Examining the prevalence of PTSD among individuals with TSCI, our study found more than one fourth (27%) meeting the diagnostic criteria (PCL-17 score > 44). The percentage diagnosed with PTSD according to DSM-IV criteria was slightly lower, that is, 25.2%. In comparison to other studies e.g., Agar et al. [16] (24%), Craig et al. [4] (27%), Cao et al. [17] (24.9%), The reported prevalence in the present study is very similar. This suggests that Nepalese individuals with TSCI may have similar psychological coping mechanisms to trauma compared to individuals with TSCI in the other parts of the world. However, in the study done by Warren et al., the prevalence of PTSD in individuals with TSCI was 52% [18], which is noticeably higher. This discrepancy in the prevalence may be due to a smaller sample size (N = 24) in the study by Warren et al. thereby making this study less generalizable.
Gender was a significant predictor of PTSD in our study with a higher prevalence of PTSD among females (35%) compared to males (22%). This finding is similar to the studies by Otis et al.[1] and Hatcher et al.[10]. Though males are more likely to experience a potentially traumatic event than females, the female: male ratio in the prevalence of PTSD is approximately 2:1 [19]. This finding is also reiterated by a study that reported a higher level of re-experiencing, avoidance and arousal symptoms among females [20]. Higher prevalence of PTSD among females may be explained by the fact that they experience higher levels of associated pre-traumatic, peri-traumatic and post-traumatic risk factors compared to males [19].
Type of family was another significant predictor of PTSD in our study. Patients living in joint families had significantly lower chances (24%) of developing PTSD compared to patients living in nuclear families (47%). This is similar to the findings by Farooq et al. who had studied the prevalence of PTSD among earthquake survivors in Kashmir, Pakistan [21]. Similarly, Yuchang et al. found the prevalence of PTSD among 2010 earthquake survivors living in joint family was 3.8% compared to 67% among survivors living in nuclear family [22]. A joint family system may have acted as an important source of support to the individuals in the face of various adversities. Our study showed higher prevalence of PTSD among SCI individuals from lower caste. In the study by Hatori et al. among 2015 earthquake survivors of Kathmandu, Nepal, higher prevalence of PTSD among lower caste earthquake survivors was found [23]. However there are no studies comparing the prevalence of PTSD among SCI individuals with respect to their ethnicity or caste. In Nepal, caste system is still prevalent in many parts of the country and individuals of lower caste face social discrimination which may contribute to higher prevalence of PTSD among individuals from lower caste.
Literacy rate was another significant predictor of PTSD in our study. Individuals with lower literacy had higher prevalence of PTSD. This is similar to the finding by Kuiper et. al. where individuals having higher PTSD symptoms were from primary/lower education background than with higher education [24]. Similarly, Tang et. al., found lower educational status predicting higher prevalence of PTSD among adult earthquake survivors [25]. Individuals with higher levels of education may have greater social resources and broader coping methods which may lessen the impact of traumatic events compared to individuals with lesser educational status.
Regarding the relationship of the clinical characteristics with PTSD, no significant association was found. Studies have suggested that individuals experiencing assaultive violence are at greater
risk of PTSD [26]. But all the individuals in our study had non assaultive trauma which may be the cause for the type of trauma not predicting the prevalence of PTSD among individuals with TSCI. Our study showed no correlation between relative loss and PTSD, though available studies have shown a strong relationship between them [27]. This may be due to a smaller number of individuals with relative loss (3.1%) making statistical comparison non-significant. Severity of neurological impairment and tetra/ paraplegia also did not show any correlation with PTSD prevalence among individuals with TSCI.
The limitation in this study was the information about the PTSD stressors and the experience of traumatic events before the incidence of SCI of all the individuals were not taken. This could have created a bias in the prevalence of PTSD among SCI individuals.
In conclusion, PTSD appears to be considerably prevalent among individuals with TSCI. Females, individuals from nuclear families, individuals with lower literacy, and individuals from lower caste are significantly vulnerable to developing PTSD. However, clinical characteristics do not appear to be influential in the development of PTSD. It can be recommended that personal variables need to be examined closely in the identification of individuals at higher risk for PTSD for the purpose of early detection and treatment.