A comparison of posttraumatic stress disorder in veterans with and without spinal cord injury

Prevalence of Posttraumatic Stress Disorder Symptoms Following Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis

BACKGROUND

Limited evidence is currently available on the prevalence of posttraumatic stress disorder (PTSD) following traumatic spinal cord injury (SCI). This systematic review and meta-analysis aims to assess the prevalence and geographic distribution of PTSD symptoms after SCI.

METHODS

After a search in the MEDLINE, Embase, Scopus, and Web of Science databases, two reviewers independently summarized relevant studies published through 20 October 2021. Observational studies were included. The studies were eligible if they assessed PTSD symptoms using standard self-report or clinician-based instruments. Data and results were reported using the overall prevalence and the odds ratio (OR), with 95% confidence intervals (CIs).

RESULTS

24 articles (5646 patients) met the inclusion criteria. The prevalence of PTSD symptoms ranged from 6.33% (95% CI, 2.73-13.97) to 61.76% (95% CI, 52.07-70.61). Pooled analysis demonstrated that the overall prevalence of PTSD symptoms in SCI patients was significantly higher in developing countries (41.64%; 95% CI, 31.11-52.55) than in developed countries (19.35%; 95% CI, 14.66-24.51) (OR = 1.24; 95% CI, 1.08-1.42; p = .003). The highest prevalence of PTSD symptoms was reported in South Africa (56.25%; 95% CI, 47.01-65.08), followed by Sri Lanka (45.71%; 95% CI, 30.47-61.81), and Greece (43.55%; 95% CI, 31.94-55.91). By contrast, Norway (6.33%; 95% CI, 2.73-13.97), Switzerland/Germany (8.65%; 95% CI, 4.8-13.42), and Denmark (10.71%; 95% CI, 6.89-16.30) were found to have the lowest prevalence of PTSD symptoms after SCI.

CONCLUSION

Many traumatic SCI patients suffer from PTSD symptoms, and their prevalence seems to be higher in developing countries than in developed countries. These findings underscore the need to consider the psychological aspects of traumatic SCI.

Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries

OBJECTIVES

Depression and other mental disorders are more prevalent among individuals living with spinal cord injury (SCI) than in the community at large, and have a strong association with quality of life. Yet little is known about the prevalence and predictors of mental disorders among U.S. military Veterans living with SCI. The primary aim of this study was to present an estimate of mental disorder point prevalence in this population. The secondary aim was to examine the relationship of mental disorders to demographics, injury characteristics, and other clinically relevant features such as impairment from mental health problems and life satisfaction.

DESIGN

Cross-sectional.

SETTING

A SCI & Disorders Center at a U.S. Veterans Affairs Medical Center.

PARTICIPANTS/METHODS

Administrative and medical records of 280 Veterans who attended annual comprehensive SCI evaluations were evaluated. Demographics, injury characteristics, self-reported mental and emotional functioning (i.e. SF-8 Health Survey), and clinician-determined mental disorder diagnoses were attained.

RESULTS

Overall, 40% of patients received at least one mental disorder diagnosis, most commonly depressive disorders (19%), posttraumatic stress disorder (12%), and substance or alcohol use disorders (11%). Several patient characteristics predicted mental disorders, including age, racial minority identity, non-traumatic SCI etiology, and incomplete (i.e. AIS D) vs. complete injury. Mental disorders were associated with greater impairment from health and mental health-related problems and less satisfaction with life.

CONCLUSIONS

Mental disorders are common among outpatients receiving VA specialty care for SCI. These findings highlight the importance of having adequate and effective available mental health services available for Veterans with SCI.

Cue-dependent inhibition in posttraumatic stress disorder and attention-deficit/hyperactivity disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD) are common among military veterans, but the comorbidity of these two psychiatric disorders remains largely unstudied. Evaluating response inhibition and cue-dependent learning as behavioral and neurocognitive mechanisms underlying ADHD/PTSD can inform etiological models and development of tailored interventions.

METHOD

A cued go/no-go task evaluated response inhibition in 160 adult males. Participants were recruited from the community and a Veterans Administration medical center. Four diagnostic groups were identified: ADHD-only, PTSD-only, ADHD+PTSD, controls.

RESULTS

Group differences were observed across most indices of inhibitory functioning, reaction time, and reaction time variability, whereby PTSD-only and ADHD+PTSD participants demonstrated deficits relative to controls. No cue dependency effects were observed.

CONCLUSION

Finding complement prior work on neurocognitive mechanisms underlying ADHD, PTSD, and ADHD+PTSD. Lack of expected group differences for the ADHD-only group may be due to limited power. Additional work is needed to better characterize distinctions among clinical groups, as well as to test effects among women and youth.

Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors

OBJECTIVES

To summarise quantitatively the available evidence relating to pretraumatic, peritraumatic and posttraumatic characteristics that may increase or decrease the risk of developing posttraumatic stress disorder (PTSD) following spinal cord injury (SCI).

STUDY DESIGN

Systematic review.

METHODS

Seventeen studies were identified from the PubMed, PsycInfo, Embase, Scopus, CINAHL, Web of Science and PILOTS databases. Effect size estimates (r) with associated 95% confidence intervals (CIs), P-values and fail-safe Ns were calculated.

RESULTS

Individual studies reported medium-to-large associations between factors that occurred before (psychiatric history r=0.48 (95% CI, 0.23-0.79) P=0.01) or at the time of injury (tetraplegia r=-0.36 (95% CI, -0.50 to -0.19) P<0.01). Postinjury factors had the strongest pooled effects: depressed mood (r_w=0.64, (95% CI, 0.54-0.72)), negative appraisals (r_w=0.63 (95% CI, 0.52-0.72)), distress (r_w=0.57 (95% CI, 0.50-0.62)), anxiety (r_w=0.56 (95% CI, 0.49-0.61)) and pain severity (r_w=0.35 (95% CI, 0.27-0.43)) were consistently related to worsening PTSD symptoms (P<0.01). Level of injury significantly correlated with current PTSD severity for veteran populations (Q_B (1)=18.25, P<0.001), although this was based on limited data.

CONCLUSION

Combinations of peri- and post-injury factors appear to be influential in the development of PTSD among persons with SCI. Further studies are needed to extrapolate these findings to the broader spinal cord-injured population. More longitudinal research, driven by multicausal models of causation such as the diathesis-stress model, is also needed to determine the temporality of PTSD risk factors.

Physical Impairments as Risk Factors for the Development of Posttraumatic Stress Disorder

The case-control method, a retrospective design useful in studying the etiology of rare diseases, was utilized to examine the relative risk of posttraumatic stress disorder (PTSD) among individuals with six types of traumatic physical impairments. Odds ratios and associated confidence intervals were calculated for each impairment in a group of 45,320 veterans receiving medical services. Four of the six impairments were found to be risk factors for PTSD. Implications for rehabilitation counseling and research are discussed.

Measuring grief and loss after spinal cord injury: Development, validation and psychometric characteristics of the SCI-QOL Grief and Loss item bank and short form

OBJECTIVE

To develop an item response theory (IRT) calibrated Grief and Loss item bank as part of the Spinal Cord Injury--Quality of Life (SCI-QOL) measurement system.

DESIGN

A literature review guided framework development of grief/loss. New items were created from focus groups. Items were revised based on expert review and patient feedback and were then field tested. Analyses included confirmatory factor analysis (CFA), graded response IRT modeling and evaluation of differential item functioning (DIF).

SETTING

We tested a 20-item pool at several rehabilitation centers across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Department of Veterans Affairs hospital.

PARTICIPANTS

A total of 717 individuals with SCI answered the grief and loss questions.

RESULTS

The final calibrated item bank resulted in 17 retained items. A unidimensional model was observed (CFI=0.976; RMSEA=0.078) and measurement precision was good (theta range between -1.48 to 2.48). Ten items were flagged for DIF, however, after examination of effect sizes found this to be negligible with little practical impact on score estimates.

CONCLUSIONS

This study indicates that the SCI-QOL Grief and Loss item bank represents a psychometrically robust measurement tool. Short form items are also suggested and computer adaptive tests are available.

Measuring psychological trauma after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Psychological Trauma item bank and short form

OBJECTIVE

To describe the development and psychometric properties of the SCI-QOL Psychological Trauma item bank and short form.

DESIGN

Using a mixed-methods design, we developed and tested a Psychological Trauma item bank with patient and provider focus groups, cognitive interviews, and item response theory based analytic approaches, including tests of model fit, differential item functioning (DIF) and precision.

SETTING

We tested a 31-item pool at several medical institutions across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Veterans Administration hospital.

PARTICIPANTS

A total of 716 individuals with SCI completed the trauma items

RESULTS

The 31 items fit a unidimensional model (CFI=0.952; RMSEA=0.061) and demonstrated good precision (theta range between 0.6 and 2.5). Nine items demonstrated negligible DIF with little impact on score estimates. The final calibrated item bank contains 19 items

CONCLUSION

The SCI-QOL Psychological Trauma item bank is a psychometrically robust measurement tool from which a short form and a computer adaptive test (CAT) version are available.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review

BACKGROUND

Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment.

METHOD

Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)).

RESULTS

25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%).

CONCLUSIONS

Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Promoting optimal functioning in spinal cord injury: the role of rehabilitation psychology

Comprehensive treatment and rehabilitation includes attention to the psychological needs of individuals with SCI and their families. This chapter is designed to familiarize neurologists and other practitioners with psychological issues and care in SCI. While psychologists play a key role, attention to psychosocial health is a responsibility shared by all members of the rehabilitation team, beginning with the patient and family, and including clinicians who are not formally identified as mental health providers. Treatment planning for a person with SCI begins with a thorough assessment of the cognitive, emotional, personality, and social factors that influence functioning and rehabilitation. Rehabilitation psychologists use a mixture of assessment tools, including clinical interviews, behavioral observations, and a wide range of standardized test instruments. Psychological interventions can involve direct intervention with the patient, in individual, family or group-based therapies. Other psychological strategies involve assistance through less direct methods - consultation and training to other rehabilitation team members or facilitating peer role-modeling and support groups. The chapter provides an overview of core clinical issues (emotional responses, substance use, pain, cognitive deficits, sexuality and vocational rehabilitation), delineates the process of psychological assessment and intervention, and provides guidance on incorporation of rehabilitation psychology into SCI rehabilitation.

Co-occurring medical and mental illness and substance use disorders among veteran clinic users with spinal cord injury patients with complexities

STUDY DESIGN

Longitudinal analysis of SCI registry merged with VHA administrative-data and Medicare claims files (FY1999-2002).

OBJECTIVES

To estimate the prevalence of mental illness (MI) and substance use disorders (SUDs) among veteran health administration (VHA) clinic users with spinal cord injuries (SCI) and examine subgroup variations by demographic, socioeconomic characteristics, and duration and level of SCI.

SETTING

VHA clinic users (N=8338) with SCI who were alive by the end of FY2002.

METHODS

ICD-9-CM codes were used to identify individual MI (anxiety disorders, bipolar, depressive disorders, psychoses, post-traumatic stress disorder (PTSD) and schizophrenia) and categories of SUDs (tobacco, alcohol and drug abuse). Chi-square tests and multinomial logistic regression were used to examine the demographic and socio-economic profile of VHA users with SCI and MI and/or SUD.

RESULTS

Over a 2-year period, 46% VHA users with SCI had either a MI or SUDs: 20% had MI only; 12% had SUD only and 14% had both. The most common MI was depressive disorder (27%) and tobacco use was highly prevalent (19%). African-Americans (versus whites) were less likely to be diagnosed with MI only. Increased duration of SCI lowered the likelihood of MI and/or SUDs. Mood and anxiety disorders were highly prevalent in veterans with SCI with chronic physical conditions such as diabetes, heart disease, hypertension, and respiratory diseases.

CONCLUSIONS

Mental illness and SUDs are highly prevalent in the VHA population with SCI and is complicated by the high rates of chronic physical conditions, presenting challenges in their healthcare management.

Spinal cord injury and mental health

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 (n=443) 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.

Locus of control among spinal cord injury patients with different levels of posttraumatic stress disorder

Two hypotheses were investigated in the present study: 1) Patients with full posttraumatic stress symptoms following spinal cord injury (SCI) would experience more general health problems than those with partial posttraumatic stress disorder (PTSD), with no-PTSD and the control group; 2) Patients with full PTSD would endorse the external locus of control more than those with partial PTSD, no-PTSD and the control group. Sixty-two patients were recruited from a specialized rehabilitation clinic for spinal cord injury. The control group comprised 60 participants without SCI. Patients with SCI were assessed using the Posttraumatic Stress Disorder Checklist, the General Health Questionnaire-28 (GHQ-28) and the Multidimensional Health Locus of Control (MHLC). The control group was assessed using the GHQ-28 and the MHLC. The full PTSD group experienced more somatic problems, anxiety, social dysfunction and depression than the partial PTSD, the no-PTSD and the control groups. The results also showed that the full PTSD group endorsed significantly more external health locus of control than the control group. However, no significant differences were found between the three patient groups in health locus of control. The three PTSD sub-scales were positively correlated with general health problems. Further analyses showed that partial PTSD patients with paraplegia and partial PTSD patients whose SCI had a medically related cause were more likely to report less internal locus of control than other patients. Patients who suffered from full PTSD experienced more general health problems than those with fewer PTSD symptoms and those without SCI. External locus of control was a distinctive strategy that SCI-PTSD patients used in coping with the effects of SCI-PTSD.

The relationship between posttraumatic stress disorder following spinal cord injury and locus of control

OBJECTIVE

This study examined whether locus of control was associated with spinal cord injury posttraumatic stress disorder (SCI-PTSD).

METHODS

Sixty-two SCI patients and 54 people without SCI participated in the study. The patients were assessed using the Posttraumatic Stress Disorder Checklist (PCL), the General Health Questionnaire-28 (GHQ-28) and the Multidimensional Health Locus of Control (MHLC). The control group was assessed using the GHQ-28 and the MHLC.

RESULTS

Forty-four percent of patients suffered from full-blown PTSD. SCI patients experienced significantly more general health problems than the control. Type of SCI and trauma recency were not significantly correlated with PTSD symptoms or general health problems but previous traumatic events were. Regression analyses showed that internal health locus of control (IHLC) and powerful other locus of control (POLC) predicted the re-experiencing symptom; IHLC predicted the avoidance symptom; POLC predicted GHQ-28 total.

CONCLUSION

SCI patients' perceptions of whether their health was or was not determined by their own behaviour (i.e. internal or external locus of control) were associated with SCI-PTSD.

Spinal cord injury, posttraumatic stress, and locus of control among the elderly: a comparison with young and middle-aged patients

This study aimed to investigate the extent to which spinal cord injury posttraumatic stress (SCI PTSD) responses and the use of the external or internal health locus of control might vary according to age. Sixty-two patients with SCI were recruited for the study and divided into young (n = 23), middle-aged (n = 25) and elderly (n = 14) groups. They were assessed using the Posttraumatic Stress Disorder Checklist (PCL), the General Health Questionnaire-28 (GHQ-28), and the Multidimensional Health Locus of Control (MHLC). The results showed no significant differences between the three age groups in terms of PTSD symptoms. The elderly patients were significantly more socially dysfunctional than the other patients. The young patients believed in chance locus of control (CHLC) significantly more than the middle-aged and elderly patients. Correlation results revealed no significant relationship between PTSD symptoms and type of locus of control for the middle-aged patients. Otherwise, for both the young and elderly patients, internal health locus of control (IHLC) was negatively correlated with the avoidance symptom. For the elderly patients, powerful other locus of control (POLC) was positively correlated with the avoidance symptom. Both young and middle-aged patients revealed significant positive correlations between POLC, CHLC, and general health problems. For the elderly patients, POLC was positively correlated with social dysfunction and depression. SCI-PTSD responses did not differ according to age; however, the use of health locus of control differed depending on whether patients were younger or older.

Conceptually driven pharmacologic approaches to acute trauma

Secondary prevention of posttraumatic stress disorder (PTSD) entails intervening in the aftermath of a traumatic event to forestall the development of PTSD. There has been little psychopharmacologic research in this area. This is surprising, given that PTSD is the mental disorder with the most clearly identified cause and onset. In a translational model of PTSD's pathogenesis presented herein: A traumatic event (unconditioned stimulus) overstimulates endogenous stress hormones (unconditioned response); these mediate an overconsolidation of the event's memory trace; recall of the event in response to reminders (conditioned stimulus); releases further stress hormones (conditioned response); these cause further overconsolidation; and the overconsolidated memory generates PTSD symptoms. Noradrenergic hyperactivity in the basolateral amygdala is hypothesized to mediate this cycle. Preventing pre-synaptic norepinephrine release with alpha2-adrenergic agonists or opioids, or blocking post-synaptic norepinephrine receptors with beta-adrenergic antagonists such as propranolol, reduces hormonally enhanced memories and fear conditioning. Two controlled studies of trauma victims presenting to emergency rooms suggest that posttrauma propranolol reduces subsequent PTSD, as does one naturalistic clinical study of morphine treatment of burned children. Cortisol both enhances memory consolidation and reduces memory retrieval, leading to mixed predictions. Two controlled studies of intensive care unit patients found that cortisol reduced PTSD. One study did not find benzodiazepines effective in preventing PTSD. Selective serotonin reuptake inhibitors, antiepileptics, and alpha2-adrenergic agonists have yet to be tried.

Do post-traumatic stress symptoms predict reactions of adaptation to disability after a sudden-onset spinal cord injury?

Based on the perspective that post-traumatic stress disorder (PTSD) reflects a reaction of adaptation to trauma, the goal of this research was to examine the ability of PTSD symptom clusters (re-experiencing, avoidance, and hyperarousal) to predict eight reactions of adaptation to disability (shock, anxiety, denial, depression, internalized anger, externalized hostility, acknowledgment, and adjustment) among individuals with non-congenital spinal cord injuries. Individuals (all of whom attended either a specialized civilian or a veteran spinal cord injury clinic in Texas) completed two self-report questionnaires--the Reactions to Impairment and Disability Inventory (RIDI) and the Purdue Posttraumatic Stress Disorder Scale Revised (PPTSD-R). According to the statistical fit indices, five of the fit indices suggested that the revised model was a good fit to the data, whereas one fit index and the chi/df ratio indicated that the revised model fit the data poorly. The model provided information on the ability of PTSD clusters to predict reactions of adaptation, which suggested a specific pattern of vacillation of post-traumatic responses during the process of adaptation. These findings need replication before proposing interventions for post-traumatic stress responses after the onset of a spinal cord injury.

Death anxiety as a predictor of posttraumatic stress levels among individuals with spinal cord injuries

Because the onset of a spinal cord injury may involve a brush with death and because serious injury and disability can act as a reminder of death, death anxiety was examined as a predictor of posttraumatic stress levels among individuals with disabilities. This cross-sectional study used multiple regression and multivariate multiple regression to examine whether death denial and death awareness predicted posttraumatic stress disorder (PTSD) among veterans and civilians with spinal cord injuries (N = 313). The results indicated that death anxiety (after controlling for demographic and disability-related variables) predicted a significant amount of the total levels of posttraumatic stress reactions among individuals with spinal cord injuries. Further, death awareness, pain level, and spiritual/religious coping significantly predicted the posttraumatic stress clusters of reexperiencing, avoidance, and hyperarousal. Death denial significantly predicted only hyperarousal. Because death anxiety predicts various aspects of PTSD reactions, one possible therapeutic implication is that addressing death-related topics may help to reduce PTSD reactions. Further research is needed to better ascertain the possible causality among these variables.

Post-traumatic stress disorder and emotional distress in persons with spinal cord lesion

STUDY DESIGN

Questionnaire.

OBJECTIVE

To evaluate the prevalence of post-traumatic stress disorder (PTSD) and emotional distress in persons with recent onset of spinal cord lesion.

SETTING

Denmark.

METHODS

A total of 69 patients with paraplegia or tetraplegia from two rehabilitation centres in Denmark filled in the questionnaire. PTSD and emotional distress were assessed using the Harvard Trauma Questionnaire and the Medical-Based Emotional Distress Scale, 83 days on average after the spinal cord lesion. The level of neurological lesion and completeness were recorded adhering to the International Standards for Neurological Classification of Spinal Cord Injury.

RESULTS

The prevalence of PTSD was 20%. Patients with PTSD experienced significantly more symptoms of depression and more emotional distress than patients without PTSD. Age and neurological level were related to PTSD in patients with traumatic injuries, but not in patients with nontraumatic lesions.

CONCLUSIONS

Persons with a recent onset of spinal cord lesions are at increased risk of having PTSD, and comorbidities such as depression and other symptoms of emotional distress.

The effect of prior trauma exposure on the development of PTSD following spinal cord injury

Posttraumatic stress disorder (PTSD) occurs in only a subset of individuals who sustain traumatic spinal cord injuries (SCIs). Several previous studies have examined the effects of additive trauma on the development of PTSD and found that a history of prior trauma increases the risk for later development of PTSD. The present study examines additive trauma by investigating the effects of previous combat exposure on the development of PTSD following spinal cord injury. Significant differences in prevalence rates for current PTSD were found for the comparisons of war theater (both combat and noncombat) versus non-war theater veterans but not for the comparison between combat and noncombat war theater veterans. Moreover, for all the comparisons, no significant differences were found in lifetime PTSD diagnoses. This implies that veterans with SCI who served in a war zone have increased difficulty recovering from their PTSD following a spinal cord injury than do non-war theater veterans.