Effectiveness of Behavioral and Pharmacologic Interventions for Depressive Symptoms After Spinal Cord Injury: Findings From a Systematic Review

OBJECTIVE

To summarize and evaluate evidence regarding the efficacy of interventions for depressive symptoms in adults living with spinal cord injury (SCI) and comorbid major depressive disorder or significant depressive symptoms to inform the development of clinical practice guidelines.

DATA SOURCES

Articles published since 2013 and available in Medline, The Cochrane Library, Embase, Scopus, CINAHL, or PsycINFO. Databases were searched in June 2022 and updated November 2023.

STUDY SELECTION

Inclusion criteria: age 18 years or older, traumatic SCI, and clinically significant depression (Population), mental health interventions including behavioral, pharmacologic, and complementary and alternative medicine (Intervention), inclusion of a control group (Comparator), with a primary outcome of depression symptom reduction (Outcome). Criteria were applied by multiple reviewers and disagreements were reconciled via unanimous decision among the entire research team. Eight articles of 2780 screened met the selection criteria.

DATA EXTRACTION

Data were extracted independently by multiple reviewers. Two reviewers independently assigned a quality score using the guidelines described by Hawker and associates and independently evaluated the risk of bias of each article using version 2 of the Cochrane risk-of-bias tool.

DATA SYNTHESIS

All studies assessed depressive symptoms during participant recruitment, screening, and/or at a baseline assessment stage. Pharmacotherapy with venlafaxine XR and several behavioral interventions appear promising, including an online mindfulness course and eye movement desensitization and reprocessing therapy. Remote interventions may be effective in reaching individuals who are unable to travel to in-person therapy sessions.

CONCLUSIONS

This systematic review provides valuable information for clinicians who treat individuals with SCI and comorbid major depressive disorder or significant depressive symptoms. It highlights the importance of considering a variety of interventions and individualizing treatment to meet individuals' needs and preferences. Future research should aim to identify effective interventions for treating depressive symptoms in individuals with SCI and optimal delivery methods for these interventions.

Lifestyle assessment in individuals with spinal cord injuries caused by accidents and disasters in qualitative studies published from 1990 to 2020: A meta-synthesis of qualitative study

Background and Aims

As a debilitating disorder, spinal cord injuries (SCIs) can bring about a range of physical, psychological, and social consequences in individuals and even have effects on their lifestyle indicators. The present study was thus to reflect on lifestyles among people with SCIs developing from accidents and disasters.

Methods

Using a meta-synthesis of qualitative research, all articles recruiting qualitative methods to examine patients with SCIs, published from 1990 to 2020, were retrieved by the researchers, good at the Persian and English languages, from the databases of ScienceDirect, MD Consult, Pedro, ProQuest, PubMed, SID, MedLib, Magiran, Scopus, Google Scholar, Iranmedex, the Cochran Library, CINAHL, and Blackwell, tapping the keywords of "spinal cord injury, SCI, manmade disaster, natural disaster, content analysis, concept analysis, thematic analysis, lifestyle, quality of life, QoL, grounded theory, meta-synthesis, mixed-methods research, historical research, ethnography, and phenomenology" in both languages for their inclusion in this study and further analyses.

Results

With reference to the inclusion criteria, 18 articles were extracted, and after all 10 studies in line with the research topic were reviewed and analyzed. Ultimately, six main themes, namely, compromise, self-reliance, income-generating activities, mental status, inability, and issues of sexuality were extracted, demonstrating their importance to individuals suffering from SCIs.

Conclusion

During the initial stages following SCIs, the abilities to engage in participatory practices and individual's power of decision-making diminish because of physical, social, psychological, and environmental constraints. It was accordingly recommended to have a holistic perspective and respect all aspects of life in individuals with SCIs.

Development of Emotional Well-Being indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Emotional Well-Being (EWB) post-spinal cord injury or disease (SCI/D) is a critical aspect of adjustment to disability. Advancing care and assuring equity in care delivery within this rehabilitation care domain is essential. Herein, we describe the selection of EWB structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission. Methods: A pan-Canadian Working Group completed the following tasks: (1) defined the EWB construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with EWB; and, (4) prepared a process map. Facilitated meetings allowed selection and review of feedback following rapid-cycle evaluations of proposed structure, process and outcome indicators. Results: The structure indicator is the proportion of staff with appropriate education and training in EWB and access to experts and resources. The process indicator is the proportion of SCI/D patients who were screened for depression and anxiety symptoms at rehabilitation admission and rehabilitation discharge. The intermediary outcome is the proportion of SCI/D patients at risk for depression or anxiety at rehabilitation discharge based on screening symptom scores. The final outcomes are: (a) proportion of individuals at risk for depression or anxiety based on screening symptom scores; and (b) proportion of individuals who received referral for EWB services or intervention. Conclusion: The proposed indicators have a low administrative burden and will ensure feasibility of screening for depression and anxiety at important transition points for individuals with SCI/D. We anticipate that the current structures have inadequate resources for at-risk individuals identified during the screening process.

SCI and depression: Does inflammation commandeer the brain?

The incidence of depression is almost twice as high in the spinally injured population compared to the general population. While this incidence has long been attributed to the psychological, economic, and social burdens that accompany spinal cord injury (SCI), data from animal studies indicate that the biology of SCI may play an important role in the development of depression. Inflammation has been shown to impact stress response in rodents and humans, and inflammatory cytokines have been associated with depression for decades. The inflammation inherent to SCI may disrupt necessary mechanisms of mental homeostasis, such as serotonin production, dopamine production, and the hypothalamic pituitary adrenal axis. Additionally, gut dysbiosis that occurs after SCI can exacerbate inflammation and may cause further mood and behavior changes. These mediators combined may significantly contribute to the rise in depression seen after SCI. Currently, there are no therapies specific to depression after SCI. Elucidation of the molecular pathways that contribute to SCI-specific depression is crucial for the understanding of this disease and its potential treatments.

Depressive mood in adults with spinal cord injury as they transition from an inpatient to a community setting: secondary analyses from a clinical trial

STUDY DESIGN

Prospective cohort controlled trial design.

OBJECTIVES

(i) To investigate mood benefits of adding group cognitive behaviour therapy (group-CBT) to standard spinal cord injury (SCI) inpatient rehabilitation (SR) that included access to antidepressant medication and individually delivered CBT on demand. (ii) To determine whether those with elevated depressive mood during inpatient rehabilitation significantly improve.

SETTING

SCI rehabilitation and community settings in New South Wales, Australia.

METHODS

Participants included 50 adults with SCI who completed SCI rehabilitation that included group-CBT compared with 38 participants who also completed SCI rehabilitation that did not contain group-CBT. Comprehensive assessment occurred after admission, within 2 weeks of discharge and 12 months post-injury. Multivariate repeated measures analyses were conducted to examine differences between groups and over time.

RESULTS

The addition of group-CBT to SR did not result in significant improvement in mood. However, participants with clinically elevated depressive mood assessed during inpatient rehabilitation experienced significant reductions in depressive mood when assessed in the community regardless of CBT dosage. Anxiety correlated with mood while no sociodemographic/injury factors correlated with mood at any time period except education level.

CONCLUSION

There were no mood advantages over time of adding group-CBT to inpatient SCI rehabilitation that contains individually delivered CBT on demand and access to antidepressant medication. However, findings showed those with elevated depressive mood during inpatient rehabilitation significantly improved when assessed in the community; however, their levels of depressive mood remain high. Future research should investigate the efficacy of providing individual preferences for managing depression in people with SCI.

Evaluating the Psychometric Properties and Responsiveness to Change of 3 Depression Measures in a Sample of Persons With Traumatic Spinal Cord Injury and Major Depressive Disorder

OBJECTIVES

To compare the measurement properties and responsiveness to change of the Patient Health Questionnaire-9 (PHQ-9), the Hopkins Symptom Checklist-20 (HSCL-20), and the Hamilton Depression Rating Scale (HAM-D) in people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD).

DESIGN

Secondary analysis of depression symptoms measured at 6 occasions over 12 weeks as part of a randomized controlled trial of venlafaxine XR for MDD in persons with SCI.

SETTING

Outpatient and community settings.

PARTICIPANTS

Individuals (N=133) consented and completed the drug trial. Eligibility criteria were age at least 18 years, traumatic SCI, and diagnosis of MDD.

INTERVENTIONS

Venlafaxine XR.

MAIN OUTCOME MEASURES

Patients completed the PHQ-9 and the HSCL-20 depression scales; clinical investigators completed the HAM-D and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) Dissociative Disorders, which was used as a diagnostic criterion measure.

RESULTS

All 3 instruments were improved with rating scale analysis. The HSCL-20 and the HAM-D contained items that misfit the underlying construct and that correlated weakly with the total scores. Removing these items improved the internal consistency, with floor effects increasing slightly. The HAM-D correlated most strongly with Structured Clinical Interview for DSM-IV Dissociative Disorders diagnoses. Improvement in depression was similar on all outcome measures in both treatment and control groups.

CONCLUSIONS

The psychometric properties of the revised depression instruments are more than adequate for routine use in adults with SCI and are responsive to clinical improvement. The PHQ-9 is the simplest instrument with measurement properties as good as or better than those of the other instruments and required the fewest modifications.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury

Study design:

Cross-sectional survey.

Objective:

To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI).

Setting:

Community-dwelling individuals with traumatic SCI living across Canada.

Methods:

Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS).

Results:

Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively).

Conclusion:

Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

Return to Work Practices and Research with Spinal Cord Injury: An Australian Perspective

Post-injury return to work (RTW) is an important rehabilitation outcome regardless of injury type. With Spinal Cord Injury (SCI), the odds of successful RTW are lower than for the general population of work-injured. Australians living with a SCI have a higher RTW rate than many other developed countries, including the United States. Important influences on relatively higher post-injury RTW rates in the Australian context include its universal disability care policy, Australia's suite of no-fault accident insurance systems that allow for multi-faceted rehabilitation services to be provided to eligible individuals in addition to appropriate rewards for rehabilitation service providers. A combination of these systemic factors is important when delivering comprehensive rehabilitation services to those with catastrophic injuries, such as SCI. The empirical evidence on drivers of successful RTW post SCI is, however, limited in comparison to the evidence on interventions for enhanced coping following SCI. Future studies could consider the relative merits of specific RTW interventions with SCI contrasting policy and capitation systems as well as utilising study designs that take into account pre-morbid work participation and secondary health conditions.

Assessment of depression in a rodent model of spinal cord injury

Despite an increased incidence of depression in patients after spinal cord injury (SCI), there is no animal model of depression after SCI. To address this, we used a battery of established tests to assess depression after a rodent contusion injury. Subjects were acclimated to the tasks, and baseline scores were collected before SCI. Testing was conducted on days 9-10 (acute) and 19-20 (chronic) postinjury. To categorize depression, subjects' scores on each behavioral measure were averaged across the acute and chronic stages of injury and subjected to a principal component analysis. This analysis revealed a two-component structure, which explained 72.2% of between-subjects variance. The data were then analyzed with a hierarchical cluster analysis, identifying two clusters that differed significantly on the sucrose preference, open field, social exploration, and burrowing tasks. One cluster (9 of 26 subjects) displayed characteristics of depression. Using these data, a discriminant function analysis was conducted to derive an equation that could classify subjects as "depressed" on days 9-10. The discriminant function was used in a second experiment examining whether the depression-like symptoms could be reversed with the antidepressant, fluoxetine. Fluoxetine significantly decreased immobility in the forced swim test (FST) in depressed subjects identified with the equation. Subjects that were depressed and treated with saline displayed significantly increased immobility on the FST, relative to not depressed, saline-treated controls. These initial experiments validate our tests of depression, generating a powerful model system for further understanding the relationships between molecular changes induced by SCI and the development of depression.

A randomized controlled trial of venlafaxine XR for major depressive disorder after spinal cord injury: Methods and lessons learned

CONTEXT/OBJECTIVE

We describe the rationale, design, methods, and lessons learned conducting a treatment trial for major depressive disorder (MDD) or dysthymia in people with spinal cord injury (SCI).

DESIGN

A multi-site, double-blind, randomized (1:1) placebo controlled trial of venlafaxine XR for MDD or dysthymia. Subjects were block randomized and stratified by site, lifetime history of substance dependence, and prior history of MDD.

SETTING

Six SCI centers throughout the United States.

PARTICIPANTS

Across participating centers, 2536 subjects were screened and 133 were enrolled into the trial. Subjects were 18-64 years old and at least 1 month post-SCI. Interventions Twelve-week trial of venlafaxine XR versus placebo using a flexible titration schedule.

OUTCOME MEASURES

The primary outcome was improvement in depression severity at 12 weeks. The secondary outcome was improvement in pain.

RESULTS

This article includes study methods, modifications prompted by a formative review process, preliminary data on the study sample and lessons learned. We describe common methodological and operational challenges conducting multi-site trials and how we addressed them. Challenges included study organization and decision making, staff training, obtaining human subjects approval, standardization of measurement and treatment, data and safety monitoring, subject screening and recruitment, unblinding and continuity of care, database management, and data analysis.

CONCLUSIONS

The methodological and operational challenges we faced and the lessons we learned may provide useful information for researchers who aim to conduct clinical trials, especially in the area of medical treatment of depression in people with SCI.

Depression and depression treatment in women with spinal cord injury

BACKGROUND

Research has documented high rates of depression in people with spinal cord injury (SCI); however, most SCI research is conducted with predominantly male study participants. Additional research is needed on depression and depression treatment among women with SCI.

OBJECTIVE

Study objectives were to examine depression, correlates of depression, and depression treatment in a sample of women with SCI.

METHODS

The sample included 51 ethnically and racially diverse women with SCI who participated in a larger study on secondary conditions of women with diverse physical disabilities. Recruited through health clinics and community organizations in a large metropolitan area, participants completed structured interviews that included demographic and disability characteristics and measures of health and health care utilization.

RESULTS

Scores on the Beck Depression Inventory-II (BDI-II) indicated that 41% of the women had depressive symptomatology in the mild to severe range. BDI-II scores were significantly related to more severe secondary conditions, greater pain, and poorer health perceptions but not to demographic or disability variables. Nearly a third (n = 16) of the women had scores exceeding the standard cutoff for significant clinical depressive symptomatology, yet only 5 of those had received any treatment for depression in the past 3 months and only 1 had received counseling or psychotherapy. Lifelong depression treatment showed a similar pattern of predominantly pharmacologic treatment.

CONCLUSION

Depression is a common problem for women with SCI, and many do not receive treatment, particularly psychological treatment. Disability-sensitive and affordable depression treatment must be made available to women with SCI.

Psychological therapies for the management of co-morbid depression following a spinal cord injury: a systematic review

The evidence about psychological therapies used to manage co-morbid depression after a spinal cord injury is presented here. A comprehensive search of five electronic databases identified nine studies (participants, n = 591) meeting inclusion criteria. Pooled statistical analyses were conducted in combination with narrative synthesis. Overall, multimodal cognitive behavioural therapy was found to be moderately effective (standardised mean difference = -0.52; 95% confidence interval = -0.85, -0.19). Activity scheduling, psychoeducation, problem solving and cognitive therapy may be particularly beneficial therapies within cognitive behavioural therapy. Further high-quality randomised controlled trials are needed to better substantiate these findings.

An exploration of modifiable risk factors for depression after spinal cord injury: which factors should we target?

OBJECTIVE

To identify modifiable risk factors for depression in people with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Outpatient and community settings.

PARTICIPANTS

Community-residing people with SCI (N=244; 77% men, 61% white; mean age, 43.1y; 43% with tetraplegia) who were at least 1 month postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Depression severity (Patient Health Questionnaire-9 [PHQ-9]), physical activity (International Physical Activity Questionnaire [IPAQ]), pleasant and rewarding activities (Environment Rewards Observation Scale [EROS]), and self-efficacy to manage the effects of SCI (Modified Lorig Chronic Disease Self-Management Scale).

RESULTS

Greater depression severity was associated with being 20 to 29 years of age, not completing high school, not working or attending school, and being ≤4 years post-SCI. After controlling for demographic and injury characteristics (adjusted R(2)=.13), lower EROS scores (change in adjusted R(2)=.34) and lower self-efficacy (change in R(2)=.13) were independent predictors of higher PHQ-9 scores. Contrary to predictions, physical activity as measured by the IPAQ did not predict depression severity.

CONCLUSIONS

Our findings suggest that having fewer rewarding activities, and to a lesser extent, having less confidence in one's ability to manage the effects of SCI are independent predictors of greater depression severity after SCI. Interventions such as behavior activation, designed to increase rewarding activities, may represent an especially promising approach to treating depression in this population.

Factors influencing acceptance of disability in individuals with spinal cord injury in Neiva, Colombia, South America

PURPOSE

The aim of the present study was to determine the level of acceptance of disability as measured by the Acceptance of Disability Scale (ADS) within a sample of individuals with spinal cord injury (SCI) from Neiva, Colombia and to examine the influence of sociodemographic variables, injury characteristics, and level of depression on ADS score.

METHODS

The ADS was administered to 40 adults with SCI from Nieva, Colombia who were recruited from an organization that connects individuals with disabilities to resources. Most (92.5%) participants were men, with a mean age of 34.75 years and approximately 12 years since injury. Fifty-five percent of subjects were diagnosed with paraplegia and the remainder with tetraplegia. Descriptive, linear model and multiple regression analyses were used to describe the relationship between the independent and dependent variables.

RESULTS

The mean total ADS score of this sample was 171.5, indicating overall low disability acceptance. After controlling for level of depression and time since injury, gender was significantly related to ADS score such that women reported higher acceptance of disability. After controlling for gender and time since injury, level of depression was significantly related to ADS score.

CONCLUSION

Acceptance of disability is a serious problem in this group of SCI survivors in Neiva, Colombia, especially among women and individuals with higher levels of depression. Because acceptance of disability is likely a problem for many individuals living with disability in the developing world, future researchers should investigate what interventions (e.g. counseling, pharmacological intervention, social service programs) can be implemented to improve acceptance of disability in this population.

A longitudinal study of depression from 1 to 5 years after spinal cord injury

OBJECTIVE

To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury.

DESIGN

Longitudinal cohort study.

SETTING

SCI Model System.

PARTICIPANTS

Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher.

RESULTS

Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found.

CONCLUSION

In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

Depression after spinal cord injury: comorbidities, mental health service use, and adequacy of treatment

OBJECTIVE

To provide data for depression rates and psychiatric comorbid conditions, mental health service use, and adequacy of depression treatment in depressed and nondepressed adults with spinal cord injury (SCI).

DESIGN

Cross-sectional survey as part of the Project to Improve Symptoms and Mood after SCI (PRISMS).

SETTING

Community setting.

PARTICIPANTS

Community-residing people with traumatic SCI (N=947).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient Health Questionnaire-9 (PHQ-9) Depression Scale, psychiatric history questionnaire, Cornell Service Index (mental health service use), and current medication use.

RESULTS

The prevalence of probable major depression (PHQ-9 score ≥10) was 23%. There was a high lifetime prevalence of other psychiatric conditions, particularly anxiety disorders. In depressed participants, 29% currently were receiving any antidepressant and 11% were receiving guideline-level antidepressant dose and duration, whereas 11% had been receiving any psychotherapy in the past 3 months and 6% had been receiving guideline-level psychotherapy in the past 3 months. Serotonergic antidepressants and individual psychotherapy were the most common types of treatment received, and there was a wide range of provider types and treatment settings. Demographic and clinical variables were not associated with receipt of mental health service or guideline-level care.

CONCLUSIONS

Findings from this study document the low rate of mental health treatment for persons with SCI and probable major depression. These findings have implications for improving the effectiveness of depression treatment in people with SCI.

Excess mortality associated with mental illness and substance use disorders among veteran clinic users with spinal cord injury

PURPOSE

Among veterans with traumatic spinal cord injury (SCI) or disease aetiologies, examine the association between diagnosed mental illness (MI) and substance use disorders (SUD) on mortality after controlling for demographic and socioeconomic factors, SCI severity, injury duration and chronic physical illnesses.

METHOD

Longitudinal analysis of Veteran Health Administration(VHA) administrative data and Medicare claims for FY 1999-2004 matched with Spinal Cord Dysfunction-Registry (SCD-R) of VHA clinic users (N = 8334) with SCI. SCI was identified through SCD-R; individual MIs (anxiety, bipolar, depressive disorders, psychoses, post-traumatic disorder and schizophrenia) and SUDs (tobacco, alcohol and/or drug) were identified through ICD-9-CM codes. Cox-proportional hazards regressions were used to examine association between MI and SUD and time to death in years.

RESULTS

Among veterans with SCI, 17% died by the end of FY 2004. Veterans with psychosis (35%), depression (22%) and alcohol and/or drug use (20%) had significantly higher rates of mortality compared to those without these diagnoses. After adjusting for other independent variables in the study, hazards ratios for psychosis was 1.47 (95%CI = 1.24, 1.75), for alcohol and/or drug use was 1.30 (95% CI = 1.11, 1.53).

CONCLUSIONS

Some types of MI and SUD were associated with excess mortality among veterans with SCI. Care for MI and SUD needs to be routinely integrated into SCI management. Future research is needed to determine whether depression and SUD treatment provides opportunity to improve survival.

Efficacy of cognitive behavior therapy for the management of psychological outcomes following spinal cord injury: a meta-analysis

This meta-analysis evaluated the impact of cognitive behavior therapy (CBT) on the psychological adjustment of adults with spinal cord injury (SCI). A comprehensive search of six electronic databases identified 10 studies (424 participants) that met the inclusion criteria. Pre- and post-data for participants who received CBT were pooled and analyzed. Large and significant group differences were noted for measures of assertiveness, coping, self-efficacy, depression and quality of life. These data suggest that CBT has a significant positive impact on short-term psychological outcomes following SCI. However, further research is needed to establish the long-term benefits.

Rasch analysis of the Beck Depression Inventory-II in a neurological rehabilitation sample

PURPOSE

To apply Rasch analysis to the Beck Depression Inventory-II (BDI-II) responses of a mixed neurorehabilitation sample to determine its suitability for assessing depression among this group.

METHOD

Three hundred and fifteen in-patients undergoing post-acute specialist in-patient rehabilitation at the Regional Rehabilitation Unit (RRU) of Northwick Park Hospital in North London were administered the Beck Depression Inventory. All patients were administered the BDI-II by a clinical psychologist using a large print version and taking as much time as patients required. Rasch analysis was completed using the RUMM2020 software. Where disordered thresholds were identified item rescoring was undertaken. Each item was also examined for Differential Item Functioning. Where misfit to model expectations was identified items were removed in an iterative fashion. The effect of any deletion upon person estimates was examined. Specific tests of unidimensionality were undertaken at each iterative phase.

RESULTS

Rescoring was necessary before Items 1-4, 6, 8-12, 20 and 21 showed ordered thresholds. Three items failed to satisfy model expectations - items 16 (changes in sleeping pattern), 18 (changes in appetite) and 21 (loss of interest in sex) and were deleted - after which good overall fit to the Rasch model was observed. The three items deleted affected person estimates in a significant way such that the 21 item version in this group of patients may be biased because of multidimensionality.

CONCLUSIONS

The BDI-II in a sample of patients undergoing neurorehabilitation satisfies unidimensional Rasch model expectations in an 18-item format. Some disordering of response categories was evident, but this evidence requires replication before any common rescoring option should be considered.

Depression and occupational disability in five diagnostic groups: A review of recent research

PURPOSE

To compare the methodologies and results of research across five diagnostic groups in which there was expected to be a high prevalence of depression and occupational disability.

METHOD

A review of research published since 1994 was carried out concerning depression and occupational disability in five diagnostic groups: Major depressive disorder (MDD), spinal cord injuries (SCI), traumatic brain injuries (TBI), chronic back pain (CP) and myocardial infarction/coronary artery bypass grafting (MI/CABG).

RESULTS

Prospective longitudinal designs were mostly undertaken in MDD studies. Diagnostic interview schedules were utilized in most MDD studies whereas self-report inventories that tend to confound somatic and depressive symptoms were mostly used in CP, SCI, TBI and MI/CABG studies. In longitudinal MDD studies both depression and occupational disability were related to access to enhanced primary care treatment. On the other hand, CP research reported different results concerning the strength of depressive symptoms, cognitive and psychosocial factors in predicting occupational disability. Different trends across diagnostic groups were evident in relation to depression, occupational disability, co-morbidity, socio-demographic factors and psychosocial resources.

CONCLUSIONS

Co-morbid, socio-demographic and psychosocial factors provide a framework from which to identify those at greater risk of depression and occupational disability. However, more CP, SCI, TBI and MI/CABG studies with diagnostic schedules, prospective designs and longer follow-up are required.

Men's adjustment to spinal cord injury: the unique contributions of conformity to masculine gender norms

Men constitute 82% of the approximately 250,000 people in the United States living with a spinal cord injury. Unfortunately, however, little is known about the impact of men's adherence to gender norms on their adjustment to such injuries. The present investigation examined the utility of masculine norms in explaining variance in depression beyond that accounted for by commonly identified predictors of men's adjustment following spinal cord injury. As hypothesized, results suggested that men's adherence to masculine norms accounted for unique variance in their depression scores beyond that contributed by social support, environmental barriers/access, and erectile functioning. Respondents who adhered to norms stressing the primacy of men's work demonstrated lower rates of depression, whereas those who conformed to norms for self-reliance demonstrated higher depression scores. The authors discuss future research directions and potential psychotherapeutic strategies for working with men with spinal cord injuries.

Psychological morbidity and spinal cord injury: a systematic review

STUDY DESIGN

A systematic review of the literature concerning the nature of the psychological morbidity in people with spinal cord injury (SCI).

OBJECTIVES

SCI is believed to place the individual at a high risk of psychological morbidity. The objective of this paper was to examine systematically the prevalence of negative psychological states in people with SCI, as well as to explore mediating and contextual factors.

METHODS

Search engines such as Medline and PsycInfo were systematically searched using specific key words, such as SCI, depression, anxiety and so on. Only studies that fulfilled certain criteria such as the use of valid measures in assessing psychological morbidity were used in the review process.

RESULTS

The systematic review revealed that clarification is still needed concerning the psychological consequences of people with SCI. However, findings suggest that approximately 30% of people with SCI are at risk of having a depressive disorder although in rehabilitation, and approximately 27% are at risk of having raised depressive symptoms when living in the community. The review also established that people with SCI have higher comparative risks of anxiety disorder, elevated levels of anxiety, feelings of helplessness and poor quality of life (QOL).

CONCLUSION

People with SCI have an increased risk of suffering debilitating levels of psychological morbidity. Future research needs to clarify the extent and nature of psychological morbidity following SCI by conducting prospective and comprehensive research in large heterogeneous samples of people with SCI during the rehabilitation phase and following reintegration into the community.

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.

Pain following spinal cord injury

Pain is one of the most common, severe, and treatment-resistant complications that follows SCI. Recent years have seen a surge of research on methods for assessing and treating spinal cord injury pain. In this article, pain after SCI is reviewed in terms of nature, scope, assessment techniques, and treatment strategies.

Prevalence of Depression Diagnoses and Use of Antidepressant Medications by Veterans with Spinal Cord Injury

OBJECTIVES

The objectives of this study were to examine the prevalence of depression diagnoses among veterans with spinal cord injuries and disabilities (SCI&D) for a 3-yr period, and to characterize patterns of antidepressant medication use in this population.

DESIGN

This study was a retrospective analysis of clinical and administrative data. The sample consisted of 3678 veterans with SCI&D who had received any health care at a Department of Veterans Affairs facility between fiscal years 1999 and 2001, a depression diagnosis, and complete data. Logistic regression analysis was used to examine associations between patient characteristics, antidepressant types, and prescription patterns.

RESULTS

Approximately 22% of veterans with SCI&D received a diagnosis of depression during at least one encounter with a healthcare provider. Of those diagnosed, 72% received antidepressant prescriptions. However, a large percentage (67%) did not continue antidepressant use for 6 mos. Patients started on a selective serotonin reuptake inhibitor were more likely to have at least 6 mos of continuous use than patients started on other, newer antidepressants.

CONCLUSIONS

Many veterans with SCI&D may not be receiving adequate treatment for depression. Veterans with SCI&D should be aggressively screened and treated for depression, and further research is necessary to determine which treatments for depression are most effective for persons with SCI&D.

An examination of depression through the lens of spinal cord injury. Comparative prevalence rates and severity in women and men

PURPOSE

This study describes the prevalence of probable major depressive disorder (MDD) as well as other depressive disorders (ODD) and severity of depressive symptoms in a national sample of women with spinal cord injury (SCI) and compares them with a case-matched sample of men with SCI.

METHODS

A sample of 585 women was drawn and case-matched with men from the SCI Model System National SCI Database according to level/completeness of injury, follow-up year, and age. The outcome measure of depression was the Patient Health Questionnaire.

MAIN FINDINGS

Prevalence rates for women were 7.9% for probable MDD and 9.7% for ODD; rates for men were 9.9% and 10.3%, respectively. Logistic regression revealed that women who were divorced or at year 1 follow-up had a higher odds of having probable MDD (odds ratio [OR], 3.4 and 2.9, respectively). Employed women and men had significantly lower odds of probable MDD (OR, 0.274 and 0.358, respectively). Statistically significant differences were not found in gender comparisons for either probable MDD or symptom severity, which also were not associated with injury characteristics.

CONCLUSION

The most significant, and unexpected, research finding is the absence of gender differences in probable MDD and symptom severity. Results challenge notions that depression will necessarily follow SCI; that injury characteristics determine the development and severity of depression; and that women experience a greater burden of depression than men. The main clinical implication is that depression screening and referral should be a routine feature of health care for women living with SCI, as well as for their male counterparts. Furthermore, nearly one fourth of women and men reported experiencing some or greater difficulty in daily life and relationships in the absence of probable depressive disorder, warranting monitoring of subsyndromal depression as well.

A Social Problem-Solving Model of Adherence to HIV Medications

HIV medication adherence remains a challenge and limits the degree to which treatment benefit can be maximized. This study tested an explanatory model of HIV medication adherence using a social problem-solving (SPS) framework. Associations of SPS with adherence are hypothesized to be direct and/or indirect via psychological health. HIV+ adults were interviewed using validated measures of SPS, psychological health, and antiretroviral therapy (ART) medication adherence. Structural equation modeling (SEM) techniques were used to test hypothesized relationships and to evaluate overall fit of the model to the data. SEM supported an indirect association (but not direct) of SPS on adherence via psychological health among the 545 HIV+ adults included in the analyses. Overall, the findings resulted in a model of adherence that offered very good fit to the data and correctly classified 97% of the cases as adherent versus nonadherent. Results support the use of SPS as a conceptual framework for understanding adherence to ART. Findings offer rationale and direction for SPS interventions to enhance adherence by improving psychological health. Such approaches, if effective, have the potential to positively impact psychological well being and adherence, thereby maximizing clinical benefit from treatment, which is linked to lower mortality from AIDS.

Depression following Traumatic Spinal Cord Injury

OBJECTIVES

To describe the epidemiology of depression following traumatic spinal cord injury (SCI) and identify risk factors associated with depression.

METHODS

This population-based cohort study followed individuals from date of SCI to 6 years after injury. Administrative data from a Canadian province with a universal publicly funded health care system and centralized databases were used. A Cox proportional hazards model was developed to identify risk factors.

RESULTS

Of 201 patients with SCI, 58 (28.9%) were treated for depression. Individuals at highest risk were those with a pre-injury history of depression [hazard rate ratio (HRR) 1.6; 95% CI: 1.1-2.3], a history of substance abuse (HRR 1.6; 95% CI: 1.2-2.3) or permanent neurological deficit (HRR 1.6; 95% CI: 1.2-2.1).

CONCLUSION

Depression occurs commonly and early in persons who sustain an SCI. Both patient and injury factors are associated with the development of depression. These should be used to target patients for mental health assessment and services during initial hospitalization and following discharge into the community.