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Mental Health After SCI

Cognitive Behavioural Therapy

In the SCI population, the application of CBT approaches to aid in the management of anxiety and depression is described as a prudent choice given its demonstrated effectiveness in a wide range of disorders (Craig et al. 1997). CBT strategies can include addressing “irrational” or negative thoughts, increasing opportunities for participating in rewarding activities, and instruction in relaxation, among others. Within this context, issues of assertiveness, social skills and discussions of sexuality have also at times been included to address the unique concerns of individuals with SCI. Employing a group setting to provide CBT can also be a cost-effective opportunity for peer support, practice of social skills and the opportunity for gaining additional viewpoints. Several authors have described the effects of group CBT interventions for individuals following SCI to reduce psychological distress and/or provide “immunization” against future difficulties.

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 SelfEfficacy Scale (MSES),
Generalized SelfEfficacy Scale (GSES), Diener
Satisfaction with Life Scale (SWLS),
Participation Assessment with
Recombined Tools – Objective (PARTO),
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 followup,
and even reduced even more,
albeit insignificantly.
Dorstyn et al., (2012)
Australia
RCT
PEDro=6
N=40
Population: Age=53.5yr; Gender:
males=69%, females=31%; Level of
injury: paraplegia=24, tetraplegia=16.
Intervention: Individuals with SCI were
randomly assigned to receive
telecounselling or standard inpatient care.
Individuals in the treatment group
received 12 weeks of biweekly phone
motivational interviewing intervention for
20 mins.
Outcome Measures: Depression Anxiety
Stress Scale-21 (DASS-21)
. Small improvement in depression
(d=0.32) were seen among
individuals that received
telecounselling compared to standard
treatment group post intervention.
2. 4 of the 8 individuals in the treatment
group that reported mild, moderate or
extremely severe levels of
depression and/or anxiety reported
no symptoms postintervention; with
maintenance up to follow-up.
3. Individuals in the standard care group
reported increase in clinically
significant symptoms of depression
over time.
Heutink et al., (2012)
Netherlands
RCT
PEDro=6
NInitial=61 NFinal=59
Population: Mean age=58.8 yr; Gender:
males=39, females=22; Duration of
pain=5.4 yr; Type of pain=neuropathic.
Intervention: Individuals with SCI with
chronic neuropathic pain were randomly
assigned to receive interdisciplinary pain
management which included Cognitive
Behavioural Therapy (CBT) and
education or wait list control group. The
intervention consisted of 10 sessions over
10 week period with a comeback session
3 weeks after the 10th session.
Outcome Measures: Chronic Pain
Grade Questionnaire; Hospital Anxiety
and Depression Scale (HADS).
1. No significant difference in HADS
depression was seen between the
two groups or over time.
Duchnick et al., (2009)
USA
RCT
PEDro=4
N=40
Population: Coping effectiveness
training (CET): Mean age=50.8yr;
Gender: males=95%; Level of injury:
tetraplegia=40%; Severity of injury: AIS
A=30%; B=30%; C=5%; D=35%;
Supportive group therapy (SGT): Mean
age=54.6yr; Gender: males=100%; Level
of injury: tetraplegia=70%; Severity of
injury: AIS A=20%, B=20%, C=20%,
D=40%. Depression status=mild (no
severe psychiatric condition score based
on Mini-Mental State Examination).
Intervention: Participants were randomly
allocated into either the CET group or the
SGT group. Each inpatient group met
1x/wk for 60 min. The CET group focused
on: stress and appraisal, problem solving,
communication skills, behavioral
strategies, cognitive strategies and social
support/assertiveness. SGT group
emphasized the sharing of experiences
and information related to SCI, emotional
and cognitive reactions, and support and
education from peers and psychologist.
Outcome Measures: Center for
Epidemiologic Studies Depression Scale
(CES-D), State Trait Anxiety Inventory
(STAI).
1. No baseline differences were found.
2. Mood change was not affected by
treatment condition.
1. Significant decrease in depression
(CES-D) was seen at discharge
(p<0.05). However, depression
(p<0.05) increased significantly
between discharge and follow-up (3
mo).
Schulz et al., (2009)
USA
RCT
PEDro=6
N=346
Population: Mean age=53 yr; Mean time
since injury=8 yr.
Intervention: Participants with SCI and
their caregivers were randomly placed
into 3 groups: caregiver only intervention;
dual target intervention; information only
control condition. Interventions were
provided through computer telephone
over a 6 mo period. The intervention
involved knowledge and cognitive
behavioural skills for coping with SCI.
Outcome Measures: Center for
Epidemiologic Studies Depression Scale
(CES-D), health symptoms, self-care
problems, social integration.
1. Significant improvement in individuals
with SCI’s CES-D and health
symptoms were seen in the dual
treatment group compared to the
caregiver only group (p=0.014 versus
p=0.031).
2. Clinically significant improvement
was also seen in caregivers in the
dual target group compared to the
caregiver only and control group on
CES-D, burden, health symptoms.
Li et al., (2019)
China
Pre-Post
N=20
Population: Intervention group (n=9):
Mean age=41.7±8.1 yr; Gender: males=9,
females=0; Time since injury=8.1±4.1 mo;
Level of injury: paraplegia=5,
tetraplegia=4; Severity of injury:
complete=5, incomplete=4.
Comparison group (n=11): Mean
age=43.0±15.7 yr; Gender: males=11,
females=0; Time since injury=8.2±4.1 mo;
Level of injury: paraplegia=7,
tetraplegia=4; Severity of injury:
complete=5, incomplete=6.
Intervention: Participants were assigned
to either an 8-wk coping oriented
supportive program (COSP) or a
comparison group going about their usual
business.
Outcome Measures: Feasibility,
acceptability, brief coping orientations to
problems experienced inventory,
experienced inventory, Moorong selfefficacy scale, hospital anxiety and
depression scale (HADS), quality of life
enjoyment and satisfaction questionnaire
– short form and six-item social support
questionnaire.
1. Recruitment rate of this study was
88% and the retention rate was
100%, but 2 participants in the COSP
group did not attend the minimum
number of sessions necessary for
analysis.
2. Participants reported that the meeting
times and the length of each meeting
were very appropriate, while one
participant mentioned meeting more
frequently on a weekly basis.
3. Encouragement and support from
peers were reported as motivation
enhancers and enjoyed the
communication during the meetings.
4. Significantly higher self-efficacy
scores in the COSP group compared
to the comparison group (p=0.048).
5. Statistically significant effects of the
COSP on participant’s life enjoyment
and satisfaction (p=0.005) and
satisfaction of social support
(p=0.022).
6. Statistically significant improvements
in self-efficacy (p=0.008), depression
(p=0.007) and satisfaction with
medicine (p=0.046) for the COSP
group, but not the comparison 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 selfefficacy 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).
7. Significant improvements from
baseline to post-treatment 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).
Verwer et al., (2016)
Netherlands
Pre-Post
NInitial=14 NFinal=7
Population: Mean age=44.7 yr; Gender:
males=11, females=3; Time since
injury=15 mo; Level of injury:
paraplegia=10, tetraplegia/unknown=4;
Severity of injury: complete=6,
incomplete=8.
Intervention: Participants engaged in an
online self-help program called Psyfit in
which they were asked to complete 2 of 6
modules with 4 wk given to complete
each module and assesments taken preintervention,
post-intervention and at 3-
mo follow-up.
Outcome Measures: Adherence,
satisfaction, mental health inventory-5
(MHI-5), center for epidemiological
studies depression scale (CES-D), and
the Warwick-Edinburgh mental well-being
scale.
1. 75% of the participants completed
the first module and 39% completed
the second, 11 participants finished
50% or more of the first module and
7 completed the entire first module
and started with the second module
and these were considered the study
completers.
2. Five of the seven completers
reported that the program was good
and they would recommend it to
others.
3. The main criticism was that the
program was not specified to SCI
participants enough, and the other
was that the program modules were
too long and rigid, making them
difficult to want to complete.
3. Study completers showed significant
improvements in the MHI-5 scores
from pre- to post-intervention
(p<0.05) and all scores decreased
significantly between postintervention and 3-mo follow-up
(p<0.05), resulting in no significant
difference from pre-intervention to 3-
mo follow-up (p>0.05).
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; Depression
status=symptoms.
Intervention: Participants who received
treatment in Heutink et al.,(2012) were
assessed at 6, 9, and 12mo follow-up.
Outcome Measures: Hospital Anxiety &
Depression Scale (HADS).
1. HADS-depression scores did not
change over time.
Dorstyn et al., 2011
Australia
PCT
N=24
Population: Treatment: Mean
age=53.2yr; Gender: males=9,
females=2; Level of injury: paraplegia=6,
quadriplegia=5; Severity of injury:
complete=8, incomplete=3; Control: Mean
age=44.5yr; Gender: males=11,
females=2; Level of injury: paraplegia=8,
quadriplegia=5; Severity of injury:
complete=11, incomplete=2;
Intervention: Individuals were assessed
using the Depression Anxiety Stress
Scale-21 (DASS-21). Those with
subclinical DASS-21 scores were placed
in the control group. Those with moderate
to severe scores were offered individual
Cognitive Behavioural Therapy (CBT)
treatment for a range of 7 to 22 sessions
for 30-60mins each. These individuals
were also prescribed low dose
amitriptyline as well as 5 control
participants for neuropathic pain.
Outcome Measures: Depression Anxiety
Stress Scale-21 (DASS-21)
1. Mood had no effect on functional
independence measure outcomes at
admission or discharge.
2. Total DASS-21 scores did not
change significantly over time in the
treatment group however, depression
subscores varied significantly.
3. Mean depression subscores
decreased significantly post
interventions; however increased
significantly at 3 mo follow-up.
3. At 3 mo follow-up, 78% of individuals
in the treatment group met clinical
levels of caseness on the DASS-21;
only 1 individual in the control group
met these criteria.
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
Intervention: Participants were offered a
computer based Cognitive Behavioural
Therapy (CBT) intervention involving 10
modules.
Outcome Measures: Depression Anxiety
Stress Scale-21 (DASS-21), PWI, SCL
EWQ
1. A reduction in DASS-21 depression
and stress scale was seen in 2
Individuals; anxiety scale in all three
individuals.
2. Overall quality of life improved in 1
individual and remained the same in
2 individuals.
Perry et al., (2010)
Australia
PCT
N=36
Population: Mean age=43.8yr;
M/F=28/8; Level of injury: tetraplegia=13,
paraplegia=20, Severity of injury:
complete=13, incomplete=23; Duration of
pain=60.5 mo; Type of pain=mixed.
Intervention: Individuals with SCI and
chronic pain were placed in either the
multidisciplinary cognitive behavioural
pain management program (PMPs) group
which involved a pharmacological
treatment plan and individual and group
based CBT for pain; or the usual care
group.
Outcome Measures: Hospital Anxiety
and Depression Scale (HADS).
1. A trend towards improvement on the
HADS depression score was seen in
the PMP group at 1 mo post
treatment; however, the HADS
depression scores returned to pretreatment levels at 9 mo follow-up.
Norrbrink Budh et al.,
(2006)
Sweden
PCT
N=38
Population: Treatment: Mean
age=53.2yr; Gender: males=9,
females=18; Level of injury: C=15, Th=6,
L/S=6; Severity of injury: AIS: A=4, C=3,
D=19, E=1; Controls: Mean age=49.9yr;
Gender: males=5, females=6; Level of
injury: C=4, Th=7; Severity of injury: AIS:
A=6, D=5; Depression status=mixed.
Intervention: The intervention group
received education, Cognitive
Behavioural Therapy (CBT), relaxation
and body awareness training totaling 5
hr/wk for 10 wk while matched controls
received no treatment for neuropathic
pain. Depression was assessed as a
secondary outcome.
Outcome Measures: Hospital Anxiety
and Depression Scale (HADS).
1.  At 1 yr follow up, the sign test
showed no significant change in
depression levels HADS in the
treatment group from baseline.
2. However, the treatment group
showed systematic decrease in
depression as measured by relative
change in position (95% confidence
interval) at 1 yr follow up.
3. Depression also decreased
systematically in the treatment group
compared to the control group at 1 yr
follow up; however, the sign test
showed no significant change
Kennedy et al., (2003)
United Kingdom
Cohort
NInitial=85; NFinal=85
Population: SCI: Age=16-65 yr; Cause of
injury: trauma; Chronicity=acute.
Depression status=mild (BDI=15)
Intervention: Consisted of 60-75 min
sessions 2x/wk for 3.5 wk in small groups
of 6-9 participants. Session topics were:
normalizing stress, appraisal skills,
problem solving, examination of thoughts
feeling and behavior, awareness of
negative assumptions, and choosing
appropriate ways both to cope and to
increase social supports.
Outcome Measures: Beck Depression
Inventory (BDI), State Trait Anxiety
Inventory (STAI), Coping Strategies Scale
(CSS), Self-Perception Scale (SPS), and
Functional Impairment Measure (FIM).
Measures were taken before and
immediately after the intervention, and at
a 6wk follow-up with the intervention
group, and every 6 weeks with the
historic control group.
1. Mood: Depression scores decreased
for the intervention group following
the intervention (p=0.001).
Craig et al., (1999)
Australia
Case Control
NInitial=58; NFinal=58
Population: SCI: Age=16-73 yr; Gender:
males=57, females=12; Severity of injury:
complete=68%-71%; Chronicity=acute.
Depression status=mixed group.
Intervention: 10 wk in small groups.
Each session lasted 1.5-2 hrs replacing
normal rehab therapy. Individuals
underwent Cognitive Behavioural
Therapy (CBT) attempts to change
behaviour and feeling associated with the
problem and considered maladaptive.
Main aim of the program was to provide
cognitive and behavioural skills to cope
with the psychological and social
difficulties encountered upon entering the
community (as described above).
Outcome Measures: Re-admissions,
drug usage, relationships, social
discrimination, self-reports of adjustment
Percentages are reported for each area
measured.
1. Re-admission: More control were
readmitted following discharge
(p<0.05).
2. Drug usage: Controls were found to
have higher self-reported drug usage
than the treatment group (cases)
(p<0.05).
3. Relationships and Social
discrimination: No significant
differences were noted between the
two groups in relation to the types of
relationship each person developed.
Self-reports of adjustment: Treatment
groups said they had a higher number of
persons who felt they had adjusted well
compared to the controls (p<0.01).
King & Kennedy (1999)
United Kingdom
PCT
NInitial=38; NFinal=38
Population: Age=16-65 yr;
Chronicity=acute; Depression status=mild
Intervention: Consisted of 60-75 min
sessions 2x/wk with 6-9 people. Sessions
included a mixture of didactic
presentations, practical exercises and
time allocated for open group
discussions. Following components made
up the program: appraisal training,
cognitive behavioural coping skills
training, and strategies for choosing an
adaptive match between appraisals and
coping skills, and obtaining and
maintaining social support.
Outcome Measures: Functional
Impairment Measure (FIM), Social
Support Questionnaire (SSQ), Beck
Depression Inventory (BDI), State Trait
Anxiety Inventory (STAI), COPE.
Pre-intervention comparisons of groups:
1. The intervention group used religion
significantly more and humour
significantly less as coping strategies
(p<0.05) than did controls.
2. There were no pre-intervention
differences between the groups on
range of injury, social support, FIM
scores, other coping strategies,
depression or anxiety.
Post-intervention comparison of groups:
1. Across time there were significant
decrease in the depression scores
(p<0.05).
Craig et al., (1998a)
Australia
Cohort
NInitial=69; NFinal=58
Population: Treatment: Mean age=31yr;
Gender: males=23; females=5;
Depression status=mixed group
Intervention: 10 wk inpatient program.
Small groups (4-5/group) for 1.5 hr/wk.
Major aim was to provide cognitive and
behavioural skills to cope with the
psychological and social difficulties
encountered upon entering the
community. Cognitive Behavioural
Therapy (CBT) included muscle
relaxation, visualization techniques,
selfhypnosis and cognitive restructuring,
social skills and assertiveness training,
and sexuality sessions.
Outcome Measures: State Trait Anxiety
Inventory (STAI), Beck Depression
Inventory (BDI).
1. Significant differences noted for
depression overall, (p<0.05).
2. Both the treatment and the control
groups appeared to be less
depressed 1 and 2 yr after injury.
3. For individuals who scored high on
the depression scale before therapy,
(9 from each group) there were
significant differences after treatment.
(p<.01) with the control group
reporting higher levels of depressive
mood.
4. Depressive mood scores showed
significant differences across time
(p<0.01) with scores 1 and 2 yr post
injury significantly lower than
pretreatment scores (p<0.01).
Craig et al., (1997)
Australia
PCT
N=69
Population: SCI: Age=16-73 yr; Gender:
males=57, females=12; Severity of injury:
complete=68%-71%; Chronicity=acute.
Depression status=mixed group
Intervention: 10 wk program. Small
groups (4-5/group), for 1.5 hr/wk.
Provided cognitive and behavioural skills
to cope with the psychological and social
difficulties encountered upon entering the
community. Cognitive Behavioural
Therapy (CBT) included muscle
relaxation, visualization techniques, selfhypnosis and cognitive restructuring,
social skills and assertiveness training,
and sexuality sessions.
Outcome Measures: State Trait Anxiety
Inventory (STAI), Beck Depression
Inventory( BDI), Rosenberg Self-Esteem
scale.
2. Significantly greater self-esteem for
treatment group (p<0.01). Taking this
into account, no significant
differences between the groups were
found immediately after injury or 1 yr
later.
3. No significant initial differences were
found between the groups on anxiety
and depression when comparing pre,
post and 1 yr scores.
4. BDI scores were significantly lower
for both conditions 1 yr after injury
(p=0.014).
5. Those who scored>14 on the
depressive mood scale were
analyzed using repeated measures
ANOVA. 22 persons (from both
groups) were examined. Significant
differences were noted between the
groups (p<0.01).
6. Significant differences were also
noted across time for the BDI scores
(p<0.01). Post hoc tests showed that
the treatment group had significantly
greater levels of improvement across
time (p<0.05).

Discussion

Several studies examined the effect of group CBT targeting mood among persons with SCI. Three studies found it was effective at reducing depressive symptoms post intervention compared to control groups (Kennedy et al. 2003, King & Kennedy 1999, Li et al. 2019); while three studies found no significant difference in mood (Craig et al. 1997, Craig et al. 1998a) (Coker et al.,2019;;. Craig et al.,(1997, 1998a, 1998b) (; 1999) found only a subgroup of participants with Beck Depression Inventory scores greater than 14 experienced a significant reduction in depressive symptoms. Among this subgroup, decreased scores were maintained at 1 and 2 year follow-ups (Craig et al. 1998a).

Several studies found significant improvement in depressive symptoms among individuals receiving CBT post intervention (Dorstyn et al. 2011, Duchnick et al. 2009, Feng & Li 2017, Norrbrink Budh et al. 2006, Perry et al. 2010). Duchinick et al.,(2009) and Dorstyn et al.,(2011) found that the effect was not maintained at 3 month follow-up; Perry (2010) found the effect was not maintained at 8 month follow-up.

Four studies examined the effect of CBT targeting pain intervention on mood compared at usual care control group (Blake et al. 2018, Heutink et al. 2014, Heutink et al. 2012, Norrbrink Budh et al. 2006, Perry et al. 2010). Only one study which provided online CBT found significant improvement in depressive symptoms between the intervention and control group (Dear et al. 2018).

One study examined the effect of telecounselling CBT programs on mood and adjustment amongst persons with SCI (Dorstyn et al. 2012). Dorstyn et al.,(2012) reported symptoms were maintained over the follow-up period. Four studies examined the role of online CBT targeting mood resulting in significant reduction in depressive symptoms post intervention (Migliorini et al. 2016, Migliorini et al. 2011). Burke and colleagues (2019) found no significant difference in depressive symptoms in the intervention group compared to the control group post intervention; however, significant decrease in depressive symptoms were seen in the treatment group at 3 month follow-up. Verwer et al.,(2016) found no significant difference in depressive symptoms through a self-directed online CBT program.

Schulz et al.,(2009) conducted a CBT trial targeting both persons with SCI and their caregivers. The study found that the dual targeted group both the persons with SCI and caregivers had the greatest reduction in depressive symptoms compared to the group targeting only persons with SCI and information only control group.

Conclusion

There is level 2 evidence (Craig et al. 1997; Craig et al. 1998a; Craig et al. 1999; Craig et al. 1998b; Kennedy & Rogers 2000; King & Kennedy 1999) to support the use group CBT intervention targeting mood to decrease depressive symptoms following SCI among those with elevated depressive symptoms.

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

There is conflicting evidence that CBT intervention results in maintained affective improvement at follow up.

There is level 1b evidence (Schulz et al. 2009) that providing CBT to caregivers and care receivers results in improved depressive symptoms in care receivers.

There is level 1 evidence (Dear et al. 2018; Dorstyn et al. 2011; Migliorini et al. 2011) that telerehabilitation or online based CBT improves symptoms of depression post SCI.

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