Self-harm and suicide before and after spinal cord injury: a systematic review

Experiences of general home visiting nurses regarding patients with suicidal ideation in Japan: Results from semi-structured interviews

WHAT IS KNOWN ON THE SUBJECT?: The leading reason for suicide attempts in Japan is health problems, among which depression is the most common, followed by physical illnesses. Patients with physical illness and suicide ideation are not rare among patients receiving home-based care. General home visiting nurses (GHVNs) without knowledge, skills or experience in psychiatric care are required to provide care for patients with physical illness who are at risk of suicide in Japan. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: More detailed understanding of GHVNs' experiences and perspectives on working with suicidal patients in home care. This study enriches our understanding of how suicide prevention strategies should be developed for GHVNs. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Focusing education on therapeutic communication skills and meanings with relationships with patients is required by GHVNs. Training for suicide risk assessment and guidelines appropriate to GHVNs' situation is crucial. Establishing a liaison service system with a multidisciplinary team, including psychiatric home-visiting nurses, is necessary for home healthcare to achieve continuity of care. ABSTRACT: Introduction In Japan, even a general home visiting nurse (GHVN) lacking psychiatric experience and training can provide home nursing care to patients at risk of suicide. Little attention is given to nursing care for suicide by GHVNs who care for patients with physical illness. However, these patients with suicidal ideation for home care are surprisingly common. Aim/Question We explored the experiences of GHVNs who cared for patients with suicidal ideation and focused on the nurses' perceptions and interactions. Method We conducted semi-structured interviews with 15 GHVNs. We discussed the nurses' experiences caring for patients with suicidal ideation, their perceptions during these interactions and their response. Results General home visiting nurses were perplexed upon learning of the patient's suicidal ideation. They interacted with such patients by 'avoiding the core of the matter' while focusing on maintaining a relationship with them. Discussion Not addressing the patient's suicidal thoughts will not only disable the suicide risk assessment but also lead to patient isolation. Suicide prevention care needs to consider the unique characteristics of home care. Implications for Practice General home visiting nurses require training in suicide risk assessment and communication skills. Establishing a liaison service, including psychiatric home visiting nurses, is necessary to achieve continuity of care.

Clarifying the relationship between physical injuries and risk for suicide attempt in a Swedish national sample

INTRODUCTION

The Interpersonal-Psychological Theory of Suicide proposes that capability for suicide is acquired through exposure to painful and provocative events (PPEs). Although there is robust evidence for a positive association between aggregate measures of PPEs and risk for suicidal behavior, little is known about the contributions of physical injuries. The present study investigated the relationship between injuries and risk of subsequent suicide attempt (SA).

METHODS

Data were from Swedish population-based registers. All individuals born in Sweden between 1970 and 1990 were included (N = 1,011,725 females and 1,067,709 males). We used Cox regression models to test associations between 10 types of injuries (eye injury; fracture; dislocation/sprain/strain; injury to nerves and spinal cord; injury to blood vessels; intracranial injury; crushing injury; internal injury; traumatic amputation; and other or unspecified injuries) and risk for later SA. Analyses were stratified by sex and adjusted for year of birth and parental education. Additional models tested for differences in the pattern of associations based on age group and genetic liability for SA. In co-relative models, we tested the association between each injury type and risk for SA in relative pairs of varying genetic relatedness to control for unmeasured familial confounders.

RESULTS

All 10 injury types were associated with elevated risk for SA (hazard ratios [HRs] = 1.2-7.0). Associations were stronger in the first year following an injury (HRs = 1.8-7.0), but HRs remained above 1 more than 1 year after injury exposure (HRs = 1.2-2.6). The strength of associations varied across injury type, sex, age, and genetic liability for SA. For example, the magnitude of the association between crushing injury and risk for SA was larger in females than males, whereas other injuries showed a similar pattern of associations across sex. Moreover, there was evidence to support positive additive interaction effects between several injury types and aggregate genetic liability for SA (relative excess risk due to interaction [RERI] = 0.1-0.3), but the majority of these interactions became non-significant or changed direction after accounting for comorbid psychiatric and substance use disorders. In co-relative models, the pattern of associations differed by injury type, such that there was evidence to support a potential causal effect of eye injury, fracture, dislocation/sprain/strain, intracranial injury, and other and unspecified injuries on risk for SA. For the remaining injury types, HRs were not significantly different from 1 in monozygotic twins, which is consistent with confounding by familial factors.

CONCLUSIONS

Injuries are associated with increased risk for subsequent SA, particularly in the first year following an injury. While genetic and familial environmental factors may partly explain these associations, there is also evidence to support a potential causal effect of several injury types on future risk for SA.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

Association between functional outcomes and psychological variables in persons with spinal cord injury

We aimed to explore the association of functional outcomes with psychological variables, including depression, anxiety, sleep quality, and suicide risk, in persons with spinal cord injuries (SCIs). The secondary aim was to determine specific functions related to the psychological variables. This retrospective study included 259 persons with SCIs who were admitted to the Korean National Rehabilitation Center between 2019 and 2021. The participants were interviewed by a psychiatrist and completed questionnaires, including the Korean Beck Depression Inventory II (K-BDI-II), Korean Beck Anxiety Index, Insomnia Severity Index, and Mini International Neuropsychiatric Interview. To assess functional outcomes, the Spinal Cord Independence Measure III (SCIM III) and Walking Index for Spinal Cord Injury were determined by a physical therapist. The findings revealed a negative correlation of SCIM III subdivisions 1 and 3 with K-BDI-II. Specifically, feeding and mobility in bed and actions to prevent pressure injuries were functional factors associated with all four psychological variables. Our findings can guide clinicians to focus on improving functional independence and activities of daily living during the management of persons with SCI to prevent psychological consequences. Developing devices that aid in improving functional independence is crucial and may improve psychological problems in such individuals.

Psychological Screening, Standards and Spinal Cord Injury: Introducing Change in NHS England Commissioned Services

Psychologist resourcing across the United Kingdom (UK) spinal cord injury centres (SCICs) varies considerably, which has detrimentally impacted standardising service provision for people with spinal cord injuries/disorders (PwSCI/D) compared with other nations. This paper presents the outcome of a project involving the Spinal Cord Injury Psychology Advisory Group (SCIPAG) and NHS England Clinical Reference Group/SCI transformation groups to agree upon screening and standards and shares data from the National Spinal Injuries Centre (NSIC) and the Yorkshire and Midlands Regional SCICs. Inpatients completed the GAD-7, the PHQ-9, and the short form of the Appraisals of DisAbility: Primary and Secondary Scale (ADAPSSsf), assessing adjustment. A total of 646 participants were included, with 43% scoring above the clinical threshold on at least one of the measures on admission. A subset of 272 participants also completed discharge measures and 42% remained above the threshold on discharge, demonstrating sustained psychological need. This paper provides support for services to move to a screen-and-assessment model supplemented by referral options for those with changing needs or who present with difficulties outside the remit of screening. The findings also support the efficacy of universal screening across the system and consideration of screening and standards for psychological care by the wider psychology community.

Risk Factors for Suicidality in Individuals With Spinal Cord Injury: A Focus on Physical and Functional Characteristics

OBJECTIVE

: To demonstrate the association between the physical and functional characteristics of individuals with spinal cord injury (SCI) and suicidality, an area of research that is less understood than the association with demographic, social, and psychological characteristics.

METHODS

: A retrospective cross-sectional study was conducted with 259 patients with SCI admitted for rehabilitation at the National Rehabilitation Center, Seoul, between January 2019 and December 2021. Demographic, SCI-related, physical, and functional data were collected from their medical records. Suicide risk was assessed using the Mini International Neuropsychiatric Interview.

RESULTS

: The 259 participants had an average age of 49.1 years, and 75.7% were male. The analysis revealed a statistically significant negative correlation between age and suicidality. No significant differences were found for sex, education, occupation, or SCI-related factors. Lower upper extremity motor score (UEMS) was significantly associated with higher suicide risk. Regarding functional factors, the inability to perform independent rolling, come to sit, wheelchair propelling, and self-driving were associated with increased suicidality. In the multiple linear regression analysis, lower UEMS, limited shoulder joint motion, upper extremity spasticity, and dependent wheelchair propulsion were predictors of higher suicide risk.

CONCLUSION

: This study highlights the associations among physical status, functional dependency, and suicide risk in individuals with SCI. These findings emphasize the need to address psychological aspects and physical and functional factors in the management of individuals with SCI who are at a high risk of suicide.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

DSM-5-TR diagnosis as a guide to suicide risk assessment

A specific mental disorder can itself constitute a risk factor for a completed suicide. Even more important, the disorder is typically a modifiable risk factor which informs its own treatment. Recent editions of the DSM have included "suicide subsections" for specific mental disorders and conditions in which the risks of suicidal thoughts and behaviors for the disorder are noted in the literature. The DSM-5-TR can therefore serve as a compendium to be referred to for initial guidance as to whether a specific disorder could contribute to the risk. Adding completed suicides and suicide attempts, also addressed in these subsections, the sections were examined individually for the four parameters of suicidality. Accordingly, the four parameters of suicidality examined here are: suicide, suicidal thoughts, suicidal behavior, and suicide attempts. After providing interpretive comments for each, the parameters for all disorders with a suicide subsection were tabulated for ease of reference. Because specific medical disorders are also associated with elevated rates of suicide, these disorders and the supporting research are tabulated and briefly acknowledged. Allowing for the limitations of the suicide subsections and their analysis, this exegesis is proposed to contribute to training in risk assessment for forensic psychiatry and psychology fellows and to highlight the potential referential value of the DSM-5-TR's suicide subsections for clinical practitioners and those who pursue research on suicide.

Risk Factors Associated With Suicidal Ideation in Individuals With Spinal Cord Injury

Objective

To assess the frequency of suicidal ideation (SI) among individuals with chronic spinal cord injury (SCI) and to identify risk factors associated with SI.

Design

Cross-sectional.

Setting

Community setting.

Participants

Two hundred and forty-six individuals with chronic SCI participating in the Spinal Cord Injury Model Systems at a Level 1 Trauma center.

Interventions

Not applicable.

Main Outcome Measure

SI, as assessed by question 9 of the Patient Health Questionnaire-9.

Results

Twenty-seven (11.0%) participants endorsed SI; 6 (22.2%) of whom endorsed active SI with a plan of self-harm. Participants who endorsed SI had significantly higher depressive symptoms, lower resilience, and lower satisfaction with life (all Ps<.001). They also had lower perceived health (P<.001), Craig Handicap Assessment & Reporting Technique Short Form (CHART-SF) physical independence (P=.013), and Spinal Cord Injury - Functional Index with Assistive Technology domains of basic mobility (P=.003), self-care (P=.042), and fine motor skills (P=.035). However, participants who endorsed SI were not significantly different in re-hospitalization rates and in other domains of CHART-SF and SCI-AT. Logistic regression, with a forward selection procedure, was used to identify significant predictors of endorsing SI in the context of multiple associated variables. Depressive symptoms (odds ratio [OR]=1.18, P=.020), resilience (OR=0.85, P=.003), and physical independence (OR=0.98, P=.019) remained significant predictors of SI.

Conclusion

Study findings suggest higher levels of SI among people with SCI, a substantial proportion of whom have active SI. Individuals with SCI who endorse SI have greater burden of poor physical and mental health, as well as poorer functional status and adaptation. Interventions targeting multiple dimensions of quality of life may help reduce risk of SI and suicide among individuals with SCI.

Exploring caregivers' perceptions of community-based service requirements of patients with spinal cord injury: a qualitative study

BACKGROUND

The incidence of spinal cord injury is increasing worldwide. Patients with spinal cord injury and their families face many difficulties during the disease course. Caregivers are more involved with these patients than anyone else, so recognizing patients' care requirements based on caregivers' opinions can facilitate care provision to these people. The purpose of this study was to explore caregivers' perceptions of the community-based services requirements of patients with spinal cord injury.

METHODS

This qualitative research was conducted in Iran from Apr 2021 to Dec 2022 using the conventional content analysis method. The participants in the study included family caregivers and providers of home care services to patients with spinal cord injury, who were selected by purposeful sampling. Data were collected by conducting 14 face-to-face interviews and analyzed based on the method proposed by Lundman and Graneheim.

RESULTS

Data analysis led to the extraction of 815 primary codes, which were organized into two themes: community reintegration (with two categories, including the need to provide a suitable social platform and lifelong care) and palliative care (with two categories, including family conference and survival management).

CONCLUSION

Social facilities and infrastructure should be modified in a way that patients with spinal cord injury can appropriately benefit from community-based care services and an independent satisfactory life. Palliative care should be continuously provided from the time of lesion development until the patient's death.

Neuromodulation and quality of life for patient with spasticity after spinal cord injury

RATIONALE

Spasticity develops in 80% of spinal cord injury cases and negatively affects the patents' quality of life. The most common method of surgical treatment for severe spasticity is a long-term intrathecal baclofen therapy (ITB). Long-term spinal cord stimulation is another possible treatment technique. This paper aims to evaluate the changes in quality of life for patients with spasticity who have been treated with neuromodulation (SCS or ITB) in 12 months after the surgery, as well to compare the changes in quality of life for patients who have been treated with spinal cord stimulation and those who received long-term intrathecal baclofen therapy.

MATERIALS AND METHODS

The influence of spasticity, experienced by the patients with a spinal cord injury, on their quality of life was analyzed before the surgery and 12 months after it. The severity of the spinal cord damage was determined with the scale of the American Spinal Injury Association (ASIA); spasticity was evaluated with the modified Ashworth scale, Penn Spasm Frequency Scale; pain levels were determined with visual analogue scale (VAS), anxiety and depression levels - with HADS. Functional activity of the patients was evaluated with the help of the Functional Independence Measure (FIM).

RESULTS

The treatment results for 33 patients (25 men and 8 women), aged from 18 to 62, are presented. After the trial stimulation, the patients were randomly assigned to either SCS or ITB group (18 and 15 people respectively). The decrease of spasticity in both experimental groups caused lower levels of pain, less functional dependency on other people, lower stress and depression rates and, as a consequence, better quality of life and social adaptation. The obtained results for SCS and ITB groups are statistically similar.

Suicidal ideation, post-traumatic stress disorder, and depression in traumatic spinal cord injury: What resilience tells us

OBJECTIVE

Identification of unmet psychiatric needs, protective and risk factors for suicide are crucial for people with traumatic spinal cord injury (SCI). In this study, we aimed to explore depression, post-traumatic stress disorder (PTSD) status (non-PTSD, partial-PTSD, full-PTSD), resilience, suicidal ideation (SI) and to examine predictors and clinical correlates of current SI in traumatic SCI.

METHOD

Sixty-three individuals with traumatic SCI who were at least 3 months post-injury were included in the study. The participants were evaluated in terms of PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), depression, SI, and resilience using the PCL-5, the Patient Health Questionnaire-9, the Brief Resilience Scale, and sociodemographic measures.

RESULTS

33% of our sample (n = 21) had SI over the past two weeks. 71.4% of the patients with SI (n = 15) had depression. A total of 52.4% of the patients with SI (n = 11) were diagnosed with full PTSD. Resilience was found to be significantly lower in individuals with depression and individuals with SI. While depression predicted SI in traumatic SCI, resilience stands as a protective factor against SI.

CONCLUSION

SI is quite common in individuals with traumatic SCI and is accompanied by substantial psychiatric comorbidities such as depression and PTSD. Along with depression and PTSD, resilience - which has protective and predictive values and is inversely associated with SI - constitutes a significant psychotherapeutic intervention and screening area.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

Association between functional disability type and suicide-related outcomes among U.S. adults with disabilities in the National Survey on Drug Use and Health, 2015-2019

While research on suicidal behavior for people with disability (PWD) suggests they experience higher risk than people without disability, less is known about variations among individuals with different disability types. This nationally representative, cross-sectional study compared differences in suicide-related outcomes (ideation, planning, attempts) among PWD by functional disability type (hearing, vision, cognitive, mobility, complex activity) and number. Secondary analysis of adult PWD in the 2015-2019 National Survey on Drug Use and Health (unweighted N = 35,544; representing 47,723,378 PWD, weighted) was used to estimate relationships between suicide-related outcomes and disability type and number. Most respondents were female (55.9%), and 36.0% were aged ≥65 years. Adjusted odds ratios (AORs) from multivariable logistic regression indicated that suicidal ideation and suicide attempt, respectively, were significantly more likely among individuals with cognitive (AOR = 1.71, 95% CI = 1.24-2.35; AOR = 2.54, 95% CI = 1.31-4.91), complex activity (AOR = 1.96, 95% CI = 1.37-2.81; AOR = 2.67, 95% CI = 1.32-5.41), and ≥2 limitations (AOR = 2.02, 95% CI = 1.52-2.69; AOR = 3.46, 95% CI = 1.84-6.50) than hearing limitation. Also, relative to other disability types, suicide-related outcomes were significantly more likely among individuals with cognitive limitation and complex activity limitation (p < 0.001). Additionally, suicide-related outcomes elevated in likelihood as the number of limitations increased, with the largest associations among those with ≥5 limitations for suicidal ideation (AOR = 2.31, 95% CI = 1.46-3.66), suicide planning (AOR = 3.34, 95% CI = 1.97-5.68), and suicide attempt (AOR = 6.37, 95% CI = 3.76-10.79). Subgroup analyses showed that presence of cognitive limitation and multiple limitations differentiated between suicidal ideators and suicide attempters. Further research is needed to identify causes of these risks and develop suicide prevention efforts for these particularly vulnerable groups.

Psychosocial Consequences of Spinal Cord Injury: A Narrative Review

Consequences of a spinal cord injury (SCI) entail much more than damage to the spinal cord. The lives of people with SCI, along with those around them, experience profound long-lasting changes in nearly every life domain. SCI is a physical (biological) injury that is inextricably combined with various psychological and social consequences. The objective of this review is to present psychosocial challenges following SCI through the biopsychosocial model, beginning with acknowledgement of the larger societal effects of ableism and stigma before addressing the many unique psychosocial aspects of living with SCI. Included in this review are qualitative studies and systematic reviews on current psychosocial outcomes and consequences. This paper attempts to structure this information by dividing it into the following sections: relationships and family; changes in finances and employment; issues related to the person’s living situation; community reintegration; factors associated with mood and coping (e.g., depression, anxiety, substance use, and PTSD); self-harm behaviors (ranging from nonadherence to suicide); effects of traumatic brain injury; considerations regarding sexual health; aging with SCI; and concludes with a brief discussion about post-traumatic growth. Cultivating an understanding of the unique and interrelated psychosocial consequences of people living with SCI may help mitigate the psychosocial aftermath and serve as a reminder to providers to maintain a person-centered approach to care.

Mental Health and Spinal Cord Injury: Clinical Considerations for Rehabilitation Providers

Purpose of Review

Assessing and addressing the mental and behavioral health concerns of individuals with SCI during rehabilitation is crucial, as untreated mental health distress can lead to reduced gains in rehabilitation and poor overall health. This review provides an overview of the latest research on prevalence rates of common mental and behavioral health concerns in the SCI population, highlighting disability-specific factors that may impact traditional assessment and treatment of mental health concerns.

Recent Findings

While those with SCI are at a heightened risk for experiencing mental health distress, overall, the majority of those with SCI adapt well, and live a full and meaningful life.

Summary

Rehabilitation psychologists are a vital aspect of rehabilitation teams, as they can address behavioral health and mental health concerns that may impede patients achieving their rehabilitation goals.

Prevalence, severity, and self-management of depressive mood among community-dwelling people with spinal cord injury in Nepal

Background

Depression is a common psychological condition after spinal cord injury. There are increased incidences of self-harm, suicidal behavior, and lower quality of life among people with spinal cord injury and depression. However, self-management of depressive symptoms in the community is less explored.

Objective

This study aimed to examine the prevalence, severity, and self-management of depressive mood in community-dwelling people with spinal cord injury.

Methods

A descriptive study was conducted in 2019 among 115 people with spinal cord injury discharged from three health centers and living in the 13 districts of Bagmati Province. Participants were selected using stratified random sampling. Questionnaires were related to demographics, health and environment, depressive mood, and self-management. Descriptive statistics and quantitative content analysis were used to analyze the data.

Results

Ninety-seven (84.3%) people with spinal cord injury had a depressive mood. Of these, 60.8% had moderate to severe depressive moods. They mainly used the internet and social media, shared feelings with family members, and practiced Hindu religious activities for depressive mood management because of the physical barriers to accessing a healthcare facility and easiness to use of non-pharmacological methods. Nearly half of participants who used sharing of feelings felt their depressive mood disappeared when they often used the method.

Conclusion

Depressive mood following initial hospitalization is highly prevalent among people with spinal cord injury in Nepal, most of whom live in rural settings. Therefore, nurses and other health professionals should provide psychoeducation for this population and their family members to better address mental health problems. Facilitating pathways for those in rural areas to engage in social activities and timely treatment access may improve depressive mood. Nurses and other rehabilitation professionals can use social media to assess depressive moods and deliver management approaches in the community.

Perspectives on medical assistance in dying amongst persons with traumatic spinal cord injury: a qualitative study

STUDY DESIGN

Qualitative.

OBJECTIVE

To explore the perspectives of persons living with chronic (>5 y) traumatic spinal cord injuries (tSCI) concerning medical assistance in dying (MAID).

SETTING

Saskatchewan, Canada.

METHODS

Qualitative exploratory using an interpretative description methodology. Individual semi-structured interviews were held with online video conferencing. Interviews were analyzed using codebook thematic analysis.

RESULTS

Ten persons with a chronic (>5 y) tSCI participated (seven males, three females; age 20s-50s; spinal cord level C2-T10). Participants expressed support for persons living with SCI having access to MAID, specifically in the context of preserving autonomy and respecting equality when compared with able-bodied individuals. However, some were concerned about the implications of access to MAID solely based on the diagnosis of a SCI. Participants also emphasized the variability in the initial personal response to injury and expressed concern about MAID being immediately available after injury. They explained the significance and necessity of reflecting on the injury in what can be a lengthy process of adjustment and acceptance. Participants also discussed the importance of hope and highlighted the irreplaceable value of peer support in shaping hope throughout rehabilitation and the need for compassionate, comprehensive, and continuous care to facilitate reintegration and support independence.

CONCLUSIONS

Access to MAID provides a greater range of choices for individuals with tSCI but could increase deaths occurring before optimal adaptation and adjustment. The involvement of inter-professional teams, mental health specialists and peers is important to frame hope and understand the potential of a fulfilling life with a tSCI.

Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death

Purpose of Review

This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers.

Recent Findings

The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide.

Summary

Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

A systematic review of suicidal ideation and behaviors among adults with spinal cord injury

CONTEXT

Suicide is a public health crisis within the United States. Individuals with spinal cord injury (SCI) are vulnerable to negative outcomes such as suicide.

OBJECTIVE

This systematic review describes frequency of suicidal ideation (SI) and behaviors (suicide attempt [SA] and deaths) among samples of adults living with SCI. Associated risk and protective factors of SI and suicidal behaviors were also explored.

METHODS

On July 7, 2021, OVID Medline, EMBASE, OVID PsycINFO, Web of Science Core Collection, CINAHL, Cochrane Library, and Google Scholar databases were searched for SI, SA, and deaths by suicide among adults with a history of SCI. Risk of bias (RoB) was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Results were synthesized descriptively considering the likely impact of RoB. The updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting method was used.

RESULTS

Sixty-nine articles were included. Frequency of SI and SAs within study samples ranged from 4% to 67%, and 0% to approximately 66%, respectively. While assessment methods for SI and SA widely varied, suicide deaths data sources were more consistent. Studies assessing SI and SA generally had high RoB and the overall strength of evidence was low. Stronger observational study designs assessing death by suicide had low RoB and the overall strength of evidence was high. Very few studies examined protective factors.

DISCUSSION

Findings support previous work. Quality of evidence, and therefore confidence in the frequency of these outcomes, was impacted by the use of assessment measures without sufficient psychometric properties. The field will benefit from use of psychometrically sound measures to assess for SI, SA and suicide deaths. Furthermore, additional work is needed to elucidate risk and protective factors and to clearly characterize samples to increase generalizability of findings to the larger SCI community, including standardized reporting of SCI characteristics (e.g. use of American Spinal Injury Association classification system). Ultimately, improved suicide assessment and risk management is expected to prevent suicide among those living with SCI.

REGISTRATION

CRD42020164686.

Inside the lived perspective of life after spinal cord injury: a qualitative study of the desire to live and not live, including with assisted dying

STUDY DESIGN

Qualitative.

OBJECTIVES

The objective of this study was to examine whether individuals with a SCI would have considered Medical-Assistance-in-Dying (MAiD) following their SCI and whether these individuals felt they would have been able to make an informed decision about this potentially permanent option early in their experience.

SETTING

Manitoba, Canada.

METHODS

Participants with varying neurological levels of SCI and classification were included. The time since SCI ranged from <6 months to >50 years. A focus group of five individuals was conducted first to calibrate questions. Twenty-three participants were then individually interviewed. Participants' responses were transcribed and coded into themes.

RESULTS

Half of the participants reported having suicidal ideation within the first 2 years of experiencing a SCI. However, no participants thought that they would have been able to make an informed decision about MAiD during this time. Most participants reported that they were able to adapt and reframe their lives to alter their views. There was higher agreement that MAiD should be available for individuals who had experienced a reframed, informed view.

CONCLUSION

This study indicates that people with SCI do not feel that informed decision making about ending their life can be made early after SCI despite high levels of reported suicidal ideation in that early time frame. A reframing process helps to facilitate informed decisions about living with a SCI. The reframing process is correlated with opportunities of rehabilitation, peer mentor support, and re-integration into the community.

Causes of death after spinal cord injury in the Czech Republic

STUDY DESIGN

A retrospective cohort study OBJECTIVES: To determine the causes of death in people with spinal cord injury (SCI) admitted to the Spinal Cord Unit (SCU) of the University Hospital Motol from 2004 to 2018.

SETTING

University Hospital Motol, Prague METHODS: From a cohort of people admitted to the SCU between 2004 and 2018, all deaths were identified based on the database of health insurance companies. The causes of death (ICD-10) were obtained from the Institute of Health Information and Statistics. The standardized mortality ratio (SMR) was calculated for most frequent causes of death.

RESULTS

During the study period, 990 patients with acute SCI were admitted to the SCU, out of which 183 (18.5%) died. Thirty-five people who had SCI due to cancer were excluded from the study. The leading cause of death in the remaining 148 people was pneumonia, followed by cardiac complications, pulmonary embolism, suicide, and urinary tract infection (UTI). In the group of the individuals who died within 1 year after SCI (N = 41), the main causes of death were pneumonia and pulmonary embolism (17.1% each). Among individuals who survived up to1 year after SCI (N = 107), the most common causes of death were pneumonia (14%) and pressure injuries (12.1%). The cause-specific SMRs were significantly increased for UTI, embolism, pneumonia, and suicide.

CONCLUSION

The frequent causes of death in our study group were pressure injuries and suicides. These findings are fundamental to the development and implementation of preventive programs to reduce mortality and increase life expectancy.

Hydrogels as delivery systems for spinal cord injury regeneration

Spinal cord injury is extremely debilitating, both at physiological and psychological levels, changing completely the patient's lifestyle. The introduction of biomaterials has opened a new window to develop a therapeutic approach to induce regeneration after injury due to similarities with extracellular matrix. Particularly, hydrogels have the ability to support axonal growth and endogenous regeneration. Moreover, they can also act as potential matrixes in which to load and deliver therapeutic agents at injury site. In this review, we highlight some important characteristics to be considered when designing hydrogels as delivery systems (DS), such as rheology, mesh size, swelling, degradation, gelation temperature and surface charge. Additionally, affinity-based release systems, incorporation of nanoparticles, or ion-mediated interactions are also pondered. Overall, hydrogel DS aim to promote a sustained, controlled and prolonged release at injury site, allowing a targeted oriented action of the therapeutic agent that will be used.

The experience and perspective of people with spinal cord injury about well-being interventions: a systematic review of qualitative studies

PURPOSE

Promoting well-being is a key aim of rehabilitation. The intentional design of interventions to address well-being requires an understanding of the factors that affect this complex phenomenon. A growing body of qualitative literature has identified determinants that people with SCI report affect their well-being. It is unclear whether or how rehabilitation interventions can influence these well-being determinants. This study sought to explore the experience and perspective of people with SCI about interventions that target their well-being.

METHOD

Systematic search of seven databases. Deductive analysis to categorize findings related to well-being determinants, and further inductive coding to identify sub-themes, relationships and additional findings.

RESULTS

Twenty studies were selected, involving a wide range of interventions. Each intervention influenced a number of well-being determinants, which were inter-related. People with SCI reported improvements in both subjective and psychological well-being. However, well-being was not always well defined in the studies and people with SCI reported lack of priority for, and opportunity to engage in, well-being interventions in the current rehabilitation system.

CONCLUSIONS

Rehabilitation interventions can influence well-being determinants. These determinants form a useful framework for the intentional design of well-being interventions, which should be informed by a broad understanding of well-being.IMPLICATIONS FOR REHABILITATIONWell-being can be influenced by rehabilitation interventions, and a more explicit focus on well-being in intervention design and evaluation is recommended.Conceptual frameworks used to define and measure well-being should adopt a broad understanding of well-being.Well-being interventions should address the determinants identified by people with SCI (engaging in occupation, responsibility, values and perspectives, self-worth, self-continuity, relationships and the environment).People with SCI want a greater priority placed on well-being interventions, and more opportunities to engage in these interventions, especially in the community.

The journey of sexuality after spinal cord injury: Implications for allied health professionals

The purpose of this phenomenological study, which reflected the lived experiences of seven individuals living in Alberta with spinal cord injury (SCI), was to gain insights into how individuals with SCI (a) are ill-equipped after injury with respect to post-injury sexual function education, (b) explore their sexuality after injury, (c) learn about the importance of role models and friends living with similar injuries, and (d) explain barriers to access reasonable care surrounding sexual health and counselling reflective of intersectionality of sexuality and disability, among other factors. The intent is also to provide a basis for others living with SCI to be aware that they are not alone in their experiences as well as inform others, including professionals working in the area of SCI, of what some experiences of living with SCI are. This study uncovered real lived experiences of individuals with SCI and their experience of sexuality and relationships after injury. Recommendations are highlighted with the intention of informing professionals, including counselling psychologists and other health related professionals.

The Relationship between Physical Activity Levels and Mental Health in Individuals with Spinal Cord Injury in South Korea

Background: The aim of this study was to assess the relationship between physical activity (PA) levels and mental health in individuals with spinal cord injury (SCI). Methods: Three hospitals in the Seoul metropolitan area were invited to recruit patients with SCI (n = 103). PA levels were measured by the Leisure Score Index of the Godin Leisure-Time Exercise Questionnaire (GLTEQ). The Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) questionnaire, and Multidimensional Scale of Perceived Social Support (MSPSS) were used to assess mental health. Results: Compared to the least physically active participants (1st tertile, 44.09 ± 52.74 min/week), the most physically active participants (3rd tertile, 670.86 ± 354.97 min/week) scored significantly lower on PHQ-9 (17.03 ± 5.70 vs. 12.49 ± 4.01, p < 0.001), GAD-7 (13.24 ± 4.78 vs. 9.86 ± 3.15, p < 0.001), while significantly higher MSPSS (51.24 ± 10.17 vs. 61.37 ± 11.90, p < 0.001) after the results were adjusted for age, gender, American Spinal Cord Injury Association impairment scale, and impaired spinal cord levels. Multivariate linear regression analysis showed that the PA was a significant predictor of depression (β = −1.50, p = 0.01), anxiety (β = −1.12, p = 0.02), and social support (β = 4.04, p = 0.01). Conclusion: Higher PA participation was associated with lower depression, anxiety, and higher social support scores.

Quality of life of persons with traumatic spinal cord injury in rural Kilimanjaro, Tanzania: a community survey

AIM

To describe the quality of life of persons with traumatic spinal cord injury (TSCI) in a rural area of a low-income country.

METHODS

This was a cross-sectional descriptive study in which snowballing was used to identify persons with TSCI in their homes. A Kiswahili version of the short version of the World Health Organization quality of life questionnaire was used for data collection. Data were analyzed descriptively and independent samples t-tests were used to calculate the difference in the mean scores between groups.

RESULTS

Eighty persons with TSCI with a mean age of 42.29 ± 11.4 years were identified, 68.8% of whom were males. The highest scoring domains were psychological (12.76 ± 2.55) and social relationships (12.62 ± 2.95). The lowest scores were for physical (11.48 ± 2.74) and environment (9.59 ± 2.68) domains. Significantly higher scores were associated with younger age in: physical (0.05), social relationships (0.01), and environment (0.02) domains (p value < 0.05).

CONCLUSIONS

Persons with TSCI in the Kilimanjaro rural area registered a relatively low quality of life in which the most affected domains are physical health and environment.Implications for rehabilitationQuality of life is the ultimate goal in the rehabilitation of persons with any irreversible disability such as spinal cord injury.It is important for rehabilitation professionals to know which domains of quality of life are most affected among persons with spinal cord injury.Rehabilitation professionals ought to understand and address physical health and environmental issues that affect persons with traumatic spinal cord injury in rural resource-constrained areas.Addressing physical health and environmental challenges for persons with spinal cord injury in resource-constrained rural areas require involvement of the family, rehabilitation personnel, policy makers, and the community.

Knowledge and attitude of nonpsychiatric physicians regarding suicide in spinal cord injury patients and need for structured psychiatric education for suicide prevention: A prospective survey pilot study

BACKGROUND

The knowledge and attitude of nonpsychiatric physicians regarding suicide in spinal cord injury (SCI) patients is important to prevent the accident related to suicide. However, most existing studies have focused on perception of and attitudes among psychiatric physician and mental health care worker.The aim of this study is to investigate awareness and attitude regarding suicide among clinicians treating patients with spinal cord injury, and the necessity of education for suicide prevention.

METHODS

A total of 29 subjects (N = 29; surgical group n = 17, nonsurgical group n = 12) participated in the study, 6 fellows and 23 residents. They answered a newly revised questionnaire that incorporated 18 items regarding perception of and attitude toward suicide, awareness of suicide in treatment of spinal cord injury patients, and psychiatric consultation; 13 items regarding education and experience; and 4 subjective items regarding their department. A χ test was performed to investigate differences in sociodemographic factors, awareness of and attitude toward suicide, and clinical experience with spinal cord injury patients. Binary logistic regression analysis was used to identify correlation between the questionnaire items.

RESULTS

There were significant differences between surgical and nonsurgical clinicians in 1 question (Q6) about awareness of and attitude toward suicide (P < .05) and in 2 questions (Q21, Q25) about psychiatric consultation and experience with suicide-related education (P < .01). The correlation analysis revealed significant differences in certain questions among awareness and attitude (P < .05) and age (P < .05) and specialty (P < .01). Two sets of questions (Q16/Q31, Q17/Q26) showed correlation between clinical experience with spinal cord injury patients and awareness of and attitude toward suicide (P < .05).

CONCLUSION

Education regarding suicide prevention and suicide-related clinical experience with spinal cord injury patients is important for nonpsychiatric clinicians, such as those in the fields of orthopedics, neurosurgery, and rehabilitation medicine.

Label-free multiphoton microscopy reveals relevant tissue changes induced by alginate hydrogel implantation in rat spinal cord injury

The development of therapies promoting recovery after spinal cord injury is a challenge. Alginate hydrogels offer the possibility to develop biocompatible implants with mechanical properties tailored to the nervous tissue, which could provide a permissive environment for tissue repair. Here, the effects of non-functionalized soft calcium alginate hydrogel were investigated in a rat model of thoracic spinal cord hemisection and compared to lesioned untreated controls. Open field locomotion tests were employed to evaluate functional recovery. Tissue analysis was performed with label-free multiphoton microscopy using a multimodal approach that combines coherent anti-Stokes Raman scattering to visualize axonal structures, two-photon fluorescence to visualize inflammation, second harmonic generation to visualize collagenous scarring. Treated animals recovered hindlimb function significantly better than controls. Multiphoton microscopy revealed that the implant influenced the injury-induced tissue response, leading to decreased inflammation, reduced scarring with different morphology and increased presence of axons. Demyelination of contralateral white matter near the lesion was prevented. Reduced chronic inflammation and increased amount of axons in the lesion correlated with improved hindlimb functions, being thus relevant for locomotion recovery. In conclusion, non-functionalized hydrogel improved functional outcome after spinal cord injury in rats. Furthermore, label-free multiphoton microscopy qualified as suitable technique for regeneration studies.

Experiences with euthanasia requests of persons with SCI in Belgium

Introduction

Living with SCI remains a challenge and some patients fear or are faced with an inability to master this challenge sufficiently to regain a satisfactory quality of life. The suicide rate within the population with SCI is elevated compared with the general population. Especially now that life expectancy of persons with SCI and age at onset of SCI are increasing, caregivers of persons with SCI can be confronted with requests for end-of-life care or even assistance in dying. Euthanasia remains worldwide a controversial topic, but has rarely been discussed in the context of SCI.

Case presentation

The medical history and the results of in-depth interviews with three persons with tetraplegia, between 36 and 88 years old, with a profound and repeated request for euthanasia testify of the importance of an open-minded dialogue concerning end-of-life questions, in which all options can be considered, and limits of patients' capacities and best care results are acknowledged.

Conclusion

These cases suggest that a well-regulated strictly controlled legal framework, handled with prudence and proficiency, can be an added value to the care for persons with SCI.

HAX1 is associated with neuronal apoptosis and astrocyte proliferation after spinal cord injury

HS1-associated protein X-1 (HAX1) is a class of multifunctional protein, participated in various physiological processes such as cell apoptosis, proliferation and motility. However, the HAX1 expression and function in the spinal cord injury (SCI) pathological process have not been investigated. In our current research, the rat model of SCI was established, and then we explored the possible role of HAX1 after SCI. The results of western blot indicated that HAX1 was present in sham operated control group and significantly elevated at 3 days post SCI, then declined gradually. Immunohistochemical studies indicated HAX1 expression was enhanced significantly in white and gray matter at 3 days post SCI compared with sham operated group. Double immunofluorescence staining showed the proportion of cells, double-labeled HAX1 and neurons, astrocytes, increased significantly at 3 days post SCI. In addition, co-localization of HAX1/active caspase-3 and HAX1/PCNA was tested in cells. Furthermore, over-expression of HAX1 inhibited neuronal apoptosis in vitro, and in astrocytes HAX1 silencing could down-regulate PCNA expression post LPS treatment. Meanwhile, CCK8 assay showed that knockdown of HAX1 could inhibit the astrocyte proliferation. In summary, our data indicated that HAX1 might play significant roles in pathological process of neuronal apoptosis and astrocyte proliferation during SCI.

The Use of Virtual Reality to Facilitate Mindfulness Skills Training in Dialectical Behavioral Therapy for Spinal Cord Injury: A Case Study

Introduction: Paralysis from a spinal cord injury (SCI) increases risk of psychological problems including suicide attempts, substance use disorder, negative emotions (e.g., anger), depression, anxiety, ASD/PTSD. Dialectical Behavioral Therapy® (DBT®) has been shown to be effective for treating similar psychological symptoms in non-SCI patient populations. The current study explored for the first time, the feasibility and clinical potential of using Immersive Virtual Reality (VR) enhanced DBT® Mindfulness skills training to help reduce psychological symptoms (negative emotions and anxiety, ASD/PTSD) of two patients with SCI. Patient 1 was a 39-year-old male patient suffering multiple spinal cord injuries, resulting in quadriplegia, after falling out of a four story building. Patient 1 had severe depression, and anxiety symptoms. Patient 2, was a 31 year old male with a C7 vertebral body fracture, leading to paresis, after suffering a blunt force trauma injury during an attempted suicide, jumping from a moving vehicle. Patient 2 had mild depression, and anxiety symptoms. Methods: Each patient looked into VR goggles, and had the illusion of slowly "floating down" a river in virtual reality while listening to DBT® Mindfulness Skills training instructions. Each patient filled out brief psychological ratings before and after each VR session, four VR DBT® sessions for patient 1, and two VR DBT® sessions for patient 2. Results: As predicted, patient 1 reported reductions in negative emotions after each VR DBT® Mindfulness session. Patient 2 had mixed results on some of the measures of negative emotions. And both patients reported feeling less depressed, less anxious, and less emotionally upset, after VR DBT® Mindfulness Skills learning. Patient 2 reported large reductions in short term ASD/PTSD symptoms after his first VR DBT® mindfulness skills training session. Conclusion: This study explored the feasibility of using VR DBT® with quadriplegic or paresis SCI patients. Both SCI patients accepted VR, the patients liked using VR, and, with assistance from the therapist, the patients were able to use the VR equipment, despite being paralyzed. Additional research and development will be needed to determine whether VR DBT® Mindfulness Skills training leads to any long term improvements in outcome.

Suicide and traumatic spinal cord injury-a cohort study

STUDY DESIGN

Retrospective and prospective observational.

OBJECTIVE

The main objective of this study was to analyse suicide attempt as a cause of traumatic spinal cord injury (tSCI) and suicide as a cause of death after tSCI.

SETTING

This study was conducted at two British spinal centres, Stoke Mandeville and Southport.

METHODS

Long-term survival of patients who were newly admitted between 1991 and 2010, had survived the first post-injury year and had neurological deficit on discharge. Follow-up was discontinued on 31 December 2014.

RESULTS

Among the 2304 newly admitted cases of tSCI, suicide attempt was the cause of injury in 63 cases (2.7%). By the end of 2014 there were 533 deaths of which 4.2% deaths were by suicide, with 91% of suicides happening in the first 10 years post injury. Multiple logistic regression analyses showed a higher mortality odds ratio (OR=4.32, P<0.001) and a much higher suicide OR (9.46, P<0.001) for persons injured in suicide attempts when compared with all other SCI aetiologies. The overall age-standardised suicide mortality rate was 62.5 per 100 000 persons per year (95% confidence interval=36.4-88.6), five times higher than the general population suicide rate for England and Wales in 2014 (12.2 per 100 000).

CONCLUSIONS

Suicide attempt was the cause of tSCI in 2.7% of the sample and suicide was the cause of death in 4.2% of all deaths. The overall mortality and death by suicide were significantly higher in persons whose tSCI was caused by an attempted suicide when compared with the rest of the sample. Continued psychological attention following SCI, especially to those who were injured by suicide attempt, is warranted.

Physical disability and suicide: recent advancements in understanding and future directions for consideration

Recent research indicates a heightened risk of suicide in this population, a concern given that suicide may be more accepted for those with physical disabilities than for those without such disabilities. The relationship between physical disability and suicide has begun to be examined within empirically supported frameworks of suicide and indicates that interpersonal factors (e.g. perceived burdensomeness) and pain are mechanisms contributing to this heightened risk of suicide. The suicide rate after acquiring a physical disability, such as a spinal cord injury, and the greater odds of suicide after reporting having a disability further support the association between physical disability and suicide. The multifaceted nature of physical disability is reflected in its relationship with suicidal ideation and behaviors.