Editor’s Spotlight/Take 5: Do Children With Accidental Gunshot-related Fractures Experience Greater Risk of Mental Illness and Psychiatric Disorders? A Propensity-matched Study

Pooya Hosseinzadeh MDWhether you believe that the problem is one of gun-related violence, or mental illness and social decay leading to violence that sometimes involves guns, let’s agree that this month’s Editor’s Spotlight study [2] is a sad, sad story. And it’s one that calls on each of us as physicians, regardless of our viewpoints on the underlying issues, to engage. Fig. 1 This well-done large-database effort performed at Washington University in St. Louis by Pooya Hosseinzadeh MD and his team [2] found that children who experienced a gunshot-related fracture were more likely than those who hadn’t to experience serious emotional distress 1 to 3 years later. This distress took the form of anxiety disorders, substance use disorders, mood disorders, non-mood psychotic disorders, and insomnia, and the hazard ratios were high: The lower bounds of the 95% confidence intervals both for anxiety and substance use disorders were ≥ 3. The database the authors used (the TriNetX US Collaborative Network) was fit-for-purpose, as it is one of the largest sources available in the United States, containing more than 115 million patients’ records from inpatient, outpatient, and emergency department visits, which capture data from more than five dozen healthcare organizations and over 100 payers [3]. Also in this study’s favor was the robust propensity matching, ensuring that the comparisons were made among children in reasonably similar circumstances. These findings suggest that pediatric orthopaedic surgeons might try to facilitate early psychological support for children whom they treat for gunshot-related fractures. The findings should also cause the rest of us to think about how we want to grapple with this important theme. I offered some suggestions for surgeons in a recent editorial [1], but I couldn’t manage even to get consensus on our small editorial board here at CORR® (see the impassioned and articulate rebuttal in that editorial from my partner and colleague, Paul A. Manner MD), which tells me that we’ve got an uphill climb ahead of us if we want to reach a consensus in our large, heterogeneous, and increasingly polarized country. Still, I believe there are things we can agree on. Join me to talk about those things with Dr. Hosseinzadeh, senior author of “Do Children With Accidental Gunshot-related Fractures Experience Greater Risk of Mental Illness and Psychiatric Disorders? A Propensity Matched Study” [2], in the Take 5 interview that follows. Take 5 Interview with Pooya Hosseinzadeh MD, senior author of “Do Children With Accidental Gunshot-related Fractures Experience Greater Risk of Mental Illness and Psychiatric Disorders? A Propensity Matched Study” Seth S. Leopold MD:Congratulations on publishing this sad but important study. How has it changed the way you treat children who’ve experienced these injuries, especially in the wake of the COVID-19 pandemic, where the demand for your solution—psychological support—far outstrips supply? Pooya Hosseinzadeh MD: Thank you, Dr. Leopold. We now pay more attention to other aspects of trauma in these children rather than only treating their fractures, but it’s true that patients nationwide face real difficulty in terms of access to care for mental health needs, especially after the COVID-19 pandemic. I believe the least we can do as surgeons is to inform the patient’s primary care professional about the child’s risk for developing mental health conditions so he or she can start the referral process for evaluation early on. My practice also has started thinking of ways to get social work services involved so they can properly assess the child and family situation, help come up with a plan, and follow up with the patient appropriately. Another avenue to consider is informing the counseling services available at the child's school. Dr. Leopold:More readers here are orthopaedic surgeons who take care of adults than take care of children. Can you think of any uncontroversial ways they can engage with this topic, or offer some solutions that few or none would disagree with? Dr. Hosseinzadeh: I completely understand that bringing up this topic with a patient’s parents or caregivers can be controversial. But as physicians, our first priority should be the physical and mental health of our patients. The conversation should focus on the potential benefits of obtaining a mental health evaluation after a gunshot-related injury. We can let parents or caregivers know that the emotional trauma resulting from gunshot-related fractures is much more severe than it is for fractures caused by other injuries, and this can lead to mental health issues for their child in the future. We should inform them that it would be beneficial for the child (and the child’s family) to be assessed by a professional to help the child better cope with this trauma. Dr. Leopold:Your work focused on accidental gunshot-related fractures. Why is that important to a reader’s interpretation of your findings? Dr. Hosseinzadeh: We only evaluated patients with accidental gunshot-related fractures because of restrictions in the database we used. But we think, if anything, that makes the study more interesting and important. One might assume, for example, that psychological trauma is mainly seen after gunshot injuries associated with purposeful assaults, but we found that psychological trauma is a big burden even after accidental gunshot injuries. We’d expect the psychological trauma to be even more severe in gunshot injuries caused in purposeful assaults, but our study could not assess that. Dr. Leopold:I can’t think of reasons other than unmeasured confounding to account for why children who experience these injuries would be more likely to have psychotic disorders than children who never had a gunshot-related fracture. To my knowledge, prior trauma hasn’t been linked in a causal way to psychosis. But one can easily imagine confounding variables that might link them. Why wouldn’t such confounding invalidate or at least undermine our confidence in your other findings? Dr. Hosseinzadeh: You bring up a great point. I agree that there are unmeasured variables that could confound the relationship between the trauma and the subsequently observed psychosis, but I do not believe that would invalidate our findings. The main take-home message of our study is that there is a group of at-risk children who would benefit from psychological evaluation and monitoring after a traumatic orthopaedic injury. This would still be the case even if there were some unmeasured confounding associating the trauma with psychosis. Dr. Leopold:OK, I’ll sneak one controversial question in. In our recent CORR editorial on this topic [1], there was strong disagreement even on our small panel when it came to solutions and even about what the problem really is. How would you help Dr. Manner—whose perspective we shared alongside mine in that editorial because we diverged so sharply—and I to find common cause? Perhaps that, writ large, could be a path to broader consensus. Dr. Hosseinzadeh: I enjoyed reading that editorial. It is a controversial topic among orthopaedic surgeons, and I see both perspectives. I think the issue we studied, which is related to children, may be one on which it is easier to find consensus. I think we all agree that firearms should be kept away from children completely, regardless of where you are on the political spectrum. We must advocate for children, who are the victims here.