Posttraumatic Stress Disorder and Depression Negatively Impact General Health Status After Hand Injury

SCIENTIFIC ARTICLE

Posttraumatic Stress Disorder and Depression Negatively Impact General Health Status After Hand Injury Allison E. Williams, ND, PhD, Justin T. Newman, BS, Kagan Ozer, MD, Amanda Juarros, BS, Steve J. Morgan, MD, Wade R. Smith, MD

Purpose To estimate the prevalence of posttraumatic stress disorder (PTSD) and depression among hand-injured patients and assess the impact of these disorders on general health status. Methods A total of 106 adult hand-injured patients (40 women, 66 men) with a mean age of 42 years (range, 18 –79 years) participated. Patients with a chronic mental illness or cognitive impairment were excluded. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD and the Beck Depression Inventory. General health status was evaluated with the Short Form-36 health survey (SF-36). We obtained demographics and injury characteristics from the patient medical records. Results Prominent mechanisms of injury included a fall (n ⫽ 38), traffic-related injuries (n ⫽ 14), machine versus operator (n ⫽ 8), gunshot wounds (n ⫽ 6), and assault (n ⫽ 6). Using the screening questionnaires, 32 persons qualified for PTSD and 19 for depression. Sixteen patients met the criteria for both PTSD and depression. The association between PTSD and depression was significant (p ⬍ .01). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role– emotional (p ⬍ .01), body pain (p ⫽ .013), social function (p ⫽ .028), and mental health (p ⬍ .01). We found no significant differences between groups for the subscales of role–physical (p ⫽ .289), general health (p ⫽ .147), vitality (p ⫽ .496), and physical functioning (p ⫽ .476). Patients who had concurrent PTSD and depression had significantly lower scores than patients who had neither PTSD nor depression on all subscales (p ⬍ .05 for all) except role–physical (p ⫽ .135). We found significant negative correlations between Beck Depression Inventory scores and all of the SF-36 subscales (p ⬍ .05 for all). Conclusions In this study, nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, according to the thresholds of the instruments used to measure these psychological aspects of illness. PTSD and depression had a negative effect on general health status after hand injury. It may be important to consider psychological status when caring for patients with hand injuries. (J Hand Surg 2009;34A:515–522. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Type of study/level of evidence Prognostic II. Key words Depression, SF-36, hand injury, posttraumatic stress disorder, Revised Civilian Mississippi score. From the Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO; VA Eastern Colorado Health Care System, Denver, CO; and University of Colorado College of Nursing, Denver, CO. Received for publication December 5, 2007; accepted in revised form November 11, 2008.

Corresponding author: Kagan Ozer, MD, 777 Bannock Street, MC 0188, Denver, CO 80204; e-mail: [email protected]. 0363-5023/09/34A03-0022$36.00/0 doi:10.1016/j.jhsa.2008.11.008

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 515

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traumatic orthopedic injuries are an increasingly recognized source of disability. Multiple prospective studies have demonstrated that a considerable percentage of patients develop symptoms of posttraumatic stress disorder (PTSD) after general trauma injury.1– 6 The orthopedic trauma population in particular appears to have a high prevalence of PTSD; one multicenter study reported that more than half of patients with traumatic orthopedic injuries (295 of 580 patients) endorsed symptoms consistent with a diagnosis of PTSD.6 Few studies have examined depression after injury; however, there is evidence that depression is a problem that affects many injured patients.2,7 In addition, studies have indicated that a large percentage of patients with PTSD after injury also have depression.7 In one study, 16 of 37 patients with PTSD also had major depression 4 months after injury.8 Patients with concurrent PTSD and major depression appear to have more complications than patients with only one of the conditions. Shalev et al. found that patients with comorbid PTSD and depression reported more symptoms and greater distress from their symptoms and were judged to have poorer functioning than people who have PTSD or major depression alone.8 Although evidence suggests that injuries to the hand have a significant emotional and psychological impact,9 –11 we could find no studies that specifically evaluated the effect of PTSD and depression on general health status in a hand-injured population. The purpose of this study was to estimate the prevalence of symptoms consistent with PTSD and depression in patients who have sustained a hand trauma, and to analyze the impact of those symptoms on general health status.

P

SYCHOLOGICAL SEQUELAE OF

PATIENTS AND METHODS After we obtained approval from the local institutional review board, we recruited patients seeking follow-up outpatient treatment between August 2006 and July 2007 at the Orthopedic Hand Clinic of a level I regional trauma center for enrollment. Eligible patients were at least 18 years of age and had experienced a hand injury a minimum of 1 month earlier. Patients with a documented history of a psychiatric diagnosis or who were cognitively impaired were excluded from the study. A total of 269 consecutive patients were approached, of whom 122 satisfied the inclusion criteria and possessed none of the exclusion criteria. Ten eligible patients refused to participate, and 6 participants were dropped owing to completion of less than 50% of each questionnaire. Thus, a total of 106 patients made up the study sample. No differences in demographic, health

status, injury, or behavioral variables were found between patients who agreed to participate and those who refused (p ⬎ .05 for all). We acquired written informed consent and permission to access protected health information from participants in either English or Spanish before study participation. Data collection and instruments We retrieved demographic and injury data from patients’ medical records. To assess PTSD, depression, and general health status, patients were administered the Revised Civilian Mississippi Scale for PTSD (RCMS), Beck Depression Inventory, version II (BDIII), and Short Form-36 health survey (SF-36). Questionnaires were self-administered after we acquired informed consent. English and Spanish versions of the instruments were available for all 3 instruments. RCMS: We assessed PTSD with the RCMS. PTSD is an anxiety disorder that follows exposure to an event that is perceived as life threatening or has the potential to cause a serious injury.12 It is characterized by a constellation of symptoms that fall into 3 domains: intrusion, avoidance, and arousal. The intrusion domain includes symptoms such as recurrent flashbacks and frightening dreams in which the person relives the experience. The avoidance domain consists of symptoms that function to isolate the person from memories of the trauma and significant others. The arousal domain includes symptoms such as insomnia, irritability, and hypervigilance. Persons with PTSD may experience symptoms in one or all of these domains. Symptoms that have persisted for less than 3 months are considered acute, and symptoms that have persisted for more than 3 months are considered chronic. In some cases, symptoms may develop more than 6 months after exposure to a traumatic event. This is referred to as delayed-onset PTSD. The RCMS is a self-report screening tool for PTSD that contains 30 items representing common symptoms of PTSD.13 The first 18 items relate specifically to the traumatic event and may be reworded to refer to a specific incident. For example, the item “Reminders of the event are upsetting” may be changed to “Reminders of the hand injury are upsetting.” The last 12 items relate to generalized symptoms. Respondents rate each item using a 5-point Likert-type scale with the response anchors: 1 ⫽ not at all true, 2 ⫽ slightly true, 3 ⫽ somewhat true, 4 ⫽ very true, and 5 ⫽ extremely true. With the exception of 5 items, the statements are symptom affirming. The RCMS has 4 subscales. Three of the subscales group items according to criteria specified by the Di-

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agnostic and Statistical Manual of Mental Disorders, Fourth Edition.12 These subscales assess intrusion, avoidance or numbness, and arousal. Items in the intrusion subscale represent symptoms related to pathologic re-experiencing of the trauma. The items assess symptoms such as flashbacks, recurrent nightmares, and environmental triggers that elicit memories of the trauma. Items in the avoidance or numbness subscale assess symptoms related to direct and indirect attempts to avoid reminders of the trauma. This subscale includes items measuring social isolation, emotional detachment, and amnesia regarding the traumatic event. The arousal subscale includes items that assess anxiety and increased arousal after the traumatic event. Items included in this subscale measure symptoms such as insomnia, hypervigilance, and an exaggerated startle response. A fourth subscale includes items that capture feelings of guilt and suicidal ideation. An algorithm including the items in the intrusion, avoidance or numbness, and arousal subscales can be used to evaluate whether a person has a constellation of symptoms that meet the criteria for PTSD. The algorithm reversecodes items that are not symptom affirming, and a positive response indicates that the person endorsed a symptom that belongs to those that make up PTSD. Respondents with 1 or more positive responses on the intrusion subscale, 3 or more positive responses on the avoidance or numbness subscale, and 2 or more positive responses on the arousal subscale are considered to exhibit symptoms consistent with a diagnosis of PTSD. We added an item to the RCMS, making the questionnaire 31 items instead of 30. The item “The emotional problems caused by the hand injury have been more difficult that the physical problems” was scored on the same 5-point Likert-type scale and is not included in analysis of the separate subscales. The RCMS has demonstrated good reliability and validity for both the English and Spanish versions. The correlation between the English and Spanish versions has been estimated as .73, which indicates that the RCMS has moderate to high cross-language stability.12 BDI scale: We measured depression using the BDI-II. Depression is a type of mood disorder characterized by symptoms including alterations in appetite, sleep patterns, weight, body image, energy level, ability to concentrate, mood, level of engagement in life activities, and self-perception. Patients experiencing depression may also have recurrent thoughts of death or suicidal ideation. Symptoms that persist for at least 2 weeks meet the criteria for a major depressive episode.12 The BDI-II is a self-report tool based on criteria outlined in the Diagnostic and Statistical Manual of

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Mental Disorders, Fourth Edition. It is used to measure the presence and degree of depression for an adult population in a research setting.14 The BDI-II consists of 21 items pertaining to specific categories of depressive symptoms and is scored on a Likert-type scale. Respondents are instructed to select the statement that best corresponds with how they have felt over the past 2 weeks. Items are summed to produce a total score that ranges from 0 to 63, with higher scores representing increased morbidity. Level of depression is categorized according to the range in which the respondent’s total score falls: 0 –13 ⫽ none to minimal, 14-19 ⫽ mild, 20 –28 ⫽ moderate, and 29 – 63 ⫽ severe.13 The BDI-II is available in English and Spanish. Reliability has been estimated above 0.90, and the instrument has demonstrated high internal consistency, with Cronbach’s ␣, a statistical measure of internal consistency, averaging 0.86.15 Analyses have also supported the validity of the instrument as well as its cross-language stability.16 –18 SF-36 general health concepts scale: We measured general health status with the SF-36, a generic health survey that provides a profile of functional health status.19 It is available in English and Spanish versions. The SF-36 measurement model has 3 levels: 36 individual items, 8 subscales and 2 summary measures that aggregate results from the subscales. With the exception of 1 item that measures health transition, all of the items belong exclusively to one of the subscales. The 8 subscales are composed of 2 to 10 items and include physical functioning, role–physical, bodily pain, general health, vitality, social functioning, role– emotional, and mental health. Table 1 provides definitions of the subscales. The subscales are scored independently of one another. The two summary measures include a mental component summary (MCS) and a physical component summary (PCS). The role– emotional, social functioning, and mental health subscales make up the MCS, and the role–physical, physical functioning, and bodily pain subscales make up the PCS. The subscales of general health and vitality correlate with and contribute to both the MCS and PCS. The SF-36 is widely used and accepted as an instrument to assess general health. It has demonstrated content, concurrent, criterion, construct, and predictive validity.20 In addition, cross-language stability has been demonstrated.21,22 Statistical analysis We cross-tabulated and statistically analyzed demographic data and responses to questionnaires to identify any significant associations among patient variables,

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TABLE 1.

SF-36 Subscales

Subscale

Definition

Physical functioning

Assesses impact physical health status has on ability to perform physical activities

Role–physical

Assesses degree to which physical health affects work and/or daily activities

Bodily pain

Assesses pain level and extent to which pain affects work and/or daily activities

General health

Assesses perceived overall health status in relation to self and others

Vitality

Assesses level of energy

Social functioning

Assesses degree to which physical health and emotional problems affect social activities

Role–emotional

Assesses degree to which emotional problems affect work and/or daily activities

Mental health

Assesses general perception of mental health, most specifically anxiety and depression

TABLE 2.

Demographic Information for Enrolled Patients

Gender

Age

Time From Injury to Participation

Type of Insurance

Female: 40 Male: 66

Range, 18–79 y (mean, 41.7 y, SD 15.1)

75 d (range, 1 mo to 24 y)

Public assisted: 56 Private: 34 Self-pay: 13 Workers’ compensation: 3

PTSD, depression, and general health status. For categorical variables, contingency tables and Fisher’s exact and chi-square tests were used to assess associations. We analyzed continuous variables using Spearman’s rho correlation coefficient, analysis of variance, and the Kruskal-Wallis test. We performed posthoc comparisons using Tukey’s test and the Mann-Whitney U test. For all analyses, statistical significance was declared at p ⬍ .05. A power analysis indicated that a total of 124 subjects (31 per group) would be required to detect a moderate effect size (f ⫽ 0.30) given alpha ⫽ 0.05 and power ⫽ 0.80. We performed statistical analyses using SPSS 16.0 (Chicago, IL). RESULTS A total of 40 women and 66 men participated, with a mean age of 42 years (range, 18 –79 years). The median time from injury to study participation was 75 days (Table 2). Prominent injury mechanisms included a fall (n ⫽ 38) and traffic-related injuries (n ⫽ 14) (Table 3). The most common injury was a distal radius or ulna fracture (n ⫽ 38), followed by finger fracture (n ⫽ 11) and metacarpal fracture (n ⫽ 10) (Table 4). Responses to the RCMS indicated that 46 patients were positive on the intrusion subscale, 38 on the avoidance subscale, and 91 on the arousal subscale. Thirtytwo persons were positive for PTSD. The BDI responses identified 19 patients with depression, 8 of whom were categorized as mild, 5 moderate, and 6

TABLE 3. Mechanism of Injury n

% of Total

Fall

38

37

Traffic-related injury

14

14

Machine versus operator

8

8

Gunshot wound

6

6

Assault

6

6

Sports injury

3

3

Crush

2

2

Bicycle

1

2

16

15

9

9

Other Unknown

severe. Of those with severe depression, all 6 were also positive for PTSD. Six patients who were categorized as mildly depressed and 4 categorized as moderately depressed were also positive for PTSD. The association between PTSD and depression was significant (p ⬍ .01), with patients with depression approximately 19 times more likely to have comorbid PTSD (odds ratio ⫽ 19.3, 95% confidence interval ⫽ 5.0–74.7). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role– emotional (p ⬍ .01), body pain (p ⫽ .013), social

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TABLE 4.

Type of Injury n

% of Total

Distal radius/ulna fracture

38

36

Finger fracture

11

11

Metacarpal fracture

10

9

Mangled hand injury

9

9

Amputation

8

8

Flexor tendon injury

7

7

Extensor tendon injury

7

7

Middistal shaft forearm fracture

6

6

Carpal bone fracture

5

5

Proximal forearm/elbow fracture

4

4

Humerus fracture

1

1

function (p ⫽ .028), and mental health (p ⬍ .01). Significant differences between groups were not found for the subscales of role–physical (p ⫽ .289), general health (p ⫽ .147), vitality (p ⫽ .496), and physical functioning (p ⫽ .476) (Table 5). Patients who had concurrent PTSD and depression had significantly lower scores than those who had neither PTSD nor depression on all subscales (p ⬍ .05 for all) except role–physical (p ⫽ .135) (Table 6). We found significant negative correlations between the BDI and all of the SF-36 subscales (p ⬍ .05 for all) (Table 7). There was an insufficient number of patients with depression only (n ⫽ 3) to compare them statistically with patients with neither PTSD nor depression. DISCUSSION This study examined the prevalence of PTSD and depression and the impact of these disorders on general health status in a hand-injured population who presented to the orthopedic hand clinic at a regional level I trauma center. The results indicate that 32 (32%) of patients with hand injuries endorsed items consistent with a diagnosis of PTSD. Although the percentage of persons with PTSD is lower than that reported in a previous study estimating PTSD prevalence in a general orthopedic population, it is on the higher end of prevalence as reported in other studies of trauma populations.7 This finding supports the study hypothesis that PTSD is as important as, or is more of an issue for, patients with hand injuries than it is for a general trauma population. In addition, the percentage of patients with depressive symptomatology falls in the middle to high range of estimates of prevalence in a general trauma popula-

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tion.7 In our study, 19 (20%) of patients were categorized as depressed. This finding suggests that depression, like PTSD, may also affect more persons who have a hand injury than those who have a general orthopedic injury. Persons with depression were approximately 19 times more likely to suffer comorbid PTSD than those without depression. We found that of those with depression, 16 also endorsed symptoms consistent with PTSD. Posttraumatic stress disorder and depression had a negative effect on general health status for patients with hand injuries. Patients whose responses categorized them as positive for PTSD had lower scores on all of the SF-36 subscales, with significant differences for the MCS subscales of role– emotional, social functioning, and mental health, and the PCS subscale of bodily pain. The significant findings regarding the MCS subscales are consistent with the anticipated effect of psychological distress created by the symptoms that characterize PTSD. In addition, increased bodily pain or awareness of bodily pain would be an anticipated consequence of PTSD. PTSD is an anxiety disorder, and the relationship between pain and anxiety is well documented.23 Accordingly, persons experiencing PTSD symptoms would be more likely to experience more pain. What remains unexplained is the lack of significance between the PTSD-only and the no-PTSD or depression groups for the subscales of role–physical, physical functioning, vitality, and general health. It is possible that differences in physical functioning and physical role may be difficult to detect among hand-injured patients because the nature of the injury has a significantly negative effect independent of psychological status. Hand injuries can severely limit a person’s ability to perform physical work whether PTSD symptoms are present or not, particularly if the injury occurs to the dominant hand. The lack of significance for general health and vitality is more elusive. These subscales correlate with both the mental and physical components of the SF-36, so it may be that respondents answered according to a physical health perspective. Thus, responses may reflect injury status more than psychological status, diminishing differences between groups. Alternatively, PTSD symptoms may not have a large effect on perception of general health and vitality among hand-injured patients. More information would be required to draw conclusions regarding this finding. Results indicated that when depression as well as PTSD was present, general health status was more deleteriously affected. Persons symptomatic for both PTSD and depression had significantly lower scores than those with neither condition for all SF-36 subscales

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PTSD AND DEPRESSION AFTER HAND INJURY

TABLE 5.

Differences in Transformed SF-36 Subscale Scores, by PTSD Status Positive PTSD

SF-36 Subscale

n

Mean

Role–physical

17

Role–emotional

17

Negative PTSD or Depression Median

n

Mean

Median

14.7

0

57

31.6

0

43.1

33.3

57

73.1

100.0

p Value .289 ⬍.01

Body pain

17

34.8

32.0

56

52.1

51.0

.013

General health

17

67.1

67.0

55

77.2

80.0

.147

Vitality

16

52.8

55.0

56

58.8

60.0

.496

Social function

17

58.8

50.0

55

73.6

75.0

.028

Mental health

17

64.5

68.0

56

77.9

82.0

Physical functioning

17

66.2

70.0

57

72.9

75.0

TABLE 6. Status

⬍.01 .476

Differences in Transformed SF-36 Subscale Scores Concurrent With PTSD and Depression Depression and PTSD

SF-36 Subscale

Negative PTSD or Depression

n

Mean

Median

n

Mean

Median

Role–physical

16

17.2

0.0

57

31.6

0.0

Role–emotional

16

22.9

0.0

57

73.1

100.0

p Value .135 ⬍.01

Body pain

15

34.8

31.0

56

52.1

51.0

General health

15

54.5

57.0

55

77.2

80.0

⬍.01

.017

Vitality

16

40.9

37.5

56

58.8

60.0

⬍.01

Social function

16

36.7

31.3

55

73.6

75.0

⬍.01

Mental health

16

47.3

50.0

56

77.9

82.0

⬍.01

Physical functioning

16

49.4

47.5

57

72.9

75.0

⬍.01

except physical role. This finding would be anticipated given the additional psychological distress of dual diagnoses and interacting symptomatology. Depression has both physical and emotional characteristics that have been shown to produce more negative health consequences when PTSD is also present.8 The lack of significance regarding physical role is notable because the other PCS subscales revealed significance. It may be that the dichotomous format of the item was not specific enough to detect the difference. Additionally, the categorization of BDI scores may also have diminished power. The results of the correlation analysis indicated that increasing levels of depression negatively affected functioning across all 8 of the domains assessed by the SF-36. Thus, by categorizing individuals according to score, important differences within categories might have been missed that may be clinically relevant. However, it is also possible that, as with PTSD alone, the SF-36 physical functioning subscale captures physical

limitations unique to hand injury that are independent of psychological status. It is most probable that an insufficient sample size was achieved to detect the difference between groups. There are several strengths to this study. Patients were prospectively enrolled and all study items were available in English and Spanish versions, which allowed most eligible patients to respond in their native language. The study demonstrated that among patients with hand injuries, PTSD and depression are significant health concerns that negatively affect general health status. There were several limitations to this study. Because we used a cross-sectional design, time since injury varied and differences across time could not be assessed. The lack of longitudinal information relating to patient changes over time does not permit conclusions regarding changes in psychological status after hand injuries. However, there is some evidence that patients’

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TABLE 7. Correlation Coefficients Between BDI and SF-36 Subscale Scores Spearman’s rho SF-36 Subscale

BDI

p Value

Role–physical

⫺0.288

Role–emotional

⫺0.468

⬍.01

Body pain

⫺0.368

⬍.01

General health

⫺0.409

⬍.01

Vitality

⫺0.612

⬍.01

Social function

⫺0.668

⬍.01

Mental health

⫺0.748

⬍.01

Physical functioning

⫺0.271

⬍.01

.012

psychological status at 3 months is predictive of their status at 1 year. Gustafsson and Ahlström demonstrated that symptoms and problems related to hand injuries decreased during the initial 3 months and then remained unchanged for the remainder of the first year.24 Nonetheless, a longitudinal design with multiple administrations of the questionnaires would have permitted a more comprehensive examination of the etiology of PTSD and depression after hand injuries. Power represented another problem. An insufficient number of subjects with depression alone was in the sample, which prohibited an analysis of depression on general health status. This analysis would be important to ascertain the relationship between PTSD and depression and how they interact in relation to general health status. In addition, there was an insufficient number of subjects to compare prevalence of PTSD, depression, or both by injury type. It is possible that important differences in psychological and general health response according to type and severity of injury were not identified. Other limitations concerned the administration of the RCMS and BDI-II. A large percentage of the study participants (n ⫽ 58; 55%) had been injured less than 3 months earlier. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, these patients fell into the acute PTSD category. It is possible that the symptoms represented an acute stress reaction and not PTSD. Consequently, the prevalence of PTSD in this sample may have been overestimated. In addition, the RCMS and BDI-II are both self-report measures. Self-report measures are generally considered less reliable for diagnosing psychiatric conditions, and neither the RCMS nor the BDI-II is intended to establish a diagnosis. Rather, the responses given to

521

these surveys indicate symptoms consistent with PTSD and depression; a diagnosis would require clinical assessment by a qualified mental health professional. Nevertheless, both instruments have demonstrated good reliability and validity for assessing symptoms of PTSD and depression, and it is possible that people are more comfortable responding to personal questions on paper than in a clinical interview. However, the findings would have been strengthened had there been a clinical interview with a mental health professional. Finally, the lack of information concerning history of trauma and exposure to violence significantly limited the study conclusions. Several studies have indicated that these variables contribute to the development of PTSD, and it is not possible to know whether the injury or a prior event precipitated the symptoms of PTSD. The RCMS was modified specifically to identify the injury as the source of symptoms, and most of the respondents who endorsed the added item that indicated that the emotional problems from their hand injury had been more difficult than the physical problems were positive for symptoms of PTSD (14 of 18, 78%). This suggests that a significant percentage of the respondents with PTSD associated the development of their symptoms with their injury. However, this finding does not permit inferences regarding cause. In future investigations, it would be important to collect and analyze historical information systematically regarding previous trauma and exposure to violence. Psychological problems following orthopedic injuries have a substantial, negative impact on functional outcomes, and carry high personal and societal costs.25 Several investigators have noted that psychological factors influence patients’ physical symptom reports, as well as their perceived quality of life.4,26 –32 This study indicated that PTSD and depression negatively affected a notable percentage of persons who experienced a hand injury, and that presence of PTSD with comorbid depression further diminished perceived general health status. Early recognition and intervention has been shown to improve long-term outcomes for persons who experience PTSD and depression. Thus, early identification and treatment of trauma-related distress in patients with hand injuries may prevent progression of psychological pathology and mitigate negative effects on general health status. Moreover, it may be important to consider psychological status when caring for patients with hand injuries. REFERENCES 1. Michaels AJ, Michaels CE, Moon CH, Smith JS, Zimmerman MA, Taheri PA, et al. Posttraumatic stress disorder after injury: impact on

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