Association of physical injury and mental health: Results from the national comorbidity survey- adolescent supplement
Introduction
Nonfatal injury accounts for 10–16% of all disability worldwide (Haagsma et al., 2016, Murray et al., 2013, World Health Organization, 2010) and is common among children and adolescents (Centers for Disease Control and Prevention (CDC) - National Center for Injury Prevention and Control, 2014). In 2014 nonfatal injuries in children and adolescents accounted for over 8 million emergency department visits in the U.S. alone, with the highest rates among adolescents across both unintentional (i.e., struck, fall, overexertion) and intentional (i.e., assault) injuries (CDC - National Center for Injury Prevention and Centers for Disease Control and Prevention, 2014). Although substantial research has investigated physical disability outcomes post-injury (World Health Organization, 2013, World Health Organization, 2011), few studies have examined associations between a broad range of injury types and mental disorders in adolescents. The present study aimed to address this gap in the literature by examining the bi-directional associations between nonfatal injury and mental disorders in a nationally representative sample of U.S. adolescents.
Numerous studies have assessed the association between mental health and nonfatal traumatic injury requiring hospitalization in adult samples (Bryant, 2011, Schweininger et al., 2015, Wiseman et al., 2013, Zatzick et al., 2008, Zatzick et al., 2007). However, adolescents are at heightened risk for injury occurrence relative to children and adults and the majority of adolescent injuries require medical attention without the need for hospitalization (CDC - National Center for Injury Prevention and Control, 2014). Prior research examining associations between injury occurrence and youth mental disorders have typically focused on either a specific injury type or cause, such as traumatic brain injury (Mackelprang et al., 2014, Rivara et al., 2012) and motor vehicle crashes (Bryant et al., 2004, Williams et al., 2015), or a specific mental health outcome. Whether injury exposure, regardless of severity, contributes to mental disorder onset or exacerbation among adolescents warrants further attention.
Existing research among children and adolescents suggests that the associations between injury and mental disorders are bi-directional, although little research has examined a wide range of mental health outcomes as predictors and consequences of injury. Behavioral (Brehaut et al., 2003, Davidson, 1987, DiScala et al., 1998, Rowe et al., 2004) and substance use (Cho et al., 2007, Hingson et al., 2000, Mo et al., 2006) disorders are associated with increased risk of injury occurrence among children and adolescents; however, these conditions have infrequently been examined as post-injury outcomes in this age group (Rowe et al., 2007). Anxiety disorders and symptoms have been found to both increase (Rowe et al., 2007) and decrease (Jokela et al., 2009) risk for subsequent injury whereas depressive disorders and symptoms have been associated with increased risk for injury (Asbridge et al., 2014, Patten, 2010, Tiesman et al., 2006). With regard to consequences of injury, elevations in anxiety disorders and symptoms have been shown following injury and motor vehicle crashes (Bryant et al., 2004, Rowe et al., 2007); however, associations between injury occurrence and depressive disorders are inconsistent with some finding an association between injury and depression (Patten, 2010, Zatzick et al., 2006) and others findings no association (Rowe et al., 2007). While associations between injury and bipolar disorder have been rarely studied in adolescents, population-based studies of non-U.S. adults observed strong associations of bipolar disorder with rates of traumatic brain injury (Mortensen et al., 2003, Orlovska et al., 2014) and mortality due to both intentional and unintentional injury (Crump et al., 2013). Overall, no studies have investigated the bi-directional associations among a broad spectrum of both mental health disorders and injury exposures in a nationally representative sample of U.S. adolescents.
We examined the association of injury with mental disorders in the National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a nationally representative sample of U.S. adolescents. The NCS-A dataset includes systematic assessments of mental disorder onset and persistence across the lifespan, which we used to understand the reciprocal associations between nonfatal injury and mental disorders. The objectives of this study were to examine: 1) associations between mental health history and subsequent risk for nonfatal injury; 2) concurrent associations between injury and mental health; and 3) associations between injury occurrence and presence of subsequent mental disorders. Given the high degree of diagnostic comorbidity within the NCS-A sample (Kessler et al., 2012b), we examined associations between nonfatal injury occurrence and comorbidity of mental health disorders across these three study aims. Finally, we conducted sensitivity analyses adjusting for lifetime mental illness across all models examining the associations between injury and concurrent and subsequent risk for mental disorders.
Section snippets
Sample
The NCS-A was based on a national dual-frame household and school sample of adolescents aged 13 through 17 years, and is described in detail elsewhere (Kessler et al., 2009a, Kessler and Merikangas, 2004). Between February 2001 and January 2004, data were collected via in-person interviews with adolescents, and self-administered questionnaires (SAQs) given to one parent or guardian of each adolescent. Written informed adolescent assent was only obtained after consent was given by parents. Both
Sociodemographics and injury characteristics
A total of 11.6% of adolescents had an injury requiring medical attention in the year before the survey. Compared to uninjured adolescents, those with history of past-year injury were more likely to be male, older, and white as shown in Table 1. Poverty, urbanicity and family structure were unrelated to injury. Table 2 highlights characteristics of adolescent-reported injuries that occurred within the last 12-months. Most injuries were unintentional (89%), and the most common resulting
Discussion
Although injury is a common occurrence among adolescents, little is known about the interplay between injury and mental health. This is the first study examining associations between injury and a wide range of mental disorders among a nationally representative sample of U.S. adolescents. Nearly 12% of adolescents in our sample reported sustaining an injury in the past year that required medical attention. Although lifetime history of mental disorders did not predict subsequent injury occurrence
Acknowledgements
We would like to thank Drs. Janessa M. Graves and Jennifer M. Whitehill for their consultation on this study's design during its most preliminary phases.
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