Analysis of anxiety and depression symptoms in adolescents with facial burns

Abstract

BACKGROUND

Anxiety and depression are common psychological reactions in teenagers with facial burns and have a significant impact on their rehabilitation and quality of life.

AIM

To analyze anxiety and depressive symptoms in teenagers with facial burns.

METHODS

We selected 50 young patients with facial burns who were treated at our hospital between October 2023 and October 2024. The Hamilton Anxiety Scale and Beck Depression Inventory were used to evaluate anxiety and depressive symptoms. Additionally, we evaluated patients’ social support levels and self-esteem. Pearson’s correlation analysis was used to evaluate factors related to depression and anxiety.

RESULTS

The overall average Hamilton Anxiety Scale score was 23.4 ± 6.2, and 16 (32%) and 34 (68%) patients showed mild to moderate and moderate to severe anxiety, respectively. The overall average Beck Depression Inventory score was 18.7 ± 7.5, and 23 (46%) and 27 (54%) patients had mild to moderate and moderate to severe depression, respectively. Furthermore, Pearson’s correlation analysis showed a significant positive correlation between burn severity and anxiety (r = 0.48, P < 0.01) and depression (r = 0.42, P < 0.01) symptoms. Self-esteem scores and social support were significantly negatively correlated with anxiety (r = -0.55 and r = -0.40, respectively; P < 0.01) and depression (r = -0.60 and r = -0.38, respectively; P < 0.01 for both).

CONCLUSION

Adolescents with facial burns commonly experience anxiety and depressive symptoms, the severity of which is closely related to burn severity, social support, and self-esteem.

Key Words: Facial burns; Adolescents; Anxiety; Depression; Social support; Self-esteem

Core Tip: The aim of this study was to analyze the symptoms of anxiety and depression in adolescent facial burn patients and the factors affecting anxiety and depression to provide a reference for the psychological treatment of adolescent facial burns. Anxiety and depression are common psychological reactions in adolescents with facial burns. The severity of anxiety and depressive symptoms in adolescents with facial burns is strongly correlated with social support and self-esteem. These psychological problems have a significant impact on adolescent recovery and quality of life.

INTRODUCTION

Burns are typically induced by high-intensity currents, elevated temperatures, chemical exposures, and physical radiation[1]. The incidence of burns increases with the ongoing processes of mechanization and urbanization. Despite government initiatives aimed at preventing and treating burn-related mortality, the disability rate among burn patients has not shown a corresponding decline. The annual incidence of burns in China is approximately 2%[2], and burns are the second leading cause of mortality among accidents. Studies have shown that facial burns account for more than half of all burn incidents[3]. In addition, patients with burns often have mental health problems such as anxiety and depression[4-6]. As adolescence is a key stage in identity formation and self-esteem, facial burns in this age group have a far-reaching negative impact on self-esteem and social interaction, leading to mental health problems among adolescents. In addition, women with facial burns are more likely to develop depression[7,8]. Social support can affect anxiety and depressive symptoms in adolescent patients with facial burns[9,10].

The aim of this study was to analyze anxiety and depressive symptoms in adolescent patients with facial burns. We used the Hamilton Anxiety Scale (HAMA)[11] and Beck Depression Inventory (BDI)[12] to evaluate anxiety and depression symptoms in adolescents with facial burns. We also analyzed the factors influencing anxiety and depression to provide a reference for the psychological treatment of adolescents with facial burns.

MATERIALS AND METHODS

Study subjects

We retrospectively collected clinical data of 50 adolescent patients with facial burns who underwent treatment at our hospital between October 2023 and October 2024. Clinical data were collected over a minimum recovery period of three months. Information was gathered from hospitals’ electronic medical records and surveys.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Age between 12 and 18 years; (2) Hospitalization for facial burns; (3) Ability to communicate effectively in Chinese to answer or complete questionnaires; and (4) Clear consciousness and cognitive abilities.

The exclusion criteria were as follows: (1) Individuals diagnosed with acute diseases affecting the cardiovascular, cerebrovascular, or digestive systems, as well as those with severe infections, malignancies, significant electrolyte imbalances, or disorders of the immune and hematological systems; (2) Individuals with dementia, various psychiatric disorders, or those demonstrating noncompliance; and (3) Individuals with a history of substance or alcohol dependence, in addition to prior use of antidepressants or anxiolytic medication.

Ethical approval

The research approved by the Medical Ethics Committee of Baoji Central Hospital, approval No. BZYL2022-49. Informed consent was not required because the study was retrospective and did not involve disclosure of patient identities.

Data collection

During hospitalization, trained researchers conducted face-to-face surveys with all participants. All measurements were obtained during the recovery period to assess the long-term effects of burns on mental health. Throughout the data collection process, the privacy of all participants and the confidentiality of the data were ensured.

Assessment of depression

The BDI was used to evaluate depressive symptoms with 21 items, each rated on a scale of 0 to 3, resulting in a total score ranging from 0 to 63. Depression was classified as mild when the severity was ≤ 17 and moderate to severe when it was ≥ 18. Cronbach’s alpha for our sample was 0.90[13,14].

Assessment of anxiety

We used the HAMA to evaluate anxiety levels in adolescent patients with facial burns. The HAMA includes 14 items, each of which includes multiple symptoms, and is scored on a scale of 0 to 4, with 4 being the most serious. The mean total HAMA scores were 56. A score of ≤ 17 indicates mild anxiety, and a score of 18-30 indicates moderate to severe anxiety[15]. The HAMA adhered to psychometric standards, with a Cronbach’s alpha of 0.93.

Assessment of social support

Social support was assessed with the Social Support Appraisals tool for children[16], featuring 30 items rated on a 6-point Likert scale from “fully agree” to “fully disagree”. The scores ranged from 30 to 180, with higher scores reflecting greater perceived social support. Scores of 30-90 indicate low social support, 91-135 indicate moderate support, and 136-180 indicate high support, respectively.

Self-esteem was evaluated using the Self-Esteem Scale, which classifies self-esteem into low, medium, and high categories[17]. Initially developed for adolescent populations, the scale comprises ten closed-ended items, with half of the items assessing the positive dimensions of self-image and self-worth and the remaining half addressing negative self-image and self-depreciation. Participants responded using a four-point Likert scale consisting of options. Higher scores on the Self-Esteem Scale reflected greater self-esteem, with scores ranging from 10 to 40: 10-20 points suggest low self-esteem, 21-30 points suggest moderate self-esteem, and 31-40 points suggest high self-esteem.

Burn severity[18]: We further classified burns into three categories based on the Abbreviated Burn Severity Index score, with mild burns scoring 2-3, moderate burns scoring 4-7, and severe burns scoring ≥ 8.

Statistical analysis

Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 26.0. Continuous variables were expressed as means and standard deviations, while categorical variables were presented as counts and percentages. Pearson’s correlation analysis was used to examine the relationships among the severity of burns, levels of social support, Self-Esteem Scores, and anxiety or depression symptoms. In the correlation analysis, Pearson’s correlation coefficients were determined, and the P value was corrected using the Benjamini-Hochberg method for multiple comparisons, ensuring a false discovery rate of < 0.05.

RESULTS

Baseline characteristics

Fifty adolescents with facial burns were included in this study, ranging in age from 12 to 18 years, with an average age of 15.3 years. Of the participants, 58% (n = 29) were male and 42% (n = 21) were female. Burns were classified as mild in 9 cases (18.0%), moderate in 19 cases (38.0%), and severe in 22 cases (44.0%).

Assessment of anxiety and depression symptoms

According to the HAMA scoring criteria, the average anxiety score among participants was 23.4 ± 6.2, with 16 cases (32%) exhibiting mild or lower anxiety symptoms, and 34 cases (68%) presenting with moderate to severe anxiety (score ≥ 18) (Figure 1A). The average BDI score was 18.7 ± 7.5, with 23 cases (46%) showing mild or lower depression symptoms, and 27 cases (54%) experiencing moderate to severe depression (score ≥ 18) (Figure 1B).

Figure 1 Assessment of anxiety and depression symptoms. A: Anxiety distribution (%); B: Depression distribution (%).

Correlation between burn severity and depression and anxiety

As shown in Table 1, there were significant statistical differences in burn severity among patients with varying degrees of depression (P < 0.05). Similarly, there were significant statistical differences in burn severity among patients with different levels of anxiety (P < 0.01) (Table 2).

Table 1 Comparison of burns in patients with different severity of depression, n (%).

Variable	Mild depression (n = 23)	Moderate-to-severe depression (n = 27)	P value
Burns
Mild burns	6 (26.09)	3 (11.11)	< 0.001
Moderate burns	13 (56.52)	6 (22.22)
Severe burns	4 (17.39)	18 (66.67)

Table 2 Comparison of burns in patients with different severity of anxiety, n (%).

Variable	Mild anxiety (n = 16)	Moderate-to-severe anxiety (n = 34)	P value
Burns
Mild burns	7 (43.75)	2 (5.88)	< 0.001
Moderate burns	8 (50)	11 (32.35)
Severe burns	1 (6.25)	21 (61.76)

The correlation between social support, self-esteem, depression, and anxiety

Assessment results for social support indicated an average score for patients’ social support of 112.5 ± 18.4. Individuals with reduced social support showed signs of anxiety and depression (P < 0.05). The average score for self-esteem assessment was 40.2 ± 9.3, with patients scoring lower showing significantly higher scores on the anxiety (P < 0.01) and depression (P < 0.01) scales, as shown in Tables 3 and 4.

Table 3 Comparison of social support and self-esteem in patients with different severity of depression, n (%).

Variable	Mild depression (n = 23)	Moderate-to-severe depression (n = 27)	P value
Social support
Low support	9 (39.13)	15 (55.56)	0.015
Moderate support	6 (26.09)	7 (25.93)
High support	8 (34.78)	5 (18.52)
Self-esteem
Low self-esteem	8 (34.78)	18 (66.67)	< 0.001
Moderate self-esteem	7 (30.43)	6 (22.22)
High self-esteem	8 (34.78)	3 (11.11)

Table 4 Comparison of social support and self-esteem in patients with different severity of anxiety, n (%).

Variable	Mild anxiety (n = 16)	Moderate-to-severe anxiety (n = 34)	P value
Social support
Low support	6 (37.5)	18 (52.94)	< 0.001
Moderate support	4 (25.0)	9 (26.47)
High support	6 (37.5)	7 (20.59)
Self-esteem
Low self-esteem	7 (43.75)	21 (61.76)	< 0.001
Moderate self-esteem	4 (25.0)	9 (26.47)
High self-esteem	5 (31.25)	4 (11.76)

Pearson correlation analysis

Furthermore, Pearson’s correlation analysis indicated that burn severity was positively correlated with depressive (r = 0.42, P < 0.01) and anxiety symptoms (r = 0.48, P < 0.01). Additionally, self-esteem scores showed a significant negative correlation with anxiety (r = -0.55, P < 0.01) and depression (r = -0.60, P < 0.01). Social support exhibited significant negative correlations with anxiety (r = -0.40, P < 0.01) and depression (r = -0.38, P < 0.01).

DISCUSSION

In this study, we assessed the anxiety and depressive symptoms in 50 adolescents with facial burn injuries. The results indicated that 68% of patients exhibited moderate-to-severe anxiety symptoms, while 54% showed moderate-to-severe depression. These findings are consistent with existing literature, suggesting that patients with burns are at a higher risk of depression and anxiety.

Notably, when stratifying by gender, our data revealed that female participants (42% of the cohort) had a trend towards higher mean scores on both the HAMA (25.1 ± 6.8) and BDI (20.3 ± 8.1) scales compared to males (HAMA: 22.2 ± 5.7; BDI: 17.4 ± 6.9), although this difference did not reach statistical significance (P > 0.05). This aligned with previous research indicating that women generally report more severe psychological distress following traumatic events, likely because of sociocultural factors influencing body image perception and emotional expression. Future studies with larger sample sizes should explore the sex-specific risk factors for depression in adolescent burn survivors. Therefore, special attention should be paid to the mental health of adolescents with facial burns. This was consistent with previous research[19].

The results showed that the severity of facial burns was significantly and positively correlated with anxiety (r = 0.48, P < 0.01) and depression (r = 0.42, P < 0.01). This was consistent with the findings of Ward et al[20]. The pathophysiological mechanisms underlying this association likely involve a complex interplay between physical pain, disfigurement, and social stigma. Adolescents with severe burns may experience prolonged hospitalization, intensive rehabilitation, and altered self-perception, all of which can exacerbate psychological distress. For example, patients with deep burns may require multiple reconstructive surgeries, which can lead to extended periods of physical discomfort and social isolation. Possible causes include pain during recovery and changes in appearance caused by burns, which can negatively impact the mental health of adolescents.

Finally, the results of this study also show that social support is negatively correlated with depression and anxiety (depression r = -0.38, P < 0.01; anxiety r = -0.40, P < 0.01). Specifically, patients with lower levels of social support were more likely to experience anxiety and depression symptoms, which aligns with existing literature[21]. O’ Brien et al[22] reported that mental health problems affect the trajectory of burn recovery by increasing the length of hospital stay for burn survivors. Therefore, a targeted intervention is required. Cognitive behavioral therapy has demonstrated efficacy in reducing anxiety and depression by addressing maladaptive thoughts and behaviors associated with burn injuries. In addition, group therapy programs tailored to adolescent burn survivors can provide a supportive community, foster social connectedness, and improve self-esteem. For instance, the “Burn Support Group Model” integrates peer counseling, educational workshops, and family involvement to enhance social support networks. Furthermore, the significant correlation between low self-esteem and anxiety (P < 0.01) and depression (P < 0.01) further supports the importance of self-esteem in mental health[23].

Limitations

This study had several limitations. First, the use of self-reported questionnaires to understand patients’ basic conditions and assess their mental health is flawed and may lead to recall bias, which, in some cases, may not accurately reflect the extent of the patients’ mental status. As this was a retrospective study, we may have overlooked some potential confounding variables, such as the quality of family support and economic status, which may undermine the reliability of the findings. Second, this cross-sectional study could not establish causal links between variables, necessitating further research. Third, the role of family history as a confounding factor for anxiety symptoms requires further investigation. Additionally, burn classification (e.g., hot fluid, flame) was missing when retrospectively collecting baseline data from patients, which may have affected the interpretation of severity. Future studies should incorporate subgroup analyses by type of burn and psychological symptoms. Finally, because the study was conducted at a single hospital in China, the findings are limited to Chinese patients. Their representativeness is difficult to generalize, and future studies should involve larger-scale, multicenter, and more rigorous prospective studies to confirm these findings.

CONCLUSION

In summary, the results of this study indicated that some adolescents with facial burn injuries exhibited symptoms of depression and anxiety. Burn severity significantly and positively correlated with anxiety and depressive symptoms. Self-esteem and social support were negatively correlated with anxiety and depression, respectively. Therefore, comprehensive treatment plans for adolescents with facial burns should include mental health assessments and interventions to improve quality of life and psychological adaptability. Future research should further explore the correlation between interventions to help adolescent patients cope better with psychological challenges following burns.