D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2019 . No. 4 CONTRIBUTORS TO POST-INJURY MENTAL HEALTH IN URBAN BLACK MEN WITH SERIOUS INJURIES Therese S. Richmond, Douglas J. Wiebe, Patrick M. Reilly, John Rich, Justine Shults, Nancy Kassam-Adams JAMA Surgery – published online June 5, 2019 KEYFINDINGS Factors over the life course affect the mental health of urban black men with serious injuries. Childhood adversity, pre- injury physical and mental health conditions, and intentional injury (violence) are risk factors for post-injury depression and posttraumatic stress. Clinicians should expand assessment beyond the acute injury event to identify patients at risk for poor mental health outcomes. THE QUESTION THE FINDINGS Although injury is a short-term event, it can lead to long-term mental The final sample included 500 black men, over half (55.5%) of whom had health problems, with up to 50% of patients experiencing post-injury intentional injuries due to interpersonal violence. Almost half (45%) met depression and posttraumatic stress disorder (PTSD). Injured black men diagnostic criteria for either depression or PTSD three months post- are particularly vulnerable because they have high exposure to stressors, injury: 65 (13%) were positive for depression, 51 (10.2%) were positive for are more likely to be injured than white men, and are more likely to have PTSD, and 111 (22.2%) were positive for both outcomes. undiagnosed psychological consequences than white men. Sending these The flow chart on the next page shows the risk and protective factors men back to the community with unrecognized mental health problems across the life trajectory that influence depression severity post-injury. contributes to suboptimal recovery, and can lead to repeated injuries, self- Childhood adversity was associated with acute psychological reactions medication for symptoms, or interactions with the criminal justice system. to injury (e.g., immediate emotional reactions, physical reactions, and Urban black men from disadvantaged neighborhoods are exposed to subjective appraisal of life threat). A history of prior mental health racism, poverty, and other traumas throughout their lives, which may challenges influenced poor pre-injury health, while psychological/ contribute to the severity of mental health conditions after injury. In this emotional health and resources (e.g., self-efficacy and hope) protected study, the authors use statistical modeling to understand the factors against poor pre-injury health. In turn, acute psychological reactions to from childhood and adulthood that contribute to depression and PTSD injury, poor pre-injury health, and intentional injury, were each associated severity in black men with serious injuries. with depression severity. The model for PTSD symptom severity showed similar results. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Life Trajectory Risk and Protective Factors for Post-injury Depression INJURY PRE-INJURY POST-INJURY Childhood Acute psychological adversity reactions to injury Prior mental health Poor pre-injury Depression severity challenges health 3 months post-injury Psychological/emotional Intentional health and resources* Injury *green arrow denotes protective effect THE IMPLICATIONS THE STUDY The intersection of prior trauma and adversity, exposure to challenging The study used a prospective, cohort design in which men were disadvantage, and poor pre-injury health should not be overlooked in enrolled during acute hospitalization at an urban, level 1 trauma center acute injury care. These findings support the importance of trauma- in Philadelphia, and followed up three months post-discharge. Men with informed care for injury patients, especially black men, who as a group injuries who were hospitalized, self-identified as black, were 18 years have disproportionately high rates of childhood adversity. or older, and resided in the Philadelphia region were eligible. Those The current findings have clinical importance since, in a national survey experiencing a cognitive dysfunction or psychotic disorder, hospitalized of trauma centers, only 7% of centers incorporated routine screening for because of attempted suicide, or receiving treatment for depression or PTSD symptoms. Because symptoms develop after hospital discharge, PTSD were excluded. The data were collected from January 2013 to further development and use of screening tools designed to assess post- October 2017. injury mental health problems is warranted. Collaborative services that Recruitment, written informed consent, and baseline interviews were integrate trauma and mental health care and cross phases of care (from conducted in the hospital when the participant was medically stable. acute to community care) are also needed. The findings of this study Demographic and injury-associated information were obtained via identify characteristics and exposures of injured black men at higher risk for self-report and from the medical record, while self-reports of acute stress poor mental health outcomes, factors that can be obtained from a focused responses and risk and protective factors were collected during interviews. history and that can help target services to those with highest need. Interviews to assess PTSD and depressive symptoms were conducted three months after hospital discharge, primarily in the participant’s home. Richmond TS, Wiebe DJ, Reilly PM, Shults J, Rich J, Kassam-Adams N. Contributors to Postinjury Mental Health in Urban Black Men with Serious Injuries. JAMA Surgery. 2019 Jun 5. doi:10.1001/jamasurg.2019.1622 LEAD AUTHOR DR. THERESE RICHMOND Therese S. Richmond, PhD, FAAN, CRNP is the Andrea B. Laporte Professor of Nursing and the Associate Dean for Research & Innovation at the University of Pennsylvania’s School of Nursing. Dr. Richmond’s research focuses on improving recovery from serious injury by addressing the interaction between physical injury and its psychological repercussions, particularly in vulnerable populations. Two decades ago she co-founded what is now the Penn Injury Science Center, an interdisciplinary center that conducts research and translates scientific discoveries into practice and policy with the greatest potential to prevent injury and violence and improve outcomes. Her co-authors are Douglas J. Wiebe, PhD, Patrick M. Reilly, MD, and Justine Shults, PhD, all of the University of Pennsylvania; John Rich, MD, MPH, of Drexel University; and Nancy Kassam-Adams, PhD, of the Children’s Hospital of Philadelphia. This research was supported by the National Institute of Nursing Research of the National Institutes of Health (grant R01NR013503).