Spinal cord injury and mental health

Christine Migliorini, Bruce Tonge, George Taleporos

Objectives: The aim of the study was to examine the mental health of adults with spinal
cord injury living in the community
Methods: The study was a representative community cross-sectional cohort self-report
survey, carried out in adults with traumatic spinal cord injury registered on the Victorian
Spinal Cord Injury Register and adults with non-traumatic spinal cord injury attending a
specialist non-traumatic spinal cord injury rehabilitation clinic. Participants (n443)
completed a self-report survey by internet, telephone or hard copy, which used reliable
and valid measures of depression, anxiety and stress (Depression, Anxiety and Stress
Scale) and post-traumatic stress disorder (Impact of Events Scale
Revised).
Results: Nearly half (48.5%) of the population with spinal cord injury suffered mental
health problems of depression (37%), anxiety (30%), clinical-level stress (25%) or post-
traumatic stress disorder (8.4%). Overall, there was a twofold or more increase in the
probability of emotional disorders compared to the general population. Of those with one
mental health disorder, 60% also had at least one other emotional disorder, representing a
substantial 56% increase over the general population in the probability of comorbidity of
psychopathology. Better health and time since injury were associated with decreasing the
risk of psychopathology.
Conclusion: The results of the present study underscore the vulnerability of the population
with spinal cord injury to emotional disorders. This study highlights the complexity of
mental health problems experienced by many individuals with spinal cord injury living in the
community. The delivery of mental health services to this vulnerable population requires
recognition of comorbidity and problems of mobility, access and stigma.
Key words: anxiety, depression, mental health, PTSD, spinal cord injury.

Australian and New Zealand Journal of Psychiatry 2008; 42:309 314

Spinal cord injury (SCI) brings sweeping changes to
life. SCI is associated with increased mental health
problems, which predict poorer outcomes such as
increased pain, medical complications and substance
abuse [1
7].
Christine Migliorini, Research Fellow (Correspondence); George
Taleporos, Research Fellow
Monash University Centre for Developmental Psychology and Psychia-
try, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168,
Australia. Email: christine.migliorini@med.monash.edu.au
Bruce Tonge, Head, Department of Psychological Medicine; Deputy
Head, School of Psychology, Psychiatry & Psychological Medicine;
Head, Monash University Centre for Developmental Psychiatry &
Psychology, Monash University, Melbourne, Victoria, Australia
Received 15 November 2007; accepted 17 December 2007.
In spite of often small sample sizes and methodo-
logical differences, contemporary studies of the acute
stage of SCI (hospitalization and early rehabilitation
phase) find that around one-third of patients suffer
significant symptoms of depression [8
10]. There is
less agreement regarding the prevalence of depression
in the longer term, after injury. For example, the
prevalence of depression within the first 6 years since
injury was 28.9% (6.5% with major depression) in a
Canadian cohort (n201) [11]. In contrast, 11.4% of
a larger US cohort (n 849) met the criteria for
major depression at their first year follow-up assess-
ment [12]. Another US study found the prevalence
of probable depression was 28% at time 1 and
21.5% the following year [13]. For all the participants

# 2008 The Royal Australian and New Zealand College of Psychiatrists

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310 SPINAL CORD INJURY AND MENTAL HEALTH
(n163) the time since injury was more than 2 years
(mean4.6 years; SD1.3 years) at the first mea-
surement time point. In a large robust US study of
1391 individuals averaging 9.7 years since injury
(range 1
50 years), 48% reported clinically signifi-
cant symptoms of depression, with half of those (24%
of the total sample) suffering a probable major
depression [14]. In contrast, a small Australian study
found that the level of depressive symptoms in 60
individuals who were injured 11 years previously on
average (range 5
33 years) indicated that they were
as psychologically well-adjusted as non-disabled
groups [15].
There have been few studies of anxiety after SCI. A
small Australian study (1 year after SCI, n 41; 2
years after SCI, n31) found that depression and/or
anxiety was suffered by 30% of individuals with SCI
and this prevalence persisted over the first 2 years
since injury [16]. In contrast, a small UK study with a
variable participation rate (n 104) found that the
prevalence of anxiety fluctuated across the first
3 years after injury: the highest prevalence (60% of
n 5) was at week 48 after injury, the lowest
prevalence (10% of n 40) was at 6 months after
discharge, and the prevalence at 2 years after
discharge was 16% (n36) [8]. An Italian study
(n100) found that symptoms of anxiety and
depression were 13% and 16%, respectively, within
a cohort in which time since injury ranged from 3
months to 28 years (mean 4.6 years) [7].
Despite the sudden and traumatic nature of SCI,
the phenomenology of post-traumatic stress disorder
(PTSD) and SCI has been less well studied. Twelve
per cent of a cohort of 125 US veterans who averaged
19 years since injury met the diagnostic criteria for
current PTSD [17
19]. In a small UK study (n 85)
of civilians with SCI who were 56 months since SCI,
14% scored within the clinically significant range of
intrusion and avoidance symptoms [20]. In contrast, a
small Danish study (n69) found that 20% of
individuals who were all less than 1 year since SCI
suffered from PTSD [21].
A consistent finding of most studies of psycho-
pathology and SCI is that the level of SCI is not
related to mental health outcomes. There were two
exceptions: individuals whose SCI had resolved had
significantly better mental health outcomes compared
to individuals with persisting SCI [11]; and veterans
who sustained a high-level SCI (tetraplegia/quadri-
plegia) had a lower likelihood of current PTSD
[17,18].
There is a lack of large-scale studies of the long-
term mental health of individuals with SCI living in
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the Australian community. The aim of the present
study was to investigate the mental health and
phenomenology of emotional disorders in Austra-
lians with SCI living in the community.
Method
Procedures
Data were collected in 2004
2005. The participants were aged
]18 years, with a history of sudden-onset SCI and living indepen-
dently in the community. They were ]6 months since injury and
on the registry of the only hospital in Victoria that treats patients
with traumatic SCI. Individuals on the registry (n929) were
initially mailed an invitation to complete the survey by either the
internet or telephone or by mail. A hard copy of the survey
questionnaire was sent approximately 4 weeks later to anyone who
had not responded. Finally a follow-up telephone call to non-
responders was used approximately 4 weeks later. Excluding those
who had died, were untraceable, had insufficient English-language
skills, or had serious mental illness (such as dementia or schizo-
phrenia) that impaired their ability to complete the survey, there
was an overall 44% response rate.
We certify that all applicable institutional and governmental
regulations concerning the ethical use of human volunteers were
followed during the course of this research. The research project
was approved by Monash University, Austin Health and Bayside
Health Ethics Committees. Each subject gave informed consent.
The surveys were strictly confidential but not anonymous. Each
subject whose survey results indicated they were likely suffering
emotional distress, were approached and offered referral for
psychological care.
Individuals who completed the survey did not differ significantly
from non-responders, in current age or gender distribution (current
age t 1.546, (df927), p 0.12; gender x2 with Yates continuity
r1.812, (df1), p 0.18). No other demographic information
was available from the registry list.
Additionally, further participants with sudden-onset SCI of a
non-traumatic cause, such as an infection, who were not on the
State SCI register were recruited through the outpatient clinic at the
only other SCI unit in Victoria, specializing in non-traumatic SCI
(n32). Overall, 14% (n62) of the cohort had non-traumatic
SCI.
Measures
The reliable and valid self-report short form of the Depression,
Anxiety and Stress Scale (DASS-21) was used to discriminate
between symptoms of depression, anxiety and clinical level of stress
using the scoring system and cut-offs published in the manual [22].
Each subscale (depression, anxiety and stress) consists of seven
questions, has a clinical cut-off score and four levels of symptoms
severity (mild moderate, severe, and extremely severe). Respon-
dents are asked to indicate on a 0
3 scale how much each statement
has applied to them over the previous week.
 C. MIGLIORINI, B. TONGE, G. TALEPOROS
Normative DASS-21 data were available from a study of a large
adult non-clinical UK population (n1794; 815 male) with a mean
age of 41.0 years (SD15.9 years, range18
91 years) [23]. Parti-
cipants were unpaid volunteers recruited from a wide variety of
sources including commercial and public service organizations [23].
The Impact of Events Scale
Revised (IES-R) [24] is a reliable and
valid self-report measure of symptoms of PTSD with a cut-off score
that indicates a likely diagnosis of PTSD [25].
The DASS, DASS-21, IES and IES-R have been successfully
used within general populations [23,26], clinical populations with
psychological disorders [25,27], populations with significant physi-
cal illnesses [28,29] and populations with physical disabilities
including SCI [18,30]. The terms ‘Depression’, ‘Anxiety’, ‘Stress’
and ‘PTSD’ will be used to indicate that the individual with SCI
had a score on the relevant scale that was above the published
clinical cut-off. These terms are not synonymous with a clinical
diagnosis but indicate a likelihood of such a diagnosis.
Health consisted of a 1
10 score where higher scores indicated
better health and was derived from two questions. One question
asked about the frequency of visits to the doctors over the previous
3 months. The other question asked for the names of medications
taken daily. Each question was scored on 1
5 scale and then
summed.
Results
Participants
A total of 443 adults with SCI participated in the study. Seventy-
eight per cent were male; 30.9% had incomplete paraplegia, 30.7%
had complete paraplegia, 25.3% had incomplete quadriplegia and
10.2% had complete quadriplegia. The average age of participants
in 2004
2005 was 51.78 years (SD 14.44 years, range18

86 years). The average time since injury was 19.2 years (SD comorbidity of psychopathology (Table 1).
13.27 years, range1
66 years). The majority of participants
were married (58.8%) and had completed 512 years of education
(57.9%).
The Cronbach alpha coefficient for the overall DASS-21 scale
was 0.927; alpha coefficient for the subscale domain Depression
was 0.902, for Anxiety, 0.748, and for Stress, 0.864. The Cronbach
alpha coefficient for the overall IES-R scale was 0.944; alpha
coefficient for the subscale domain Intrusion was 0.894, for
Avoidance, 0.873, and for Hypervigilance, 0.823.
Prevalence of emotional disorders
Approximately half (51.5% or n222) of the cohort scored
within the normal non-clinical range for Depression, Anxiety,
Stress and PTSD. But 37% suffered from depression, 30% suffered
anxiety, 25% suffered clinically significant stress and 8.4% (n37)
suffered from PTSD.
The distribution of age in the normative data [23] was similar to
that of the cohort but the proportion of female subjects was higher
in the normative data (54%) compared to the present cohort
(22%).
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311
In comparison to the normative sample, the odds ratio (OR) for
any Depression was OR2.09 (95%CI 1.67
2.62). The OR for
Anxiety was OR 2.19 (95%CI1.72
2.79). The OR for Stress
was OR1.35 (95%CI1.057
1.72). The risk was consistent
across the levels of severity of psychopathology as indicated by
the DASS-21 subcategories of mild, moderate, severe and extremely
severe. In comparison to the normative sample, the likelihood of
experiencing any emotional disorder whether that was Depression,
Anxiety or Stress was OR1.81 (95%CI1.46
2.23).
The risk of experiencing Depression, Anxiety or Stress did not
significantly differ according to gender within the cohort. The OR
of female subjects with SCI experiencing Depression over male
subjects with SCI was OR1.55 (95%CI0.98
2.44), for Anxiety
it was OR1.44 (95%CI0.90
2.33) and for Stress it was OR
1.19 (95%CI0.72
1.98).
When compared with the normative data, the risk of experien-
cing Depression did significantly vary by gender: the odds of
Depression for female subject with SCI was OR 2.74 (95%CI
1.79
4.19) and for male subjects with SCI it was OR 2.09
(95%CI1.58
2.77). The increased risk of Anxiety compared
with the normative sample also varied with gender: the odds of
Anxiety for female subjects with SCI was OR 2.43 (95%CI
1.56
3.79) and for male subjects with SCI it was OR 2.59
(95%CI1.90
3.53). The risk of experiencing Stress was not
significantly different to the normative sample for female subjects
with SCI but just reached significance for male subjects: the odds of
Stress for female subjects with SCI was OR 1.43 (95%CI0.89

2.29) and for male subjects with SCI it was OR1.44 (95%CI
1.06
1.95).
Comorbidity of emotional disorders
Around 60% of those with one probable diagnosis were also
likely to suffer at least one other disorder, indicating a substantial
Comparing this cohort with normative data for the DASS-21,
the OR of comorbidity of Depression, Anxiety and/or Stress was
OR1.56 (95%CI1.13
2.15), representing a 56% increase in the
likelihood of comorbidity over the non-SCI population.
Individuals with PTSD were highly likely to suffer Depression,
Anxiety and Stress. Scores of the IES-R (total scores) when
compared with scores from the DASS-21 were significantly
correlated (p 0.01 level, two-tailed): IES-R/Depression r0.577;
IES-R/Anxiety r0.559; and IES-R/Stress r0.577. Eighty-six
Table 1. Comorbidity of depression, anxiety and
clinically significant stress
Presence of emotional disorder n %
None 222 51.5
1 diagnosis 83 19.3
2 diagnoses 50 11.6
3 diagnoses 54 12.5
4 diagnoses 22 5.1
Total 431 100.0
312 SPINAL CORD INJURY AND MENTAL HEALTH

per cent of those with PTSD also scored within the clinical range of
Depression, 78% within the clinical range of Anxiety and 78.4%
within the clinical range of Stress. To express this in another way: if
a probable case of PTSD was indicated then the odds of Depression
also being present was OR12.98 (95%CI4.93
34.15), the odds
of Anxiety being present was OR9.96 (95%CI 4.40
22.55), and
the odds of Stress being present was OR14.15 (95%CI6.23

32.10).
95%CI0.139
0.753). Pseudo R2 statistics indicate that the
independent variables accounted for only a modest portion (13

17%) of the variance in the outcome (Cox & Snell R2 0.127,
Nagelkerke R2 0.170).
Discussion

This large-scale study of an Australian community

Associations with psychopathology population of people with SCI found that 37% suffer
from depression. This relatively high level of depres-
A logistic regression with ‘presence of psychopathology’ as the sive symptoms is similar to that reported in a large
dependent variable found that only three variables were associated
overseas study [14]. The prevalence of anxiety (30%)
with the outcome (Table 2). They were time since injury, health and
was in accord with a previous small Australian study
level of injury. Both time since injury and health had a negative
association with psychopathology. Each year since injury decreased
[16] but higher than other small overseas studies of
the likelihood of psychopathology by 2.6% (OR0.975, 95%CI
community-dwelling adults with SCI [7,8]. The 8.4%
0.956
0.994) and each unit increase in health decreased the prevalence of PTSD was less than that in previous
likelihood of psychopathology by 30% (OR0.768, 95%CI overseas studies of adults with SCI (12
14%) but not
.687
0.858). Further examination of the level of injury variable substantially so [19,20]. PTSD has not been studied in
showed that it was only the discrete dummy category of Complete an Australian population with SCI previously. The
Quadriplegia that was substantially less likely to coexist with the prevalence of PTSD is higher than that found in
presence of psychopathology. Those with complete quadriplegia the general Australian population (12 month pre-
were more than threefold less likely to be experiencing psycho- valence 1.33%) [31] but is consistent with a pre-
pathology compared to the other levels of SCI OR0.323, vious Australian study of non-SCI individuals who
had experienced a significant physical trauma (10%
prevalence) [32].
Table 2. Logistic regression with the presence of
Clinically significant stress has not been used as a
psychopathology outcome (n 413)
mental health outcome in any previous population
study of individuals with SCI. It must be emphasized
Coefficient p that this measure represents a tension
stress syn-
(SD)
drome that is more than the tension or stress felt by
Reference 1.157 (0.779) 0.138
Female 0.207 (0.272) 0.446 most during taxing times of life. Nor is it simply a
Age 0.002 (0.010) 0.815 range of non-specific symptoms related to depression
Health 0.264 (0.056) 0.000 or anxiety but is a construct distinct from depression
Marital status and anxiety [33]. The correlations of stress with
Married/de facto/living with 0.253 depression and anxiety in the present study (Spear-
partner
Single 0.406 (0.282) 0.149 man’s r with depression rs 0.656, p 0.000, n435;
Separated/divorced/widowed 0.347 (0.314) 0.269 and anxiety rs 0.611, p0.000, n436) are high but
Non-metro resident 0.131 (0.227) 0.563 do not account for all the variance, thus supporting it
BTertiary Education 0.120 (0.241) 0.619 as a separate aspect of psychopathology.
SCI level Three variables significantly impacted on the like-
Incomplete paraplegia 0.002
Complete paraplegia 0.374 (0.285) 0.190
lihood of psychopathology: health, level of injury, and
Incomplete quadriplegia 0.379 (0.302) 0.209 time since injury. Each improvement in health de-
Complete quadriplegia 1.130 (0.432) 0.009 creased the likelihood of the presence of psycho-
Time since injury 0.026 (0.010) 0.010 pathology by 30%. Each year since injury decreased
Traumatic aetiology 0.571 (0.374) 0.126
No compensation received 0.121 (0.230) 0.601 the likelihood of the presence of psychopathology to
No personal support available 0.284 (0.234) 0.225 the order of 2.6%. And those with complete quad-
Loss of consciousness at time 0.160 (0.246) 0.516 riplegia were more than threefold as likely to not
of injury suffer psychopathology compared with any other level
No recall of injury event 0.014 (0.254) 0.956
No counselling 0.290 (0.238) 0.222 of injury. The latter might seem counterintuitive. The
most likely explanation for these findings became
SCI, spinal cord injury. apparent when exploring the cohort demographics in
more detail. The cohort may be a large sample but the

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 C. MIGLIORINI, B. TONGE, G. TALEPOROS
distribution according to the level of injury and time
since injury was not equal. This is to be expected
because SCI aetiologies are not an equally distributed
phenomenon. Those with incomplete injuries were
injured significantly more recently compared to those
with complete injuries (F(3, 437) 0.6.551, p 0.000).
What is more, individuals with a high-level complete
quadriplegia are more likely to reside in supported
accommodation compared to other levels of SCI and
were therefore not included in the present study of
adults with SCI living independently in the commu-
nity. Those with complete quadriplegia formed the
smallest subgroup (n45 or 10%). A large propor-
tion of those with complete quadriplegia were injured
many years ago; 45% (n 20) were injured ]20 years
ago and 27% (n 12) were injured]30 years ago. But
those with complete paraplegia had the highest mean
time since injury compared to the other levels
(complete paraplegia mean 23.02 years, SD scales and did not include a diagnosis confirmed by
13.21; incomplete paraplegia mean 16.89 years,
SD 14.03 years; complete quadriplegia mean  strated good predictive and discriminatory validity
20.58 years, SD 11.77 years; incomplete quadriple-
gia mean 17.14 years, SD 11.86 years). Therefore
the finding of relative mental health in those with
complete quadriplegia and for the longest survivors is
a systemic sample bias probably created by a healthy
survivor effect. Although there was a small to medium
effect size (h2 0.04) of injury level on time since
injury, the overall impact of those variables on the
likelihood of psychopathology was small. All the
independent variables in the logistic regression model
accounted for only 13
17% of the variance.
The present study found that many with SCI were
remarkably resilient but there remained around 50%
who suffered from emotional disorders, 60% of
whom suffered two or more emotional disorders.
This is a substantial 56% increase in the likelihood of
comorbidity in emotional disorders over the general
population. The likelihood of comorbid emotional
disorders has a number of consequences. It means
that any emotional disorder associated with SCI is
likely to be more complex to treat. Much of the
previous research into the emotional consequences of
SCI focused on either depression or depression and
anxiety [7,8,11
14,24]. Treatments that focus on only
one aspect of the profile of psychopathology suffered
by a person with SCI, such as depression, are less
likely to be effective.
Study limitations
A post-hoc examination for the potential confound
introduced by the physical sequelae of SCI with the
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313
physical symptoms diagnostic of psychological dis-
orders was conducted. The anxiety subscale was
chosen because this scale included the highest number
of items relating to physical symptoms (three auto-
nomic arousal items out of a total of seven items).
The sample was divided into anxious and non-
anxious groups based on scores that passed the
published threshold. Participants in both the anxious
and non-anxious group responded to the autonomic
and non-autonomic items, but the anxious group
responded more positively to the non-autonomic
items while the non-anxious group responded
more positively to the autonomic items (Table 3).
The results indicated that, rather than confounding
the results, the autonomic items played a legitimate
role indicating the presence of anxiety. This is
congruent to previous research [12].
The measures of psychopathology were self-report
clinical interview, but the scales used had demon-
in normative and clinical populations as well as in
populations with disabilities. On the whole, the
representativeness and size of the sample should
enhance the generalizability of the findings for Aus-
tralian people with SCI who live in the community.
Clinical implications
Although the number of people in Australia with
SCI is relatively small (estimate 2007 n 10 000) [34]
the suffering and the burden from clinical levels of
depression, anxiety, stress and PTSD is high, affect-
ing around 50% of this group. Given that 60% of the
sample could not recall receiving any specific treat-
ment for their mental health problems there is a need
for better mental health assessment and treatment
services that recognize the problems of mobility,
access and stigma faced by those with SCI.
Table 3. Correlations of autonomic and non-
autonomic items of anxiety subscale
Non-anxious Anxious group
group (n305) (n132)
Autonomic items 0.799** 0.643**
only
Non-autonomic 0.565** 0.824**
items only
**p B0.01.
314 SPINAL CORD INJURY AND MENTAL HEALTH
Acknowledgements
The Monash University Postgraduate Publications
Award and the Robert Rose Foundation PhD
Scholarship (Migliorini), the provision of the norma-
tive data by J. Henry, University of NSW Australia
and J. Crawford, Kings College, University of
Aberdeen UK, and support by Assoc Professor D.
Brown, Austin Hospital and Dr. P. New, Caulfield
General Medical Centre.
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