18. Depression and SCI

Screen for depression annually in patients with SCI, using the PHQ-2 (cut off score > 3). Treat at standard guideline levels.

The Problem

It is estimated that half of individuals with a spinal cord injury (SCI) experience some form of significant mental health problem. The most common among these is depression, with a prevalence 3 – 4 times greater among people with spinal cord injuries than in the general population. Other mental health issues include anxiety, clinically-significant stress, and post-traumatic stress disorder. Rates of suicide are 3 – 5 times those reported in the general population.

Evidence-based Best Practice

Symptoms of depression can be overlooked or misidentified in people with spinal cord injuries; depressive symptoms like fatigue and sleep disturbances are often attributed to SCI. Risk factors for depression with SCI include: younger age / shorter time since onset of SCI; lack of rewarding activities, such as work or education; co-morbidities or health complications; pain intensity and interference; self-concept/self-efficacy; marital disruption; substance abuse; pre-existing depression; family history.

Many standardized depression inventories have been used in research and practice with people with spinal cord injuries, with acceptable values for sensitivity, specificity, and reliability. The very brief PHQ-2 (1st two questions of the PHQ-9) is recommended as a clinical screening tool for use in primary care. It has been found to have 83% sensitivity and 98% specificity using the 3-point cut-score.

Studies show that only 29% of SCI patients with depression receive treatment – either psychological or pharmacological. Only 11% of those treated pharmacologically are treated with dosages and durations consistent with clinical guidelines.

Key Reference

Poritz, J. M. P., Mignogna, J., Christie, A. J., Holmes, S. A., & Ames, H. (2018). The patient health questionnaire depression screener in spinal cord injury.The Journal of Spinal Cord Medicine, 41(2), 238-244. doi:10.1080/10790268.2017.1294301

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Cadel, L., DeLuca, C., Hitzig, S. L., Packer, T. L., Lofters, A. K., Patel, T., & Guilcher, S. J. (2018). Self-management of pain and depression in adults with spinal cord injury: A scoping review. The journal of spinal cord medicine, 1-18.

Lim, S., Shiue, Y., Ho, C., Yu, S., Kao, P., Wang, J., & Kuo, J. (2017). Anxiety and depression in patients with traumatic spinal cord injury: A nationwide population-based cohort study.PloS One, 12(1), e0169623. doi:10.1371/journal.pone.0169623

Placeres, A. F., & Fiorati, R. C. (2018). Assessment instruments and depression rates in people with spinal cord injury: A systematic review.Revista Da Escola De Enfermagem Da U S P, 52, e03388. doi:10.1590/s1980-220×2017037303388

Saurí, J., MS, Chamarro, A., PhD, Gilabert, A., PhD, Gifre, M., PhD, Rodriguez, N., MS, Lopez-Blazquez, R., MS, . . . Soler, D., PhD. (2016;2017;). Depression in individuals with traumatic and nontraumatic spinal cord injury living in the community.Archives of Physical Medicine and Rehabilitation, 98(6), 1165-1173. doi:10.1016/j.apmr.2016.11.011

VanDerwerker, C., Gregory, C., & Simpson, K. (2017). Time to depression in a spinal cord injury inception cohort.Archives of Physical Medicine and Rehabilitation, 98(10), e121-e121. doi:10.1016/j.apmr.2017.08.394

Winget, J., Sweet, J., & Raad, J. (2016). Depression and spinal cord injury: A scoping review of clinical recommendations and guidelines.Archives of Physical Medicine and Rehabilitation, 97(12), e38-e38. doi:10.1016/j.apmr.2016.09.104