Psychological support needed to reduce incidence of self-inflicted burns
Psych assessment and support, screening tool for psychiatric morbidity, essential
By Ruwan Laknath Jayakody
In order to reduce the incidence of self-immolation as a method of self-harm, a local study has highlighted the importance of conducting psychiatric assessments of all patients with burn injuries, the need for the development of a validated screening tool for the screening of psychiatric morbidity, and the provision of appropriate psychological support.
These recommendations were made by J.S. Galhenage and I.C. Perera (both attached to the Colombo University’s Psychiatry Unit at the National Hospital), M. Amarasuriya, R. Hanwella and M. Dayabandara (attached to the same University’s Medical Faculty’s Psychiatry Department) in an original paper titled “Demographic and clinical characteristics of patients with burns referred for psychiatric assessment to a tertiary care hospital in Sri Lanka” which was published in the Sri Lanka Journal of Psychiatry recently.
Burns cause, as noted in a study (M.G. Jeschke, R. Pinto, R. Kraft, A.B. Nathens, C.C. Finnerty, R.L. Gamelli, N.S. Gibran, M.B. Klein, B.D. Arnoldo, R.G. Tompkins, D.N. Herndon, and the Inflammation and the Host Response to Injury Collaborative Research Programme’s “Morbidity and survival probability in burn patients in modern burn care”), high morbidity and mortality.
A study (J.R. Gueler, K. McMullen, K. Kowalske, R. Holavanahalli, J.A. Fauerbach, C.M. Ryan, F.J. Stoddard, S.A. Wiechman, and K. Roaten’s “Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries”) has shown that co-morbid psychiatric illness adversely affects the outcome in burn injuries.
Regarding how burns can be associated with psychiatric morbidity, studies (S.W. Askay and D.R. Patterson’s “What are the Psychiatric Sequelae of Burn Pain?”, C. Oster and J. Sveen’s “The psychiatric sequelae of burn injury”, and R. Palmu, K. Suominen, J. Vuola, and E. Isometsa’s “Mental disorders among acute burn patients”) have found that it can first be due to the pain caused by the burn, its treatment, associated disability, and disfigurement; secondly due to severe metabolic derangements and infections which can lead to delirium; and, thirdly, trauma in the acute stage which can in turn lead to acute stress disorders and later to post-traumatic stress disorder (PTSD).
Concerning how psychiatric morbidity is associated with the increased risk of burns, studies (Palmu et al., C.M. Chang, K.Y. Wu, Y.W. Chiu, H.T. Wu, Y.T. Tsai, Y.L. Chau, and H.J. Tsai’s “Psychotropic drugs and the risk of burn injury in individuals with mental illness: A 10-year population based case control study”, K. Mahendraraj, D.M. Durgan, and R.S. Chamberlain’s “Acute mental disorders and short and long-term morbidity in patients with third degree flame burn: A population based outcome study of 96,451 patients from the Nationwide Inpatient Sample database 2001-2011”, and R. Palmu, T. Partonen, K. Suominen, S.I. Saarni, J. Vuola, and E. Isometsa’s “Health-related quality of life six months after burns among hospitalised patients: Predictive importance of mental disorders and burn severity”) found that due to the sedative effect of psychotropic medications, their use may also indirectly increase the risk of burns, while psychological distress during the hospital stay is significantly associated with greater physical disability, one year after the burn injury.
Hence, Galhenage et al. emphasised that the early identification and treatment of psychiatric illness in burn patients, sans delay, is essential in order to help patients return to a satisfactory level of functionality.
In Sri Lanka, where studies (V. Laloe’s “Epidemiology and mortality of burns in a general hospital of Eastern Sri Lanka”, S. Pirasath, V. Jasotharan, and P. Jeepara’s “Burn injuries in the Eastern Province of Sri Lanka: An analysis and outcome in a tertiary care hospital, Batticaloa”, V. Laloe and M. Ganesan’s “Self-immolation a common suicidal behaviour in Eastern Sri Lanka”, and R. Fernando, M. Hewagama, W.D. Priyangika, S. Range, and S. Karunaratne’s “A study on suicide by self-immolation”) have identified a high prevalence of self-immolation, a high proportion of self-inflicted intentional burns in females, triggered due to interpersonal conflicts, and suicidal deaths due to burns.
The “Crime Statistics: Mode of Suicide for 2019”, compiled by the Police Information Technology Division, noted that self-inflicted burns accounted for 3% of all suicides with 66% of such involving females. According to the study of Fernando et al., focused on the Colombo Coroner’s Court, in 2006, 34% of suicides were due to self-immolation, with a female-to-male ratio of 3.3:1.
Therefore, Galhenage et al. carried out a retrospective study by examining the clinic records (patient reports, collateral history/information, clinic records of patients maintained by medical officers and postgraduate trainees) of 87 inpatients (49-56.3% female and male) with burn injuries referred from the Colombo National Hospital’s Burns Unit (259 total admissions in 2019, whereas, in 2018, islandwide, there were 13,364 burn injury-related hospital admissions with the majority [56.6%] being males, according to the Indoor Morbidity and Mortality Statistics compiled by the Health Ministry’s Medical Statistics Unit) for psychiatric assessment to the Colombo University’s Psychiatry Unit at the National Hospital (all patients who were suspected to have psychological disturbances and others who were medically stable were referred for further evaluation and management, where, in the majority of the cases, the initial psychiatric assessment was conducted within two weeks after the burn injury, while in other cases, the initial assessment took place a few days following the burn or in one month) during the period from 1 January 2018 to 31 December 2019. The mean age was 37.4 years. The largest proportion of burn patients (38-43.7%) were less than 30 years while the least were above 60 years (12-13.8%). In both female and male, the highest proportions thus admitted, were in the 17-49 year age group. The majority (49-56%) were married while two were pregnant at the time of assessment. The level of education was not documented in the majority (50-57%) while 22 (25.28%) were educated up to Grade 11. The majority of burns (52-59.8%) had occurred at home.
Patients who had been diagnosed with a psychiatric disorder or who gave a history of suffering from symptoms suggestive of a psychiatric disorder prior to the burn were categorised as having a psychiatric diagnosis before the burn injury while patients who were confirmed to have been in remission prior to the burn but who relapsed after the burn, and patients without a previous diagnosis or history of psychiatric symptoms but who were diagnosed with a mental illness after the burn injury, with temporal and understandable association with the burn injury, were categorised as having psychiatric illness as a sequelae of the burn injury. Psychiatric illness has, according to a study (J.M. Duke, S.M. Randall, J.H. Boyd, F.M. Wood, M.W. Fear, and S. Rea’s “A population-based retrospective cohort study to assess the mental health of patients after a non-intentional burn compared with uninjured people”), a strong association with burns.
The mean body surface area of the burns was 36.26, with 28 (32.2%) patients having a burnt body surface area of less than 30%, while 15 (17.2%) had sustained burns to more than 30% of the body surface area.
According to the reports by the patients, 48 (55%) had sustained accidental burns, 27 (31%) had self-inflicted burns (over a quarter of all patients referred for psychiatric assessment), and three (3.4%) had had burns deliberately inflicted on them by others.
Mortality rates for intentional burns are three times as high as is the case for accidental burns, B.B. Lama, J.M. Duke, N.P. Sharma, B. Thapa, P. Dahal, N.D. Bariya, W. Marston, and H.J. Wallace found in “Intentional burns in Nepal: A comparative study”. Moreover, self-inflicted burns have been shown by Gueler et al. to lead to worse outcomes with complicated hospitalisations and resistant depression and anxiety symptoms even at 10 years.
Galhenage et al. estimated that since it is usual to refer all patients with self-inflicted burns for psychiatric assessment, a minimum of 18 (6.9%) of all inpatients managed in the Burns Unit of the Colombo National Hospital may have presented with self-inflicted burns.
Among patients with deliberate self-inflicted burns, 12 (13.8%) reported planning the act for less than 30 minutes (symptomatic of impulsivity), while three (3.4%) had planned it for over 30 minutes.
Of those with self-inflicted burns, 24 (27.6%) reported that a conflict or stressful event had taken place within a duration of 24 hours prior to the incident, and that these included conflicts with a partner (18-20.7%) and an immediate family member such as a parent (four). Pirasath et al. and Fernando et al. have found that marital and/or relationship problems were the main provoking factors for self-inflicted burns, and according to Laloe and Ganesan, and V. Laloe’s “Patterns of deliberate self-burning in various parts of the world”, it is a culturally influenced phenomenon in Sri Lanka, especially in the Eastern Province.
With regard to the reasons for self-immolation, only four reported a clear intent to die, while the majority (18) had stated that their attempt was carried out mostly with the intention to influence or frighten another. Three of these patients had schizophrenia.
In terms of the altered mental state of the 87 patients, 36 (41.4%) were in a depressed mood (the same is noted in J.E. Tedstone, N. Tarrier, and E.B. Faragher’s “An investigation of the factors associated with an increased risk of psychological morbidity in burn injured patients” and according to Galhenage et al., depression is associated with burns on the head, neck, and face, than burn injuries on other sites), eight (9.2%) were anxious, six (6.9%) were irritable, 26 (29.9%) were euthymic (normal, neutral, tranquil mood), nine (10.3%) had ongoing suicidal ideation, while six (6.9%) had psychotic symptoms.
Out of the 87 patients, 17 reported consuming alcohol with nine stating that they used alcohol once a week or more.
A past history of pre-existing mental illness was recorded in 31 patients (35.6%). The diagnoses considered included substance use disorder, depressive disorder, adjustment disorder, personality disorder/maladaptive personality traits, schizophrenia, delusional disorder, dementia, delirium, and PTSD (reported in one-third of patients in the third and sixth month after the burn injury, according to J. Difede, J.T. Ptacek, J. Roberts, D. Barocas, W. Rives, W. Apfeldorf, and R. Yurt’s “Acute stress disorder after burn injury: A predictor of PTSD?”). The common diagnoses in those with a past history of mental illness were substance use disorder (10-11.5%), personality disorder with maladaptive personality traits (9-10.3%), and depressive disorder (6-6.9%).
In the case of the 52 (59.8%) patients who were diagnosed with the burden of a mental illness as a sequelae of the burn injuries, the common diagnoses were depressive disorder, adjustment disorder (14-16.1%), delirium (six), PTSD symptoms (two), and newly diagnosed schizophrenia (one). According to studies (M.G. Madianos, M. Papaghelis, J. Ioannovich, and R. Dafni’s “Psychiatric disorders in burn patients: A follow up study” and R. Palmu, K. Suominen, J. Vuola, and E. Isometsa’s “Mental disorders after burn injury: A prospective study”), the prevalence of psychiatric illness after burns, varies, ranging from 46% to 55%.
It was found by Galhenage et al. that the majority of depressed patients (60%) and those with adjustment disorder (78%) had accidental burns.
In this regard, L. Kearney, E.C. Francis, and A.J. Clover’s “New technologies in global burn care – a review of recent advances” observed that due to the advancements in medical and surgical management, in the past half-a-century period, mortality and disability caused by burn injuries have been halved.
In the psycho-pharmacological management, antidepressants were the commonly prescribed medications (21-24%) followed by benzodiazepines (18-21%), antipsychotics (5-6%), and a combination of antipsychotics and antidepressants (4-4.6%). The majority of the patients (50-57%) were seen twice or more for psychiatric treatment while the rest were seen only once during their hospital stay or as outpatients. A patient who underwent the initial assessment had died due to the burn injuries.
In terms of significant associations between factors, it was found by Galhenage et al. that gender, in this case being female, age, in this case being below 30 years, and being previously diagnosed with a psychiatric illness were significantly associated with having a self-inflicted burn. According to the findings of Galhenage et al., being single, separated, divorced, or widowed, was associated with a higher degree of mental illness after the burn injury when compared with the group of patients who were married.
Marital status and the body surface area of the burn being less than 30%, and demographic and clinical factors and being diagnosed with a mental illness subsequent to the burn injury, as per the findings of Galhenage et al., were not significantly associated.
Galhenage et al. also noted that participants with less than 30% burn injury (89.5%) were more likely to be diagnosed with a mental illness but these associations were not statistically significant.
As explained by Galhenage et al., since a proportion of the self-inflicted burns were not intended to end in death and were impulsive, factors including ongoing depression, psycho-social stressors, and personality-related factors may have contributed to adopting such a method.
Psychiatric morbidity in patients with burns, studies (Mahendraraj et al., “Health-related quality of life six months after burns among hospitalised patients: Predictive importance of mental disorders and burn severity” by Palmu et al., and F. Li and D. Coombs’s “Mental health history – a contributing factor for poorer outcomes in burn survivors”) have shown increases in the duration of the hospital stay, rates of re-grafting, and the time taken to return to satisfactory daily functioning levels, and has led to poor health-related quality of life.
Palmu et al., have, in “Mental disorders among acute burn patients”, found that the prevalence of pre-existing substance use disorders, personality disorders, and psychotic disorders have been high in burn patients. Gueler et al. reported that patients with self-inflicted burns had increased suicidal ideation even at five years. Studies (Madianos et al. and Difede et al.) have also described the development of acute stress disorders, simple phobia, generalised anxiety, and somatoform disorder, in the wake of burn injuries.
The need of the hour, therefore, is for Sri Lanka to, Galhenage et al. emphasise, explore the implementation of novel and appropriate burn prevention strategies.