Spinal Cord Injury andDepression

Melissa Gard, M.A, Glen W. White, Ph.D. and Sam Ho

Research and Training Center on Independent Living

at the University of Kansas

This training sponsored through a

grant from the Christopher and

Dana Reeve

Special thanks to…• The Christopher and Dana Reeve Foundation

• Centers for Disease Control

• Ann Sullivan Center of Perú

• Dra. Liliana Mayo and Staff members

• Scott Richards, Ph.D. – Spain Rehabilitation Center, University of Alabama at Birmingham

• Suzanne Groah, M.D., M.S.P.H. – National Rehabilitation Hospital, Rehabilitation Research & Training Center on Secondary Conditions in the Rehabilitation of Individuals with Spinal Cord Injury

Special thanks to…• Sam Ho

• Jaime Huerta

• Monica Ochoa

• And special thanks to Julio Chojeda for translation of materials from English to Spanish…

Acknowledgement of sources used for this presentation: Yes You Can! (Paralyzed Veterans of America) SCI: A Manual for Healthy Living (TIRR) Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) Depression (RTC/IL & PVA) Depression: What You Should Know by the

Consortium for Spinal Cord Medicine)

Presentation Review• Define depression

• Causes and signs of depression

• Types of depression

• Diagnostic criteria

• Identify who is at risk

• Implications of depression for a person with SCI

• Reducing or preventing depression

• Treatment of depression

Depression• The most common of all of the mental illnesses

in the U.S. – General population: 7-12 % of males and

20-25% of all women– Persons with SCI: 25% of males and up to

47% in women• Interferes with a person’s ability to function,

feel pleasure, or maintain interests

Depression can be caused by:• A chemical imbalance in the brain• An illness/injury that changed the body’s

chemistry (e.g. hormonal disorder, Parkinson’s)• A predisposition to be depressed

• It is a treatable condition

Person factors Environment

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Personal Factors• Genetic predisposition – Mother or father has depression or bipolar disorder– Brother or sister has depression or bipolar disorder

• Chemical imbalance in the brain: • low levels of some neurotransmitters (serotonin &

norepinephrine) • This regulates emotions and reactions to stress, sleep,

appetite, and sexuality

• Other personal risk factors• High frustration when trying to problem solve• Low personal activity levels• Social isolation from others• Alcohol/drug abuse

Environmental Factors• Chemical imbalance due to injury

• Medications for other conditions: Some medications cause depression as a side effect (noticeable the first 10 days after beginning the medication)• For heart disease (beta blockers,

statins, calcuim-channel blockers)• Cancer treatment medications • For women (hormone replacement

therapy: estrogens, birth control: Norplant)

Environmental Factors• Accessibility of home and community

environment (transportation, jobs, education, shopping, leisure)

• Availability of professional help• Psychiatrists, psychologists, counselors, peer

counselors

• Availability of social support• Community: rural vs. urban setting• Family• Friends

• Availability of Medications• availability and cost of antidepressants

Signs of Depression• Depressed mood or extreme

sadness (more than just feeling blue)

• More withdrawn from others

• Loss of pleasure in favorite things or activities

• Irritability

• Changes in eating habits

• Changes in sleeping habits

• Thoughts of suicide

How do you know if you are just sad or depressed?

• A person may be sad but not meet the diagnostic criteria for depression. Sadness alone will not severely affect a person’s ability to function on a daily basis.

• Usually people are sad for a short time, but depression usually lasts a longer period of time.

• Many medications can affect your mood (e.g., those for spasticity, pain). Tell the doctor who is looking for depression about your medications, dosage, and when they are taken.

Types of Depression

• Major Depression

• Dysthymic Disorder

• “Situational Depression or Reactive Depression” (not a form of clinical depression)

Major Depression• At least 2 weeks of depressed mood OR• At least 2 weeks with a loss of interest or

pleasure in nearly all activities• Sex• Hobbies • Work• Socializing• Previously enjoyable

activities seem to take a great amount of effort

• AND…

Major Depression• At least 4 of the following symptoms that

are NOT a result of a general medical condition:• Changes in appetite or weight• Changes in sleep• Changes in motor activity• Fatigue (without physical exertion)• Feelings of worthlessness or guilt (delusional

blaming oneself for being sick)• Loss of memory, inability to think, concentrate,

or make decisions• Thoughts of death or suicide, suicide attempts

Changes in Appetite or Weight• Weight gain• Weight loss• Overeating• Not eating enough• Changes in eating habits

(cravings)• No change in eating

habits but loss of appetite (force self to still eat regularly)

Changes in motor activity• Increase or decrease of

activity is obvious to others

• Agitation• Can’t sit still• Pacing• Hand wringing

• Delay in activities• Slowed speech• Slowed body movements• Long pauses before

responses• Speech has decreased

volume and inflection

Insomnia

• Middle insomnia: waking up during the night and struggling to get back to sleep

• Initial insomnia: difficulty falling asleep

• Terminal insomnia: waking up too early in the morning and struggling to get back to sleep

Insomnia

• Hypersomnia: an increase in daytime or nighttime sleep

Dysthymic Disorder• Same symptoms as Major Depressive

Disorder except

• Symptoms: depressed mood and 2 other symptoms (instead of 4)

• Symptoms must be present for more days than not (but not every day) over a period of at least 2 years

• Symptom free intervals can last up to 2 months

• Depressive symptoms are chronic and less severe

It is NOT depression if . . .• All of the symptoms present are fully

accounted for by a medical condition• e.g., weight loss for a person with a spinal cord

injury would not be a symptom of depression UNLESS• The person also had thoughts of suicide, insomnia,

and loss of pleasure in socializing.

• Symptoms begin within 2 months of a loss of a loved one (or trauma), and do not persist beyond 2 months (this is normal grief)• Unless person loses functional abilities or is

constantly preoccupied with the loss or trauma

Risk Factors for Depression

• Age 25-44 years

• Twice as likely in women as it is in men (although no gender difference in children)

• Parent or sibling with depression (1.5-3% more likely to develop it)

• History of depression (50-90% more likely)

Risk Factors for Depression• Medical Condition: 20-25% of individuals

with certain medical illness (heart attack, cancer, stroke) are likely to develop depression

• Other mental health conditions: • Drug abuse• Alcohol abuse • Eating disorders • Anxiety disorders • Obsessive-compulsive disorders

Depression and People with SCI

Depression can contribute to:• Pressure ulcers• Urinary tract infections• Chronic pain• Substance abuse• Problems with caregivers • Higher medical expenses • Longer or more frequent hospital stays• Problems with personal relationships• Higher risk of suicide (especially during the first 5

years post-injury)

Depression and People with SCI

• Fatigue, decrease in activity, and increase in sleeping may

lead to pressure sores, weight gain, deconditioning

• Lower ability to concentrate or make decisions may lead to carelessness with skin care, bowel care, or eating habits

• Behavioral changes due to the symptoms of depression may contribute to secondary conditions

• Some antidepressants have side effects that may contribute to other secondary conditions

Depression and People with SCI

• Weight gain

• Changes in urinary tract or bowel function

• Loss of erectile function

Depression and People with SCI

• When prescribing antidepressants . . . • Give recommendations for self-

care (like bowel or skin care)• Alert patients of possible side

effects of all medications

Treatment Options

Combination of both

MedicationsPsychotherapy

Psychotherapy

• Individual counseling

• Marriage/family counseling

• Interpersonal counseling

APPROACHES

• Psychodynamic

• Client Directed

• Problem Centered

Cognitive behavioral therapy

Usually short term (as few as 10 visits)

• Goals: • Stop person’s negative thoughts• Decrease the behaviors that could invite

depression (poor eating, being alone, etc)• Increase the behaviors that help prevent

depression (create meaningful relationships with others, set goals, etc)

MedicationAlso referred to as psychopharmacology

• Goal: to reestablish a chemical balance in the brain

• Medication can only be prescribed by a medical physician. This includes primary care physicians and psychiatrists, but not

psychologists.

Tips for taking antidepressants• Be aware of the side effects:• Ask your doctor what to expect, when, and for how long

• Possible drug interactions • With other prescriptions

• With herbal supplements, alcohol, street drugs

• Dosage may need to be changed regularly• Medications may take (4-6 weeks) to begin working• Ask doctor about when the medications will take effect.• Ask doctor what you should do if depression continues

• Do NOT stop taking medication without asking the doctor• May need to reduce dose

Medications• Antidepressants are not habit forming

• May take up to 8 weeks to see improvement

• Should continue taking 4-9 months after symptoms have improved

• Two most commonly prescribed:• Selective serotonin reuptake inhibitors

(SSRIs): (e.g. Prozac)

• Serotonin & Norepinephrine reuptake inhibitors (SNRIs): (e.g. Cymbalta)

Medications: Pros and Cons

• SSRIs: works by blocking the re-uptake of serotonin in the brain, which increases the amount of serotonin available to send to nerve impulses

Medications: Pros and Cons

• SSRIs• Pros: specifically targets the level of serotonin

in the brain, causes fewer and weaker side effects, safer to take with other medications, little risk of overdose

• Cons: momentary nausea, nervousness, insomnia, agitation • Serotonin Syndrome: rare but potentially life-

threatening side effect. Occurs when SSRI interacts with other medication (e.g, MAOI, St. John’s wort)

Medications: Pros and Cons

• SNRIs (Serotonin & Norepinephrine Reuptake Inhibitors): block absorption of serotonin and norepinephrine• Pros: Similar to SSRIs• Cons: Similar to SSRIs• Examples:• Duloxetine (Cymbalta)• Venlafaxine (Effexor)• Desvenlafaxine (Pristiq)

Medication: Pros and Cons• Tricyclic Antidepressants (TCAs): work by

correcting the chemical imbalance—but also affect other chemicals throughout the body• Pros: helps with nerve related pain

• Cons: dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, sensitivity to sunlight

• Also, autonomic dysfunction in SCI patients leaves them more susceptible to certain side effects of TCAs

Medications: Pros and Cons

• Monoamine Oxidase Inhibitors (MAOI): blocks the enzymes that break down norepinephrine and serotonin• Pros: alternative if other medications were not

effective• Cons: serious side effects including interactions

with food, beverage, other medications and a sharp increase in blood pressure

Medications: Pros and Cons• While all of these side effects may be discouraging

they can be useful in treatment of depression.

• For example, a patient experiencing weight gain and fatigue in addition to depression could be prescribed fluoxetine since it is an activating antidepressant and can cause decreased appetite.

• Of course, collaboration between a patient’s primary care physician and mental health provider is of particular importance in this case.

Medication: Caution

• US Food and Drug Administration• Issued a warning to monitor adults and

children taking antidepressants for signs of worsening symptoms (including suicide), especially when beginning treatment or changing dosage.

Preventing Depression• Remind your patients to:– Exercise

– Get involved in their community

– Learn about community resources

– Develop hobbies

– Set realistic goals (break large tasks into small ones)

– Discuss important decisions with others

– Think positively

– Know the signs of depression

Review of Today’s Session

Today we:• Defined depression• Discussed causes and signs of depression• Outlined the types of depression• Reviewed diagnostic criteria• Identified who is at risk• Explored implications of depression for a

person with SCI• Discussed prevention and treatment of

depression