Risk factors for posttraumatic stress disorder in patients with multiple injuries and its relationship with anxiety and depression

Abstract

BACKGROUND

Patients with multiple injuries endure not just physical trauma and suffering but are also at risk of psychological conditions such as posttraumatic stress disorder (PTSD), anxiety, and depression. The co-occurrence of PTSD in these patients may cause prolonged physical and mental health complications, thereby further increasing their healthcare expenses.

AIM

To determine the association between the high-risk factors of PTSD and anxiety as well as depression among patients with multiple injuries.

METHODS

This study selected 110 patients with multiple injuries who were admitted to our hospital from November 2022 to November 2024. The number and percentage of patients developing PTSD were tallied. Univariate and multivariate analyses were conducted to investigate the high-risk factors of PTSD in these patients. Subsequently, the associations between these factors and the anxiety and depression levels of patients were analyzed.

RESULTS

Of the 110 patients, 33 suffered from PTSD, representing an incidence rate of 30.0%. The univariate analysis identified age, personality, Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), economic status, negative life events, and smoking history to be significantly associated with PTSD in patients with multiple injuries. Further, the multivariate analysis revealed age, HAMA, HAMD, monthly income, and negative life events as prominent high-risk factors for PTSD in such patients. Regarding the relationships between these factors and HAMA and HAMD, age exhibited a significant positive correlation (r = 0.398, P < 0.001; r = 0.387, P < 0.001), monthly income showed a significant negative correlation (r = -0.437, P < 0.001; r = -0.319, P < 0.001), and negative life events demonstrated a significant positive correlation (r = 0.505, P < 0.001; r = 0.365, P < 0.001).

CONCLUSION

These results indicate age, HAMA, HAMD, monthly income, negative life events, etc. as high-risk factors for PTSD in patients with multiple injuries, among which age, monthly income, and negative life events are closely associated with anxiety and depression.

Key Words: Multiple injuries; Posttraumatic stress disorder; High-risk factors; Anxiety; Depression

Core Tip: Posttraumatic stress disorder (PTSD) in patients with multiple injuries results in long-term physical and psychological complications, which significantly impair postoperative recovery. This study investigates the risk factors for PTSD in patients with multiple injuries and explores its association with anxiety and depression. Considering the limited existing research in this field, our results may help address crucial knowledge gaps. The results indicate advanced age, high Hamilton Anxiety Scale scores, high Hamilton Depression Scale scores, low monthly income, and negative life event exposure as significant risk factors for PTSD in such patients. Furthermore, advanced age, low monthly income, and negative life events are considered key contributors to emotional distress in this population. These results provide valuable information for the early screening and stratified intervention of PTSD in patients with multiple injuries, providing potential clinical guidance to improve outcomes.

INTRODUCTION

Traumatic events rank fifth among the leading causes of death in China, following tumors, strokes, heart diseases, and respiratory diseases[1,2]. Such events involved severe traumatic injuries, characterized by suddenness, severity, and a high risk of complications. Despite the 10.0% incidence rate of all traumatic occurrences, they remained responsible for 30.0%-50.0% of traumatic fatalities[3,4]. Patients with multiple injuries constitute approximately 25.0% of major trauma admissions, and compared to those with major trauma, they display a notably higher static incidence risk, greater injury severity, and increased mortality rate[5]. This condition not only inflicts physical trauma and distress upon patients but potentially results in posttraumatic stress disorder (PTSD), anxiety, depression, and other psychological issues[6]. PTSD is a psychological disorder in which individuals experience intense reactions (such as abusing addictive drugs, aggression, self-harm, or suicidal impulses) after a sudden and severe trauma. It is manifested as trauma re-experiencing, numbness, avoidance, and persistent arousal, and is closely associated with adverse outcomes related to quality of life and overall function[7-9]. Statistics indicate a 6.0%-8.0% prevalence risk of PTSD in the general population, whereas the incidence can soar to 25.0%-35.0% in those who have endured severe trauma (such as refugees, veterans, and assault victims). Further, this disorder is susceptible to environmental, genetic, and other factors[10,11]. Patients with multiple injuries who develop PTSD frequently endure long-term physical and mental health complications, causing trauma-related emotional distress such as anxiety, depression, anger, sadness, guilt, shame, and fear[12]. This not only hinders the patients’ daily functioning and physical recovery after injury but also escalates their medical costs[13]. Currently, research focusing on the relationship between the high-risk factors of PTSD and anxiety and depression in patients with multiple injuries is lacking. Hence, this study conducts relevant analyses to determine the potential associations, which is instrumental in uncovering the high-risk factors of PTSD in these patients to forestall its occurrence and clarifying the latent associations of these factors with anxiety and depression, thereby facilitating the identification of the root causes of patients’ emotional distress. Our study holds the potential to further mitigate the risk of PTSD in patients with multiple injuries.

MATERIALS AND METHODS

Case selection

The study included 110 patients with multiple injuries admitted to Zhongda Hospital Southeast University from November 2022 to November 2024. The inclusion and exclusion criteria are as follows.

Inclusion criteria: Diagnosed with multiple injuries[14]; ages between 18 and 65 years; conscious and capable of participating in various questionnaires and scale surveys; absence of other major stress events within the past year; expected to stay in the intensive care unit for > 3 weeks and survive.

Exclusion criteria: Pregnant or lactating women; patients with severe cardiovascular, pulmonary, cerebral, renal insufficiency, etc.; individuals with mental disorders or unclear speech; those with malignant diseases receiving palliative treatment; individuals with obvious disabilities or dysfunctions such as amputation or fistula; patients with defective clinical data.

Data collection and outcome measurement

Patients’ clinical characteristics were collected, including sex, age, personality, Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores, monthly income, negative life events, smoking history, and alcohol dependence history. Of these, personality traits (introversion/extroversion) were assessed with the Eysenck Personality Questionnaire[15]. Extroversion involved patients with an extroversion dimension score above the normative threshold, whereas introversion included those scoring below the normative threshold.

Negative life events were major stressful incidents (e.g., bereavement, violent assault, or significant financial loss) occurring within the 6 months before the study. These events were identified through patient self-reports or physician documentation in medical records. Cases without explicit records were categorized as “none”.

HAMA and HAMD were used to assess anxiety and depressive symptoms, respectively[16]. The HAMA consists of 14 scoring items and is scored following a five-point scale (0-4 points), with a total score of 56 points and a cut-off value of 14 points. The HAMD contains 24 scoring items and is scored according to a 4-point scale (0-72 points), with a total score of 72 points and a cut-off value of 20 points. Higher scores on these scales indicate more severe anxiety or depression.

Univariate and multivariate analyses were conducted to investigate the high-risk factors of PTSD in patients with multiple injuries, followed by an analysis of the relationships between these factors and patients’ HAMA and HAMD scores.

Statistical analysis

Measurement data were presented as mean ± SD, whereas count data were expressed as n (%). The χ² test was applied to investigate the two groups of count data. Statistical Package for the Social Sciences version 20.0 software was used for statistical analysis in this study. The high-risk factors of PTSD in patients with multiple injuries were identified with Binary Logistic regression analysis. Pearson/Spearman correlation coefficients were used for analysis for the determination of the association of the high-risk factors of PTSD with HAMA and HAMD. A P value of < 0.05 was used as the significance threshold.

RESULTS

Univariate analysis of high-risk factors affecting PTSD in patients with multiple injuries

The univariate analysis revealed that sex and alcohol dependence history were not significantly correlated with PTSD in patients with multiple injuries (P > 0.05), whereas age, personality, HAMA, HAMD, monthly income, negative life events, and smoking history were significantly associated with PTSD in such patients (P < 0.05; Table 1).

Table 1 Univariate analysis of high-risk factors affecting posttraumatic stress disorder in patients with multiple injuries, n (%).

Variable	PTSD (n = 33)	Non-PTSD (n = 77)	χ2	P value
Sex			0.063	0.803
Male	18 (54.55)	40 (51.95)
Female	15 (45.45)	37 (48.05)
Age (years)			6.004	0.014
< 50	16 (48.48)	56 (72.73)
≥ 50	17 (51.52)	21 (27.27)
Personality			8.255	0.004
Extroverted	9 (27.27)	44 (57.14)
Introverted	24 (72.73)	33 (42.86)
HAMA (points)			6.692	0.010
< 14	1 (3.03)	18 (23.38)
≥ 14	32 (96.97)	59 (76.62)
HAMD (points)			12.128	< 0.001
< 20	5 (15.15)	39 (50.65)
≥ 20	28 (84.85)	38 (49.35)
Monthly income (CNY)			10.509	0.001
< 5000	30 (90.91)	46 (59.74)
≥ 5000	3 (9.09)	31 (40.26)
Negative life events			6.068	0.014
Without	14 (42.42)	52 (67.53)
With	19 (57.58)	25 (32.47)
Smoking history			5.827	0.016
Without	11 (33.33)	45 (58.44)
With	22 (66.67)	32 (41.56)
History of alcohol dependence			1.001	0.317
Without	19 (57.58)	52 (67.53)
With	14 (42.42)	25 (32.47)

PTSD: Posttraumatic stress disorder; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Multivariate analysis of high-risk factors affecting PTSD in patients with multiple injuries

The factors that demonstrated differences in the univariate analysis, such as age, personality, HAMA, HAMD, monthly income, negative life events, and smoking history, were determined as independent variables, with PTSD serving as the dependent variable. The multivariate analysis revealed that age, HAMA, HAMD, monthly income, and negative life events were all significant high-risk factors for PTSD in patients with multiple injuries (P < 0.05; Tables 2 and 3).

Table 2 Assignments.

Variable	Variable	Assignment
Age (years)	X1	< 50 = 0, ≥ 50 = 1
Personality	X2	Extroverted = 0, introverted = 1
HAMA (points)	X3	< 14 = 0, ≥ 14 = 1
HAMD (points)	X4	< 20 = 0, ≥ 20 = 1
Monthly income (CNY)	X5	< 5000 = 0, ≥ 5000 = 1
Negative life events	X6	Without = 0, with = 1
Smoking history	X7	Without = 0, with = 1
PTSD	Y	Without = 0, with = 1

PTSD: Posttraumatic stress disorder; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Table 3 Multivariate analysis of high-risk factors affecting posttraumatic stress disorder in patients with multiple injuries.

Variable	β	SE	Wald	P value	Exp (β)	95%CI
Age (years)	1.651	0.633	6.795	0.009	5.214	1.506-18.046
Personality	1.183	0.630	3.525	0.060	3.265	0.949-11.226
HAMA (points)	2.551	1.253	4.145	0.042	12.818	1.100-149.395
HAMD (points)	1.457	0.644	5.125	0.024	4.293	1.216-15.157
Monthly income (CNY)	-1.717	0.745	5.310	0.021	0.180	0.042-0.774
Negative life events	1.494	0.603	6.143	0.013	4.455	1.367-14.522
Monthly income (CNY)	0.760	0.548	1.924	0.165	2.138	0.731-6.257

PTSD: Posttraumatic stress disorder; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Association between age and anxiety/depression

The Pearson correlation analysis was conducted to assess the correlation of age with HAMA and HAMD. Age exhibited a notably positive correlation with HAMA and HAMD (r = 0.398, P < 0.001; r = 0.387, P < 0.001; Figure 1).

Figure 1 Relationship between age and anxiety/depression. A: Relationship between age and Hamilton Anxiety Scale; B: Relationship between age and Hamilton Depression Scale. HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Association between monthly income and anxiety/depression

The correlation between monthly income and HAMA/HAMD was investigated using the Pearson correlation method. The results indicated a significant negative correlation between monthly income and HAMA and HAMD (r = -0.437, P < 0.001; r = -0.319, P < 0.001; Figure 2).

Figure 2 Link between monthly income and anxiety/depression. A: Link between monthly income and Hamilton Anxiety Scale; B: Link between monthly income and Hamilton Depression Scale. HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Correlation between negative life events and anxiety/depression

The Spearman correlation coefficient was employed to investigate the connection between negative life events and HAMA/HAMD. Negative life events were coded as 1 when not present and 2 when present in this analysis. Data demonstrated a significant positive correlation between negative life events and HAMA and HAMD (r = 0.505, P < 0.001; r = 0.365, P < 0.001; Figure 3).

Figure 3 Correlation between negative life events and anxiety/depression. A: Correlation between negative life events and Hamilton Anxiety Scale; B: Correlation between negative life events and Hamilton Depression Scale. HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

DISCUSSION

In this study, age, personality, HAMA, HAMD, monthly income, negative life events, and smoking history were significantly associated with PTSD in patients with multiple injuries. Individuals with an extroverted personality are more likely to receive adequate social support after a traumatic event, which can, to a certain degree, contribute to reducing the risk of PTSD. In contrast, smoking alleviated stress and anxiety to some extent; however, it exacerbated the risk of developing PTSD[17,18]. The multivariate analysis further revealed that age, HAMA, HAMD, monthly income, and negative life events were all crucial high-risk factors for PTSD in patients with multiple injuries. This is because the older population may be relatively more vulnerable physiologically and psychologically, face greater difficulties in regaining autonomy, and possess a weaker ability to cope with trauma, thereby being more prone to developing PTSD symptoms[19]. Patients with high HAMA and HAMD scores experience higher anxiety and depression levels either before or after trauma, which will undermine their coping abilities to some extent and augment the risk of PTSD[20,21]. People with low monthly income may have limited access to medical resources during treatment and rehabilitation due to financial constraints, which may impact the effectiveness of their treatment experience and also readily trigger anxiety, thereby potentially increasing the risk of PTSD[22]. Patients who have experienced more negative life events may endure more hardships, and their coping abilities and psychological resilience may be impaired, rendering them more psychologically vulnerable and more likely to develop PTSD symptoms[23]. Further, Stewart et al[24] revealed that middle-aged and elderly patients with high autistic traits are more likely to experience trauma throughout their life cycle and that this can exacerbate the effect of severe trauma on PTSD symptoms. Subsequently, the correlation analysis revealed that age and negative life events demonstrated a significant positive correlation with HAMA and HAMD, whereas monthly income exhibited a significant inverse association with HAMA and HAMD. These results can be associated with the relatively limited social support for older patients, the decline in individual psychological resilience, and the possible increase in chronic diseases with age, which may cause psychological distress such as anxiety and depression. On the one hand, negative life events impose direct psychological stress on patients, on the other hand, they may disrupt the patients’ social support networks, thereby potentially exacerbating their psychological load. In contrast, high-income patients can not only endure less economic pressure and more easily access high-quality medical resources but are more prone to enjoying a high quality of life, which provides a certain degree of protection to their emotional state. Rouleaux et al[25] revealed a significant positive correlation between negative life events and PTSD symptoms among individuals with intellectual disabilities, which is congruent with the results of our study. Further, evidence has proposed that depressive symptoms act as a mediator in the relationship between negative life events and PTSD symptoms[26].

The results of this study demonstrate significant clinical applicability in the early identification of high-risk populations for PTSD. In clinical practice, multiple injury patients demonstrating risk factors such as advanced age, low socioeconomic status (particularly low-income individuals), exposure to negative life events, or increased anxiety/depression symptoms, should be prioritized for early psychological screening and intervention. Furthermore, these results provide a foundation for developing tailored intervention approaches, including improved social support systems (such as medical cost subsidies and psychological counseling allowances), specialized trauma-focused counseling, and coordinated multidisciplinary care models involving geriatric and psychiatric follow-up services. However, several limitations should be addressed in future research. First, the single-center design and relatively small sample size may impact the generalizability of results, warranting multicenter studies with larger cohorts to confirm the identified risk factors through prospective clinical analysis. Second, the study establishes correlations, but the causal relationships remain unclear. Hence, longitudinal studies are required to identify whether anxiety and depression represent prodromal symptoms or consequences of PTSD development. Finally, the biological mechanisms were not investigated; thus, future research should incorporate analyses of inflammatory biomarkers in high-risk populations to investigate potential associations with anxiety/PTSD symptoms and determine the possible mechanistic role of inflammatory pathways in PTSD pathogenesis.

CONCLUSION

Our research reveals advanced age, high HAMA and HAMD scores, low monthly income, and the presence of negative life events as high-risk factors for PTSD in patients with multiple injuries. Hence, special care should be provided to those patients with multiple injuries demonstrating the above characteristics. Endeavors, using timely and efficacious psychological counseling and family support, should be made to maximize their potential for posttraumatic development. Further, age, monthly income, and negative life occurrences are all intimately associated with anxiety and depression. Specifically, advanced age, meager monthly income, and the presence of negative life events are the pivotal factors underlying the emotional distress experienced by patients with multiple injuries.