| | Acute Pain at Discharge From Hospitalization is a Prospective Predictor of Long-Term Suicidal Ideation After Burn InjuryAbstract Edwards RR, Magyar-Russell G, Thombs B, Smith MT, Holavanahalli RK, Patterson DR, Blakeney P, Lezotte DC, Haythornthwaite JA, Fauerbach JA. Acute pain at discharge from hospitalization is a prospective predictor of long-term suicidal ideation after burn injury. ObjectiveTo determine the extent to which pain contributes to risk for suicidal ideation after burn injury. DesignThis longitudinal cohort study evaluated participants at discharge, 6 months, and 1 year after burn injury. SettingInpatient rehabilitation units of multiple regional burn centers. ParticipantsSurvivors of major burns (N=128). InterventionsNot applicable. Main Outcome MeasuresPain severity, assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain subscale, and passive and active suicidal ideation, assessed by self-report. ResultsAt each time point, approximately one quarter to one third of the sample reported some form of suicidal ideation. In logistic regression analyses, pain severity at discharge was the sole consistent predictor of suicidal ideation at follow-up, with greater pain severity being associated with enhanced risk for both passive and active suicidal ideation. These associations were observed even after controlling for discharge mental health. ConclusionsThese are the first findings to suggest an association between acute pain severity and the development and maintenance of suicidal ideation in burn patients. Further research in this area, including the study of improved pain management programs as a prophylaxis against suicidal ideation, may benefit those who are at elevated suicide risk as a consequence of burn injuries. A CONFLUENCE OF RECENT findings from both epidemiologic and clinically based studies strongly suggests that pain is an important risk factor for a constellation of self-injurious behaviors. The presence of persistent pain is associated with elevated rates of suicide-related cognitions and behaviors,1, 2, 3, 4, 5, 6 requests for physician-assisted suicide,7 and completed suicides.8, 9, 10 This elevation in suicidality is greater than that observed in other nonpainful physical illnesses,11, 12 highlighting the importance of understanding the mechanisms by which the experience of pain influences suicide-related thoughts and behaviors.8 Given that suicide is among the leading causes of death in the United States,13 it is important to understand the factors contributing to the disproportionately high suicide rates among people suffering from pain. In general, rather than focusing on completed suicides, which is almost certain to be rare in any given sample, many researchers evaluate factors contributing to suicidal ideation (SI), a nearly universal correlate of suicidal acts. Because the vast majority of both planned and unplanned suicide attempts occur within 1 year of the onset of SI,14 identification of risk factors for new-onset or worsening SI is of substantial importance. However, one presently unanswered question is to what extent the severity of pain contributes to risk for suicide-relevant outcomes such as SI in patients suffering from painful conditions. For example, although some studies report that suicidal ideation is more common in the context of more severe pain,1, 15 other research indicates no association between pain severity and suicidal ideation after controlling for depression,5, 16 an important methodologic consideration in such studies.17, 18 A potentially valuable forum in which to study these associations is in the context of burn injuries, which are often painful,19 disabling, and disfiguring, and are prospectively associated with high rates of accidental death, including suicides.20 It is interesting to note that although there is substantial and growing literature on psychosocial outcomes after burn injury21, 22 and an equally large number of studies concerning self-inflicted burns as a method for committing suicide,23, 24, 25, 26 relatively little research has evaluated the prevalence of suicidal ideation in the postburn period,27 and to our knowledge no studies have evaluated predictors of SI postburn. Two studies28, 29 have investigated the link between pain during hospitalization and subsequent psychosocial burn outcomes, but did not consider SI in their analyses. Indeed, the question of whether greater pain severity is an independent risk factor for suicidal ideation has important practical consequences because a variety of interventions have proven effective in managing both acute and chronic pain in other settings,30 though many professionals opt not to use them. Collectively, arguments to convince burn teams to control pain more effectively are needed, and none may be stronger than showing a link between poor pain control and suicides or SI.31, 32 At present, though, whether individual differences in the severity of pain in the acute care setting, in which most people have some degree of pain, can predict suicidal ideation is a crucial yet unanswered question. In the present investigation, we sought to identify whether the severity of pain at discharge was prospectively related to suicidal ideation in patients who had experienced burn injuries. We hypothesized that more severe pain would be associated with greater report of passive and active SI at postdischarge follow-up time points. Methods  Participants Participants were consecutive admissions from 3 regional burn centers in the United States; we recruited patients if they were at least 16 years of age, cognitively competent to provide informed consent, and met American Burn Association criteria for major burn injuries.33 All participants provided informed consent for a prospective, longitudinal Burn Model Systems (BMS) study sponsored by the National Institute on Disability and Rehabilitation Research. The data reported here were gathered between 1994 and 2000 as part of this larger study. Participants were evaluated at discharge from their acute hospital stay, and then again at 6 and 12 months after burn injury by trained personnel using standard procedures and measures. Several prior studies provide detailed information on the BMS study and the patients who have enrolled.34 The present sample includes all patients who provided discharge data and also provided data at both the 6-month and 12-month follow-up time points. A total of 407 patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and Brief Symptom Inventory (BSI) at discharge. Of those 407 patients, 207 (50.9%) provided data at the scheduled 6-month postdischarge follow-up. Of those 207 patients, 128 (61.8%) provided data at the 12-month follow-up. Thus, a total of 128 patients provided complete discharge and follow-up data. Interestingly, these 128 patients did not differ from the 279 who did not provide complete follow-up data on demographic or burn-related characteristics (age, sex, burn area), on discharge SI, or discharge scores on the SF-36 bodily pain, general health, or mental component subscales (all P>.05). Of the 128 “completers,” 70.3% were men, consistent with a typical preponderance of men among burn survivors. In addition, the sample was largely white (77.3%), with an average age of 40.6±15.0 years. The etiology of the burn injuries was generally flame (57.0%), contact (25.0%), or electrical (7.0%). The most commonly affected anatomic sites in this sample were the arm (67.2%), hand (58.7%), and trunk (53.4%); many patients were burned at multiple sites. In terms of burn severity, the mean total body surface area (TBSA burned) was 18.7%, and mean total body surface grafts (TBSA grafted) was 9.6%. Measures Demographic and injury-related variables Patient demographics (race, age, sex) were evaluated by self-report as part of the standard history and physical on admission to the burn center. In addition, multiple aspects of a patient’s injury were recorded, including the total body surface area affected by burn injury (TBSA burned), and the total body surface area on which skin grafts were performed (TBSA grafted). SF-36 The SF-36 is a 36-item measure of quality of life that includes composite or summary scales reflecting patient-reported physical, psychologic, and social health and function. The SF-36 is the most widely used health status measure in the world; it possesses excellent psychometric properties across a wide variety of patient and nonpatient samples.35, 36, 37, 38 Two subscales and component scale of the SF-36 were used as measures of pain, general health, and psychosocial function.37, 38 The bodily pain and general health subscales provide scores from 0 (eg, very poor health and extremely severe pain) to 100 (optimal health and no pain), which characterize levels of pain and perceived overall health over the past 4 weeks. The SF-36 mental component scale (MCS) is a summary of 4 additional subscales: mental health, social functioning, role interference from emotional problems, and vitality. Patients completed the SF-36 at 4 different time points: the first was during their hospital stay, in reference to their preinjury functioning, the second was at discharge in reference to their current functioning, the third was at 6-month follow-up, and the fourth was at 12-month follow-up. Brief Symptom Inventory The BSI is a short form of the Symptom Checklist-90–Revised.39 It assesses psychologic symptomatology over the past week across a range of domains. As in prior studies40 we used responses to 2 BSI items to classify the reported degree of suicidal ideation (see Classification of Suicidality section below). Patients completed the BSI at discharge and 6-month and 12-month follow-up points. Classification of Suicidality We classified the presence and degree of suicidal ideation using questionnaire items as in previous studies of pain and suicide.15, 16 Although this method is not ideal (ie, a clinical interview and complete suicide questionnaire would be preferable), an earlier study of chronic pain patients comparing the use of a single questionnaire item with results from a semi-structured interview revealed reasonable convergence between these 2 assessment methods.5 In the present study, items 9 and 39 on the BSI (for an example, see Edwards et al6) were used to classify subjects into 1 of 3 categories at each study time point: (1) no self-reported SI (ie, scores of zero on each item), (2) self-reported passive SI (ie, non-zero score on BSI item 39 [thoughts of death or dying] but a score of zero for BSI item 9 [thoughts of ending your life]), and (3) self-reported active SI (ie, a non-zero score on BSI item 9 [thoughts of ending your life]). In effect, this category of “active SI” could be labeled “both active and passive SI” because over 90% of those who report active SI also report passive SI. The specified time frame for these self-report items was “over the past week. . . .” Data Reduction and Analysis We conducted analyses examining pain as a prospective predictor of SI in 2 ways. First, as a more conceptually simple method, subjects were categorized according to their course of SI from discharge to 1-year follow-up. The following 4 mutually exclusive and exhaustive classifications were used: (1) “No SI,” approximately 52% of the sample, included subjects who reported no SI at any study time point; (2) “Develop any SI,” approximately 20% of the sample, included subjects with no SI at discharge who subsequently reported passive or active SI at follow-up; (3) “Persisting or Worsening SI,” approximately 17% of the sample, included those who reported SI at discharge, and who continued to report the same or a greater degree of SI out to 1 year follow-up; and (4) “Resolving or Improving SI,” just over 10% of the sample, included subjects who reported SI at discharge but whose SI was either reduced (ie, from active SI to passive SI) or absent at follow-up. Analysis of variance (ANOVA) was used to compare discharge bodily pain scores in these 4 groups, with follow-up contrasts to determine the nature of group differences. Second, we used multinomial logistic regression to predict membership in the 3 SI categories at each time point (ie, discharge, 6-mo follow-up, 12-mo follow-up) while controlling for important covariates. In each regression, TBSA burned and TBSA grafted were included as measures of burn severity. In addition, age, sex, and race (ie, coded as white and nonwhite) were included, because all have previously shown associations with both pain and SI. The 3 SF-36 scores described in Measures were also included; this permitted us to evaluate the impact of pain severity independent of general health and general psychosocial functioning. For each regression analysis, we included preburn and discharge MCS scores, preburn and discharge bodily pain scores, and the discharge general health score. For regressions predicting SI at follow-up, discharge SI categorization was included as a covariate. Finally, to determine whether any potential effects of discharge pain were mediated by ongoing pain, regression analyses predicting 6-month and 12-month SI were re-run after controlling for concurrent pain. Results Patients’ estimates of preburn pain suggested mild pain, on average, prior to injury (mean preburn SF-36 bodily pain score, 85.5); at discharge, the mean SF-36 bodily pain score for the sample was 33.7 (note that the SF-36 bodily pain subscale yields scores from 0 to 100 where 100 indicates no pain and 0 indicates very severe, disabling pain), reflecting a moderate to severe degree of pain (table 1). At 6- and 12-month follow-up, pain severity had substantially decreased (represented by higher SF-36 bodily pain scores) compared with discharge levels. Correlations between pain reports at each study time point are presented in table 2. Rates of suicidal ideation at discharge and follow-up are presented in table 1; generally, rates of SI were fairly stable at a group level across the duration of the study, with one quarter to one third of patients reporting some form of SI. Despite this stability at the group level, however, many participants varied in SI over the course of the study. See figure 1 for the percentage of patients with particular courses of SI. When reduced to the 4 categories described above, approximately 52% of the sample reported no SI at any study time point, nearly 20% of the sample had no SI at discharge but later developed SI, around 17% of the sample reported persistent or worsening SI from discharge to 1-year follow-up, and just over 10% of the sample described SI that improved or resolved from discharge to follow-up. | | |  | Scores and Classifications | Preburn | Discharge | 6 Months | 12 Months | |
|---|
| SF-36 bodilypain | 85.5±22.2 | 33.7±23.9 | 61.1±28.3 | 64.8±28.6 | | | SF-36MCS | 51.1±12.1 | 44.3±13.4 | 45.3±14.7 | 45.4±14.1 | | | NoSI | ND | 95/128(74.2) | 94/128(73.4) | 87/128(68.0) | | | Thoughtsofdeath | ND | 21/128(16.4) | 19/128(14.8) | 22/128(17.2) | | | ActiveSI | ND | 12/128(9.4) | 15/128(11.7) | 19/128(14.8) | | | | |
| | | | Time Point | Preburn | Discharge | 6 Months | 12 Months | |
|---|
| Preburn | 1.0 | | | | | | Discharge | .13 | 1.0 | | | | | 6 months | .15 | .30† | 1.0 | | | | 12 months | .17⁎ | .22† | .68‡ | 1.0 | | | | |
Linear trend analysis, assessing changes over time in the variables of interest, revealed that pain severity changed significantly over the course of the 1-year follow-up period (F1,127=99.5, P<.001), as did MCS scores on the SF-36, although this change appeared due entirely to a reduction in MCS scores from preburn to postburn (F1,127=12.6, P<.001). In contrast, rates of SI did not change from discharge to 1-year follow-up (F1,127=2.4, P=.21). In table 3 we present the raw (ie, unadjusted) SF-36 bodily pain scores at each study time point, as a function of discharge SI classification. | | | | SI Status | Time | |
|---|
| Preburn | Discharge | 6 Months | 12 Months | |
|---|
| No SI at discharge | 87.9±20.7 | 37.4±25.4 | 63.9±26.2 | 70.0±30.5 | | | PSI at discharge | 80.8±23.7 | 35.1±26.7 | 63.3±28.7 | 65.2±27.0 | | | ASI at discharge | 79.3±24.0 | 16.9±13.5 | 37.3±25.2 | 49.5±28.7 | | | | |
Predicting the Course of SI An ANOVA comparing the 4 groups described above on discharge bodily pain scores revealed a significant omnibus effect (F3,125=5.3, P<.01), indicating at least some group difference. Follow-up univariate contrasts revealed that the “No SI” group and the “Resolving or Improving SI” group reported significantly less pain at discharge (P<.01, P<.05, respectively) than the “Persisting or Worsening SI” group (fig 2). The group of participants who developed SI had lower mean scores than the “No SI” and “Resolving or Improving SI” groups, but these differences did not approach statistical significance. Logistic Regressions In univariate analyses, worse general health at discharge, higher pain severity at discharge, lower MCS scores at discharge, lower preburn MCS score, and female sex were associated with a higher probability of reporting SI at discharge (all P<.05). In the multivariate model predicting SI at discharge, only female sex was associated with increased SI risk, specifically with respect to active SI (table 4). | | | | Variable | Adjusted OR No SI vs PSI | Adjusted OR No SI vs ASI | P | |
|---|
| TBSA burned | 1.02 | 0.97 | .68 | | | TBSA grafted | 0.98 | 1.02 | .75 | | | Minority race | 0.74 | 0.48 | .69 | | | Female sex | 0.33 | 6.00 | .01 | | | Age | 0.98 | 0.98 | .46 | | | Preburn SF-36 MCS | 1.01 | 0.73 | .60 | | | Preburn SF-36 bodily pain | 0.84 | 0.98 | .40 | | | Discharge SF-36 general health | 0.96 | 0.80 | .58 | | | Discharge SF-36 MCS | 0.57 | 0.64 | .06 | | | Discharge SF-36 bodily pain | 0.99 | 0.65 | .22 | | | | |
In the multivariate model predicting SI at 6-month follow-up after controlling for discharge SI, only more severe pain at discharge was prospectively associated with an elevated likelihood of active SI. Intriguingly, this association persisted even after controlling for concurrent pain severity at the 6-month follow-up time point, which was an independent predictor of 6-month SI. That is, in the model that included both discharge pain and 6-month pain, both were unique positive predictors of 6-month SI (ie, more pain was associated with a greater probability of SI) (table 5). | | | | Variable | Adjusted OR No SI vs PSI | Adjusted OR No SI vs ASI | P | |
|---|
| SI at discharge | 5.94 | 3.67 | .01 | | | TBSA burned | 1.01 | 1.04 | .55 | | | TBSA grafted | 0.92 | 0.90 | .08 | | | Minority race | 1.44 | 1.06 | .89 | | | Female sex | 0.28 | 2.96 | .05 | | | Age | 0.99 | 0.93 | .20 | | | Preburn SF-36 MCS | 1.35 | 0.71 | .23 | | | Preburn SF-36 bodily pain | 1.36 | 0.84 | .10 | | | Discharge SF-36 general health | 0.87 | 0.97 | .74 | | | Discharge SF-36 MCS | 0.88 | 0.75 | .69 | | | Discharge SF-36 bodily pain | 0.95 | 0.40 | .002 | | | Parameters after insertion of concurrent pain into the model | | | Concurrent (6mo) SF-36 bodily pain | 1.00 | 0.57 | .004 | | | Discharge SF-36 bodily pain | 0.95 | 0.33 | .001 | | | | |
Finally, in the model predicting SI at 12-month follow-up, a similar pattern of findings was noted; after controlling for discharge SI, only the bodily pain subscale of the SF-36 (at discharge) was associated with 12-month SI (table 6). After including concurrent pain severity at 12 months as a covariate, discharge pain showed a statistical trend toward association with SI at 12-month follow-up (see table 6). For each of the regression analyses, the omnibus test for the predictive capacity of the independent variables was significant (all P<.05), with the overall models explaining between 29% and 48% of the variance in SI (see Table 4, Table 5, Table 6). | | | | Variable | Adjusted OR No SI vs PSI | Adjusted OR No SI vs ASI | P | |
|---|
| SI at discharge | 2.07 | 3.64 | .11 | | | TBSA burned | 1.01 | 1.01 | .93 | | | TBSA grafted | 0.99 | 1.00 | .96 | | | Minority race | 0.94 | 1.38 | .88 | | | Female sex | 0.70 | 2.92 | .15 | | | Age | 1.02 | 0.98 | .45 | | | Preburn SF-36 MCS | 0.80 | 0.65 | .25 | | | Preburn SF-36 bodily pain | 1.12 | 1.02 | .70 | | | Discharge SF-36 general health | 1.13 | 1.01 | .70 | | | Discharge SF-36 MCS | 1.01 | 1.04 | .98 | | | Discharge SF-36 bodily pain | 0.77 | 0.77 | .04 | | | Parameters after insertion of concurrent pain into the model | | | Concurrent (12mo) SF-36 bodily pain | 0.88 | 0.62 | .001 | | | Discharge SF-36 bodily pain | 0.80 | 0.77 | .09 | | | | |
Discussion This investigation prospectively characterized the spectrum of SI, including passive thoughts of dying and active thoughts of suicide, in patients following traumatic burn injury. Each step up this continuum represents a more potentially lethal form of SI,14 and early identification of even transient passive SI (eg, nonspecific thoughts of death) is an important aspect of suicide prevention.41 Approximately 90% of unplanned and 60% of planned suicide attempts occur within 1 year of the onset of SI,14 highlighting the importance of early identification of factors that increase the risk of suicidal ideation, pain-related or otherwise. The rates of SI in this sample of burn survivors (eg, ≈25%−30% of the sample at any given time point) are generally consistent with previous investigations of patients experiencing persistent pain,4, 8, 15 and are well above SI rates in the general population.14 Although we were not able to locate previously published estimates of the prevalence of SI in patients after major burns, a substantial proportion of burn survivors (ie, 25%−65%) are reported to experience at least moderate depressive symptoms in the postburn period,27 1 survey reported that 11% exhibited the “loss of will to live,”42 and a recent epidemiologic study noted high rates of accidental or violent deaths among adults who had sustained burn injuries (ie, 40 per 1000 risk-years).20 Together with our findings, these data suggest that suicidal thoughts and behaviors may be common yet under-recognized sequelae of burn injury. It should also be recognized that the questionnaires used in this study might underestimate the true rate of SI, because patients might seek to avoid any intervention that an endorsement of SI could trigger.5 Finally, it is important to note that there was significant individual variation in the experience of SI across the study period. For example, fully 20% of the sample did not initially report SI but developed SI at some point between discharge and the 1-year follow-up, and about half that number of participants reported that their SI improved or resolved over that same period. Thus, it is important to identify prospective predictors of the later course of SI, not just the experience of SI at discharge. Demographic characteristics were only weakly and inconsistently associated with SI, with the exception of sex, as women were more likely than men to endorse SI. It is important to note that the severity of burn injury, indexed by TBSA burned and TBSA grafted, and patients’ estimates of their general health at discharge, were not predictive of SI in any of the models. Although poor health is a clear risk factor for SI in the general population,7, 41 these findings suggest that injury severity and perceived physical health (at discharge) in the context of a burn injury are not strong determinants of SI. Similarly, depression is among the most robust correlates of suicidal behavior in the suicide literature.43 In the present study, in the multivariate models which included pain severity, the SF-36 MCS (a general measure of psychologic health and function) at discharge was unrelated to SI. That is, assessing global mental health at discharge did not provide, in this sample, significant information about future risk of suicidal ideation. In contrast, pain severity was the most robust discharge risk factor for SI. This was the central finding of this study, one which has not previously been examined in the context of burn injury. Prior investigations of the relationship between pain severity and SI in the context of chronic pain have been mixed, with some reports documenting a positive relationship,1, 15 and others finding none.5, 16 Recent studies of conditions that may or may not include pain as a concomitant have indicated that the degree of physical pain reported in the context of conditions such as human immunodeficiency virus infection,44 lung cancer,45 and major depression46, 47 correlated positively with SI. It seems plausible, though speculative, to suggest that pain severity may be most robustly associated with SI in the early stages following pain onset, whereas over very long durations of persistent pain, other factors begin to assume more prominent roles. For example, in a large (n>1500) sample of patients seeking treatment for chronic pain, with a mean pain duration of over 3 years, pain severity was not associated with SI, whereas depressive symptoms and the use of certain pain-coping strategies was strongly predictive of SI.6 The mechanisms by which greater pain severity at discharge impacts future suicidal ideation are not evident from the present data, though several possibilities are immediately apparent. First, greater acute pain severity is associated with a greater likelihood of developing chronic pain,48 which in turn is robustly associated with the development of significant symptoms of depression.18, 49 It is also possible that the endurance of SI observed in this sample may be linked with patients’ coping responses to their experience of acute burn pain. In particular, pain-related catastrophizing appears to contribute to poorer adjustment,50 which may include SI. Another possibility is that severe pain may have detrimental effects on patients’ social environments, which could engender increases in SI, because social isolation is a powerful risk factor for suicidal ideation and behavior.51 Prior studies have suggested that negative family responses to pain are common,52, 53 and chronic pain is associated with reduced social support,54, 55 suggesting that greater pain severity at discharge might produce maladaptive changes in the social environment of patients, which could then facilitate SI. Finally, pre-existing, stable characteristics such as high levels of neuroticism or personality disorders might also serve as risk factors both for elevated report of pain severity,56, 57 and for the development or worsening of SI after an acute injury such as a burn. In attempting to explain the relationship between pain and suicidal ideation, it is useful to discuss some similar studies done on the relationship between burn pain and distress after hospitalization. Ptacek et al29 developed a composite score of pain during wound care during hospitalization and investigated how well it predicted distress as measured by the BSI at 1 month postdischarge. Pain during hospitalization had a stronger correlation with distress than did the size of the burn injury, the length of hospitalization, or any other variable that was investigated. More recently, Patterson et al28 reported that such composite scores of pain were the strongest predictors of post-traumatic stress disorder, distress, and health-related quality of life at 1- and 1-year follow-up. Clearly, pain is among the strongest long-term predictors of distress and quality of life, as well as suicidal ideation. Study Limitations Several limitations of this study should be considered in interpreting the findings. First, the methodology relied on paper-and-pencil measures of SI, but a clinical interview is considered the criterion standard for assessment of suicidality.58 Second, we obtained no formal psychiatric diagnoses, which might have allowed more refined prediction of SI. Third, several variables that have been identified as important contributors to SI were not measured in the present study, including family history of suicidal behavior.5 Moreover, in future studies it would be desirable to classify participants according to whether the burns were self-inflicted, which might certainly have implications for future SI risk. Fourth, although the pain being reported was “due to the burn,” the specific source of the pain which patients were reporting was not clear (eg, pain directly attributable to the burn injury, pain due to infections, pain due to surgical procedures or débridement), and this will be an important factor to assess in future studies. Fifth, although the sample size in the present study appears reasonable, there was a significant degree of dropout over the course of the study, raising questions about the generalizability of the findings. Finally, as noted above, we do not have data on the specific mechanisms by which pain prospectively influences SI. Conclusions This investigation is the first to rigorously evaluate inter-relationships between pain and SI in the context of burn injury. 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58. 58Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychol Med. 2006;1–12. a Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD b Johns Hopkins Burn Center, Johns Hopkins Bayview Medical Center, Baltimore, MD c University of Texas–Southwestern Medical Center, Dallas, TX d University of Washington, Harborview Burn Center, Seattle, WA e Galveston Burn Center, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, TX f University of Colorado, Health Sciences Center, Denver, CO.  Reprint requests to Robert R. Edwards, PhD, Dept of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 1-108, Baltimore, MD 21287
Supported by Burn Model Systems grants from the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Education (grant no. H133A020101), and by the National Institutes of Health (grants nos. AR 051315, NS02225). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(07)00441-8 doi:10.1016/j.apmr.2007.05.031 © 2007 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. | |
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