Research paperAssociation between traumatic spinal cord injury and affective and other psychiatric disorders–A nationwide cohort study and effects of rehabilitation therapies
Introduction
Traumatic spinal cord injury (TSCI) is defined as the permanent neurological dysfunction and disability resulted from an external physical impact that damages the spinal cord, which is associated with a high socioeconomic burden (Ahuja et al., 2017; Freund et al., 2019; Moreno et al., 2017), including severe neurologic deficits (Hachem et al., 2017), systematic complications (Sweis and Biller, 2017), and negative impact on the quality of life (Andresen et al., 2016). Even though the survival and life expectancy of patients with TSCI has improved over the years due to improved care (Shavelle et al., 2007), the presence of disability and functional impairment in these patients are associated with emotional distress in their life span after the injury (Giardino et al., 2003).
Previous studies have shown that the psychiatric sequalae of TSCI include dementia (Huang et al., 2017), anxiety and depression (Pakpour et al., 2016), post-traumatic stress disorder (Pollock et al., 2017), sleep disorder (January et al., 2017), and substance use disorder (Tetrault and Courtois, 2014). However, no study has been conducted to determine the overall association between TSCI and important affective and other psychiatric disorders; therefore, a nationwide population-based study was deemed necessary.
Rehabilitation therapies, including physical therapy (PT) and occupational therapy (OT), are important for the TSCI patients for the recovery from the neurologic deficits.(Ma et al., 2014) Several preliminary reports have shown neurologic functional improvement from the rehabilitation therapies for patients with TSCI (Christodoulou et al., 2019; James et al., 2018; Ramer et al., 2014). However, the role of the rehabilitation therapies in the risk of developing psychiatric disorders is yet to be studied.
We hypothesize that TSCI is associated with the risk of affective and other psychiatric disorders, in comparison to the non-TSCI group. We also hypothesize that the TSCI patients with rehabilitation therapies are associated with a decreased risk of affective and other psychiatric disorders, in compassion to the TSCI patients without rehabilitation therapies, by using the National Health Insurance Research Database (NHIRD), We aimed to corroborate the association between TSCI and the increased risk in affective and other psychiatric diseases, and the role of rehabilitation therapies and the risk of the development of affective and other psychiatric disorders.
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Data sources
The national health insurance (NHI) program, a single-payer and universal health coverage system, was launched in Taiwan in 1995, and as of June 2009, included contracts with 97% of medical providers and approximately 23.67 million beneficiaries in 2016 (Ho Chan, 2010). The NHIRD contains the medical documentation of all the claims data of the beneficiaries. It employs the international classification of diseases, 9th revision, clinical modification (ICD-9-CM codes) to record all diagnoses. The
Increased risk of psychiatric disorders in the TSCI cohort
There were no significant differences between the TSCI and non-TSCI cohorts in terms of sex, age distribution after the matching, and the differences in other covariates at the baseline (Table S1). The Kaplan-Meier analysis for the cumulative risk of psychiatric disorders in the TSCI and non-TSCI cohorts with the log-rank test revealed a significant difference over the 15-year follow-up period (p < 0.001) (Fig. 1).
Of the TSCI cohort, 5,392 in 16,151 patients (2940.15 per 100,000 persons/year)
The association between TSCI and the increased risk of psychiatric disorders
This is a retrospective cohort study on the association between TSCI and the risk of affective and other psychiatric disorders. In addition, in the sensitivity analysis of excluding the psychiatric diagnoses in the first year, and the first five years after the injury, the TSCI were still associated with the risk of overall psychiatric disorders, including affective disorders. The patients with TSCI only and polytrauma were associated with the risk of psychiatric disorders. Furthermore, this
Limitations
This study has several limitations. First, the diagnosis of TSCI was obtained based on the ICD-9-CM codes instead of the validated structural diagnostic instruments. However, several studies have depicted the accuracy and validity of several diagnoses, on the ICD-9-CM codes, in the NHIRD, including diabetes mellites (Cheng et al., 2015; Lin et al., 2005), cancer (Li-Ting et al., 2014; Liang et al., 2011; Yang et al., 2015), myocardial infarction (Cheng et al., 2015; Cheng et al., 2014;
Conclusion
This study found a significantly higher risk of psychiatric disorders in patients with TSCI. In addition, rehabilitation treatment with PT or OT was associated with a lowered risk of psychiatric disorders in the TSCI cohort.
Role of funding sources
This work was supported by the Tri-Service General Hospital Research Foundation (TSGH-C107-004, TSGH-C107-106, TSGH-C108-003, and TSGH-C108-151), and the Medical Affairs Bureau, Ministry of Defense, Taiwan (MAB-107-084).
CRediT authorship contribution statement
Fang-Jung Wan: Conceptualization, Investigation, Writing - original draft. Wu-Chien Chien: Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software. Chi-Hsiang Chung: Data curation, Investigation, Methodology, Software, Visualization. Yun-Ju Yang: Data curation. Nian-Sheng Tzeng: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing - review & editing.
Declarations of Competing Interest
None.
Acknowledgments
We appreciate the support from the Tri-Service General Hospital Research Foundation and the Medical Affairs Bureau, Ministry of Defense, Taiwan, ROC. We also thank Mr. Michael Wise who revised and proofread the language in the manuscript Data Availability is deposited in the website of Taiwan's National Health Research Database (https://nhird.nhri.org.tw/en/), We also appreciate the database provided by the Health and Welfare Data Science Center, Ministry of Health and Welfare (HWDC, MOHW).
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