Chapter V Depression and Women with Spinal Cord Injury

1 Chapter V Depression and Women with Spinal Cord Injury L ike all women with disabilities, women with spinal cord injury (SCI) may be at an elevated risk for depression due to the double jeopardy of being female and having a disability. Depression is at least twice as common among women compared to men (McGrath, Keita, Strickland & Russo, 1990), and persons with physical disabilities appear to be at greater risk for depression than the general population (Turner & Noh, 1988). It has been estimated that people with SCI are five times as likely to experience depression compared to people in general; the rates of depression following an SCI may be as high as 45%, which may underestimate depression in women (Boekamp, Overholser, & Schubert, 1996). The primary purpose of this study was to examine the phenomenon of depression among a sample of women with SCI (Hughes, Swedlund, Petersen, & Nosek, 2001). The current study sought to answer the following specific questions: 1) Does a sample of women with SCI report elevated levels of depression? 2) Do women with SCI reporting higher levels of perceived stress, social isolation, and pain, and lower levels of mobility, vitality, employment, and social support report V-1 Chapter V - FINAL REPORT

2 higher depression scores compared to those reporting positive outcomes on these factors? 3) Do Caucasian women with SCI report lower levels of depression compared to ethnic minority women with SCI? and 4) Would women with SCI reporting current abuse report higher levels of depression compared to those not reporting abuse? METHOD Procedures Participants in the larger study from which this subsample was drawn were recruited from public and private chronic care clinics as described in Chapter II. Eligibility requirements included women 18 to 64 years old with a physical disability that was symptomatic for at least two years. Of the 511 participants, 81 women had an SCI, 64 of whom completed the depression instrument. These 64 women comprised the sample for the current study. The recruitment procedures, the setting, and a description of the questionnaire and the measures are included in Chapters II and III of this report. The main outcome measure used for this study was the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977). Data Analysis V-2 Chapter V - FINAL REPORT

3 Univariate analysis of variance (ANOVA) assessed the relation of CES-D scores to categorical variables. Pearson s r correlations determined the association between CES-D scores and continuous variables. To determine the variables most highly associated with depression, a stepwise linear regression model was run. Because of the small sample size, the initial set of variables considered for the regression was restricted to the variables most highly associated with the CES-D score in the univariate analyses: perceived stress, social isolation, social support, vitality, employment status, and current abuse. Variables were allowed to enter the regression model if their p value was less than or equal to.05, and they were removed if their p value exceeded.10. The proportion of the total variation in the CES-D score explained by the variables in the final model was measured using the adjusted R 2 value. RESULTS The sample was composed of 64 women who were African American (29.7%), Hispanic (17.2%), Caucasian (43.8%), and members of other ethnic groups (9.4%). The majority of the women were unmarried (59.4%), unemployed (76.6%), and of low income (median household income $18,000). The mean age was 44.6 (SD = 11.7). The sample was well educated, with 71.4% of participants having at least 12 years of school. Nine women reported that they had experienced abuse during the past year. Nearly all women reported using some type of assistive device (95.3%) and requiring some help with daily activities (92.2%). The mean CES-D score was 20.9 (SD = 12.6), and 59.4% of the sample scored at a level indicating the likelihood of depression using the recommended cut- V-3 Chapter V - FINAL REPORT

4 off score of 16. Specifically, 37.5% of the sample scored from 16 30; 15.6% scored 31 45; and 6.3% scored 46 or higher. Pearson s r correlations were calculated to determine the association of CES-D scores with other continuous variables (see Table 5.1). Higher CES-D scores were significantly associated with lower levels of education and income, but the correlation of age with CES-D was not significant. Most disability-related measures were significantly correlated with CES-D scores. Elevated CES-D scores were highly correlated with greater perceived stress, less social support, lower vitality, greater social isolation, less mobility, and greater pain. As reported on Table 5.2, one-way ANOVAs were conducted to determine the association of categorical variables with CES-D scores. CES-D scores were significantly higher for participants who were unemployed versus those who were employed, and they were higher for the nine women reporting current abuse compared to women not reporting abuse. Although associations of CES-D scores with marital status and ethnicity were not significant, mean CES-D scores were higher for Hispanic and African American women than for those who were Caucasian. V-4 Chapter V - FINAL REPORT

5 Table 5.1 Correlations of depression (CES-D) scores with other variables Variable Mean SD r p Age 44.6 11.7.061.632 Years of school 12.9 4.0 -.349.005 Household income $36,318 $48,990 -.349.011 Age at injury 32.4 14.7.258.041 Time since injury 12.0 10.8 -.279.027 CHART Mobility Scale a 71.5 22.8 -.468.000 Social Isolation Index a 14.1 8.2 -.495.000 Perceived Stress Scale (10-item) b 18.6 7.8.803.000 SF-36 Pain Scale a 41.4 26.8 -.461.000 SF-36 Physical Functioning Scale a 16.9 17.9 -.287.021 SF-36 Vitality Scale a 46.3 24.8 -.519.000 Social Support Scale a 24.6 8.3 -.524.000 Note: CES-D = Center for Epidemiologic Studies Depression Scale; CHART = Craig Handicap Assessment and Reporting Technique; SF-36 = Medical Outcomes Study Short Form-36. a Higher scores on these instruments indicate better functioning. b Higher scores indicate higher levels of perceived stress. V-5 Chapter V - FINAL REPORT

6 Table 5.2 Analyses of variance with depression (CES-D) scores Variable n Mean SD F p CES-D score Ethnicity 1.60.20 African American 19 22.5 13.8 Caucasian 28 17.8 12.6 Hispanic 11 26.0 10.1 Other 6 19.8 9.4 Marital status 2.32.13 Married/in relationship 26 18.1 14.2 Single, widowed, divorced 38 22.9 11.0 Employment status 7.22.01 Employed 15 13.7 9.1 Not employed 49 23.2 12.7 Abuse 4.41.04 Abuse within past year 9 28.9 14.6 No reported abuse 55 19.7 11.8 Note: CES-D = Center for Epidemiologic Studies Depression Scale. A dichotomous variable classified women as depressed or not depressed. Chi-square analyses indicated that single or unemployed women were more likely to be classified as depressed than women who were married, in a relationship, or employed (see Table 5.3). Univariate ANOVAs indicated that depressed women had greater perceived stress, were more isolated, had less mobility, less social support, more pain, lower levels of physical functioning, and lower vitality than nondepressed women (see Table 5.4). The six variables most highly associated with depression in the ANOVAs were entered into a stepwise linear regression. Perceived stress and social isolation remained in the final model, accounting for 71.1% of the total variation in the CES- D score. V-6 Chapter V - FINAL REPORT

7 Perceived stress scores were positively associated with the CES-D scores, but social isolation index scores were negatively associated (see Table 5.5). Higher CES-D scores were associated with higher levels of stress and greater social isolation. For every increase in the perceived stress score of one unit, the predicted depression score increased by 1.16, when the isolation index was held constant. Although social support, vitality, and employment status were significant in the ANOVAs, they did not enter the final regression model because of their strong associations with perceived stress or social isolation. Abuse did not enter the model because it did not explain additional variation in the CES-D scores over what was explained by stress and social isolation. Table 5.3 Depression status by ethnicity, marital status, employment, and abuse Variable n Depressed, Not depressed, Chi-sq p n (%) n (%) Ethnicity 6.812.078 African American 19 12 (63.2) 7 (36.8) Caucasian 28 13 (46.4) 15 (53.6) Hispanic 11 10 (90.9) 1 (9.1) Other 6 3 (50.0) 3 (50.0) Marital status 5.288.037 Married/in relationship 26 11 (42.3) 15 (57.7) Single, widowed, divorced 38 27 (71.1) 11 (28.9) Employment status 8.690.006 Employed 15 4 (26.7) 11 (73.3) Not employed 49 34 (69.4) 15 (30.6) Abuse 1.47.291 Abuse within past year 9 7 (77.8) 2 (22.2) No reported abuse 55 31 (56.4) 24 (43.6) V-7 Chapter V - FINAL REPORT

8 Table 5.4 Depression (CES-D) by current age, education, income, age at injury, time since injury, and scores on study instruments Depressed (n = 38) Not depressed (n = 26) Variable Mean SD M SD F p Current age 44.5 11.7 44.7 11.9.004.951 Years of school 12.0 4.2 14.4 3.2 5.56.022 Household income $23,476 $25,770 $52,508 $65,015 4.84.032 Age at injury 34.4 13.5 29.4 16.0 1.801.185 Time since injury 9.9 9.0 15.1 12.6 3.640.061 CHART Mobility Scale a 62.3 21.9 85.1 17.0 20.045.000 Social Isolation Index a 12.0 8.2 17.3 7.1 7.242.009 Perceived Stress Scale b 22.0 7.1 13.7 6.1 24.029.000 SF-36 Pain Scale a 34.0 22.7 52.1 29.0 7.820.007 SF-36 Physical Functioning Scale a 12.1 13.9 23.8 20.8 7.311.009 SF-36 Vitality Scale a 37.0 20.6 60.0 24.4 16.570.000 Social Support Scale a 21.4 9.0 29.3 3.9 17.625.000 a Higher scores indicate better functioning. b Higher perceived stress scores indicate greater stress.. V-8 Chapter V - FINAL REPORT

9 Table 5.5 Results of stepwise regression of selected variables with CES-D score Variable Beta coefficient SE t p Constant 5.567 3.075 1.810.075 Perceived stress 1.159.114 10.190.000 Isolation index -.441.109-4.042.000 CONCLUSION Psychosocial factors, especially stress and social isolation, appeared to play a more potent role in the depression of women with SCI than disability-related or demographic factors. Since the linkage between stress and depression in SCI has been documented in other research (Frank & Elliott, 1987), we expected our finding that perceived stress would be elevated and positively associated with more depression. Our finding that social isolation was the second most powerful predictor of depression highlights the importance of social connectedness among women with disabilities, a finding that offers an important contribution to the relevant literature. Moreover, based on the literature, we expected our findings that pain and depression would be positively associated (Boekamp et al., 1996). As anticipated, this study confirmed other research suggesting that less mobility (Tate, Forchheimer, Maynard, & Dijkers, 1994), lower levels of social support (Boekamp et al., 1996), and less education (Krause, Kemp, & Coker, 2000) were associated with higher levels of depression. V-9 Chapter V - FINAL REPORT

10 References Boekamp, J. R., Overholser, J. C., & Schubert, D. S. P. (1996). Depression following a spinal cord injury. Int J Psychiatry Med, 26, 329-349. Frank, R. G. & Elliott, T. R. (1987). Life stress and psychologic adjustment following spinal cord injury. Arch Phys Med Rehabil, 68, 344-347. Hughes, R. B., Swedlund, N., Petersen, N., & Nosek, M. A. (2001). Depression and women with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 7, 16-24. Krause, J. S., Kemp, B., & Coker, J. (2000). Depression after spinal cord injury: Relation to gender, ethnicity, aging, and socioeconomic indicators. Arch Phys Med Rehabil, 81, 1099-1109. McGrath, E., Keita, G.P., Strickland, B.R., & Russo, N.F. (Eds). (1990) Women and depression: Risk factors and treatment issues: Final report of the American Psychological Association's National Task Force on Women and Depression (1990). Washington, DC: American Psychological Association. V-10 Chapter V - FINAL REPORT

11 Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Tate, D., Forchheimer, M., Maynard, F., & Dijkers, M. (1994). Predicting depression and psychological distress in persons with spinal cord injury based on indicators of handicap. American Journal of Physical Medicine and Rehabilitation, 73, 175-183. Turner, R. J. & Noh, S. (1988). Physical disability and depression: A longitudinal analysis. Journal of Health and Social Behavior, 29, 23-37. V-11 Chapter V - FINAL REPORT