Scientific Article   |    
Psychological Distress Associated with Severe Lower-Limb Injury
Melissa L. McCarthy, MS, ScD; Ellen J. MacKenzie, PhD; David Edwin, PhD; Michael J. Bosse, MD; Renan C. Castillo, MS; Adam Starr, MD; James F. Kellam, MD; Andrew R. Burgess, MD; Lawrence X. Webb, MD; Marc F. Swiontkowski, MD; Roy W. Sanders, MD; Alan L. Jones, MD; Mark P. McAndrew, MD; Brendan M. Patterson, MD
View Disclosures and Other Information
Investigation performed at MetroHealth Medical Center, Cleveland, Ohio; R Adams Cowley Shock Trauma Center, Baltimore, Maryland; Carolinas Medical Center, Charlotte, North Carolina; Vanderbilt University, Nashville, Tennessee; Tampa General Hospital, Tampa, Florida; Harborview Medical Center, Seattle, Washington; North Carolina Baptist Hospital, Winston-Salem, North Carolina; and Parkland Memorial Hospital, Dallas, Texas

Melissa L. McCarthy, MS, ScD
Ellen J. MacKenzie, PhD
David Edwin, PhD
Renan C. Castillo, MS
Departments of Emergency Medicine (M.L.McC.), Health Policy and Management (E.J. MacK. and R.C.C.), and Psychiatry (D.E.), Johns Hopkins University, Baltimore, MD 21205. E-mail address for M.L. McCarthy: mmccarth@jhmi.edu

Michael J. Bosse, MD
Department of Orthopaedic Surgery, Carolinas Medical Center, MEB 503, 1000 Blythe Boulevard, Charlotte, NC 28203

Adam Starr, MD
Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390

*The LEAP (Lower Extremity Assessment Project) Study Group included Ellen J. MacKenzie, PhD, Michael J. Bosse, MD, James F. Kellam, MD, Andrew R. Burgess, MD, Lawrence X. Webb, MD, Marc F. Swiontkowski, MD, Roy W. Sanders, MD, Alan L. Jones, MD, Mark P. McAndrew, MD, Brendan M. Patterson, MD, Melissa L. McCarthy, MS, ScD

In support of their research or preparation of this manuscript, one or more of the authors received Grant R01 AR42659 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Sep 01;85(9):1689-1697
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Background: Little is known about the psychological morbidity associated with limb-threatening injuries. It was hypothesized that a substantial proportion of patients who sustain a severe lower-limb injury will report serious psychological distress.

Methods: Adult patients who were admitted to one of eight level-I trauma centers for treatment of an injury threatening the lower limb were enrolled during their initial hospitalization. Patients were recontacted at three, six, twelve, and twenty-four months after the injury and asked to complete the Brief Symptom Inventory (BSI), a fifty-three-item, self-reported measure of psychological distress. Patients who screen positive on the BSI are considered likely to have a psychological disorder and should receive a mental health evaluation. Longitudinal regression techniques were used to model positive case status (i.e., likely to have a psychological disorder) as a function of patient, injury, and treatment characteristics.

Results: Of the 569 patients enrolled, 545 (96%) completed at least one BSI and 385 (68%) completed all four. Forty-eight percent of the patients screened positive for a likely psychological disorder at three months after the injury, and this percentage remained high (42%) at twenty-four months. Two years after the injury, almost one-fifth of the patients reported severe phobic anxiety and/or depression. While these two subscales reflected the highest prevalence of severe psychological distress, none of the BSI subscales reflected the prevalence expected from a normal sample (i.e., 2% to 3%). Factors associated with a likely psychological disorder included poorer physical function, younger age, non-white race, poverty, a likely drinking problem, neuroticism, a poor sense of self-efficacy, and limited social support. Relatively few patients reported receiving any mental health services following the injury (12% at three months and 22% at twenty-four months).

Conclusions: Severe lower-limb injury is associated with considerable psychological distress. More attention to the psychological as well as the physical health of patients who sustain a limb-threatening injury may be needed to ensure an optimal recovery following these devastating injuries.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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