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Immunizing against depression and anxiety after spinal cord injury
375
Immunizing Against Depression and Anxiety After Spinal Cord Injury Ashley R. Craig, PhD, Karen Hancock, BSc, Esther Chang, PhD, Hugh Dickson, MBBS ABSTRACT. Craig AR, Hancock K, Chang E, Dickson H. Immunizing against depression and anxiety after spinal cord injury. Arch Phys Med Rehabil 1998;79:375-77.
Objective: To further report on the effectiveness of early psychological intervention in reducing anxiety and depressive mood in persons with spinal cord injury 2 years after injury. Design: A nonrandomized, longitudinal, controlled trial. Setting, Outcome Measures, and Intervention: Twentyeight spinal cord injured persons participated in group cognitive behavior therapy during hospital rehabilitation. They were assessed for depressive mood and anxiety before, immediately after, and 12 and 24 months after treatment. The intervention group's responses on the measures were compared with a control group of 31 spinal cord injured persons who only received traditional rehabilitation services during their hospitalization. Results: Subjects in the treatment group with high depression and anxiety scores before treatment were significantly less depressed and reduced their anxiety to a greater extent 2 years after the injury in comparison with similar persons in the control group. Conclusions: Group cognitive behavior therapy for spinal cord injured persons who are abnormally depressed and anxious appears to reduce depressive mood and anxiety in the short and long term. © I998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation PERSONS WITH spinal cord injury (SCI) can ~¢~rHILE enjoy a high quality of life, 1 about 30% of persons with SCI have been found to have raised levels of anxiety and depressive mood up to 2 years after injury. 2 Many health professionals, as well as persons with SCI, have expressed a need for the spinal cord injured to have greater access to psychological support during the rehabilitation phase. 3,4 There is, however, a lack of empirical evidence that psychological treatment enhances adjustment to SCI. 5 As reported earlier in this journal, 6 group cognitive behavior therapy is beneficial in lowering depressive mood and anxiety in a SCI population up
From the Department of Health Science, University of Technology, Sydney, NSW, Australia. Submitted for publication May 5, 1997. Accepted in revised form September 26, 1997. Supported by a grant from the Research and Development Grants Advisory Committee, Department of Community Services and Health, Canberra, by a competitive research grant from the University of Technology, Sydney, and by the Motor Accidents Authority, New South Wales, Australia. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Ashley Craig, PhD, Department of Health Science, University of Technology, Sydney, PO Box 123, Broadway, NSW, Australia, 2007. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7904-448953.00/0
to 1 year after treatment. The purpose of the present study was to provide 2-year follow-up data on this population.
METHODS Full details of patients and methods can be found in a previous report. 6 The treatment group consisted of 23 men and 5 women with a mean age of 31 years (16 to 58 yrs) who were undergoing hospital rehabilitation after an acute SCI. There was an attrition of one subject at the 2-year follow-up, resulting in a final sample of 27 subjects. The sample was mainly Australianborn (75%), 43% were married or in a de facto relationship, and the majority had an educational level of 10 years of schooling or less (64%). Forty-sfx percent of the group were diagnosed as paraplegic and 54% as quadriplegic. There were no significant differences between these two groups in terms of demographics or the psychological outcome measures employed, so they were combined as one sample for this study. The majority of subjects (71%) had complete lesions, while 29% were incomplete. All injuries but one were traumatic. The controls were selected on the same criteria for suitability as the treatment group. There was an attrition of 10 subjects from the third to the fourth assessment, resulting in a final sample of 31 subjects. However, those who did not participate in the 2-year study were no different to the final sample in terms of demographics or depression and anxiety. Half were admitted to the ward the year before the introduction of the cognitive behavior therapy and the other half were recruited from a similar acute SCI ward that did not have standardized psychological programs as part of the rehabilitation process. The controls received traditional rehabilitation services only. The control group was not significantly different from the treatment group in terms of demographics, with 51% diagnosed as paraplegic and 49% as quadriplegic. The majority of subjects (68%) had complete lesions, while 32% were incomplete. No significant differences were found for site of lesion or completeness of break in terms of demographics or overall scores on the psychological measures, so the controls were combined as one sample. All injuries were traumatic in nature. Treatment was conducted at one of the two acute SCI wards in Sydney, Australia. A group cognitive behavior therapy approach was employed specialized for SCl. 7 The program was conducted over 10 weeks in small groups (an average of 4 to 5 persons per group) for 1.5 to 2 hours per week. Cognitive behavior therapy attempts to change behavior and feelings that are believed to be associated with the problem and that are considered maladaptive. A group cognitive behavior therapy approach was employed based on treatment protocol for the study, 6,7 including components that addressed anxiety, depression, self-esteem, assertion, sexuality, and family relations. The aim of the program was to provide cognitive and behavioral skills to cope with the psychological and social difficulties encountered upon entering the community. Further details of the program can be found in an earlier publication in this journal. 6 The effectiveness of the cognitive behavior therapy in reducing anxiety and depressive mood was determined by comparing the responses of the treatment group with the control Arch Phys Med Rehabil Vol 79, April 1998
376
LONG-TERM SCI OUTCOME, Craig Table 1: Spielberger Trait Anxiety and Beck Depression Scores Across Time for the Treatment and Control Groups Anxiety Group
Before
After
Depression 1Yr
2Yrs
Before
After
1Yr
2Yrs
Treatment (n = 27)
37.9 (9.9)
36,6 (11.6)
35.6 (9.6)
35.4 (9.8)
10.8 (6.0)
7.7 (7.1)
7.6 (5.1)
7.7 (6.6)
Control (n - 31)
40.7 (8.4)
38.0 (10.8)
36.6 (10.2)
37.2 (11.6)
11.0 (6.6)
9.4 (8.0)
8,5 (8.1)
9.1 (7.9)
Scores reported as mean (SD).
group on anxiety and depressive mood. Anxiety was assessed by the Spielberger State-Trait Anxiety Scale (STAIC) 8 (although only trait anxiety is reported here) and depression by the Beck Depression Inventory (BDI). 9 For the treatment subjects the first assessment occurred immediately before therapy (when no longer immobilized in bed), immediately after therapy (approximately 10 to 12 weeks), and 1 and 2 years after therapy. The control group was similarly assessed. To determine those who had elevated levels of trait anxiety on the Spielberger scale, a score of 42 (one standard deviation above the mean for the STAIC) was used. 8 Those with scores higher than 42 were considered highly anxious. To determine those who had elevated levels of depressive mood on the BDI scale, a score of 14, which has been shown to differentiate between depressives and nondepressives, was used. 2 Those with scores higher than 14 were considered to have high levels of depressive mood. The validation and reliability of the BDI and Spielberger State-Trait Anxiety scales are well documented. The BDI has been shown to have high reliability and validity,9 and to be a sensitive screening instrument for depression in SCI persons. 2 Trait anxiety has been also shown to have high internal and test-retest reliabilities.8
repeated measures analysis of variance (ANOVA) demonstrated significant differences between the treatment and control subgroups (F (1, 16) = 6.78, p < .01, n = 9 per group). The control subgroup had higher levels of depressive mood in the long term than the treatment subgroup. There were also significant differences in BDI scores across time (F (3, 48) = 6.47, p < .01), with both 1-year and 2-year postinjury scores significantly lower than pretreatment scores (p < .01). Twelve persons from the control subgroup and 7 from the treatment subgroup were in the abnormally anxious category. A repeated measures ANOVA demonstrated no significant differences overall between the two groups on trait anxiety scores. There were significant differences in scores overall across time (F (3, 51) = 10.29, p < .01), with anxiety scores decreasing over time. There were no significant interactions, suggesting that both the treatment and control groups became less anxious across time. The mean anxiety scores for the treatment group decreased by 11 points after treatment and continued to gradually decrease up to 2 years, while the control group's mean anxiety initially declined by 5 points followed by only slight change over the first year.
RESULTS Table 1 lists mean depression and anxiety scores over the first 2 years of SCI for all subjects. While the treatment group had lower depressive mood and anxiety scores, there were no significant differences on these scores between the two groups. There were no significant differences overall across time for anxiety, but there were significant differences overall for depression (BDI) scores across time ( F (3, 168) = 3.246, p < .05). Post hoc Scheffe tests showed that subjects were less depressed 1 and 2 years after injury, and this was so for both the treatment and control groups, suggested by the lack of significant interactions for anxiety and for depression. The mean BDI scores for the treatment group decreased after treatment and remained stable up to 2 years, while the control group mean BDI declined slightly over the first year. A further analysis was conducted to deterlnine whether those in the two groups who reported abnormally high levels of depression or anxiety before therapy were significantly improved after treatment. Table 2 lists mean depression and anxiety scores for the subgroups of subjects over the first 2 years of SCI. For depressive mood, 9 persons from the control group and 9 from the treatment group who completed all assessments had BDI scores greater than 14. Results of the
DISCUSSION Although treatment subjects had lower levels of depressed mood and anxiety after 24 months compared with controls, these differences were not large enough to be significant. This raises the possibility that not all SCI people need specialized cognitive behavior therapy intervention. However, it was clinically important to determine whether cognitive behavior therapy is effective in those SCI persons suffering abnormally high levels of depressive mood mad anxiety. This was tested by analyzing the results of the subgroups who reported high levels of depressive mood and anxiety before treatment. Cognitive behavior therapy was shown to reduce depressive mood from severe to mild immediately after, and this improvement was maintained 2 years after treatment. These findings support the conclusion that the treatment had both short- and long-term effectiveness for those who reported high levels of depressive mood before treatment. In contrast, the controls did not improve in the short term and were only slightly improved after 1 to 2 years. From the interview at 2 years, it was established that none of the treatment group had sought further intensive psychological therapy during the time between the 12- and the 24-month period. Those in both the treatment and control subgroup who were
Table 2: Spielberger Trait Anxiety and Beck Depression Scores Across Time for the Treatment and Control Subgroups Who Had Elevated Levels of Depressive Mood and Anxiety Before Treatment Anxiety
Depression
Group
Before
After
1Yr
2Yrs
Before
After
1Yr
2Yrs
Treatment* ControF
51.4 (6.1) 49.0 (3.8)
40.3 (11.1) 43.9 (6.0)
36.6 (8.5) 41.3 (8.1)
33.7 (8.6) 41.4 (7.9)
17,5 (2.6) 19,3 (3.8)
9.1 (8.7) 16.9 (6.0)
7.3 (4.8) 16.2 (8.1)
9.0 (8.6) 11.6 (7.9)
Scores reported as mean (SD). * Treatment anxiety subgroup n = 7, depression subgroup n = 9. Control anxiety subgroup n = 12, depression subgroup n = 9.
Arch Phys Med Rehabil Vol 79, April 1998
LONG-TERM SCI OUTCOME, Craig
abnormally anxious before treatment were less anxious across time. There was no significant interaction between group and time, but a power problem due to small subject numbers prevented detection of significance. An inspection of the subgroup means for those who were anxious shows that the treatment subgroup lowered anxiety scores from high levels to within norms for the general population 2 years after injury. The control subgroup after 2 years remained almost one standard deviation above general population norms. Those in the treatment subgroup who were initially anxious were therefore more likely to improve than were similar persons in the control group. The present study suggests that group cognitive behavior therapy is an effective short- and long-term treatment for those who have depressive problems after SCI. Psychological treatment such as group cognitive behavior therapy may well be necessary to break the cycle of psychological distress and upset that can remain for a high proportion of persons with SCI. Improvements could result in potential cost benefits such as reductions in readmissions and in licit or illicit drug intake. Benefits such as these might be expected to occur contingent with the rapid improved mood and emotions after treatment. Hypothetically, in untreated SCI persons, depressed mood and anxiety may eventually decrease to normal levels in the absence of psychological treatment. Improvement may take a protracted period of time to occur, however, increasing health costs in society and diminishing quality of life for the individual. In contrast, group cognitive behavior therapy resulted in immediate improvements in mood and anxiety that were maintained after 2 years. It is therefore a potentially valuable treatment for those with SCI who are clinically depressed and anxious.
377
Acknowledgments: A special thanks to Joanne Oates for her dedication to the research. Thanks to the staff and patients of the spinal units of Prince Henry and Royal North Shore Hospitals, without whom this research would not be possible.
References 1. Eisenberg MG, Saltz CC. Quality of life among aging spinal cord injured persons: long term rehabilitation outcomes. Paraplegia 1991;29:514-20. 2. Craig AR, Hancock KM, Dickson HG. A longitudinal investigation into anxiety and depression over the first two years of spinal cord injury. Paraplegia 1994;32:675-9. 3. Lightpole E. Quadriplegia: what I feel. Med J Aust 1991;154:562-3. 4. Pelletier JR, Rogers S, Thurer S. The mental health needs of individuals with severe physical disability: a consumer advocate perspective. Rehabil Lit 1985;46:186-93. 5. Trieschmann R. Spinal cord injuries: psychological, social and vocational rehabilitation. New York: Demos Publications; 1988. 6. Craig AR, Hancock KM, Dickson HG, Chang E. Long-term psychological outcome in spinal cord injured persons: the results of a controlled trial using cognitive behaviour therapy. Arch Phys Med Rehabil 1997;78:33-8. 7. Craig AR, Hancock KM, Martin J, Dickson H. Adjusting to spinal cord injury: treatment manual. Sydney: University of Technology; 1989. 8. Spielberger CD, Gorsucb RL, Lushene RE, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto (CA): Consulting Psychologists Press; 1983. 9. Beck AT, Ward CH, Mendelson M, Mock J, Erbough J. An inventory for measuring depression. Arch Gen Psychiatry 1967;4: 351-63.
Arch Phys Med Rehabil Vol 79, April 1998
Immunizing Against Depression and Anxiety After Spinal Cord Injury Ashley R. Craig, PhD, Karen Hancock, BSc, Esther Chang, PhD, Hugh Dickson, MBBS ABSTRACT. Craig AR, Hancock K, Chang E, Dickson H. Immunizing against depression and anxiety after spinal cord injury. Arch Phys Med Rehabil 1998;79:375-77.
Objective: To further report on the effectiveness of early psychological intervention in reducing anxiety and depressive mood in persons with spinal cord injury 2 years after injury. Design: A nonrandomized, longitudinal, controlled trial. Setting, Outcome Measures, and Intervention: Twentyeight spinal cord injured persons participated in group cognitive behavior therapy during hospital rehabilitation. They were assessed for depressive mood and anxiety before, immediately after, and 12 and 24 months after treatment. The intervention group's responses on the measures were compared with a control group of 31 spinal cord injured persons who only received traditional rehabilitation services during their hospitalization. Results: Subjects in the treatment group with high depression and anxiety scores before treatment were significantly less depressed and reduced their anxiety to a greater extent 2 years after the injury in comparison with similar persons in the control group. Conclusions: Group cognitive behavior therapy for spinal cord injured persons who are abnormally depressed and anxious appears to reduce depressive mood and anxiety in the short and long term. © I998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation PERSONS WITH spinal cord injury (SCI) can ~¢~rHILE enjoy a high quality of life, 1 about 30% of persons with SCI have been found to have raised levels of anxiety and depressive mood up to 2 years after injury. 2 Many health professionals, as well as persons with SCI, have expressed a need for the spinal cord injured to have greater access to psychological support during the rehabilitation phase. 3,4 There is, however, a lack of empirical evidence that psychological treatment enhances adjustment to SCI. 5 As reported earlier in this journal, 6 group cognitive behavior therapy is beneficial in lowering depressive mood and anxiety in a SCI population up
From the Department of Health Science, University of Technology, Sydney, NSW, Australia. Submitted for publication May 5, 1997. Accepted in revised form September 26, 1997. Supported by a grant from the Research and Development Grants Advisory Committee, Department of Community Services and Health, Canberra, by a competitive research grant from the University of Technology, Sydney, and by the Motor Accidents Authority, New South Wales, Australia. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Ashley Craig, PhD, Department of Health Science, University of Technology, Sydney, PO Box 123, Broadway, NSW, Australia, 2007. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7904-448953.00/0
to 1 year after treatment. The purpose of the present study was to provide 2-year follow-up data on this population.
METHODS Full details of patients and methods can be found in a previous report. 6 The treatment group consisted of 23 men and 5 women with a mean age of 31 years (16 to 58 yrs) who were undergoing hospital rehabilitation after an acute SCI. There was an attrition of one subject at the 2-year follow-up, resulting in a final sample of 27 subjects. The sample was mainly Australianborn (75%), 43% were married or in a de facto relationship, and the majority had an educational level of 10 years of schooling or less (64%). Forty-sfx percent of the group were diagnosed as paraplegic and 54% as quadriplegic. There were no significant differences between these two groups in terms of demographics or the psychological outcome measures employed, so they were combined as one sample for this study. The majority of subjects (71%) had complete lesions, while 29% were incomplete. All injuries but one were traumatic. The controls were selected on the same criteria for suitability as the treatment group. There was an attrition of 10 subjects from the third to the fourth assessment, resulting in a final sample of 31 subjects. However, those who did not participate in the 2-year study were no different to the final sample in terms of demographics or depression and anxiety. Half were admitted to the ward the year before the introduction of the cognitive behavior therapy and the other half were recruited from a similar acute SCI ward that did not have standardized psychological programs as part of the rehabilitation process. The controls received traditional rehabilitation services only. The control group was not significantly different from the treatment group in terms of demographics, with 51% diagnosed as paraplegic and 49% as quadriplegic. The majority of subjects (68%) had complete lesions, while 32% were incomplete. No significant differences were found for site of lesion or completeness of break in terms of demographics or overall scores on the psychological measures, so the controls were combined as one sample. All injuries were traumatic in nature. Treatment was conducted at one of the two acute SCI wards in Sydney, Australia. A group cognitive behavior therapy approach was employed specialized for SCl. 7 The program was conducted over 10 weeks in small groups (an average of 4 to 5 persons per group) for 1.5 to 2 hours per week. Cognitive behavior therapy attempts to change behavior and feelings that are believed to be associated with the problem and that are considered maladaptive. A group cognitive behavior therapy approach was employed based on treatment protocol for the study, 6,7 including components that addressed anxiety, depression, self-esteem, assertion, sexuality, and family relations. The aim of the program was to provide cognitive and behavioral skills to cope with the psychological and social difficulties encountered upon entering the community. Further details of the program can be found in an earlier publication in this journal. 6 The effectiveness of the cognitive behavior therapy in reducing anxiety and depressive mood was determined by comparing the responses of the treatment group with the control Arch Phys Med Rehabil Vol 79, April 1998
376
LONG-TERM SCI OUTCOME, Craig Table 1: Spielberger Trait Anxiety and Beck Depression Scores Across Time for the Treatment and Control Groups Anxiety Group
Before
After
Depression 1Yr
2Yrs
Before
After
1Yr
2Yrs
Treatment (n = 27)
37.9 (9.9)
36,6 (11.6)
35.6 (9.6)
35.4 (9.8)
10.8 (6.0)
7.7 (7.1)
7.6 (5.1)
7.7 (6.6)
Control (n - 31)
40.7 (8.4)
38.0 (10.8)
36.6 (10.2)
37.2 (11.6)
11.0 (6.6)
9.4 (8.0)
8,5 (8.1)
9.1 (7.9)
Scores reported as mean (SD).
group on anxiety and depressive mood. Anxiety was assessed by the Spielberger State-Trait Anxiety Scale (STAIC) 8 (although only trait anxiety is reported here) and depression by the Beck Depression Inventory (BDI). 9 For the treatment subjects the first assessment occurred immediately before therapy (when no longer immobilized in bed), immediately after therapy (approximately 10 to 12 weeks), and 1 and 2 years after therapy. The control group was similarly assessed. To determine those who had elevated levels of trait anxiety on the Spielberger scale, a score of 42 (one standard deviation above the mean for the STAIC) was used. 8 Those with scores higher than 42 were considered highly anxious. To determine those who had elevated levels of depressive mood on the BDI scale, a score of 14, which has been shown to differentiate between depressives and nondepressives, was used. 2 Those with scores higher than 14 were considered to have high levels of depressive mood. The validation and reliability of the BDI and Spielberger State-Trait Anxiety scales are well documented. The BDI has been shown to have high reliability and validity,9 and to be a sensitive screening instrument for depression in SCI persons. 2 Trait anxiety has been also shown to have high internal and test-retest reliabilities.8
repeated measures analysis of variance (ANOVA) demonstrated significant differences between the treatment and control subgroups (F (1, 16) = 6.78, p < .01, n = 9 per group). The control subgroup had higher levels of depressive mood in the long term than the treatment subgroup. There were also significant differences in BDI scores across time (F (3, 48) = 6.47, p < .01), with both 1-year and 2-year postinjury scores significantly lower than pretreatment scores (p < .01). Twelve persons from the control subgroup and 7 from the treatment subgroup were in the abnormally anxious category. A repeated measures ANOVA demonstrated no significant differences overall between the two groups on trait anxiety scores. There were significant differences in scores overall across time (F (3, 51) = 10.29, p < .01), with anxiety scores decreasing over time. There were no significant interactions, suggesting that both the treatment and control groups became less anxious across time. The mean anxiety scores for the treatment group decreased by 11 points after treatment and continued to gradually decrease up to 2 years, while the control group's mean anxiety initially declined by 5 points followed by only slight change over the first year.
RESULTS Table 1 lists mean depression and anxiety scores over the first 2 years of SCI for all subjects. While the treatment group had lower depressive mood and anxiety scores, there were no significant differences on these scores between the two groups. There were no significant differences overall across time for anxiety, but there were significant differences overall for depression (BDI) scores across time ( F (3, 168) = 3.246, p < .05). Post hoc Scheffe tests showed that subjects were less depressed 1 and 2 years after injury, and this was so for both the treatment and control groups, suggested by the lack of significant interactions for anxiety and for depression. The mean BDI scores for the treatment group decreased after treatment and remained stable up to 2 years, while the control group mean BDI declined slightly over the first year. A further analysis was conducted to deterlnine whether those in the two groups who reported abnormally high levels of depression or anxiety before therapy were significantly improved after treatment. Table 2 lists mean depression and anxiety scores for the subgroups of subjects over the first 2 years of SCI. For depressive mood, 9 persons from the control group and 9 from the treatment group who completed all assessments had BDI scores greater than 14. Results of the
DISCUSSION Although treatment subjects had lower levels of depressed mood and anxiety after 24 months compared with controls, these differences were not large enough to be significant. This raises the possibility that not all SCI people need specialized cognitive behavior therapy intervention. However, it was clinically important to determine whether cognitive behavior therapy is effective in those SCI persons suffering abnormally high levels of depressive mood mad anxiety. This was tested by analyzing the results of the subgroups who reported high levels of depressive mood and anxiety before treatment. Cognitive behavior therapy was shown to reduce depressive mood from severe to mild immediately after, and this improvement was maintained 2 years after treatment. These findings support the conclusion that the treatment had both short- and long-term effectiveness for those who reported high levels of depressive mood before treatment. In contrast, the controls did not improve in the short term and were only slightly improved after 1 to 2 years. From the interview at 2 years, it was established that none of the treatment group had sought further intensive psychological therapy during the time between the 12- and the 24-month period. Those in both the treatment and control subgroup who were
Table 2: Spielberger Trait Anxiety and Beck Depression Scores Across Time for the Treatment and Control Subgroups Who Had Elevated Levels of Depressive Mood and Anxiety Before Treatment Anxiety
Depression
Group
Before
After
1Yr
2Yrs
Before
After
1Yr
2Yrs
Treatment* ControF
51.4 (6.1) 49.0 (3.8)
40.3 (11.1) 43.9 (6.0)
36.6 (8.5) 41.3 (8.1)
33.7 (8.6) 41.4 (7.9)
17,5 (2.6) 19,3 (3.8)
9.1 (8.7) 16.9 (6.0)
7.3 (4.8) 16.2 (8.1)
9.0 (8.6) 11.6 (7.9)
Scores reported as mean (SD). * Treatment anxiety subgroup n = 7, depression subgroup n = 9. Control anxiety subgroup n = 12, depression subgroup n = 9.
Arch Phys Med Rehabil Vol 79, April 1998
LONG-TERM SCI OUTCOME, Craig
abnormally anxious before treatment were less anxious across time. There was no significant interaction between group and time, but a power problem due to small subject numbers prevented detection of significance. An inspection of the subgroup means for those who were anxious shows that the treatment subgroup lowered anxiety scores from high levels to within norms for the general population 2 years after injury. The control subgroup after 2 years remained almost one standard deviation above general population norms. Those in the treatment subgroup who were initially anxious were therefore more likely to improve than were similar persons in the control group. The present study suggests that group cognitive behavior therapy is an effective short- and long-term treatment for those who have depressive problems after SCI. Psychological treatment such as group cognitive behavior therapy may well be necessary to break the cycle of psychological distress and upset that can remain for a high proportion of persons with SCI. Improvements could result in potential cost benefits such as reductions in readmissions and in licit or illicit drug intake. Benefits such as these might be expected to occur contingent with the rapid improved mood and emotions after treatment. Hypothetically, in untreated SCI persons, depressed mood and anxiety may eventually decrease to normal levels in the absence of psychological treatment. Improvement may take a protracted period of time to occur, however, increasing health costs in society and diminishing quality of life for the individual. In contrast, group cognitive behavior therapy resulted in immediate improvements in mood and anxiety that were maintained after 2 years. It is therefore a potentially valuable treatment for those with SCI who are clinically depressed and anxious.
377
Acknowledgments: A special thanks to Joanne Oates for her dedication to the research. Thanks to the staff and patients of the spinal units of Prince Henry and Royal North Shore Hospitals, without whom this research would not be possible.
References 1. Eisenberg MG, Saltz CC. Quality of life among aging spinal cord injured persons: long term rehabilitation outcomes. Paraplegia 1991;29:514-20. 2. Craig AR, Hancock KM, Dickson HG. A longitudinal investigation into anxiety and depression over the first two years of spinal cord injury. Paraplegia 1994;32:675-9. 3. Lightpole E. Quadriplegia: what I feel. Med J Aust 1991;154:562-3. 4. Pelletier JR, Rogers S, Thurer S. The mental health needs of individuals with severe physical disability: a consumer advocate perspective. Rehabil Lit 1985;46:186-93. 5. Trieschmann R. Spinal cord injuries: psychological, social and vocational rehabilitation. New York: Demos Publications; 1988. 6. Craig AR, Hancock KM, Dickson HG, Chang E. Long-term psychological outcome in spinal cord injured persons: the results of a controlled trial using cognitive behaviour therapy. Arch Phys Med Rehabil 1997;78:33-8. 7. Craig AR, Hancock KM, Martin J, Dickson H. Adjusting to spinal cord injury: treatment manual. Sydney: University of Technology; 1989. 8. Spielberger CD, Gorsucb RL, Lushene RE, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto (CA): Consulting Psychologists Press; 1983. 9. Beck AT, Ward CH, Mendelson M, Mock J, Erbough J. An inventory for measuring depression. Arch Gen Psychiatry 1967;4: 351-63.
Arch Phys Med Rehabil Vol 79, April 1998