Depression Following Spinal Cord Injury

Orenczuk S, Mehta S, Slivinski J, Teasell RW (2014). Depression Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-35. 

Psychological adjustment to catastrophic injuries and illnesses is a topic of much interest for practitioners providing clinical rehabilitation services. This chapter attempts to summarize evidence garnered from spinal cord injury (SCI) research that has investigated the treatment of post-SCI depression and depressive symptoms potentially affecting successful adjustment to SCI. Though limited, these findings can assist in developing a foundation for evidence-based practice, and hopefully lead to improved and more consistent care. It should be emphasized, however, that evidence-based practice constitutes more than the routine use of treatments supported by the best research evidence available. Such practice also necessitates that the practitioner employ his or her clinical judgment in determining the applicability of such research conclusions to the treatment provided each patient (American Psychological Association 2005).

Concerns regarding “depression” are commonly reported by SCI survivors, staff, or their families. Indeed et al. (1995) report that depression is the most frequently researched psychological issue in individuals who have sustained a SCI. Given the losses and innumerable adjustments necessitated following a SCI, an individual will likely encounter repeated strains upon available coping resources. The emergence of depressive symptoms is not then a surprising outcome of such challenges (Kemp et al. 2004) and some early investigators have described it as an “inevitable” outcome (e.g. Hohmann 1975). Of added concern, rates of suicide average approximately 3 to 5 times that reported in the general population (e.g. DeVivo et al. 1991; Charlifue & Gerhart 1991; Hartkopp et al. 1998) and stand in contrast to the reductions achieved in other preventable causes of death following SCI (e.g. septicemia, respiratory illness, diseases of the urinary system) (Soden et al. 2000). The many consequences of SCI pose multiple stressors for families (e.g., 15% of caregivers reported symptoms consistent with Major Depressive Disorder, MDD; Dreer et al. 2007) and can also result in emotional challenges for rehabilitation staff (North 1999).

The term “depressed mood” refers to a state of dysphoria that occurs routinely and is considered a normal process (Elliott & Frank 1996). In contrast, a diagnosable “depressive syndrome” refers to a constellation of observable affective, cognitive and neuro-vegetative symptoms of sufficient frequency and severity to negatively impact the functioning of an individual. The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) is a frequently cited classification system for establishing diagnoses of various depressive and other mental disorders. According to the DSM-IV-TR5, depression is not a single entity, but instead represents a range of disorders which are classified according to symptom type, number, severity, duration and functional impact. Adiagnosis of Major Depressive Disorder in an adult requires at least a two-week period of five or more symptoms, with at least one either depressed mood or a loss of interest or pleasure in almost all activities. Further symptoms may include:

  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
  • Insomnia (inability to sleep) or hypersomnia (sleeping too much) nearly every day.
  • Psychomotor agitation or retardation nearly every day.
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day.
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Symptoms together must result in impairment in functioning (social, occupational or other) and are not due to the direct physiological effects of a substance or medical condition. The classification of affective symptoms continues to be revised with the next edition (DSM-V) anticipated for 2013. As an example, a mixed anxiety and depressive disorder is proposed when anxiety and depression are both present, but neither set of symptoms, considered separately is sufficient to justify a diagnosis (American Psychiatrist Association 2010).

Identifying clinical depression is often more difficult than might be anticipated. Rehabilitation staff has been shown to overestimate the incidence of depression in inpatient populations (Cushman & Dijkers 1990) while underestimating patients’ reported coping ability and mental health (Siosteen et al. 2005). Similarly, the life satisfaction and well-being of persons in the community with complete tetraplegic injuries (including those who required ventilator support) was shown to be underestimated by health care professionals (Bach & Tilton 1994). Conversely, Kemp and Mosqueda (2004) caution that symptoms of depression can be overlooked or misidentified in people with disabilities.

Various methodological issues have “served to constrain” the study of depression in the SCI population (Elliott & Frank 1996). The use of ambiguous definitions and the unclear or inconsistent use of diagnostic criteria are two of many such challenges. Others issues include a lack of theoretical models, selection biases, limited longitudinal studies and ethical concerns that limit more rigorous experimental designs.

How best should the occurrence of depression be viewed in the process of adjustment to SCI? Anecdotal models of adjustment have incorporated the “clinical lore” that depression was to be universally anticipated soon after injury (Elliott & Kennedy 2004), and demonstrating the individual’s rational acceptance of the permanence of the injury and associated losses (Frank et al. 1985).Taken further, those individuals who do not evidence depression were considered to be in “denial” and potentially vulnerable to a more precarious adjustment (e.g. Siller 1969). Accordingly, it had been also proposed that depression be induced to encourage appropriate grieving (Nemiah 1957). More recently, both the universality and the benefits of depression in the adjustment process have been questioned by numerous investigative findings (e.g. Howell et al. 1981; Judd et al. 1986). Given the many negative outcomes associated with depression post injury (e.g. longer hospitalization, decreased longevity, increased rates of suicide, reduced health, daily functioning, limited community participation) it is likely best viewed as a secondary complication or sequelae rather than an adaptive process facilitating overall emotional adjustment (Consortium for Spinal Cord Medicine 1998).

Kemp et al. (2004) noted that depression is not simply a necessary consequence of sustaining a SCI, that not all who sustain a SCI become depressed. Tirch et al. (1999) studied depressive symptoms in 11 pairs of monozygotic twins where one of the pair had sustained a SCI. The SCI and non-SCI co-twins did not differ significantly in their self-report lending additional support to the view that SCI does not inevitably lead to increased depression. Further, there is little relationship between depression and the level of SCI or the completeness of the lesion (Kemp et al. 2004). As an example, Hall et al. (1999) sampled 82 individuals with C1-4 quadriplegia between 14 and 24 years post injury, and these individuals reported their self-esteem and quality of life to be high – with 95% feeling they were “glad to be alive”.

Depression post SCI can be a function of difficulties coping with the multiple environmental, social and health-related problems that follow. If depression is not inevitable following SCI, then it is noteworthy that depression is related to modifiable factors that play a role in its development and maintenance (Kemp et al. 2004). In a summary of the adjustment literature, Elliott & Rivera (2003) described a model determining psychological well-being and physical health post-SCI. The components include demographics, injury characteristics, pre-injury behaviours and psychopathology, personality factors, social/environmental factors and styles of appraisals. The authors highlight how the consequences of physical disability exist within a larger context and that changes in public and health policies can dramatically impact post-injury quality of life.