This chapter has summarized research highlighting several promising approaches to the management of post-SCI depression. Additionally, there is also some evidence for the effectiveness of these approaches for related therapeutic targets such as anxiety and self-esteem. However, many of the studies cited note limitations that may introduce caution regarding the generalizability of conclusions to other samples and settings. These have included:
- Small samples sizes and high rates of attrition (due to illness or other factors)
- Possible selection biases
- Ethical concerns that may preclude randomized designs
- Multifaceted interventions complicate understanding of most relevant component(s)
- Impact of social contact in the intervention group often not accounted for in “standard treatment” or “wait list” controls
- Potential impact of adjunctive psychological interventions is unclear
- Use of antidepressant medications not consistently reported
- Lacking long term follow up
- Variability of outcome measures limit comparisons across studies
When leavened with clinical judgment, this research offers preliminary empirical support to guide the practitioner in employing evidenced-based therapeutic strategies. Future investigations, particularly those employing more stringent research designs, will continue to expand the options and confidence of clinical efforts to assist those individuals who have sustained spinal cord injuries. The reader is encouraged to also consider the following topic reviews of depression and SCI (Consortium for Spinal Cord Medicine 1998; Elliott & Frank 1996; Elliott & Kennedy 2004) and also, more generally, a recent state of the science review of SCI rehabilitation (Sipski & Richards 2006).
Though not universal, depression can be a complication for many persons with spinal cord injury that poses a significant impediment to their functioning and adaptation.
Identifying depression can be difficult, but is most likely to develop during the initial year post-injury. Though many will experience a remission of symptoms over time, for others depressive symptoms may persist for many years.
Self-report measures of depression should be viewed as screening tools to alert the clinician to arrange a more thorough evaluation. In addition to affective symptoms, endorsement of somatic symptoms (e.g. sleep disturbance, poor energy and appetite disturbance) during inpatient or outpatient contact merits clinical review to clarify possible mechanisms underlying their emergence.
There is level 2 evidence (from several studies; Table 2) to support the use of small group CBT based treatment packages to decrease depressive symptoms following SCI.
Follow-up findings (1 year post treatment) showed maintenance of affective improvement in four level 2 studies; conversely, evidence from two level 2 studies found that post intervention reduction of depressive symptoms were not sustained at follow up of up to one year.
There is level 1b evidence (from one randomized controlled trial; Schulz et al. 2009) that providing CBT to caregivers and care receivers results in improved depressive symptoms in care receivers.
There is level 4 evidence (from a pre-post study; Migliorini et al. 2011) that computer based CBT may improve symptoms of depression, anxiety and stress post SCI.
Evidence of the benefits of pharmacotherapy alone and in combination with individual psychotherapy in the treatment of depressive symptoms in individuals with SCI is encouraging, although support is largely from investigations in other populations.
There is level 4 evidence (from one prospective controlled trial and three pre-post studies; Kahan et al. 2006; Kemp et al. 2004; Judd et al. 1989, 1986) indicating the effectiveness of pharmacotherapy combined with cognitive behavioral psychotherapy for treatment of depression in SCI and other chronic disabling conditions.
Regular physical exercise may contribute to a reduction of pain, stress, and depression as well as potentially offering a prophylactic effect on sources of recurrent pain and in preventing a decline in quality of life following SCI.
There is level 1a evidence (from three randomized controlled trials; Hicks et al. 2003; Ginis et al. 2003; Latimer et al. 2005) that exercise based programs reduced subjective pain, stress and resulting depressive symptoms.
There is level 1b evidence (from one randomized controlled trial and one pre-post study; Ginis et al. 2003; Guest et al. 1997) that exercise reduces depressive symptoms.
There is level 2 evidence (from one cohort study; Bradley et al. 1994) that individuals with unrealistic expectations report more depressive symptoms following a functional electrical stimulation exercise program.
There is level 2 evidence (from one randomized controlled trial; Zemper et al. 2003) that a wellness and health promotion program does not significantly decrease intensity of depressive symptoms.
There is level 2 evidence (from one prospective controlled trial; Dunn et al. 2000) that access to medical follow-up for individuals with SCI results in better health, independence, less depression and fewer secondary complications.
There is level 1b evidence (from one randomized controlled trial; Diego et al. 2002) that massage therapy can reduce depressive symptoms.
There is level 1b evidence (from one randomized controlled trial; Defrin et al. 2007) for the effectiveness of transcutaneous magnetic stimulation in reducing depressive symptoms.