An increasing amount of study has gone into the gradual process by which patients with SCI psychologically assimilate changes in their bodies, their self-concepts, and their interactions with their environment.233 Life satisfaction, on average, tends to be lower for those with SCI compared to the general population of age-matched community dwellers. It is better in those who have less handicap in social integration, occupation, and mobility, regardless of the degree of neurologic impairment and disability. Subjective ratings of QOL are strongly associated with perceived control, self-assessed health, and social support. The best QOL is experienced by married white females who are currently employed, have more than a high school education, and are more than a few years past the SCI.235
Depression is not an inevitable effect of SCI.236 Suicide rates, however, were 2-4 times that of the general population within 5 years of SCI237 and range from 6% to 13% or about 5 times higher than the general population.238 Measures of despondency both before and after the SCI were higher in persons who died of suicide compared to a control group that did not commit suicide. Feelings of shame and apathy were documented during the rehabilitation hospitalization. This information poses an opportunity for intervention. Depressed or distressed patients with SCI reported spending more hours in bed, fewer days out of the house, and received more personal care assistance compared to persons who had adjusted to the SCI by 2-7 years after injury.239 Depressed people also perceived having greater handicap with limitations, for example, in getting transportation. Again, by obtaining this information from the patient, clinicians can propose psychosocial interventions and possibly drug therapy for depression.
Anxiety and depression can also arise from a PTSD associated with the event that led to the SCI (see Chapter 8). In pediatric patients with SCI, the incidence of PTSD is approximately 30%.240 Its presence is associated with poorer functional independence. The symptoms and signs of PTSD, such as environmental cues that set off anxiety attacks, intrusive recollections, hyperarousal, nightmares, and pananxiety should be sought in every patient in the first months after injury and treated with counseling and medications such as sertraline or a ben-zodiazepine.241
Psychological and social adjustment after SCI appear to be stronger predictors for long-term survival than antecedent medical complications. Using the Life Situation Questionnaire, one prospective study found that boredom, depression, loneliness, lack of transportation, conflicts with attendants, inability to control their lives, and alcohol and drug abuse characterized those who died in the last 4 years of a 15-year follow-up.242 Personality and mood disorders associated with self-destructive behaviors such as getting little exercise, letting bladder infections and skin sores go without attention, and abusing tobacco, alcohol, narcotics, and sedatives contributes to this mortality. In one survey, 70% of people with traumatic SCI reported substance abuse before or after injury. Although 16% believed they needed treatment, only 7% received specific help.243
Families, the rehabilitation team, and the physicians who provide chronic care must monitor the psychosocial adjustments, mood, and behavior of SCI-disabled persons and provide assistance as soon as a problem is identified. Over the long run, clues about potential problems may be brought to light by periodically giving patients a standard QOL questionnaire.
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