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Mental Health After SCI

Pharmacotherapy

Pharmacotherapy is a commonly prescribed for treatment of depression post SCI. Poor tolerance to pharmacotherapy may lead to exacerbation of other secondary issues such as spasticity (Stolp-Smith & Wainberg 1999). However, research on its efficacy among persons with SCI is limited.

Author Year
Country
Research Design
PEDro Score
Total Sample Size
Methods Outcome
Fann et al., (2015)
USA
RCT
PEDro=10
NInitial=133 NFinal=126
Population: Mean age=40yr; Gender:
males=99, females=34; Level of injury:
paraplegia=70, quadriplegia=62,
unknown=1; Severity of injury:
incomplete=62, complete=71; Mean time
post injury=11yr; Depression
status=Major Depressive Disorder.
Intervention: Individuals were
randomized to receive venlafaxine
extended-release (150mg/d, n=69) or
placebo (control, n=64) for 12wk.
Outcomes were assessed pre and post
treatment.
Outcome Measures: Hamilton
Depression Rating Scale (HAM-D), Maier
Subscale, Symptom Checklist 20 (SC20).
1. There was no significant difference
between groups in improvement on the
HAM-D (p=0.42) or SC-20 (p=0.14).
2. On the Maier subscale, there was a
significant improvement in the treatment
group when compared to the control
group (p=0.02).
Richards et al.,
(2015)
USA
RCT
PEDro=10
NInitial=133 NFinal=123
Population: Mean age=40.0±11.0 yr;
Gender: males=99, females=34; Time
since injury=10.9±10.6 yr; Level of injury:
C=62, T=58, L=12; Severity of injury: AIS
A=71, B=20, C=12, D=30.
Intervention: Participants were
randomized to either a venlafaxine XR
group or a placebo group using a flexible
titration schedule over the course of 12
wk.
Outcome Measures: Numeric rating
scale 0-10 (NRS) for pain intensity, pain
interference items of the brief pain
inventory (BPI)
1. No significant difference was seen in
mood among those with neuropathic or
mixed pain.
2. Significant improvement in mood was
reported among those with nociceptive
pain.
Salinas et al.,(2012)
Colombia
RCT
PEDro=9
NInitial=46 NFinal=44
Population: Mean age=36yr; Gender:
males=42, females=4; Level of injury:
paraplegia=28, quadriplegia=18; Severity
of injury: incomplete=13, complete=33;
Mean time post injury <2wk; Depression
status=symptoms.
Intervention: Individuals without
neuropathic pain were randomized to
receive carbamazepine (600mg/d, n=24)
or placebo (control, n=22) for 1mo.
Outcomes were assessed pre and post
treatment, and at 3 and 6mo follow-up.
Outcome Measures: Zung Self-Rating
Depression Scale (ZSDS).
1. There was no significant between groups
on the ZSDS at 1mo (p=0.829), 3mo
(p=0.421), or 6mo (p=0.551).
Rintala et al., (2007)
USA
RCT Crossover
PEDro=6
NInitial=38 NFinal=22
Population: Mean age=41yr; Gender:
males=36, females=2; Level of injury:
paraplegia=18, quadriplegia=20; Mean
time post injury=11yr; Depression
status=symptoms.
Intervention: Individuals with chronic
neuropathic pain received amitriptyline
(50mg, 3x/d), gabapentin (1200mg, 3x/d),
and diphenhydramine (25mg, 3x/d,
control) for 8wk each in a randomized
sequence. Outcomes were assessed
every 2wk during each drug trial.
Outcome Measures: Center for
Epidemiologic Studies Depression Scale
– Short Form (CES-D-SF).
1. There was no significant change in
CESD-SF scores across time for any
medication.
2. There was no significant difference in
CES-D-SF scores between the three
medications at any given time point.

Discussion

Four studies examined the effect of pharmacotherapy alone in the reduction of depressive symptoms post SCI (Fann et al. 2015; Richards et al. 2015; Rintala et al. 2007; Salinas et al. 2012). Richards et al. (2015) found venlafaxine resulted in significant improvement in pain interference of mood among those with noiciceptive pain compared to placebo. No significant effect of venlafaxine was seen among those with neuropathic or mixed pain. The remaining three studies found no significant improvement in depressive symptoms after amitriyptyline (Rintala et al. 2007), gababentin (Rintala et al. 2007), and carbamazepine (Salinas et al. 2012) compared to placebo. Fann et al. (2015) reported significant decrease in depressive symptoms based on the Maier subscale of the HAM-D among persons receiving venlafaxine compared to placebo.

Conclusion

There is limited evidence that carbamazepine, amitriptyline, and gabapentin may not improve symptoms of depression post SCI.

There is level 1b evidence (Fann et al. 2015) that venlafaxine improves depressive symptoms post SCI.

There is level 1b evidence (Richards et al. 2015) that venlafaxine improves pain interference with mood post SCI.

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