Prevalence and Determinants of Depression among Burn Injured Patients Admitted To Specialized Burn Hospital, Baghdad, Iraq

Background: Burn injuries are associated with extreme stress and affect psychological and physical aspects of patients’ health. Depression is a major result of burn injury which affect recovery and rehabilitation of burn injury patients. Objectives: To estimate the prevalence and determinant of depression and severity of depression in burn injury patients admitted to the Specialized Burn Hospital, Baghdad, Iraq Method: Case control study included all adult patients, who fulfilled inclusion criteria. Sociodemographic data and burn related information were assessed by a questionnaire prepared for this study. DSM-V criteria of depression were used to ascertain the diagnosis of depression. Beck depression inventory II was used for assessment of severity of depression. Results: This study included 120 burn victims. The prevalence of depression was 83.3%. Severity of depression was; mild (36.0%), moderate (44%) and severe depression 20%. Conclusion: Proper psychiatric assessment for depression of all burn patients is of great importance because depression can affect recovery process in burn survivors.

associated with greater social isolation, loss of independence, economic dependency, loss of sociooccupational functioning and increased distress 3 . Scars in visible areas are associated with social anxiety, avoidance and poor quality of life 4 . Facial burns in women are associated with greater risk of depression, and research has suggested that women are generally more vulnerable to the consequences of disfigurement 5 . Due to their long-term disabilities, burn injuries have become a great global health problem 6 . While it is reported as the sixth main cause of mortality, 28% of the survived patients cannot return to their previous functional level due to the severity of injuries and their consequences 7 . Burn injuries are associated with extreme stress and affect psychological and physical aspects of patients' health 8 . Mood is one of the most important mental aspects being affected by burn injuries. A research showed that the prevalence of at least mild to moderate symptoms of depression was 23% to 26% 9 . Another study shows that the prevalence of depression of at least moderate severity, was higher in female patients (46%) compared to all survivors from the center (29%), as well as a national sample of burn survivors (27%) 10 . In other study, symptoms of moderate to severe depression was observed in 54% of the patients within the first month and a follow up during the second month showed that 43% of them still meet the criteria for depression with unchanged severity 11 . Major depressive disorder (MDD) may deteriorate the condition of patients by increasing pain feeling and decreasing physical functioning of these patients 12 . Studies investigating depressive symptoms in survivors of burn injuries have some methodological differences. A systematic review revealed that studies using the depression subscale of the Hospital Anxiety and Depression Scale 13 report the prevalence of depression to be 4% to 13%, whereas generally higher rates were estimated by studies that used the Beck Depression Inventory 14 , being 13% to 26% for moderate to severe symptoms and 22% to 54% for at least mild symptoms. However, moderate to severe symptoms of depression have been found in 18-45% of burn survivors, years after their physical injuries have healed .Basic information about prevalence of depressive symptoms in survivors of burn injuries at different geographical areas is of high importance 15 . With increasing rates of survival among burn patients, it is important to address the psychological needs of burn survivors, with the aim of achieving a quality of life and functioning as close as possible to the preborn level, and successful reintegration of the survivor into society with a healthy mind and body 1 . The study aims were to estimate the prevalence and severity of depression in burn patients and study the correlation of sociodemographic characteristics of the patients with depression.

Methodology:
Design and setting a case control study undertaken at the Specialized Burn Hospital in Medical City Campus in Baghdad from 1st of March 2017 to 1st of September 2017. Study Population and Sampling: All patients were interviewed and those who meet inclusion criteria were enrolled in the study.
Inclusion criteria: the study includes adult burn injured inpatient, both gender, age ≥18 years, able to communicate, can give consent, experienced burn for the first time, no history of psychiatric disorders, no history of medical illness, epilepsy and learning disability.
Exclusion criteria: Patients who were not willing to participate, unable to communicate due to their medical condition and severity of burn or inhalational burn injury, age <18years, burn severity above 60% that may affect their ability to communicate due to pain and complications of burn, period of admission less than 2 weeks (to meet required criteria of major depression in DSM-V), patients experiencing more than one hospitalization due to previous burn injury (possibility of preexisting depression due to previous burn), selfinflicted burn injury (possibility of suicide attempt due to preexisting depression or mental illness), patients with history of mental illness, and patients with history of medical illness, epilepsy or learning disability. Data collection tools: information list included two parts; socio-demographic data and burn related information prepared for this study used. Information was taken from the patient directly, a close family member, and from the case file. Wearing overshoes and gowns were required to enter the burn wards. Patients interviewed 14 days after admission. Assessing symptoms of depression were according to DSM-V criteria of depression. Assessing degree of depression done by the administration of the second version of Beck Depression Inventory scale BDI-II, which is a selfreported question assessing mood during the last 2 week period, this scale was introduced in its second version at 1996 as 21 self-rating questions each question has 4 items ranging from 0 to 3. Scores indicate: 0-9 No depression, 10-18 Mild depression, 19-29 Moderate depression, 30-63 Severe depression.
Definition of variables: The independent variables evaluated to explain depression were; sociodemographics( age, gender, marital status, education, occupation) and burn related information ( surface area of burn, cause of burn, types of burn, areas involved, degree of burn).
Statistical analysis Data were subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS-version 20) program. Chi-square association test was used. P value of ≤ 0.05 was considered statistically significant.
Official Agreements and ethical issues: The study protocol was approved by the Arabic council of Health Specializations. A letter of facilitation was addressed from the council of Arabic board of Health specialization to the Specialized Burn Hospital. Permission of the plastic surgical team responsible for the cases was taken. Verbal informed consent was taken from all patients. All information is kept confidential.

Results:
This case control study included 120 burn victims and 120 as control group. The mean age 27 (62.0%) married, and 2(2.0%) divorced, and this had no significant statistical association with depression (P>0.05). There were significant statistical association between marital state and severity of depression (P< 0.05). (Table7). Depression did not show any significant statistical association with cause of burn. Severity of depression had no significant statistical association with cause of burn. There was no statistically significant association between depression and type of burn. There was significant statistical association between type of burn and severity of depression (P<0.05). Facial involvement of burn had revealed statistically significant association with depression, upper limb involvement showed significant statistical association with depression. Severity of depression had no association with any area involved. Degree of burn had no significant statistical association with depression and severity of depression. There was statistically significant difference in mean surface area involved, which indicated that larger surface areas are associated with depression. There was no statistically significant difference between surface area and categorical classification of severity of depression (Table 8)         24 where 65.7% females and 34.3% males. Most of the patients in this study were married 63% and marital status has significant association with severity of depression most had moderate depression while single represent 35% of the study sample and most suffered mild type of depression. This is consistent with Alvi T 18 study. Level of education among depressed group had significant statistical association with burn, most burn victims were primary school graduates 54 (54.0%), and most of comparison group were among secondary 12 (30.8%) and higher educational level 8 (20.5%). But there was neither statistically significant association with severity nor statistically significant differences in mean BDI scores. In Hussein E 16 study majority were of high education 50%. In Ptacek J T et al study 25 there was no significant association between educational status and depression. Depressed military showed 52% of total depressed burn victims due to high number of military in the study sample and difficulties they encountered in battle field and impact of burn, most of them with moderate severity. Housewife 30% of total depressed burn patients as females constituted small number in the study sample 30 out of 32 females were depressed which is 93% of mild, moderate and severe depression. Severity of depression had no statistical significance association between depression and occupation. In Hussein E 16 study 50% were unemployed with no statistical difference. In Alvi T 18 unemployment leads to higher depression scores due to financial burden. In Clarke MA 26 study; no association found.
Most of the depressed burn patients had combat related burn 52% being military, mostly of moderate severity of depression. 48% of depressed patients suffered accidental burn of mild and moderate severity. Cause and severity of burn had no statistical association with depression. In Hussein E