Depression After Spinal Cord Injury: Relation to Gender, Ethnicity, Aging, and Socioeconomic Indicators James S. Krause, PhD, Bryan Kemp, PhD, Jennifer Coker, BA ABSTRACT. Krause JS, Kemp B, Coker J. Depression after spinal cord injury: relation to gender, ethnicity, aging, and socioeconomic indicators. Arch Phys Med Rehabil 2000;81: 1099-1109. Objective: To investigate the relation among aging, gender, ethnicity, socioeconomic indicators, and depressive symptoms after spinal cord injury (SCI). Design: Survey was done to collect cross-sectional data. A mediational model was used to analyze the interrelationships between predictors and depressive outcome variables. Setting: A large Southeastern rehabilitation hospital. Participants: Participants, identified from outpatient records who met the following inclusion criteria: (1) traumatic SCI; (2) at least 18 years old at the time of study; and (3) injured for at least 1 year. There was an initial pool of 1923 potential participants in 1997, of whom 1391 (72%) participated. Main Outcome Measures: The Older Adult Health and Mood Questionnaire, a 22-item measure of depressive symp- toms designed following Diagnostic and Statistical Manual of Mental Disorders (DSM III-R) criteria, was used to measure depression. It has been validated against clinical assessments by psychiatrists and psychologists. Results: Forty-eight percent of the participants reported clinically significant symptoms. Minority participants, particu- larly women, were at a substantially higher risk for depressive symptoms. This risk diminished but did not disappear after controlling for years of education and income, both of which were highly negatively correlated with depressive symptoms. Aging factors were modestly positively correlated with depres- sion, although education or income did not mediate these associations. Conclusions: Symptoms of depression are highly prevalent after SCI and are related to aging, gender or ethnicity, and socioeconomic status indicators (education and income). Key Words: Spinal cord injuries; Depression; Gender; Ethnicity; Aging; Rehabilitation.  2000 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation B ECAUSE LARGE NUMBERS of people with spinal cord injury (SCI) are now reaching major milestones of longev- ity, it is important for rehabilitation professionals to better understand the long-term physical and emotional consequences of SCI. Perhaps the greatest potential adverse emotional consequence is depression. Unfortunately, we know little about the associations between depression, general psychosocial outcomes, and aging after SCI, particularly among ethnic minorities, who now comprise a significant portion of the SCI population. 1 DEPRESSION AND SCI Depressive disorders are the most common form of psycho- logic distress in SCI and appear to be more common than in the nondisabled population. 2-4 Depressive disorders range in sever- ity from minor depression and adjustment disorders to major depressive episodes, depending on the number, type, and pervasiveness of symptoms, their duration, and their effect on function. 5 Even ‘‘minor’’ and ‘‘moderate’’ levels of depression (‘‘clinically significant symptoms’’ or ‘‘subsyndromal’’ disor- ders) have been found to have a major impact on health, activities of daily living, and interpersonal relationships among nondisabled persons. 6 It would seem reasonable that they would have an equal or greater effect on people with SCI. The estimated prevalence of depression after SCI is quite variable from study to study, depending on the type of measure, the definition of depression, and whether the measure was taken during rehabilitation, shortly after, or somewhat later. Rates of clinically significant symptoms (symptoms severe enough to affect function) range from about 14% to 35%, 3,4,7 and major depression has been reported in 10% to 15% of people with SCI. 2 More recent studies suggest even higher rates of clinically significant symptoms. 8 Because these rates are substantially higher than in the nondisabled population, they must be of concern to rehabilitation professionals. GENDER, ETHNICITY, AGING, AND SUBJECTIVE OUTCOMES AFTER SCI In a recent study of self-reported depression, Kemp et al 8 found ethnic differences in depressive symptoms, with Latino participants reporting more symptoms than either white or African-American participants. 8 African-American participants were not significantly different from whites; however, the sample size was quite small (n = 28). No differences were noted as a function of aging variables, although only linear correlational methods were used for data analysis, potentially masking nonlinear relationships. Also, there were not enough cases to adequately evaluate gender differences. Other research has suggested that ethnic differences in subjective outcomes are limited to specific life areas, rather than general measures of affect for individuals with SCI. For instance, Krause 9 found that minority participants reported similar overall scores on general measures of life engagement and negative affect compared with whites, but reported lower well-being related to financial and career areas. Krause and Anson 10 noted similar findings in an earlier study, with minority participants reporting lower well-being related to career, fi- nances, and opportunities for skill development. 10 An interest- ing finding was an interaction between gender and ethnicity on From Shepherd Center, Atlanta, GA (Krause, Coker), and Rancho Los Amigos National Rehabilitation Center, Downey, CA (Kemp). Submitted October 29, 1999. Accepted in revised form January 3, 2000. Supported by a Model Spinal Cord Injury System grant from the National Institute for Disability and Rehabilitation Research of the Office of Special Education and Rehabilitation Services (H133N00023), and the Rehabilitation Research and Training Center on Aging with Spinal Cord Injury (H13337001). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to James S. Krause, PhD, Crawford Research Institute, Shepherd Center, 2020 Peachtree Road NW, Atlanta, GA 30309. 0003-9993/00/8108-5910$3.00/0 doi:10.1053/apmr.2000.7167 1099 Arch Phys Med Rehabil Vol 81, August 2000