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1.  Association of Daily Stressors and Salivary Cortisol in Spinal Cord Injury 
Rehabilitation psychology  2009;54(3):288-298.
Objective
Examine the diurnal variation of salivary cortisol in adults with spinal cord injury (SCI) and the effect of stressors on cortisol and mood.
Method
Ecological momentary assessment (EMA) to capture cortisol, stress and mood from 25 persons with SCI and 26 without SCI. Data were analyzed using linear mixed models.
Results
There were no systematic differences between groups on missing data. Diurnal variation of cortisol of participants with SCI reflected an expected pattern. No significant group differences for cortisol diurnal pattern, stress or mood; when group interactions were significant, results indicated lower cortisol reactivity to stress in participants with SCI. Stress had a significant impact on positive, negative and agitated moods.
Conclusions
Stress in daily life and its association with cortisol and mood were largely similar between persons with and without SCI. A key methodological contribution is the demonstration of using EMA to collect biological and behavioral data in the field from participants with SCI. The use of EMA in rehabilitation psychology research has great potential to advance our understanding of the dynamics of daily life with disability.
doi:10.1037/a0016614
PMCID: PMC2924200  PMID: 19702427
spinal cord injuries; stress, psychological; hydrocortisone; ecological momentary assessment
2.  Patient Health Questionnaire-9 in Spinal Cord Injury: An Examination of Factor Structure as Related to Gender 
Background/Objective:
Despite the attention depression after spinal cord injury (SCI) has received, research and clinical practice have been hampered by inadequate emphasis on reliable and valid measurement. Assessment of symptoms in persons with SCI is challenged by the presence of “transdiagnostic” symptoms and unexamined effects of gender. The objective of this study was to examine the factor structure of the Patient Health Questionnaire-9 (PHQ-9; the 9-item depression scale of the Patient Health Questionnaire) and determine whether the structure replicates across gender.
Methods:
A total of 1,168 women and men were matched on level/completeness of SCI, follow-up year, and age to create 584 pairs. Exploratory factor analysis examined 1- and 2-factor models and congruence in 2 randomly split half samples to establish congruence of the factor solution and replication across gender.
Results:
The 1- and 2-factor solutions fit the structure of the items accounting for 41% to 51% of original item variance. Congruence between random samples was uniformly high for the 1-factor solution (r = 0.791–0.948) but variable for the 2-factor solution. Although congruence was high for the combined sample and men (r = 0.90–0.97 and 0.71–0.94, respectively), it was variable for women (r = 0.29–0.85).
Conclusions:
Although there was support for the 1-factor structure of the PHQ within and between sexes, the low congruence between sexes and within women for the 2-factor structure indicates potentially important differences about how certain symptoms may be experienced or interpreted differently by men and women with SCI. Future research should focus on where sexes diverge in cognitive, affective, and somatic dimensions of depressive symptoms and whether sex-specific or sex-neutral measures are warranted.
PMCID: PMC2678286  PMID: 19569462
Spinal cord injuries; Affective disorders; Depression; Gender issues; Psychometrics; Factor analysis

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