Shalan Joodah Rhemah Al Abbudi*, Khalida Ibraheem Ezzat, Ali Abdelilah Zebala, Delkhwaz Jameel Hamdy, Mohammad Shalan Joda Al-Beedany and Mohammed Shalal Farhan
Deptartment of Medicine, Al-Imamein Al-Kadhimein Medical City, Baghdad, Iraq
Received Date: August 10, 2017; Accepted Date: September 25, 2017; Published Date: September 30, 2017
Citation: Al Abbudi SJR, Ezzat KI, Zebala AA, Hamdy DJ, Al-Beedany MSJ, et al. (2017) Prevalence and Determinants of Depression Among Traumatic Spinal Cord Injured Patients Attending Ibn-Al-Quff Hospital, Baghdad, Iraq. J Psychiatry 20: 428. doi:10.4172/2378-5756.1000428
Copyright: © 2017 Al Abbudi SJR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Journal of Psychiatry
Objective: To identify the prevalence and potential risk factors of depression among spinal cord injured inpatients, and assessment of the severity of depression. Methods: A cross-sectional study conducted at Ibn Al Quff Hospital for spinal cord injury rehabilitation. All inpatients with traumatic spinal cord injury were recruited excluding severely injured and those injured due to congenital and medical causes. Socio-demographic variables, spinal cord injury characteristics and comorbidity were compiled. Self-Reporting Questioner (SRQ-20) was used to identify mental symptoms. DSM-IV criteria for depression and Hamilton-17 Scale, for assessment of severity of depression were used. Results: A total of 274 spinal cord injured inpatients were approached; 93% responded; paraplegics 75.7% and tetraplegics 24.3%. Violence was the major cause of injury. Seventy four percent (74.1%) had depression; 44% of them had severe and very severe depression. Depression was significantly associated with age (P=0.001), gender (P=0.001), education level (P=0.038), occupation (P=0.003); smoking habit (P=0.035), duration of injury (P=0.003), times of admission (P=0.000), and comorbidity (P=0.18). Conclusion: Prevalence of depression is high and frequent among spinal cord injured patients. Demographic and spinal cord injury variables are significantly associated with depression and are the most important determinants of depression.
Depression; Spinal cord injury; DSM-IV criteria; Psychological disorders
SRQ: Self-Reporting Questionnaires; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders-IV; SCI: Spinal Cord Injury; MDD: Major Depressive Disorder; WHO: World Health Organization; HAM-D: Hamilton Scale for Severity of Depression
Spinal cord injury (SCI) is a devastating condition causing profound life changes for millions of people around the world . Over 80% of traumatic SCI are male, with an average age at injury s of about 40 years and most frequent causes of injuries include motor vehicle accidents, violence, falls, and recreational accidents . SCI typically causes paralysis and permanent disability. Despite costly and aggressive rehabilitative options, injuries to the spinal cord remain permanent and create lifelong challenges for survivors . SCI results in diminished mobility, greatly reduced functional independence, and difficulties with socialization and employment . Exposure to life-threatening conditions or severe mental stress may lead to various psychological reactions including depression. One of the deleterious stresses is that experienced during war. Veterans encumbered with physical disabilities are more prone to depression, among other psychological disorders . During the Iraq-Iran war, many young soldiers and paramilitary troops sustained physical disabilities which were compounded by psychological conflicts . The impact of SCI on psychological status has been variously debated. Several studies have suggested that SCI is associated with raised risks of psychological problems. Negative psychological states have been found in 30-40% percent of patients with SCI [6-8]. The Diagnostic and Statistical Manual of Mental Disorders- IV (DSM-IV)  defines many disorders including MDD on the basis of the presence of a minimum number of symptoms or features from a list [10,11]. Depression is the most common psychological issue associated with SCI , reportedly affecting approximately 30% of patients, and is generally characterized by depressed mood and diminished pleasure over a two-week span accompanied by issues including energy loss, concentration difficulties, and sleep or appetite disturbances . There is a large body of literature documenting the high prevalence of depression, psychological distress, and psychological morbidity after spinal cord injury (SCI) [12-14]. In a recent study of community-residing people with traumatic SCI, the rate of probable major depression was found to be 3 times that of the general population [12-15].
In Iraq, Ibn Al-Quff hospital for spinal cord injuries was opened on October 1982 after increased incidence of spinal cord injuries at beginning of Iraq-Iran war [16,17]. More than four thousand spinal cord injured (SCI) patients had been rehabilitated in Iraq during the last three decades at Ibn Al-Quff hospital spinal cord injury rehabilitation . About 84.8% of spinal cord injured persons were paraplegic, and about 15.2% were quadriplegic persons, 90.5% male and 9.5% were female. The causes of SCIs, are approximately 50% for high velocity missiles, 18% road traffic accidents, 16% fall from height, 6% stab wound, and 10% for others. A total of 1768 spinal cord injured persons were admitted to the Ibn AL-Quff hospital during 2003-2010 .
Design and setting
This is a cross-sectional study with analytic component. It was conducted in Ibn Al Quff hospital for spinal cord injuries, Baghdad, Iraq. The data collection was done during the period from June, 1st, 2011 to November, 1st, 2012. Study Population and Sampling: All inpatients with traumatic spinal cord injury, both genders were included.
All traumatic spinal cord injured patients with paraplegia or quadriplegia, aged ≥ 18 years, of both sexes, and accepted to participate and have the interview.
Severe injured patients, who cannot respond to questions, age >18 years, with paraplegia or quadriplegia by other non-traumatic causes like medical disorder or congenital disorders, and those with substance abuse.
Data collection tools
Basic socio-demographic variables, spinal cord injury history and history of co morbid characteristic and complications were compiled using a questionnaire filled through a direct interview. Mental status of the traumatic spinal cord injured inpatient was assessed using selfreporting questionnaires scale (SRQ-20) that was developed by the WHO and used in many countries. According to previous studies conducted in Iraq, the cut-off point identified used to categories “potential psychiatric cases” and more generally persons with significant psychological distress was seven . Those with positive SRQ-20 results were assessed for the presence of depression using the DSM-IV criteria . Those with “depression” were further assessed for the severity of depression using the Hamilton scale. It contains 17 items to be rated (HAM-17) .
Definition of variables
The independent variables evaluated to explain depression were socio-demographics (age, gender, marital status, level of education, occupation, smoking habits, characteristics of the disability (types, causes, duration, admission times, and rehabilitation), complications and bed sores, and comorbid condition.
SPSS version 17 used for data entry and analysis. The prevalence of depression and its 95% confidence interval was calculated. Univariate analysis using Chi square was applied to identify potential risk factors of depression.
Informed consent was obtained from the patients after clarifying the objectives of the study. Names were kept anonymous and interviews were conducted with full privacy.
A total of 274 spinal cord injured inpatients were approached; 255 welcomed and accepted to participate (response rate: 93%). Paraplegics were 193 (75.7%) and quadriplegics were 62 (24.3%). Distribution by socio-demographic and spinal cord injury characteristics and comorbid conditions are shown in (Tables 1 and 2).
|Socio demographic characteristic||Spinal Cord Injury||Total (255)|
|Age Group||18 yrs - 25 yrs||70||23||93||36.5|
|26 yrs - 35 yrs||51||18||69||27.1|
|36 yrs - 45 yrs||33||9||42||16.5|
|46 yrs - 55 yrs||28||8||36||14.1|
|56 yrs - 65 yrs||11||4||15||5.9|
|Institute and college||14||1||15||5.9|
Table 1: Distribution of the study group by socio-demographic characteristics and smoking habit.
|Spinal Cord Injury||Total (255)|
|Cause of injuries||Bullet||28||12||40||15.7|
|Duration of Injury||Less than 1 year||104||27||131||51.4|
|1 - 5 years||46||7||53||20.8|
|More than 5 years||43||28||71||27.8|
|Duration of Admission||Less than 1 month||14||7||21||8.2|
|1 - 6 months||148||47||195||76.5|
|More than 6 months||31||8||39||15.3|
|Times of Admission||First Admission||133||38||171||67.1|
Table 2: Distribution of the study group by spinal cord injury characteristics and co-morbid conditions.
The prevalence of depression was 74.1%. About 44.7% of the sample has severe and very severe depression. None were receiving treatment; psychotherapy or medications. A cross classification of patients with and without depression by socio-demographic and spinal cord injury patients characteristics and co-morbid conditions is shown in (Tables 3 and 4).
|Depression||Total (255)||P value|
|Age Group||18 yrs - 25 yrs||21||22.6||72||77.4||93||36.47||0.001|
|26 yrs - 35 yrs||33||47.83||36||52.17||69||27.05|
|36 yrs - 45 yrs||6||14.29||36||85.71||42||16.47|
|46 yrs - 55 yrs||3||8.34||33||91.66||36||14.11|
|56 yrs - 65 yrs||3||20||12||80||15||5.88|
Table 3: Distribution of the study group by depression and the socio-demographic characteristics.
|Depression||Total (255)||P value|
|Cause of injuries||Bullet||4||10||36||90||40||15.7||0.086|
|Duration of injury||Up to 1 year||44||33.6||87||66.4||131||51.37||0.003|
|1 - 5 years||5||9.4||48||90.6||53||20.8|
|More than 5 years||17||23.9||54||76.1||71||27.8|
|Duration of admission||Less than 1 month||5||23.8||16||76.2||21||8.2||0.0744|
|1 - 6 months||49||25.1||146||74.9||195||76.5|
|More than 6 months||12||30.8||27||69.2||39||15.3|
|Times of Admission||First Admission||57||33.3||114||66.7||171||67.1||0.000|
Table 4: Distribution of the study group by depression and spinal cord injury characteristics and presence of complication or comorbid condition.
The degree of severity of depression was explored according to socio-demographic characteristics and other co morbid features associated with spinal cord injury shown in (Tables 5 and 6).
|No Depression||Mild Depression||Moderate Depression||Severe Depression||Very Severe Depression||No.||(%)|
|Age Group||18 yrs - 25 yrs||21||22.5||3||3.2||21||22.5||18||19.3||30||32.2||93||36.5||0.000|
|26 yrs - 35 yrs||33||47.8||6||8.7||9||13.05||9||13.05||12||17.4||69||27.1|
|36 yrs - 45 yrs||6||14.3||9||21.43||6||14.3||6||14.3||15||35.7||42||16.5|
|46 yrs - 55 yrs||3||8.3||6||16.7||9||25||3||8.3||15||41.7||36||14.1|
|56 yrs - 65 yrs||3||20||6||40||0||0||0||0||6||40||15||5.9|
Table 5: Distribution of the study group by degree of severity of depression and the socio-demographic characteristics.
|Depression||Total (255)||P value|
|No Depression||Mild Depression||Moderate Depression||Severe Depression||Very Severe Depression||No.||%|
|Cause of injuries||Bullet||4||10||1||2.5||6||15||13||32.5||16||40||40||15.7||0.010|
|Duration of injury||Less than 1 year||44||33.6||15||11.5||21||16.03||21||16.03||30||22.9||131||51.4||0.011|
|1 - 5 years||5||9.4||6||11.32||9||17||6||11.32||27||50.9||53||20.8|
|More than 5 years||17||23.95||9||12.7||15||21.1||9||12.7||21||29.6||71||27.8|
|Duration of admission||Less than 1 month||5||23.8||5||23.8||7||33.3||0||0||4||19.05||21||8.2||0.089|
|1 - 6 months||49||25.1||22||11.3||32||16.4||33||16.9||59||30.3||195||76.5|
|More than 6 months||12||30.8||3||7.7||6||15.4||3||7.7||15||38.5||39||15.3|
|Times of Admission||First Admission||57||33.3||24||14.04||24||14.0||24||14.04||42||24.6||171||67.1||0.000|
Table 6: Distribution of the study group by degree of severity of depression and spinal cord injury characteristics and presence of complication or comorbid condition.
The prevalence of depression was highest among those aged (46- 55) years (91.66%) and lowest among those aged 26-35 years (52.17%) (P=0.001). Females had significantly higher proportion of depression (94.12%) compared to males (69.12%) (P=0.001). Depression was significantly higher among illiterate (90%) than other educated patients (P=0.038). Unemployed (85.7%) and housekeepers (92.2%) patients had significantly higher prevalence of depression than employed patients (66.6%) (P=0.003). Depression was significantly higher among smokers (83.3%) than non- smokers (P=0.035).
The prevalence of depression was not significantly different by marital status (P=0.258), types of disability (P=0.727), and causes of spinal cord injury (P=0.086). The prevalence of depression was highest among those with injury of spinal cord for 1-5years duration (90.6%) (P=0.003), those with frequent admissions to the hospital (89.3%) (P=0.001), those who have other comorbid illnesses (P=0.018), and among those exposed to life events (P=0.008).
The prevalence of depression was not significantly affected by family history of mental illness (P=0.116), duration of admission (P=0.744), accompanied persons (P=0.688), visitors (P=0.646), rehabilitation (P=0.434), walking aids (P=0.935), complications (P=0.253), and presence of bed sores (P=0.324).
The assessment of depressed spinal cord injured patients by severity of depression revealed that 25.9% had mild depression, 11.8% had moderate depression and 44.7% had severe or very severe depression (Tables 5 and 6). The severity of depression was significantly associated with socio-demographic characteristics; age of the patients (P=0.000), gender (P=0.000), marital status (P=0.029), education level (P=0.000), occupation (P=0.000), and smoking habit (P=0.000).
The severity of depression was significantly associated with the causes of spinal cord injury (P=0.010), duration of injury (P=0.011), times of admission (P=0.000), complications (P=0.001), and comorbidity (P=0.015).
The prevalence of depression was 74.1% which is higher than many studies done across cultures. There was a strong correlation between degree of severity of depression and socio-demographic characteristics of the SCI inpatients. American meta-analysis (2014) of 19 studies found the mean prevalence estimate of depression diagnosis after SCI was 22.2% . In a number of studies it has been reported that depression scores varies between 20-40% in SCI patients [23-25]. In Italian sample averaging 6 years post-SCI, found 16% reported significant symptoms of depression [25,26] employed an Australian sample who averaged 19 years post-SCI, 37% were identified as depressed [26,27] study of 233 Albertans with SCI; 28.9% were treated for depression following their traumatic SCIs [27,28] in a review found rates of major depression following SCI to vary widely across studies and can range from 7% to 31% of studied population [28,29] surveyed 568 adult traumatic SCI inpatient rehabilitation clients; approximately 22% met self-reported symptoms consistent with major depressive disorder [28,29] surveyed 849 SCI outpatients at one-year post injury and found 11.4% met criteria for MDD [27,30] suggest a 42% overall rate of depression with a 21% probable rate of major depression .
Prevalence of depression of this study (74.1%) was lower than result of study done in Bangladesh (2007) on 167 spinal cord injured patients that found rate of depression to be around 80.24% . Iranian study (2004) showed that the prevalence of depression in physically disabled veterans was (71%) , while recent Iranian study (2015) found 91 of 226 (40.2%) had moderate to severe depression . Estimates of the prevalence of depression are affected by the nature of the measures used, how depression is defined, aging characteristics of the samples studied, and when symptoms are assessed post-injury.
Current study found that depression and severity of depression among spinal cord injured patients significantly associated with duration of disability; 66.4%, 90.6%, 76.1% for duration; 1 year, 1-5 years, <5 years respectively, while Richardson and Richards, in a cross sectional study, found that rates of clinically significant depressive symptoms were reported by approximately 21%, 18%, 12% and 12% of SCI survivors surveyed at 1, 5, 15 and 25 years post injury, suggesting rates tended to decrease with time since injury [33,34] followed 411 SCI model system participants and found approximately 20% of at 1 year post injury and 18% at year 5 post-injury reported symptoms consistent with major depression [34,35]. In a longitudinal analysis, found a substantial relationship between reported depressive symptoms at 3 months and approximately a decade post injury, with 38% and 35% of SCI survivors surveyed meeting a criterion for moderate depression at these times [35,36] reported that anxiety, depression and hopelessness gradually increased beginning at week 30 post injury and continued until discharge from rehabilitation (week 48). At that point 60% of SCI clients scored above a clinical cut-off for depression (i.e., Beck Depression Inventory) . This study showed significant gender association with depression and severity of depression, while Kalpakjian and Albright founded an absence of gender differences in probable major depression and symptom severity . Turkish study that depression was more frequent in females .
Current study found no statistical significance between depression and patient receiving rehabilitation or not. Krause et al. suggested that depressive symptoms may not peak during inpatient rehabilitation and it may take additional time for the “low point of emotional adaptation to appear” .
In this study, no any patient received treatment; dedication or psychotherapy. In a review of American veterans with spinal cord injuries and disabilities, Smith et al.  concluded that many may not be receiving adequate treatment for depression and the authors encouraged more aggressive screening and treatment . Similarly, while a substantial percentage of their SCI clinic sample reported symptoms suggestive of major depression, Kemp and Krause found that none were receiving treatment (psychotherapy or medications) .
About 50% of causes of Spinal cord injury were bullets and shell explosions due to the security status and violence of Iraq and ongoing explosions and terrors events were major etiological factors associated with disability. Finding consistent with Sabah  violence is the commonest cause of Traumatic Spinal Cord Injuries in Iraq, which affect mainly the males at their most productive age.
The severity of depression of this study was the following; 25.9% mild depression, 11.8% moderate depression and 44.7% severe or very severe depression. Pakistanian study indicate the level of depression in people with physical disability, found that out of 35 individuals; 2.86% had mild mood disturbance, 2.86% had borderline clinical depression, 42.86% were moderately depressed, and 37.14% severely depressed and 14.29% were in extreme depression . Whelen SR et al. found that 41% of the women with spinal cord injury had depressive symptomatology in the mild to severe range. Nearly a third of the women had very severe depressive symptomatology .
In conclusion the prevalence of depression among SCI inpatients was 74.1%. About 45% of them were severely depressed. Severity of depression was significantly associated with sociodemographic characteristics, duration of disability, causes of injury, complications, and comorbidity. None of the depressed SCI patients received psychotherapy or medication. Violence was the commonest cause of Traumatic Spinal Cord Injuries. The results were compared with other studies from different cultures; prevalence of depressed spinal cord injured patients was higher than many studies and less than few.
We greatly appreciate the patients and medical staff of the Ibn Al Quff hospital for their participation and assistance with this research study.
Authors explore there was no fund for this study.
The authors declare no conflicts of interest.