Characteristics Associated With Perceived Underemployment Among Participants With Spinal Cord Injury.

Objective: To identify job characteristics related to perceived underemployment among people with spinal cord injury (SCI), while controlling for demographic, injury, and educational factors. Design: Cross-sectional, logistic regression with predicted probabilities of underemployment. Setting: Medical University in the Southeastern United States. Participants: 952 were adults with traumatic SCI, all of whom were a minimum of 1-year post-injury and employed at the time of the study. They averaged 46.7 years of age, the majority were male (70.5%), and over half (52%) were ambulatory (N=952). Interventions: Not applicable. Main Outcome Measures: Perceived underemployment was defined and measured by a dichotomous variable (yes/no). Results: Demographic, injury, and educational factors explained only 4.8% of the variance in underemployment, whereas the full model explained 21.8%. Underemployment was significantly lower for women (odds ratio [OR]=0.66, 95% confidence interval [CI; .44, .98]), those who were either married or in a nonmarried couple (OR=0.63, 95% CI [.42, .93]), those with health benefits (OR=0.58, 95% CI [.37, .91]) and higher for those with lower earnings and occupations in the category of sales, professional/managerial. Postsecondary educational milestones, having received a promotion or recognition, and working full time were not identified as significant predictors in the multivariate model, although each was significantly related to a lower likelihood of underemployment when using a restricted model that controls only for demographics, SCI, and educational status (rather than all variables simultaneously). Age, years since injury, and injury severity were not significant. Conclusion: Underemployment is a concern among people with SCI and is more prevalent in low-paying jobs, without benefits, and opportunities for recognition and promotion. Vocational counseling strategies need to promote quality employment, including jobs with recognition and benefits.

Job Retention Among Individuals With Multiple Sclerosis: Relationship With Prediagnostic Employment and Education; Demographic Characteristics; and Disease Course, Severity, and Complications.

OBJECTIVE: To identify how prediagnosis employment, education, demographic statuses, and disease factors relate to job retention among people with multiple sclerosis (MS). DESIGN: Cross-sectional logit model. SETTING: Data were collected at an academic Medical University and a specialty hospital, both in the Southeastern US. PARTICIPANTS: People with MS (N=1126) who were employed at the time of MS diagnosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Job retention was measured by employment status at the time of follow-up assessment. RESULTS: Prediagnostic educational attainment was predictive of job retention. Among several prediagnostic employment characteristics, only working in production, transportation, and material moving was significantly related to a lower odds of job retention compared with those working in professional/managerial occupations. Aging factors were strongly related to job retention, with declines in job retention observed with increasing age and years since diagnosis. Non-Hispanic Black and Hispanic participants reported lower odds of job retention than non-Hispanic White participants, although there were no observed effects of sex. A significantly lower job retention rate was observed among those with progressive MS, compared with relapsing-remitting. Job retention was also less likely among people with greater MS severity and fatigue. CONCLUSIONS: Job retention strategies and interventions should target people with greater MS complications and severity, as well as non-Hispanic Black and Hispanic persons, because these characteristics are more highly related to job retention than our prediagnostic employment and vocational history.

Barriers and Facilitators to Employment: A Comparison of Participants With Multiple Sclerosis and Spinal Cord Injury.

OBJECTIVE: To compare self-reported barriers and facilitators to employment among employed and unemployed participants with multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Cross-sectional study using self-report assessment obtained by mail or online. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants (N=2624) identified from either a specialty hospital or a state-based surveillance system in the southeastern United States, including 1234 with MS and 1390 with SCI. All participants were aged <65 years at the time of assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported barriers and facilitators to employment. RESULTS: Overall, the MS participants reported more barriers, particularly stress, cognition, and fatigue, whereas those with SCI were more likely to report not having the proper education and training, resources, transportation, and attendant care. Follow-up analyses broken down by employment status indicated that several barriers and facilitators were significantly related to diagnosis for either employed or unemployed participants, but not both. Among those employed, participants with SCI were more likely to report they could not do the same types of jobs as they could pre-SCI and those with MS were more likely to state that they did not know much about jobs for people with disabilities (no differences were noted for these variables among unemployed participants). Unemployed individuals with SCI were more likely to report that the jobs for which they were trained were not accessible. CONCLUSIONS: The primary barriers for individuals with MS revolve around the condition itself, whereas the barriers for SCI appear to be more related to modifiable factors. Vocational rehabilitation specialists need to identify diagnostic-specific barriers to promote employment outcomes.

Employment status, hours working, and gainful earnings after spinal cord injury: relationship with pain, prescription medications for pain, and nonprescription opioid use.

STUDY DESIGN: Cross-sectional self-report assessment. Econometric modeling. OBJECTIVES: Identify the relationship of multiple pain indicators, prescription pain medication, nonprescription opioid use, and multiple indicators of quality employment among those with spinal cord injury (SCI). SETTING: Data were collected at a medical university in the Southeastern United States (US). METHODS: Participants included 4670 adults with traumatic SCI of at least one-year duration who were enrolled in a study of health and longevity. They were identified from three sources including a specialty hospital and two population-based state SCI surveillance systems. Econometric modeling was used for three outcome variables: employment status, hours per week spent working, and earnings. RESULTS: Several pain parameters were significantly related to multiple employment outcomes. Prescription medication to treat pain was associated with lower odds of employment, fewer hours working, and lower conditional earnings. Nonprescription opioid use was only related to fewer hours working. Painful days, number of painful conditions, and pain intensity were all related to employment outcomes, but the pattern varied by outcome. The number of painful conditions was most consistently related to employment. Multiple demographic, injury, and educational factors were related to employment, with better outcomes among those with less severe SCI and greater educational achievements. CONCLUSIONS: The presence of significant pain and use of either prescription pain medications or the use of nonprescription opioids may have a significant adverse effect on both the probability of employment and quality of employment. Rehabilitation and vocational professionals should routinely assess pain and associated medications in vocational and career planning.

Employment and Job Benefits Among Those With Spinal Cord Dysfunction: A Comparison of People With Spinal Cord Injury and Multiple Sclerosis.

OBJECTIVE: (1) Identify the proportion of participants with spinal cord dysfunction (SCD) reporting each of 10 job benefits and compare the proportions between participants with spinal cord injury (SCI) and multiple sclerosis (MS); and (2) examine if diagnostic criteria, demographics, education level, and functional limitations are associated with the number of job benefits received. DESIGN: Econometric modeling of cross-sectional data using a 2-step data analytic model of employment and job benefits. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants (N=2624) were identified from the southeastern United States. After eliminating those age 65 and older, there were 2624 adult participants with SCD; 1234 had MS and 1390 had SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Current employment status; number of benefits received and specific benefits received. RESULTS: A greater proportion of participants with MS received benefits, with significant differences observed on all but 1 type of benefit. Among those who were employed, a greater number of benefits was associated with having MS, greater education, younger age, married or in an unmarried couple, and not having functional restrictions with cognition, doing errands, or shopping alone in the community, and walking. CONCLUSIONS: Employed participants with MS were more likely to receive job benefits, indicative of a higher quality of employment, compared to participants with SCI. Employment without benefits is a form of underemployment that disproportionately affects individuals with many of the same characteristics that initially lead to disparities in probability of gainful employment.

Employment and Gainful Earnings Among Those With Multiple Sclerosis.

OBJECTIVE: To identify demographic, educational, and disease-related characteristics associated with the odds of employment and earnings among participants with multiple sclerosis (MS). DESIGN: Cross-sectional using self-report assessment obtained by mail or online. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants with MS (N=1059) were enrolled from a specialty hospital in the southeastern United States. All were adults younger than 65 years at the time of assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Current employment status and earnings. RESULTS: MS factors were highly related to employment, yet not as strongly to conditional earnings. Those with no symptoms reported 6.25 greater odds of employment than those with severe current symptoms. Compared with those with progressive MS, those with relapsing or remitting had greater odds of employment (odds ratio [OR]=2.24). Participants with no perceived cognitive impairment had 1.83 greater odds of employment than those with moderate to severe perceived cognitive impairment. Those with <10 years since MS diagnosis had 2.74 greater odds of employment compared with those with >20 years since diagnosis. An absence of problematic fatigue was highly related to the probability of employment (OR=5.01) and higher conditional earnings ($14,454), whereas the remaining MS variables were unrelated to conditional earnings. For non-MS variables, education was highly related to employment status and conditional earnings, because those with a postgraduate degree had 2.87 greater odds of employment and $44,346 greater conditional earnings than those with no more than a high school certificate. Non-Hispanic whites had 2.22 greater odds of employment and $16,118 greater conditional earnings than non-Hispanic blacks, and men reported $30,730 more in conditional earnings than women. CONCLUSIONS: MS indicators were significantly associated with employment status including time since diagnosis, fatigue, symptom severity, and presence of cognitive impairment. However, among those who were employed, conditional earnings were less highly related to these factors and more highly related to educational attainment.

Comparison of factor structure models for the Beck Anxiety Inventory among cardiac rehabilitation patients.

OBJECTIVE: Individuals with cardiovascular disease (CVD) experience greater rates of distress symptoms, such as anxiety and depressive symptoms, than the general population. These psychological outcomes have been linked to greater risk for negative outcomes following a cardiac event; however, research examining the relationship between specific components of anxiety and outcomes in CVD is limited. Further, prior research has not investigated the structure of anxiety symptoms in CVD. This study sought to compare previously established one, two, and four-factor models of the Beck Anxiety Inventory (BAI) in individuals enrolled in cardiac rehabilitation (CR). METHODS: Our sample included 208 individuals with CVD recruited during enrollment in a phase II CR program. Participants completed the BAI at enrollment in CR (Time 1) and again 12weeks later at CR completion (Time 2, n=151). RESULTS: Consistent with prior literature, 41% of our sample reported at least mild symptoms of anxiety (BAI>8), and the BAI proved to be a reliable measure within this sample (α=0.89). Confirmatory factor analysis (CFA) results indicated that a second-order model with four first order factors, consisting of cognitive, autonomic, neuromotor, and panic components, fit our data well. A multi-group CFA approach supported measurement invariance across time. CONCLUSION: These results suggest that anxiety following CVD can be evaluated based on cognitive, autonomic, neuromotor, and panic components as well as the encompassing anxiety construct.

Impact of Health Behaviors and Health Management on Employment After SCI: Psychological Health and Health Management.

Objective: The purpose of this study was to examine the relationship between employment and psychological health and health management as described by individuals with spinal cord injury (SCI) who were employed at least once following injury. Methods: A qualitative approach used 6 focus groups at 2 sites with 44 participants who were at least 10 years post SCI. All had been employed at some point since injury. Heterogeneous and homogeneous groups were delineated based on specific characteristics, such as education, gender, or race. Group sessions followed a semi-structured interview format with questions about personal, environmental, and policy related factors influencing employment following SCI. All group sessions were recorded, transcribed, and coded into conceptual categories to identify topics, themes, and patterns. Inferences were drawn about their meaning. NVivo 10 software using the constant comparative method was used for data analysis. Results: Narratives discussed the relationship between employment and psychological and emotional health and health management. Four themes were identified: (1) adjustment and dealing with emotional reactions, (2) gaining self-confidence, (3) preventing burnout, and (4) attitudes and perspectives. Most themes reflected issues that varied based on severity of injury as well as stage of employment. Conclusions: Individuals with SCI who are successful in working following injury must determine how to perform the behaviors necessary to manage their health and prevent emotional or physical complications. The emotional consequences of SCI must be recognized and addressed and specific behaviors enacted in order to optimize employment outcomes.

The Impact of Health Behaviors and Health Management on Employment After SCI: Physical Health and Functioning.

Background: Research has shown that employment following spinal cord injury (SCI) is related to health and functioning, with physical health and functioning after SCI frequently identified as a primary barrier to employment. Objective: To examine the relationship between employment and behaviors associated with the management of physical health and functioning as described by individuals with SCI who have been employed post injury. Methods: A qualitative approach using 6 focus groups at 2 sites included 44 participants with SCI who had worked at some time post injury. Heterogeneous and homogeneous groups were created based on specific characteristics, such as education, gender, or race. A semi-structured interview format asked questions about personal, environmental, and policy-related factors influencing employment after SCI. Groups were recorded, transcribed, and entered into NVivo before coding by 2 reviewers. Results: Within the area of behaviors and management of physical health and functioning, 4 overlapping themes were identified: (1) relearning your own body and what it can do; (2) general health and wellness behaviors; (3) communication, education, and advocacy; and (4) secondary conditions and aging. Specific themes articulate the many types of behaviors individuals must master and their impact on return to work as well as on finding, maintaining, and deciding to leave employment. Conclusions: Individuals with SCI who are successfully employed after injury must learn how to perform necessary behaviors to manage health and function in a work environment. The decision to leave employment often appears to be associated with secondary complications and other conditions that occur as persons with SCI age.

It's All of the Above: Benefits of Working for Individuals with Spinal Cord Injury.

BACKGROUND: The majority of research on employment among persons with spinal cord injury (SCI) focuses on the employment rate at a given point in time to the exclusion of quality employment outcomes. OBJECTIVE: To identify the employment outcomes of greatest importance as defined by those with SCI who have worked since injury. METHODS: A qualitative approach was used with 6 focus groups at 2 sites (Minnesota and Georgia). Participants (N = 44) were a minimum of 10 years after injury and had been employed at some point after SCI. We identified participants through a 40-year longitudinal study of SCI and a community resource. A combination of homogeneous (race/ethnic minority group, female group) and heterogeneous groups were convened. A semi-structured interview format queried participants about personal, environmental, and policy-related factors that impacted obtaining, maintaining, and advancing in employment. RESULTS: Seven overlapping themes were identified under the 2 broad categories of compensation and subjective well-being: (1) salary and what it can support, (2) health insurance and other fringe benefits, (3) promotions and recognition, (4) social connection and support, (5) job satisfaction and enjoyment from working, (6) making a difference and helping others, and (7) psychological and emotional health. CONCLUSION: The results indicate several common themes among persons with SCI who have successful employment histories, suggesting that the benefits of employment are multifaceted and go beyond monetary compensation.

Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research.

BACKGROUND: To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies. OBJECTIVE: Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention. METHODS: We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research. CONCLUSIONS: The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.

The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury.

OBJECTIVE: To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators. DESIGN: Cohort study. SETTING: A large rehabilitation hospital in the southeastern US. PARTICIPANTS: 1466 white and African American adults at least 1-year post-traumatic SCI. OUTCOME MEASURES: (a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury. RESULTS: In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU. CONCLUSION: These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.

Factor structure and predictive validity of somatic and nonsomatic symptoms from the patient health questionnaire-9: a longitudinal study after spinal cord injury.

OBJECTIVE: To investigate the factor structure and predictive validity of somatic and nonsomatic depressive symptoms over the first 2.5 years after spinal cord injury (SCI) using the Patient Health Questionnaire-9 (PHQ-9). DESIGN: Somatic and nonsomatic symptoms were assessed at baseline during inpatient hospitalization (average of 50 days after onset) and during 2 follow-ups (average of 498 and 874 days after onset). SETTING: Data were collected at a specialty hospital in the Southeastern United States and analyzed at a medical university. We performed time-lag regression between inpatient baseline and follow-up somatic and nonsomatic latent factors of the PHQ-9. PARTICIPANTS: Adults with traumatic SCI (N=584) entered the study during inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: PHQ-9, a 9-item measure of depressive symptoms. RESULTS: The inpatient baseline nonsomatic latent factor was significantly predictive of the nonsomatic (r=.40; P=.000) and somatic latent factors at the second follow-up (r=.29; P=.006), whereas the somatic factor at inpatient baseline did not significantly predict either factor. In contrast, when regressing latent factors between the 2 follow-ups, the nonsomatic factor predicted only the nonsomatic factor (r=.66; P=.002), and the somatic factor predicted only future somatic symptoms (r=.66; P=.000). In addition, the factor structure was not stable over time. Item analysis verified the instability of somatic items between inpatient baseline and follow-up and also indicated that self-harm at inpatient baseline was highly predictive of future self-harm. CONCLUSIONS: Nonsomatic symptoms are better predictors of future depressive symptoms when first assessed during inpatient rehabilitation, whereas somatic symptoms become stable predictors only after inpatient rehabilitation. Self-harm (suicidal ideation) is the most stable symptom over time. Clinicians should routinely assess for suicidal ideation and use nonsomatic symptoms when performing assessments during inpatient rehabilitation.

A structural analysis of health outcomes after spinal cord injury.

OBJECTIVE: To develop and validate a latent model of health outcomes among persons with spinal cord injury. METHODS: Survey data were collected at a large specialty hospital in the southeastern USA from 1,388 adult participants with traumatic spinal cord injury of at least 1 year's duration. Multiple indicators of health outcomes were used, including general health ratings, days adversely affected by poor health and poor mental health, treatments and hospitalizations, depressive symptoms, symptoms of illness or infection (eg, sweats, chills, fever), and multiple individual conditions (eg, pressure ulcers, subsequent injuries, fractures, contractures). RESULTS: We performed exploratory factor analysis on half of the sample and confirmatory factor analysis on the other. A 6-factor solution was the best overall solution, because there was an excellent fit with the exploratory factor analysis (root mean square error of approximation = 0.042) and acceptable fit with the confirmatory factor analysis (root mean square error of approximation = 0.065). Four of the factors were types of secondary conditions, including symptoms of illness or infection, orthopedic conditions, pressure ulcers, and subsequent injuries. The 2 remaining factors reflected global health and treatment. Gender, race-ethnicity, age, injury severity, and years of education were all significantly related to at least 1 factor dimension, indicating variations in health outcomes related to these characteristics. CONCLUSION: Identification of the 6 factors represents an improvement over the utilization of multiple individual indicators, because composite scores generated from multiple individual indicators provide more informative and stable outcome scores than utilization of single indicators.

Comparison of the Patient Health Questionnaire and the Older Adult Health and Mood Questionnaire for self-reported depressive symptoms after spinal cord injury.

OBJECTIVE: To directly compare estimates of potential depressive disorders and clinically significant depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) and Older Adult Health and Mood Questionnaire (OAHMQ) among participants with spinal cord injury (SCI). RESEARCH DESIGN: 727 participants from a hospital in the Southeastern United States were administered the PHQ-9 and OAHMQ during a follow-up survey. We compared the rates of depressive disorders using cutoff scores and diagnostic criteria for each instrument. No independent psychiatric diagnostic interviews were conducted. RESULTS: The PHQ-9 and OAHMQ were significantly correlated (r = .78), and both were correlated with satisfaction with life (r = -.48, -.54). Using recommended diagnostic scoring procedures, 10.7% of participants met the diagnostic criteria for major depressive disorder with the PHQ-9; 9.3% met the criteria for major depression based on PHQ-9 > or = 10; and 19.7% based on PHQ-9 > or = 15. Using the OAHMQ, 19.7% reported probable major depression and 44.5% clinically significant symptomatology. CONCLUSIONS: The measures were highly correlated overall. However, the estimated prevalence of depressive disorders varied substantially between the 2 instruments. These estimates were comparable to those previously reported for each instrument (i.e., higher rates with the OAHMQ). Therefore, differing estimates of depressive disorders reported in the literature using these instruments were largely attributable to the instruments themselves.

Life satisfaction and self-reported problems after spinal cord injury: measurement of underlying dimensions.

OBJECTIVE: Evaluate the utility of the current 7-scale structure of the Life Situation Questionnaire-Revised (LSQ-R) using confirmatory factor analysis (CFA) and explore the factor structure of each set of items. DESIGN: Adults (N = 1,543) with traumatic spinal cord injury (SCI) were administered the 20 satisfaction and 30 problems items from the LSQ-R. RESULTS: CFA suggests that the existing 7-scale structure across the 50 items was within the acceptable range (root-mean-square error of approximation [RMSEA] = 0.078), although it fell just outside of this range for women. Factor analysis revealed 3 satisfaction factors and 6 problems factors. The overall fit of the problems items (RMSEA = 0.070) was superior to that of the satisfaction items (RMSEA = 0.80). RMSEA fell just outside of the acceptable range for Whites and men on the satisfaction scales. All scales had acceptable internal consistency. CONCLUSION: Results suggest the original scoring of the LSQ-R remains viable, although individual results should be reviewed for special population. Factor analysis of subsets of items allows satisfaction and problems items to be used independently, depending on the study purpose.

A latent variable structural path model of health behaviors after spinal cord injury.

BACKGROUND/OBJECTIVE: To develop a latent behavioral model by identifying and confirming the factor structure of health behaviors of people with spinal cord injury (SCI) and their relationships with biographic, injury, and educational characteristics. RESEARCH DESIGN: Survey data were collected from 1388 adults with traumatic SCI of at least 1 year duration. MAIN OUTCOME MEASURES: Selection of health behaviors was based on a bidimensional behavioral risk model. Behaviors were measured by core item sets from the Behavioral Risk Factor Surveillance System and supplemented by an alcohol screening measure, select fitness proxies, and the SCI Health Survey. RESULTS: Latent variable structural equation modeling was used to identify underlying factors and their relationship with participant characteristics. Seven specific factors were identified by exploratory factor analysis and were cross-validated using confirmatory factor analysis. They included: (a) healthy nutrition, (b) unhealthy nutrition, (c) fitness, (d) smoking, (e) alcohol use, (f) psychotropic prescription medications, and (g) SCI healthy activities. Two higher-order dimensions were also identified, including a risk dimension (b, d, e) and a protective dimension (a, c, g). Participant characteristics were associated with the domains. For instance, participants with the most severe injuries scored lower on smoking and alcohol but higher on psychotropic medications; age was positively correlated with healthy nutrition and negatively correlated with alcohol and tobacco use but also negatively correlated with fitness. CONCLUSION: Behaviors can be meaningfully combined into underlying dimensions to more efficiently use them as predictors of secondary conditions.

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-R(2) 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.