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Researchers advocate routine depression screening
A growing body of research establishes a link between rehabilitation and depression. There are many questions still unanswered, but researchers agree on one fact: If you work in rehab, you’re going to have to deal with depression.
"Depression is for many people a first- or second-tier response to trauma," says Greg Smith, PhD, clinical rehabilitation psychologist and director of Progressive Rehabilitation Associates in Portland, OR. "Depression is No. 1 or No. 2 on anybody’s problem list in a rehab program when they’re dealing with chronic disabilities."
So it’s not so much a question of if, but rather when a patient will begin to have feelings of depression. Patients go through a range of emotions that may start with disbelief and denial and move on to fear, anger, or depression once they begin to confront the true nature of their new limitations, Smith says.
"The way the rehab team functions is to say where is this person in the process of adapting and coping and learning to address this issue," Smith says. "Typically, patients will find themselves on antidepressants, but the medications are really adjunctive to the treatment. They aren’t the treatment. The treatment should occur not only with the rehab psychologist but with the other team members as well. In a rehab setting, what we’re looking for is assisting the person to adjust. It’s a behavior-change strategy."
The rehab team should be looking for depressive symptoms all through the rehab process but should be particularly alert to emotional difficulties that rise as therapy decreases. The highest suicide rate in the United States is among quadriplegics and paraplegics, Smith says, and it usually happens as much as a year after injury.
"The more medically stable they are, the stronger they get, the more they wake up," he explains. "The therapy begins to diminish in frequency, and they’re kind of on their own; and it’s at that point where they’re at the highest risk for suicide. All the focus of attention had been on getting better, and now this is it." Every rehab plan should have a behavioral aspect that is updated weekly or even daily as needed, Smith says.
It’s not hard to understand why patients with sudden severe physical limitations might become depressed. But what if the depression is a biological reaction caused by the traumatic event itself? Researchers now believe that depression in stroke patients may correlate with the size and location of the lesion on the brain. The presence of a biological mechanism may explain why a recent study from the University of Iowa in Iowa City found that antidepressant treatment for stroke victims appears to reduce mortality, whether the patients are depressed.1 "This finding suggests that the pathophysiological processes determining the increased mortality risk associated with post-stroke depression last longer than the depression itself and can be modified with antidepressants," the authors write.
Ricardo Jorge, MD, a co-investigator of the study who is a neurologist and assistant professor of psychiatry at the University of Iowa, says almost 68% of patients who received 12 weeks of antidepressant treatment were alive after nine years, compared with about 36% of patients who received 12 weeks of placebo. Forty percent of patients develop a depressive disorder within two years of a stroke, he points out. There doesn’t seem to be any association between the severity of the stroke and the severity of the depression.
Reasons for depression in stroke patients include:
1. Biological causes. Patients who develop depression tend to have a greater degree of atrophy in the brain, Jorge says.
2. Socioeconomic factors. Patients who are socially isolated with a poor social support network are more vulnerable to depression.
3. Genetic endowment. Certain personality types and reactions to stress can lead to depression.
4. Previous history of depression. According to Jorge, the causes of depression may vary along the course of the patient’s recovery. "Those factors prominent in acute phases may not be so prominent in later phases. Biological causes may play a big role at the beginning, and lack of social support later on."
Whatever the causes, adequate treatment of depression leads to significant improvement in activities of daily living and cognitive function, he says. "Lack of motivation is one of the cardinal signs of depression. Depressed patients, in general, have less degree of involvement with every type of rehab effort. One of the reasons those patients don’t recover in the same way is they don’t participate in the same degree in the rehab process."
Jorge and his colleagues are exploring further the mechanism by which antidepressants seem to be increasing stroke patients’ chances of living longer. They say it’s possible the drug’s action may be independent of depression. They also say giving antidepressants early after stroke potentially could prevent the onset of depression later.
But Jorge cautions that it’s too soon to start prescribing antidepressants to every stroke patient. "Many rehab physicians have a very low threshold to start antidepressants, even if they are in doubt that the patient is really depressed. It’s not easy to diagnose depression," he continues. "But we need more research, bigger studies, to be sure about the results and also to select the most adequate medications. Using antidepressants is not devoid of side effects. We don’t have the empirical evidence to start treating every patient at this point. We need to be cautious."
Assessment is critical
The first step, Jorge says, is to strive for correct assessment of depression. Patients in rehab facilities need an evaluation by a psychiatrist who has rehab experience.
At Burke Rehabilitation Hospital in White Plains, NY, all stroke patients get a depression evaluation, straight from a clinical investigator himself. Pasquale Fonzetti, MD, PhD, a neurologist and principal investigator in clinical neuropharmacology, is working with Jorge on a three-site depression prevention protocol. So far, he has 10 patients enrolled in the study that seeks to confirm the results of Jorge’s earlier study and lead to a new standard of care for rehabilitation hospitals around the country.
They are enrolling patients who are not depressed, starting them on a trial medication, and following them for 18 months to see if they develop depression or have other medical events. Patients who do develop depression are removed from the study and started on proper treatment. Another arm of the study will compare the effects of behavioral treatment with the antidepressant.
Burke Rehab patients are fortunate, Fonzetti says, to get the depression screening because of the clinical trials done there. "But screening is not widely done unless a hospital is involved in clinical trials. It should be," he explains. "Depressed patients have less motivation to improve, less attention and concentration. Depression is a factor for [patients’ conditions] to deteriorate instead of gradually improve. This is an issue that is well known to neurologists who work in a rehab setting, but other neurologists are not as aware of the problem."
Another area of disability in which there is not nearly enough awareness about depression is vision loss, says Amy Horowitz, DSW, senior vice president for research and director of the Arlene R. Gordon Research Institute at Lighthouse International. Lighthouse is a nonprofit organization based in New York City that serves as a worldwide resource on vision impairment and rehabilitation.
"People absolutely do not know there is such a thing as vision rehabilitation. It’s not like having a hip fracture and knowing you’re going into rehab," Horowitz says. "They don’t know there is anything that can be done or what’s available, and therefore, they see the situation as hopeless. People do not have to expect vision loss or depression as a normal consequence of aging. A lot of people say, What do you expect? They’re losing their vision; of course, they’re depressed.’ But that doesn’t have to be the case. It’s highly prevalent, but it’s not inevitable."
Horowitz recommends that ophthalmologists routinely screen for depression, especially in patients with age-related macular degeneration. "You speak to a lot of specialists and they say, of course, they see a lot of depression in their practice. They just don’t do anything about it," she says. "It’s important to acknowledge it and make the appropriate referral."
Lighthouse is in the data analysis phase of a five-year longitudinal study of the prevalence of depression in people with vision loss and its relation with disability over time. The researchers are looking at the impact of depression on rehabilitation and also the impact of rehabilitation on depression.
About one-third of people older than 65 who have vision impairment also suffer from depression, Horowitz says. That’s a higher percentage than has been reported for elderly people in the community and also higher than the estimates for elderly patients with other medical conditions. "One thing that is clear is that the relationship between vision impairment and functional disability is profound compared to other common medical conditions. It’s comparable to stroke and arthritis. There is a strong relationship between disability and depression," she says.
"There’s something unique about the subjective feelings about the loss of vision. It has a great deal of meaning to people over and beyond sometimes what kind of functional limitations it might cause. It’s associated with feelings of dependence, fear, loss of autonomy," Horowitz explains.
According to research from the Lighthouse, depressed people are less likely to follow through with rehabilitation and have a bigger dropout rate. But in a recent study published in Aging and Mental Health, Horowitz and her colleagues reported that use of rehabilitation services led to a decline in depression over time.2 "When they do engage in services, they tend to receive fewer hours of service. Depression dulls the affect, dulls the ability to engage in activities of all sort, including rehabilitation," she explains. "Depression should never be left untreated. The ironic part is that rehabilitation can impact one’s mental health status."
The key is determining how best to address this reciprocal relationship between depression and rehab. "For some people, you may have to deal with the depression before you deal with the rehabilitation," Horowitz adds. "For some, you may be able to deal with them concurrently. Which do you need to address first so you can improve both function and mental health? The goal of rehabilitation is not only to improve function but to improve one’s adaptation to a disability."
There is evidence that rehabilitation cannot only alleviate depression but also can improve physical problems related to the disabling condition. A large randomized trial reported in the Journal of the American Medical Association last fall found effective depression treatment in arthritis patients led to less pain, enhanced functioning, and a better quality of life.3 The IMPACT study was a multisite study of depression care in 1,801 patients seen in their primary-care physician’s office.
"Older adults with depression commonly cope with several chronic illnesses on a daily basis," explained principal investigator Elizabeth H.B. Lin, MD, MPH, in a news release about the study. Lin is a family medicine physician at Group Health Cooperative in Seattle.
An estimated 15% to 20% of elderly folks in the community have depressive symptoms, but the prevalence of depression jumps to between 30% and 50% in elderly patients with medical conditions requiring rehabilitation. Those most frequently affected tend to be patients dealing with stroke, arthritis, and vision loss. "This research suggests that we can lessen their pain, improve their outcomes, and enhance their quality of life by reorganizing primary care practices to better treat their depression. We did not use any magic bullet — no new medication or technology. We simply used existing treatments more effectively," Lin asserts.
1. Jorge R, Robinson R, et al. Mortality and post-stroke depression: A placebo-controlled trial of antidepressants. Am J Psychiatry 2003; 160:1,823-1,829.
2. Horowitz A, Reinhardt JP, et al. The influence of health, social support quality, and rehabilitation on depression among disabled elders. Aging Mental Health 2003; 7:342-350.
3. Lin EH, Katon W, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: A randomized controlled trial. JAMA 2003; 290(18):2,428-2,429.
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