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Summer 2001: Volume 10, Number 2

Depression and Spinal Cord Injury

Major depressive disorder (MDD) is a common condition that occurs in about 5% of Americans (over 11 million people). MDD is more than being sad or feeling grief after a loss; it refers to a pathological syndrome of observable symptoms that include depressed mood, loss of pleasure or interest in usual activities, changes in sleep and eating patterns, difficulty concentrating, lack of energy, self-criticism or hopelessness, and frequently thoughts of death or suicide.

MDD is highly disabling in the general population. In patients with chronic medical conditions such as SCI, MDD can make physical symptoms worse.

According to Charles Bombardier, PhD, associate professor in the Department of Rehabilitation Medicine and project co-director for the Northwest Regional SCI System, "most people with SCI are not depressed. They adjust and gradually feel better about their lives." On the other hand, the medical, social, and functional challenges of SCI conspire to create higher than normal rates of depression in this population. MDD is common among all medical patients (6%-10%), but much more common after SCI (23%-30%).

In the SCI patient depression can result in longer lengths of hospital stay and fewer functional improvements; increased occurrence of pressure sores and urinary tract infections; and greater use of paid personal care and higher medical expenses. Although depression may be more common soon after injury and subside after several months, some studies suggest that about 30% of patients remain highly depressed and anxious at least two years after injury. Symptoms of depression, such as despondency, hopelessness, shame and apathy, are the variables most predictive of suicide one to nine years after SCI.

MDD is highly treatable using psychotherapy, pharmacotherapy (antidepressants), or a combination of both. Cognitive behavioral therapy and interpersonal therapy are known to be effective in treating depression, and psychotherapy aimed at teaching people to cope more effectively with the stresses of SCI seems to have good potential to help. In many cases, pharmacotherapy is preferred because it is more widely available, more accessible, and probably more acceptable than psychotherapy for many people with SCI. However, "people with more severe depression will probably do best if they receive both medication and psychotherapy," Bombardier said.

Tricyclic drugs (e.g., imipramine) are often effective for treating depression but frequently have intolerable side-effects. SSRIs (selective serotonin reuptake inhibitors), such as Prozac, have fewer side effects and are as effective as tricyclics. However, there is evidence that SSRIs may exacerbate spasticity in some persons with SCI.

Among the newest antidepressants, venlafaxine (Effexor) is chemically similar to tricyclics and has fewer side effects. In theory, it may also alleviate some forms of SCI-related pain, a disabling complication that affects 50%-70% of the SCI population and contributes to depression. "We are hoping to do research on this drug," Bombardier said. "Overall, antidepressants are effective in about 70% of patients, so it's worthwhile to pursue treatment."

Bombardier believes that aggressive treatment of pain problems is crucial to the prevention of depression. Finding meaningful, enjoyable activities after injury, maintaining good interpersonal relationships, and resolving the role changes that almost always come with SCI are also important steps toward psychological health.

People with MDD may be at risk for suicide. "Take suicidal comments seriously," Bombardier warned. "Inquire further to find out if the person has a serious intent or plan. Lots of people who mention suicide are hoping someone will notice and offer help. People are often ambivalent right up to the moment they attempt suicide. If we can intervene at that time, we can support the part of them that wants to live."

Bombardier urges people with SCI who are experiencing symptoms of MDD to "seek treatment, tell your doctor about pain, and be hopeful. Depression is not a weakness or an inevitable result of SCI, it is a treatable disease."

Charles Bombardier, PhD, can be reached via MEDCON at 206-543-5300 or 800-326-5300.

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