Novel Risk Factors Associated With Current Suicidal Ideation and Lifetime Suicide Attempts in Individuals With Spinal Cord Injury

Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2015;96:799-808

ORIGINAL RESEARCH

Novel Risk Factors Associated With Current Suicidal Ideation and Lifetime Suicide Attempts in Individuals With Spinal Cord Injury Cheryl B. McCullumsmith, MD, PhD,a,c Claire Z. Kalpakjian, PhD, MS,b J. Scott Richards, PhD,c Martin Forchheimer, MPP,b Allen W. Heinemann, PhD,d,e Elizabeth J. Richardson, PhD,c Catherine S. Wilson, PsyD,d,f Jason Barber, MS,g Nancy Temkin, PhD,g Charles H. Bombardier, PhD,g,h Jesse R. Fann, MD, MPH,g,h for the PRISMS Investigators From the aDepartment of Psychiatry and Behavioral Neurobiology, University of Cincinnati, Cincinnati, OH; bDepartment of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI; cSpain Rehabilitation Center, University of Alabama at Birmingham, Birmingham, AL; dDepartment of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL; eRehabilitation Institute of Chicago, Chicago, IL; fDepartment of Physical Medicine and Rehabilitation, James A. Haley Veterans’ Hospital, Tampa, FL; g Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA; and hDepartment of Rehabilitation Medicine, University of Washington, Seattle, WA.

Abstract Objective: To determine unique associations of suicidal ideation (SI) and lifetime suicide attempts (SAs) in individuals with spinal cord injury (SCI). Design: Cross-sectional analysis. Setting: Outpatient. Participants: Individuals with SCI (NZ2533) who were 18 years or older with a history of traumatic SCI. Interventions: None. Main Outcome Measures: Any SI in the past 2 weeks (9-item Patient Health Questionnaire) and any lifetime SA. Results: Three hundred twenty-three individuals (13.3%) reported SI in the past 2 weeks and 179 (7.4%) reported lifetime SA. After controlling for other factors, both lifetime SA and current SI were associated with study site and current level of depression. In addition, SA was associated with less education, younger age at injury, having current or past treatment of depression, and having bipolar disorder or schizophrenia. SI was associated with more years since injury and lifetime SA. Several psychological factors were associated with current SI and lifetime SAs, including lower environmental reward and less positive affect. In addition, control of one’s community activities and spiritual well-being were associated with current SI. In bivariate comparisons, severity of SCI was also associated with the 47% of the SAs that occurred after injury. Conclusions: Several unique associations of SI and lifetime SA in individuals with SCI were identified, including level of environmental reward and control, spiritual well-being, and severity of SCI. These factors bear further investigation as prospective risk factors for suicidal behavior after SCI. Archives of Physical Medicine and Rehabilitation 2015;96:799-808 ª 2015 by the American Congress of Rehabilitation Medicine

Supported by the National Institute on Disability and Rehabilitation Research (grant nos. H133A060107-06A and H133N060033). Clinical Trial Registration No.: NCT00592384. Disclosures: none.

Suicide risk after spinal cord injury (SCI) is 3 or more times that in the general population,1 yet prediction of those with SCI at risk for suicidal behavior remains elusive. The identification of specific risk factors in those with SCI may provide critical insights into prevention strategies. Individuals with SCI have high rates of

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2014.12.017

800 Table 1

C.B. McCullumsmith et al Exploratory psychological function scales used

Psychological Function Scales

Scale Abbreviation

Posttraumatic growth questionnaire

PTG

International Physical Activity Questionnaire Modified Lorig Chronic Disease Self-Management Scale

IPAQ

Environmental Reward Observation Scale Functional Assessment of Chronic Illness TherapieseSpiritual WellBeing: Meaning Peace and Faith subscales Community Participation Inventory dcontrol and involvement

EROS

Positive and Negative Affective Schedule Neurological Quality of Life

PANAS

Self-efficacy

FACIT-Sp12

CPI

Neuro-QOL

Psychometric Properties Assessed Positive psychological change after a traumatic event Intensity and frequency of physical activity; modified for wheelchair users Confidence in one’s ability to manage pain, fatigue, and emotional distress associated with chronic illness Enjoyment of daily activities and accomplishments Importance of spirituality in day-to-day functioning with questions on the level of peacefulness, sense of purpose, and strength of spiritual beliefs Individual’s feelings of control over community participation and sense of involvement in life situations 10 positive and 10 negative emotions experienced in the previous week Positive affect and general well-being

established risk factors for suicidal ideation (SI) and suicidal behavior, including depression, anxiety, post-traumatic stress disorder, social stress and isolation, chronic medical illness, and disability.2-8 Furthermore, a subset of individuals with SCI have a history of high-risk suicidal behaviors and increased impulsivity, characteristics also associated with suicidal behavior.9-11 However, unique risk factors for suicidal behavior are not yet well established for individuals with SCI. Several studies have demonstrated an increased risk of suicide after SCI compared to the general population.1,12-14 A 10-year study of more than 9000 people from 13 SCI centers found a standardized mortality ratio of 4.9 for suicide, with the highest risk between 1 and 5 years after SCI and with complete paraplegia.12 Both a 40-year retrospective Danish study and a 30-year retrospective examination of data from the National Spinal Cord Injury Statistical Database found the highest rates of suicide in those with the least severe disabilities.1,15 However, little is known about risks of common antecedents to suicide: SI and suicide attempts (SAs), which have some shared and many distinct risks from death by suicide.16-21 For example, SI and SAs are both more prevalent in women, yet death by suicide is more prevalent in men. Both SI and SAs are significant risk factors for future SI, SAs, and death by suicide and probably account for much of the predictive value of psychiatric illness in suicidal behavior.22 Attempts and ideation carry their own morbidity, with decreased

List of abbreviations: EROS Environmental Reward Observation Scale FACIT-Sp12 Functional Assessment of Chronic Illness TherapieseSpiritual Well-being scale Neuro-QOL Neurological Quality of Life PHQ-9 9-item Patient Health Questionnaire SA suicide attempt SCI spinal cord injury SI suicidal ideation

No. of Subjects

Reference No.

5

905

24

4

566

25, 26

6

662

27

10

661

28, 29

12

585

30

Control: 13 Involvement: 14

570

31-34

20

210

35

9

210

36-38

No. of Questions

functioning, hospital admissions, and short- and long-term medical consequences. We examined factors associated with current SI and lifetime attempts in a general population of individuals with SCI. In particular, we were interested in whether different characteristics were associated with SAs and SI in individuals with SCI than had been shown in the population without SCI. We also examined factors associated with SAs that occurred before versus after SCI, with the hypothesis that SCI characteristics such as more severe injury or more violent etiology might differentially increase SAs. Risk factors determined from this study can help guide practitioners to identify and treat individuals with SCI at risk of suicidal behavior.

Methods Participants A total of 2533 participants were recruited between July 2007 and May 2012 from 4 National Institute on Disability and Rehabilitation Researchefunded SCI Model System sites and 2 additional sites as part of the Project to Improve Symptoms and Mood after SCI23: Rehabilitation Institute of Chicago (nZ874), University of Washington (nZ417), University of Michigan (nZ517), University of Alabama at Birmingham (nZ434), Baylor Rehabilitation Institute (nZ233), and University of Miami (nZ58). Study inclusion criteria were as follows: individuals 18 years or older with a history of traumatic SCI. We excluded persons who were none English speakers, too cognitively impaired to comprehend study materials, and referrals based on clinical status of depression rather than screened on a nonselected basis. All participants gave informed consent, and each site obtained approval from its local institutional review board. The 6 sites had statistically significant differences in frequencies of all demographic and baseline characteristic measures: mean age, 39 years at Baylor Institute of www.archives-pmr.org

Suicidal ideation and suicide attempts in individuals with SCI Table 2

801

Demographic characteristics of the study population Any Current SI* (PHQ-9 Score >0)

History of SAs* Characteristic

Total

No

Yes

No. of subjects Site UW UAB UM RIC BIR Miami Age at screening (y)* Sex: female* Completed high schooly Marital statusz Never married Married Divorced/separated/widowed Age at injury (y)* Years postinjury (
2y)* Cause of injuryz Fall Vehicular Violence Other SCI severityx Tetraplegia, complete Tetraplegia, incomplete Paraplegia, complete Paraplegia, incomplete

2435

2256

179 (7.4)

Significance

417 (16) 434 (17) 517 (20) 874 (35) 233 (9) 58 (2) 42.9
13.7 562 (23) 1960 (87)

364 (91) 331 (90) 480 (93) 807 (93) 224 (97) 50 (86) 43.2
13.8 499 (22) 1810 (88)

38 (9) 35 (10) 34 (7) 57 (7) 8 (3) 8 (14) 39.7
12.4 61 (34) 134 (79)

1157 (49) 781 (33) 421 (18) 31.7
14.1 11.4
10.7

1057 (49) 731 (34) 374 (17) 32.0
14.2 11.4
10.7

86 (49) 46 (26) 43 (25) 27.5
11.0 12.3
10.6

No

Yes

2112

323 (13.3)

Significance

325 (85) 364 (86) 440 (92) 749 (86) 191 (82) 47 (81) 42.9
13.7 468 (23) 1640 (87)

58 (15) 61 (14) 39 (8) 124 (14) 41 (18) 11 (19) 41.8
13.8 82 (25) 249 (86)

975 (49) 657 (33) 342 (17) 31.5
14.0 11.6
10.7

152 (50) 97 (32) 58 (19) 32.4
14.2 9.5
10.1

.011

385 1059 473 455

(16) (45) (20) (19)

353 977 426 427

(16) (45) (20) (20)

28 76 40 25

(17) (45) (24) (15)

385 637 649 393

(19) (31) (31) (19)

351 593 590 354

(19) (31) (31) (19)

30 35 56 34

(19) (23) (36) (22)

.001 .000 .002 .023

.000 .131 .358

.016

314 885 397 393

(16) (44) (20) (20)

55 142 71 50

(17) (45) (22) (16)

318 536 538 326

(19) (31) (31) (19)

60 78 97 54

(21) (27) (34) (19)

.137

.131 .321 .641 .743

.189 .000 .325

.476

NOTE. Values are presented as mean
SD or as n (%). P<.05 was used for statistical significance. Abbreviations: BIR, Baylor Rehabilitation Institute; Miami, University of Miami; RIC, Rehabilitation Institute of Chicago; UAB, University of Alabama at Birmingham; UM, University of Michigan; UW, University of Washington. * Missing data:<5% but >1%. y Missing data:<15% but >10%. z Missing data:<10% but >5%. x Missing data:<20% but >15%.

Rehabilitation to 45.6 years at University of Michigan; women, 20% at University of Washington to 31% at the University of Alabama at Birmingham; non-Hispanic white race, 86% at University of Washington to 24% at the University of Miami; less than high school education, 7% at University of Washington to 17% at Rehabilitation Institute of Chicago; divorced/widowed/ separated, 14% at Baylor Institute of Rehabilitation and Rehabilitation Institute of Chicago to 23% at University of Washington; violent etiology of SCI, 7% at University of Michigan to 33% at Rehabilitation Institute of Chicago; and SCI severity of complete tetraplegia, 9% at the University of Miami to 23% at Rehabilitation Institute of Chicago. The sites also had statistically significant differences in frequencies of antidepressant treatment at the time of screening (from a high of 34% at University of Washington to a low of 5% at the University of Miami), psychotherapy ongoing at the time of screening (5% at University of Washington, University of Michigan, University of Miami and 3% at University of Alabama at Birmingham, Rehabilitation Institute of Chicago, Baylor Institute of Rehabilitation), and history of www.archives-pmr.org

taking medications for depression (from a high of 38% at University of Michigan to a low of 23% at the Rehabilitation Institute of Chicago).

Materials Data for this cross-sectional study were collected by means of inperson (35%) and telephone-based (54%) structured interviews (mode not recorded in 11%). Injury characteristics were based on self-report and included time since SCI, injury level (tetraplegia or paraplegia), and cause of injury. Primary outcome measures were depression and SCI characteristics. Secondary measures were exploratory psychological function questions (table 1).

Depression The 9-item Patient Health Questionnaire (PHQ-9) depression scale is a screening measure based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depressive disorder. Nine items are rated as occurring not at all (0)

802 Table 3

C.B. McCullumsmith et al Psychiatric characteristics of suicide attempters and those with SI History of SAs

Characteristic No. of subjects PHQ-9 score Antidepressant at screening Lithium at screening Psychotherapy for depression at screening History of medication for depression Ever treated for bipolar/manic Ever treated for schizophrenia Psychological factors Posttraumatic growth (PTG) Physical activity (IPAQ) Self-efficacy (Lorig) Environmental reward (EROS) Community participation (CPIecontrol) Community participation (CPIeinvolvement) Negative affect (PANAS) Positive affect (PANAS) Spiritual well-being (FACIT SP-12) Positive affect and well-being (Neuro-QOL)

N

905 566 662 661 570

Any Current SI

Total

No

Yes

Significance No

2435 6.3
5.8 353 (24) 22 (1) 96 (4) 432 (30) 67 (3) 26 (1)

2256 6.0
5.7 313 (23) 16 (1) 72 (3) 370 (28) 39 (2) 14 (1)

180 10.4
6.5 39 (40) 6 (6) 24 (13) 61 (62) 26 (15) 12 (7)

.000 .000 .002 .000 .000 .000 .000

12.3
6.9 2.10
0.94 7.35
2.04 27.7
5.6 53.3
10.3

12.2
6.9 2.10
0.93 7.42
2.01 27.9
5.5 53.7
10.2

13.7
6.9 2.20
0.97 6.42
2.37 24.9
6.6 47.6
10.5

.084 .471 .004 .000 .001

585 42.7
13.4 43.0
13.4 38.3
12.9 .073 210 210 210 210

32.8
9.6 19.2
8.2 34.1
10.4 33.8
8.5

33.4
9.6 18.3
7.4 35.1
10.3 34.6
8.2

26.0
6.4 29.1
9.7 23.9
4.9 25.4
6.4

.001 .000 .000 .000

Yes

Significance

2116 5.1
4.9 272 (22) 17 (1) 65 (3) 332 (27) 41 (2) 20 (1)

334 13.7
5.7 69 (37) 4 (2) 27 (8) 89 (47) 22 (7) 4 (1)

.000 .000 .510 .000 .000 .000 .762

12.3
7.0 2.12
0.93 7.56
1.95 28.6
5.2 54.4
9.7

12.3
6.7 2.02
0.98 6.07
2.14 22.8
5.6 44.6
12.0

.911 .425 .000 .000 .000

43.6
13.5 35.3
11.8 .000 33.8
9.4 18.0
7.6 36.2
9.3 35.5
7.3

28.1
9.1 24.8
8.9 24.1
10.2 25.6
9.1

.000 .000 .000 .000

NOTE. Values are presented as mean
SD or as n (%). P<.05 was used for statistical significance. Abbreviations: CPI, Community Participation Inventory; IPAQ, International Physical Activity Questionnaire; PANAS, Positive and Negative Affect Schedule; PTG, post-traumatic growth questionnaire; Self-efficacy, Modified Lorig Chronic Disease Self-Management Scale.

to nearly every day (3) during the past 2 weeks. The PHQ-9 has good internal consistency and construct validity39 and has been validated for use in the population with SCI.40 To assess the association of depression with SI, we used the PHQ-8, a wellvalidated version of the scale that does not include the 9th item measuring SI.41-43

successive blocks of screened patients (see table 1) during screening sequentially over the course of the study.

Suicidal ideation Current SI was evaluated by a nonzero answer to question 9 of the PHQ-9: “Over the last 2 weeks, how often have you been bothered by.thoughts that you would be better off dead or of hurting yourself in some way?”

Statistical analyses

SA history SA history was determined by the following questions: 1) Has there ever been a suicide attempt? 2) How many times? 3) Last attempt? 4) What was the age at first attempt. Timing of an SA relative to SCI was determined by comparing the date of first reported SA to the date of SCI. In 32 of 180 (17.8%) cases, the timing of the SA relative to SCI could not be determined because of either lack of information or unclear dates. In 8 of 180 (4.4%) cases, study participants had SAs both before and after SCI. Neither those cases in which timing was indeterminate or cases with SAs before and after SCI were included in analyses comparing factors associated with SAs only before SCI to those that occurred only after SCI. Psychological function questions Exploratory psychological function questions were selected to explore specific topics related to depression but not necessarily suicidal behavior and were administered during screening in

Psychiatric history/mental health treatment Subjects were asked whether they had ever been diagnosed or treated for depression, bipolar disorder, or schizophrenia.

All bivariate relationships with SI and SA history were evaluated using t tests, Mann-Whitney tests, and Fisher exact tests, as appropriate. Row percentages are reported for all categorical variables, and means and SDs are reported for continuous variables. Missing data rates are reported in footnotes for each table. Multivariate logistic regression was used to assess the relationship between screening measures and each of SI and SA history. First a base model was constructed from a pool of bivariate significant covariates using a forward stepwise algorithm, and then the remaining explanatory significance of each screening measure was determined by adding it to the base model. For the psychological factors that were given only to subgroups of individuals, thirdorder modeling was performed, where each psychological factor was individually tested with the significant factors from the base model for the entire population, using only the subjects who received that test of psychological function in that wave. All analyses were performed using SPSS version 17.0.a

Results Of 2435 individuals with SCI screened for depression, 179 (7.4%) reported a lifetime SA and 323 (13.3%) reported any SI in the past 2 weeks (table 2). Factors associated with current SI included www.archives-pmr.org

Suicidal ideation and suicide attempts in individuals with SCI Table 4

803

Characteristics of individuals with SAs before and after SCI All Participants With History of SAs

Timing of First Attempt

Characteristic

Yes

Before SCI Only

After SCI Only

No. of subjects No. of attempts Attempted before injury* Attempted after injuryy Attempted before and after injuryy Years since injury to attempt Site UW UAB UM RIC BIR Miami Age at screening (y) Age at injury (y) Years postinjury (
2y) 0e1 >1 SCI severity Tetraplegia, complete Tetraplegia, incomplete Paraplegia, complete Paraplegia, incomplete PHQ-9 score Antidepressant at screening Lithium at screening Psychotherapy at screening for depression Ever taken medications for depression Treatment of bipolar/manic Treatment of schizophrenia

180 2.1
2.9 90 (61) 66 (45) 8 (7)

82 2.1
2.0

58 1.8
2.6

Significance NA NA NA NA

6.1 (6.7) .016 38 (9) 35 (10) 34 (7) 57 (7) 8 (3) 8 (14) 42.9
13.7 31.7
14.1 11.4
10.7 539 (22) 1905 (78)

20 (71) 18 (56) 11 (35) 22 (61) 6 (100) 5 (71) 37.4
12.2 29.2
10.1 8.4
8.5 22 (27) 60 (73)

8 (29) 14 (44) 20 (65) 14 (39) 0 (0) 2 (29) 41.1
11.8 23.3
11.0 17.9
10.9 1 (2) 57 (98)

30 35 56 34 10.4 39 6 24 61 26 12

8 23 18 24 10.7 20 3 12 37 14 9

10 9 22 5 9.8 15 2 8 20 6 1

.048 .001 .000

.003 (19) (23) (36) (22) (6.5) (40) (6) (13) (62) (15) (7)

(11) (32) (25) (33) (6.4) (38) (6) (15) (67) (18) (11)

(22) (20) (48) (11) (6.1) (44) (6) (14) (59) (11) (2)

.497 .655 1.000 .377 .736 .231 .045

NOTE. Values are presented as mean
SD or as n (%). P<.05 was used for statistical significance. Abbreviations: BIR, Baylor Rehabilitation Institute; Miami, University of Miami; NA, not applicable; RIC, Rehabilitation Institute of Chicago; UAB, University of Alabama at Birmingham; UM, University of Michigan; UW, University of Washington. * Missing data: <15% but >10%. y Missing data:<25% but >20%.

study site, fewer years since SCI (especially in the first year), lifetime SA, current depressive symptoms, past treatment of depression or bipolar disorder, and current pharmacological or psychotherapeutic treatment of depression (tables 2 and 3). In those with a lifetime SA, number of SAs averaged 2.1, with a range of 0 to 25 lifetime attempts. No difference in the number of lifetime attempts was seen between those with and without current SI. Factors associated with lifetime SA included study site, younger age at screening, female sex, not having completed high school, younger age at the time of injury, being previously but not currently married, current depressive symptoms, and current and past treatment of depression, bipolar disorder, or schizophrenia. Both lifetime SAs and current SI were associated with significantly lower scores on Modified Lorig Chronic Disease SelfManagement Scale, Environmental Reward Observation Scale (EROS), Community Participation Inventoryecontrol, Community Participation Inventoryeinvolvement (ideation only), Positive and Negative Affective Schedule positive (higher Positive and www.archives-pmr.org

Negative Affective Schedule negative), Functional Assessment of Chronic Illness TherapieseSpiritual Well-being scale (FACITSp12), and Neurological Quality of Life (Neuro-QOL) (see table 3). We were able to determine the timing of SAs relative to SCI in 140 of 180 individuals (table 4). Of those 140 individuals, 90 (64%) had made an attempt before their SCI, 66 (47%) had made an attempt after injury, and 8 (6%) had made attempts both before and after their SCI. Cases with only SAs before or only after SCI were compared with each other. No differences were seen in basic demographic characteristics, current depression, past or current treatment of mood disorders or psychological function measures between those attempting suicide only before SCI and those attempting suicide only after SCI. Individuals who had attempted suicide only after SCI were more likely to be older at screening, younger at the time of injury, more years after SCI, and SCI severity of complete tetraplegia or paraplegia than those who attempted only before SCI. Although the numbers were small,

804 Table 5

C.B. McCullumsmith et al Multivariate logistic regression for current suicidal ideation

Stepwise Model*

B

Odds Ratio

Significance

Site UAB (vs UW) UM (vs UW) RIC (vs UW) BIR (vs UW) Miami (vs UW) Years postinjury Previous suicide attempt PHQ-8 (without the ideation item) Constant

0.15 0.75 0.10 0.16 0.22 0.02 0.76 0.19 3.21

0.87 0.47 0.90 1.17 0.80 0.98 2.13 1.21 0.04

.015 .545 .003 .614 .536 .602 .023 .000 .000 .000

Abbreviations: BIR, Baylor Rehabilitation Institute; Miami, University of Miami; PHQ-8, 8-item Personal Health Questionnaire; RIC, Rehabilitation Institute of Chicago; UAB, University of Alabama at Birmingham; UM, University of Michigan; UW, University of Washington. * Only considering covariates with <15% missing.

schizophrenia diagnosis was associated more with those who had attempted suicide only before SCI than those attempting suicide only after SCI. In multivariate logistic regression, the following variables remained independently significantly associated with current SI: study site, fewer years after SCI, current depressive symptoms, and lifetime SA (table 5). For the model in Table 5, NZ2340 and R2Z15.6%. In third-order modeling (table 6), each of the psychological factor assessments was added individually to the model containing the above significant associations for that subpopulation (adjusted N values in the table). The EROS, Community Participation Inventoryecontrol, FACIT-Sp12, and Neuro-QOL added significantly to the explanation of the variance (R2) for the model. In multivariate logistic regression, the following variables remained significantly associated with lifetime SAs: study site, younger age at the time of injury, not completing high school, current depressive symptoms, current treatment of depression, and past treatment of bipolar or schizophrenia (table 7). For the model in Table 7, NZ2103 and R2Z8.1%. Female sex lost independent association when controlling for current depressive symptoms. In third-order modeling (table 8), where the psychological factors were added individually to the model containing the above significant associations for each subpopulation (N values reported in the table), the EROS and

Table 6

Neuro-QOL each added significantly to the explanation of the variance (R2) for the model.

Discussion In our study population, individuals with SCI had high rates of SI and SAs than did the general population. The 7.4% lifetime prevalence of SAs is much higher than the 4.6% lifetime prevalence reported for the general US population.20 The 13.3% prevalence of SI occurring in just the last 2 weeks before screening is much higher than even the annual prevalence of 3.3% reported in the US general population44,45 but is more consistent with a 34.8% past-year SI prevalence in Korean persons with SCI.46 Risk factors associated with current SI largely paralleled those found in the general population: current depression and history of an SA with some notable negative findings of age, sex, race, marital status, and educational level.19,47 In our study, risk factors for lifetime SAs also paralleled those found in the general population, including past treatment of bipolar disorder or schizophrenia, current treatment of depression, current depression severity, and having less than high school education.19,20,45,48 The association of female sex with lifetime SAs drops out after controlling for current depressive symptoms. Some unique factors associated with current SI and lifetime SAs emerged in this study. Current SI was independently

Effect of psychological factors on the base model logistic regression for current SI*

Psychological Factor

B

Odds Ratio

Significance

N

Cox-Snell R2 (%)

Self-efficacy (Lorig) Environmental reward (EROS) Community participation (CPIecontrol) Community participation (CPIeinvolvement) Negative affect (PANAS) Positive affect (PANAS) Spiritual well-being (FACIT-Sp12) Positive affect and well-being (Neuro-QOL)

0.10 0.12 0.04 0.02 0.02 0.04 0.09 0.12

0.90 0.88 0.97 0.99 0.98 1.04 0.91 0.88

.146 .000 .022 .247 .407 .185 .000 .000

631 630 548 562 206 206 206 206

20.5 22.5 14.3 13.6 17.3 17.7 23.3 24.8

NOTE. P<.05 was used for statistical significance. Abbreviations: CPI, Community Participation Inventory; PANAS, Positive and Negative Affect Schedule; Self-efficacy, Modified Lorig Chronic Disease Self-Management Scale. * Applying each psychological factor individually to the base model in table 5.

www.archives-pmr.org

Suicidal ideation and suicide attempts in individuals with SCI Table 7

805

Multivariate logistic regression for lifetime SAs

Second-Order Stepwise Model*

B

Odds Ratio

Significance

Site UAB (vs UW) UM (vs UW) RIC (vs UW) BIR (vs UW) Miami (vs UW) Age at injury Sex: maley Completed high school Current psychotherapy for depression Treatment for bipolar Treatment for schizophrenia PHQ-9 Constant

0.06 0.23 0.38 1.76 0.03 0.04 0.36 0.47 0.99 2.01 1.59 0.10 1.50

1.06 0.80 0.68 0.17 0.97 0.96 0.70 0.62 2.70 7.43 4.89 1.10 0.22

.032 .840 .432 .158 .003 .953 .000 .072 .044 .002 .000 .002 .000 .000

Abbreviations: BIR, Baylor Rehabilitation Institute; Miami, University of Miami; RIC, Rehabilitation Institute of Chicago; UAB, University of Alabama at Birmingham; UM, University of Michigan; UW, University of Washington. * Adding variables <15% missing. y Sex left in the model despite nonsignificance.

associated with less time after SCI, especially for the first year after SCI, but was not associated with any severity or etiology of SCI. Nam et al46 also did not find a relationship between SCI characteristics and SI in individuals with SCI in Korea. Previous work has found a decreased risk of suicide with increased time from SCI, and our findings provide further support for more intensive suicide screening and preventive interventions early after SCI.1,12 The association of younger age at the time of SCI with lifetime SAs bears further examination, but the cause and effect is not clear. For example, impulsive young adults might be more likely to have both SCI and SAs. Alternatively, an early serious life-changing event such as an SCI might increase the risk of SA. As might be expected, mental health factors predicted both SAs known to occur only before SCI and those occurring only after SCI. Only schizophrenia was more strongly associated with SAs occurring before SCI, whereas completeness of SCI injury, older age at screening, and younger age at the time of injury were more strongly associated with SAs that occurred only after

Table 8

SCI. The high association of schizophrenia with SAs before SCI bears further investigation; however, the number of subjects with schizophrenia was small. Severity of SCI was associated significantly more with SAs occurring after SCI, which parallels findings on death by suicide by DeVivo and coworkers,1 but contrasts with 2 studies showing decreased risk of death by suicide in the most severely injured individuals, perhaps because the risk factors for SAs do not always overlap with risk factors for suicide.16,21,49,50 Our work, combined with that by DeVivo et al and others, suggests a need for careful monitoring of SI and suicidal behavior in individuals with complete tetraplegia or complete paraplegia.12,15 Rates of both current SI and lifetime SAs were significantly different among the 6 study sites. As delineated in the Methods section, the 6 study sites did differ significantly in the frequencies of all demographic variables tested, but there were no clear patterns in these differences that clearly correlate with elevated suicide risk. For example, the University of Miami site has the highest prevalence of lifetime SAs and current SI but

Effect of psychological factors on the base model logistic regression for current SI*

Third-Order Modelingy

B

Odds Ratio

Significance

N

Cox-Snell R2 (%)

Self-efficacy (Lorig) Environmental reward (EROS) Community participation (CPIecontrol) Community participation (CPIeinvolvement) Negative affect (PANAS) Positive affect (PANAS) Spiritual well-being (FACIT-Sp12) Positive affect and well-being (Neuro-QOL)

0.20 0.11 0.03 0.02 0.04 0.08 0.09 0.14

0.82 0.90 0.97 0.99 0.96 1.08 0.92 0.87

.081 .010 .202 .419 .487 .211 .130 .024

478 478 543 556 203 203 203 203

12.3 13.0 9.0 8.9 25.6 26.0 26.4 27.8

Abbreviations: PANAS, Positive and Negative Affect Schedule; Self-efficacy, Modified Lorig Chronic Disease Self-Management Scale. * Applying each psychological factor individually to the base model in table 7. y Adding each screening measure individually.

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806 was not the highest in traditional demographic risk factors for suicidal behavior including age, female sex, non-Hispanic white race, less education, and previously but not currently married. The 6 study sites also differed significantly in frequencies of current and historical treatment of depression, with suggestion of effect. For example, the University of Miami had the lowest current use of antidepressants (but second highest historical use of antidepressants) and the highest prevalence of both current SI and lifetime SAs. However, Rehabilitation Institute of Chicago and Baylor Institute of Rehabilitation each had the 2 lowest rates of historical use of antidepressant medications and also the lowest rates of lifetime SAs. Examination of the psychological factors provides insights into some additional questions that might be of use in assessing suicide risk in the population with SCI. Significantly, the EROS, Community Participation Inventoryecontrol, FACIT-Sp12, and Neuro-QOL all independently significantly increased the predictive models for current SI. Similarly, the EROS and Neuro-QOL also independently significantly increased the predictive models for lifetime SAs. These questionnaires all focus on different aspects of sense of purpose, enjoyment of daily activities, and general well-being. The EROS asks questions such as “A lot of activities in my life are pleasurable” and “Other people seem to have more fulfilling lives,” and it has been associated with depression and scores improve with behavioral activation therapy.28,51 The Community Participation Inventoryecontrol asks questions such as “I am in control of my own life” and “I have choices about the activities I do.” Although community enfranchisement measured by the Community Participation Inventory has been shown to be significantly affected by depression in this population, our finding suggests that the level of control of involvement in community activities is an additive risk factor for SI on top of depressive symptoms.52 The FACIT-Sp12 asks agreement with statements such as “I have a reason for living” and “I find comfort in my faith or spiritual practice,” and it has been associated with less distress and more emotional well-being in patients with cancer.53 The positive affect and well-being scale for the Neuro-QOL asks agreement with statements such as “My life was peaceful” and “Many areas of my life were interesting to me.”36 Taken together, these findings strongly suggest that the lack of ability to engage in one’s environment and pursue activities that one chooses may significantly add to depression in creating risk of SI and SAs. The additive predictive value of these questions suggests a need to develop further questions focused on daily life engagement and enjoyment as well as sense of purpose in the evaluation of suicidal risk in individuals with SCI.

Study limitations Limitations of this study include its cross-sectional nature, bias of individuals who are presenting to SCI centers, recall bias from patient self-report, lack of multiple comparison testing, and the exploratory nature of the psychological function questions (including these not being administered to all subjects). Although several exploratory psychological variables tested demonstrated statistically significant associations with SI and SAs, the clinical significance of these differences is not known. Further information about specific timing of SCI relative to SAs would have allowed a more nuanced understanding of our findings. Our findings echo the high association of depression and mood disorders with SI and SAs, a concern especially appropriate in the

C.B. McCullumsmith et al population with SCI, where depression may not be adequately recognized or treated. Previous work done by our group has demonstrated that only 29% of those with depression in the population with SCI receive pharmacotherapy and 11% receive psychotherapy, but only half or less of these interventions meet standard guidelines for adequate antidepressant treatment.54 Our work suggests that patients with lifetime SAs and current SI have received more care than those with depression only, but might not have received adequate treatment to fully treat their illness. This finding, combined with recent work in the general population that demonstrated highest suicide risk for those with most time spent in depressive episodes,55 suggests a need for dramatic increases in screening and treatment efforts for depression and especially for SI and SAs in SCI.

Conclusions This cross-sectional study of prevalence of lifetime SAs and current SI suggests further work to be done in recognition and treatment of those at highest risk of suicidal behavior after SA. Certainly, all individuals with current or past mood disorder, psychosis, or lifetime SAs should be carefully evaluated and treated to remission. Furthermore, individuals with recent SCI, young age at SCI, and the most severe SCI classificationsdcomplete tetraplegia and paraplegiadshould receive regular monitoring of suicidal ideation and plans as well as treatment of depression. Further work needs to be done to explore methods for assessing suicide risk and the temporal associations between engagement in community activities, quality of life, depression, and SI and SAs in the population with SCI.

Supplier a. SPSS, Inc.

Keywords Depression; Rehabilitation; Spinal cord injuries; Suicide; Suicide, attempted; Suicidal ideation

Corresponding author Cheryl B. McCullumsmith, MD, PhD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, 260 Stetson St, Suite 3200, Cincinnati, OH 45219. E-mail address: [email protected].

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