Keywords
spinal cord injury - anxiety - depression - sexual dysfunction - suicide
Introduction
Spinal cord injury (SCI) represents a significant life event for an individual, encompassing
physiological, psychological, and social changes. The emotional, cognitive, and social
manifestations following an SCI are highly individualized, fluctuate across time and
setting. Living with SCI requires an individual to make changes in their life to account
for new physical, psychological, social, and environmental realities. Adaptation is
a natural process following an SCI and can encompass internal elements such as grief/loss,
feelings of uncertainty, changes in thinking processes, and alterations in identity/self-concept
and sense of self-efficacy, as well as external elements, such as learning to navigate
one's environment and social spaces with a disability, and addressing structural and
systematic barriers and exclusion.[1]
[2]
[3] While many significant lifestyle changes occur within the first few years following
an SCI, adaptation extends over the lifespan and is culture-, situation-, and context-dependent.[1] Whereas many psychological reactions to acquiring an SCI represent normal adaptation
and processing a major life change, untreated distress can have negative impacts on
rehabilitation outcomes and overall quality of life.[4] Because distress can result in reduced functional gains during initial rehabilitation
treatment, increased follow-up care and medical comorbidities, and diminished health
status and functioning, evaluation of mental health issues is warranted. The potentially
traumatic or distressing nature of acquiring an SCI and the associated life changes
that ensue following an injury can increase the risk of mental health concerns. Not
surprisingly, some individuals with SCI do experience psychological distress, including
clinical levels of depression and anxiety. Prevalence rates of clinical depression
among those with SCI are estimated at 22 to 28%; rates of clinical anxiety are around
20%; and rates of posttraumatic stress disorder (PTSD) are around 12%; whereas among
the general adult population in the United States, rates for clinical depression,
anxiety, and PTSD are approximately 7, 3, and 3.5%, respectively.[5] It is important for providers to assess and monitor mood and psychological distress
following injury, as untreated mental health conditions can impact pain levels, self-management,
goal achievement during rehabilitation, length of hospitalization, and overall health
and life satisfaction.[6]
Materials and Methods
The objectives of this article were to review studies on prevalence of behavioral
pathologies and interventions following SCI across the world in last 35 to 40 years.
We included all types of original research, reviews of any kind (excluding case reports,
case series), which focused on behavioral pathology after SCI or types of intervention
post-SCI or both. We excluded studies that concerned neurosurgical or neurological
issues and interventions related to it. We included studies with patients of any age
and gender who had suffered from SCI. A literature search of the following databases
in English language was conducted in May 2023 on PubMed and Google scholar; in addition,
the reference lists of the pertinent literature were screened for the relevant studies.
The search started with SCI and psychological impact. Further, to identify the articles
of interest for this review, the search was narrowed by using the combination of search
terms as follows: “Spinal Cord Injury”, “Depression,” “Anxiety,” “Psychological Impact,”
“Quality of Life,” and “Sexual Dysfunction.” Data was reviewed, collected, and extracted,
including details of the data authors, year of study, sample size, study design, and
country. Intervention information included psychopharmacological, psychotherapeutic,
and neuromodulation. Review objective was to identify prevalence of behavioral pathology
in the community and interventions for the same. The quality of review was assessed
using scale for the quality assessment of narrative review articles.
Depression and Anxiety in SCI
Depression and Anxiety in SCI
While reviewing the literature we came across different studies that quoted varying
figures for prevalence of depression and anxiety in people afflicted with SCI. It
was noted to be in the range of 7 to 47.7%, as presented in [Table 1]. A study by Judd et al reported the prevalence of depressed mood in people with
SCI to be about 7%, whereas study done by Rabadi and Vincent reported it to be 47.7%.[7]
[8] Tzanos et al reported mild depression in 36% patients, moderate in 12.8%, and severe
in 3.7%, whereas Bombardier et al reported depression in 10% and low mood in 20 to
38% patients.[9]
[10]
[11]
Table 1
Prevalence of depression in traumatic SCI across various studies
|
Study
|
Sample size
|
Study design
|
Diagnostic method (MDD)
|
Depression diagnosis (%)
|
Intervention
|
|
Fullerton et al 1981[12]
|
30
|
Cross-sectional
|
SADS (MDD)
|
30.00
|
Antidepressants in one patient
|
|
Howell et al 1981[13]
|
22
|
Cross-sectional
|
SADS (minor depression)
|
22.70
|
|
|
Frank et al 1985[14]
|
32
|
Cross-sectional
|
SSI (MDD)
|
37.50
|
|
|
Judd et al 1986[7]
|
84
|
Cross-sectional
|
SSI (MDD)
|
7.00
|
Antidepressants
|
|
Fedoroff et al 1991[15]
|
55
|
Cross-sectional
|
PSE (mixed)
|
22.00
|
|
|
Frank et al 1992[16]
|
134
|
Cross-sectional
|
IDD (MDD)
|
13.00
|
|
|
Tate et al 1993[17]
|
30
|
Retrospective analysis
|
SSI (MDD)
|
23.00
|
|
|
Kishi et al 1994[18]
|
60
|
Cross-sectional
|
Modified PSE (MDD)
|
21.70
|
|
|
Clay et al 1995[19]
|
133
|
Cross-sectional
|
IDD (MDD)
|
13.50
|
|
|
Dryden et al 2005[20]
|
201
|
Cohort study
|
MR/ICD-9 (mixed)
|
28.90
|
|
|
Banerjea et al 2009[21]
|
8,338
|
Retrospective analysis
|
MR/ICD-9 (mixed)
|
26.70
|
|
|
Findley et al 2011[22]
|
8,334
|
Retrospective analysis
|
MR/ICD-9 (mixed)
|
26.20
|
|
|
Rabadi and Vincent 2011[8]
|
87
|
Retrospective analysis
|
MR/ICD-9 (mixed)
|
47.70
|
|
|
Weeks et al 2011[23]
|
67
|
Retrospective cohort study
|
MR/ICD-9 (mixed)
|
15.00
|
Antidepressants
|
|
Bombardier et al 2012[10]
|
142
|
Cross-sectional survey
|
SCID (MDD)
|
10.00
|
|
|
Bombardier et al 2016[11]
|
168
|
Cohort study
|
PHQ-9
|
29.10
|
|
Abbreviations: IDD, inventory to diagnose depression; MDD, major depression disorder;
MR/ICD-9, Medical Records/International Classification of Diseases, Ninth Revision;
ND, no data; PHQ-9, Patient Health Questionnaire-9; PSE, Present State Exam; SADS,
Schedule of Affective Disorders; SCI, spinal cord injury; SCID, Structured Clinical
Interview for DSM Disorders; SSI, semi-structured clinical interview.
A cross-sectional study by Adhikari et al evaluated 95 patients and caregivers and
found the prevalence of depressed mood to be high in the patients and high level of
caregiver burden.[24] This study also reported a direct correlation between depressed mood in traumatic
SCI and the caregiver burden among their caregivers. In contrast to this, Bombardier
et al found the stable low depression among their study subjects in their cohort study.[11] A few studies also dealt with the factors associated with depression in patients
with spinal cord injury. One of these studies was by Li et al, a cross-sectional study,
which scrutinized the relationship between pain intensity and probable major depression
in patients of SCI and concluded that pain intensity was related to greater risk of
probable major depression, although it was not found to be significant after consideration
of pain interference.[25] Another study by Lim et al evaluated anxiety and depression in patients with traumatic
SCI and found that these patients had 1.33 times greater incidence of new-onset anxiety
or depression.[26] In contrast to this, a cross-sectional study done by Saurí et al showed higher prevalence
of probable major depression disorder (PMDD) in nontraumatic SCI (21.1%) as compared
to traumatic SCI (13.8%).[27] Prevalence of anxiety disorders following SCI has been comprehensively studied in
the meta-analysis by Le and Dorstyn, in which 18 independent studies were included
consisting of 3,158 participants and reported the prevalence of generalized anxiety
disorder and panic disorder to be 5% and agoraphobia to be 2.5%.[28]
Sexual Dysfunction in SCI
Sexual Dysfunction in SCI
SCI patients were also commonly seen to be associated with sexual dysfunction (SD).
This has been primarily associated with problems with sensation and mobility, spasticity,
control of the bladder and bowel, and pain management.[29] In certain instances, females have also been observed to experience orgasmic dysfunction
and a loss of vaginal lubrication with SCI,[30] as mentioned in [Table 2]. The person's psychological condition, socioeconomic circumstances, and the information
given on the subject during rehabilitation have been associated with the sexual health
of this population.[31]
[Table 2] also describes how SCI affects the Female Sexual Function Index and male sexual
quotient, especially affecting orgasm in females and erectile function, ejaculation
and orgasm in males, respectively.[32]
[33] While studying about the predictive factors of male SD after traumatic SCI, Ferro
et al in their observational study reported that protective factors for SD are fixed
partner and masturbation, whereas predictors of SD are erectile dysfunction, orgasmic,
and infrequent SD.[34] Whether or not adequate sexual adjustment resources are provided to patients with
SCI was studied by Kathnelson et al, who reported that all participants found resources
available to support sexual adjustment were inadequate and most of them thought that
the healthcare providers lacked knowledge and comfort discussing sexuality after SCI.[31] Lim et al also studied the less looked upon factors contributing to SD in men with
SCI, which included hormonal influences, psychological factors and secondary SCI complications
and to address these factors physical activity, diet, and specific medications were
recommended for symptom relief.[35] From all the above stated findings, it can be inferred that SD associated with SCI
affects a person significantly and hence it becomes important to study the factors
associated with it. In a study carried out by Barrett et al using qualitative semi-structured
interview, which generated six inductive themes.[36] These themes included internalizing societal views and stigmatization, diminished
sexual confidence, navigating communication, managing relationship dynamics, lack
of sexual support provision, and intervention development recommendations. Building
further upon these themes, Barrett et al conducted another qualitative study, in which
they interviewed 16 healthcare professionals about the barriers and facilitators in
supporting sexual functioning and satisfaction during rehabilitation after SCI.[37] This was also a semistructured interview that generated five inductive themes, namely
integrating sexual wellbeing in rehabilitation, sex-informed multidisciplinary teams,
acknowledging awkwardness, enhancing approachability, and recognizing the partner.
These studies helped identify the factors associated with SD leading to deterioration
of lifestyle and to identify the factors to enhance sexual functioning. Several studies
also delved into the interventions adopted, which included both pharmacological and
surgical measures, as mentioned in [Table 2]. The pharmacological interventions included drugs such as phosphodiesterase inhibitors
like sildenafil and tadalafil, which are the first-line agents for SCI-related SD.[38]
[39]
[40]
[41] Certain studies also mentioned a few devices like the penile vibratory stimulation
and electroejaculation and vacuum erection devices, whereas surgical options like
penile prosthesis were considered important in many patients with severe injury and
minimal improvement with other measures.
Table 2
Prevalence of sexual dysfunction in SCI and their treatment modalities
|
Sexual dysfunction
|
|
Sr. no.
|
Study
|
Author, year
|
Design
|
Sample size
|
Country
|
Outcome
|
|
1
|
Sexual dysfunction in women with spinal cord injury living in Greece[30]
|
Tzanos et al 2021
|
Cross-sectional study
|
30
|
Greece
|
6.3% had SD with mean FSFI score of 14.4
|
|
2
|
Sexual concerns after spinal cord injury: an update on management[42]
|
Alexander et al 2017
|
Narrative review
|
|
United States of America
|
Sexual activity and satisfaction decreased after SCI. Orgasm in 50% patients with
SCI
|
|
3
|
Spinal cord injury and women's sexual life: case–control study[32]
|
Merghati-Khoei et al 2018
|
Case control study
|
62 women (31 cases and 31 controls)
|
Iran
|
SQOL-F and FSFI significantly worse in cases versus controls
|
|
4
|
Evaluation of sexual dysfunction in men with spinal cord injury using the male sexual
quotient (MSQ)[33]
|
Miranda et al 2016
|
Cross-sectional study
|
295
|
Brazil
|
Erectile function, ejaculation, and orgasm most severely affected domains. MSQ provides
a more comprehensive assessment
|
|
5
|
Sociodemographic factors associated with sexual dysfunction in Mexican women with
spinal cord injury[43]
|
Moreno-Lozano et al 2016
|
Cross-sectional study
|
83
|
Mexico
|
Negative correlation between age and FSFI scores
|
|
6
|
Efficacy and safety of sildenafil in men with sexual dysfunction and spinal ord injury[44]
|
Ohl et al 2017
|
RCT
|
248 men
|
United States of America
|
Achieving and maintaining erection and ejaculation frequency significantly more with
sildenafil (vs. placebo). Successful intercourse attempts and preference for sildenafil
significantly more
|
|
7
|
Non-invasive neuromodulation for bowel, bladder and sexual restoration
following spinal cord injury: a systematic review[45]
|
Parittotokkaporn et al 2020
|
Systematic review
|
46 studies (n = 1801)
|
New Zealand
|
Most studies (43/46) reported improvements in bowel (5/5), bladder (32/35), and sexual
(6/6) dysfunction after SCI. Quality of included studies had a high risk of bias and
were inconsistent
|
|
8
|
Male sexual dysfunction and infertility in spinal cord injury patients: state-of-the-art
and future perspectives[38]
|
Di Bello et al 2022
|
Narrative review
|
|
Switzerland
|
Worldwide annual incidence of SCI is 40 to 80 cases per million population. PVS and
EEJ, PDE5i, ICI, VEDs,
and surgical as PP
|
|
9
|
Male erectile dysfunction following spinal cord injury: a systematic review[39]
|
DeForge et al 2006
|
Systematic review
|
49 studies
|
Canada
|
Behavioral therapy, topical agents, intraurethral alprosatadil, intracavernous injections,
vacuum tumescence devices, penile implants, sacral stimulators, and oral medication;
Penile injections produced an effective erection in 90% (95% CI: 83–97%) of men. 79%
(95% CI: 68–90%) of patients who took sildenafil noticed success; the disparity in
efficacy was not statistically significant
|
|
10
|
Specific aspects of erectile dysfunction in spinal cord injury[40]
|
Ramos and Samsó, 2004
|
Narrative review
|
|
Spain
|
First-line treatment of choice is oral drugs, such as phosphodiesterase inhibitors
(sildenafil, tadalafil, and vardenafil)
Sublingual second-line treatments include intracavernous injections of prostaglandin
E1, papaverine, and phentolamine, alone or in combination, which have been shown to
be highly effective in the treatment of ED in men with SCI. Penile prostheses and
neuroprosthesis of anterior sacral roots
|
|
11
|
Neuroprosthesis for individuals with spinal cord injury[46]
|
Kilgore et al 2023
|
Narrative review
|
|
United States of America
|
Sacral root stimulation can be used to activate bladder, bowel, and sexual function
|
|
12
|
Fertility in men with spinal cord injury[41]
|
Čehić et al 2016
|
Narrative review
|
|
Croatia
|
Phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile
prostheses. Medically assisted ejaculation using penile vibratory stimulation or electroejaculation
and via prostate massage or surgical procedures
|
Abbreviations: CI, confidence interval; ED, erectile dysfunction; EEJ, electroejaculation;
FSFI, Female Sexual Function Index; ICI, intracavernosal injections; MSQ, male sexual
quotient; PDE5i, phosphodiesterase 5 inhibitors; PP, penile prosthesis; PVS, penile
vibratory stimulation; SCI, spinal cord injury; SD, sexual dysfunction; SQOL-F, sexual
quality of life-female; VEDs, vacuum erection devices.
Substance Use Disorders in SCI
Substance Use Disorders in SCI
In a cross-sectional study on 1,619 participants, Clark et al studied the risk of
pain medication misuse (PMM) after SCI and concluded that the risk of PMM is found
in individuals with SCI with caution to the prescribers to be aware of risk factors
for PMM including substance use behaviors and psychological indicators such as loss
of employment, financial constraints and interpersonal issues with spouse.[47]
Suicidal Behavior in SCI
Patients with spinal cord injuries have an increased likelihood of suicide than that
in the general population.[48] In the United States, patients with SCIs have a suicide rate that is two to six
times higher than that of the general population.[49] In Denmark, the patients commit suicide five times more frequently than general
population.[50] According to an Australian study, people with SCIs have a suicide rate that is 4.4
times higher, and according to one in Norway, the suicide rates among women and men
with SCIs were 3.7 and 37.6 times higher, respectively, than in the corresponding
general populations of men and women.[51]
[52] In a different study, 10 to 15% of patients who had SCIs said they had planned a
suicide attempt within 6 months of their injury, and 50% of patients reported having
suicidal thoughts.[53]
[54] It is socially and culturally taboo to document mental health symptoms, and the
unwillingness of nonpsychiatric clinicians to talk about mental health symptoms with
their patients is increasingly linked to mental health disorders and higher rates
of suicide in patients with SCIs. Mental health issues are closely linked to suicide
in both healthy individuals and those who have SCIs; therefore, medical staff who
treat patients with SCIs, such as orthopaedic surgeons, neurosurgeons, and rehabilitation
physicians, need to determine whether their patients are at risk of suicide and take
the necessary action.[55]
Psychological Impact of SCI
Psychological Impact of SCI
Certain studies examined the psychological impact SCI had over an individual and did
not classify it into different categories like depression or anxiety. One of the studies
by Gruener et al evaluated the psychological distress among individuals with SCI and
central neuropathic pain and found that SCI patients with central neuropathic pain
have higher levels of posttraumatic stress disorder, anxiety, stress, depression,
and pain catastrophizing as compared to those without.[56] Another study with important findings regarding the psychological repercussions
of a SCI was done by Peterson et al.[57] In this cohort study, the authors longitudinally studied 14,83,313 individuals,
out of which 9,081 people had SCI and 14,74,232 were controls. This study found that
adults with SCI had a significantly higher incidence of any psychological morbidity
(59.1%) as compared to the controls (30.9%). Also, it was found that all psychological
disorders were associated with central neuropathic pain in patients with SCI.
Interventions for SCI
As mentioned in the studies stated before, the psychological morbidity associated
with SCI was significant, making it pertinent to study the measures to improve them.
The role of mindfulness in ameliorating these symptoms has been evaluated in a few
studies. A systematic review was done by Hearn and Cros, consisting of five studies,
which assessed the role of mindfulness for pain, depression, anxiety, and quality
of life in people with SCI and found that the support was mixed for the therapy with
only one study showing significant decrease in depression and anxiety.[58] Another study by Bhattarai et al showed that mindfulness uniquely contributed to
the higher quality of life above and beyond sociodemographic and injury-related variables.[59] Also, indirect effects of mindfulness on functional limitation and quality of life
through pain were significant. Other psychological interventions like cognitive behavioral
therapy were studied by Mehta et al, who reported that guided Internet-delivered cognitive
behavioral therapy showed improvement in symptoms of depression and anxiety with 60%
eligible participants recruited with high rates of program completion.[60] In addition to psychotherapy, application of hyperbaric oxygen therapy (HBO) was
also studied for depression and anxiety in patients of SCI. One such study by Feng
and Li comprised a randomized controlled trial performed with 60 participants divided
into three groups of 20 participants.[61] One of these groups received HBO, another group received psychotherapy and the last
group received conventional treatment. It was found that the Hamilton Depression Rating
Scale score was significantly lower in the group that received HBO and psychotherapy
as compared to the group that received conventional treatment, thus demonstrating
that HBO could be a viable option in SCI patients. Other modalities of treatment like
noninvasive neuromodulation were also evaluated. In a systematic review by Parittotokkaporn
et al, which included 46 studies with 1,801 participants, among which improvements
in bowel (5/5), bladder (32/35), and SD (6/6) were reported in 43 out of 46 studies.[45] The included studies' quality varied widely and was strongly correlated with bias.
Role of pharmacological interventions has also been evaluated wherein efficacy and
safety of sildenafil were studied in men with SD and SCI by Ohl et al.[44] It was reported in this study that sildenafil led to significantly higher frequency
of achieving and maintaining erection and ejaculation, as compared to placebo. The
number of sexual intercourses attempts that were successful was more leading to sildenafil
being significantly more preferred as compared to placebo.
Conclusion
SCI is a debilitating illness with its effects strewed not only on the physical health
but also on the mental health of the afflicted persons. In this study, we focused
upon the psychological impact of the illness, encompassing, but not limited to, depression,
anxiety disorders, SD, substance use disorders, and suicidal behavior. The prevalence
of depression and anxiety disorders was observed to vary across different studies,
plausibly due to the different techniques used to assess depression.[62] Studies that gauged depression with self-rating questionnaires had a higher prevalence
of depression as compared to the studies which estimated it through clinician rated
diagnoses via the standard diagnostic classificatory systems. Despite the discrepancy,
rate of depression in patients with SCI is far more than that in the general population,
making it an important area to invest our resources into. Another important area of
distress was noted to be the SD resulting from the injury, including arousal difficulty,
orgasmic dysfunction, inadequate vaginal lubrication, and dyspareunia.[29] The dysfunction was noted to be in both males and females, but far less studied
in females. The qualitative studies related to the impact of SD in SCI have generated
certain iterative themes like elimination of stigma around these topics and integration
of sexual health in rehabilitation of the patients. Some studies reported about the
association of central neuropathic pain with increased psychiatric morbidity in the
form of increased prevalence of posttraumatic stress disorder, depression, anxiety,
and pain catastrophizing as compared to those without psychotherapies including mindfulness-based
therapy and cognitive behavioral therapy have shown to be effective in the treatment
of depression and anxiety in patients with SCI. HBO has shown improvement in depressed
SCI patients. As far SD is concerned, apart from empowering and educating healthcare
providers, neuromodulation has been shown to be an efficient treatment along with
pharmacological management in the form of phosphodiesterase-5 inhibitors like sildenafil.
