Dysphoria: a major symptom factor in persons with disability or chronic illness

The spinal cord-gut-immune axis as a master regulator of health and neurological function after spinal cord injury

Most spinal cord injury (SCI) research programs focus only on the injured spinal cord with the goal of restoring locomotor function by overcoming mechanisms of cell death or axon regeneration failure. Given the importance of the spinal cord as a locomotor control center and the public perception that paralysis is the defining feature of SCI, this "spinal-centric" focus is logical. Unfortunately, such a focus likely will not yield new discoveries that reverse other devastating consequences of SCI including cardiovascular and metabolic disease, bladder/bowel dysfunction and infection. The current review considers how SCI changes the physiological interplay between the spinal cord, the gut and the immune system. A suspected culprit in causing many of the pathological manifestations of impaired spinal cord-gut-immune axis homeostasis is the gut microbiota. After SCI, the composition of the gut microbiota changes, creating a chronic state of gut "dysbiosis". To date, much of what we know about gut dysbiosis was learned from 16S-based taxonomic profiling studies that reveal changes in the composition and abundance of various bacteria. However, this approach has limitations and creates taxonomic "blindspots". Notably, only bacteria can be analyzed. Thus, in this review we also discuss how the application of emerging sequencing technologies can improve our understanding of how the broader ecosystem in the gut is affected by SCI. Specifically, metagenomics will provide researchers with a more comprehensive look at post-injury changes in the gut virome (and mycome). Metagenomics also allows changes in microbe population dynamics to be linked to specific microbial functions that can affect the development and progression of metabolic disease, immune dysfunction and affective disorders after SCI. As these new tools become more readily available and used across the research community, the development of an "ecogenomic" toolbox will facilitate an Eco-Systems Biology approach to study the complex interplay along the spinal cord-gut-immune axis after SCI.

Diagnostic accuracy and feasibility of depression screening in spinal cord injury: A systematic review

Context: Individuals with spinal cord injury or disease (SCI/D) are at increased risk of depression, which is associated with poor short- and long-term outcomes. Accurate diagnosis is complicated by overlapping symptoms of both conditions, and a lack of consensus-derived guidelines specifying an appropriate depression screening tool. Objective: To conduct a systematic review to: (1) identify the diagnostic accuracy of established depression screening tools compared to clinical assessment; and, (2) to summarize factors that influence feasibility of clinical implementation among adults with SCI/D. Methods: A systematic search using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane databases using the terms spinal cord injury, depression or mood disorder, and screening or diagnosis identified 1254 initial results. Following duplicate screening, five articles assessing eight screening tools met the final inclusion and exclusion criteria. Measures of diagnostic accuracy and feasibility of implementation were extracted. The Quality Assessment Tool for Diagnostic Accuracy Studies 2 (QUADAS-2) was used to assess study quality. Results: The Patient Health Questionnaire-9 (PHQ-9) had the highest sensitivity (100%), and specificity (84%). The 2-item version, the PHQ-2, comprised the fewest questions, and six of the eight tools were available without cost. Utilizing the QUADAS-2 tool, risk of bias was rated as low or unclear risk for all studies; applicability of the results was rated as low concern. Conclusion: The PHQ-9 is an accurate and feasible tool for depression screening in the adult SCI/D population. Future studies should evaluate the implementation of screening tools and the impact of screening on access to mental health interventions.

Depressive symptomatology after spinal cord injury: A multi-center investigation of multiple racial-ethnic groups

OBJECTIVE

To identify (1) racial-ethnic differences in depressive symptomatology after spinal cord injury (SCI) and (2) the relationship of multiple additional factors to depressive symptoms, including health behaviors, employment, fatigue, and pain interference.

DESIGN

Cross-sectional Setting: Data were collected at 3 specialty hospitals in different regions of the USA (Southeastern, Mountain, Western).

PARTICIPANTS

Participants (N = 1,063) were identified from outpatient records of the 3 hospitals with oversampling of racial-ethnic minority groups.

INTERVENTIONS

N/A Main Outcome Measure(s): The outcome, depressive symptomatology, was measured by the Older Adult Health and Mood Questionnaire (OAHMQ). Participant demographic and injury characteristics were measured as statistical controls, as well as other variables including health behavior factors, depression/stress relief medication usage, fatigue, and pain interference. The multivariate analyses were developed using OLS regression models and logistic regression models.

RESULTS

Employment was protective for depressive symptomatology, whereas fatigue, pain interference, and binge drinking were risk factors for higher OAHMQ scores. Although there were no bivariate racial-ethnic differences in depressive symptoms, fatigue and pain interference had suppression effects on the relationship between race-ethnicity and depressive symptomatology. After controlling for fatigue and pain interference, Hispanic participants had significantly lower OAHMQ scores and lower odds of probable major depression (PMD) than non-Hispanic Whites and Blacks.

CONCLUSIONS

Fatigue and pain interference are associated with both race-ethnicity and depressive symptomatology. Assuming the same level of fatigue and pain interference, Hispanics will have a lower risk of depressive symptoms than non-Hispanic Whites and Blacks.

Racial, Ethnic, and Sociodemographic Differences in the Level of Psychosocial Distress among Older Americans

More than 2 million older Americans suffer from some form of depression. Yet late-life depression is often undiagnosed or underdiagnosed. The aim of this study was to explore the reasons for the observed differences in the level of depressive symptoms between older African Americans, Hispanics, and Whites. The data are from Wave 1 of the Asset and Health Dynamics Among the Oldest Old survey administered during 1993-1994. Ordinary least-squares regression results indicate that language acculturation, the number of years of education, and the number of years of U.S. residency are significant factors that help to explain differences in self-reported levels of depressive symptoms among this older population. In general, those who are men, are married, have more education, and are in better health have lower levels of depressive symptoms.

Measuring depression after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Depression item bank and linkage with PHQ-9

OBJECTIVE

To develop a calibrated spinal cord injury-quality of life (SCI-QOL) item bank, computer adaptive test (CAT), and short form to assess depressive symptoms experienced by individuals with SCI, transform scores to the Patient Reported Outcomes Measurement Information System (PROMIS) metric, and create a crosswalk to the Patient Health Questionnaire (PHQ)-9.

DESIGN

We used grounded-theory based qualitative item development methods, large-scale item calibration field testing, confirmatory factor analysis, item response theory (IRT) analyses, and statistical linking techniques to transform scores to a PROMIS metric and to provide a crosswalk with the PHQ-9.

SETTING

Five SCI Model System centers and one Department of Veterans Affairs medical center in the United States.

PARTICIPANTS

Adults with traumatic SCI.

MAIN OUTCOME MEASURES

Spinal Cord Injury--Quality of Life (SCI-QOL) Depression Item Bank

RESULTS

Individuals with SCI were involved in all phases of SCI-QOL development. A sample of 716 individuals with traumatic SCI completed 35 items assessing depression, 18 of which were PROMIS items. After removing 7 non-PROMIS items, factor analyses confirmed a unidimensional pool of items. We used a graded response IRT model to estimate slopes and thresholds for the 28 retained items. The SCI-QOL Depression measure correlated 0.76 with the PHQ-9.

CONCLUSIONS

The SCI-QOL Depression item bank provides a reliable and sensitive measure of depressive symptoms with scores reported in terms of general population norms. We provide a crosswalk to the PHQ-9 to facilitate comparisons between measures. The item bank may be administered as a CAT or as a short form and is suitable for research and clinical applications.

Depression Following Spinal Cord Injury: Its Relationship to Demographic and Socioeconomic Indicators

BACKGROUND

Depression is a common psychological problem that decreases life satisfaction and quality of life in people with spinal cord injury (SCI).

OBJECTIVE

The aim of this study was to investigate the prevalence of depression after SCI and its association with pathophysiological, demographic, and socioeconomic factors, including sex, age, level of injury, financial status, and suicidal thoughts.

METHODS

This was a cross-sectional study of 134 adults (≥ 18 years old) with SCI who were referred to the Brain and Spinal Cord Injury Research Center (BASIR) clinic, Tehran University of Medical Sciences, for outpatient rehabilitation. The Beck Depression Inventory (BDI-II Persian), a 21-question multiple-choice inventory, was used to measure the presence and severity of depression. Data were collected by interview.

RESULTS

Sixty-six (49.3%) participants had mild to severe depression. There was a higher probability of depression in individuals with SCI who were female, had tetraplegia, had suicidal thoughts, had a history of suicide attempt, had a low education level, or were taken cared for by a family member other than a spouse or parents.

CONCLUSIONS

Depression was highly prevalent in individuals with SCI and was related to some demographic, pathophysiological, and socioeconomic indicators. The primary predictive indicators and the factors influencing depression should be determined to provide early detection and timely treatment to prevent more complications and improve quality of life for individuals with SCI.

Prevalence of depression after spinal cord injury: a meta-analysis

OBJECTIVES

To use meta-analysis to synthesize point prevalence estimates of depressive disorder diagnoses for persons who have sustained a spinal cord injury (SCI).

DATA SOURCES

We searched PsycINFO, PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Dissertation Abstracts International (DAI) for studies examining depression after SCI through 2013. We also conducted a manual search of the reference sections of included studies.

STUDY SELECTION

Included studies contained persons with SCI; used a diagnostic measure of depression (ie, an unstructured, semi-structured, or structured clinical interview, and/or a clinician diagnosis); and provided a diagnosis of major or minor depressive episodes for the subjects in the study. Diagnostic criteria were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or the Diagnostic and Statistical Manual of Mental Disorders-Third Edition (including Research Diagnostic Criteria) criteria.

DATA EXTRACTION

The 2 authors of this study screened the titles and abstracts of 1053 unique studies for inclusion in this meta-analysis. Nineteen studies, containing 35,676 subjects and 21 effect size estimates, were included.

DATA SYNTHESIS

The mean prevalence estimate of depression diagnosis after SCI was 22.2%, with a lower-bound estimate of 18.7% and an upper bound estimate of 26.3%. Random effects and mixed effects models were used in this work. A small number of study moderators were explored, including sample sex composition, Diagnostic and Statistical Manual of Mental Disorders version used, data collection method (primary vs secondary), sample traumatic etiology composition, sample injury level and completeness composition, and sample diagnostic composition. Data collection method, Diagnostic and Statistical Manual of Mental Disorders version, and diagnostic composition significantly predicted variation in observed effect size estimates, with primary data collection studies having lower estimates compared with secondary data analysis studies, studies using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria having higher estimates compared with studies using Diagnostic and Statistical Manual of Mental Disorders, Third Edition, criteria, and samples comprising individuals diagnosed only with major depression having lower prevalence estimates.

CONCLUSIONS

The existing data on depression after SCI indicate that the prevalence of depression after SCI is substantially greater than that in the general medical population. These results underscore the importance of continued research on measuring depression in persons with SCI and on treatments for depression after SCI.

Depression and anxiety in adolescents with pediatric-onset spinal cord injury

BACKGROUND

Little is known about depression and anxiety in adolescents with spinal cord injury (SCI).

OBJECTIVE

To examine how depression, anxiety, suicidal ideation, and usage of treatment differ by age and sex among adolescents with SCI.

METHOD

Youth 12 to 18 years old who had acquired SCI at least 1 year prior were recruited from 3 specialty hospitals. They completed the Children's Depression Inventory (ages 12-17 years) or Beck Depression Inventory-II (18 years), and Revised Children's Manifest Anxiety Scale (12-18 years). Analyses assessed differences between younger and older adolescents and between males and females.

RESULTS

The 236 participants were an average age of 15.58 years (SD 1.98), 58% were male, and 60% Caucasian. Average age at injury was 10.57 years (SD 5.50), and 62% had paraplegia. For depression, 5.5% of adolescents ages 12 to 17 years exceeded the clinical cutoff and 12.7% of 18-year-old adolescents fell into a range of moderate or severe depression. For anxiety, 10.6% of adolescents ages 12 to 18 years exceeded the clinical cutoff. Univariate results revealed that older adolescents were more depressed than younger adolescents, and girls were more anxious than boys. An interaction between sex and age emerged, in that older adolescent girls were significantly more anxious than other youth. Older adolescents were also more likely to be taking medications for emotional, psychological, or behavioral reasons. Reports of suicidal ideation did not differ by adolescent age or sex.

CONCLUSION

For these adolescents, depression differed with age, and anxiety differed based on age and sex. Implications for intervention include early identification and treatment for struggling adolescents.

Evaluating a spinal cord injury-specific model of depression and quality of life

OBJECTIVES

To determine whether demographic, injury, health, and functional factors similarly have the same predictive relation with both somatic and nonsomatic symptoms of depression, as well as whether somatic and nonsomatic symptoms of depression have the same association with quality of life (QOL).

DESIGN

Secondary analysis of cross-sectional survey data.

SETTING

Community

PARTICIPANTS

Patients with traumatic spinal cord injury (N=4976) who completed an interview at 1 year postinjury between 2006 and 2011.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Somatic and nonsomatic symptoms of depression from the Patient Health Questionnaire-9 and QOL measured by the Satisfaction With Life Scale.

RESULTS

Structural equation modeling showed that the hypothesized model provided a good fit to the data, but modification of the model led to a significant improvement in model fit: Δχ(2)(1)=226.21, P<.001; comparative fit index=.976; χ(2)(199)=585.39, P<.001; root mean square error of approximation=.027 (90% confidence interval, .025-.030). The health-related factors including pain severity, pain interference, and health status were similarly associated with both somatic and nonsomatic symptoms of depression. QOL was negatively associated with nonsomatic symptoms of depression but was unrelated to somatic symptoms of depression.

CONCLUSIONS

Assessment of depression after spinal cord injury should include a careful assessment of health concerns given the relation between health-related factors and both somatic and nonsomatic symptoms of depression. Treatments of depressive symptoms may be improved by targeting health concerns, such as pain, along with a specific focus on nonsomatic symptoms to improve the QOL.

Effect of gender on recovery after spinal cord injury

Spinal cord injury (SCI) is a debilitating condition that affects thousands of new individuals each year, the majority of which are males. Males with SCI tend to be injured at an earlier age, mostly during sports or motor vehicle accidents, whereas females tend be injured later in life, particularly in the age group 65 and older. In both experimental and clinical studies, the question as to whether gender affects outcome has been addressed in a variety of patient groups and animal models. Results from experimental paradigms have suggested that a gender bias in outcome exists that favors females and appears to involve the advantageous or disadvantageous effects of the gonadal sex hormones estrogen and progesterone or testosterone, respectively. However, other studies have shown an absence of gender differences in outcome in specific SCI models and work has also questioned the involvement of female sex hormones in the observed outcome improvements in females. Similar controversy exists clinically, in studies that have examined gender disparities in outcome after SCI. The current review examines the experimental and clinical evidence for a gender bias in outcome following SCI and discusses issues that have made it difficult to conclusively answer this question.

Risk and protective factors for mortality after spinal cord injury

Our purpose was to systematically review research on postacute risk and protective factors for mortality after spinal cord injury including psychological, environmental, behavioral and health factors. A theoretical risk model was used to identify these sets of predictive factors and to structure this article. The majority of research identifies basic demographic (age and race) and injury factors (severity). More limited research has indicated that personality, purpose in life, income, social support and negative risk behaviors predict mortality. In terms of health factors and secondary conditions, pressure ulcers, amputations, depressive diagnosis and need for treatment also predict mortality. Interventions are needed that diminish the risk of secondary conditions and early mortality.

Depressive symptoms in rheumatoid arthritis

OBJECTIVE

To determine the prevalence of depressive and anxiety symptoms in patients with rheumatoid arthritis (a chronic inflammatory disease) in comparison to a control group with osteoarthritis (a chronic non-inflammatory degenerative disease) and to identify the sociodemographic and clinical variables associated with depressive symptoms in these patients.

METHOD

Sixty-two rheumatoid arthritis patients and 60 osteoarthritis patients participated in the study. Sociodemographic and clinical data were collected and the Hospital Anxiety and Depression Scale and the Disability Index of the Health Assessment Questionnaire were applied.

RESULTS

The prevalence of depressive symptoms was of 53.2% in rheumatoid arthritis and 28.3% in osteoarthritis (p = 0.005). The prevalence of anxiety symptoms was of 48.4% in rheumatoid arthritis and 50.0% in osteoarthritis (p = 0.859). The mean (and standard deviation) scores in the Disability Index of the Health Assessment Questionnaire were 1.4 (0.8) in rheumatoid arthritis and 1.4 (0.6) in osteoarthritis (p = 0.864). Rheumatoid arthritis patients with depressive symptoms had lower education and higher disease activity and functional disability.

CONCLUSION

Although these two rheumatic diseases are similar in terms of the pain and functional disability that they cause, a significantly higher prevalence of depressive symptoms was found in rheumatoid arthritis patients. This difference might be explained by the hypothesis of a neuroimmunobiological mechanism related to cytokines in inflammatory diseases, which has been considered as a candidate to the development of depressive symptoms.

Brief problem-solving training for family caregivers of persons with recent-onset spinal cord injuries: a randomized controlled trial

Our objective was to examine the effectiveness of a brief individualized problem-solving intervention for family with caregivers of persons with recent-onset spinal cord injury (SCI). Family caregivers were randomly assigned to a usual care control group (N=30) or an intervention group (N=30) in which participants were to receive three face-to-face problem-solving training sessions (PST), educational materials, and telephone contacts as requested over the first year of caregiving. The participants included 60 caregivers (49 women, 11 men). The Social Problem-Solving Inventory-Revised, the Inventory to Diagnose Depression, and the SF-36 were administered at baseline, 6 months and 12 months. Caregivers in the intervention group reported a significant decrease in dysfunctional problem-solving styles scores over time; there were no observable effects for PST on caregiver depression. There was also some indication that the intervention had beneficial effects on caregiver social and physical functioning. An intervention for new caregivers featuring brief PST, education, and contact may be associated with lower dysfunctional problem-solving styles over time and may promote certain aspects of caregiver quality of life. We also discuss limitations and implications of the present study.

Measuring depression in persons with spinal cord injury: a systematic review

BACKGROUND/OBJECTIVE

Depression has been studied extensively among people with spinal cord injury (SCI). However, basic questions persist regarding the reliability and validity of depression measurement in the context of SCI. The objective of this study was to evaluate the state of knowledge of depression measurement in persons with SCI.

METHODS

English-language peer-reviewed citations from MEDLINE, CINAHL, PsycINFO, ProQuest, Google Scholar, and Web of Science from 1980 to present. Two reviewers screened 377 abstracts on SCI and depression topics to identify 144 containing classifiable psychometric data. All 144 were reviewed by 6 reviewers. Twenty-four studies reporting psychometric data on 7 depression measures in SCI samples were identified, including 7 validity studies.

RESULTS

Reliability data were limited to internal consistency and were consistently good to excellent across 19 studies. Validity data were limited to concurrent validity, construct validity, and/or clinical utility in 10 studies. Measures were comparable with respect to internal consistency, factor structure, and clinical utility. Results are limited to peer-reviewed, English literature, and studies were not judged for quality.

CONCLUSIONS

Greater attention should be paid to the psychometric evaluation of established measures. Although existing evidence may not justify universal screening, we recommend depression screening in clinical practice when patients may be seen by nonpsychology personnel. There is insufficient evidence to recommend one screening measure over another. Therefore, selection of measures will depend on clinician preferences. Psychometric studies are needed to show test-retest reliability, criterion validity, and sensitivity to change to improve depression recognition and treatment.

Patient health Questionnaire-9 in spinal cord injury: an examination of factor structure as related to gender

BACKGROUND/OBJECTIVE

Despite the attention depression after spinal cord injury (SCI) has received, research and clinical practice have been hampered by inadequate emphasis on reliable and valid measurement. Assessment of symptoms in persons with SCI is challenged by the presence of "trans-diagnostic" symptoms and unexamined effects of gender. The objective of this study was to examine the factor structure of the Patient Health Questionnaire-9 (PHQ-9; the 9-item depression scale of the Patient Health Questionnaire) and determine whether the structure replicates across gender.

METHODS

A total of 1,168 women and men were matched on level/completeness of SCI, follow-up year, and age to create 584 pairs. Exploratory factor analysis examined 1- and 2-factor models and congruence in 2 randomly split half samples to establish congruence of the factor solution and replication across gender.

RESULTS

The 1- and 2-factor solutions fit the structure of the items accounting for 41% to 51% of original item variance. Congruence between random samples was uniformly high for the 1-factor solution (r = 0.791-0.948) but variable for the 2-factor solution. Although congruence was high for the combined sample and men (r = 0.90-0.97 and 0.71-0.94, respectively), it was variable for women (r = 0.29-0.85).

CONCLUSIONS

Although there was support for the 1-factor structure of the PHQ within and between sexes, the low congruence between sexes and within women for the 2-factor structure indicates potentially important differences about how certain symptoms may be experienced or interpreted differently, by men and women with SCI. Future research should focus on where sexes diverge in cognitive, affective, and somatic dimensions of depressive symptoms and whether sex-specific or sex-neutral measures are warranted.

Problem-solving training via videoconferencing for family caregivers of persons with spinal cord injuries: a randomized controlled trial

OBJECTIVE

To examine the effectiveness of an individualized problem-solving intervention delivered in videoconferencing sessions with family caregivers of persons living with a spinal cord injury (SCI) and possible contagion effects on care recipients.

DESIGN

Family caregivers were randomly assigned to an education-only control group or an intervention group in which participants received problem-solving training (PST) in monthly videoconference session for a year.

PARTICIPANTS

Sixty-one caregivers (54 women, 7 men) and their care recipients (40 men, 21 women) consented to participate.

MAIN OUTCOME MEASURES

The Social Problem-Solving Inventory-Revised was administered to caregivers. Caregivers and care recipients completed the Inventory to Diagnose Depression, the SF-36 and the Satisfaction with Life scale at pre-treatment, 6 months and 12 months.

RESULTS

Twenty-eight caregivers discontinued the study and their follow-up data were unavailable at the final assessment. Older caregivers were more likely than younger caregivers to remain in the study. Intent-to-treat analyses projected a significant decrease in depression among caregivers receiving PST; efficacy analyses indicated this effect was pronounced at the 6th month assessment. ITT analyses and efficacy analyses revealed that care recipients of caregivers receiving PST reported gains in social functioning over time.

CONCLUSIONS

Community-based, telehealth interventions may benefit family caregivers and their care recipients, but the mechanisms of these effects are unclear. Attrition and sample issues should be considered in future studies with these populations.

Improving the efficiency of screening for major depression in people with spinal cord injury

BACKGROUND/OBJECTIVE

To investigate the metric properties, relative efficiency, sensitivity and specificity, and positive predictive value of a short form of the Patient Health Questionnaire-9 (PHQ-9) that may be used as a screening test for depression.

METHODS

Data from the National Spinal Cord Injury Statistical Center Database containing 3,652 records with complete data for the PHQ-9 were analyzed using Confirmatory Factor Analysis, Item Response Theory Graded Response Model analysis, and sensitivity and specificity analysis of classification.

RESULTS

A scale comprised of items 1, 2, and 6 from the PHQ-9 has a relative efficiency of 0.66 compared to the 9-item scale. Using this 3-item scale and a cutoff score of 3 or more provides specificity of 0.93 and sensitivity of 0.87; a cutoff of 4 provides specificity of 0.95 and sensitivity of 0.82. The shorter version of the scale reduces the effect of response bias caused by gender. The relative efficiency of the 9-item scale is 0.88 for women compared to men; the 3-item scale increases the relative efficiency to 0.93.

CONCLUSION

A 3-item scale provides adequate information for clinical screening purposes. Cutoff scores of either 3 or 4 are acceptable and present options for decision making within a particular clinical setting. Additionally, the 3-item scale reduces the effect of gender of the respondent on the score obtained.

Resilient, undercontrolled, and overcontrolled personality prototypes among persons with spinal cord injury

A sample of 199 persons with spinal cord injury (SCI) were assessed on Big Five personality dimensions using the NEO Five-Factor Inventory (NEO-FFI; Costa & McCrae, 1992) at admission to an inpatient medical rehabilitation program. A cluster analysis of the baseline NEO-FFI yielded 3 cluster prototypes that resemble resilient, undercontrolled, and overcontrolled prototypes identified in many previous studies of children and adult community samples. Compared with normative samples, this sample had significantly fewer resilient prototypes and significantly more overcontrolled and undercontrolled prototypes. Undercontrolled individuals were the modal prototype. The resilient and undercontrolled types were better adjusted than the overcontrolled types, showing lower levels of depression at admission and higher acceptance of disability at discharge. The resilient type at admission predicted the most effective reports of social problem-solving abilities at discharge and the overcontrolled type the least. We discuss the implications of these results for assessment and interventions in rehabilitation settings.

Communal Behaviors and Psychological Adjustment of Family Caregivers and Persons With Spinal Cord Injury

OBJECTIVE: Examined the influence of mutual communal behaviors on the adjustment reported by persons with spinal cord injury (SCI) and their family caregivers. Previous research has found that persons who have a history of mutually communal behaviors in relationships may react differently to relationship changes after an acquired physical disability than dyads with few communal behaviors. METHOD: Family caregivers and persons with SCI were administered measures of mutual communal behaviors, depression, and life satisfaction. Structural equation modeling was used to test the relations among caregivers' communal behaviors and care recipients' communal behaviors, depression, and life satisfaction. RESULTS: Caregiver and care recipient reports of communal behaviors were not significantly correlated. Significant paths indicated that care recipients' communal behavior scores were positively associated with their life satisfaction, and care recipients' depression was inversely associated with their life satisfaction. Caregivers' communal behavior scores were unrelated to their self-reported adjustment. CONCLUSIONS: Caregiver-care recipient dyads may differ in their perceptions of communal behaviors in their relationships. Although care recipient reports of communal behavior may be related to their life satisfaction, communal behaviors may not serve a similar function among caregivers of persons with SCI.

Family Caregivers of Persons With Spinal Cord Injury: Predicting Caregivers at Risk for Probable Depression

OBJECTIVE: To determine the percentage of family caregivers of persons with spinal cord injury (SCI) with probable depression and to test the hypothesis that dysfunctional problem-solving abilities would be significantly predictive of risk status after taking into account important demographic characteristics and caregiver health. DESIGN: Correlational and logistic regression analyses of data collected in a cross-sectional design. PARTICIPANTS: Eighteen men and 103 women caregivers (mean age of caregivers = 45.66 years, SD = 12.88) of individuals with SCI. MAIN OUTCOME MEASURE: The Inventory to Diagnose Depression. RESULTS: Nineteen caregivers (15.7%) met criteria on the Inventory to Diagnose Depression for a major depressive disorder. A dysfunctional problem-solving style was significantly predictive of caregiver depression, regardless of the severity of physical impairment of the care recipient or the physical health of the caregiver and caregiver demographic variables. CONCLUSIONS: The percentage of caregivers with probable depressive disorder may parallel that observed among persons with SCI, using a more conservative self-report measure designed to assess symptoms associated with a depressive syndrome. Family caregivers with a dysfunctional problem-solving style and assisting individuals with more severe injuries may have probable depression.

Depressive symptoms of patients using clean intermittent catheterization for neurogenic bladder secondary to spinal cord injury

STUDY DESIGN

Prospective, cross-sectional study, based on cases of spinal cord injury (SCI).

SETTING

Three outpatient medical departments in Seoul, Korea.

OBJECTIVES

To assess depressive symptoms in patients on clean intermittent catheterization after SCI.

METHODS

In total, 102 subjects (68 males and 34 females, mean age 39.5 with a range of 18-75 years) were included in the primary analysis. A control group of 110 was selected from the routine health checkup. All subjects completed the Beck Depression Inventory (BDI).

RESULTS

For patients and controls, the average total BDI scores were 20.3+/-1.0 and 11.4+/-0.5, respectively (P<0.001). With regard to severity of depression among patient groups, three (3.0%) reported normal; four (3.9%) reported mild to moderate depression; 24 (23.5%) reported moderate to severe depression; and 71 (69.6%) reported severe depression. On the multivariate logistic regression analysis, a positive association with the risk of depression was observed in gender and type of catheterization. Female patients had a 3.8-fold higher risk (odds ratio (OR) 13.83; 95% confidence interval (CI) 1.42-10.31; P=0.008) of depression than male patients. In the same model, patients who were unable to perform catheterization independently had a 4.6-fold higher risk (OR 4.62; 95% CI 1.67-12.81, P=0.003) of depression than those who were able to perform self-catheterization.

CONCLUSIONS

The results demonstrate that the patients with neurogenic bladder secondary to SCI have higher degrees of depression than normal population. In addition, our findings also suggest that depression is closely related to gender and patient's ability to perform self-catheterization.

Family Caregivers of Women with Physical Disabilities

Cross-sectional, correlational analyses of data from two separate studies were conducted to examine the correlates of adjustment among family caregivers of women with disabilities. Participants included 40 caregivers of women with spinal cord injuries in the first study and 53 caregivers of women with cerebral palsy, traumatic brain injury, and other neuromuscular disabilities in the second study. It was hypothesized that a negative problem-solving style would be associated with greater caregiver distress in both studies, and that caregiver adjustment would be associated with care recipient depression in the second study. As expected, results indicated that a higher negative orientation toward solving problems was associated with caregiver depression and lower well-being. However, in the second study, caregiver characteristics were not associated with care recipient depression. These data indicate that considerable variability exists in caregiver adjustment. Methodological limitations and the implications for research, service, and policy formation are! discussed.

Racial disparities in health outcomes after spinal cord injury: mediating effects of education and income

OBJECTIVE

The purpose of this study was to investigate heath disparities as a function of race and gender and the extent to which socioeconomic factors mediate disparities among participants with spinal cord injury.

DESIGN

Survey methodology. Cross-sectional data.

SETTING

A large Southeastern specialty hospital.

PARTICIPANTS

There were 1342 participants in the current analysis, all of whom were identified from patient records. There were 3 inclusion criteria: (a) traumatic SCI, (b) at least 18 years of age at the time of study, and (c) injury duration of more than 1 year.

MAIN OUTCOME MEASURES

Six outcomes were measured, including 3 general outcomes (self-ratings, days impacted by poor health, days impacted by poor mental health) and 3 that reflect utilization of services (hospitalizations, days hospitalized, and nonroutine physician visits in the past 2 years).

RESULTS

RESULTS of multivariate analysis of variance (MANOVA) indicated significant main effects for both race and gender. Follow-up tests identified racial disparities on 3 of the 6 outcomes, whereas gender disparities were observed for a single outcome. Years of education and household income mediated interrelationships between race and health (but not gender) as racial disparities disappeared after consideration of these factors.

CONCLUSIONS

These findings suggest the need to work more diligently to promote better health outcomes among African Americans and to further investigate how socioeconomic factors and access to health care related to diminished health outcomes among African Americans with spinal cord injury.

Subsyndromal depression in the elderly: underdiagnosed and undertreated

Major depressive illness is present in about 5.7% of US residents aged>or=65 years, whereas clinically significant nonmajor or "subsyndromal" depression affects approximately 15% of the ambulatory elderly. Risk of developing subsyndromal depression increases as elderly people get older. Because they have numerous distressing ailments, everyday life can be burdensome for many elderly persons. Almost one third of Americans aged 75 years or older rate their health as "fair to poor." Yet, the physical discomforts experienced by so many elderly individuals are unlikely to generate a clinically significant depression unless other ingredients such as loneliness, impairment of mobility, loss of a spouse, a serious financial reverse, and--probably most important--genetic susceptibility are added to the psychophysiological mix. Because depression damages quality of life and is usually eminently treatable, it is essential that physicians and other health professionals be trained to recognize true depression and distinguish it from confounding conditions caused by medications, organic brain disease, or short-term grief reactions. In the medically ill elderly, depressive symptoms may be overlooked because of the assumption that they are a part of the concurrent medical illness. Diagnosis of depression in the elderly can be greatly assisted by use of age-specific screening instruments such as the Geriatric Depression Scale. Ultimately, brain imaging and biochemical and physiological measurements may prove useful in diagnosis. The presence of somatic concomitants of depression such as severe neck and low back pain should alert the clinician to the possibility of an underlying mood disorder. Suicide and suicide attempts occur all too frequently in the depressed elderly; therefore, screening for late-life depression is urgently required among the elderly in primary and residential health care settings.

Symptoms of major depression in people with spinal cord injury: implications for screening

OBJECTIVES

To provide psychometric data on a self-report measure of major depressive disorder (MDD) and to determine whether somatic symptoms are nonspecific or count toward the diagnosis.

DESIGN

Survey.

SETTING

Data from the National Spinal Cord Injury Statistical Center representing 16 Model Spinal Cord Injury Systems.

PARTICIPANTS

Eight hundred forty-nine people with spinal cord injury who completed a standardized follow-up evaluation 1 year after injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 (PHQ-9), a measure of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition . We computed descriptive statistics on rates of depressive symptoms and probable MDD, evaluated internal consistency and construct validity, and analyzed the accuracy of individual items as predictors of MDD.

RESULTS

Exactly 11.4% of participants met criteria for probable MDD. Probable MDD was associated with poorer subjective health, lower satisfaction with life, and more difficulty in daily role functioning. Probable MDD was not related to most demographic or injury-related variables. Both somatic and psychologic symptoms predicted probable MDD.

CONCLUSIONS

The PHQ-9 has promise as a tool with which to identify probable MDD in people with SCI. Somatic symptoms should be counted toward the diagnosis and should alert health care providers to the likelihood of MDD. More efficient screening is only one of the quality improvement efforts needed to enhance management of MDD.

Perceived importance of activities of daily living and arthritis helplessness in rheumatoid arthritis; a prospective investigation

OBJECTIVE

To examine the contribution of perceived importance of activities of daily living (ADL) to arthritis-specific helplessness in a sample of rheumatoid arthritis (RA) patients over a 1-year period.

METHOD

Forty-two individuals from an outpatient rheumatology clinic completed measures of ADL importance, helplessness, depression, pain, and disability; the physician's assistant provided objective ratings of disability.

RESULTS

Time 1 importance of ADL predicted a significant amount of variance in Time 2 arthritis helplessness after statistically controlling disease and psychological covariates. Moreover, increased perceived ADL importance predicted decreased arthritis helplessness over the 1-year period.

CONCLUSIONS

Results indicate that RA patients' experience of arthritis-specific helplessness may be minimized over time when performing ADL is perceived as important. Furthermore, these findings provide preliminary evidence for one possible antecedent to increased perceptions of arthritis helplessness in individuals with RA.

The Diagnostic Inventory for Depression: A self-report scale to diagnose DSM-IV major depressive disorder

In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Diagnostic Inventory for Depression (DID), a new self-report scale designed to assess the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) symptom inclusion criteria for a major depressive episode, assess psychosocial impairment due to depression, and evaluate subjective quality of life. A large sample of 626 psychiatric outpatients completed the DID and were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The measure's test-retest reliability, discriminant and convergent validity, and sensitivity to clinical change were investigated. The DID subscales achieved high levels of internal consistency and test-retest reliability. The DID was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The DID also was highly correlated with interviewer ratings of the severity of depression and psychosocial functioning, and DID symptom severity scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The DID was a valid measure of symptom change. Finally, the DID was significantly associated with a diagnosis of major depressive disorder.

Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis

OBJECTIVE

This systematic review and meta-analysis examined the strength of association between rheumatoid arthritis and depression. In addition, we investigated the extent to which sociodemographic characteristics, level of pain, and method of assessing depression might affect the degree of depression.

METHODS

CD-ROM databases and bibliographies were searched to identify all studies comparing depression in patients with rheumatoid arthritis and control subjects using standardized assessments. Effect sizes (Pearson's r) and probabilities were combined across studies. We examined the extent to which the association between rheumatoid arthritis and depression could be attributed to level of pain (using contrasts), sociodemographic differences between groups (combining methodologically restricted studies), and methods of assessing depression (examining heterogeneity across studies).

RESULTS

Twelve independent studies comparing depression in patients with rheumatoid arthritis with depression in healthy control subjects were found. Effect sizes for depression were small to moderate (r =.21, p <.0001; heterogeneous). This effect was not reduced in studies controlling for sociodemographic characteristics (r =.27, p <.0001). The effect sizes did vary in a linear manner in proportion to the effect size for pain (z = 2.67, p =.0064). The effect sizes produced by different measures of depression were heterogeneous (chi(2) for Fisher's Z = 24.6, p =.0002), with the Hospital Anxiety and Depression Scale giving effect sizes most dissimilar to those of other measures.

CONCLUSIONS

Depression is more common in patients with rheumatoid arthritis than in healthy individuals. This difference is not due to sociodemographic differences between groups, but it may be attributable, in part, to the levels of pain experienced. Variation in the methods of assessing depression partly accounts for the differences among studies examining the levels of depression in patients with rheumatoid arthritis.

Synthesis of research and evidence on factors affecting the desire of terminally ill or seriously chronically ill persons to hasten death

Review of empirical studies indicates that suicide is more common in persons suffering from some physical illnesses (e.g., epilepsy, head injuries, Huntington's Chorea, gastrointestinal diseases, AIDS, and cancer), but other chronic diseases and disabilities have not been linked to increased suicide risk (e.g., blindness, senile dementia, multiple sclerosis, and other physical handicaps). The timing of increased suicide risk varies in different illnesses from early presymptomatic stages to the terminal phase. Difficulties in reliably determining when someone is “terminally ill” and problems of the competence of persons with a poor prognosis complicate empirical investigations of euthanasia, assisted suicide, and the desire to hasten death. The role of family and caregivers in end of life decisions needs further clarification. Researchers have found that pain and suffering and quality of life variables may be linked to the desire to die prematurely, particularly in cancer patients. Others find that clinical depression is a major factor. But, since depression is often present, we do not know why a small minority of depressed patients desire and choose to hasten death. Support for alternative hypotheses is examined, including the role of pre-morbid suicidality and depression, individual differences in coping strategies and indirect consequences of the illness. There is a need to clarify links between attitudes, which is the major variable studied, and actual behaviors and decisions. Furthermore, we need theoretical and empirical links between studies of suicide, which is linked to clinical depression and characterized by ambivalence and studies of euthanasia, which is often depicted as rational and with little ambivalence. Evaluative research should be conducted to determine if interventions to reduce the desire for a premature death by suicide, euthanasia, or assisted suicide are effective. In the light of this review, we present several considerations for those involved in proposing changes in public policy concerning euthanasia and assisted suicide.

Depression after spinal cord injury: relation to gender, ethnicity, aging, and socioeconomic indicators

OBJECTIVE

To investigate the relation among aging, gender, ethnicity, socioeconomic indicators, and depressive symptoms after spinal cord injury (SCI).

DESIGN

Survey was done to collect cross-sectional data. A mediational model was used to analyze the interrelationships between predictors and depressive outcome variables.

SETTING

A large Southeastern rehabilitation hospital.

PARTICIPANTS

Participants, identified from outpatient records who met the following inclusion criteria: (1) traumatic SCI; (2) at least 18 years old at the time of study; and (3) injured for at least 1 year. There was an initial pool of 1923 potential participants in 1997, of whom 1391 (72%) participated.

MAIN OUTCOME MEASURES

The Older Adult Health and Mood Questionnaire, a 22-item measure of depressive symptoms designed following Diagnostic and Statistical Manual of Mental Disorders (DSM III-R) criteria, was used to measure depression. It has been validated against clinical assessments by psychiatrists and psychologists.

RESULTS

Forty-eight percent of the participants reported clinically significant symptoms. Minority participants, particularly women, were at a substantially higher risk for depressive symptoms. This risk diminished but did not disappear after controlling for years of education and income, both of which were highly negatively correlated with depressive symptoms. Aging factors were modestly positively correlated with depression, although education or income did not mediate these associations.

CONCLUSIONS

Symptoms of depression are highly prevalent after SCI and are related to aging, gender or ethnicity, and socioeconomic status indicators (education and income).

Symptoms of depression and psychological distress among hispanics with rheumatoid arthritis

OBJECTIVE

To explore the roles played by Hispanic ethnic background and acculturation to the mainstream English language culture of the United States in the depressive symptoms and mental health of rheumatoid arthritis (RA) patients.

METHODS

Members of a consecutive cohort of patients with RA were studied cross-sectionally. All underwent a comprehensive clinical and psychosocial evaluation. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D), and psychological distress was measured with the Medical Outcomes Study Short Form 36 (SF-36) mental health scale.

RESULTS

Two hundred thirty-six patients were studied. Women had significantly higher median CES-D scores than men (19 versus 14, P = 0.0004), Hispanics scored higher than non-Hispanics (14 versus 8, P = 0.0002), and foreign-born scored higher than US-born patients (14 versus 10, P = 0.009). Compared with those who were fully acculturated, patients who were partially acculturated were more likely to have a score > or = 16 on the RA-adjusted CES-D (odds ratio [OR] = 1.79, 95% confidence interval [95% CI] 1.37 to 2.35, P < or = 0.001). Among unacculturated patients, the likelihood of a score > or = 16 increased 6-fold (OR = 6.68; 95% CI 3.50 to 12.72; P < or = 0.001). A similar, inverse pattern was observed for the SF-36 mental health scale. In multivariate models accounting for age, sex, education, income, articular pain, deformity, and the level of disability, low acculturation was independently associated with high depressive symptoms, and a Hispanic background was independently associated with lower SF-36 mental health.

CONCLUSIONS

In this consecutive series of RA patients, Hispanics, particularly those who are not fully acculturated to the mainstream Anglo society, had more depressive symptoms and psychological distress than did non-Hispanics.

Suicide in a spinal cord injured population: its relation to functional status

OBJECTIVE

To determine the relation between functional status and risk of suicide among individuals with spinal cord injury (SCI).

DESIGN

A follow-up study of all individuals who survived a traumatic SCI during the period from 1953 through 1990.

SETTING

An SCI center in eastern Denmark.

SUBJECTS

A total of 888 individuals with SCI, including 236 who died, 23 of whom committed suicide.

MAIN OUTCOME MEASURES

Standardized Mortality Ratios (SMRs) of suicides among individuals with SCI.

RESULTS

A 100% follow-up was established January 1, 1993. The total suicide rate among individuals with SCI was nearly five times higher than expected in the general population and lower for men than for women. The suicide rate doubled from an early inclusion period (1953-1971) to a later period (1972-1990). An unexpected finding was that the suicide rate in the group of marginally disabled persons was nearly twice as high as the group of functionally complete tetraplegic individuals.

CONCLUSION

Given the high frequency of suicide, there is a need for increased awareness by rehabilitation staff and general practitioners regarding depression and psychological adjustment difficulties. Such conditions should be given special attention during rehabilitation and follow-up, especially among women with SCI and the marginally disabled.

Spinal cord injury rehabilitation. 4. Individual experience, personal adaptation, and social perspectives

This learner-directed module highlights contemporary perspectives on personal success in the adjustment and adaptation of patients with spinal cord injury (SCI). It is the fourth in a series of five modules within the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This module explores models of the multisystem effects on a person after SCI, disablement, theories of adjustment, patient autonomy, quality of life, community experience, adaptations enhancing sexuality, and minimization of pain after SCI. Perspectives of the patient's experience in disablement, interdisciplinary person-centered rehabilitation, and success of the individual in chosen life roles are emphasized. The module is designed to update SCI issues reviewed in past syllabi.

Psychiatric aspects of rheumatology

The rheumatic diseases pose significant and challenging problems for the consulting psychiatrist because of their multifaceted clinical features. Consideration must be given to the complexity of the social system in which the patient lives, the rheumatologist-patient relationship, the losses incurred by the illness, immunologic vulnerability to opportunistic infections, the effects of concurrent medical treatments (especially drug treatments), and any antecedent pathologic conditions. This article examines the clinical and treatment highlights of two representative rheumatologic diseases: rheumatoid arthritis and systemic lupus erythematosus.

Depression following spinal cord injury

Although depression has been widely studied among persons with spinal cord injury, the ubiquitous and unsophisticated use of the term and presumptions about its manifestations in the rehabilitation setting have needlessly encumbered the understanding and treatment of depression. Major themes and issues in the study, measurement, and treatment of depression among persons with spinal cord injury are reviewed. Greater precision is recommended in distinguishing diagnosable depression from displays of negative affect, anxiety, distress, and dysphoria. Correlates of depressive behavior among persons with SCI are surveyed, and guidelines for research and practice in the SCI setting are explicated.