Download Depression - The Christopher & Dana Reeve Foundation

Spinal Cord Injury and
Depression
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
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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 2025% 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
Outcomes that would help avoid
or postpone depression
J
J
J
N
N
N
N
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
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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
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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:
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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
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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
• Initial insomnia: difficulty
falling asleep
• Middle insomnia: waking up
during the night and struggling to
get back to sleep
• 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:
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Drug abuse
Alcohol abuse
Eating disorders
Anxiety disorders
Obsessive-compulsive disorders
Depression and People with SCI
Depression can contribute to:
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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
• Behavioral changes due to the symptoms of
depression may contribute to secondary
conditions
• 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
Depression and People with SCI
• Some antidepressants have side effects that
may contribute to other secondary
conditions
• Weight gain
• Changes in urinary tract
or bowel function
• Loss of erectile function
Depression and People with SCI
• When prescribing
antidepressants . . .
• Give recommendations for selfcare (like bowel or skin care)
• Alert patients of possible side
effects of all medications
Treatment Options
Psychotherapy
Medications
Combination of both
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)
Medication
Also 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 reuptake 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 lifethreatening 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:
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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:
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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