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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 29
| Issue : 1 | Page : 40-46 |
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Depressive symptoms in individuals with burns: A Brazilian study
Sandra Renata Pinatti de Moraes1, Joao Fernando Marcolan2
1 PhD Student in the Graduate Nursing Program, Paulista School of Nursing, Federal University of São Paulo, SP; Nurse at the Burn Treatment Center, Londrina, Paraná, Brazil
2 PhD Student in the Graduate Nursing Program, Paulista School of Nursing, Federal University of São Paulo, SP, Brazil
| Date of Submission | 12-Jul-2021 |
| Date of Acceptance | 23-Nov-2021 |
| Date of Web Publication | 08-Jun-2022 |
Correspondence Address:
Sandra Renata Pinatti de Moraes
Nurse, PhD student, Avenida Robert Koch, 60 Vila Operária, CEP: 86038-350, Londrina, Paraná
Brazil
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijb.ijb_18_21
Objectives: The objective of the study is to analyze the presence and intensity of depression symptoms in burn survivors.
Methods: This is a descriptive and quantitative study, with 36 participants with burns admitted to a referral center in Londrina/PR, between January 2016 and May 2019. Interviews were conducted at two moments after hospital discharge with the application of psychometric scales for depression (Beck, Hamilton, and Montgomery-Asberg) and a semi-structured questionnaire for information on sociodemographic data. Data analysis was performed using statistical tests.
Results: Most participants presented moderate and severe depressive symptoms, which were higher in the second interview. Regardless of having a previous diagnosis, there was an increase in the intensity of depressive symptoms from the first to the second assessment due to dissatisfaction with self-image, but without a significant association with sociodemographic variables. Most participants reported not wearing clothing to cover the injury and not worrying about hiding the injury.
Conclusion: The expressive majority of the participants had depressive symptoms, the majority of which were of moderate and severe intensity.
Keywords: Burns, depression, mental health
How to cite this article:
Pinatti de Moraes SR, Marcolan JF. Depressive symptoms in individuals with burns: A Brazilian study. Indian J Burns 2021;29:40-6 |
| Introduction | |  |
Burning is one of the cruelest conditions in human life, being potentially lethal and traumatic. Its origin is unforeseen, has an immediate effect, and causes aesthetic, economic, social, and emotional problems. The scars resulting from the injury are long-lasting or permanent and can cause several types of limitations and dependence. Besides being a difficult process, it is also related to the cultural context of each country.[1]
In developing countries such as Brazil, burns have become a public health problem. It is estimated that only one hundred thousand people are treated in specialized centers and even with the advancement in treatment techniques, they still suffer prolonged hospitalization, slow and painful invasive procedures, and a long process of adaptation to scars, not to mention the psychological damage that is extremely debilitating and needs to be overcome.[2]
Depression is a common mental disorder in people with burns, as burn treatment requires long hospitalization and advanced care. In addition to physical difficulties, it can impair quality of life, so further investigations are needed.[3],[4],[5],[6] According to the World Health Organization, depression is a highly prevalent disorder, affecting more than 300 million people in all age groups in the world, mainly the female gender, in addition to contributing to the global burden of diseases. If not treated properly, it can affect the quality of life and cause suicidal ideation.[7]
Considering that the detection of depressive symptoms in the burned individual can contribute to early treatment of suffering and prevent chronicity, the objective of this study was to evaluate the presence and intensity of depressive symptoms related to body burn in individuals undergoing treatment in a highly complex reference center.
| Methods | | |
Location, ethical aspects, and sample
The study was conducted with burned individuals treated at a highly complex reference center in the region of Londrina, a city located in the northern region of the state of Paraná, in Brazil. It has 16 beds, six of which in the Intensive Care Unit.
The study was approved by the Ethics and Research Committees of Universidade Estadual de Londrina and Universidade Federal de São Paulo, under opinions 1,794,796 and 1,794,332, respectively.
The voluntary consent form was signed and the research was carried out as recommended by national and international legislation regarding research in human beings. The sample used was nonprobabilistic, with 36 individuals who were under treatment at the unit from January 2017 to May. 2019.
Inclusion, noninclusion, and exclusion criteria
We included in the survey participants aged 18 or over, of both sexes, with a history of burns of any cause and of second-degree or third-degree extension, who remained hospitalized for at least 30 days, with cognitive conditions that enabled them to answer the questionnaire and psychometric scales, and who participated in both moments of interviews.
We did not include in the study those who were admitted exclusively for restorative surgery, those affected by skin diseases other than burns, and patients with burns who were hospitalized again for further procedures. A participant who answered only the first interview was also excluded.
Data collection
Data collection was carried out by the main author through an interview in a private room with the application of a semi-structured questionnaire for sociodemographic characterization with data related to burns (age, sex, skin color, marital status, education, family income, support groups, season, the circumstance of the accident, degree of burn, etiology, causing agent, change in the way of dressing) and three psychometric scales for assessing depressive symptoms at two different times: the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D), and the Montgomery–Asberg Depression Rating Scale (MADRS).
The application of psychometric scales took place at two different times. The first occurred at hospital discharge or the first return between 7 and 14 days after discharge. The second moment occurred between the 4th and 6th weeks after the first return when the presence and course of depressive symptoms were reassessed.
To obtain information regarding the exposed area (the area not covered by clothing) and unexposed burnt area (the body area necessarily covered by clothing), the percentage of body surface affected by the burn in different parts of the body was checked in the medical record according to Lund and Browder rule.[8] We considered in this study as an exposed area: head, neck, right arm, left arm, right forearm, left forearm, right hand, and left hand. The other areas of the body normally hidden by clothing were considered as unexposed area.
Data analysis and treatment
Quantitative data on sociodemographic characterization and psychometric scales were entered by the researcher and exported to the Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM Corporation, SPSS INC. Armonk, New York) in which the analyzes were performed. The Shapiro–Wilk test was used for descriptive analysis. Categorical data were compared with the Chi-square test; Mann–Whitney nonparametric tests and unpaired Student's t were used to compare the two groups of participants according to data distribution and homogeneity of variances. The intensity of the relationship between the variables was measured by the Spearman correlation coefficient. When calculating the power of the study, we found a correlation of 0.89 between the psychometric instruments and 1.00 as the test power. The level of significance used was 5% (P ≤ 0.05) for all tests.
| Results | | |
The sample consisted of 36 individuals treated at the Burns Treatment Center (Center for Teaching Quality [CTQ]). Their age had a median of 38 (27–51) years, and their length of stay in the hospital had a median of 45 (34–60) days. The male gender was the most affected (66.67%). Most of the participants reported being in a consensual marriage (63.89%), were white (69.44%), and had an education level up to the 9th year of school (50%). When asked about the circumstances of the accident, half of the participants suffered an accident at work (50%), followed by a domestic accident (30.55%). Second-degree burns were the most prevalent degree of severity (66.66%), caused by flammable products (33.33%). Most respondents reported not having a support network to assist in adversity (55.56%), and 61.11% of the sample said they did not change their clothing after the accident.
[Table 1] shows data related to the presence and intensity of depressive symptoms in participants with and without a previous diagnosis of depression when applying psychometric scales in the first interview. | Table 1: Depressive symptoms detected by psychometric scales in participants with and without a previous diagnosis of depression in the first interview Londrina - PR. 2020 (n=36)
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[Table 2] shows data related to the presence and intensity of depressive symptoms in participants with and without a previous diagnosis for depression when applying psychometric scales for depression in the second interview. | Table 2: Depressive symptoms detected by psychometric scales in participants with and without a previous diagnosis of depression in the second interview. Londrina, PR. 2020 (n=36)
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[Figure 1] shows the distribution of exposed and unexposed areas and their relationship with depression in participants with previous depression. | Figure 1: Distribution of exposed and unexposed burned area of participants with previous depression. Londrina-PR. 2020 (n = 36)
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The burned area was subdivided into exposed and unexposed areas, and the comparison with depression was evaluated. Individuals who had depression and exposed burnt area had a median of 12 (6%–17%) and those with depression and unexposed burnt area had a median of 13 (5%–18%). When comparing the total of participants who presented depressive symptoms and the exposed and unexposed areas, we did not find a positive association (P = 0.46) [Figure 1].
[Figure 2] shows the distribution of exposed and unexposed areas and their relationship with depression in participants without previous depression. | Figure 2: Distribution of exposed and unexposed burned area of participants without previous depression. Londrina-PR. 2020 (n = 36)
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Those participants who did not report depression, but had an exposed burnt area, had a median of 3 (6%–11%) and those who did not report depression and an unexposed burnt area showed a median of 11 (7%–21%) However, when compared, we observed that the participants who did not have depression were those who had the largest unexposed area (P = 0.01) [Figure 2].
| Discussion | | |
In our research, there was a higher prevalence of burns in males, a result endorsed by national[9] and international[10] investigations, affecting the young adult age group in the productive phase.[11] When assessing the psychopathological consequences of burns, depressive symptoms were more prevalent in females[6],[12],[13],[14],[15] and influenced by the type of injury, religion, age and marital status.[13] They appeared mainly when the return to activities and socialization was impaired.[12],[16] In this study, no significance was found regarding gender and other sociodemographic variables.
The growing number of survivors of extensive burns has aroused interest due to the psychological consequences resulting from injuries. The results of this study corroborate with other studies that also investigated depression in burns.[3],[9],1[4]
Because it is a disorder that can occur in people with burns due to several factors such as prolonged hospitalization, environment, and unknown people, severe pain, altered body image, slow rehabilitation process, and difficult adaptation to the new life condition, depression symptoms can fluctuate in periods of improvement and worsening and compromise the life quality.[4]
The diverse way in which researchers choose body areas as exposed or unexposed and the development of a depressive condition make the comparison between studies difficult. A study by Ali, Pervaiz,[17] pointed out that multiple burns predispose to depression, and those who had head, face, and neck injuries had a 50% chance of developing depressive symptoms, indicating that the burned surface is related to depression. In a European study,[18] the regions of the head and anterior trunk were the places that were associated with an emotional disorder. In a German study,[19] there was no statistical significance for those who had injuries in nonvisible areas and had depression, and there was statistical significance for those who had injuries in exposed areas of the body, such as face and hands, and depressive condition.
In the study by Madianos, Papaghelis, Ioannovich, Dafni,[20] the surface of the burn and the lesions in exposed areas of the head, neck, and face indicated a 50% chance of forming psychological problems and adjustment difficulties due to facial disfigurement, but only 21% sought psychological support due to the injury.
According to a Brazilian study,[21] burns in more visible regions of the body caused a change in the individual's way of dressing in an attempt to hide the injury, minimize discomfort, and especially to protect oneself from a curious or disgusted look and thus, to remain in society.
The exposed and unexposed area of this study was categorized by the researchers, and the data showed that participants who did not have depression were those who had the largest unexposed area (P = 0.01) even though they reported that they did not change the way they dressed after the accident, corroborating with data from the studies mentioned above. However, identifying the relationship of areas with burns is a difficult task because how each individual accepts their condition is unique and independent of the extent of trauma, functional impairment, and changes in personal image.[22]
The scars resulting from the burn usually do not leave a satisfactory appearance and that the larger the burned body surface, the more depressive symptoms observed and negative results over time.[6],[23],[24],[25] In a Brazilian study,[11] the female gender suffered a greater emotional impact from the burn due to the visibility of the injuries, contrary to our findings, which did not point out a statistical difference between genders (P = 1.00).
Depression can also be manifested by dissatisfaction with the image after the burn, especially when the lesions are in exposed areas.[26] As the individuals no longer have the appearance of the past and feel stigmatized by society, they may have a feeling of low self-esteem and end up socially isolating themselves, with the risk of developing a depressive state and suicidal ideation.[11]
When psychometric scales were applied to assess depression, participants were asked about a previous or current diagnosis before starting to apply the scales. Twenty eight (77.78%) of these participants reported having frequent depressive symptoms (sadness, anxiety, discouragement, anguish) before the burn but did not seek medical help to carry out diagnosis and treatment. Only eight (22.22%) participants stated that they had already resorted to medical help in some period of life when the diagnosis was made, however, all reported that they did not undergo the treatment or discontinued it.
According to studies,[15],[27] mental health before burn as well as disorders before the accident complicates the situation after the accident and lead to worse results if they are not treated.
When participants were assessed for depressive symptoms in the first interview by Beck's inventory, 23 (63.88%) of them denied the symptoms. However, this is a self-administered scale, and there is a possibility that the participants may have marked symptoms below those presented or omitted information because they were not comfortable showing their suffering regarding depressive symptoms due to personal reasons.
When the same participants were evaluated by the researcher using the HAM-D and MADRS scales, depressive symptoms appeared almost completely in both groups of participants (except one participant by MADRS). This was because the scale is observational and the interviewer points out the alternatives through communication, observation, and perception of attitudes.
In this study, we observed a worsening of the intensity (moderate and severe) and an increase in the prevalence of depressive symptoms when the same instruments were reapplied in the second interview in relation to the first application, demonstrating a change in self-image and self-esteem due to the burns.
In an Italian study carried out with major burns, moderate (36.90%) and severe (42.10%) depression were detected in individuals who already had a previous psychiatric problem, as well as in those who had their hands incapacitated to work by the burn.[28] In an Iraqi study, most of the sample (56%) showed depressive symptoms with an incidence of severe depression (24.7%).[24] In other studies, the prevalence of depressive symptoms showed a variation in the intensity of the results in the mild, moderate and severe form.[17],[29],[30] As many differences have been found in psychic aspects, rehabilitation in this area must be carried out regardless of the intensity of depressive symptoms.
A Brazilian study investigated stigmatization and depression between the general and burned population and found no significant differences although the general population showed lower levels of depression when compared to burned ones.[11] Another Brazilian study with burns after hospital discharge found that 15% of the participants had a depressive condition and only 5.5% of them sought treatment.[9] A Greek study assessed burns 1 year after the occurrence and although 40% reported psychological problems, only 21% sought help.[20]
The results of this study showed progressive emotional impairment and the development of depressive symptoms within 6 weeks after discharge and the participants reported not having support groups in this difficult phase. The data from the study by Xie et al.[31] showed psychological impairment in 2 years after the accident that affected body image. However, interpersonal and affective relationships were considered positive because the participants had the support and support of family and friends.
A study that evaluated burns and psychological disorders[20] found more than 46% of respondents diagnosed with mood disorders. Disfigurement was the only significant variable for the presence of a psychopathological diagnosis. The evaluation was carried out in the 3rd week of hospitalization and 1 year later, differently from the evaluation time used in this study; in turn, a common aspect was that suffering a burn was related to a psychopathological reaction.
In our research, although suicidal ideation was not investigated, it emerged in the speech of the participants when they answered the psychometric scales when they reported about discrimination due to the end of physical beauty, attracting looks of disgust. As observed in another study,[12] individuals reported a death wish even without a concrete execution plan, due to invasive procedures, pain, permanent sequelae, and difficulties in reintegrating into society.
Although the difficulty in accepting the new condition was evident in both sexes, the female gender represented by two participants (5.55%) expressed suicidal ideation due to functional impairment, aesthetic, emotional, and social repercussions that affected their personal lives. Such repercussions are in line with what was pointed out in a study by Echevarría-Guanilo et al.[32] where the scars caused social withdrawal and damaged the relational life.
The burned individual suffers from extensive injuries, pain, financial, family, and emotional difficulties during the long period of hospitalization and rehabilitation, in addition to terrible sequels. Thus, suicide can be seen as a way out of difficulties.[4]
Psychological follow-up is still rarely addressed in the burned individual and the assessment of the presence and intensity of depressive symptoms during treatment is of utmost importance so that interventions in coping can be performed.
The strength of this study is the fact that it is the first assessment using standardized instruments to portray mental suffering and depressive symptoms in burned individuals treated at this reference center.
Some limitations of this study were the evaluation in a single reference center, having a small sample, a short evaluation period, and a lack of follow-up.
| Conclusion | | |
Participants had depressive symptoms due to burns. We found a prevalence of depressive conditions of moderate and severe intensity, which intensified in the second interview. Burned individuals must undergo a routine assessment of their mental health, specifically for depressive symptoms, and early interventions to avoid compromising their condition and preventing suicidal behavior.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Zamanzadeh V, Valizadeh L, Lotfi M, Salehi F. Preserving self-concept in the burn survivors: A qualitative study. Indian J Palliat Care 2015;21:182-91.  [ PUBMED] [Full text] |
| 2. | |
| 3. | Nilsson A, Orwelius L, Sveen J, Willebrand M, Ekselius L, Gerdan B, et al. Anxiety and depression after burn, not as bad as we think – A nationwide study. Burns 2019;45:1367-74. |
| 4. | Jain M, Khadilkar N, De Sousa A. Burn-related factors affecting anxiety, depression and self-esteem in burn patients: An exploratory study. Ann Burns Fire Disasters 2017;30:30-4. |
| 5. | Giannoni-Pastor A, Gomà-i-Freixanet M, Valero S, Fidel Kinori SG, Tasqué-Cebrián R, Arguello JM, et al. Personality as a predictor of depression symptoms in burn patients: A follow-up study. Burns 2015;41:25-32. |
| 6. | Su YJ. Prevalence and predictors of posttraumatic stress disorder and depressive symptoms among burn survivors two years after the 2015 Formosa Fun Coast Water Park explosion in Taiwan. Eur J Psychotraumatol 2018;9:1512263. |
| 7. | World Health Organization. Depression and other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. |
| 8. | Lund CC, Browder N. The estimation of areas of burn. Surg Gynecol Obs 1994;79:352-8. |
| 9. | Ricci H, Gonçalves N, Gallani MC, Ciol MA, Dantas RA, Rossi LA. Assessment of the health status in Brazilian burn victims five to seven months after hospital discharge. Burns 2014;40:616-23. |
| 10. | Ciftçi I, Arslan K, Altunbaş Z, Kara F, Yilmaz H. Epidemiologic evaluation of patients with major burns and recommendations for burn prevention. Ulus Travma Acil Cerrahi Derg 2012;18:105-10. |
| 11. | De Oliveira Freitas N, Pitta NC, Dantas RAS, Farina JA Jr, Rossi LA. Comparison of the perceived stigmatization measures between the general population and burn survivors in Brazil. Burns 2020;46:416-22. |
| 12. | Rubab S, Kalsoom AC. Assessment of self-esteem and depression in burn afflicted women. Depress Anxiety 2018;7:2. |
| 13. | Ahrari F, Salehi SH, Fatemi MJ, Soltani M, Taghavi S, Samimi R. Severity of symptoms of depression among burned patients one week after injury, using Beck Depression Inventory-II (BDI-II). Burns 2013;39:285-90. |
| 14. | Roh YS, Chung HS, Kwon B, Kim G. Association between depression, patient scar assessment and burn-specific health in hospitalized burn patients. Burns 2012;38:506-12. |
| 15. | Ter Smitten MH, de Graaf R, Van Loey NE. Prevalence and co-morbidity of psychiatric disorders 1-4 years after burn. Burns 2011;37:753-61. |
| 16. | Thombs BD, Haines JM, Bresnick MG, Magyar-Russell G, Fauerbach JA, Spence RJ. Depression in burn reconstruction patients: Symptom prevalence and association with body image dissatisfaction and physical function. Gen Hosp Psychiatry 2007;29:14-20. |
| 17. | Ali H, Pervaiz M. Depression in adults post burn injury: A descriptive study conducted in the burn centre of a tertiary care hospital in Karachi. Ann Burns Fire Disasters 2019;32:33-6. |
| 18. | Fidel-Kinori SG, Eiroa-Orosa FJ, Giannoni-Pastor A, Tasqué-Cebrián R, Arguello JM, Casas M. The Fenix II study: A longitudinal study of psychopathology among burn patients. Burns 2016;42:1201-11. |
| 19. | Pallua N, Künsebeck HW, Noah EM. Psychosocial adjustments 5 years after burn injury. Burns 2003;29:143-52. |
| 20. | Madianos MG, Papaghelis M, Ioannovich J, Dafni R. Psychiatric disorders in burn patients: A follow-up study. Psychother Psychosom 2001;70:30-7. |
| 21. | Aiquoc KM, Dantas DV, Dantas RA, Costa IB, Oliveira SP, Lima KR, et al. Evaluation of satisfaction with body image of burned patients. Rev Enferm UFPE On line 2019;13:952-9. |
| 22. | Yurdalan SU, Ünlü B, Seyyah M, Şenyıldız B, Çetin YK, Çimen M. Effects of structured home-based exercise program on depression status and quality of life in burn patients. Burns 2018;44:1287-93. |
| 23. | Sobanko JF, Sarwer DB, Zvargulis Z, Miller CJ. Importance of physical appearance in patients with skin cancer. Dermatol Surg 2015;41:183-8. |
| 24. | Arfai A, Amiri S. Depressive symptoms among survivors of burn Injuries. Clin Res Gov 2014;3:38-41. |
| 25. | Willebrand M, Andersson G, Kildal M, Gerdin B, Ekselius L. Injury-related fear-avoidance, neuroticism and burn-specific health. Burns 2006;32:408-15. |
| 26. | Faisal A, Amjad A, Zehra N. Impact of facial burn injury on self esteem of burn patients: A hospital-based study from Karachi. Dow Uni Health Sci Karachi 2016;10:25-30. |
| 27. | |
| 28. | Pavoni V, Gianesello L, Paparella L, Buoninsegni LT, Barboni E. Outcome predictors and quality of life of severe burn patients admitted to intensive care unit. Scand J Trauma Resusc Emerg Med 2010;18:24. |
| 29. | Thombs BD, Bresnick MG, Magyar-Russell G, Lawrence JW, McCann UD, Fauerbach JA. Symptoms of depression predict change in physical health after burn injury. Burns 2007;33:292-8. |
| 30. | Fauerbach JA, McKibben J, Bienvenu OJ, Magyar-Russell G, Smith MT, Holavanahalli R, et al. Psychological distress after major burn injury. Psychosom Med 2007;69:473-82. |
| 31. | Xie B, Xiao SC, Zhu SH, Xia ZF. Evaluation of long term health-related quality of life in extensive burns: A 12-year experience in a burn center. Burns 2012;38:348-55. |
| 32. | Echevarría-Guanilo ME, Gonçalves N, Farina JA, Rossi LA. Avaliação da qualidade de vida relacionada à saúde no primeiro ano após a queimadura. Esc Anna Nery. 2016;20:155-66. Doi: 10.5935/1414-8145.20160021. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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