Evaluation and Treatment of Depression in Adult Trauma Patients
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.
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.
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).
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).