18. Depression and SCI

Actionable Nuggets for SCI (2nd ed., 2013)

Screen for depression annually in patients with SCI, using the PHQ-9 or PHQ-2, and treat at standard guideline levels.

The Problem:

It is estimated that half of individuals with a spinal cord injury (SCI) also experience a significant mental health problem. The most common among these is depression, with a prevalence of 23-37% of people with SCI. Other mental health issues include anxiety, clinically-significant stress, and post-traumatic stress disorder.

Evidence-based Best Practice:

Risks for mental health problems are 2 – 4 times greater among people with spinal cord injuries than among non-disabled individuals. Rates of suicide are 3 – 5 times those reported in the general population. Symptoms of depression can be overlooked or misidentified in people with spinal cord injuries, because depressive symptoms like fatigue and sleep disturbances are often attributed to SCI. Risk factors for depression with SCI include: younger age and shorter time since onset of SCI; lack of rewarding activities, such as work or education; multiple co-morbidities or complications; marital disruption; substance abuse; pre-existing condition or family history.

The PHQ-9 has been shown to be an effective screening tool, with excellent sensitivity, specificity, and reliability in the SCI population. The very brief PHQ-2 (1st two questions of the PHQ-9) has been found to have 86% sensitivity and 78% specificity in the primary care setting, using the 2-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 (PHQ-9 scores ≥ 10).

Key reference:

    Fann, J.R., Bombardier, C.H., Richards, J.S., Tate, D.G., Wilson, C.S., & Temkin, N. (2011). Depression after spinal cord injury: Comorbidities, mental health service use, and adequacy of treatment. Archives of Physical Medicine & Rehabilitation92(3): 352-60.

Additional references:

    Arrol, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., et al. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Annals of Family Medicine8(4): 348-53.
    Bombardier, C.H., Fann, J.R., Tate, D.G., Richards, J.S., Wilson, C.S., Warren, A.M., Temkin, N.R., et al. (2012). An exploration of modifiable risk factors for depression after spinal cord injury: Which factors should we target? Archives of Physical Medicine & Rehabilitation, 93(5): 775-81.
    Bommbardier, C.H., Kalpakjian, C.Z., Graves, D.E., Dyer, J.R., Tate, D.G., & Fann, J.R. (2012). Validity of the Patient Health Questionnaire-9 in assessing major depressive disorder during inpatient spinal cord injury rehabilitation. Archives of Physical Medicine & Rehabilitation93(10): 1838-45.
    Bombardier, C.H., et al. (2004). Symptoms of major depression in people with spinal cord injury: implications for screening. Archives of Physical Medicine & Rehabilitation85(11): 1749-56.
   Bonanno, G.A., Kennedy, P., Galatzer-Levy, I.R., Lude, P., & Elfstrom, M.L. (2012). Trajectories of resilience, depression, and anxiety following spinal cord injury. Rehabilitation Psychology57(3): 236-47.
    Burns, S.M., Boyd, B.L., Hill, J., & Hough, S. (2010). Psychosocial predictors of employment status among men living with spinal cord injury. Rehabilitation Psychology, 55(1): 81-90.
    Consortium for Spinal Cord Medicine (1998). Depression following spinal cord injury: A clinical practice guideline for primary care physicians. Paralyzed Veterans of America, Washington DC.
    Craig, A., Tran, Y., & Middleton, J. (2009). Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord47(2): 108-14.
    DeVivo, M.J., et al. (1991). Suicide following spinal cord injury. Paraplegia29(9): 620-7.
    Graves, D.E. & Bombardier, C.H. (2008). Improving the efficiency of screening for major depression in people with spinal cord injury. Journal of Spinal Cord Medicine31(2): 177-84.
    Hagen, E.M., Grimstad, K.E., Bovim, L., & Gronning, M. (2012). Patients with traumatic spinal cord injuries and their satisfaction with their general practitioner. Spinal Cord50: 527-32.
    Hartkopp, A., et al. (1998). Suicide in a spinal cord injured population: its relation to functional status. Archives of Physical Medicine & Rehabilitation79(11): 1356-61.
    Hoffman, J.M., Bombardier, C.H., Graves, D.E., Kalpakjian, C.Z., & Krause, J.S. (2011). A longitudinal study of depression from 1 to 5 years after spinal cord injury. Archives of Physical Medicine & Rehabilitation92(3): 411-8.
    Kalpakjian, C.Z., Houlihan, B., Meade, M.A., Karana-Zebari, D., Heinemann, A.W., Dijkers, M.P., Wierbicky, J., et al. (2011). Marital status, marital transitions, well-being, and spinal cord injury: An examination of the effects of sex and time. Archives of Physical Medicine & Rehabilitation, 92(3): 433-40.
    Kennedy, P., Sherlock, O., McClelland, M., Short, D., Royle, J., & Wilson, C. (2010). A multi-centre study of the community needs of people with spinal cord injuries: The first 18 months. Spinal Cord48(1): 15-20.
    Krause, J.S., Kemp, B., & Coker, J. (2000). Depression after spinal cord injury: relation to gender, ethnicity, aging, and socioeconomic indicators. Archives of Physical Medicine & Rehabilitation81(8): 1099-109. http://dx.doi.org/10.1053/apmr.2000.7167
    Krause, J.S., Saunders, L.L., Bombardier, C., & Kalpakjian, C. (2011). Confirmatory factor analysis of the Patient Health Questionnaire-9: A study of the participants from the spinal cord injury model systems. Archives of Physical Medicine and Rehabilitation3(6): 533-40; quiz 540.
    Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine16(9): 606-13.
    McDermott, S., Moran, R., Platt, T., Issac, T. Wood, H., & Dasari, S. (2005). Depression in adults with disabilities, in primary care. Disability Rehabilitation27(3): 117-23.
    Migliorini, C.E., New, P.W., & Tonge, B.J. (2009). Comparison of depression, anxiety and stress in persons with traumatic and non-traumatic post-acute spinal cord injury. Spinal Cord47(11): 783-8.
    Migliorini, C., & Tonge, B. (2009). Reflecting on subjective well-being and spinal cord injury. Journal of Rehabilitation Medicine41(6):445-50.
    Migliorini, C., Tonge, B., & Taleporos, G. (2008). Spinal cord injury and mental health. Australian and New Zealand Journal of Psychiatry42(4): 309-14.
    Wolfe, D.L., Legassic, M., McIntyre, A., Cheung, K., Goettl, T., Walia, S., Loh, E., et al. (2012). Bladder health and function following spinal cord injury. Spinal Cord Injury Rehabilitation Evidence, Version 4.0: 1-143.
    Orenczuk, S., Silvinski, J., Mehta, S., & Teasell, R.W. (2012). Depression following spinal cord injury. Spinal Cord Injury Rehabilitation Evidence, Version 4.0: 1-32.
    Pang, M.Y., Eng, J.J., Lin, K.H., Tang, P.F., Hung, C., & Wang, Y.H. (2009). Association of depression and pain interference with disease-management self-efficacy in community-dwelling individuals with spinal cord injury. Journal of Rehabilitation Medicine41(13): 1068-73.
    Sakakibara, B.M., et al. (2009). A systematic review of depression and anxiety measures used with individuals with spinal cord injury. Spinal Cord47(12): 841-51.
    Saunders, L.L., Krause, J.S., & Focht, K.L. (2012). A longitudinal study of depression in survivors of spinal cord injury. Spinal Cord50(1): 72-7.