Depression (major depressive disorder) is a psychological disorder which involves depressed mood, loss of interest in activities, and a number of other symptoms that affect emotions, thoughts, behaviours, and the body.

Depression is not simply ‘feeling blue’ or the sadness that can accompany life events like the death of a loved one. It is a serious medical condition involving persistent and widespread feelings of distress that affect all aspects of a person’s life.

The main symptoms of depression are a depressed mood and/or a loss of interest or pleasure in activities. Other symptoms may include some or all of these physical, emotional and cognitive (thinking) symptoms:

Physical Symptoms: 

• • Changes in weight or appetite
  • Changes in sleep – either sleeping too much or too little
  • Moving or speaking slowly, or being fidgety and restless
  • Feeling tired or low energy

Emotional Symptoms:

• • Feeling ‘down’, sad, or empty
  • Feeling worthless, hopeless, or guilty
  • Feeling irritable or angry

Cognitive (Thinking) Symptoms:

• • Trouble concentrating or making decisions
  • Thinking about death or suicide

Symptoms have to last for at least two weeks and be severe enough to interfere with the person’s life to be diagnosed as depression.

Depression affects everyone differently, so its exact symptoms will be different from person to person. Depression is not always easy to recognize. If you suspect that you or a loved one may have depression, it is important to speak to a healthcare provider for more information.

Scientists do not know for sure what causes depression. Depression can affect anyone and happens for different reasons for each person. There are many different factors that may be related to depression, such as:

Potential sources of depression include your DNA and various factors in the brain.^6-7

• Stressful life events, like experiencing a serious injury or losing a job
• Personal characteristics, such as personality and life experiences
• Environmental factors, such as social support and personal security
• Genetics
• Medical conditions
• Certain medications

Depression may be related to lower levels of certain brain chemicals called neurotransmitters. Neurotransmitters are chemicals in the brain that allow nerve cells to send messages. Lower levels of certain neurotransmitters, including serotonin, norepinephrine, and dopamine, are linked with depression. However, this is a complex relationship that scientists are still working to understand.

Depression is diagnosed through interviews with a health provider such as a doctor or psychologist. The health provider will ask questions about mood and a number of other symptoms, and may have you complete questionnaires about your symptoms.

There is no lab test that can diagnose depression, but lab testing may be done to rule out other conditions that may have similar symptoms, such as thyroid problems.

There are many different ways of treating depression. The first treatments are usually counseling and talk therapies and antidepressant medications. Other treatments for depression may include exercise and a number of other medical, alternative, and self-help therapies.

Counseling and Talk therapies

Counseling and talk therapies involve talking with a mental health provider such as a psychologist, counselor, or social worker. There are many different types of talk therapies. Research done on depression after SCI has focused primarily on one type of therapy called cognitive behavioural therapy or CBT.

Cognitive behavioural therapy is a type of therapy that addresses how thoughts, feelings, and behaviours can contribute to mental health problems. It focuses on developing practical skills to help manage these conditions and can be done in many different formats, including one-to-one counseling, group therapy, and computer programs.

There is moderate evidence that cognitive behavioural therapy can help to improve depression symptoms after SCI. However we do not know whether these effects last long-term.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Antidepressant medications

Antidepressant medications (antidepressants) are another common treatment option for depression. There is a wide range of different antidepressants that may be used. Some antidepressant medications can treat sleep, nerve pain and mood simultaneously, and these are often used in people with SCI. Antidepressants are prescribed by medical doctors.

The use of antidepressants to treat depression after SCI is mostly based on research studies done in the general population because there are not many studies done among people with SCI. However, there is weak evidence that combined antidepressant medications and talk therapies may help to improve the symptoms of depression among people with SCI.

Exercise

Exercise is now becoming more widely known as a treatment option for depression. Exercise may help treat depression because it helps to reduce pain and stress, cause the release of ‘feel-good’ chemicals like endorphins, and helps to maintain mobility and quality of life.

A number of different exercise-based programs have been studied for their effects on depression, after SCI. There is strong evidence that exercise helps to reduce the symptoms of depression after SCI.

Other treatments and strategies for depression

There are many other treatments used for depression. These treatments have not been studied extensively among people with SCI, so we do not know how effective they are for depression after SCI.

• Organized wellness and health promotion programs
• Living a healthy lifestyle (getting enough rest, eating healthy, and staying active)
• Participating in enjoyable activities
• Meditation and mindfulness training
• Massage therapy
• Acupuncture
• Light therapy
• Herbal and dietary supplements
• Brain stimulation therapies such as Transcranial Magnetic Stimulation (TMS)

Addressing other medical problems

There are a number of factors related to spinal cord injury that may contribute to depression, such as chronic pain, fatigue, sleep problems, medication side effects, and health problems like repeated infections. Treating these problems may be another strategy that can help manage depression.

Depression is a psychological disorder involving depressed mood, loss of interest in activities, and a
number of other symptoms. Depression is one of the most common mental health concerns after SCI.
The research evidence suggests that cognitive behavioural therapy, combined medication and talk
therapy, and exercise programs help to improve the symptoms of depression after SCI. Further
research specific to people with SCI is needed to better understand which treatments are most
effective.

If you are concerned that you or a loved one has depression, it is important to speak to a healthcare
provider for more information and to determine the best treatment options for you

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Suicide Crisis Lines (External):

• Canada: Canadian Association for Suicide Prevention
• United States: National Suicide Prevention Lifeline
• Australia: Lifeline Australia
• United Kingdom: Samaritans

Here to Help – Self-screening and Depression information pages (External)

Pain after Spinal Cord Injury

Evidence for “How is depression after SCI treated?” is based on the following studies:

Counseling and Talk Therapies

[1] Dorstyn D, Mathias J, Denson L, Robertson M. Effectiveness of telephone counseling in managing psychological outcomes after spinal cord injury: A preliminary study. Arch Phys Med Rebabil 2012;93:2100-8.

[2] Heutink M, Post MW, Bongers-Janssen HM, Dijkstra CA, Snoek GJ, Spijkerman DC, et al. The CONECSI trial: results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury. Pain 2012;153:120-8.

[3] Schulz R, Czaja SJ, Lustig A, Zdaniuk B, Martire LM, Perdomo, D. Improving the quality of life of caregivers of persons with spinal cord injury: a randomized controlled trial. Rehabil Psychol 2009;54:1-15.

[4] Craig AR, Hancock K, Dickson H, Chang E. Long-term psychological outcomes in spinal cord injured persons: results of a controlled trial using cognitive behavior therapy. Arch Phys Med Rehabil 1997;78:33-8.

[5] Craig AR, Hancock K, Chang E, Dickson H. Immunizing against depression and anxiety after spinal cord injury. Arch Phys Med Rehabil 1998a;79:375-7.

[6] Craig A, Hancock K, Chang E, Dickson H. The effectiveness of group psychological intervention in enhancing perceptions of control following spinal cord injury. Aust N Z J Psychiatry 1998b;32:112-8.

[7] Perry KN, Nicholas MK, Middleton JW. Comparison of a pain management program with usual care in a pain management center for people with spinal cord injury-related chronic pain. Clin J Pain 2010;26:206-16.

[8] King C, Kennedy P. Coping effectiveness training for people with spinal cord injury: Preliminary results of a controlled trial. Br J Clin Psychol 1999;38:5-14.

[9] Norrbrink BC, Kowalski J, Lundeberg T. A comprehensive pain management programme comprising educational, cognitive and behavioural interventions for neuropathic pain following spinal cord injury. J Rehabil Med 2006;38:172-80.

[10] Dorstyn D, Mathias J, Denson L. Efficacy of cognitive behaviour therapy for the management of psychological outcomes following spinal cord injury: A meta-analysis. J Health Psychol 2010;16:374-91.

[11] Kennedy P, Duff J, Evans M, Beedie A. Coping effectiveness training reduces depression and anxiety following traumatic spinal cord injuries. Br J Clin Psychol 2003;42:41-52.

[12] Craig A, Hancock K, Dickson H. Improving the long-term adjustment of spinal cord injured persons. Spinal Cord 1999;37:345-50.

[13] Duchnick JJ, Letsch EA, Curtiss G. Coping effectiveness training during acute rehabilitation of spinal cord injury/dysfunction: a randomized clinical trial. Rehabil Psychol 2009;54:123-32.

[14] Migliorini C, Tonge B, Sinclair A. Developing and piloting ePACT: A flexible psychological treatment for depression in people with chronic spinal cord injury. Behaviour Change 2011;28:45-54.

Medications

[1] Kahan JS, Mitchell JM, Kemp BJ, Adkins RH. The results of a 6-month treatment for depression on symptoms, life, satisfaction, and community activities among individuals aging with a disability. Rehabil Psychol 2006;51:13-22.

[2] Kemp BJ, Kahan JS, Krause JS, Adkins RH, Nava G. Treatment of major depression in individuals with spinal cord injury. J Spinal Cord Med 2004;27:22-8.

[3] Judd FK, Stone J, Webber JE, Brown DJ, Burrows GD. Depression following spinal cord injury. A prospective in-patient study. Br J Psychiatry 1989;154:668-71.

[4] Judd FK, Burrows GD, Brown DJ. Depression following acute spinal cord injury. Paraplegia 1986;24:358-63.

Exercise

[1] Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J, McCartney N. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41:34-43.

[2] Ginis KAM, Latimer AE, McKechnie K, Ditor DS, McCartney N, Hicks AL, et al. Using exercise to enhance subjective well-being among people with spinal cord injury: the mediating influences of stress and pain. Rehabil Psychol 2003;48:157-64.

[3] Latimer AE, Ginis KA, Hicks AL, McCartney N. An examination of the mechanisms of exercise-induced change in psychological well-being among people with spinal cord injury. J Rehabil Res Dev 2004;41:643-52.

[4] Guest RS, Klose KJ, Needham-Shropshire BM, Jacobs PL. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: Part 4. Effect on physical self-concept and depression. Arch Phys Med Rehabil 1997;78:804-7.

Other references:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Bombardier CH, Richards JS, Krause JS, Tulsky D, Tate DG. Symptoms of major depression in people with spinal cord injury: implications for screening. Arch Phys Med Rehabil 2004;85:1749-56.

DeVivo MJ, Black KJ, Richards JS, Stover SL. Suicide following spinal cord injury. Paraplegia1991;29:620-7.

Charlifue SW, Gerhart KA. Behavioral and demographic predictors of suicide after traumatic spinal cord injury. Arch Phys Med Rehabil 1991;72:488-92.

Hartkopp A, Bronnum-Hansen H, Seidenschnur AM, Biering-Sorensen F. Suicide in a spinal cord injured population: Its relation to functional status. Arch Phys Med Rehabil 1998;79:1356-61.

Dreer L, Elliott T, Shewchuk R, Berry J, Rivera P. Family caregivers of persons with spinal cord injury predicting caregivers at risk for probable depression. Rehabil Psychol 2007;52:351-7.

Consortium for Spinal Cord Medicine. Depression following spinal cord injury: A clinical practice guideline for primary care physicians. Washington, DC: Paralyzed Veterans of America. 1998.

Dryden DM, Saunders LD, Rowe BH, May LA, Yiannakoulias N, Svenson LW, et al. Depression following traumatic spinal cord injury. Neuroepidemiology 2005;25:55-61.

Kennedy P, Rogers B. Anxiety and depression after sinal cord injury: A longitudinal analysis. Arch Phys Med Rehabil 2000;81:932-7.

Krause JS, Bombardier C, Carter RE. Assessment of depressive symptoms during inpatient rehabilitation for spinal cord injury: Is there an underlying somatic factor when using the PHQ? Rehabil Psychol 2008;53:513-20.

Hoffman JM, Bombardier CH, Graves DE, Kalpakjian CZ, Krause JS. Natural history of major depression after spinal cord injury. J Spinal Cord Med 2008;31:236.

Mehta S, Aubut JL, Legassic M, Orenczuk S, Hansen KT, Hitzig SL,et al. An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury. Rehabil Psychol 2011;56:15-25.

Elliott TR, Kennedy P. Treatment of depression following spinal cord injury: An evidence-based review. Rehabil Psychol 2004;49:134-9.

Zemper ED, Tate DG, Roller S, Forchheimer M, Chiodo A, Nelson VS, et al. Assessment of a holistic wellness program for persons with spinal cord injury. Am J Phys Med Rehabil 2003;82:957-68.

Dunn M, Love L, Ravesloot C. Subjective health in spinal cord injury after outpatient healthcare follow-up. Spinal Cord 2000;38:84-91.

Diego MA, Field T, Hernandez-Reif M, Hart S, Brucker B, Field T, et al. Spinal cord patients benefit from massage therapy. Int J Neurosci 2002;112:133-42.

Defrin R, Grunhaus L, Zamir D, Zeilig G. The effect of a series of repetitive transcranial magnetic stimulations of the motor cortex on central pain after spinal cord injury. Arch Phys Med Rehabil 2007;88:1574-80.

Perkes SJ, Bowman J, Penkala S. Psychological therapies for the management of co-morbid depression following a spinal cord injury: a systematic review. J Health Psychol. 2014 Dec;19(12):1597-612.

Dezarnaulds A, Ilchef R. Psychological Adjustment after Spinal Cord Injury – Useful strategies for health professionals. Agency for Clinical Innovation. Feb 2014. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/155197/Psychosocial-Adjustment.pdf. Accessed Feb 22, 2016.

Image credits:

1. 1. A woman suffering from Clinical Depression ©Berkah Icon, CC BY 3.0 US
   2. Insomnia ©Gan Khoon Lay, CC BY 3.0 US
   3. Sad ©Juan Pablo Bravo, CC BY 3.0 US
   4. depression ©Gan Khoon Lay, CC BY 3.0 US
   5. wheelchair lonely physical hospital land care ©ferobanjo, Pixabay License
   6. Nerve cell neuron brain neurons nervous system ©ColiN00B, Pixabay License
   7. DNA ©Servier Medical Art, CC BY 3.0
   8. Clinician and client © The SCIRE Community Team
   9. therapy ©Adrien Coquet, CC BY 3.0 US
   10. White green and red medication capsules ©Pikrepo, CC0 1.0
   11. Exercising with trainer © The SCIRE Community Team