Introduction
Traumatic spinal cord injury (TSCI) is a severe condition causing permanent motor, sensory, and autonomic impairments that lead to long-term disability and reduced quality of life. It predominantly affects young, economically productive individuals, most commonly due to road traffic injuries, falls, and interpersonal violence.1–3 In low- and middle-income countries, outcomes are further compromised by delayed care, limited specialized services, and restricted rehabilitation resources. Consequently, the burden of TSCI extends beyond physical disability to significant psychological and social impacts with implications for long-term rehabilitation and health system planning.1,4–7
Depression is a common psychological sequela following TSCI, affecting patients at higher rates than the general population, with approximately one in five individuals affected.2,3,8 It is associated with poorer rehabilitation participation, reduced functional recovery, diminished quality of life, increased health care use, and higher risks of complications and mortality.9–12
Depression following TSCI is multifactorial. While injury characteristics such as neurological level and completeness may influence psychological outcomes, evidence is inconsistent. More consistent associations are seen with modifiable factors including chronic pain, complications, prolonged hospitalization, limited independence, and inadequate social support.5,9–12 This suggests depressive symptoms may relate more to functional limitations and secondary complications than to neurological severity alone.
Despite growing global evidence, data from sub-Saharan Africa remain limited, particularly from prospective hospital-based studies using validated screening tools. Available studies suggest a substantial burden of depressive symptoms among individuals with TSCI, often compounded by delayed rehabilitation, complications, and limited psychosocial support.1,4,5 In Tanzania, evidence on prevalence and determinants remains scarce, restricting the development of context-appropriate screening and integrated mental health care within spinal injury services.
Understanding the burden and correlates of depression is essential for informing comprehensive, patient-centred rehabilitation strategies. Integrating mental health assessment into spinal injury care pathways is increasingly recognized as a priority in comprehensive trauma system development. Therefore, this study aimed to determine the prevalence of depressive symptoms and to identify factors associated with depression among adults with TSCI admitted to a national orthopaedic referral institute in Tanzania.
Methodology
Study design and setting
This prospective hospital-based analytical cross-sectional study was conducted between June and December 2024 at a national referral orthopaedic and trauma centre in Dar es Salaam, Tanzania. The tertiary teaching institution receives spinal cord injury referrals nationwide, has a capacity exceeding 400 beds, and manages a high clinical workload, including approximately 4000 outpatient visits and over 100 admissions per week, providing an appropriate setting for assessing depressive symptoms and associated factors.
Study population and eligibility criteria
The study included adult patients admitted with TSCI. Eligible participants were aged ≥18 years with isolated injury and admitted for at least 72 hours to allow clinical stabilization and reliable neurological assessment. Participants were required to communicate effectively and provide written informed consent.
Patients without confirmed spinal cord injury, with prior psychiatric illness, severe cognitive impairment, or altered consciousness precluding participation were excluded, as were those who declined consent.
Sampling technique
Due to the low incidence of isolated traumatic spinal cord injury at the study centre, and absence of reliable local prevalence estimates, a census sampling approach was used. All eligible patients admitted during the six-month study period were consecutively enrolled to ensure comprehensive case capture and minimize selection bias.
Data collection tools and variables of interest
Data were collected using a structured interviewer-administered questionnaire through patient interviews and medical record review. The primary outcome was the prevalence of depressive symptoms.
Socio-demographic variables included age, sex, education, marital status, employment, income, residence, and payment mode. Clinical variables included injury mechanism, neurological level and completeness, treatment modality, pain intensity, and in-hospital complications defined as the presence of one or more clinically documented complications during during follow up, including pressure ulcers, bladder dysfunction, bowel dysfunction, or sexual dysfunction..
Social support was assessed as a binary variable (available vs none) based on patient-reported presence of consistent emotional, financial, or caregiving support from family members, caregivers, or close social networks.
Neurological status was assessed using the ASIA Impairment Scale (AIS), classifying injury severity from grade A (complete) to grade E (normal), with grades B–D indicating incomplete injury.
Pain intensity was assessed using the Visual Analogue Scale (VAS), a validated one-dimensional measure of pain severity. Participants rated their pain intensity on a 10-point scale anchored at 0 (no pain) and 10 (worst pain imaginable).
Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a widely validated screening instrument based on Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for major depressive disorder. A PHQ-9 score ≥5 was used to indicate the presence of depressive symptoms. This threshold was selected to improve sensitivity for detecting early psychological distress in hospitalized patients and has been widely applied in clinical and epidemiological studies as a screening cutoff to identify individuals who may benefit from further assessment. Symptom severity was categorized as minimal (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27).
The PHQ-9 has demonstrated good reliability and construct validity across diverse clinical settings, including low- and middle-income countries. The PHQ-9 is a screening tool and does not establish a clinical diagnosis of major depressive disorder; therefore, outcomes in this study are reported as depressive symptoms.
Data collection process
Data collection was conducted prospectively by trained members of the research team to ensure consistency and completeness. Socio-demographic characteristics, mechanism of injury, and preexisting comorbidities were recorded at admission through patient interviews and medical record review.
Neurological assessment, including determination of injury level and completeness, was based on documented examinations performed at least 72 hours after injury to allow for clinical stabilization and accurate neurological evaluation.
Pain intensity, in-hospital complications, and depressive symptoms (using the PHQ-9 tool) were assessed at a minimum of four weeks following injury. This timing was selected to reduce potential misclassification related to acute psychological stress responses and transient emotional reactions immediately following traumatic injury. All assessments were conducted using standardized instruments to promote uniformity of measurement across participants.
Data management and statistical analysis
Data were entered and managed using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). Data management procedures included anonymization of participant identifiers, verification of completeness, and consistency checks prior to analysis.
Cleaned datasets were exported to IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA) for statistical analysis. Descriptive statistics were used to summarize study variables. Categorical variables were presented as frequencies and percentages, while continuous variables were summarized using means and standard deviations for normally distributed data or medians and interquartile ranges for nonnormally distributed data.
Depressive symptoms were defined as a binary outcome variable using a PHQ-9 score ≥5, indicating at least mild depressive symptoms. Neurological injury severity was categorized as complete (AIS grade A) or incomplete (AIS grades B-D). Pain intensity was analyzed both as a continuous variable and categorized as mild–moderate (VAS 1–6) or severe (VAS 7–10).
Bivariate analyses were conducted using Pearson’s chi-square test or Fisher’s exact test, as appropriate. Variables with a P-value < 0.20 at bivariate analysis, together with clinically relevant covariates, were considered for inclusion in a multivariable binary logistic regression model to identify factors independently associated with depressive symptoms while adjusting for potential confounders. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported.
Given the anticipated limited number of outcome events, the events-per-variable ratio was expected to be below conventional recommendations for stable multivariable modeling. Therefore, the regression model was specified primarily for exploratory purposes. Model estimates were reported with corresponding 95% CIs to reflect statistical precision. No penalized regression techniques or formal model reduction procedures were applied due to the limited sample size. Statistical significance was defined as P < .05. There were no missing data for the primary outcome or key covariates; therefore, complete-case analysis was performed.
Ethical considerations
Ethical approval was obtained from the Institutional Review Board of the Muhimbili University of Health and Allied Sciences (Ref. no. DA.282/298/01.C/2405). Permission to conduct the study was granted by the Muhimbili Orthopaedic Institute administration.
Written informed consent was obtained from all participants prior to enrolment. Participants were informed of the study purpose, procedures, potential risks and benefits, and their right to decline participation or withdraw at any time without affecting their medical care. Confidentiality was maintained through anonymization of data and secure storage, with access restricted to the research team. The study was conducted in accordance with the Declaration of Helsinki.
Results
Participant characteristics and prevalence of depressive symptoms
During the study period, 75 patients with TSCI were admitted; 54 met eligibility criteria after excluding polytrauma (n = 13), altered consciousness (n = 5), and refusal to consent (n = 3). The mean age was 38.9 years (SD 6.1), and most participants were male (87.0%) and urban residents (81.5%).
Depressive symptoms (PHQ-9 ≥5) were identified in 10 participants, giving a prevalence of 18.5% (95% CI 9.3%–31.4%). Most cases were mild (70.0%), with the remainder moderate (30.0%); no participants had moderately severe or severe symptoms.
The mean PHQ-9 score was 3.5 (SD 2.7). Participants with depressive symptoms were slightly older than those without (40.6 vs 38.5 years), though this difference was not statistically significant (P = .318)
Socio-demographic factors associated with depressive symptoms
Socio-demographic associations are shown in Table 1. Age, sex, residence, marital status, employment, social support, and income were not significantly associated with depressive symptoms. Although females and unmarried participants had higher odds, and those with social support or higher income had lower odds, these differences were not statistically significant.
Education level was significantly associated with depressive symptoms (P = .033), with participants having higher educational attainment demonstrating increased odds compared with those with lower education (OR 5.10, 95% CI 1.23-21.14)
Clinical factors associated with depressive symptoms
Bivariate associations are shown in Table 2. Payment mode, mechanism of injury, and treatment modality were not significantly associated with depressive symptoms.
Depressive symptoms were significantly associated with cervical injury level (OR 6.75, 95% CI 1.54-29.60; P = .025), complete neurological injury (OR 5.83, 95% CI 1.39-24.38; P = .037), and severe pain (OR 9.07, 95% CI 1.95-42.25; P = .005), with higher mean VAS scores observed among affected participants (7.6 vs 5.4; P = .002).
The presence of complications showed the strongest association with depressive symptoms (OR 20.50, 95% CI 3.70–114.70; P < .001).
Multivariate analysis
Variables with P < .20 at bivariate analysis were entered into a multivariable logistic regression model (Table 3). Given the small number of participants with depressive symptoms (n = 10), the multivariable analysis was exploratory in nature, and findings were interpreted with caution. After adjustment, the presence of complications (aOR 12.44, 95% CI 1.26-122.46; P = .031) and higher educational attainment (aOR 8.55, 95% CI 1.03-71.18; P = .047) remained associated with depressive symptoms. Pain intensity, anatomical level, and neurological completeness were not significant.
CIs were wide, reflecting limited precision, and results should be considered exploratory.
Discussion
Proportion of depressive symptoms among patients with TSCI
This study assessed the proportion of depressive symptoms and associated factors among adults with isolated TSCI admitted to a national referral orthopaedic centre in Tanzania. Nearly one in five participants (18.5%) screened positive for depressive symptoms using the PHQ-9, with most exhibiting mild to moderate symptom severity.
This proportion is broadly consistent with findings from systematic reviews and meta-analyses reporting that approximately 20%–25% of individuals with spinal cord injury experience clinically relevant depressive symptoms when assessed using validated screening tools or diagnostic criteria .8 Hospital-based and population-based studies across diverse settings have similarly demonstrated a substantial psychological burden following TSCI, although reported estimates vary depending on study design, timing of assessment, and screening thresholds.2,3
The proportion observed in this study is lower than that reported in a recent Tanzanian study conducted at another tertiary centre, where more than one-third of patients with spinal cord injury screened positive for depressive symptoms.5 This difference may reflect variations inpatient characteristics, time since injury, burden of complications, access to rehabilitation services, and methodological differences, including screening thresholds.
Socio-demographic factors and depressive symptoms
Most socio-demographic characteristics, including age, sex, marital status, place of residence, employment status, income, and social support, were not significantly associated with depressive symptoms in this study. These findings are consistent with previous studies reporting weak or inconsistent associations between demographic characteristics and depressive symptoms following spinal cord injury.2,3,11 Although females and unmarried participants demonstrated higher odds of depressive symptoms, these estimates were imprecise and should be interpreted cautiously.
Higher educational attainment was associated with increased odds of depressive symptoms after adjustment. Although this contrasts with studies linking lower socioeconomic status to poorer mental health outcomes, it is consistent with evidence suggesting that individuals with higher educational attainment may experience greater psychological distress following spinal cord injury due to heightened awareness of functional loss, disruption of professional identity, and altered expectations regarding recovery and social participation.5,13 Similar observations have been reported in studies emphasizing the role of perceived loss of independence and reduced participation, rather than material deprivation alone, in shaping psychological outcomes after spinal cord injury.11,14 However, this association should be interpreted with caution given the limited number of outcome events and the resulting imprecision of the estimates.
Injury characteristics and clinical factors
Several injury-related factors were associated with depressive symptoms at the bivariate level. Participants with cervical spinal cord injuries and those with complete injuries (AIS grade A) had higher odds of depressive symptoms compared with those with thoracic or lumbar injuries and incomplete injuries. These findings are consistent with previous studies linking greater neurological severity and functional dependence to increased psychological burden following spinal cord injury.15,16
However, these associations did not remain statistically significant after adjustment, suggesting that their relationship with depressive symptoms may be influenced by downstream clinical consequences rather than neurological impairment alone.17
Pain intensity was also associated with depressive symptoms. Participants reporting severe pain had higher odds of depressive symptoms, consistent with existing evidence demonstrating an association between pain, psychological distress, and reduced quality of life following spinal cord injury.9,12 Pain-related activity limitation, sleep disturbance, and reduced participation are recognized contributors to psychological distress in this population, underscoring the importance of effective pain management as part of comprehensive spinal cord injury care9,18
Complications and depressive symptoms
The presence of complications was associated with higher odds of depressive symptoms after adjustment. This observation is consistent with prior studies identifying secondary complications, such as pressure injuries, bladder and bowel dysfunction, infections, and sexual dysfunction, as important contributors to psychological distress following spinal cord injury.5,9,12,17 However, this finding should be interpreted cautiously given the limited number of outcome events and the resulting wide CIs.
Complications may exacerbate physical discomfort, prolong hospitalization, delay rehabilitation, and increase dependence on caregivers, all of which can adversely affect participation and quality of life.11,12 The observed association highlights the potential role of preventable clinical complications in shaping psychological outcomes among individuals with TSCI.
Interpretation within the Tanzanian and LMIC context
While this study was conducted at a single national referral centre, the findings may offer insights relevant to spinal cord injury care in Tanzania and similar low- and middle-income settings. Limited access to specialized rehabilitation services, prolonged inpatient stays, high out-of-pocket health care expenditures, and constrained social support systems may intensify the psychological impact of spinal cord injury.4,5
Although income and payment mode were not significantly associated with depressive symptoms in this study, financial strain may exert indirect effects through delayed rehabilitation, reduced access to supportive services, and increased risk of complications, as suggested by broader socioeconomic and mental health literature.6
These considerations highlight the potential value of integrating psychological support within multidisciplinary spinal cord injury care pathways in resource-constrained settings.19
Clinical and policy implications
The findings underscore the importance of routine screening for depressive symptoms among patients with TSCI, particularly those experiencing complications and severe pain. Integrating mental health assessment into standard spinal cord injury care, alongside proactive prevention and management of complications, may improve psychological and functional outcomes.
Multidisciplinary rehabilitation approaches incorporating psychosocial support, patient education, and timely referral to mental health services are important components of comprehensive spinal cord injury care in resource-limited settings. Strengthening collaboration between orthopaedic, rehabilitation, and mental health services may enhance holistic care for individuals with TSCI.
Strengths and limitations
This study has several strengths. First, the prospective design reduced recall bias and enabled systematic data collection. Second, the use of validated assessment tools, including the PHQ-9, VAS, and AIS, enhanced measurement reliability and comparability with existing literature. Third, the census sampling approach, which enrolled all eligible patients during the study period, minimized selection bias within the study setting. In addition, assessment of depressive symptoms at least four weeks after injury reduced potential misclassification related to acute stress responses in the immediate post-injury phase.
Several limitations should be acknowledged. The relatively small sample size reduced statistical power and resulted in wide CIs, limiting the precision of estimates. In addition, the small number of outcome events relative to the number of predictors constrained the stability of the multivariable model; therefore, adjusted estimates should be interpreted as exploratory. The cross-sectional design precludes inference regarding temporal relationships between clinical factors and depressive symptoms. Furthermore, as the study was conducted at a single national referral centre, generalizability to lower-level facilities may be limited. Potentially relevant factors, such as preinjury mental health status, coping mechanisms, and longitudinal psychological trajectories, were not assessed. Finally, depressive symptoms were evaluated in the subacute phase, and longer follow-up may have identified a higher prevalence or greater severity of symptoms.
Conclusion
Depressive symptoms were observed in a notable proportion of adults with TSCI, predominantly of mild to moderate severity, highlighting a psychological burden. Complications and higher educational attainment were associated with increased odds of depressive symptoms, suggesting a closer link to downstream clinical consequences than to neurological severity alone. However, these findings should be interpreted cautiously and considered exploratory given the limited sample size and the resulting imprecision of the estimates.
Routine screening, complication prevention, effective pain management, and multidisciplinary rehabilitation may support improved outcomes. Further longitudinal studies are needed to clarify causal relationships and guide context-appropriate psychosocial interventions in low- and middle-income settings.
Acknowledgments
The authors acknowledge the support of the staff of Muhimbili Orthopaedic Institute for their assistance during patient recruitment and data collection.
Ethical Approval
Ethical approval for this study was obtained from the Institutional Review Board of the Muhimbili University of Health and Allied Sciences (Ref. no. DA.282/298/01.C/2405).
Informed Consent
Written informed consent was obtained from all participants prior to enrolment. Refusal to participate did not affect the patients’ medical care.
Data Availability
Data are available upon reasonable request from the corresponding author. Deidentified participant data will be shared subject to institutional approval.
Conflict of Interest
The authors declare that they have no competing interests.
Funding
None