Psychological Implications Resulting From Injuries And Illnesses Across The Lifespan

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R E S E A R C H

ABSTRACT A retrospective study examined in-hospital antidepressant

medication (ADM) use in adult trauma patients with an

intensive care unit stay of 5 or more days. One fourth of

patients received an ADM, with only 33% of those patients

having a documented history of depression. Of patients

who received their first ADM from a trauma or critical care

physician, only 5% were discharged with a documented

plan for psychiatric follow-up. The study identified a need for

standardized identification and management of depressive

symptoms among trauma patients in the inpatient setting.

Key Words antidepressant medication , critical care , depression , injury ,

psychiatry , trauma

Author Affiliations: UnityPoint Health, Des Moines, Iowa (Ms Spilman

and Drs Smith and Tonui); and Fort Sanders Regional Medical Center,

Knoxville, Tennessee (Dr Schirmer).

The abstract was presented at 47th Annual Society for Epidemiological

Research (SER) Meeting, Seattle, Washington, June 24–27, 2014.

None of the authors have any conflicts of interest to disclose.

Correspondence: Sarah K. Spilman, MA, Trauma Services, Iowa Methodist

Medical Center, 1200 Pleasant St, Des Moines, IA 50309 ( sarah.spilman@

unitypoint.org ).

Evaluation and Treatment of Depression in Adult Trauma Patients

Sarah K. Spilman , MA ■ Hayden L. Smith , PhD ■ Lori L. Schirmer , PharmD ■ Peter M. Tonui , MD

approaches require resources and training of hospital personnel. 5 Regardless of the method, however, assess- ment of depression is often confounded by the variable nature of depressive symptoms. Some depressive symp- toms (eg, fatigue, insomnia, weight loss) can be similar to symptoms of other medical illnesses or may resemble temporary conditions, such as delirium or adjustment dis- order. 6 , 7 In addition, trauma patients in the intensive care unit (ICU) may often lack the ability to display or report classic depressive symptoms due to the effects of medica- tion, pain, or sleep deprivation. 8 , 9

A major issue, though, is that many hospitals do not routinely screen for depression or assess depressive symptoms during hospitalization. To our knowledge, there is no consensus as to when assessments (and re- assessments) are appropriate. Symptoms of depression most often are noted through subjective observation by family or nurses and reported to physicians. Because of limited resources, mental health experts are often only involved in the most severe or complicated cases. This is a fundamental problem in that large numbers of patients may be overlooked because of the subjective nature and timing of these observations. Findley and colleagues 4 found that when a psychiatrist was actively involved in the trauma service, identification and treatment of psy- chopathology were increased by 78%. While the rate of mood and anxiety disorders recognized by trauma phy- sicians remained unchanged, involvement of psychiatry resulted in a broader range of psychiatric diagnoses and more than doubled the treatment of substance abuse or dependence.

Complicating matters further, many trauma patients present with preexisting depression. Traumatic injury is related to depression as both a causal factor and a result- ing condition. 2 , 4 , 10 If patients are unable to self-report their health history, the trauma team relies on family report or pharmacy records. This presents challenges in timely reinitiation of medications.

STUDY RATIONALE A review of the medical literature found no relevant published research on physician and medical team re- sponse to depressive symptoms during the patient’s ini- tial hospitalization within settings where mental health screening is not the standard of care. Current research DOI: 10.1097/JTN.0000000000000102

I t is well-established in the literature that critically ill trauma patients can often suffer from depression and posttraumatic stress disorder in the months and years following hospitalization. 1-3 Many hospitals may not have a standardized process for assessing and treat-

ing trauma patients with depressive symptoms. 3-5 During the acute phase of recovery, the trauma team is primarily in charge of treating the injuries and preparing to dis- charge the patient to the next phase of recovery. With- out a standardized process for recognizing, screening, and treating the psychological and emotional needs of the patient, there may be increased risk that depression will go unrecognized and untreated or misinterpreted and improperly treated.

Formal assessment of depression can be accom- plished through clinical interview or screening tools; both

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that examines depression screening has been primarily funded by grant dollars, which provide hospitals with resources to staff special assessment teams (eg, Dicker et al 2 ) and may not represent practices at many hospi- tals. These studies have established the importance of early detection of depression, although this may be ex- tremely difficult in hospitals that do not have protocols for managing depression in the critically ill or special teams for assessing, treating, and reassessing mental health symptoms.

The purpose of this study was to examine how a trau- ma team recognizes and treats depression in the absence of a screening tool and to document antidepressant medi- cation (ADM) usage and prescribing patterns. Study data can assist in the evaluation and understanding of institu- tion processes and possibly help design protocols to miti- gate some of the long-term mental health issues that can result from traumatic injury.

METHODS

Study Design and Patient Sample A retrospective study was performed at an urban tertiary hospital in the Midwestern region of the United States. The hospital’s trauma registry was used to identify adult patients (aged 18 years or older) who met trauma criteria during the 5-year study period of 2008 to 2012. A trauma patient was defined as an individual who sustained a traumatic injury with an International Classification of Diseases, 9th Revision, Clinical Modification code rang- ing from 800 and 959.9, excluding codes for late effects of injury (905-909.9), superficial injuries (910-924.9), and foreign bodies (930-939.9). Patients were included in the study if they were admitted to the hospital and stayed in the ICU for 5 or more days. The study was approved by the hospital’s institutional review board. Psychological Implications Resulting From Injuries And Illnesses Across The Lifespan

Study Data Study variables were grouped into 3 categories: patient and injury characteristics, depression diagnoses, and ADM use. Patient characteristics included gender, race, age, hospital length of stay (LOS), ICU LOS, and mechani- cal ventilator days. Discharge status was coded as alive or deceased, while discharge location was coded as home or institutional setting (including hospice facility, rehabili- tation facility, skilled nursing facility, federal hospital, or intermediate care facility). Psychological Implications Resulting From Injuries And Illnesses Across The Lifespan

Injury characteristics included the Injury Severity Score, which is an anatomical coding system ranging from 0 (no injury) to 75 (most severe). Finally, mechanism of injury was recorded on the basis of the External Causes of In- jury and Poisoning Code (E-Code): Vehicle accident (810- 848), Accidental Fall (880-888), or Other.

Depression diagnoses were assessed retrospectively through chart review. Patients were classified as having a documented history of depression if it was specifically noted in the medical history or if the patient was taking an ADM at the time of hospital admission. If the patient’s history was not obtained at admission, the patient was considered to be on a prior ADM if he or she received a dose within the first 72 hours of the hospital stay. We also noted if a patient received a psychiatric consultation during their stay and if the patient was discharged with a plan for psychiatric follow-up. The latter was used to indicate whether or not discharge instructions included directions for psychiatry follow-up.

The ADM use was ascertained through pharmacy dis- pensing records. Specifically, it was recorded if a patient received any of the following drugs: selective seroto- nin reuptake inhibitors (SSRIs; citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline); selective norepinephrine reuptake inhibitors (SNRIs; desvenlafax- ine, duloxetine, venlafaxine); dopamine reuptake inhibi- tors (bupropion); and alpha-2 antagonists (mirtazapine). Some ADMs were excluded from the study, including tricyclics and monoamine oxidase inhibitors, which can be used to treat other diagnoses in addition to depres- sion; vilazodone, which was not approved by the Food & Drug Administration until 2011; trazodone because it can be prescribed as a sleep aid; and milnacipran because its Food & Drug Administration indication is for fibromyalgia.

The first dispensed ADM was used for basic descrip- tive purposes. For example, if a patient received multiple ADMs during the stay, only the first ADM was used to describe patient treatment. If an ADM was not a medica- tion taken prior to admission, it is hereafter referred to as a new ADM. Days between hospital admission and first ADM dose were used to calculate time of initiation. If an ADM medication was listed in the discharge summary or the patient received a dose of the medication on the last day of the stay, then the patient was classified as being discharged on an ADM.

Statistical Procedures Descriptive statistics were reported for continuous data as medians with interquartile ranges; normality was tested using the Shapiro-Wilk test. Categorical data were re- ported as counts with percentages. Comparative statistics were conducted by stratifying patients based on whether or not they received an ADM during their hospital stay. These groups were examined using the Fisher exact test (nominal variables) and the independent samples Mann- Whitney U Test (2-group medians). All analyses were 2-tailed and based on a 0.05 significance level. Analy- ses were performed with IBM SPSS Basic Statistics for Windows, version 19.0 (IBM Corp, 2010; Armonk, NY).

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Trauma Patients Admitted During Study Period (N=4947)

ICU Length of Stay < 5 Days (n=4635)

ICU Length of Stay > 5 Days (n=312)

Received No Antidepressant Medication (n=230)

Restarted Antidepressant Medication (n=55)

Received New Antidepressant Medication (n=27)

Figure 1. Trauma patients admitted to the hospital during the study period, 2008-2012. ICU indicates intensive care unit.

RESULTS There were 4947 trauma patients admitted to the hospital during the 5-year study period, with 312 (6.3%) staying in the ICU for 5 or more days (see Figure 1 ). Patient char- acteristics are presented in Table 1 . More than two-thirds of the patients in the study sample were male, and the majority of patients were white. Fifteen percent of the patients died.

There were 82 patients (26.3%) who received an ADM during the hospital stay (see Table 2 ). Bivariate analy- ses (not shown) revealed significant differences in age, with older patients more likely to receive an ADM than younger patients ( P = .002). Men were less likely to re- ceive an ADM. There were no significant bivariate differ- ences between patients based on hospital LOS, ICU LOS, ventilator days, Injury Severity Score, discharge location, or injury mechanism.

Patients who received an ADM during the hospital stay were significantly more likely to have a documented his- tory of depression upon admission to the hospital. Specif- ically, 67.1% of patients who received an ADM during the hospital stay were taking an ADM prior to admission and 19.5% had depression mentioned in their medical history. Patients who received an ADM were also significantly more likely to receive a psychiatric consultation during the hospital stay and were more likely to be discharged with a plan for psychiatric follow-up.

Of the 82 trauma patients who received an ADM dur- ing hospitalization, 9 (11.0%) were initiated by a psychia- trist and 73 (89.0%) were initiated by a critical care or other nonpsychiatric physician (see Table 3 ). One-third of patients who received an ADM during their stay were prescribed a new ADM; 29.6% of these new prescriptions were initiated by psychiatry and 70.3% were initiated by a nonpsychiatric physician. There were no significant

differences in ADM choice based on the physician who initiated the medication.

Patients whose ADM was prescribed by a psychiatrist received their first dose many days later in the hospital stay than those patients whose ADM was prescribed by a critical care or other physician. Patients whose ADM was prescribed by psychiatry were also more likely to be discharged with a plan for psychiatric follow-up. Nearly all patients who received an ADM during hospitalization were discharged with the medication, regardless of the provider who initiated it.

DISCUSSION Study data revealed that 26.3% of trauma patients spend- ing 5 of more days in the ICU received an ADM during the hospital stay; 33% of these patients did not have a documented history of depression or ADM use upon ad- mission. This is considerably higher than ADM use in the general population, which is estimated at 10% to 11%. 11 , 12 Female trauma patients were more likely to receive an ADM than male patients, which is consistent with trends in the general population. 12

Trauma or critical care physicians were the practition- ers most likely to continue home ADMs and initiate new ADMs, compared with psychiatry physicians. However,

TABLE 1 Descriptive Characteristics for Trauma Patients With Intensive Care Unit Length of Stay 5 or More Days, 2008-2012 (N = 312) a

All Trauma Patients (N = 312)

Male 218 (70.1%)

White 271 (86.9%)

Median age, y 55.00 (39.75-69.00)

Median hospital length of stay, d 17 (10-25)

Median intensive care unit length of stay, d

8.5 (6-14)

Median ventilator days 5 (1.5-10)

Deceased 48 (15.4%)

Discharged to home 68 (25.8%)

Median injury severity score 25 (15.5-33.25)

Injury mechanism

Vehicle accident 174 (55.8%)

Fall 105 (33.7%)

Other 31 (9.9%)

a Data are presented in medians (interquartiles) and counts

(percentages).

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leads to oversights in posttrauma care. Primary care physicians or other health care providers may not be alerted to the task of titrating the medication, monitor- ing adherence to the medication, and/or evaluating the appropriateness of the ADM in the months and years after the trauma.

when the ADM was initiated by trauma or critical care physicians, patients were frequently discharged without a plan for psychiatric follow-up. This may be a critical omission, especially for patients started on new ADMs. Since the trauma or critical care physician manages care during the acute phase of the injury, this potentially

TABLE 2 Prescription of Antidepressant Medication in Trauma Patients (N = 312) a ADM Received During

Stay (n = 82) ADM Not Received During

Stay (n = 230) Fisher Exact

Test, P b

Documented history of depression 56 (68.3%) 17 (7.4%) < .001

Taking ADM prior to admission 55 (67.1%) 7 (3.0%) < .001

Depression mentioned in medical history 16 (19.5%) 13 (5.7%) < .001

Received psychiatric consultation visit during stay

17 (20.7%) 18 (7.8%) .004

Discharged with plan for psychiatric follow-up c

8 (12.1%) 6 (3.0%) .009

Abbreviation: ADM, antidepressant medication.

a Data are presented in medians (interquartiles) and counts (percentages).

b p values are presented for comparisons between patients based on whether or not they received an ADM during their hospital stay.

c Excludes patients who expired.

TABLE 3 Prescribing Patterns for Patients Who Received an Antidepressant Medication, 2008-2012 (n = 82) a

First Dose Prescribed by Psychiatry (n = 9)

First ADM Prescribed by Other Physician (n = 73) P b

Taking ADM prior to admission 1 (11.1%) 54 (74.0%) < .001

Median days between hospital admission and first dose

12 (7.25-19.75) 2.5 (2-7) .010

New ADM during hospitalization 8 (88.9%) 19 (26.0%) < .001

Escitalopram 5 (62.5%) 6 (31.6%) .206

Citalopram 2 (25.0%) 7 (36.8%) .676

Sertraline 1 (12.5%) 2 (10.5%) 1.00

Paroxetine … 2 (10.5%) …

Mirtazapine … 1 (5.3%) …

Venlafaxine … 1 (5.3%) …

Discharged with plan for follow-up c

4 (44.4%) 4 (5.5%) 0.005

Discharged with prescription for ADM c

9 (100.0%) 62 (93.9%) 1.00

Abbreviation: ADM, antidepressant medication.

a Data are presented in medians (interquartiles) and counts (percentages).

b p values are presented for comparisons between patients based on whether the first dose of an ADM was authorized by a psychiatrist or another

physician.

c Excludes patients who expired.

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The study explores ADM use in the trauma and acute care setting. While ADM use is not a direct measure of de- pression, it serves as a proxy for how trauma and critical care teams recognize and respond to depression in the absence of screening tools. Many hospitals lack a stand- ardized process for assessing and treating trauma patients with depressive symptoms; therefore, we expect that these results are generalizable to other facilities where mental health screening is not standard of care. When a patient is taking an ADM prior to hospitalization, the trauma team must ensure that the medications are restart- ed when the patient is hemodynamically stable. But the situation is less clear in prescribing new ADMs. Initiation of a new ADM may be done when the physician, nurse, or family members recognize emerging symptoms of de- pression or as a preventative approach for symptoms that are likely to emerge in the future.

We recognize that pharmacological intervention should not be the first-line treatment to manage depres- sion. However, since our hospital does not have a stand- ardized screening tool for depression and does not have a mental health care professional embedded in the core trauma team, we believe that these findings are similar to patterns at other hospitals. It is presumed that patients are started on ADMs based on feedback from nursing and family members or recognition of depressive symptoms during the recovery process, but further analysis is war- ranted to determine how these decisions are made. Some patients may be placed on an ADM without warrant, and conversely, depressed patients may go untreated. Both scenarios may complicate recovery and lead to adverse psychological and physical outcomes following the trau- matic injury.

It deserves mention that it would be ideal for all trau- ma patients to be screened for depression and mental health issues. This could potentially improve their recov- ery process and reduce the likelihood of traumatic injury in the future, 2 but such an approach may not be practical in many settings. It is unclear how often patients would need evaluation to detect change, and how well they can self-report their symptoms in the first place. Future re- search efforts should be directed at prospective evaluation of increased involvement of psychiatrists in the treatment of trauma patients, as well as increased use of screening tools for early detection of depressive symptoms. Because our trauma population is primarily older adults, additional analyses should focus on the mental health needs of this aging population and the role that preexisting depression plays in their injury patterns and recoveries.

Limitations This study had several limitations. Identification of the prevalence of depression and ADM use was performed retrospectively. Reliance on medical documentation to

Acknowledgments The authors thank Catherine Hackett Renner, James Rasmussen, and Eric Barlow for assistance in data collec- tion, analysis, and interpretation.

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CR , Silove D . The psychiatric sequelae of traumatic injury . Am J Psychiatry . 2010 ; 167 : 312-320 .

2. Dicker RA , Mah J , Lopez D , et al. Screening for mental illness in a trauma center: rooting out a risk factor for unintentional injury . J Trauma . 2011 ; 70 : 1337-1344 .

3. O’Donnell ML , Creamer M , Bryant RA , Schnyder U , Shalev A . Posttraumatic disorders following injury: an empirical and methodological review . Clin Psych Rev . 2003 ; 23 : 587-603 .

4. Findley JK , Sanders KB , Groves JE . The role of psychiatry in the management of acute trauma surgery patients . J Clin Psychiatry . 2003 ; 5 : 195-200 .

5. Steel JL , Dunlavy AC , Stillman J , Paper HC . Measuring depression and PTSD after trauma: common scales and checklists . Injury . 2011 : 42 : 288-300 .

6. Casey P , Bailey S . Adjustment disorders: the state of the art . World Psychiatry . 2011 ; 10 : 11-18 .

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determine history of depression may be inaccurate in in- stances for patients with an undocumented history of de- pression or patients who received depression diagnoses based on inadequate clinical assessments. Other mental health diagnoses may have been present, such as anxi- ety or adjustment disorder, but they too may have been misdiagnosed, underdiagnosed, or misdocumented. Re- latedly, information was lacking from the medical record if the patient or a family member was unable to provide a medical history upon admission to the emergency de- partment. Given the study design, it was not possible to access compliance with home medications. In particular, an ADM in a patient’s medical history may not neces- sarily depict whether the patient was actively taking the medication prior to admission. Finally, the main focus of the study was to examine how physicians assess and treat depression in trauma patients admitted to the ICU for 5 or more days, which does not allow for generalizations toward general trauma populations.

CONCLUSIONS Despite difficulties in the diagnosis of depression in trauma patients, critical care physicians and psychiatrists do initiate ADMs in patients who exhibit symptoms of clinical depression. This study identifies a need to more accurately identify depressive symptoms among trauma patients and reveals a need for protocols to assess for mental health diagnoses and manage ADM use among trauma patients in the inpatient setting and postdis- charge.

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8. Beliles K , Stoudemire A . Psychopharmacologic treatment of depression in the medically ill . Psychosomatics . 1998 : 39 : S2S19 .

9. Jackson JC , Hart RP , Gordon SM , Hopkins RO , Girard TD , Ely EW . Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem . Crit Care. 2007 ; 11 : R27 .

10. O’Donnell ML , Creamer M , Pattison P . Posttraumatic stress disorder and depression following trauma: understanding comorbidity . Am J Psychiatry . 2004 ; 161 : 1390-1396 .

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12. Pratt LA , Brody DJ , Gu Q . Antidepressant use in persons aged 12 and over: United States, 2005-2008 . NCHS Data Brief . October 2011 : 76 .

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