IMPACT OF BURNS ON ANXIETY, DEPRESSION AND SELFESTEEM AMONG PATIENTS WITH BURN INJURIES: A CROSS-SECTIONAL STUDY

SUMMARY

Burns are a major public health issue. Psychiatric issues require special attention. According to research, lowering stigma and anxiety and raising self-esteem are efficient ways to encourage the social reintegration of burn patients. The current study was aimed at investigating the association between burn patients’ anxiety, depression, low self-esteem levels and the total body surface area (TBSA) affected by burn injuries. This single-center, cross-sectional study was conducted from January to June 2022. A sample size of 200 burn patients was calculated. Any patient with a prior psychiatric diagnosis was disqualified from the trial except for nicotine dependency. The patients were evaluated for anxiety, depression and self-esteem using specific scales. The data were tabulated and statistically analyzed using SPSS 25.0. There was male predominance as 55% (n=110) of participants were males. The age range was 18-70 years, and the average age of participants was 36.4±8.6 years. About 68.50% of participants were married, 29.50% were unmarried and 2% were divorced/widowed. Men tended to experience anxiety symptoms more frequently. More than half (58.0%) suffered from burns involving 20-39% of total body surface area (TBSA). No significant relationship was found between TBSA and anxiety, depression or self-esteem. Psychiatric issues are highly prevalent in burn victims. More research is necessary to determine the extent and determinants of psychological issues in burn patients.

Introduction

Burns are a global public health concern because they cause almost 11 million individuals to need medical care each year, and cause about 300,000 fatalities worldwide each year.¹ The incidence of burns varies over the world, ranging from 3 to 10%, with low-income countries having the highest prevalence.²

Many burn patients now survive the acute stage of recovery thanks to advances in medical care, but they still must deal with the complicated and individually unique long-term psychosocial impacts of burns.³

Scarring from burn injuries to the face, neck and head is common. One of the most prevalent and challenging post-burn issues to treat is scarring and contractures. Women who have suffered facial burns are more likely to experience depression as a result, and evidence suggests that overall, women are more susceptible to the effects of disfigurement.^4,5

Pain, anxiety, depression, low self-esteem, post-traumatic stress disorder, stigmatization, stress about bodily disfigurement, social isolation, and financial liability are the most frequent psychological issues experienced by burn injury patients because of prolonged length of hospitalization and required treatment.^6,7 Addressing burn patients’ psychological issues significantly improves their quality of life and well-being.⁸ If these issues are not addressed instantaneously, they can lead to chronic mental disorders.⁹

Anxiety and stress are known to accompany burn-related pain throughout surgical interventions and physical therapy, and studies have revealed that procedural pain-associated anxiety grows as therapy advances.¹⁰

Post-traumatic stress symptoms start right away after the accident, last during hospitalization, and often last for years after patients are discharged.¹¹ Patients’ social isolation, sense of loss of independence, financial dependence, loss of socio-occupational activity, and level of distress have all been linked to lengthier hospital stays.¹²

The influence of depressive symptoms is substantial, exemplified by several studies reporting a negative impact on life quality¹³ and physical work¹⁴ in burn survivors. Despite the link between psychiatric morbidity and burn injuries, psychological support for burn patients is still insufficient, and the burns unit needs a psychiatric staff.^15,16

Only a little burn research has examined the underlying mechanisms causing depressive symptoms in patients with facial burns to date, therefore little is known about the eliciting and sustaining factors. With burn patient survival rates rising, it is critical to address the psychological needs of burn survivors to help them return as closely as possible to their pre-burn functioning and quality of life, and successfully reintegrate back into society with a healthy body and mind.

The current study’s objective was to investigate the association between burn patients’ anxiety, depression, low self-esteem levels and the total body surface area (TBSA) affected by burn injuries.

Methodology

This was a prospective monocentric cohort study conducted at the National Burn Care Centre, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, over a 6-month period from January to June 2022. The Centre is a government sector facility providing free-of-cost services to patients with burn injuries since 2007. The study was approved by the ethical review committee of Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad.

Simple random sampling was used to pick participants based on a 95% confidence interval (CI). A formula where n is the sample size, N is the population size, p is the estimated proportion of the attribute, and ε is the sampling error was used to determine the sample size of 200 adult burn patients for a maximum sampling error of 5% over a 6-month data collection period.

Patients of either gender who were over 18 years old, admitted to the Burn Center, gave their consent to be included and were within 8 weeks of their burn injury, met the inclusion criteria. Any patient with a prior psychiatric diagnosis was disqualified from the trial except for nicotine dependency. Patients were interviewed about depression and anxiety during the acute burn, i.e. at the initial period of burn injury, and were questioned about self-esteem in the post-burn rehabilitative stage. Pre-burn depression was determined by questioning the patient if they had experienced depression before the burn occurrence. A yes or no question was utilized in the analyses, i.e. Have you ever experienced depression?

Burn-related factors such as burned TBSA, burn depth, facial involvement and psychiatric morbidity using the appropriate scales, and a clinical interview were among the parameters evaluated in the study. All data were recorded in the case file and in a separate MS excel sheet for the present study. Three scales were used in the study, namely Hamilton Anxiety Rating Scale (HAM-A),¹⁷ Hamilton Depression Rating Scale (HAM-D),¹⁸ and Rosenberg Self-Esteem Scale (RSES).^19,20

The HAM-A scale consists of 14 items that are used to gauge a patient’s level of anxiety. There are multiple symptoms associated with each of the 14 questions, and each group of symptoms is evaluated from 0 to 4, with 4 being the most severe. Anxiety is classified as mild if the total score is 17 or less, mild to moderate if the total score is 18 to 24, and moderate to severe if the total score is 25 to 30.

The HAM-D scale has 21 components, however, only the first 17 are used for scoring. Scores between 8 and 13 denote mild depression, 14 and 18 denote moderate depression, and 19 and 22 denote severe depression.

The RSES is a 10-item, 4-point Likert-type scale that ranges from “strongly agree” to “strongly disagree”. There are five statements that are positively worded and five that are negatively worded for each item.

With the aid of IBM SSPS software version 25.0, data were analyzed using fundamental descriptive statistics like mean, standard deviation, and median. Where applicable, the Chi-square test was applied. The p-value was set as 0.05.

Results

There was male predominance as 55% (n=110) of participants were males. Out of 90 female participants, 77 (85.55%) were housewives and 13 (14.45%) were working women. Among the male participants (n=110), about 83 (75.45%) were employed, 11 (10%) unemployed, and 16 (14.55%) were retired. The age range was 18-70 years, and the average age of participants was 36.4±8.6 years. About 68.50% of participants were married, 29.50% were unmarried and 2% were divorced/widowed. About half of the participants 48.5% (n=97) were educated up to high school level (grade 9-12) followed by 28.5% with higher academic level (i.e. beyond class 12) (n=57).

TBSA was classified as Group I (20-39%), II (40-59%), and III (>60%) respectively. A TBSA of 20-39% (Group I) was seen in 58% (n=116) burn patients, 40-59% TBSA in 37% (n=74) patients (Group II) while 5% patients (n=10) showed a TBSA >60% (Group III). Regarding the site of burn injury, we found 77 subjects (38.50%) with facial burns: 40 males and 37 females.

Every participant in the study displayed anxiety symptoms that ranged from mild to moderate. Men tended to experience anxiety symptoms more frequently. 21.56% of the Group I cases had severe anxiety, compared to 9.45% of the Group II cases and 30% of the Group III cases, but the difference was not statistically significant (p-value = 0.885; χ² = 1.152) (Tables I and II).

Table I.

Gender-wise anxiety scores

Anxiety severity	Males	Females	Total
Mild	55 (50.0%)	44 (48.88%)	99 (49.50%)
Moderate	34 (30.90%)	34 (37.77%)	68 (34.0%)
Severe	21 (19.09%)	12 (13.33%)	33 (16.50%)
Total	110 (100.0%)	90 (100.0%)	200 (100.0%)

Table II.

%TBSA-wise anxiety scores

Anxiety severity	TBSA (20-39%) n = 116	TBSA (40-59%) n = 74	TBSA (>60%) n = 10	Total
Mild	48 (41.37%)	36 (48.64%)	2 (20%)	99 (49.50%)
Moderate	43 (37.06%)	31 (41.89%)	5 (50%)	68 (34.0%)
Severe	25 (21.56%)	7 (9.45%)	3 (30%)	33 (16.50%)
Total	116 (100.0%)	74 (100.0%)	10 (100.0%)	200 (100.0%)

Almost all of the sample (96.5%; n=193) displayed depressive symptoms. Most of them had symptoms that ranged from mild to very severe. Female individuals exhibited very severe symptoms somewhat more frequently than male subjects. About 90% of the Group III cases had severe to very severe depression compared to 63.51% of the Group II cases and 43.63% of the Group I cases but the difference was not statistically significant (p-value = 5.049; χ² = 0.752) (Tables III and IV). In patients with facial burn injuries, 74.9% had severe to very severe depression.

Table III.

Gender-wise depression scores

Depression severity	Males	Females	Total
Normal	3 (2.72%)	1 (1.11%)	4 (2.0%)
Mild	17 (15.45%)	19 (21.11%)	36 (18.0%)
Moderate	39 (35.45%)	20 (22.22%)	59 (29.50%)
Severe	20 (18.18%)	13 (14.44%)	30 (15.0%)
Very severe	31 (28.18%)	37 (41.11%)	71 (35.5%)
Total	110 (100.0%)	90 (100.0%)	200 (100.0%)

Table IV.

%TBSA-wise depression scores

Depression severity	TBSA (20-39%) n = 116	TBSA (40-59%) n = 74	TBSA (>60%) n = 10	Total
Normal	4 (3.44%)	None	None	4 (2.0%)
Mild	36 (31.03%)	None	None	36 (18.0%)
Moderate	28 (24.13%)	27 (36.48%)	1 (10.0%)	59 (29.50%)
Severe	6 (5.17%)	23 (31.08%)	4 (40.0%)	30 (15.0%)
Very severe	42 (36.20%)	24 (32.43%)	5 (50.0%)	71 (35.5%)
Total	116 (100.0%)	74 (100.0%)	10 (100.0%)	200 (100.0%)

Regarding self-esteem analysis, 53.0% in total had low self-esteem. A total of 42.24% of Group I cases had normal self-esteem, in comparison to 58.11% of Group II and 20.0% of Group III cases, but the difference was not statistically significant (p-value = 0.0002; χ² = 1.0576). The maximum low self-esteem level was observed in Group III with a TBSA >60% (Table V).

Table V.

Self-esteem scores

Depression severity	TBSA (20-39%) n = 116	TBSA (40-59%) n = 74	TBSA (>60%) n = 10	Total
Normal	49 (42.24%)	43 (58.11%)	2 (20.0%)	94 (47.0%)
Low	67 (57.76%)	31 (41.89%)	8 (80.0%)	106 (53.0%)
Total	116 (100.0%)	74 (100.0%)	10 (100.0%)	200 (100.0%)

Discussion

Burn injury is a stressful experience that leaves a patient with both short-term and long-term physical and mental health issues. The growth in burn survivors due to medical advancements poses a problem for long-term care and intensifies the interest of medical professionals in increasing the quality of life of this cohort of patients.²¹ The primary goals of the current study were to evaluate the prevalence of common psychiatric issues in burn injury victims and to comprehend the various burn variables that influence patients’ psychological outcomes. The socio demographic traits of the participants were consistent with the epidemiological data on burns reported from Pakistan.²² The most frequent type of injury was accidental burns, which is consistent with findings in the international literature on the source that causes burn injuries.²³

Our investigation revealed an unexpected result: male patients had a higher prevalence of anxiety. Earlier studies have noted a comparable prevalence in both sexes.²⁴ Males may have had a higher prevalence of anxiety due to a variety of variables, including the high expense of treatment, worries about the future and returning to work, and fear of disfigurement, among others. Our study’s male participants were employed and married, however, differences based on marital status and place of employment were not investigated because they did not further the study’s objectives.

While analyzing the relationship between total body surface area (TBSA) and depression, the TBSA affected had no impact on the patient’s level of depression. This was consistent with an earlier finding reported from Italy.²⁵ The same was correct for anxiety scores. However, in contrast, a research study from South Africa had previously shown a link between total body surface area affected and the degree of anxiety.²⁶ It is imperative to note that the medications these patients were taking, including any painkillers, and the dressings they were wearing also had an impact, although these factors were not thoroughly examined in the research.

According to earlier studies, there is a strong correlation between facial burns and the degree of depression, demonstrating that facial deformity increases the incidence of post-burn depression.¹³ The same was true in our study where 74.9% of patients with facial burn injuries had severe to very severe depression.

Burn victims undergo various surgical procedures in later stages to avoid functional disabilities. Patients undergoing surgical interventions may have higher depression, anxiety and lower self-esteem compared to patients with the same TBSA but no surgeries being performed. Further studies are required in future to assess the psychological state of patients considering surgical intervention as a parameter.

Differences between our results and earlier published studies regarding some of the findings could be attributed to different methodologies and scale systems. There was no correlation found between TBSA and the psychological parameters of the present study. Similar results were found in studies done in 2017²⁷ and 2023.²⁸

Limitations

The sample used in the study may not be representative of the whole burn population because it was a single-center cross-sectional study. As there was no long-term follow-up, the evaluation of psychiatric comorbidity may under-report the occurrence of psychiatric sequel occurring later in the disease course. The scales used in the study vary when compared with other studies, thus confusing the results obtained and their subsequent comparison.

Conclusion

The needs of burn survivors on a psychological level are little understood. Every burn patient must undergo routine screening for psychiatric morbidity, and every case must be examined by a psychiatrist at least once while they are admitted. Equally crucial is educating the burns ward staff on the patient’s psychosocial needs.