Study design: Cohort study. Objectives: The objective of this study is to assess depression over a 5-year period in persons with spinal cord injury (SCI) and to assess risk factors for depression over time. Results: In all, 22.1% of participants had PMD at Time 1 and 20.2% at Time 2. There was a nonsignificant trend for change in PMD status (P ¼ 0.058). Of those who had PMD at Time 1, 55.7% had PMD at Time 2. Between the two time points, the most change occurred in the group with clinically significant symptomatology. Demographic factors (race-gender, age, time since injury) and health behaviors (pain medication use, hours out of bed, days out of the house, exercise) were significantly associated with PMD over time. Socioeconomic factors (income, education) were significantly related to depression but were not significant after controlling for behavioral factors. Conclusion: Depression is fairly consistent over time in persons with SCI, with the majority of change coming from those in the clinically significant symptomatology group. Examining depression at multiple time points, our results underscore the importance of health behaviors in relation to PMD, even after controlling for demographic, injury and environmental factors.

Objective To evaluate the association of health status, secondary health conditions, hospitalizations, and risk of mortality and life expectancy (LE) after spinal cord injury (SCI). Design Prospective cohort study. Setting Preliminary data were collected from a specialty hospital in the Southeastern United States, with mortality follow-up and data analysis conducted at a medical university. Participants A total of 1361 adults with traumatic SCI, all at least 1 year post-injury at the time of assessment, were enrolled in the study. There were 325 deaths. After elimination of those with missing data on key variables, there were 267 deaths and 12,032 person-years. Interventions None Main Outcome Measures Mortality status was determined by routine follow-up using the National Death Index through December 31, 2008. A logistic regression model was developed to estimate the probability of dying in any given year using person years. Results A history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized within the past year were all predictive of mortality. LE estimates were generated using the example of a male with non-cervical, non-ambulatory SCI. Using 3 age examples (20, 40, 60), the greatest estimated lost LE was associated with chronic pressure ulcers (50.3%), followed by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and the diagnosis of probable major depression (18%). Symptoms of infections was associated with a 6.7% reduction in LE for a 1 standard deviation increase in infectious symptoms. Conclusion Several secondary health conditions represent risk factors for mortality and diminish LE after SCI. The presence of 1 or more of these factors should be taken as an indicator of the need for intervention.

Objective To evaluate a theoretical model for mortality after spinal cord injury (SCI) by sequentially analyzing 4 sets of risk factors in relation to mortality (i.e., adding 1 set of factors to the regression equation at a time). Design Prospective cohort study of data collected in late 1997 and early 1998 with mortality status ascertained in December 2005. We evaluated the significance of 4 successive sets of predictors (biographic and injury, psychologic and environmental, behavioral, health and secondary conditions) using Cox proportional hazards modeling and built a full model based on the optimal predictors. Setting A specialty hospital. Participants 1,386 adults with traumatic SCI, at least 1 year post-injury, participated. There were 224 deaths. After eliminating cases with missing data, there were 1,209 participants, with 179 deceased at follow-up. Interventions N/A. Main Outcome Measures Mortality status was determined using the National Death Index and the Social Security Death Index. Results The final model included one environmental variable (poverty), 2 behavioral factors (prescription medication use, binge drinking), and 4 health factors or secondary conditions (hospitalizations, fractures/amputations, surgeries for pressure ulcers, probable major depression). Conclusions The results supported the major premise of the theoretical model that risk factors are more important the more proximal they are in a theoretical chain of events leading to mortality. According to this model, mortality results from declining health, precipitated by high-risk behaviors. These findings may be used to target individuals who are at high risk for early mortality as well as directing interventions to the particular risk factor.

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