Latent constructs are represented in dark squares and standardized weights as numbers placed above light squares. The root mean square error of approximation is 0.019; the comparative fit index is 0.99. ACEs indicates adverse childhood experiences.
The root mean square error of approximation is 0.044; the comparative fit index, 0.93. Standardized weights appear as numbers placed atop arrows.
The root mean square error of approximation is 0.045; the comparative fit index, 0.93. Standardized weights appear as numbers placed atop arrows.
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Richmond TS, Wiebe DJ, Reilly PM, Rich J, Shults J, Kassam-Adams N. Contributors to Postinjury Mental Health in Urban Black Men With Serious Injuries. JAMA Surg. 2019;154(9):836–843. doi:10.1001/jamasurg.2019.1622
What risk and protective factors contribute to postinjury mental health symptom severity in black men with serious injuries?
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.
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.
Physical injury is associated with postinjury mental health problems, which typically increase disability, cost, recidivism, and self-medication for symptoms.
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.
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.
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.
Physical injury is associated with considerable mental health problems, with 20% to 50% of patients experiencing postinjury depression1 and posttraumatic stress disorder (PTSD).2-4 Injury costs in the United States exceed $400 billion, primarily from lost productivity.5 Psychological and physical comorbidity combine to increase disability and cost.6,7
Health problems are unequally distributed across race and class.8 There are racial disparities in medical care and outcomes (eg, injury mortality)9; these disparities can be explained by cumulative effects of social and health inequalities.10 Health care quality is suboptimal for racial/ethnic minority and low-income groups and for residents of inner-city areas.11 Thus, urban black men from predominately low-income neighborhoods who are injured exemplify this ongoing disparity. Black men have high exposure to stressors,12 are more likely to be injured than white men,13 and are more likely to have psychological consequences but less likely to have mental health disorders diagnosed than white men.14 These injured men are typically transported to trauma centers where they are resuscitated, treated, and rapidly discharged to the community. Screening for psychological effects of injury is uncommon, even in level 1 and 2 trauma centers.15 Discharging these men from inpatient care with unrecognized psychological consequences contributes to suboptimal recovery and behavioral manifestations that contribute to injury recidivism, self-medication for symptoms, or interactions with the criminal justice system.16,17
Existing biases, dehumanization, and devaluation of this group have limited scientific progress in understanding the health consequences of injury for black men. Although injury is a short-term event, it can be an entrée into long-term health problems and disability. Addressing the psychological effects of injury can improve health and reduce the disparate outcomes of injury.
Building on evidence that information about the injury event alone is insufficient to identify who will develop depression or posttraumatic stress disorder (PTSD) after injury, in this study, we consider a life course of cumulative exposure, risk, and protective factors. Urban black men from disadvantaged neighborhoods have life experiences such as exposure to racism, poverty, and other traumas, and these cumulative exposures add to the psychological burden that likely contributes to the severity of postinjury depression and PTSD symptoms. The purpose of this study was to determine risk and protective factors from both childhood and adulthood that contribute to severity of depressive and posttraumatic stress symptoms at 3 months posthospital discharge in urban black men with serious injuries.
Depression and PTSD at 3 months postinjury are the primary study outcomes. Two parallel models were constructed (one each for depressive symptom severity and PTSD symptom severity) to examine the complex interplay among factors across the life course as these associate with each other and the primary outcomes. We broadly conceptualized relevant factors in temporal order across the life trajectory: first, childhood adversity both inside the child’s household (adverse childhood experiences) and outside the home (perceived neighborhood characteristics); then, several aspects of adult preinjury status: preinjury health, mental health, and psychological resources; then the injury event from an intentional mechanism (ie, violence) or unintentional mechanism (eg, a fall or car crash); and finally longer-term psychological reactions in the immediate aftermath of the injury event.
The present study was a prospective, cohort design in which men were enrolled during acute hospitalization and followed up for 3 months postdischarge. We selected the 3-month point for outcome assessment based on the previous research in an injured cohort that demonstrated most diagnoses of depression and PTSD were made at 3 months, with only 2 of 62 new diagnosed cases emerging after this point.18 The setting was an urban, level 1 trauma center located at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center located in the Northeastern United States.
Patients hospitalized for injury were consecutively recruited from a large urban trauma center between January 2013 and June 2017. This study focused exclusively on outcomes of injury in urban, black men. Patients with injuries who self-identified as black men, were 18 years or older, were hospitalized for injury, and resided in the greater Philadelphia metropolitan region were eligible. Exclusion criteria included a cognitive dysfunction or injury that precluded informed consent, active psychotic disorder, suicide attempt as the mechanism of injury, and/or current treatment for depression or PTSD.
This study was approved by the University of Pennsylvania institutional review board. Patients were vetted by a professional enrollment nurse on the trauma service who explained the study and answered all questions. Patients then provided informed consent to enter the study.
Recruitment, written informed consent, and the baseline interview were conducted in the hospital when the participant was medically stable. Once consent was completed, the research team performed all interviews. This full-time research staff consisted of a senior research project coordinator who is a master’s level–prepared licensed therapist and a data coordinator and interviewer. When additional research assistants were used, they were trained by the research coordinator for in-hospital interviews.
Demographic and injury-associated information were obtained via self-report and from the medical record. Interviews (approximately 1 hour) were conducted in a private room to obtain self-reports of acute stress responses and risk and protective factors. Outcome interviews (depression and PTSD) took place 3 months after hospital discharge, primarily in the participant’s home, and were conducted by the full-time research staff.
Depression and PTSD symptoms were assessed using the Quick Inventory of Depressive Symptoms–Self-report19 and the PTSD Check List–5.20,21 The Quick Inventory of Depressive Symptoms–Self-report is a psychometrically strong self-report scale for current depressive symptoms and was used as a substitute for a clinician’s assessment for symptom severity in clinical trials. The total severity score ranges from 0 to 27 points. The PTSD Check List–5 was built on the PCL-C to meet the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) diagnostic criteria for PTSD. It is a 20-item self-report instrument and summed severity scores range from 0 to 80 points.
Demographic information was collected. We assessed injury severity using the standard Injury Severity Score, which provides 1 numerical score to indicate the anatomic severity of multiple injuries across body systems ranging from 1 point (least severe) to 75 points (incompatible with life).22 Injury information was abstracted from the medical record by a trained registrar, and mechanism of injury categorized as intentional or unintentional.
The Peritraumatic Distress Inventory is a 13-item measure of experiences during a traumatic event, including immediate emotional reactions, physical reactions, and subjective appraisal of life threat. Scores range from 0 to 52 points.23 The Trauma Screening Questionnaire is a 10-item measure of early symptoms of intrusive thoughts and arousal, optimized for administration soon after a traumatic event, with scores ranging from 0 to 10 points.24
Psychological and emotional health resources were considered protective. Hope for the future was measured by the Trait Hope Scale, which has established convergent and divergent validity and good internal consistency, with scores ranging from 4 to 16 points.25 Self-efficacy was measured using the 10-item General Self-efficacy Scale, with established criterion validity and high internal reliability. Scores range from 10 to 40 points.26
Prior mental health challenges included were based on self-report of ever having been diagnosed with depression or PTSD prior to the injury. Preinjury health was coded to reflect risk and labeled poor preinjury health status. Participants reported the number of days that function was impaired because of poor physical or mental health, respectively, in the 30 days preinjury. Poor physical or mental health was defined as 14 or more days of impairment.27,28 Sleep disturbance was measured using the short form of the Patient-Reported Outcomes Measurement Information System Sleep scale.29 Scores range from 8 to 40 points. The 16-item Simple Screening Instrument for Substance Abuse collected data on alcohol use and drug use,30 with scores ranging from 0 to 14 points.31,32
Men were asked to report on exposures to 7 types of childhood adversity in their household, using the original questions from the National Adverse Childhood Experiences (ACE) study.33 Participants were asked about the neighborhoods in which they grew up, using the 18-item Neighborhood Environment Scale,34 which measures perceived neighborhood context (eg, feeling safe; observations of social disorder) and provides an estimate of cumulative exposure to adversity during childhood.35
Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the University of Pennsylvania. REDCap is a secure, web-based application designed to support data capture.36 Conventional verification was used to prevent logic errors and reduce incorrect, out-of-range values. Periodic analysis of each data field was conducted to examine the expected distributions of data and to identify outliers for possible errors.
We conducted descriptive analyses, using SPSS version 23 (IBM) for sample demographic and injury characteristics as well as key observed variables. The primary analytic approach was structural equation modeling, a method useful for examining complex associations among multiple constructs, using Mplus version 8 (Muthén & Muthén).37 We first specified and evaluated the fit of a measurement model by incorporating latent variables in the proposed model and their observed variables (indicators) and checked the correlations between the latent variables. Given acceptable fit of the measurement model, we then specified and evaluated the fit of structural models based on the conceptual model of the associations among risk and protective factors and postinjury mental health outcomes. We tested separate but parallel models for depression and PTSD symptom outcomes. The fit of each model was examined: the root mean square error of approximation (RMSEA) and the comparative fit index (CFI). The RMSEA is considered to indicate adequate fit when it is less than 0.08, and good model fit when it is less than .05. A CFI greater than 0.90 indicates adequate model fit.
Demographic and injury characteristics for all participants (n = 623) and the presence and severity of mental health outcomes for those retained at follow-up (n = 502 [80.6%]) are presented in Table 1. The mean (SD) age of the full cohort was 35.6 (14.9) years, and most men reported being single (369 [59.2%]). A large percentage of the men completed high school, some college, or a 2-year degree (460 [74.0%]); however, 243 (39.0%) were unemployed.
Reasons for loss to follow-up included researchers’ inability to contact the participant (n = 87), participant incarceration (n = 26), and participant withdrawal (n = 7). Participants who were lost to follow-up vs retained were compared on all baseline variables. The mean (SD) age among those lost to follow-up was younger (30.9 [11.3] years vs 36.8 [15.1] years; P < .001). Retention also varied by injury intent (intentional, 267 of 346 [77.2%]; unintentional, 236 of 277 [85.2%]; P = .01).
Two of the retained participants did not have complete primary outcome data. Of the remaining 500 participants, 225 (45.0%) met the cut point criteria for depression and/or PTSD at 3 months postinjury. Of this sample, 65 (13.0%) were positive for depression only, 51 (10.2%) were positive for PTSD only, and another 111 (22.2%) were positive for both depression and PTSD.
The measurement model (Figure 1) demonstrated excellent fit (RMSEA, 0.019; CFI, 0.99). Correlations among latent variables in the measurement model are shown in Table 2.
We then specified a structural model in which the 3-month mental health outcome (depression or PTSD symptom severity) was associated with poor preinjury health, acute psychological reactions, and an observed binary variable denoting whether this injury was intentional. In this model, we posited that acute psychological reactions were influenced by the individual’s experiences of childhood adversity. We also posited that the individual’s history of prior mental health challenges and psychological or emotional health and resource level operate on postinjury mental health via the effect of these 2 factors on poor preinjury health. Results are shown in Figure 2 (depression) and Figure 3 (PTSD symptoms). For both mental health outcomes, the models fit the data well: depression (RMSEA, 0.044; CFI, 0.93) and PTSD (RMSEA, 0.045; CFI, 0.93), and all hypothesized paths were significant and in the hypothesized direction. With respect to depression severity, childhood adversity was associated with acute psychological reaction (standardized weight, 0.33; P < .001). Prior mental health challenges (standardized weight, 0.70; P < .001) and psychological/emotional health and resources (standardized weight, −0.22; P = .003) were associated with poor preinjury health, which was in turn associated with acute psychological reaction (standardized weight, 0.44; P < .001). Acute psychological reactions (standardized weight, 0.34; P < .001), poor preinjury health (standardized weight, 0.28; P < .001), and intentional injury (standardized weight, 0.16; P < .001) were each associated with depression severity.
With respect to the model assessing severity of PTSD symptoms, childhood adversity was associated with acute psychological reactions (standardized weight, 0.36; P < .001). Prior mental health challenges was associated with pretrauma health (standardized weight, 0.70; P < .001), and psychological/emotional health and resource level was negatively associated with the same (standardized weight, −0.23; P = .003); pretrauma health was then associated with acute psychological reaction (standardized weight, 0.42; P < .001). Acute psychological reactions (standardized weight, 0.38; P < .001), poor preinjury health (standardized weight, 0.17; P = .02), and intentional injury (standardized weight, 0.24; P < .001) were each associated with PTSD symptom severity.
Almost one-half of the included men met diagnostic criteria for depression and/or PTSD, showing the considerable burden of postinjury mental health problems. The findings are consistent with prior research, in which 58% of randomly selected survivors of injuries identified psychological concerns, a percentage that ranked second only to physical health concerns (73%).38 The current findings have clinical importance since, in a national survey of trauma centers, only 7% of centers incorporated routine screening for PTSD symptoms.15 Patients are discharged only to find their psychological symptoms surface when they are back in the community, yet they do not understand these symptoms nor take steps to seek treatment.39,40
Given broader lifetime exposure to personal, institutional, and environmental risk among urban black men, understanding the risk for poor outcomes solely through features of the index injury is grossly inadequate. These findings suggest that both depression and PTSD symptoms in the months after an injury were influenced by the individual’s acute postinjury psychological reactions (assessed during hospitalization) as well as his recent (preinjury) physical and functional health. Both childhood adversity and poor preinjury health were associated with men’s acute psychological reactions. Further, among the black men with injuries in this sample, prior mental health and more global psychological resources (ie, hope, self-efficacy) played a role as key influences on poor preinjury health and functioning.
Findings were largely similar for depression and PTSD symptom outcomes. Examination of the path weights in the structural models for depression and PTSD suggest that that poor preinjury health play a somewhat larger role in postinjury depression, while acute psychological reactions and being injured by interpersonal violence play a larger role in the trajectory to postinjury PTSD symptoms.
This study takes a life-trajectory approach, helps inform potential points of intervention to improve outcomes, and adds to the understanding of both risk and protective factors across the life trajectory in an understudied group at high risk for injury. The intersection of prior trauma and adversity, prior exposure to challenging disadvantage, and poorer preinjury health should not be overlooked, even in the midst of acute injury care. These findings support the importance of trauma-informed health care for patients with injuries,41 particularly for those such as black men who, as a group, have disproportionately high rates of childhood adversity at the individual and neighborhood level. Trauma-informed injury care explicitly considers the effects of prior traumatic experiences as well as the potential for traumatic stress responses to the current injury event. Because symptoms develop after hospital discharge, further developing and using screening instruments designed to assess the future development of postinjury mental health problems is warranted to focus services on those patients at highest risk.42,43 Collaborative services that integrate trauma and mental health professionals and cross phases of care (from acute care to community care) are needed. The findings of this study identify the characteristics and exposures of injured black men at higher risk for poor mental health outcomes, factors that can be obtained from a focused history and that can facilitate the targeting of services to those with highest need.
While race and sex can be markers for disparate health outcomes, this study allowed us to look at heterogeneity within a group at higher risk for health disparities and examine the association of this heterogeneity (for example, in life trajectory and previous exposures) with postinjury mental health outcomes. We are hopeful these findings will help clinicians target resources to those at highest risk.
The strengths of this study include the consecutive enrollment and an overall 80% retention. It is important to note that although more men with intentional injury than unintentional injury were lost to follow-up, the retention rate of 77.2% of men in this subgroup is important in furthering understanding of acute intentional injury.
Results should be interpreted with the understanding that this cohort was enrolled in 1 urban trauma center in the Northeastern United States, which may limit generalizability. Childhood adversity (both adverse childhood experiences and neighborhood disadvantage) were assessed retrospectively, making recall bias a potential limitation.
This study identified risk and protective factors across the life course from childhood to adulthood that play a role in the mental health outcomes of black men who are injured. Prior research has linked each of these factors to racial disparities, further highlighting the potentially cumulative and synergistic role of disparities across a lifetime as they alter outcomes from a new acute injury event. Clinicians should expand assessment beyond the acute injury event to identify those patients at risk for poor mental health outcomes.
Accepted for Publication: March 2, 2019.
Corresponding Author: Therese S. Richmond, PhD, CRNP, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Fagin Hall 330, Philadelphia, PA 19104 (firstname.lastname@example.org).
Published Online: June 5, 2019. doi:10.1001/jamasurg.2019.1622
Author Contributions: Drs Richmond and Kassam-Adams had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Richmond, Wiebe, Rich, Kassam-Adams.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Richmond, Kassam-Adams.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Richmond, Shults, Kassam-Adams.
Obtained funding: Richmond, Rich.
Administrative, technical, or material support: Richmond, Reilly.
Supervision: Richmond, Wiebe.
Conflict of Interest Disclosures: Dr Richmond reported personal fees from Sigma Theta Tau International outside the submitted work. No other disclosures were reported.
Funding/Support: Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health (grant R01NR013503 [Dr Richmond]).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We acknowledge Jessica Webster, MS, LPC, who served as the senior research coordinator, and Andrew Robinson, BA, data coordinator, at the University of Pennsylvania, School of Nursing for their contributions to the conduct of this study. They were compensated by study funders for their contributions.
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