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Mental Health After SCI

Psychological Interventions: Cognitive Behavioural Therapy

Author Year
Country
Research Design
PEDro Score
Total Sample Size
Methods Outcome
Burke et al., (2019)
Ireland
RCT
PEDro=8
NInitial=69 NFinal=57
Population: Mean age=52±13 yr; Gender:
males=52, females=17; Time since injury=16±12.1
yr; Level of injury: C=17, T=30; L=14, Not
reported=8; Severity of injury: AIS A=4, B=2, C=3,
D=4, Not reported=55.
Intervention: Participants were randomly assigned
to either a control group where they went about
their normal routine and the intervention group
received an online six module cognitive behavioural
therapy pain management program once per wk for
12 wk.
Outcome Measures: World Health Organization
Quality of Life Bref (WHOQOL-Bref), International
Spinal Cord injury Quality of Life Basic Data Set
(ISCIQOLBDS), International Spinal Cord Injury
Pain Basic Data Set (ISCIPBDS), Douleur
Neuropathique en 4 Questions (DN4), Chronic Pain
Acceptance Questionnaire 8 (CPAQ8), Brief Pain
Inventory (BPI), Hospital Anxiety and Depression
Scale (HADS) and Pittsburgh Sleep Quality Index
(PSQI).
1. . Moderate linear relationship
found between the number
of modules in which the
users engaged in 80% or
more of the content and
reductions in overall pain
intensity ((NRS) (p=0.05),
the ISCIPBDS pain
interference score (p=0.08),
the LSF domain (p=0.039),
the BPI interface scale
(p=0.10) and the
depression subscale of the
HADS (p=0.10).
2. At 3-mo follow-up a
moderate linear relationship
between module
engagement and
improvements in sleep
quality (p=0.06), the AMS
subcategory of the
ISCIPBDS (p=0.09) and
both the depression
(p=0.03) and anxiety
(p=0.05) subscales of the
HADS.
Coker et al., (2019)
USA
RCT
PEDro=8
N=81
Population: Control Group (n=40): Mean
age=52±15.3 yr; Gender: males=32, females=8;
Time since injury=81.5 mo; Level of injury:
complete=16, incomplete=24; Severity of injury:
AIS A=16, B=3, C=8, D=13.
Intervention Group (n=41): Mean age=48±12.8;
Gender: males=34, females=7; Time since
injury=95 mo; Level of injury: complete=19,
incomplete=22; Severity of injury: AIS A=19, B=2,
C=7, D=13.
Intervention: Participants were randomized to
either a control group in which they continued their
normal rehabilitation or an intervention group in
which they took part in an interactive cognitive
behaviour therapy based learning program for one
session per wk, 2 hrs per session for 6 wk with
assessments at baseline, post intervention and at
8-wk intervals post intervention.
Outcome Measures: Moorong Self-Efficacy Scale
(MSES), Generalized Self-Efficacy Scale (GSES),
Diener Satisfaction with Life Scale (SWLS),
Participation Assessment with Recombined Tools –
Objective (PART-O), Patient Health Questionnaire
– 9 (PHQ-9), and General Anxiety Disorder 7-Item
(GAD-7).
1. Non-significantly greater
increase in MSES for the
treatment group compared
to the control group from
baseline to 6-wk and
neither group showed
significant difference from
baseline to the 30-wk
follow-up (p=0.15).
2. The treatment group
showed significant
improvements for the
GSES, PHQ-9 and GAD-7
from baseline to 6-wk
whereas the control group
did not.
3. Neither group showed
significant changes in
SWLS or PART-O from
baseline to 6-wk.
4. Despite the significant
differences for the
treatment group from
baseline to 6-wk or from
baseline to 30-wk follow-up,
there are no significant
differences in results
between treatment and
control.
Migliorini et al., (2016)
Australia
RCT
PEDro=8
NInitial=59 NFinal=48
Population: Intervention group (n=34): Mean
age=47.5±12.2 yr; Gender: males=25, females=9;
Time since injury=11.4±11.9 yr; Level of injury:
complete paraplegia=5, incomplete paraplegia=8,
complete tetraplegia=1, incomplete tetraplegia=18,
unknown=2. Waitlist control group (n=25): Mean
age=52.8±12.9 yr; Gender: males=17, females=8;
Time since injury=19.8±14.0 yr; Level of injury:
compete paraplegia=7, incomplete paraplegia=13,
complete tetraplegia=2, incomplete tetraplegia=2,
unknown=1.
Intervention: Participants were randomized to
either an Electronic Personal Administration of
Cognitive Therapy (ePACT) group in which the
participants completed 10-module skills or a
Waitlist Control group with assessments at
baseline, 3 mo follow-up and 6 mo follow-up.
Outcome Measures: Depression, anxiety and
stress scale-short (DASS21), personal well-being
index, helplessness subscale and score above
normative threshold of the depression, anxiety and
stress scale-short form (DASS21).
1. 71 individuals accepted the
option to try the ePACT, but
12 did not complete the
intake process and those
that completed the intake
process and those that did
not only differed
significantly with regards to
stress scores (p=0.05).
2. No significant differences
between groups at baseline
besides for time since injury
(p=0.02) and level of injury
distribution.
3. Dropouts from the
intervention group did not
differ significantly from
those that did not drop out
in any outcome measure.
4. At post-intervention, the
ePACT group showed a
significant reduction in
depression, anxiety and
stress and satisfaction with
life significantly improved
(p<0.05 for all) while the
waitlist control group
improved significantly with
a reduction in depression
(p=0.01).
5. Significant reductions in
depression, anxiety and
stress were maintained from
post-intervention to 6
mo follow-up, and even
reduced even more, albeit
insignificantly.
Dorstyn et al., (2012)
Australia
RCT
PEDro=6
NInitial=40 NFinal=39
Population: Age=53.5yr; Gender: males=28,
females=12; Level of injury: paraplegia=24,
quadriplegia=16; Anxiety status=symptoms.
Intervention: Individuals were randomly assigned
to receive biweekly telecounselling for 20min over
12wk (n=20, treatment) or standard inpatient care
(n=20, control).
Outcome Measures: Depression Anxiety Stress
Scale-21 (DASS-21).
1. Small improvements in
DASS-21 depression
(d=0.32), anxiety (d=0.24)
and stress levels (d=0.27)
were found in the treatment
group compared to the
control group post
intervention.
2. Of the 8 individuals in the
treatment group that
reported mild, moderate or
severe levels of depression
and/or anxiety, 4 reported
no symptoms post
intervention.
3. Individuals in the control
group reported increases in
clinically significant
symptoms of depression
and/or anxiety over time.
Heutink et al., (2012)
Netherlands
RCT
PEDro=6
NInitial=61 NFinal=59
Population: Mean age=58.8yr; Gender: males=39,
females=22; Level of injury: paraplegia=42,
quadriplegia=19; Severity of injury: incomplete=39,
complete=22; Anxiety status=symptoms.
Intervention: Individuals with chronic neuropathic
pain were randomly assigned to receive a
multidisciplinary Cognitive Behavioural Therapy
(CBT, n=31) program or waitlist group (n=30). The
intervention consisted of 10 sessions over 10wk
and afollow-up session 3wk later.
Outcome Measures: Hospital Anxiety and
Depression Scale (HADS).
1. Individuals in the CBT
group found significant
improvement in HADSanxiety (p<0.027) and
participation (p<0.008)
compared to the waitlist
group.
Duchnick et al.,(2009)
RCT
PEDro=4
NInitial=41 NFinal=35
Population: Mean age=52.6yr; Gender: males=40,
females=1; Level of injury: paraplegia=19,
quadriplegia=22; Severity of injury: incomplete=31,
complete=10; Mean time post injury=53.2d; Anxiety
status=symptoms.
Intervention: Participants were randomly allocated
to either coping effectiveness training (CET, n=20)
or supportive group therapy (SGT, n=20). CET
focused on stress appraisal, problem solving,
communication skills, behavioral strategies,
cognitive strategies and social support. SGT
emphasized sharing experiences and information
related to SCI, emotional and cognitive reactions,
and support from peers and therapist. Each
inpatient group met 1x/wk for 60min. Outcomes
were assessed pre and post treatment, and at 3mo
follow-up.
Outcome Measures: Center for Epidemiologic
Studies Depression Scale (CES-D), State Trait
Anxiety Inventory (STAI).
1. Significant decreases in
STAI scores were seen at
discharge in both groups
(p<0.05).
2. STAI (p<0.001) scores
increased significantly
between discharge and
follow-up in both groups.
3. STAI was not affected by
group.
Dear et al., (2018)
Australia
Pre-Post
N=68
Population: Mean age=48.0±13.0 yr; Gender:
males=34, females=34; Time since injury=8.0±10.0
yr; Severity of injury: : complete=15,
incomplete=44, unsure=9.
Intervention: Participants completed five online
lessons and homework tasks for pain management
with weekly support from a clinical psychologist.
Outcome Measures: Pain disability index (PDI),
patient health questionnaire 9-item (PHQ-9),
generalized anxiety disorder scale 7-item),
Wisconsin brief pain questionnaire (WBPQ), pain
self-efficacy questionnaire (PSEQ), pain
catastrophizing scale (PCS), satisfaction with life
scale (SWLS).
1. Significant overall effect
observed for pain-related
disability (p<0.001), anxiety
(p<0.001) and depression
(p<0.001), as well as
improvements in all three
from baseline to posttreatment (p<0.001) and
even further improvements
at 3-mo follow-up
(p<0.015).
2. Significant overall time
effect observed for pain
self-efficacy (p<0.001), pain
catastrophizing (p<0.001)
and life satisfaction
(p<0.001).
3. Significant improvements
from baseline to posttreatment for pain
catastrophizing and life
satisfaction (p<0.001) with
life satisfaction improving
from post-treatment to
follow-up (p=0.006) but not
pain catastrophizing
(p=0.062).
Heutink et al. (2014)
Netherlands
Follow-Up
N=29
Population: Mean age=56.5yr; Gender: males=21,
females=8; Level of injury: paraplegia=18,
quadriplegia=11; Severity of injury: incomplete=14,
complete=15; Mean time post injury=5.4yr; Anxiety
status=symptoms.
Intervention: Participants who received treatment
in Heutink et al.,(2012) were assessed at at 6, 9,
and 12mo follow-up.
Outcome Measures: Hospital Anxiety &
Depression Scale (HADS).
1. HADS-anxiety scores
significantly decreased
across from pre- to posttreatment, to 6mo, and
to12mo (p<0.05).
Dorstyn et al., (2011)
Australia
PCT
NInitial=24 NFinal=19
Population: Mean age=48.5yr; Gender: males=20,
females=4; Level of injury: paraplegia=14,
quadriplegia=10; Severity of injury: incomplete=5,
complete=19; Anxiety status=symptoms.
Intervention: Participants with moderate to severe
DASS-21 scores received Cognitive Behavioural
Therapy (CBT, treatment, n=11) and those with
subclinical scores received standard care (control,
n=13). CBT was delivered via 7-22 sessions, each
for 30-60mins. The treatment group was also
prescribed low dose amitriptyline. Outcomes were
assessed pre and post treatment, and at 3mo
follow-up.
Outcome Measures: Depression Anxiety Stress
Scale-21 (DASS-21).
2. DASS-21 total scores did
not change significantly
over time in the treatment
group.
3. DASS-21 total scores,
anxiety subscores and
stress subscores
decreased post treatment
and increased at follow-up.
4. DASS-21 scores did not
change significantly over
time in the control group.
Migliorini et al., (2011)
Australia
Pre-Post
N=3
Population: Age range=41-65yr; males=2,
females=1; Severity of injury: incomplete=2,
complete=1; Anxiety status=symptoms.
Intervention: Participants were offered a computer
based Cognitive Behavioural Therapy (CBT)
intervention involving 10 modules.
Outcome Measures: Depression Anxiety Stress
Scale-21 (DASS-21), Symptoms Checklist-90
(SCL-90), Personal Wellbeing Index (PWI),
Emotional Wellbeing Questionnaire (EWQ).
1. DASS-21 anxiety score
decreased in all 3
individuals.
Perry et al. (2010)
Australia
PCT
NInitial=36 NFinal=30
Population: Mean age=44yr; Gender: males=28,
females=8; Level of injury: paraplegia=20,
quadriplegia=13, Severity of injury: incomplete=23,
complete=13; Mean time post injury=70.5mo;
Anxiety status=symptoms.
Intervention: Individuals with chronic neuropathic
pain received either a multidisciplinary cognitive
behavioural pain management program (treatment,
n=19) or standard care (control, n=17). Treatment
involved 10 sessions and pharmacotherapy over
6mo. Outcomes were assessed pre and post
treatment, and at 1mo and 9mo follow-up.
Outcome Measures: Hospital Anxiety and
Depression Scale (HADS).
1. HADS-anxiety scores
significantly improved over
time in the treatment group
when compared to the
control group (p=0.007).
Norrbrink Budh et al.
(2006)
PCT
N=38
Population: Mean age=52yr; Gender: males=14,
females=24; Level of injury: paraplegic=19,
quadriplegic=19; Severity of injury: incomplete=28,
complete=10; Mean time post injury=12yr; Anxiety
status=symptoms.
Intervention: Individuals with neuropathic pain
received cognitive behavioural therapy, education,
relaxation, and body awareness training (treatment,
n=27) while matched controls received no
treatment for neuropathic pain (n=11). Treatment
was delivered 5hr/wk for 10wk. Outcomes were
assessed pre and post treatment, and at 3mo,
6mo, and 12mo follow-up.
Outcome Measures: Hospital Anxiety and
Depression Scale (HADS).
1. At 12mo, there was no
significant change in
anxiety scores on the
HADS in the treatment
group from baseline.
2. However, the treatment
group showed systematic
decrease in anxiety on the
HADS as measured by
relative change in position
(95% CI) at 12mo.
Kennedy et al., (2003)
United Kingdom
PCT
N=85
Population: Mean age=?yr; Gender: males=69,
females=16; Level of injury: paraplegia=39,
quadriplegia=46; Severity of injury: incomplete=36,
complete=49; Mean time post injury=20wk; Anxiety
status=symptoms.
Intervention: Participants received coping
effectiveness training (CET, treatment, n=45) or no
treatment (control, n=40). CET was delivered in 60-
75min sessions for 2x/wk over 3.5wk and involved
problem solving, mindfulness, coping, and
improving social supports. Outcomes were
assessed pre and post treatment, and at a 6wk
follow-up.
Outcome Measures: Beck Depression Inventory
(BDI), State Trait Anxiety Inventory (STAI), Coping
Strategies Scale (CSS), Self-Perception Scale
(SPS).
1 Post CET, the treatment
group showed a significant
reduction in STAI scores
(p=0.001) compared to
controls.
King & Kennedy (1999)
United Kingdom
PCT
N=38
Population: Mean age=33yr; Gender: males=29,
females=9; Level of injury: paraplegia=19,
quadriplegia=19; Severity of injury: incomplete=11,
complete=27; Mean time post injury=19yr; Anxiety
status=symptoms.
Intervention: Participants received coping
effectiveness training (treatment, n=19), while
matched controls received standard care (n=19).
Treatment was delivered in 60-75min sessions
2x/wk with 6-9 other participants. Sessions
included a mixture of didactic presentations,
practical exercises and group discussions.
Outcomes were assessed pre and post treatment,
and at 6wk follow-up.
Outcome Measures: Beck Depression Inventory
(BDI), State Trait Anxiety Inventory (STAI), COPE
Inventory.
1. There were significantly
greater reductions in
HADS- anxiety (p<0.05) in the treatment group than in
controls.
Craig et al., (1997)
Australia
PCT
N=69
Population: Mean age=31yr; Gender: males=57,
females=12; Level of injury: paraplegia=34,
quadriplegia=35; Severity of injury: incomplete=21,
complete=48; Time post injury=acute; Anxiety
status=symptoms.
Intervention: Participants received standard care
(control, n=41) or small group cognitive behavioural
therapy (CBT, treatment, n=28). CBT was provided
for 1.5hr/wk over 10wk and included muscle
relaxation, visualization techniques, self-hypnosis,
cognitive restructuring, social skills training, and
sexuality sessions. Outcomes were assessed pre
and post treatment, and at 1yr follow-up.
Outcome Measures: Beck Depression Inventory
(BDI), State Trait Anxiety Inventory (STAI),
Rosenberg Self-Esteem scale (RSES).
1. STAI and RSES scores did
not improve significantly at
1yr.
Craig et al., (1998a)
Australia
Follow-Up
N=58
Population: Mean age=31yr; Gender: males=57,
females=12; Level of injury: paraplegia=34,
quadriplegia=35; Severity of injury: incomplete=21,
complete=48; Time post injury=acute; Anxiety
status=symptoms.
Intervention: Participants from Craig et al.,(1997)
were assessed at 2yr follow-up.
Outcome Measures: Beck Depression Inventory
(BDI, State Trait Anxiety Inventory (STAI)
1. Those with high STAI
scores showed a significant
improvement on STAI over
time (p<0.01).

Discussion

Several studies examined the effect of in person group CBT related programs compared to standard care on improvement of anxiety symptoms for persons with SCI (Craig et al. 1997; Kennedy et al. 2003; King & Kennedy 1999; Li et al. 2019). Three of these studies found significant improvement in anxiety symptoms among those in the CBT group compared to the standard care group (Kennedy et al. 2003; King & Kennedy 1999; Li et al. 2019). Coker et al. (2019) found no significant effect of group based CBT on anxiety symptoms. Craig et al. (1997) found no improvement in anxiety symptoms among the participants overall. However, a subgroup of participants with high levels of anxiety experienced significant improvement in their anxiety symptoms (Craig et al. 1998b). One study examined the effect of telerehabilitation based CBT for managing anxiety symptoms. Dorstyn et al. (2012), in an RCT, reported small effects of telecounselling in improving anxiety symptoms compared to standard care. Migliorini et al. (2011) reported improvement in anxiety scores after an online CBT program for persons with SCI. Burke and colleagues (2019) found no significant difference in anxiety symptoms in the intervention group compared to the control group post intervention. However, significant decrease in anxiety symptoms were seen in the treatment group at 3 month follow-up. Four studies examined the effect of CBT program among persons with SCI and chronic pain (Blake et al. 2018; Heutink et al. 2014; Heutink et al. 2012; Norrbrink Budh et al. 2006; Perry et al. 2010) Blake et al. (2018) provided a guided 8 week online CBT program and found significant improvement in anxiety symptoms post intervention. Heutnick et al. (2012) in an RCT, found significant improvement in anxiety symptoms in the intervention group compared to the wait list control group; these results were maintained at 1 year follow up (Heutink et al. 2014). Perry et al. (2010) also found a multidisciplinary CBT program resulted in improvements
in anxiety over time. However, Norrbrink Budh et al. (2006) found no significant reduction in anxiety symptoms among those in the CBT group compared to the no treatment group. Duchnick et al. (2009) evaluated the effectiveness of a CBT training intervention compared to a supportive group program. The study reported significant decrease in anxiety scores among both groups and no group effect. Dorstyn et al. (2011) compared CBT combined with low dose amitriptyline to a standard care group and found those in the combined CBT and amitriptyline group had a significantly greater reduction in anxiety symptoms compared to the standard care group. However, this was not maintained at follow-up.

Conclusion

There is level 2 evidence from MISSING CONTENT (Craig et al. 1997; Craig et al. 1998a; Craig et al. 1999; Craig et al. 1998b; Kennedy et al. 2003; King & Kennedy 1999) that in person CBT may improve anxiety symptoms compared to standard treatment among those with elevated symptoms.

There is level 1a evidence (Dear et al. 2018; Dorstyn et al. 2011; Miglorini et al. 2011) that telerehabilitation based CBT improves symptoms of anxiety among persons with SCI.

There is level 1 evidence (Duchnick et al. 2009; Feng & Li 2017) that CBT is effective in improving anxiety symptoms post intervention.

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