Effectiveness of Supported Employment for Veterans With Spinal Cord Injury: 2-Year Results

Objective

To examine if supported employment (SE) remains more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI) at 2-year follow-up.

Design

Prospective, randomized, controlled, multisite trial of SE versus TAU with 24 months of follow-up.

Setting

SCI centers.

Participants

Subjects (N=201) were enrolled and completed baseline interviews. At interventional sites, subjects were randomized to SE (n=81) or TAU (n=76). At observational sites, 44 subjects were enrolled in a nonrandomized TAU condition.

Intervention

The intervention was a SE program called the SCI Vocational Integration Program, which followed the principles of the individual placement and support model of SE for persons with mental illness.

Main Outcome Measures

Competitive employment in the community within 2 years.

Results

For the entire 2-year follow-up period, SE subjects were significantly more likely to achieve employment (30.8%; 95% confidence interval [CI], 21.8–41.6) than either the TAU subjects at the intervention sites (10.5%; 95% CI, 5.2–19.7; P<.001) or the TAU subjects at the observational sites (2.3%; 95% CI, 0.0–12.9; P<.002). Most subjects who obtained competitive employment did so in year 1, and the average time to first employment was about 17 weeks.

Conclusions

SE was better than usual practices in improving employment outcomes for veterans with SCI across a 2-year follow-up period. Although SE continued to be superior to traditional practices over the entire study, the first year of participation in SE may represent a critical window for achieving employment after SCI.     

Predictors of Participation Enfranchisement After Spinal Cord Injury: The Mediating Role of Depression and Moderating Role of Demographic and Injury Characteristics

Objectives

(1) To examine the mediating effects of depressive symptoms on the relations between employment, grief, depression treatment, and participation enfranchisement after spinal cord injury (SCI); and (2) to examine the moderating role of demographic and injury characteristics, including sex, race, marital status, education, and injury level, and completeness on these relations.

Design

Cross-sectional survey as part of the Project to Improve Symptoms and Mood after SCI (PRISMS).

Setting

Rehabilitation facilities.

Participants

Persons with SCI (N=522; average age, 42y; 76% men; 64% white; 64% completed at least a high school education) enrolled from 2007 to 2011.

Interventions

Not applicable.

Main Outcome Measure

Participation enfranchisement.

Results

The final model fit the data relatively well (comparative fix index=.939; Tucker-Lewis Index=.894; root mean square error of approximation=.066; 90% confidence interval, .043–.089), explaining 32% of the variance in participation enfranchisement. Enfranchisement was positively related to employment and negatively related to depression. Grieving the loss of a loved one and the use of an antidepressant or psychotherapy were related to participation enfranchisement; these relations were mediated by depressive symptoms. Multigroup analyses supported the model's invariance across sex, marital status, severity of injury, and level of injury.

Conclusions

Depression appears to mediate the influence of employment, grief, and depression treatments on participation enfranchisement after SCI. These relations are applicable regardless of sex, marital status, and injury completeness and level. These findings highlight efforts to improve the detection and treatment of depression in SCI rehabilitation programs that may enhance participation.     

Psychologic Factors and Risk of Mortality After Spinal Cord Injury

Krause JS, Carter R, Zhai Y, Reed K. Psychologic factors and risk of mortality after spinal cord injury.

Objective

To identify the association of 2 distinct psychologic constructs, personality and purpose in life (PIL), with risk of early mortality among persons with spinal cord injury (SCI).

Design

Prospective cohort study with health data collected in late 1997 and early 1998 and mortality status ascertained in December 2005.

Setting

A large rehabilitation hospital in the southeastern United States.

Participants

Adults (N=1386) with traumatic SCI, at least 1 year postinjury.

Interventions

Not applicable.

Main Outcome Measures

We first evaluated the significance of a single psychologic predictor (a total of 6 scales) while controlling for biographic and injury predictors using Cox proportional hazards modeling and subsequently built a comprehensive model based on an optimal group of psychologic variables.

Results

There were a total of 224 (16.2%) observed deaths in the full sample. The total number of deaths was reduced to 164 in the final statistical model (of 1128 participants) because of missing data. All 6 psychologic factors were statistically significant in the model that was adjusted for biographic and injury factors, whereas only 3 psychologic factors were retained in the final comprehensive model, including 2 personality scales (Impulsive Sensation Seeking, Neuroticism-Anxiety) and the PIL scale. The final comprehensive model only modestly improved the overall prediction of survival compared with the model with only biographic and injury variables, because the pseudo-R² increased from 0.121 to 0.129, and the concordance increased from 0.730 to 0.747.

Conclusions

The results affirm the importance of psychologic factors in relation to survival after SCI.     

Depression Treatment Preferences After Acute Traumatic Spinal Cord Injury

Objective

To examine preferences for depression treatment modalities and settings and predictors of treatment preference in persons with spinal cord injury (SCI).

Design

Cross-sectional surveys.

Setting

Rehabilitation inpatient services.

Participants

Persons with traumatic SCI (N=183) undergoing inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Patient Health Questionnaire-9 depression scale, history of psychiatric diagnoses and treatments, and a depression treatment preference survey.

Results

Among inpatients with SCI (28% had Patient Health Questionnaire-9 score ≥10 indicating probable major depression), a physical exercise program was the most preferred treatment option (78% somewhat or very likely to try) followed by antidepressants prescribed by a primary care provider (63%) and individual counseling in a medical or rehabilitation clinic (62%). All modalities were preferred over group counseling. Although not statistically significant, more depressed individuals stated a willingness to try antidepressants and counseling than nondepressed individuals. Subjects preferred treatment in a medical/rehabilitation setting over a mental health setting. Those with a prior diagnosis of depression and a history of antidepressant use were significantly more willing to take an antidepressant. Age ≥40 years was a significant predictor of willingness to receive individual counseling.

Conclusions

Treatment preferences and patient education are important factors when choosing a depression treatment modality for patients with SCI. The results suggest that antidepressants, counseling, and exercise may be promising components of depression treatment in this population, particularly if they are integrated into medical or rehabilitation care.