Combined Psychotherapy and Pharmacotherapy
Several case series studies have reported positive results using pharmacotherapy for depression in SCI individuals; for example, amitriptyline (Kim et al. 1977; Fullerton et al. 1981) mianserin and nomifensine (Judd et al. 1986), and tetracyclic and tricyclic antidepressants (Judd et al. 1989). Though reports of depressive symptoms were infrequent, Osteraker & Levi (2005) note that 25% and 30% of an inpatient Swedish SCI rehabilitation sample were prescribed antidepressants at admission and discharge, respectively. In an electronic record review of over 17,000 veterans with “SCI and disorders” who sought inpatient or outpatient services during a three year period, Smith et al. (2007) noted that 22% had at least one encounter with a diagnosis of “depression”. The majority of these depressed individuals (72%) received antidepressant therapies, typically a selective serotonin reuptake inhibitor (SSRI) – most often sertraline. In a Canadian centre, approximately a third of traumatic spinal cord injured individuals and approximately 40% of those with non-traumatic spinal cord injuries received antidepressant therapy during inpatient rehabilitation in addition to other counselling and therapeutic services (2006-2008; J. Conlon, personal communication, December 16, 2008).
Overall, support for pharmacological treatment of depression in individuals with SCI is largely an extrapolation from the extant literature concerning use in the general population and comparative trials of medications and cognitive behavioural interventions are “sorely needed” (Elliott & Kennedy 2004).
Discussion
Kemp et al. (2004) used a pre-post treatment design to assure access to services and avoid ethical concerns that might arise in a randomized trial. A total of 43 community living adult SCI survivors were identified as depressed using the Older Adult Health and Mood Questionnaire and confirmed by clinical interview. Citing distance problems, 15 subjects subsequently declined participation but served as a “quasi-control” group. The 28 remaining subjects began a combined 6-month trial of antidepressant medications and individual cognitive behavioural psychotherapy. The participants were somewhat older but did not differ from non-participants in terms of level of injury, gender, or race/ethnicity. Medications employed included SSRI and tricyclic antidepressants. A clinical psychologist provided psychotherapy that included education regarding the signs, symptoms and consequences of depression, cognitive restructuring, problem solving and encouraging greater community involvement (average of 14 sessions). During the treatment trial, four subjects discontinued their medications, one discontinued psychotherapy and three developed medical complications. When these eight subjects were excluded, all of the remaining 20 subjects improved, no longer meeting criteria scores for major depression (12 appeared mildly depressed and eight appeared non-depressed). Their participation in community activities doubled over the 24 weeks, while life satisfaction showed improvement, primarily during the final 16 weeks of the program. The average depression score for non-treated subjects did not change significantly over a 24-month follow-up period and suggests that untreated depression can become a chronic disorder.
In a subsequent investigation combining a reanalysis of previous SCI participant data (40 of 43 were presented in above study) and an expansion to include 36 community dwellers with polio, cerebral palsy, stroke, rheumatoid arthritis, or other impairments, Kahan et al. (2006) explored the effects of a 6 month program of CBT and antidepressant therapy in an adult sample reporting major depression (54 received treatment and 22 no treatment). A pre-post treatment design was employed to assure access to services and avoid ethical concerns that might arise in a randomized trial. A clinical psychologist provided psychotherapy that included education regarding the signs, symptoms and consequences of depression, cognitive restructuring, problem solving and encouraging greater community involvement (average of 8 sessions; ranging from 4 to 17). Most commonly used were SSRIs (18 participants) while 7 took tricyclic antidepressants.
On average, depression scores declined 50% over the course of treatment. Seventy six percent improved to a less severe category of depression, while 24% remained unchanged. Of those who improved, approximately 30% no longer were classified as depressed. Of those who reported continued major depression despite treatment, they showed a decrease in the number of symptoms reported. In contrast, approximately a third of the no-treatment group improved, over half remained unchanged, and the remainder became worse. While the small sample sizes precluded statistical analysis, a pattern of improvement across disability subgroups was apparent. Benefits of treatment were significant by approximately 10 weeks.
The authors conclude that community dwelling individuals who have long term impairments and report depression can derive benefit from a combined intervention, with six months of treatment suggested as a minimum standard. The frequency of participation in community activities was specifically targeted and doubled over the course of treatment. Further, reported life satisfaction also improved, despite persistent dissatisfaction in physical status.
Furthermore, in two pre-post studies Judd et al. (1989; 1986) found improvement in inpatient’s BDI and anxiety levels post pharmacological and psychological treatment. Fullerton et al. (1981) interviewed 30 SCI rehabilitation patients using the SADS and identified nine as depressed. While three initiated treatment with amitriptyline, one patient responded and side effects required the intervention be discontinued in the remaining two. Depression was reported to have remitted in all patients at time of discharge (average 12 weeks).
Conclusion
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.
