
Postburn deformity seems to be the major significant negative outcome after survival from of a burn injury. Deformity in any form is devastating and can result in disfigurement that affects QOL, which in turn can lead to depression, lowered self-esteem, social isolation, prejudicial societal reactions, and job discrimination. Scarring has also profound rehabilitation consequences including loss of function, disability and difficulties in pursuing recreational, and vocational pursuits. In our study, burn scar visibility and severity did have a strong relationship with the QOL and depression in the survivors of a major burn who are seeking for reconstructive surgery. Therefore, more effort must be placed on developing psychosocial interventions that help survivors to accept scars, reduce depression, and improve the outcome of the surgery. Specialized burn care centers using a multidisciplinary approach should not only successfully treat large burns and their complications, but should also provide the necessary rehabilitation and psychological support required for readjustment back into society.
Limitation of study
Sample size should have been still larger to infer the interpretation in a wider perspective. It would have been even more informative and comparable if the control group had involved patients planned for some other kind of reconstructive surgery excluding burns.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]