Spinal Cord Injury and its Association with Negative Psychological States

The International Journal of Psychosocial Rehabilitation

Spinal Cord Injury and its Association with Negative Psychological States

Ashley Craig
Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Sydney, NSW Australia

Yvonne Tran, PhD
Department of Medical and Molecular Biosciences, University of Technology, Sydney
NSW, Australia

Judy Lovas, MSc
Department of Medical and Molecular Biosciences, University of Technology, Sydney
NSW, Australia

James Middleton, PhD
Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney & Royal Rehabilitation Centre, Sydney, NSW Australia

Citation:
Craig A, Tran Y, Lovas J, Middleton J (2008). Spinal Cord Injury and its Association with
Negative Psychological States. International Journal of Psychosocial Rehabilitation. 12 (2), 115-121

Communications and reprints: Professor Ashley Craig, Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
Email: a.craig@uts.edu.au

Abstract
Spinal cord injury (SCI) is believed to place the individual at a high risk of psychological disorder. The objective of this paper was to examine the relationship between SCI and negative psychological states by comparing levels of negative psychological states in SCI and able-bodied controls. Participants included 33 people with SCI who had completed their inpatient rehabilitation (that is, when living in the community) and 33 able-bodied controls matched for age and sex. In order to determine levels of negative psychological states, the Profile of Mood States and the Spielberger Trait Anxiety Inventory were completed by all participants. The SCI group was found to have raised levels of psychopathology, with 20% having elevated negative psychological states typical of people with a psychiatric disorder. People with SCI have an increased risk of suffering debilitating levels of psychopathology. Future research needs to investigate psychosocial rehabilitation strategies for lowering negative psychological states such as depressive mood in people with SCI after they have completed their rehabilitation program.
Key Words: spinal cord injury, depression, anxiety, post-traumatic stress disorder

Introduction
Spinal cord injury (SCI) results from trauma when the cord is lacerated, bruised, severed or damaged as a result of disease. While SCI is a relatively uncommon disorder, its effects can be devastating (Middleton, Tran & Craig, 2007). The level of impairment resulting from the injury depends upon factors such as the level and completeness of the lesion. The consequence of SCI is usually permanent paralysis of voluntary muscles below the lesion, reduced mobility, impairment of social and vocational activities, with a negative impact on body systems such as respiratory, cardiovascular, urinary, gastrointestinal, reproductive and sensory (Sommer, 2001). Due to improved survival rates, the prevalence of SCI is increasing and the risk (world standardized incidence) is low, at around 15 per million persons per year, though risk is higher for males aged 15 to 24 years at around 40 per million (O’Connor, 2006; Wyndaele & Wyndaele, 2006). The majority of people who sustain a SCI commonly do so as a result of motor vehicle accidents, fall related injuries (especially in the elderly), and sports injuries (O’Connor, 2006).

The impact of SCI on mental health and psychological function has been variously debated (Elliott & Kennedy, 2004; Middleton et al., 2007). Stage theorists assumed that risk of psychopathology was minimal, suggesting that any psychological upset or despondency was a necessary component of a stage process of adjustment to their injury (Buckelew, Frank, Elliott, Chaney & Hewett, 1991; Elliott & Kennedy, 2004). Other more recent research has suggested that SCI is associated with raised risks of negative psychological outcomes that should not be considered a “normal” response to the injury (Craig, Hancock & Dickson, 1994a; Craig, Hancock & Dickson, 1999; Elliott & Kennedy, 2004; North, 1999). Rates of depression have been estimated to range from 20% to 43% when the person with SCI is attending rehabilitation as an inpatient (Frank, Kashani, Wonderlich, Lising, & Visot, 1985; Judd, Stone, Webber, Brown, & Burrows, 1989). Risk of depressive symptoms such as depressive mood and anxiety after discharge from rehabilitation has been estimated to be around 15% (Bombardier, Richards, Krause, Tulsky, & Tate, 2004) up to 50-60% (Craig et al., 1994a; MacDonald, Neilson, & Cameron, 1987; Kennedy & Rogers, 2000). Research also suggests that risks of negative psychological states remain high unless SCI individuals receive effective treatment such as cognitive behaviour therapy during rehabilitation (Hancock, Chang, & Dickson, 1998).

The risk of negative psychological states has been found to be associated with factors such as pain, poor sleep and feelings of helplessness (Craig, Hancock & Dickson, 1994b; Norrbrink Budh, Hultling, & Lundeberg, 2005; Rintala, Loubser, Castro, Hart, & Fuhrer, 1998) as well as frequent hospitalization, medical complications, poor self-care, and difficulties with transportation (Tate, Forchheimer, Maynard, & Dijkers, 1994). In preliminary research, some researchers are finding risks of post-traumatic stress disorder (PTSD) in people with SCI (Kennedy & Evans, 2001; Radnitz, Schlein, & Hsu, 2000). This is not surprising given that SCI is generally a traumatic and life-threatening event. Additionally, while the majority of people with SCI have been found to be not at risk of negative psychological states, around 30-40% have been found to have more helpless expectations and externally focussed in their thinking (Craig, Hancock & Chang, 1994). While factors such as level of lesion, age, age at the time of injury, sex, time since injury and completeness of the lesion have not been consistently found to be associated with lower quality of life (QOL), negative psychological states and pain intensity have been found to lower QOL in people with SCI (Middleton et al., 2007). Coupled with the potential raised risks of psychological disturbance, research has also shown that substance abuse and risk of suicide are more prevalent in the SCI population relative to the able-bodied population before and after the injury (Craig et al., 1999; Heinemann, Doll, Armstrong, Schnoll, & Yarkony, 1991; Stanford, Soden, Bartrop, Mikk, & Taylor, 2007). Unfortunately, rarely has research compared the risk of negative psychological states to matched able-bodied controls during rehabilitation or after rehabilitation when the SCI person is living in the community. Therefore, the aim of the present study was to investigate the level of negative psychological states in people with SCI living in the community relative to able-bodied persons matched for age and sex.

Methodology
Participants
Subjects included 33 adult persons (26 males; 7 females) who had a SCI (mean age= 41.1, SD=11.6; range 22 to 60 years). Exclusion criteria included a history of psychopathology before the SCI, traumatic brain injury, and non-English speaking. The mean time since their injury was 11.7 years (SD=11) and 42% had complete lesions (that is, American Spinal Injury Association or ASIA impairment grade A). The able-bodied controls consisted of 33 adult persons with a similar sex ratio (7 females) and similar age (mean age= 39.5, SD=12.3; range 22 to 57 years). All SCI and able-bodied subjects were approached to take part in the present study while they were participating in an ongoing larger study into the relationship between brain activity and neurological damage. They were admitted into the study after they gave written consent. Institutional ethics approval was obtained prior to their participation in the study.

Measure of negative psychological states
The Profile of Mood States (POMS; McNair, Lorr, & Droppleman, 2005) was used to estimate the level of negative psychological states in the two groups. The six POMS sub-constructs (Tension, Depression, Anger, Vigor, Fatigue, Confusion) and the Total POMS mood state score were used. The POMS has been shown to be a reliable and valid instrument in measuring psychological states and psychopathology (McNair et al., 2005). Inspection of the items of the POMS suggests it will provide an estimate of psychopathology free of medical conditions prevalent in a disease like SCI that are likely to inflate the depressive mood score (eg. such as problems sleeping, or reduced physical activity). Even though the POMS has been used widely in non SCI fields, it has rarely been used to estimate the extent of psychopathology in SCI people. Therefore, we believed the use of the POMS for this task would make a valuable contribution to the rehabilitation literature. The Spielberger Trait Anxiety Inventory (Spielberger, Gorsuch, Luschene, Vagg, & Jacobs, 1983) was used to assess trait anxiety. This has also been shown to be a reliable and valid questionnaire (Spielberger et al., 1983).

Analysis
Independent t-tests were used to detect significant differences between the two groups. Based upon prior studies, a moderate to large effect size (0.6) was assumed to occur for the difference between the SCI and able-bodied groups (Craig et al., 1994a), with 33 subjects in each group providing sufficient power to detect true differences (power= 70%). The Sign Test (Siegal, 1956) was used to determine the probability that the SCI group would always be higher in negative psychological state scores than the able-bodied group. A value of 0.5 was therefore given to each prediction of difference for all 8 measures between the two groups, since there is theoretically a 1 in 2 probability of the SCI group being greater or lower than the able-bodied group. A value of 1 was given to each incorrect prediction (that is, SCI value was actually lower than relevant score for the able-bodied group). Using this technique, the probability of estimating the direction of difference by chance can be determined.

Table 1: Descriptive statistics for the POMS sub-contructs and POMS Total Score for SCI Group 1 and Able-bodied Control Group 2

	Mean 1 SCI	Mean 2 Control	SD1	SD2	±95CI 1	±95CI 2	t-value (df=64)	prob.
Tension	7.5	6.9	6.6	4.8	5.2-9.9	5.3-8.7	0.4	.69
Depression	9.0	4.4	12.0	4.1	4.8-13.3	2.9-5.8	2.1	.03 *
Anger	8.1	5.3	8.3	4.6	5.2-11.1	3.6-6.9	1.7	.09
Vigor	15.6	17.5	6.1	4.8	13.5-17.7	15.8-19.2	-1.4	.15
Fatigue	8.3	7.9	6.9	4.5	5.8-10.7	6.4-9.6	0.2	.83
Confusion	6.5	5.5	4.6	3.1	4.8-8.1	4.4-6.6	1.0	.32
POMS Tot	23.8	12.6	38.6	18.3	10.1-37.6	6.1-19.1	1.5	.13
Trait anxiety	36.8	34.9	10.5	6.7	33.1-40.6	32.4-37.4	0.8	.39

*<.05

Table 2: 2x2 contingency table with the number of participants with SCI who reported abnormally high levels of psychopathology versus those with low levels relative to the able bodied controls

Low POMS Total

(<70)

High POMS Total (≥70)

SCI

100%

Able-bodied controls

100%

Χ²=4.0, df=1, p<.05, Odds ratio= 7.1

Results
Table 1 shows the results for the independent t-tests for the POMS sub-constructs, the POMS Total score and Spielberger trait anxiety measure. Inspection of the data demonstrates that the people with SCI had consistently higher levels of psychopathology in all the 8 measures relative to the able-bodied controls (in some cases only marginally, such as for Fatigue). The Sign Test analysis suggests that the chance probability of all 8 measures being higher in the SCI sample relative to the control is remote (p<.05). The SCI group was found to have significantly higher levels of depressive mood (p<.05, df=64). The failure to find significant differences for Anger and POMS Total was due in part to the large variation in scores in the SCI sample (in all POMS measures the SCI standard deviations were as large or larger than the mean values). It is noteworthy that the POMS Total psychopathology score for the SCI sample was twice the level of the able-bodied controls (23.8 versus 12.7). This large variation in psychopathology scores in the SCI sample is further illustrated in Table 2, which shows 2x2 contingency data in which participants who reported abnormally high levels of psychopathology were compared to those with lower levels in both groups. A score of 70 in the POMS Total score was used as the cut off score given that scores of 70 or over typically occur in psychiatric populations (McNair et al., 2005). Persons with SCI had a significantly higher chance of having a psychopathology score of 70 or above (Χ²=4.0, df=1, p<.05), with a high odds ratio score of 7.1 (that is, the odds of persons with SCI having high levels of psychopathology is seven times that of able-bodied persons). There were no significant correlations between time since injury and ASIA level with self-reported psychological states.

Discussion
The data presented in this paper confirmed the findings of the literature that suggest a significant proportion of people with SCI are at risk of developing negative psychological states (Elliott & Kennedy, 2004; Middleton et al., 2007; North, 1999). The SCI group had significantly raised levels of self-reported depressive mood relative to the able-bodied controls. While differences between the SCI group and the controls did not reach significance for the other seven measures, the SCI group had consistently higher levels of negative psychological states for all measures, compared to the able-bodied controls. Furthermore, people with SCI had seven times the risk of having increased levels of negative psychological states typical of people with a psychiatric disorder compared to the able-bodied controls (20% of the SCI people had elevated levels of negative psychological states). It is possible that some questionnaires (such as the Beck Depression Inventory) inflate negative mood scores because they contain items biased towards medical complications associated with SCI (eg. items that focus on sleep, weight and physical performance). However, inspection of the items in the POMS suggests this is not a problem, as items require subjects to respond to 60 adjectives about how they feel. Therefore, the elevated POMS scores associated with SCI more than likely reflect valid increases in self-reported negative psychological states. This finding is somewhat concerning given that the participants had been living in the community on average 11 years after their injury, and were people who were getting on with their lives. They were not psychologically upset people recruited from hospital wards due to complications or mental health problems. Clearly, the findings have implications for current psychosocial strategies being used during and after rehabilitation.

One limitation in this study was the use of only a self-report questionnaire to assess psychological states. Future research therefore needs to utlize a comprehensive range of assessment including diagnostic clinical interviews designed to detect psychopathology. However, as stated above, the findings of this paper have revealed possible challenges for current rehabilitation strategies designed to counter negative psychological states. Further research should assess and gather best evidence regarding treatments that can reduce psychological states in SCI people during rehabilitation, as this may then reduce the prevalence of negative states in the long-term by assisting the person with SCI to maintain a healthy mental health and adjustment (Craig et al., 1998). Potential treatments include pharmacological therapies to counter psychopathology such as depression, as well as non-pharmacotherapies such as cognitive behavioral therapy or other psychosocial therapies known to be beneficial for improving psychological status. It is crucial however, that psychosocial and mental health be seen as important outcomes for rehabilitation following SCI (Middleton et al., 2007).

It is also becoming clear that our knowledge about the association between negative psychological states and SCI needs clarification. Ten years ago rehabilitation researchers and clinicians were calling for comprehensive research that could clarify the nature of the psychological reaction of people to SCI (Elliott & Frank, 1996; Jacobs, Zachariah & Bhattacharji, 1995). Unfortunately, little has changed today. We need to determine the prevalence of people with SCI who develop despondency or mild depressive disorder (eg. elevated negative psychological states) as distinct to a major depressive disorder (MDD), dysthymia or possibly adjustment disorder. We also need to determine how many people with SCI develop depressive symptoms due to a primary anxiety disorder such as PTSD. The influence of pre-morbid psychopathological factors on psychopathology both during and after rehabilitation also needs clarification. Clearly, prospective research needs to be conducted to resolve the gaps in our knowledge about the association between SCI and negative psychological states. Such comprehensive data could well lead to an improvement in rehabilitation strategies that address the psychosocial needs of people with SCI.

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