Experts offer guidance for treating depression
Experts offer guidance for treating depression
Case studies illustrate problem and solutions
When rehabilitation patients become depressed, it often takes a team effort to treat them. Likewise, a rehabilitation patient’s ability to regain optimal physical health may be tied to whether the patient’s spouse, parent, or other immediate caregiver is suffering from depression. These challenges require a great deal of effort on the part of rehab staff.
"Our job with these folks is to give them a positive orientation and to help them work through the emotional adjustment to many things that won’t be changed in their lives," says Ralph Bruno, PhD, rehabilitation psychologist for Walton Rehabilitation Hospital in Augusta, GA.
Rehab patients may exhibit various levels of depression or sadness. Those with severe clinical depression will need to be treated aggressively, whereas patients who have a mild depression may just need more staff time and family support to recover, says Nicky Ozbek, PhD, supervisor of psychological services for Siskin Hospital for Physical Rehabilitation in Chattanooga, TN.
"The idea that time heals all wounds is true when a person tends to have a mild depression and is going through an adjustment period, but it’s not true when the depression is severe," Ozbek explains.
Ozbek and Bruno offer these guidelines to improving your facility’s treatment of depression:
1. Train all staff in treating depression.
At Walton Rehabilitation Hospital, all clinical staff look for signs of depression, such as an unwillingness to participate in therapy or negative statements about the future, Bruno says.
Employees are trained to reinforce positive behaviors and to distract patients from negative self-talk. They guide patients away from unrealistic expectations and don’t let them dwell on their anger, he adds. "We just reinforce and guide patients gently to look at what they’ve accomplished each day, and we give them a realistic appraisal of what they can do in the future."
There are two major benefits when rehab staff encourage depressed patients to challenge themselves physically: First, the patient’s activities of daily living will improve as the patient continues to regain strength. Second, the very activity itself can help to elevate the patient’s mood. Animal studies have demonstrated that gross motor exercise helps to change serotonin levels, which elevates mood, Ozbek says.
"So if you stay in bed and not move much, it won’t help," she adds. "It’s better to get into physical therapy and get out of bed."
Rehab professionals often are — by nature of their work — very encouraging and cheerful people who will have a positive effect on depressed patients, Ozbek says. "They’re very good at reinforcing patients for small gains in behavior, and they are themselves pleasant people to be around. It’s almost part of the job criteria for rehab professionals."
2. Assist physicians with medication.
Treating depression often requires a combination of medication and therapy. So a rehab team working to reduce patients’ depression also will need to include a physician in any treatment plan.
Likewise, the rehab team can assist the physician with identifying and monitoring a patient’s depression. For instance, if rehab psychologists or other staff are the first to notice signs of depression in a patient, they should call the patient’s physician to discuss the possibility of prescribing antidepressant medications.
Rehab staff also can be instrumental in noting changes in patients’ behavior after the patients have been on the medication for a period of time. Physicians may use this information when deciding whether to increase the dosage or make other changes in the prescription.
3. Provide follow-up support when patients return home.
It’s a good idea to teach staff that a patient’s mood will not be constant throughout therapy. The patient who seems to be coping very well with a spinal cord injury during the inpatient phase of treatment suddenly may shift into a withdrawn, depressed mood during outpatient therapy. "The way it is on a given day may not be the way it is three months later," Ozbek says. "A lot of people don’t have emotional problems until they go into outpatient treatment because when they’re in the hospital, they may still have the hope that someone is going to fix it for them."
Siskin Hospital calls and makes sure patients do not fall into a dangerous depression after they return home, even those patients not receiving outpatient services from the hospital.
"Essentially, it’s a telephone conversation to ask how the person’s doing and whether they have received services as follow-up care and how they’ve adjusted," Ozbek says.
Siskin hired a peer counselor to make these phone calls. The counselor is a person who had been a patient at the hospital after a spinal cord injury. So if the counselor discovers that a patient is having problems adjusting at home, then he or she will make sure the patient is connected with community and health care resources that can help him or her.
4. Use support groups and peer counseling.
Support groups for patients with specific disabilities, such as traumatic brain injury or spinal cord injury, may help patients with depression because it shows them that they are not alone in their struggles.
In addition to having a peer counselor on staff, Siskin Hospital has a peer counseling program in which survivors are trained to help others get through rehabilitation. "They go through these classes where we talk about communication skills and confidentiality and how to handle problems and when to refer," Ozbek says. "We make sure patients don’t feel like they’re alone."
5. Help patients focus on activities they can do.
Sometimes, even in cases where the injury is mild to moderate, patients can become so mired in their fears, pain, and feelings of helplessness that they stop trying. When this happens, the rehab team needs to help patients gain confidence through activities they can do while steering the patients’ thoughts away from the abilities they have lost.
Bruno gives this case study as an example: A male patient had suffered an injury to his neck and shoulders while at work. The musculoskeletal injury gave him chronic pain, and the pain led to depression. "He had given up trying to do anything and was trying to get disability from workers’ compensation," Bruno recalls. "He had stopped supporting his wife and family and was in dan
Depressed patients may give up hope
The man often simply sat through therapy sessions, resisting efforts to engage his participation because he thought his situation was hopeless. "We worked with him to build him up physically because his body had the disuse syndrome from so much sitting," Bruno says. "Then we highlighted what he was capable of doing by evaluating him cognitively and physically, and he was intellectually able to do much more than he had been doing."
The team worked with him collaboratively, following a psychological treatment plan over an eight-week period. The facility treated his depression with antidepressant medications, cognitive and behavioral therapy, and physical and occupational therapists worked with him. The team also helped him manage his pain. As a result, the man regained his confidence and his mood improved. Whereas before the rehab treatment he hadn’t worked for nearly two years, after the treatment he began working at a new job in a hotel. Several years later, he still holds that job, and his marriage and family still are intact.
"All of this teamwork helped this man, who would be on disability if we had not intervened, to become a productive member of society," Bruno says.
6. Treat patients’ caregivers for depression, too.
Rehab facilities need to pay attention to the emotional states of caregivers, also. Especially since treatment success often relies so heavily on a patient being able to receive the emotional and physical support of family members, it’s important that family members are coping with all of the trauma and changes in their lives.
"A depressed caregiver may ask a patient to do more than the patient is capable of doing, or the caregiver may not have the energy to push the patient to do a skill that is frustrating for the patient," Ozbek explains. "When you’re depressed, you either do too much for them or you get angry at them for not being able to do more for themselves."
This type of problem could prevent the patient from achieving optimal physical recovery, leading to longer lengths of stay and a greater number of physical and emotional setbacks.
Caregivers suffer with the patient
Ozbek offers this case study: A young man who had just completed college developed a brain tumor. Then he had a stroke within 48 hours of surgery. This caused a severe brain injury, and the man had to re-learn how to talk, walk, and perform other basic skills. The young man was grateful to be alive, and he appeared to be coping well with his disability. However, his mother became depressed.
The mother had been looking forward to a bright future for her son, and then instead she found herself having to relive the caretaking role that she had performed when he was an infant and young child.
Siskin staff recognized that the mother’s depression could hurt the patient’s progress toward recovery, and they helped her meet with a physician to receive antidepressants. Also, the mother began to meet twice a month with a therapist. "Therapy focused on teaching the caregiver that the patient’s disability didn’t have to be a handicap," Ozbek says.
While a handicap relates to how a person functions socially in the world, a disability refers merely to a person’s physical abilities and limitations. As the caregiver learned to see the two as separate concepts, she gave her son more autonomy and more choices, even though there still were many things he couldn’t do physically.
Her therapy continued for a year and a half, and eventually she began to see the tragedy in a more positive light. Ozbek says it especially helped her when her son began to speak and express his joy for living.
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