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Depressed mood during rehabilitation of persons with spinal injury.

Spinal cord injuyr (SCI) represents a catastrophic interruption and alteration not only in physical functioning but psychological functioning as well. Persons who incur a spinal cord injury are faced with changes in voluntary movement, sensation and proprioception, body image, bowel and bladder functioning, and sexual functioning, to which they must adapt. Since World War II, numerous clinicians have attempted to characterize the psychological adjustment of persons who incur a spinal cord injury, and to explain how and why the typical patient reacts the way he or she does (e.g., Wittkower, Gingras, Mergler et al., 1954; Siller, 1969).

In the 1950s and '60s, one of the areas explored was the premorbid (pre-injury) psychological status of patients. For example, Mueller (1962) described hostility and uncontrolled emotionality as prominent features. A similar clinical presentation in most patients lent credence to the idea that there were premorbid features common to SCI patients. However, Trieschmann (1988) has critically reviewed the literature and concluded that there is no specific personality type associated with SCI. Rather, a suggested by Crewe and Krause (1987), adjustment to disability is congruent to that required by most major life changes. Successful adjustment to disability requires the positive characteristics seen in successful, well-adjusted persons in general, namely, high self-esteem, productivity, and the ability to maintain satisfactory relationships.

Both lay persons' and clinicians' impression of psychological adjustment after SCI appears to be founded on one of many stage theories (e.g., Gunther, 1969; Kerr and Thompson, 1972; Hohmann, 1975). These stage theories are invariably based solely on the clinical assumption that depression is a necessary, positive step in adjustment. However, the vast majority of these studies provide no empirical evidence to support this assumption (Trieschmann, 1988). As Crewe and Krause (1987) have pointed out, stage theories may be a heuristic tool in the education of family, staff and patients. However, when forcibly applied to a given patient, they become counterproductive, at the least. Stage theories usually view depression as inevitable, so much so that when it doesn't appear, it must be concluded that denial is operative (Siller, 1969).

A review of studies done to determine the incidence of depression in newly spinal cord injured persons shows vastly different rates, from 10 to 100 percent. Crewe and Krause (1987) explain this variability as resulting from the wide variety of instruments used, from staff ratings to the MMPI, and whether or not a correction for somatic symptoms resulting from the SCI itself was used. Using a unique approach, Lawson (1978) performed a daily study of 100 quadriplegic patients throughout their rehabilitation stay, and reported no clear periods of depression. Furthermore, he found evidence that staff should more actively seek to combat (rather than encourage or tolerate) the patients' depression.

Factors that have been cited as essential to the methodological adequacy of studies of SCI patients' mood include the use of multiple instruments and multiple observations; in some cases, staff may mistakenly identify despondency or grief for clinical depression. The latter was thought to be true in Fullerton et al.'s (1981) study in which the incidence of depression (at 30%) was greater than the national average (for a nondisabled population) of 5.7, but certainly not universal among the SCI patients studied. Also, patients with a diagnosis of clinical depression often have a premorbid history of depression (Gans, 1981).

The present study was developed as part of a larger project examining changes in staff perception of SCI patient mood over time. Its aim was to describe patients' subjective experience of depressed mood (not clinical depression) at regular intervals over the course of their hospitalization. We hypothesized that patients' reported level of depressed mood would significantly decrease over the course of their stay on a rehabilitation unit. Rather than use a psychometric measure (such as the MMPI) at a single point, we used an objective self-report measure on a number of occasions. The measure chosen, the DACL (Depression Adjective Check List, Lubin, 1965), is not influenced by somatic symptoms (often of physical origin in spinal cord injured patients) as are measures such as the Beck Depression Inventory (1972), since it offers no descriptions related to sleep, appetite, etc.



Subjects in this study were 102 persons with new traumatic SCI who were patients at one of two Model Spinal Cord Injury Centers located in Rochester, New York and Detroit, Michigan. One-hundred-seventeen patients were asked to participate in the study; 11 declined and four were transferred before completing any ratings.

Fifty-five of the subjects were white; 46 were black, and one person was Hispanic. Eighty-eight subjects were male; 14 were female. Fifty subjects were paraplegic; of these, 25 had complete injuries and 25 had incomplete injuries. Of the 52 patients with quadriplegia, 23 had complete injuries while 29 had incomplete injuries.

Thirty-nine subjects had more than 12 years of education; 23 had 10 or fewer years of formal education, and 37 subjects completed 11 or 12 years. Information on the educational level of two subjects was unavailable.

Subjects were admitted to the rehabilitation units after intervals ranging from less than one week to 24 weeks after injury. However, the majority of patients (57) were admitted 2 to 4 weeks after injury and 85 (83 per cent) were admitted within 1 to 7 weeks post injury.


The Depression Adjective Check List (DACL) (Lubin, 1965) was used in this study to assess patient mood. Both Form E and Form F (shown to be equivalent; Lubin, 1967) were used. Each form of the instrument is comprised of 34 mood-related adjectives, both positive (e.g., "peaceful") and negative (e.g., "blue"). Subjects are instructed to mark the adjectives they feel reflect their mood. The score obtained is the sum of the number of negative adjectives chosen and the number of positive adjectives not chosen; thus, a higher score reflects increased feelings of depression. Theoretically, scores range from 0 to 34.

The DACL has been used with a variety of psychiatric and medical populations and its reliability (typically .8 to .9) and validity have been described in a number of studies (e.g., Christenfeld, 1978; Lubin, 1965).


Patients consecutively admitted to the Spinal Cord Injury unit of the collaborating centers over a 24-month period were asked to participate in the research project. Patients were typically contacted on the second day of their stay on the rehabilitation unit. Those who agreed to participate signed a consent agreement. They were then sequentially assigned to one of three groups with staggered times of first assessment, either one, two, or three weeks after admission. At three-week intervals throughout their stay, patients rated their mood by completing the DACL. The instrument took approximately 5 minutes to complete. For greater consistency, patients were asked to fill out the instrument at midday, when possible. Additionally, they completed a DACL during the week of their discharge from the hospital, no matter what the interval from the previous administration was. Demographic information regarding patients was obtained from their medical records.

Data Analysis

A repeated measured analysis of variance with patient's mood rating (as measured with the DACL) as the dependent variable would be the preferred method of analyzing the data. However, the staggered starting points, the extreme variability in the length of stay, and the missing data points (i.e., weeks when a patient scheduled to complete the DACL did not do so) make this a practical impossibility. Instead, one-way analysis of variance (ANOVA) was used, with every DACL completion considered an independent case (thereby increasing the number of cases from 102 to approximately 300). This does violate the assumption of independence of observations, but this was considered a minor issue given the time elapsing between DACL completions. The independent variable in each ANOVA is a patient characteristic (e.g., level of injury) or a characteristic of the DACL completion (e.g., weeks since injury). Where appropriate in time-trend analyses, a test for linearity was applied.


The patients' mean DACL score (9.0; SD = 4.2), across all 300 observations, was lower than that of a local control group (w = 10.7) of 98 hospital visitors (z = 2.91, p.01). Also, patients' scores (both mean and variance) were not appreciably different from those of national normative samples, whose mean scores typically range between 8 and 10 (with a SD of 4.3 to 4.9).

Patients were categorized according to their level of injury (paraplegia and quadriplegia) and completeness of the injury (i.e., complete or incomplete). Their mean DACL scores did not vary by level (F (1,295) = 1.31, p.05) or completeness of injury (F (1,295) = .33, p.05).

The patients' mean DACL scored did not vary significant by the week in which the scores were obtained (here, the number of weeks corresponds to patients' length of stay of the rehabilitation unit)(F (1,276) = .949, p.50). A trend analysis revealed no systematic increase or decrease in DACL over weeks of stay (F (1,276) = 1.40, p.20).

Patient's DACL scores were found to decrease systematically according to the number of days remaining until discharge; there was a significant linear trend seen for DACL scores by number of days until discharge (F (1,276) = 5.43, p .05). This did not appear to be accounted for by the amount of time that had passed since injury; DACL scores did not differ systematically according to weeks after injury (F (20,293) = 1.41, p.40).

To further examine change over time, a score corresponding to the difference between first and last DACL rating was calculated for each patient. The last DACL rating always occurred within 1 week of discharge from the rehabilitation unit. If a change of 5 points or more (i.e., more than 1 standard deviation) is considered clinically significant, 13 percent of patients were more less depressed at the time of discharge while 2 percent were more depressed. Eighty-five percent evidenced no significant change. There was considerable variability in the number of weeks between admission and discharge; however, 75 percent had a stay of 3 to 12 weeks (the range was 1 to 22 weeks).

Several months after the study began, 2 questions were appended to patients' final DACL rating sheet (i.e., the form for the week of discharge from the hospital); this was completed by a total of 42 patients. The questionnaire asked whether the patient had noticed a change in his or her mood while on the rehabilitation unit, and what the nature of the change was. Answers to the latter question were classified in six categories developed by the authors in pilot work. In response to the first question, sixty-four percent (27) of the patients surveyed stated they had experienced a change in mood; 36 percent reported no change. Of those 27 patients who reported a change in mood, seven (26 percent) noted an overall improvement in mood. Nine (33 percent) reported an improvement in positive feelings and 7 (26 percent) described a decrease in negative feelings. Two patients (7 percent) could not specify what change had occurred. One patient reported wide mood swings ("all up and down") and another reported having all negative feelings.


The results of this study indicate that persons with SCI, as a group, describe their mood in a manner similar to control samples. In fact, the subjects who comprised our patient group reported somewhat less depression, on average, as measured by the DACL, than a group of hospital visitors. However, this diference, although statistically significant, is not apt to be clinically meaningful.

We hypothesized that patient's depressed mood, reflected by DACL scores, would decrease over the course of their hospital stay. The results, however, indicated that DACL scores did not vary according to the week of stay on the rehabilitation unit. Likewise, the number of weeks that had elapsed since injury was not significantly related to DACL scores. The number of days remaining until discharge was, however, associated with patient scores on the DACL; scores significantly decreased as the date of discharge drew nearer. This suggest that a patient's report of depression is, in fact, more closely associated with situational factors (e.g., preparation for discharge) than with passage of a specific interval of time (e.g. 8 weeks post injury) or the length of time spent in a formal rehabilitation program.

Overall, the findings do not provide strong support for our hypothesis that DACL scores would decrease over time. Most patients (approximately 85 percent) showed a minimal change in DACL score from admission to discharge. Of the small subgroup who did evidence a significant change, (i.e., more than 1 standard deviation), however, a majority did report a less depressed mood at the time of discharge.

The instrument used in our study did not discriminate between clinical depression and what has been called grief, sadness or depressed mood, although the latter seems the best interpretation. Lubin (1965) suggests that a score of 17 or greater on the DACL represents clinically significant depression. On average, the SCI patients in our study did not report depressed mood and did not exhibit marked variation in mood during their stay on the rehabilitation unit. A small subgroup (N=16) of patients reported significantly depressed mood (DACL score of 15 or more), but this way typically found on only one occasion (11 patients had a high DACL score on 1 occasion, 4 on 2 occasions, and 1 patient had 5 such scores).

The fact that a consistent decrease in depressed mood was not widespread may reflect, in large part, the fact that most patients had scores in the average range (i.e., comparable to controls) at the time of their entry into the study and, due to a floor effect, would not be expected to show a significant decrease in their report of depressed mood.

An alternative explanation for our findings is that patients may not have accurately reported their mood states but rather tried to present the most acceptable (i.e., socially desirable) information. However, if Wright's (1983) hypothesis of the requirements of mourning is correct, staff expect SCI patients to be more, not less, depressed than others. If patients simply complied with what staff seemed to expect, we would have found a much higher level of depression.

Another possible explanation for the discrepancy between the findings of the present study and the reports by clinicians referred to earlier is that what has in the past been assumed to be depressed mood in SCI patients is really a general blunting of affect associated with a decreased physiological experience of all emotional feelings as a direct consequence of the injury to the cord (Hohmann, 1975). However, several recent studies (Lowe and Carroll, 1985; Nesteros, et al., 1982) have cast serious doubt on this hypothesis; their data suggest that SCI does not produce a change in experienced emotion related to level of lesion. Bermond et al. (1987) found that the general mood states of SCI patients did not differ from a normative group. However, these patients were, on average, 5 years post-injury; there is no information on whether their mood states reported in the study were consistent with those experienced during rehabilitation.

Overall, our findings support the view (Goldiamond, 1976) that depression is not a universal stage that all or even most persons with SCI will experience in the initial months after injury. Our results do imply that, rather than anticipating that patients will undergo a specific, time-dependent change in mood state, staff should focus on patients' perception of where they stand in the rehabilitation process and, as a concrete step, facilitate patients' view of themselves as well-prepared for discharge.


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Nesteros, J. W., Demers-Desrosiers, L. A., Dalicandro, L.A. (1982). Levels of anxiety and depression in spinal cord-injured patients. Psychomatics, 23, 823-830.

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Trieschmann, R. B. (1988). Spinal cord injuries: Psychological, social, and vocational rehabilitation (2nd ed.). New York: Demos Publications.

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LAURA A. CUSHMAN, University of Rochester, School of Medicine and Dentistry, 601 Elmwood Avenue, Box 664, Rochester, New York 14642.
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Author:Dijkers, Marcel
Publication:The Journal of Rehabilitation
Date:Apr 1, 1991
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