Understanding and managing depression after physical injury

Dr. Diana Dorstyn, Senior Lecturer, School of Psychology

diana.dorstyn@adelaide.edu.au

My background

Public HealthDisability SASA Health

Community

Guardianship Board of SA

Tertiary

University of Adelaide

Learning outcomes

• recognise clinical effects and harms to mental health related to traumatic injury

• increase understanding of managing depressive symptomology in an adult trauma cohort

• improve awareness of evidence-based psychological interventions

What is depression?

Most of us know this feeling…

Depression: signs and symptoms

• feelings of sadness or lowered mood

• loss of interest in activities

• changes in appetite/weight

• sleeping difficulties

• fatigue and loss of energy

• feelings of worthlessness, helplessness, hopelessness, or excessive guilt

• trouble concentrating

• a feeling that life is not worth living

Defining depression

• symptom severity based on self report vs. clinical diagnosis

• as a result, prevalence estimates vary:

– average of 22%, based on DSM III or DSM IV criteria (Williams &

Murray, 2015)

– approximately 30% of inpatients with SCI, and approximately 27% living in the community (Craig et al., 2009).

Major Depressive Disorder

DSM-5 (DSM Psychiatry Online) and ICD-10 (ICD-10Data.com)

• discrete episodes of at least 2 weeks’ duration (most episodes are considerably longer)

• changes in affect, cognition, and neurovegetative functions

• diagnosis based on a single episode is possible

Number of symptoms required for a diagnosis of depressive episode/major depression:

• DSM-5 requires 5 symptoms

• ICD-10 requires 4 symptoms

Causes of depression

• stressful life events might trigger depression.

• diathesis-stress factors that may place a person at a higher risk of developing depression– family history

– social factors

– psychological factors

– neurochemistry

Monroe et al. (1991)

Trajectory of depression post-injury

0

5

10

15

20

25

30

35

40

45

Hospital 1 3 6

Time (months)

Dep

ress

ion

(C

ES-D

)

Chronic

Recovering

Delayed

Low symptoms

deRoon-Cassini et al. (2010)

Depression comorbidity

• PTSD

• anxiety symptoms and disorders

• health care utilisation

• pharmaceutical prescriptions (anti-depressants)

• SCI comorbidities: pain, fatigue etc.

• psychological correlates: life satisfaction, disability acceptance

• social/intimate relationships

• participation levels (i.e. employment)

Craig et al. (2015); Ullrich et al. (2014)

Depression: how do we intervene?

• self-management and self-control (e.g. self-efficacy)

• an ability to problem-solve

• social access

• community integration and participation (e.g. employment)

Findings from 21 yr longitudinal study of SCI

• “The way an individual initially appraises the situation is crucial as it can have a huge influence on their subsequent behaviors through selection of coping strategies as well as affecting psychological related outcomes” (Kennedy et al., 2016)

SCI Adjustment Model: a psychological model of coping

Craig et al. (2017)

Biological factors

Psychological factors

Social, environmental,

political, cultural and

religious factors

Appraisal & reappraisal Coping strategies

Positive

adjustment

Negative

adjustment

Modifying factors/

stressors/ resources

Perceptions and

beliefsBehavioural and

mental actions

Adjustment

outcome

Biopsychosocial treatment and management

• adjustment is a multi-

factorial process

• reciprocal relationship

between biological,

socio-environmental

and psychological

variables

Psychological

Social

Biological

Rehabilitation implications

• emphasis on:

– individual variation

– preventative intervention

– longer-term intervention

– comprehensive & multidisciplinary services

McDonald et al. (2017); Russell et al. (2016)

Rehabilitation implications

• rehabilitation is an educational process designed to enhance an individual’s social and community integration skills, in addition to their functional independence

• rehabilitation is a lifelong learning process

• key rehabilitation goals:

• accurate assessment of medical, psychosocial and environmental issues

• development of realistic & flexible therapy goals in collaboration with the individual

• provision of treatment and/or therapy intervention

• evaluation of the effectiveness of interventions

Depression assessment

• Self-report:– Beck Depression Inventory, Depression Anxiety

Stress Scales, Patient Health Questionnaire, Inventory to Diagnose Depression, Center for Epidemiologic Studies Depression Scale, Hamilton

Rating Scale, Zung Self-Rating Scale

• Interview:– MINI, Structured Clinical Interview for DSM

• Cognitive impairment:– Geriatric Depression Scale, Older Adults Health

and Mood Questionnaire, Depression Intensity Scale Circles

Kalpakjian et al. (2009); Turner-Stokes et al. (2005)

Psychological interventions for depression

• psychological interventions during inpatient rehabilitation can improve mood

• more RCTs are needed to enhance intervention validity and generalisability

• intervention duration and intensity should be targeted to the individual patient’s biopsychosocial needs

Dorstyn et al. (2013)

Cognitive behaviour therapy (CBT)

Thoughts:The role our

thinking plays in determining our

emotions and behaviour

Feelings/Emotions

Behaviour:

How we act and what we

do

• mental health problems reflect an interaction of thoughts, feelings & behaviours:– our cognitions influence our

emotions & behaviour

– how we behave affects our thoughts & emotions

Why CBT?

• Is it the only therapy? No

• Is it the best therapy? Maybe…

• currently the single therapy with the strongest evidence-base for the widest number of psychological problems.

• widely-used by clinicians

• in Australia, CBT is one of the evidence-based therapies for which clients can receive Medicare rebates

Group CBT: Coping Effectiveness Training

Aim:• To improve strategies for managing stress

Results:• pilot study: 19 treatment vs. 19 Controls with SCI. CET group showed greater

reductions in depression immediately post-treatment and at 6 wk follow-up

• findings replicated in larger inpatient sample (N = 85) with 3 month follow-up

• improvements in depression with fewer sessions, in comparison to supportive group therapy

• efficacious in building resilience and positive adaptation

• currently being used as a peer mentoring–provider model in UK

Dorstyn D et al. (2011)

Coping Effectiveness Training

• Session 1: Introduction to concepts of stress and coping. Reactions to stress; SCI as a source of stress; coping strategies

• Session 2: Appraisal skills. Coping realistically by using problem-focused coping (i.e. managing the stressor – if the problem can be changed), vs. emotion focused coping (i.e. changing emotional reactions to the stressor – when the problem can’t be changed)

• Session 3: Problem solving coping – with case scenarios.

• Session 4: Active coping: understandable reactions to SCI vs. harmful emotions; negative thoughts & use of behavioural activation/relaxation.

• Session 5: Challenging negative thinking

• Session 6: Maladaptive vs. adaptive coping

• Session 7: Social support: social skills; assertiveness vs. aggressiveness.

Kennedy & Kilvert (2017)

Focus on coping strategies

Problem focussed

• managing or resolving the problems that are causing stress.

– problem solving

– making decisions

– rehearsing solutions

– assertive communication

– instrumental social support

• changing emotional reactions

– relaxation/mindfulness

– changing the way we think about the problem/situation

– re-evaluating the significance of an issue

– changing the meaning of something for us

– humour

– emotional support

Emotion focussed

Coping Effectively with Spinal Cord Injuries. Order from: http://www.oup.com/us/catalog/

Problem focussed coping

• What external aspects of the situation can be changed?

• What elements of the problem are amenable to change?

• Is it possible to change or manage in a different way your behaviour or your actions (towards who, what, where and whom)?

Case example: newly injured, in hospital

Break down global stressors into specific and manageable stressors:

• Who is involved? The staff on the ward.

• What kind of situation? ‘When I need help with things, staff always say they are busy. I feel like they are ignoring me’

• Where are these situations likely to occur? ‘On the ward mostly, when I need help with things.’

• When did they last occur? ‘This morning when I needed some help with washing, and at dinner time, when I need help with my meals.’

• When are they likely to occur again? ‘In the morning and at meal times.’

Example: Jane is feeling stressed and upset

• What are the external aspects of the situation that can be changed? ‘The staff’s behaviour’, ‘My behaviour’

• What elements of the problem are amenable to change? ‘Staff could be more understanding’ ‘ I could change the way I ask for help’, ‘I could change the way I react to not getting help’

• Is it possible to change or manage in a different way your behaviour or your actions towards who, what, where and whom? ‘ I will be more assertive with staff when I need help’, ‘I will pre-arrange a time for staff to help me in the morning and at dinner’

Emotion-focussed coping

• some situations cannot be changed and require an attempt at reducing distress by changing emotional reactions to the situation.

Antecedent

SCI

Beliefs

“I’m useless”

Consequence

Depression

Ellis (1997)

Cognitions: consider alternatives to the following

• ‘I feel inadequate and helpless’

• There’s no point in doing things if I cant do them as well as before’

• ‘I am a burden to others’

• ‘What is the point of living like this?’

• ‘I am no good at anything’

Emotion-focussed coping: mindfulness

• a focus on awareness and acceptance of thoughts and feelings (vs. CBT focus on changing thoughts & feeling).

• preliminary evidence for mindfulness as a technique to promote adaption to illness and disability

Hardison & Roll (2016)

Mindfulness: applications in rehabilitation

• in place of relaxation training – or as a starting point

• to increase insight and awareness of thoughts and related feelings/sensations/actions

• further assessment of the relationship between thoughts, feelings, bodily sensations and behaviours

• to aid concentration

• as a preface to cognitive appraisal

• to teach triggers and when to engage in relapse prevention plan

Ciarrochi & Bailey (2008); Harris (2009)

Which coping strategy?

Can I change the problem?

Yes

Is NOW a good time?

Yes

Problem-focussed

No

No

Emotion-focussed

Digital health

• the use of information and communication technologies to deliver health services

• need for further evidence, particularly randomized controlled trials, to establish benefits and clinical viability

Australian Psychological Society standard and guidelines for online therapy and information about telehealth

Dorstyn et al. (2013); Titov et al. (2010)

Enhancing work self-efficacy and coping

low level of evidence….but promising, preliminary data underpinned by theories of self-efficacy and coping

• Work and SCI

– 30 participants – still recruiting

• Back2Work

– 24 participants, 3 yr follow-up

• InVoc

– 100 participants, 30 mth follow-up

Bloom et al. (2017); Dorstyn et al. (2017); Middleton et al. (2015); Roels et al. (2016)

To conclude

• monitor mood and refer if sadness persists

• assess at critical time points in rehabilitation

• integrate effective, evidence-based psychological intervention into inpatient rehabilitation as early as possible

• training on positive appraisal and successful coping strategies are critical

• need to bring these interventions into the community to promote long lasting change

Online resources

• Paralysed Veterans of America (Clinical Practice Guidelines - Depression)

• The Spinal Cord Injury Rehabilitation Evidence (SCIRE).

• Spinal Cord Injury Agency for Clinical Innovation

• Spinal Cord Injuries Australia

• International Spinal Cord Society, e-learning

• PSYCBITE Tate R et al.(2004) Neuropsychological Rehabilitation 14 (5): 517-534

• NICE Guideline on the Treatment and Management of Depression in Adults

Rehabilitation Psychology Interest Group

Work areas:

Benefits for members: • facilitating communication between psychologists• development of professional standards• support for early career psychologists• research opportunities

spinal cord injury psychiatric disability chronic pain

traumatic brain injury congenital & developmental disorders

acquired developmental disorders

burns neurological diseases etc.

ReferencesBloom J et al. (2017). Integrated services and early intervention in the vocational rehabilitation of people with spinal cord injuries. Spinal Cord Ser Cases 3, 16042.

Ciarrochi JV, Bailey A (2008). A CBT practitioner’s guide to ACT. New Harbinger Publications Inc: CA

Craig A et al. (2009). Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord 47: 108–114

Craig A et al. (2015). Prospective study of the occurrence of psychological disorders and comorbidities after spinal cord injury. Arch Phys Med Rehabil 96(8): 1426–1434

Craig A et al. (2017). Theory of adjustment following severe neurological injury: evidence supporting the Spinal Cord Injury Adjustment Model. In: Costa A, Villalba E (Eds). Horizons in Neuroscience Research, Volume 29, Chapter: 3, Nova Science, pp.117-139

deRoon-Cassini et al. (2010). Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis. Rehabil Psychol 55 (1): 1-11

Dorstyn D et al. (2011). Efficacy of cognitive behavior therapy for the management of psychological outcomes following spinal cord injury: a meta-analysis. J Health Psychol 16(2): 374–391.

Dorstyn D et al. (2013). Applications of teleocunselling in spinal cord injury rehabilitation. Clin Rehabil 27(12):1072-83.

Dorstyn et al. (2017) Can targeted job-information for adults with spinal cord dysfunction be effectively delivered online? A pilot study. J Spinal Cord Med. [Epub ahead of print]

Ellis A. (1997). Using Rational Emotive Behavior Therapy techniques to cope with disability. Prof Psychol Res Pr 28(1): 17-22.

Hardison ME, Roll SC. (2016). Mindfulness interventions in physical rehabilitation: a scoping review. Am J Occ Ther 70(3): 1-9Harris, R. (2009). ACT made simple. New Harbinger Publications Inc: CA

Kalpakjian CZ et al. (2009). Measuring depression in persons with spinal cord injury: a systematic review. J Spinal Cord Med 32(1): 6–24.

Kennedy P et al. (2016). A 21-year longitudinal analysis of impact, coping, and appraisals following spinal cord injury. Rehabil Psychol61(1):92-101.

Kennedy P, Kilvert A. (2017) Coping Effectiveness Training. In: Budd M, Hough S, Wegener S, Stiers W. (Eds) Practical Psychology in Medical Rehabilitation. Springer, Cham

ReferencesKennedy P, Kilvert A. (2017) Coping Effectiveness Training. In: Budd M, Hough S, Wegener S, Stiers W. (Eds) Practical Psychology in Medical Rehabilitation. Springer, Cham

McDonald SD et al. (2017). Research made useful for busy rehabilitation providers. In Budd, M. A., Hough, S., Stiers, W., & Wegener, S. (Eds.). Practical Psychology in Medical Rehabilitation (pp. 547-556). Springer.

Middleton et al. (2015). Early access to vocational rehabilitation for spinal cord injury patients. J Rehabil Med 47: 626–631

Monroe SM et al. (1991). Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders. Psychol Bull 110(3): 406-425.

Roels et al. (2016). Hospital- and community-based interventions enhancing (re)employment for people with spinal cord injury: a systematic review. Spinal Cord 54(1):2-7.

Russell HF et al. (2016). Professional standards of practice for psychologists, social workers, and counselors in SCI rehabilitation. J Spinal Cord Med 39(2): 127–145.

Titov N et al. (2010). Computer-delivered cognitive behavioural therapy: effective and getting ready for dissemination. F1000 Medicine Reports 2:49

Turner-Stokes L et al. (2005). The Depression Intensity Scale Circles (DISCs): initial evaluation of a simple assessment tool for depression in the context of brain injury. J Neurol Neurosurg Psychiatr 76:1273-8.

Ullrich PM et al. (2014). Depression, healthcare utilization, and comorbid psychiatric disorders after spinal cord injury. J Spinal Cord Med 37(1): 40–45.

Williams R, Murray A. (2015) Prevalence of depression after spinal cord injury: a meta-analysis. Arch Phys Med Rehabil 96(1):133-40.