Anxiety and Depression in Saudi Patients with Traumatic Spinal Cord Injury

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1 Anxiety and Depression in Saudi Patients with Traumatic Spinal Cord Injury Dr. Rafat Al-Owesie, MD, Msc Consultant Psychiatrist Head Department of Psychiatry & Psychology in Sultan BinAbdulAziz Humanitarian City Many studies have ascertained that anxiety and depression are more prevalent in the TSCI population than in the general population 20-44%. Depression and anxiety are associated with increased stays in hospital, less functional improvement in rehabilitation, increased mortality and morbidity, and the occurrence of more secondary complications (pressure sores, urinary tract infections). Studies that investigated the relation between ethnic, sociodemographic, injury related factors with the level of depression and anxiety in TSCI are scarce. One study found that women, were at a substantially higher risk for depressive symptoms. Dryden et al., 2004,Frank et al., 1992, Woolrich et al., 2006, Fann et al., 2011 Zimmerman et al., 1994, Catalano et al., 2011, S. Krause et al.,2000. A cross-sectional study from November 2009 to April 2011, in 102 (age range years; 84 males, 18 females) TSCI patients admitted to the Spinal Cord Injury Unit, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia. We used Mini International Neuropsychiatric Interview (M.I.N.I) for the diagnosis of depression and anxiety. short structured diagnostic interview, Compatible with (ICD-10) as well as the (DSM-IV). Simple, Clear, and easy to administer, takes 15 minutes. M.I.N.I has high inter-rater reliability and good predictive power. There is remarkable consistency in the prevalence rates of psychiatric disorders across sites and cultures when these interviews are used We used the Hospital Anxiety and Depression Scale (HADS) to measure the level of anxiety and depression of the study population. Sheehan et al.,

2 14-item scale, seven relating to depression and seven to anxiety, with responses in frequency or severity. Responses relate to the past week and patients are asked for their immediate reactions. Self-completion scale of the existence and severity of relatively mild degrees of mood disorder in non-psychiatric hospital out-patients. Zigmond and Snaith (1983). Advantages Self-administered tool, taking 5 minutes Easily understood and acceptable to patients. Easily incorporated into clinical practice and completed in waiting rooms, etc. Scale scores not affected by the existence of physical illness, making it applicable to clinical research of physical conditions. It has also been of use in spinal cord injury studies. Can also be used to assess outcome during hospitalisation. High response rates. Bowling (1995); Fallowfield et al (1987); Wilkinson and Barczak (1988) Reliability Zigmond and Snaith (1983) reported good reliability and validity, and scale scores did not seem to be affected by the existence of physical illness, which widened its use to clinical research of physical conditions. Satisfactory internal consistency. Inter-item correlation on depression scale was between 0.30 and Validity Validity was confirmed when HAD was compared with existing measures of anxiety and depression. There is evidence that the HAD scale performed better than the GHQ in identifying cases against the criterion of a research psychiatric interview This test was validated on the Arab population, and could discriminate patients from controls at a sensitivity of 79%, and a specificity of 87%. The test was also validated in TSCI population. A study in the United Kingdom (UK) established preliminary psychometric properties of the HADS with an outpatient sample of people with TSCI.The 2-factor structure of the HADS was detected with good internal consistency (HADS- A was 0.85, and HADS-D was 0.79), and promising content validity (HADS-A: 7.419, p5.001; HADS-D: 7.660, p5.001) and the HADS total score (7.585, p5.001) Aylard et al (1987); Snaith and Taylor (1985); Wilkinson and Barczak (1988) Malasi, Mirza IA, el-islam. 1991, Zigmond and Snaith, 1983 Sakakibara et al., 2009, Heinrich and Tate 1996, Tate et al.,

3 The incidence of depression was 24.5% and that of generalized anxiety was 21.6 %. This figure is similar the rates of clinically significant symptoms observed in previous studies, which ranged from about 14% to 35%. Most of the patients diagnosed as having depression and anxiety were in the mild to moderate severity as graded in the HADS score 3

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5 In this study women were significantly more likely to have elevated level anxiety and depression compared to their counterparts. This was consistent with the findings from previous research showing that Women are at substantially higher risk of psychological morbidity after major trauma than men, with significantly higher rates of post injury depression, symptoms of acute stress reaction (SASR), and posttraumatic stress disorder (PTSD). Peter et al 2001, Thietje et al 2011, Becker et al,2007 Chevalier et al., 2009, Dijkers, 2005 The present study found that there was a positive correlation between levels of depression, anxiety, and university education. A recent study reported that a higher level of education is associated with a greater risk of depression. In contrast, another report showed years of education negatively correlated with depressive symptoms. higher levels of personal insight in university-educated patients. The patient s family and workplace frequently have the perception that victims are totally dependent and useless. They encourage this option by providing a lifetime pension which means the end of a career and personal generativity. Yang et al.,2011. Krause et al., The cross-sectional design of this study precludes determination of causality. The size, especially for female patients is small. Respondents were from a subset of TSCI who were admitted for inpatient rehabilitation program and may not be representative of the general TSCI population. The HADS test is based on patients self-reports. The selfreport questionnaires bring forth several limitations regarding the accuracy and truthfulness of responses. Generalized anxiety and depression are very common in Saudi Traumatic Spinal Cord Injury victims. Saudi women with TSCI were at a significantly higher risk of having anxiety and depressive symptoms. Level of university education was modestly correlated with higher level anxiety and depression in Saudi TSCI population. 5

6 Adoption of a longitudinal design and more sophisticated statistical analysis methods to assess causal directions, relationships and assess the predictive nature of coping strategies over time. Investigate depression among spinal cord injury patients not only in rehabilitation hospital setting but also in community settings why, after the traumatic spinal cord injury, do some people adapt more successfully than others? What psychological characteristics of the individual lead to this difference? How resilience is related to successful rehabilitation from a traumatic injury? What coping strategies that can be employed remain critical in accounting for proper adjustment? 6