Rebecca Guest

Prospective Study of the Occurrence of Psychological Disorders and Comorbidities After Spinal Cord Injury

OBJECTIVE To conduct a prospective study of the occurrence of psychological disorders and comorbidities after spinal cord injury (SCI), determine psychotropic medication usage, and establish predictors of psychological disorders after transition to the community. DESIGN Longitudinal design with multiple measures. SETTING Assessment occurred in SCI units and the community. PARTICIPANTS Adults with SCI (N=88) admitted over a period of 32 months into 3 SCI units. INTERVENTIONS Participants completed inpatient rehabilitation for an acute SCI. Longitudinal assessment occurred up to 6 months postdischarge. MAIN OUTCOME MEASURES Measures were chosen that had a theoretical and clinical foundation for contributing to recovery after SCI. The Mini International Neuropsychiatric Interview, a structured diagnostic psychiatric interview, was conducted to determine the presence of psychological disorders. Medical measures included severity of secondary conditions or complications. Psychological measures included measures of anxiety and depressive mood, resilience, pain catastrophization, self-efficacy, and cognitive capacity. RESULTS Rates of psychological disorders of 17% to 25% were substantially higher than rates found in the Australian community. The occurrence of psychological disorder comorbidities was also very high. Anxiety was significantly elevated in those with a psychological disorder. Psychotropic medications were prescribed to more than 36% of the sample, with most being antidepressants. Factors predictive of psychological disorders included years of education, premorbid psychiatric/psychological treatment, cognitive impairment, secondary complications, resilience, and anxiety. CONCLUSIONS SCI can have a substantial negative impact on mental health that does not change up to 6 months postdischarge. Findings suggest a substantial minority experience increased psychosocial distress after the injury and after transitioning into the community. Additional resources should be invested in improving the mental health of adults with SCI.

Adjustment following chronic spinal cord injury: Determining factors that contribute to social participation

OBJECTIVES Spinal cord injury (SCI) is a catastrophic event that may result in diminished physical, social, and mental health. The main objective of this research was to establish inpatient factors that contribute to social participation following discharge into the community. DESIGN Prospective longitudinal design with measures taken three times, soon after admission to rehabilitation (N = 88), at discharge from the inpatient phase (N = 81) and 6 months following discharge (N = 71). METHODS Participants included adults with SCI admitted into three SCI units over a 33-month period. Assessment included demographic, injury, and psychosocial health measures. Adjustment was defined by the extent of social re-integration or participation post-discharge after 6 months in the community. Social participation was measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Logistic regression models were used to establish inpatient factors that significantly predicted social participation 6 months post-discharge. RESULTS Six months after discharge, around 55% of the sample had difficulties with social participation. The odds against being employed for an adult with poor social participation was found to be 8.4 to 1. Factors that predicted social participation included a younger age, having less severe secondary medical complications like bladder and bowel dysfunction, having a higher cognitive capacity, perceiving one has control (self-efficacy) over ones life and environment, and having greater perceived social support. CONCLUSIONS These results provide direction for enhancing existing psychosocial health strategies within SCI rehabilitation, affording an opportunity for every person who sustains a permanent SCI to have optimal capacity for social participation. Statement of contribution What is already known on this subject? Spinal cord injury (SCI) is associated with significant challenges to wellbeing, including a high risk of secondary chronic illnesses, risk of co-morbid mental health problems, financial insecurity and social isolation. Research has shown poor social participation can lead to problems in re-integration into society following discharge from inpatient rehabilitation. Research to date has examined various factors related to poor social participation, but the majority of this research has been survey based with convenience samples. What does this study add? This study adds results of prospective longitudinal research on adjustment following SCI, where adjustment was defined by the rate of social participation when living in the community. About one-third of SCI participants were found to have very poor social participation, and only one-third had found some form of employment 6 months after discharge. Multiple factors were found to predict and contribute to poor social participation, including older age when injured, more severe medical complications, cognitive deficits, poor perceptions of control or self-efficacy, and poor social support.

Psychological impact of injuries sustained in motor vehicle crashes: Systematic review and meta-analysis

Objective The aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries. Design Systematic review and meta-analysis. Data sources Multiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses. Study selection A high-yield search strategy was employed. Terms like ‘psychological distress’, ‘depression’, ‘PTSD’ and ‘motor vehicle accident’ were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC. Data extraction Searches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI). Results Elevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC. Conclusions Rehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.

Resilience following spinal cord injury: A prospective controlled study investigating the influence of the provision of group cognitive behavior therapy during inpatient rehabilitation.

PURPOSE To examine change in resilience in people with spinal cord injury (SCI) when group cognitive behavior therapy (GCBT) was added to routine psychosocial rehabilitation (RPR). RESEARCH METHOD/DESIGN A prospective repeated-measures cohort design was used to determine the efficacy of the addition of GCBT (n = 50). The control group consisted of individuals receiving RPR, which included access to individual CBT (ICBT) when required (n = 38). Groups were assessed on 3 occasions: soon after admission, within 2 weeks of discharge, and 6-months postdischarge. Measures included sociodemographic, injury, and psychosocial factors. The outcome variable was resilience, considered an important outcome measure for recovery. To adjust for baseline differences in self-efficacy, depressive mood and anxiety between the 2 groups, these factors were entered into a repeated measures multivariate analysis of covariance (MANCOVA) as covariates. Latent class analysis was used to determine the best-fitting model of resilience trajectories for both groups. RESULTS The MANCOVA indicated that the addition of GCBT to psychosocial rehabilitation did not result in improved resilience compared with the ICBT group. Trajectory data indicated over 60% were demonstrating acceptable resilience irrespective of group. CONCLUSION/IMPLICATIONS Changes in resilience mean scores suggest the addition of GCBT adds little to resilience outcomes. Latent class modeling indicated both groups experienced similar trajectories of improvement and deterioration. Results highlight the importance of conducting multivariate modeling analysis that isolates subgroups of related cases over time to understand complex trajectories. Further research is needed to clarify individual differences in CBT intervention preference as well as other factors which impact on resilience.

Factors predicting resilience in people with spinal cord injury during transition from inpatient rehabilitation to the community

Study Design:This is a longitudinal design study.Objectives:The objective of this study was to determine factors that predict resilience in people with spinal cord injury (SCI) at discharge from inpatient rehabilitation and after reintegration into the community 6 months post discharge.Setting:This study was conducted in SCI rehabilitation units and the community in New South Wales, Australia.Methods:Participants included 88 adults with SCI admitted over almost 3 years into three SCI Units in Sydney. Standardized self-report and clinician-based measures were used. Longitudinal assessment occurred up to 6 months post discharge. Sociodemographic, injury and psychological variables were assessed at admission, before discharge and 6 months post discharge. Standard multiple regression was used to determine factors that predict resilience at discharge from hospital and 6 months post discharge.Results:Almost 70% of the participants were classified as resilient at discharge and 66% after 6 months of living in the community. Multiple factors significantly predicted resilience at discharge and 6 months post discharge, including self-efficacy, low levels of negative mood and lower functional independence, whereas social support and low severity of secondary conditions trended to significance. Demographic and injury variables did not contribute significantly.Conclusion:Self-efficacy and low levels of negative mood states strongly contribute to resilience. The determination of these predictors will assist in improving rehabilitation programs to strengthen the resilience of people with SCI. However, given that 40–44% of the variance in resilience was explained by the group of factors entered, future longitudinal research is needed to determine not only whether resilience correlates but also whether these associations change over time.

Developing an algorithm capable of discriminating depressed mood in people with spinal cord injury

Study design:Cross-section design.Objectives:The development of reliable screen technology for predicting those at risk of depression in the long-term remains a challenge. The objective of this research was to determine factors that classify correctly adults with spinal cord injury (SCI) with depressed mood and to develop a diagnostic algorithm that could be applied for prediction of depressed mood in the long-term.Setting:SCI rehabilitation unit, rehabilitation outpatient clinic and Australian community.Methods:Participants included 107 adults with SCI. The assessment regimen included demographic and injury variables, negative mood states, pain intensity, health-related quality of life and self-efficacy. Participants were divided into those with ‘normal’ mood versus those with elevated depressed mood. Discriminant function analysis (DFA) was then used to isolate factors that in combination, best classify the presence or absence of depressed mood.Results:At the time of assessment, 24 participants (22.4%) had elevated depressed mood. DFA identified six factors that discriminated between those with depressed mood (P<0.01) and those with normal mood, explaining 61% of the variance. Factors consisted of pain intensity, mental health, emotional and social functioning, self-efficacy and fatigue. DFA correctly classified 91.7% (n=22 of 24) of those with depressed mood and 95.2% (n=79 of 83) of those without. Demographic, injury and physical health function variables were not found to discriminate depressed mood.Conclusion:Clinical implications of applying a diagnostic algorithm for detecting depression in adults with SCI are discussed. Prospective research is needed to test the predictive efficacy of the algorithm.

Cognitive impairment and mood states following spinal cord injury.

Spinal cord injury (SCI) is believed to be associated with high rates of cognitive impairment, which can result in complications in recovery. This study concerned two groups of adults with SCI. The first sample involved 150 participants with SCI who were assessed once for cognitive capacity with comparisons made with 45 able-bodied adults. Sample 2 were drawn from Sample 1, and included 88 participants with SCI who were prospectively assessed for mood states (anxiety, depressive mood, and fatigue) and pain intensity at three time periods: at admission to SCI rehabilitation, at discharge, and 6 months after transition into the community. Results showed that the SCI sample had significantly lower cognitive performance than the able-bodied control group. Further, almost 29% of the adults with SCI had lowered cognitive performance believed to be indicative of cognitive impairment. The risk of an adult with SCI having cognitive impairment was almost 13 times that of someone without an SCI. Results from Sample 2 revealed that the development of negative mood states was a significant problem in those with cognitive impairment after they transitioned into the community, a time when personal resources are severely challenged. Findings suggest all adults with SCI admitted to rehabilitation should receive a cognitive screen, and that rehabilitation strategies should then be guided by the cognitive performance of the person. Special attention should also be given to improving skills of those with cognitive impairment before they transition into the community, so as to reduce risk of comorbid mental health problems.

Psychological distress following a motor vehicle crash: A systematic review of preventative interventions.

INTRODUCTION Psychological distress following a motor vehicle crash (MVC) is prevalent, especially when the person sustains an associated physical injury. Psychological distress can exhibit as elevated anxiety and depressive mood, as well as presenting as mental disorders such as Post Traumatic Stress Disorder (PTSD) or Major Depressive Disorder (MDD). If unmanaged, psychological distress can contribute to, or exacerbate negative outcomes such as social disengagement (e.g., loss of employment) and poor health-related quality of life, as well as contribute to higher costs to insurers. This systematic review summarises current research concerning early psychological intervention strategies aimed at preventing elevated psychological distress occurring following a MVC. METHOD A systematic review of psychological preventative intervention studies was performed. Searches of Medline, Embase, PsychINFO, Web of Science and Cochrane Library were used to locate relevant studies published between 1985 and September 2015. Included studies were those investigating MVC survivors who had received an early psychological intervention aimed at preventing psychological distress, and which had employed pre- and post- measures of constructs such as depression, anxiety and disorders such as PTSD. RESULTS Searches resulted in 2608 records. Only six studies investigated a psychological preventative intervention post-MVC. Interventions such as injury health education, physical activity and health promotion, and therapist-assisted problem solving did not result in significant treatment effects. Another six studies investigated psychological interventions given to MVC survivors who were assessed as sub-clinically psychologically distressed prior to their randomisation. Efficacy was varied, however three studies employing cognitive behaviour therapy (CBT) found significant reductions in psychological distress compared to wait-list controls. CONCLUSION Psychological interventions aimed at preventing psychological distress post-MVC are limited, often involving small samples, with subsequent poor statistical power and subsequent high risk of bias. These factors make it difficult to draw conclusions, however CBT appears encouraging and therefore worthy of consideration as a preventative intervention.

Psychological distress following a motor vehicle crash: evidence from a statewide retrospective study examining settlement times and costs of compensation claims

Objective To determine whether psychological distress associated with musculoskeletal injuries sustained in a motor vehicle crash (MVC), regardless of time of onset, impacts compensation outcomes such as claim settlement times and costs. Second, to identify factors routinely collected by insurance companies that contribute to psychological distress during the compensation process. Design Statewide retrospective study. Data source Analysis of the New South Wales statewide (Australia) injury register for MVC survivors who lodged a compensation claim from 2011 to 2013. Participants 6341 adults who sustained a musculoskeletal injury and who settled a claim for injury after an MVC. Participants included those diagnosed with psychological distress (n=607) versus those not (n=5734). Main outcome measures Time to settlement and total costs of claims, as well as socio-demographic and injury characteristics that may contribute to elevated psychological distress, such as socio-economic disadvantage, and injury severity. Results Psychological distress in those with a musculoskeletal injury was associated with significantly longer settlement times (an additional 17 weeks) and considerably higher costs (an additional

A Prospective Study of the Change in Quality of Life in Adults with a Newly Acquired Spinal Cord Injury

A41 575.00 or 4.3 times more expensive). Multivariate logistic regression analysis identified risk factors for psychological distress including being female, social disadvantage, unemployment prior to the claim, not being at fault in the MVC, requiring ambulance transportation and rehabilitation as part of recovery. Conclusions Results provide compelling evidence that psychological distress has an adverse impact on people with musculoskeletal injury as they progress through compensation. Findings suggest that additional resources should be directed toward claimants who are at risk (eg, the socially disadvantaged or those unemployed prior to the claim), the major aim being to reduce risk of psychological distress, such as post-traumatic stress disorder, and associated risk of increased settlement times and claim costs. Prospective studies are now required that investigate treatment strategies for those at risk of psychological distress associated with an MVC.