please add reference for these paragraphs from database :One of the main findings of this review is that depression is a common and serious morbidity among SCI patients in Iran, with a prevalence higher than the global average. Depression is associated with various biological, psychological and social factors, such as pain, anxiety, low education, unemployment, low income, low self-esteem, low self-efficacy, low life satisfaction, low social support and negative religious coping. Depression also has negative consequences on the physical, psychological and social well-being of SCI patients, such as reduced motivation, self-esteem, coping skills, social support and sexual satisfaction. These findings are consistent with previous studies that have reported high rates of depression and its associated factors and outcomes among SCI patients in other countries. However, the findings also suggest that SCI patients in Iran may face more challenges and difficulties than their counterparts in other countries due to the lack of adequate health care resources, social services and support systems. Therefore, there is a need for more effective and accessible interventions to prevent and treat depression among SCI patients in Iran. Such interventions should target not only the biological aspects of depression (such as pain management and medication use), but also the psychological and social aspects (such as cognitive-behavioral therapy, psychoeducation, peer support and vocational rehabilitation).

Another important finding of this review is that pain is the most consistent and significant risk factor for depression among SCI patients in Iran. Pain is reported by more than 80% of SCI patients and is associated with higher levels of depression scores. Pain can affect the physical, mental and social well-being of SCI patients, impairing their recovery, rehabilitation and quality of life. These findings are in line with previous studies that have demonstrated the high prevalence and impact of pain among SCI patients worldwide. However, the findings also indicate that pain management is a major challenge for SCI patients in Iran due to the lack of availability and affordability of analgesics, the lack of knowledge and skills among health care providers and the lack of adherence to pain management guidelines. Therefore, there is a need for more comprehensive and multidisciplinary approaches to pain management among SCI patients in Iran. Such approaches should include pharmacological and non-pharmacological modalities (such as physical therapy, acupuncture, electrical stimulation and biofeedback), as well as patient education, self-management strategies and psychological interventions (such as relaxation techniques, mindfulness-based therapy and coping skills training).

A third key finding of this review is that sexual dysfunction is a common and serious problem among both male and female SCI patients in Iran. Sexual dysfunction affects 70% to 90% of male SCI patients and 80% to 90% of female SCI patients. Some of the factors associated with sexual dysfunction include age, level and completeness of injury, pain, spasticity, bladder and bowel problems, medication use, hormonal status, psychological factors, partner relationship and cultural norms. Sexual dysfunction also affects the quality of life and mental health of SCI patients and their partners,
leading to lower self-esteem, depression, anxiety and marital dissatisfaction. These findings are similar to previous studies that have reported high rates of sexual dysfunction and its associated factors and outcomes among SCI patients in other countries. However, the findings also suggest that sexual health care is a neglected area for SCI patients in Iran due to the lack of awareness and sensitivity among health care providers and the lack of appropriate sexual education and counseling services. Therefore, there is a need for more comprehensive and tailored interventions to improve the sexual health and quality of life of SCI patients and their partners in Iran. Such interventions should include medical evaluation and treatment of sexual dysfunction (such as hormonal therapy, pharmacotherapy or surgical procedures), as well as psychosexual education and counseling (such as providing information on anatomy and physiology of sexual function, causes and treatment options for sexual dysfunction, contraceptive methods, sexually transmitted infections prevention etc.).

A fourth major finding of this review is that quality of life is generally lower among SCI patients in Iran than the general population across all domains. Quality of life is also lower among veterans with SCI than non-veterans with SCI. Quality of life is influenced by various factors such as physical health status (such as pain intensity), psychological health status (such as depression level), social relationships (such as social support level) and environmental factors (such as accessibility). Quality of life also affects other outcomes such as functional ability (such as mobility level), mental health (such as anxiety level) and sexual health (such as sexual satisfaction level). These findings are consistent with previous studies that have reported lower quality of life among SCI patients in other countries. However, the findings also indicate that quality of life improvement is a challenging goal for SCI patients in Iran due to the lack of adequate resources, services, and policies to address their needs.