Distinguishing Grief From Depression During Acute Recovery From Spinal Cord Injury

Acute Management of Cervical Spinal Cord Injuries

Traumatic cervical spinal cord injury can cause significant neurologic disability. A cervical spine injury impacts not only the neurologic system but also numerous other organ systems of the body. This complex injury requires a systematic approach to assessment and care aimed at preventing, recognizing, and treating potentially devastating secondary spinal cord injury and multisystem complications. This article focuses on the pathophysiology, initial presentation, and treatment of cervical spinal cord injury by body system.

The role of arousal and motivation in emotional conflict resolution: Implications for spinal cord injury

Under many conditions, emotional information is processed with priority and it may lead to cognitive conflict when it competes with task-relevant information. Accordingly, being able to ignore emotional information relies on cognitive control. The present perspective offers an integrative account of the mechanism that may underlie emotional conflict resolution in tasks involving response activation. We point to the contribution of emotional arousal and primed approach or avoidance motivation in accounting for emotional conflict resolution. We discuss the role of arousal in individuals with impairments in visceral pathways to the brain due to spinal cord lesions, as it may offer important insights into the “typical” mechanisms of emotional conflict control. We argue that a better understanding of emotional conflict control could be critical for adaptive and flexible behavior and has potential implications for the selection of appropriate therapeutic interventions.

A Narrative Review of Research on Adjustment to Spinal Cord Injury and Mental Health: Gaps, Future Directions, and Practice Recommendations

Spinal cord injury (SCI) results in autonomic, motor, and sensory impairments that can compromise mental health. Guidelines directing the management of mental health following SCI presently address clinical anxiety, depression, post-traumatic stress, substance use disorders, and suicide. However, evidence suggests that perhaps as many as 70% of individuals with SCI do not develop a clinically diagnosable mental health disorder. Therefore, the authors contend that understanding non-clinical cognitive and psychological aspects of adjustment post-SCI is paramount and that the application of this knowledge to the formulation of adjustment-enhancing interventions is crucial. To assist with this endeavour, we examine existing mental health guidelines targeting SCI, and present a narrative review of research on the under-represented topics of adjustment, coping, grief, and resilience. We include mild cognitive impairment, which reflects a common factor that can compromise adjustment. Loss and stress trigger processes of adjustment, coping, grief, and resilience. SCI involves loss and stress triggering these processes, arguably without exception. Our study applied a narrative review methodology searching Google Scholar and PsychInfo databases for terms adjustment, coping, grief, resilience, and cognitive impairment. Qualitative studies and quantitative studies were selected to capture bottom-up and top-down perspectives. Reference lists of retrieved papers were searched as appropriate. Reviewed literature suggested that existing guidelines concerning mental health following SCI neglect positive processes of adjustment and suggest this neglect contributes to a deficits-based view of mental health following SCI. Research into "positive" or adjustment-enhancing processes is mostly cross-sectional, heterogenous, and poorly positioned to inform future guideline-development. Researchers should achieve consensus over the operationalisation of essential processes and overcome a fixation with "outcomes" to better inform management of mental health after SCI.

Investigating Dynamics of the Spinal Cord Injury Adjustment Model: Mediation Model Analysis

Spinal cord injury (SCI) is a severe neurological injury that results in damage to multiple bodily systems. SCI rehabilitation requires a significant focus on improving adjustment to the injury. This paper presents a detailed description of the Spinal Cord Injury Adjustment Model (SCIAM), which clarifies how individuals adjust to SCI and contends that adjustment to SCI is a multifactorial process involving non-linear dynamic adaptation over time. Evidence supporting SCIAM is also discussed. Mediation analyses were conducted to test the mediator dynamics proposed by the model. The analyses tested the relationship between two moderators (self-care and secondary health conditions), mediators (two self-efficacy items and appraisal of quality of life or QoL), and positive versus negative vitality/mental health as outcomes. Results showed that higher self-efficacy and perceived QoL was related to greater independence in self-care and reduced negative impacts of secondary health conditions. This study supported the mediation role of self-efficacy and other appraisals such as perceived QoL in enhancing self-care and buffering the negative impact of health challenges. In conclusion, it is important to employ a holistic model such as SCIAM to conceptualise and increase understanding of the process of adjustment following a severe neurological injury such as SCI.

Grieving a disrupted biography: an interpretative phenomenological analysis exploring barriers to the use of mindfulness after neurological injury or impairment

BACKGROUND

Mindfulness has demonstrated strong utility for enhancing self-management and health outcomes in chronic illness. However, sensation-focused mindfulness techniques may not be appropriate for clinical populations with neurological injury. This study aimed to identify how expert mindfulness teachers with sensory loss/impairment naturalistically adapt and experience mindfulness. We aimed to highlight the rationale for and barriers to mindfulness practice when living with sensory loss.

METHODS

A qualitative, semi-structured interview design was used, analysed via Interpretative Phenomenological Analysis (IPA). Eight (5 females, 3 males) mindfulness teachers with neurological injury were recruited via a national registry of Mindfulness for Health teachers. Interviews (range: 50-93 min) were completed, transcribed verbatim and analysed idiographically for descriptive, linguistic and conceptual themes, before a cross-case analysis was completed.

RESULTS

Two superordinate themes were identified: (1) Overcoming a disrupted biography; and (2) Proactive self-management. These themes considered the challenge of reconciling, through grief, a past health status with the present reality of living with sensory loss due to Spinal Cord Injury, Multiple Sclerosis or Functional Neurological Disorder. Mindfulness was experienced as a method by which proactive choices could be made to maintain control and autonomy in health, reducing perceptions of suffering, psychological distress, cognitive reactivity and rumination.

CONCLUSIONS

Mindfulness was found to support the self-management of health after neurological injury/impairment. Mindfulness meditation presented an initial challenge as trauma and grief processes were (re-)activated during mindfulness sessions. However, mindfulness was found to support the resolution of these grief processes and encourage adaptive approach-based coping and acceptance of health and neurological impairment/injury.

"This New Chapter of Life": Content Analysis of Facebook Posts After Traumatic Brachial Plexus Injury

Background: After traumatic brachial plexus injuries (BPI), the sudden loss of physical function is often accompanied by psychological distress. Given the complex nature and relative infrequency of the injury, BPI patients will often use online resources for information about their injury as well as emotional support. Questions/Purpose: Recognizing the influence of social media, we sought to search a popular social media platform to identify challenges faced by BPI patients and strategies used to overcome these challenges. Methods: We searched "traumatic brachial plexus injury" on Facebook and selected the 2 most popular BPI support groups. We collected posts regarding traumatic BPI from November 1, 2018 through November 1, 2019. We performed inductive and deductive thematic analysis of the posts to identify recurring topics, knowledge gaps, and peer interaction dynamics. Results: We analyzed 7694 posts from the 2 Facebook support groups. The following themes emerged: (1) BPI patients express discontent regarding the inability to use their arm and the slow or stagnant pace of recovery; (2) BPI patients are frustrated over their inability to retain their preinjury livelihood; and (3) BPI patients emphasize that acceptance and moving on are key components of adjustment to their condition. Some patients described the role of limb amputation in achieving these goals. Conclusions: Our analysis demonstrates the areas in which BPI patients are in need of emotional support. Adjustment to BPI might be facilitated through multidisciplinary care that addresses emotional aspects of recovery and emphasizes self-management skills, in addition to the traditional focus on physical function.

A Primary Care Provider's Guide to Depression After Spinal Cord Injury: Is It Normal? Do We Treat It?

Although most people with spinal cord injury (SCI) are emotionally resilient, as a group they are at increased risk of major depressive disorder. Depression tends to be undertreated in people with SCI, perhaps because depression is mistakenly viewed as an expected reaction to severe disability or is confused with grief. Depression and grief are distinguishable, and the Patient Health Questionnaire-9 is a reliable and valid screen for major depression in this population. Major depression can be treated with antidepressants, especially venlafaxine XR, and with psychotherapy, especially cognitive behavioral therapy, focused on helping the person resume activities that were previously enjoyable or meaningful. Structured exercise also may help relieve depressed mood.

Grief and Loss Among Veterans With Spinal Cord Injury: A Qualitative Study

PURPOSE

The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI).

DESIGN/METHODS

Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach.

RESULTS

The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience.

CONCLUSIONS/CLINICAL RELEVANCE

A better understanding of veterans living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

How do healthcare providers manage depression in people with spinal cord injury?

STUDY DESIGN

An online survey.

OBJECTIVES

To describe how healthcare providers manage depression after spinal cord damage (SCD) and to identify factors that predict use of recommended depression management practices.

SETTING

An international cohort of respondents who provide clinical care to individuals with SCD.

METHODS

An online survey was distributed to clinicians caring for individuals with SCD. The 20-question survey inquired about participant demographic and professional information, their knowledge and beliefs about depression after SCD, their methods of treating depression in SCD, and perceived barriers to treatment of depression.

RESULTS

One hundred eleven individuals took this survey. Participants estimated on average that 48.7% of their patients with SCD have depression, and nearly two-thirds (62.2%) reported using their own clinical judgment to identify the condition. Respondents cited barriers to depression treatment including patient denial of depression (47.7%), stigmas attached to depression (41.4%), and lack of availability and high cost of counseling (45.9% and 35.1%, respectively) and antidepressant medications (5.4% and 10.8%, respectively). The belief that one is well trained to handle depressive symptoms predicted increased frequency of screening for depression and implementation of recommended treatments for depression.

CONCLUSIONS

Respondents to this survey under-utilize valid screening measures and likely over-estimate the prevalence of depression in SCD. They cited a number of barriers to treatment for depression. Our results underscore the need for improved mental health education among SCD providers and the use of valid depression screening measures to help focus limited mental health services and treatments on those who need them.

National Institutes of Health Toolbox Emotion Battery: Application of Summary Scores to Adults With Spinal Cord Injury, Traumatic Brain Injury, and Stroke

OBJECTIVE

To examine the validity of factor analytically based summary scores that were developed using the National Institutes of Health Toolbox Emotion Battery (NIHTB-EB); (ie, psychological well-being, social satisfaction, negative affect) normative sample in individuals with neurologic conditions.

DESIGN

Cross-sectional, observational cohort.

SETTING

Community.

PARTICIPANTS

A total of 1036 English-speaking adults from the National Institutes of Health Toolbox (NIHTB) normative project and 604 community-dwelling adults with neurologic conditions including spinal cord injury (SCI n=209), traumatic brain injury (TBI n=184), and stroke (cerebrovascular accident [CVA] n=211) (N=1640).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The NIHTB-EB.

RESULTS

A series of univariate analyses comparing summary scores across the 4 groups (SCI, TBI, CVA, normative group) were conducted to identify group differences. Base rates (defined as >1 SD toward the problematic direction) were also identified. The normative group demonstrated better emotional functioning characterized by greater social satisfaction and psychological well-being (normative group > SCI, TBI, CVA; P's <.0001), and less negative affect (normative group < SCI, P=.016; normative group < TBI, P<.001; normative group < CVA; P=.034) compared with each neurologic group. Using base rates to identify problematic emotions for the 3 summary scores, there were higher rates of problematic emotions on all 3 summary scores for the neurologic groups compared with the normative group.

CONCLUSIONS

The NIHTB-EB summary scores demonstrate an increased prevalence of problematic emotions among individuals with 3 neurologic conditions, and might be useful for identifying individuals with similar conditions and potentially in need of psychological support.

What determines low satisfaction with life in individuals with spinal cord injury?

OBJECTIVE

To examine variables associated with satisfaction with life (SWL) in individuals with a spinal cord injury (SCI).

DESIGN

Cross-sectional, national survey to assess SWL, demographic and injury characteristics, health care utilization, chronic conditions (obesity, diabetes, heart problems, lung problems, hypertension, high cholesterol), symptoms (poor sleep, pain, depression), social support, grief/loss, and independence.

SETTING/PARTICIPANTS

Community-dwelling Veterans with SCI. Outcome Measures/Analyses: Bivariate analyses were conducted to assess differences in demographics, injury characteristics, chronic conditions, symptoms, social support, grief/loss, and independence in individuals who reported low SWL (≤20) vs. average/high SWL (21-35). Multivariate logistic regression assessed factors independently associated with low SWL.

RESULTS

896 Veterans with SCI (62%) responded. Average age was 62 years, the majority were male (94%), Caucasian (77%), and had paraplegia (61%). Odds of low SWL were 2.4 times greater for individuals experiencing pain (OR = 2.43, CI95: 1.47-4.02, P = 0.0005). Odds of low SWL were increased for individuals reporting greater grief/loss due to their SCI (OR = 1.14, CI95: 1.10-1.18, P < 0.0001). Lesser odds of low SWL were seen for individuals reporting greater emotional social support (OR = 0.97, CI95: 0.96-0.99, P < 0.0001) and independence (OR = 0.94, CI95: 0.90-0.97, P < 0.0001).

CONCLUSIONS

Pain and feelings of grief/loss due to injury were associated with low SWL. Self-perceived independence and good social support were associated with better SWL. Along with addressing pain and facilitating independence and social support, these findings suggest that interventions to improve SWL should focus on helping individuals deal with grief/loss due to injury.

Assessment instruments and depression rates in people with spinal cord injury: a systematic review

ABSTRACT Objective: To identify, describe, differentiate and qualify the instruments used to evaluate depression and also identify the percentage and average rates of depression in people with spinal cord injury. Method: This is a systematic review of the literature implementing a qualitative approach. SciELO, LILACS, PubMed and PsycINFO databases were consulted. Original articles were classified according to the variables (Spinal Cord Injury, Depression and Assessment instruments). The studies are presented according to the instruments in recent publications in the past 11 years. Results: Five evaluation instruments were found. PHQ-9, a screening instrument for diagnosing depression was used in most studies, with all being performed in the United States and having a higher impact factor and number of participants. Studies with PHQ-9 presented a total score of people who met the criteria for depression without grading by severity with an average of 17.6% ± 7.3%, while BDI presented 51.6% ± 15.1% and the HADS showed 37.5% ± 31% of people with some degree of depression. Conclusion: This study was important in identifying which instruments can be used to assess depression, the description of each, some of their differences, which ones are used in the best studies and o the depression rates in different parts of the world. It was also important to show how the PHQ-9 is an important instrument, but is limited to being used in the USA.

Depression Trajectories During the First Year After Spinal Cord Injury

OBJECTIVE

To determine the number and type of longitudinal depression trajectories during the first year after spinal cord injury (SCI) and to identify baseline predictors of these trajectories.

DESIGN

Cohort study.

SETTING

Rehabilitation and postacute community settings.

PARTICIPANTS

Of 168 consecutive admissions to inpatient rehabilitation for acute SCI, 141 (115 men, 26 women) patients were enrolled in a randomized controlled trial telephone follow-up intervention, which showed no outcome differences, and completed assessments on at least 2 of the 4 follow-up occasions (3, 6, 9, and 12 months after SCI). Participants were on average 41 years old, most were non-Hispanic (96%) and white (86%), and 61.7% had tetraplegia.

INTERVENTIONS

Data were drawn from the ineffective randomized controlled trial.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Unconditional linear latent class growth analysis models of PHQ-9 total scores revealed an optimal 3-class solution: stable low depression (63.8%), mild to moderate depression (29.1%), and persistent moderate to severe depression (7.1%). Preinjury mental health history and baseline pain, quality of life, and grief predicted class membership.

CONCLUSIONS

The modal response to SCI was stable low depression, whereas persistent moderate to severe depression primarily represented a continuation or relapse of preinjury depression. This line of research has the potential to improve identification of subgroups destined for poor outcomes and to inform early intervention studies.