Oxford University Department of Psychiatry, Warneford Hospital, Oxford, UK
Correspondence: Professor Richard Mayou, Oxford University Department of Psychiatry, Warneford Hospital, Oxford OX37JX, UK. Tel: 01865 226477; fax: 01865 793101
Declaration of interest The research was funded by the Wellcome Trust.
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ABSTRACT |
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Aims To determine psychological and social outcome at 3 months and 1 year following a road traffic accident.
Method A cohort study of a 1-year sample of consecutive attenders (n=1148) aged 17-69 years at the accident and emergency department of a teaching district general hospital (excluding major head injury). Data were extracted from medica notes and from self-report at baseline, 3 months and 1 year.
Results Most (61%) injuries were physically minor. At 1 year 45% reported major physical problems and 32% reported psychiatric consequences. Non-injury variables were the principal predictors of outcome.
Conclusions Outcome across a range of variables is considerably worse than would be expected from the nature of the physical injuries. There is a need for changes in clinical care and socio-legal policy to prevent, identify and treat distressing and disabling chronic problems.
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INTRODUCTION |
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METHOD |
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The initial questionnaire covered demographic items, memories of the accident, previous travel, previous emotional problems, current feelings and attitudes; it was based on our previous research (Mayou et al, 1993) and a six-item version of the SF36 scale (Ware et al, 1992). The 3-month and 1-year questionnaires covered present health, consultation and treatment, effects of the accident on finances, work, travel and travel avoidance and also intentions to seek compensation. All subjects were asked to complete the Hospital Anxiety and Depression (HAD) scale (Zigmond & Snaith, 1983) and a self-report of PTSD symptoms (Foa et al, 1993) that provides both a severity score and a DSM-IV (American Psychiatric Association, 1994) diagnosis. We used the standard cut-off on the HAD scale and replies to self-report questions to define categories of anxiety and depression and specific phobia about travel that were similar to standard psychiatric criteria. Information was abstracted from the medical notes, and the Injury Severity Score (ISS) of the Abbreviated Injury Scale (American Association for Automotive Medicine, 1990) was calculated. This standard measure of injury severity, used in trauma research, is based on the summed squares of the three highest scoring injuries across five body regions. A score of 1-3 indicates minor injury, usually soft-tissue injury such as bruises and lacerations but also minor fracture such as a broken finger or nose.
Analysis used 2 together with logistic regression to
identify the predictors of 1-year outcome. The choice of predictors was
influenced by theoretical considerations and our previous findings
(Ehlers et al, 1998),
but the main concern was to consider variables that might be observed or
assessed easily by those providing immediate treatment for accident
victims.
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RESULTS |
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Characteristics of the sample
Table 1 shows some of the
characteristics of the participants. Just over half were men and half were
younger than 30 years old. The great majority of injuries (61%) were minor
(ISS score of 1-3, indicating abrasions or lacerations) and 20% were
uninjured. Twenty-two per cent (n=278) were admitted, of whom half
spent only one night in hospital.
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Non-respondents and drop-outs
To examine for selection bias, the 293 eligible people who did not take
part in the study were compared with the 1148 participants. Men were
significantly less likely to take part initially (78% v. 82% of
women; 2=4.85, 1 d.f., P<0.05), as were younger
people (76% of those aged
30 years v. 84% of those aged 30+
years;
2=11.13, 1 d.f., P<0.01) and people who
were not admitted to hospital (77% v. 89% of those admitted;
2=19.49, 1 d.f., P<0.001). The 375 participants
who dropped out of the study during the follow-up year also were compared with
the 773 who remained in the study, and again fewer men, younger people and
those not admitted completed the 1-year follow-up. Those out of work or off
sick at the first assessment also were less likely to stay in the study.
However, none of the other variables measured at first assessment or at 3
months were related to subsequent participation.
What are the consequences during the year after the accident?
There was a wide range in immediate reactions. One-third rated the accident
as not, or only mildly, frightening and one-fifth did not feel at all
distressed. At the other extreme, 36% found the accident very frightening and
27% were highly distressed. Distress was strongly associated with perceived
threat but not with injury severity. One-third (35%) felt moderately
to extremely angry.
Almost half of the subjects (46%) said that they were physically recovered at 3 months and 55% at 1 year. There was a correlation of 0.355 (n=787; P<0.01) between physical recovery and psychological consequences at 1 year (Table 2).
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Physical
At 3 months, 7% reported major problems in physical recovery
and there was little improvement at 1 year. Most problems related to serious
disabling injuries or to musculo-skeletal complaints that had limited
physically demanding work or leisure. At least six patients described severe
chronic pain syndromes that appeared out of proportion to the physical
impairment. Minor problems (39% at 1 year) were mainly musculo-skeletal
complaints.
Psychological
One-third of the responders had at least one of the four psychological
conditions (PTSD, phobic travel anxiety, general anxiety, depression) at 3
months (36%) and 1 year (32%). More women than men had at least one of these
disorders (3 months: 45% of women v. 28% of men;
2=26.90, 1 d.f., n=864; 1 year: 41% of women
v. 24% of men;
2=23.30, 1 d.f., n=773).
There was considerable overlap between these disorders but also a sizeable
number of people who had only one or two types of psychological complication.
Although there was some improvement during follow-up, with 82 people (12%)
getting better between 3 months and 1 year, 66 subjects (9%) suffered
late-onset psychological complications.
Social and financial
Most respondents (69%) were working at 3 months, of whom half had been off
work for less than a week and four-fifths were back at work within 4 weeks of
the accident. Although the proportion in work at 1 year (74%) was similar to
before the accident, 23% said that they still suffered work difficulties and
four-fifths said that they had financial difficulties as a result. Limitations
of travel, both as drivers and as passengers, were conspicuous.
Legal
The 9% of subjects who were prosecuted for driving offences had similar
outcomes to the remainder, except that they were significantly less likely to
report travel anxiety. Seeking compensation was associated significantly with
worse physical, psychological and social outcomes, but claimants also had
suffered more severe injury and loss.
Resource use
Although most subjects were discharged from the A&E Department without
a follow-up appointment, there was substantial continuing use of health care
resources throughout the follow-up year.
Are there differences in outcome according to the severity or type of
injuries?
The one-tenth of subjects who suffered medically serious injury (defined in
terms of injury resulting in admission for at least 3 nights) had poorer
outcomes on almost all measures (physical, psychological and social) at both 3
months and 1 year (Table 3). However, there was little association between clinical classification of
severity (no injury, soft tissue or bony), which was highly correlated with
ISS score (Spearman's correlation coefficient =0.834, P<0.01)
and outcomes. Physical recovery was poorest for those with fractures but there
were no differences for psychiatric consequences or for most social outcomes
at 3 months or 1 year.
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There were few associations between specific type of injury (of which whiplash neck injury was the most frequent) and any aspect of outcome at either 3 months or 1 year. Patients with leg fractures reported more limitation in activities than other subjects at 3 months and 1 year; those with arm fractures were more limited than others at 3 months but not at 1 year.
Are there differences according to the type of accident?
Those who reported immediately after the accident that they had been
very frightened had significantly worse outcomes at both 3
months and 1 year (Table
4).
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There were significant differences between the road user groups in medical
outcome at 3 months, but patterns of psychological and social consequences
were very similar. The main difference was in the occurrence of phobic travel
anxiety. Passengers were more likely than other groups to report travel
anxiety at 1 year (28% compared with 20% of motorcyclists, 17% of cyclists,
13% of pedestrians and 12% of drivers, 2=22.95, 4 d.f.,
P<0.01). It was mainly a problem for female passengers, with twice
as many female passengers (34%) being classified as suffering from phobic
travel anxiety at 1 year than female drivers (17%) and male passengers (16%).
Only 7% of male drivers had phobic travel anxiety at 1 year.
Can we identify those who are at risk of chronic problems?
Self-report of physical recovery at 3 months was substantially predicted in
a logistic regression by the severity of the accident injuries. However, by 1
year other factors also entered the prediction psychological
complications at 3 months, blame and involvement in compensation
proceedings.
Logistic regression also was used to determine whether those at risk of chronic psychological problems at 1 year could be identified by clinical features that might be assessed easily in the A&E Department or at early follow-up review (Table 5). In the first stage, all the baseline variables included were significant predictors of 1-year outcome when entered on their own. After adjustment for the effects of the other variables and using a strict criterion of significance to take account of the number of variables (Bonferroni correction), negative emotion, prior emotional problems, perceived threat, feeling not to blame and severity of injury remained significant. The proportion of deviance explained was modest. In the second stage a number of 3-month variables, thought likely on theoretical grounds to be associated with later outcome, were added to see if this increased the accuracy of prediction. Continuing medical problems and three of the cognitive maintaining factors at 3 months were significant predictors of 1-year psychological outcome, accounting for an additional 12% of the deviance. In a final stage, any psychological complications at 3 months was added to the model as a further predictor variable. This increased the deviance explained to 30% and the proportion of cases correctly classified to 81%.
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DISCUSSION |
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The study has the important advantages of being prospective, large size and a representative sample of all attenders following road accident injury, having a comprehensive view of outcome and using systematic emergency department medical data. Although there were high rates of response at each stage for the postal survey, there were some non-respondents. The gender differences (and the small over-representation of women among the participants) mean that overall frequencies of psychiatric disorders should be used with care. Findings also are limited by being based on self-report and by the lack of objective medical assessment at follow-up. However, the validity of our findings is supported by comparison with our previous research (Mayou et al, 1993) and with an interview subgroup within the present study, both of which had very high response rates throughout and were based on detailed interview. The findings are consistent with previous reports from several countries, both of disability associated with multiple and other very severe injuries (Holbrook et al, 1999) and of the psychiatric complications (Hickling & Blanchard, 1999).
Physical and psychological outcomes
Reports of continuing physical problems at 1 year were considerably more
common than would have been expected from the nature of the injuries recorded
in the A&E Department notes. Written comments and the verbal reports of
admitted patients who were interviewed suggest that most were musculo-skeletal
complaints. They were often restricting and frustrating for people who had
previously had physically demanding work or leisure interests. Psychiatric
complications were frequent; there were serious effects on travel and other
aspects of daily life. The association between physical and psychological
variables suggests that psychiatric complications affect perception of pain
and impairment and that interim physical problems may maintain post-traumatic
symptoms.
Predicting outcome
The analysis of predictive factors reported here, taken with our report of
an earlier cohort (Mayou et al,
1993) and comparison of detailed analyses of prediction of PTSD
(Mayou et al, 2001)
and other psychiatric outcomes (Ehlers
et al, 1998), emphasises the importance of non-medical
variables for all domains of outcome. We conclude that a poor outcome
following a road traffic accident should be seen as resulting not only from
the physical injury but from the psychiatric consequences of a
life-threatening experience, financial losses and a system of compensation
that perpetuates frustration while delaying resolution. Even though large
health, social and legal resources are involved, many difficulties are
unrecognised and untreated.
Clinical implications
Improving clinical care has to be considered in a context in which most
patients are discharged after a single A&E department attendance, but many
of those who see themselves as innocent victims of a very frightening form of
trauma are angry about the suffering and the apparent lack of recognition from
others. We need to consider the following.
Our account of the outcome for a representative sample of A&E department attenders shows that problems are greater, more varied and more persistent than has been recognised previously. This very large public health and economic problem requires legal and social (Cassidy et al, 2000) as well as medical answers.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication February 7, 2001. Revision received June 18, 2001. Accepted for publication June 22, 2001.
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