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Original Investigation
June 5, 2019

Contributors to Postinjury Mental Health in Urban Black Men With Serious Injuries

Author Affiliations
  • 1Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia
  • 2Penn Injury Science Center, University of Pennsylvania, Philadelphia
  • 3Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 4Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5Department of Health Policy & Management, School of Public Health, Drexel University, Philadelphia, Pennsylvania
  • 6Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 7Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Surg. Published online June 5, 2019. doi:10.1001/jamasurg.2019.1622
Key Points

Question  What risk and protective factors contribute to postinjury mental health symptom severity in black men with serious injuries?

Findings  In this cohort study that included 623 urban black men with serious injuries, early adverse childhood exposures, preinjury physical and mental health conditions, acute postinjury stress responses, and intentional injury contribute to postinjury depressive and posttraumatic stress symptom severity.

Meaning  The intersection of prior trauma and adversity, prior exposure to challenging disadvantage, and poorer preinjury health should not be overlooked in the midst of acute injury care when assessing for risk of postinjury mental health symptoms.


Importance  Physical injury is associated with postinjury mental health problems, which typically increase disability, cost, recidivism, and self-medication for symptoms.

Objective  To determine risk and protective factors across the life span that contribute to depression and posttraumatic stress symptom severity at 3 months after hospital discharge.

Design, Setting, and Participants  This prospective cohort study used a 3-month postdischarge follow-up of patients who had been treated at an urban, level 1 trauma center in the Northeastern United States. Men with injuries who were hospitalized, self-identified as black, were 18 years or older, and resided in the Philadelphia, Pennsylvania, region were eligible and consecutively enrolled. Those who were experiencing a cognitive dysfunction or psychotic disorder, hospitalized because of attempted suicide, or receiving current treatment for depression or posttraumatic stress disorder (PTSD) were excluded. Data were collected from January 2013 to October 2017. Data analysis took place from January 2018 to August 2018.

Exposures  A serious injury requiring hospitalization; adverse childhood experiences, childhood neighborhood disadvantage, and preinjury physical and mental health; and emotional resources, injury intent, and acute stress responses.

Main Outcomes and Measures  Depression and PTSD symptom severity were assessed with the Quick Inventory of Depressive Symptoms–Self-report and the PTSD Check List–5. The a priori hypothesis was that risk and protective factors are associated with depression and PTSD symptom severity. The analytic approach was structural equation modeling.

Results  A total of 623 black men were enrolled. Of these, 502 participants (80.6%) were retained at 3-month follow-up. Their mean (SD) age was 35.6 (14.9) years; 346 (55.5%) had experienced intentional injuries, and the median (range) Injury Severity Score was 9 (1-45). Of the 500 participants with complete primary outcome data, 225 (45.0%) met the cut point criteria for mental health diagnoses at 3 months. For both mental health outcomes, the models fit the data well (depression: root mean square error of approximation [RMSEA], 0.044; comparative fit index [CFI], 0.93; PTSD: RMSEA = 0.045; CFI = 0.93), and all hypothesized paths were significant and in the hypothesized direction. Outcomes were associated with poor preinjury health (standardized weights: depression, 0.28; P < .001; PTSD, 0.17; P = .02), acute psychological reactions (depression, 0.34; PTSD, 0.38; both P < .001), and intentional injury (depression, 0.16; PTSD, 0.24; both P < .001). Acute psychological reactions were associated with childhood adversity (depression, 0.33; PTSD, 0.36; both P < .001). A history of prior mental health challenges (depression, 0.70; PTSD, 0.70; both P < .001) and psychological or emotional health resources (depression, −0.22; PTSD, −0.23; both P = .003) affected poor preinjury health, which was in turn associated with acute psychological reaction (depression, 0.44; PTSD, 0.42; both P < .001).

Conclusions and Relevance  The intersection of prior trauma and adversity, prior exposure to neighborhood disadvantage, and poorer preinjury health and functioning are important, even in the midst of acute medical care for traumatic injury. These results support the importance of trauma-informed health care and focused assessment to identified patients with injuries who are at highest risk for poor postinjury mental health outcomes.

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