Psychiatric morbidity, quality of life and self-esteem in patients with burn scars

 

 

Abstract               Objective: Sustaining a burn injury is considered a devastating event and it is associated with both physical and psychological problems. With advances in medical management of burn scars, addressing the physical problems has greatly improved. But many patients suffer from significant psychological impact of burn scars. This study aimed to assess the psychiatric morbidity including depression and anxiety and also the quality of life and self-esteem in burn scar patients. Methods:            This was a cross sectional observational study conducted in a tertiary care hospital in India. 30 patients with burn scars of more than 6 months duration were chosen for the study. Psychiatric morbidity was assessed by General Health Questionnaire- 28 (GHQ-28), depression and anxiety by Hamilton rating scale for Depression (HAM-D) and Hamilton rating scale for anxiety(HAM-A) respectively. The quality of life was assessed by Dermatological quality of life index (DLQI) and self-esteem assessed by Rosenberg self-esteem scale. Statistical analysis was done using SPSS version 20 Results: There was very high psychiatric morbidity (56.7%) and high rates of depression (43.3%) and anxiety (23.3%) in the cases. Also 46.6% reported very large effect in quality of life due to burn scars. The average self-esteem score in the cases was low. Shorter duration of scars, lesions on exposed areas, extensive lesions were associated with significantly more psychiatric morbidity, depression and anxiety and lower self-esteem and quality of life. Depression was more in patients with facial scars. Conclusion: This study shows that a high percentage of patients with burn scars suffer from depression and anxiety which contribute to low self-esteem and poor quality of life. Among them, patients with scars on exposed areas, facial scars and extensive scars appear to be affected more. Hence, a regular psychiatric screening and follow up of burn scar patients would help in addressing the high psychiatric morbidity and also improve the quality of life in these patients.

Key Word: burn scars, psychiatric morbidity, depression, quality of life, self-esteem

 

INTRODUCTION

The relation between the mind and the body has been well known. Any condition affecting one has potential to affect the other. Many physical illnesses cause significant psychiatric morbidity. Our Skin is a unique part of our body with many biological functions including sensation and thermoregulation. But from a psychosocial point of view, it is an organ of expression A Healthy skin is equated with a better self-image and a sense of confidence.¹ Burn is a type of coagulative necrosis caused by heat transferred from a source to the body. Burn injuries are a major cause of mortality and morbidity. In a developing country like India, every year, an estimated 6-7 million people suffer burn injuries. Of these, nearly 10% require admission and approximately 1-1.5 lakh people are crippled every year².Recent advances in medical management of burns have increased the survivability of burn scar patients. But this also means that many patients with extensive and disfiguring lesions survive which contribute to increase in psychological burden. Burn survivors experience a sequence of traumatic assaults to the body and the mind that presents extraordinary challenges to their psychological resilience. Facial and body disfigurement as a result of burns are known to cause major embarrassment and stigmatization. Deep burns often cause significant cosmetic damage. Many of these burn victims suffer long-term psychiatric morbidity as a result of functional impairment and low self-esteem. Also among the burn patients, facial burn survivors reported low psychosocial scores compared with those with no facial burns.³ The psychiatric consequences of burns are either immediate, due to the traumatic event like Post traumatic stress disorder or delayed due to the psychological impact of the burn scars like depression, anxiety, adjustment disorder, etc. This study focuses on only the psychological impact of burn scars. So, patients are selected so that at least 6 months have passed from the time of burn.

 

OBJECTIVES

1. To assess the prevalence of psychiatric morbidity, depression and anxiety and assess the quality of life and self-esteem in patients with burn scars.
2. To study the relationship between the socio demographic variables and, the psychiatric morbidity and quality of life in patients with burn scars
3. To study the relationship between variables like exposure and extension involvement and the psychiatric morbidity in burn scar patients.

 

MATERIALS AND METHODS

Study Sample: The sample consists of a total of 30 patients. Informed consent was obtained from all the patients. The study was approved by the ethical committee board present in the hospital. Sampling was simple random sampling.

Study Setting: The Study was conducted in the department of plastic surgery in Stanley Medical College Hospital, Chennai, India in 2013.

Inclusion Criteria

Patients with Burn scar with more than 6 months since the onset of the scars.

Exclusion Criteria

1. Patients less than 18 years and more than 60 years
2. Patients with previous history of psychiatric illness
3. Patients with burns within past 6 months
4. Patients not providing consent

Instruments Used: Semi-structured proforma used, which included the socio demographic details and clinical information.

 

 

 

Scales used

1. General Health Questionnaire–28 (Goldberg): (GHQ – 28) which is a screening tool designed to detect nonpsychotic psychiatric illnesses and which has been shown to be reliable and valid⁸.
2. Hamilton Rating Scale for Depression (HAM D) (Max Hamilton) - is a standardized tool for assessing severity of depression⁹.
3. Hamilton Rating Scale for Anxiety (HAM - A) (Max Hamilton) - a standardized tool for assessing severity of anxiety and is reliable and valid¹⁰.
4. Rosenberg Self Esteem Scale(Dr. Morris Rosenberg) - is a Likert scale with items answered on a four point scale - from strongly agree to strongly disagree. It is a standardized scale for assessing Self Esteem.
5. Dermatological Quality of Life Index (DLQI) - well-known instrument for measuring dermatological distress. It has also been used to assess the quality of life in burn patients.
6. Diagnosis of depression, anxiety and other psychiatric illnesses were made by psychiatrist with ICD-10 criteria. Statistical analysis of the data was done using SPSS version 20.

OBSERVATION AND RESULTS

Demographic variables: The sex ratio among the cases was 1:1. The mean age was around 35 years. Most (36.7%) of them were skilled workers. Since study was conducted in urban setting, 73.3% were from urban background. Majority (33%) of them had completed primary education. 56.7 % were of middle socio-economic status. Regarding marital status, 73.3% of the patients were married. The primary care giver was the spouse in 22 (73.3%) of the patients. Only one patient had no care giver.

Disease related variables: On dividing the duration of having burn scar as <1year, 1-5 years, 5-10 years and > 10 years, majority (53.3%) had the disease for less than a year. But all cases were selected such that duration was at least more than 6 months. Facial involvement which is considered an important parameter in previous studies was present in 36.7 % of patients. The extension of the scars was calculated using the popular method of “Rule of Nine”. Majority of the patients had scarsin 26 – 50 % of body surface area. When asked to choose the most troublesome aspect of the scars among embarrassment, loneliness, symptoms and the feeling of incurability, majority (53.3%) chose embarrassment as the most disturbing aspect.

 

Psychiatric morbidity: According to GHQ-28, psychiatric morbidity was present in 56.7% of the cases. The predominant psychiatric symptoms were depression and anxiety. By means of HAM-D, depression was seen in 43.3 % of the cases. On dividing them according to severity, most of them had moderate depression. The Mean HAM-D Score was 10.53. According to HAM-A scores, anxiety was present in 23.3% of the cases. The most common type according to severity was mild anxiety. The mean HAM-A score was 9.07. The fact that cases of depression and anxiety together exceed the total number of cases with psychiatric morbidity can be explained by the fact that many patients had mixed depression and anxiety.

 

 

Dermatological Quality of Life Index (DLQI): According to DLQI, the quality of life of persons with skin related problems are scored by using ten items. The quality of life is interpreted as being either affected or not affected by the illness (in this case – burn scars). This is divided as No effect, small effect, moderate effect, very large effect and extremely large effect. Majority of the cases (46.7%) had scores that placed them in the very large effect category. The mean DLQI score was 12.70.

 

 

Self Esteem: Self Esteem calculated using the Rosenberg Self Esteem scale showed that the mean score was 18.07 among the cases. This was out of a maximum score of 30. This indicates moderate to low self-esteem since it is below 20.

Other Significant findings

 

 

 

 

 

Psychiatric morbidity was more in patients with lesser duration of illness, more extensive scars and those with scars on exposed parts of the body. 76.5% of burn scar patients with duration of scars less than a year had psychiatric morbidity. No patients with scars more than 5 years had any psychiatric morbidity.66.7% of patients with scars more than half of the total body surface had psychiatric morbidity but only 18.2% of patients with scars on less than one-fourth of body surface had psychiatric morbidity. Psychiatric morbidity was present in 88.2% of patients with scars on exposed areas compared to 15.4% in those with scars on non-exposed areas.

 

Both Anxiety and Depressive symptoms were more in patients with scars on exposed parts of body and with extensive scars. 47.1% and 64.7% of patients with scars on exposed parts of body had anxiety and depressive symptoms respectively compared to 0% and 15.4 % of patients with scars on non-exposed areas. Anxiety and Depressive symptoms were present in 100% of patients with scars more than 50% of body compared to 8.3% of patients for scars affecting less than 25 % of body surface. Regarding facial involvement, 72.7 % of patients with facial involvement had depression compared to depression in only 26.3% of patients without facial involvement. There was no significant difference in psychiatric morbidity, Depression, Anxiety, or quality of life with respect to sex, socio economic status, education or residence. There was significant negative correlation between age and GHQ and DQLI scores which shows that older patients had lesser psychiatric morbidity and better quality of life.

 DISCUSSION

Psychiatric morbidity was present in more than half of the patients. The major psychiatric illnesses were depression and anxiety present in 43.3% and 23.3% of patients respectively. This correlates with other studies which have found depressive and anxiety symptoms ranging from 25 to 65 % of patients⁴. This shows that a large number of persons with burn scars suffer from depression and anxiety which is quite high compared to that in general population where the average rates of depression and anxiety are 7.6% - 10% and 1.2% -17% according to previous studies^5,6 Important factors that affected the outcomes of psychiatric morbidity, depression and quality of life were the duration of scar, whether scar was exposed or not and extension of scar. Psychiatric morbidity, depression and anxiety were less in patients with longer duration of scars. This has been shown in some other studies ⁷. The explanation is that patients tend to better adapt to the physical and psychological effects of scars over time. All these outcomes were more in patients with scars on exposed parts of the body compared to those with scars on non-exposed parts. Also, the outcomes were more in patients with higher extension of scar, i.e. patients with more body surface area covered by scars had more psychiatric morbidity, depression and anxiety. Facial involvement was also an important factor related to depression. Depression was significantly more in patients with facial scars compared to those without any facial scars.The quality of life in patients with burn scars is significantly affected due to various reasons. In our study, on assessing quality of life, many patients (46.6%) fell into category of very large effect due to the burn scar. There are several reasons for the poor quality of life in burn scar patients including psychological, physical and social. Depression and anxiety by themselves can contribute to poor quality of life ⁸. In addition, patients with burn scars have body image disturbance which can lead to lower quality of life as reported by other studies ⁹. In our study patients reported that embarrassment was the most disturbing aspect of their scars. Many physical characteristics of burn scars also affect the quality of life including muscle contractures, itch, decrease in range of movement and functional impairment as seen in other studies ¹⁰. The quality of life was better in older patients compared to younger patients. This is similar to that shown in other studies which explain that older patients have better coping strategies^11,12. Also, in our study the quality of life was better in older individuals. Quality of life was less in patients with larger extension of scars and those with scars on exposed areas. Self-esteem as an average was quite low in most patients. Among them it was significantly lower in younger patients, those with extensive scars and having scars in exposed areas. Our study has highlighted the high prevalence of psychiatric morbidity including depression and anxiety in patients with burn scars. When evaluating for outcomes, patients with scars on exposed areas, those with extensive scars and younger patients had significantly more anxiety and depression and lesser quality of life and self-esteem. Also depression was more in patients with facial scars. This study also reiterates that in burn survivors psychological morbidity is not restricted to the initial periods following burns but persists or increases over time.

 

LIMITATIONS

1. The small sample size and the lack of a control group are limitations.
2.  Factors relating to burn scars like sexual dysfunction, effect of various types of treatment were not considered.
3. Patients with previous psychiatric illnesses were excluded from this study.

 

CONCLUSION

We can conclude that this study emphasises the importance of recognising and treating psychiatric morbidity in burn scars. Hence a healthy liaison between the departments of psychiatry, surgery and plastic surgery andregular screening of patients with burn scars for symptoms of depression and anxiety will help in significantly improving the quality of life and self-esteem and also decrease the overall disease burden in burn scar patients.

 

REFERENCES