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

Longitudinal Comparisons in Health, Participation, Life Satisfaction, and Depressive Symptoms From Pre- to Post-COVID-19 Pandemic Among People With Spinal Cord Injuries

OBJECTIVE

To identify changes in health, health care utilization, participation, life satisfaction, and depressive symptoms from before the coronavirus disease 2019 pandemic to after among ambulatory and nonambulatory participants with spinal cord injury.

DESIGN

Longitudinal study with the first measurement taken within 3 months prior to pandemic restrictions and 2 follow-ups at approximately 1-year intervals.

SETTING

Medical university.

PARTICIPANTS

Adult participants (N=219) with spinal cord injury, including ambulatory (n=155) and nonambulatory (n=64).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-report assessment of health outcomes from the Behavioral Risk Factor Surveillance System; health service utilization including physician visits, emergency department visits, and hospitalizations; items from the Craig Handicap Assessment Reporting Technique; 3 life satisfaction scales from the Life Situation Questionnaire; and the brief version of the Patient Health Questionnaire.

RESULTS

After using a z score correction for nonnormality, none of the time effects or interaction effects of time by ambulatory status were significant. Six comparisons between ambulatory and nonambulatory were statistically significant. Ambulatory participants reported 3 more days in poor physical health (P=.02; statistically significant) and 2 more days feeling worried, tense, or anxious in the last 30 days (P=.03). They visited the emergency department on 0.3 fewer occasions (P=.02) while reporting leaving the house 1 more day every week (P=.02), 2 hours more of sitting tolerance (P<.01), and 1 higher score of vocational satisfaction (P=.03).

CONCLUSIONS

The absence of statistically significant changes from before to after the pandemic and the absence of time by ambulatory status interactions suggest stability of outcomes, even in the presence of pandemic challenges.

Pain interference and depressive symptom severity across 10 years in individuals with long-term spinal cord injury

OBJECTIVE

To examine change in pain interference and depression over a 10-year time period in individuals with long-term traumatic spinal cord injury (SCI) and to identify the extent to which changes in pain interference over time predicts change in depressive symptoms.

DESIGN

Longitudinal analyses of self-report assessment data.

SETTING

Specialty and university hospitals in the Southeastern and Midwestern United States.

PARTICIPANTS

Adults with a history of traumatic SCI (n = 504) who responded to the three most recent data collection periods of the SCI Longitudinal Aging Study (2008 [Time 1], 2013 [Time 2], and 2018 [Time 3]). The participants averaged 59 years of age and 32 years since injury onset at Time 3.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient Health Questionnaire (PHQ-9) assessed depressive symptom severity. The 7-item Pain Interference scale from the Brief Pain Inventory assessed pain interference.

RESULTS

Over the three study timepoints, the sample averaged moderate levels of pain interference and mild depressive symptom severity. Unconditional linear growth models, reflecting changes in central tendency, indicated that pain interference significantly decreased and depressive symptom severity significantly increased over time. Multiple independent variables random coefficient modeling based on correlations suggested that change in pain interference was positively associated with change in depressive symptom severity over the 10-year study follow-up.

CONCLUSION

Average depressive symptom severity worsened over time. Change in pain interference was positively associated with change in depressive symptom severity. These results point to the complexity of aging related changes in depressive symptoms and pain interference. They further support the need for continued assessment of mood and pain experiences, particularly among individuals reaching aging milestones with SCI.

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

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

Mediating Effects of Pain Interference on the Relationships Between Pain Intensity and Probable Major Depression Among Participants With Spinal Cord Injury

OBJECTIVE

To evaluate whether pain interference mediates the relationship between pain intensity and probable major depression (PMD) among persons with spinal cord injury (SCI), accounting for differences in the frequency of prescription medication use and resilience.

DESIGN

Cross-sectional analysis using self-report assessment.

SETTING

Medical university in the Southeastern United States.

PARTICIPANTS

There were a total of 4670 participants (N=4670), all of whom had traumatic SCI of at least 1-year duration, identified from the Southeastern Regional SCI Model System and 2 state-based surveillance systems.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 was used to define PMD. Covariates included demographic and injury characteristics, pain severity, pain interference, and resilience. Separate sets of multistage logistic regression analyses were conducted for 3 levels of prescription pain medication use (daily, occasional/weekly, none).

RESULTS

Pain intensity was related to a greater risk of PMD (odds ratio [OR]_{daily pain medication user}, 1.28; 95% confidence interval [CI], 1.21-1.35; OR_{occasional/weekly pain medication user}, 1.26; 95% CI, 1.16-1.36; OR_{nonpain medication user}, 1.44; 95% CI, 1.33-1.56), but this relationship disappeared after consideration of pain interference (OR_{daily pain medication user}, 0.97; 95% CI, 0.90-1.04; OR_{occasional/weekly pain medication user}, 0.94; 95% CI, 0.84-1.05; OR_{nonpain medication user}, 1.07; 95% CI, 0.95-1.20), which indicates pain interference was a mediator between pain intensity and PMD and there was no direct relationship between pain intensity and PMD. Resilience was protective of PMD in each model but was not a mediator.

CONCLUSIONS

Although pain intensity was associated with PMD, the relationship was mediated by pain interference. Resilience was an important protective factor. Therefore, clinicians should assess pain interference when screening for PMD and direct treatment at reducing pain interference. Building resilience may further reduce the risk of PMD.