• Depression following spinal cord injury. A clinical practice guideline for primary care physicians. Washington (DC): Paralyzed Veterans of America; 1998. 35 p. [112 references]

This is the current release of the guideline.

According to the guideline developer, this guideline is still considered to be current as of January 2005, based on a review of literature published since the original guideline publication.

Assessment

1. Perform routine screening for depression during the individual's initial visit and annually thereafter. Self-report measures of depression may be helpful in screening psychological status, but should never be used without a clinical interview to establish the existence or absence of a depressive disorder.

   (Scientific evidence—III; Grade of recommendation—B; Strength of expert panel opinion—Strong)

2. Assess the individual for the presence of the following general risk factors for depression:
   • Prior episodes of depression
   • Family history of depressive disorder or bipolar disorder
   • Family history of suicide attempts
   • Current suicidal ideation
   • Age of onset under 40
   • Chronic pain
   • Female gender
   • Lack of social support
   • Postpartum
   • Multiplicity of life stressors
   • Concurrent medical illness
   • Concurrent substance abuse

   (Scientific evidence—IV; Grade of recommendation—C; Strength of expert panel opinion—Strong)

3. Assess individuals with spinal cord injury (SCI) for the specific risk factors of depression, including:
   • Complete neurologic injury
   • Medical comorbidity, including but not limited to traumatic brain injury (TBI)

   (Scientific evidence—V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

4. Assess the individual for signs and symptoms of depression and potential for suicide during a history and physical examination.

   (Scientific evidence—V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

5. Identify the biological factors that may cause or contribute to depression, including the following physiological factors:
   • Biological effects of SCI, such as fatigue, anorexia, sleep disturbance, decreased energy
   • History of mood disorder
   • Family history of mood disorder
   • Presence of general medical condition that may cause or contribute to depression
   • Presence of medications or drugs that may cause or contribute to depression

   (Scientific evidence—IV; Grade of recommendation—C; Strength of expert panel opinion—Strong)

6. Conduct a comprehensive assessment of the social factors specific to spinal cord injury that contribute to depression to evaluate the adequacy of the individual's social support system in meeting basic needs and to determine the presence of depression in response to an inadequate support network. Specifically, the assessment should include but not be limited to:
   • The individual's social network, including family members, friends, and community organizations
   • The individual's financial resources
   • Vocational and avocational interests and issues
   • Current living arrangements, including wheelchair accessibility
   • Adaptive equipment needs and resources
   • Personal assistance needs and resources
   • Transportation needs and resources

   (Scientific evidence—II; Grade of recommendation—B; Strength of expert panel opinion—Strong)

7. Assess the psychological factors specific to spinal cord injury that contribute to depression, including the following:
   • Coping style
   • Self-blame for the injury
   • Unresolved conflicts from previous losses or traumas
   • Preinjury psychological or psychiatric impairment
   • Cognitive style
   • Grief and bereavement from SCI

   (Scientific evidence—V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

Diagnosis

8. Use established diagnostic criteria to diagnose depression.

   (Scientific evidence V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

9. Identify the mental health factors that indicate referral to the appropriate mental health provider including:
   • Active suicidal ideation
   • Psychotic depression
   • Bipolar disorder
   • Complex psychiatric diagnoses such as depression that are associated with post traumatic stress disorder, obsessive-compulsive disorder, eating disorder, schizophrenia, schizophreniform disorder, schizoaffective disorder, and personality disorders
   • Persistent substance abuse complicating the diagnosis and/or management of depression (especially when detoxification or more intensive treatment beyond a 12-step program is needed)

   (Scientific evidence—V; Grade of Recommendation—C; Strength of expert panel opinion—Strong)

Treatment

10. Formulate a treatment plan identifying:
    • Which treatments are to be provided by the primary care physician
    • What type of individual and family education needs to be provided and by whom
    • Who will address comorbid conditions and how those conditions will be treated
    • Specific criteria for referring the individual to a mental health provider

    (Scientific evidence-IV; Grade of recommendation—C; Strength of expert panel opinion—Strong)

11. Provide or refer for psychotherapy by matching the type of psychological intervention to both the identified problem and the therapeutic capacity of the individual.

    (Scientific evidence—IV; Grade of recommendation—C; Strength of expert panel opinion—Strong)

Psychopharmacological Agents

12. If indicated, select appropriate antidepressant medications. Psychopharmacological agents should be considered for individuals who present significant biological, somatic, and/or mood-related symptoms of sufficient severity to disrupt the person's life and activities of daily living. Selection of a specific agent should be predicated upon the unique characteristics of the individual and the presenting signs and symptoms of depression.

    (Scientific evidence—I; Grade of recommendation—A; Strength of expert panel opinion—Strong)

Environmental and Social Factors and Social Support System

13. Address environmental and social factors and refer to a social worker, rehabilitation counselor, or case manager, as appropriate. When problems in the individual's support system are identified, treatment interventions should be implemented to strengthen the social support system. These interventions should be directed at one or more of the following areas:
    • Education and information regarding available resources
    • Referrals to existing community resources
    • Development of alternative to access services or assistance where no existing community resource is readily available
    • Advocacy to change public policy to ensure that individuals with SCI have the resources to meet their lifelong needs

    (Scientific evidence—V; Grade of recommendation C; Strength of expert panel opinion—Strong)

14. Provide patient and family education on the following topics:
    • Signs and symptoms of depression
    • Treatment options
    • Medications, side effects, adverse reactions, and drug interactions
    • Effect of depression on individuals with SCI/D
    • Effect of depression on the family
    • Community resources

    (Scientific evidence—V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

Evaluation and Modification of Treatment Plan

15. Evaluate treatment, focusing on the following elements:
    • Evaluation of treatment efficacy
    • Modification of treatment, as indicated
    • Follow-up with referral sources

    (Scientific evidence—V; Grade of recommendation—C; Strength of expert panel opinion—Strong)

Definitions

Hierarchy of levels of scientific evidence:

1. Large randomized trial with definite results
2. Small randomized trials with uncertain results
3. Nonrandomized studies with concurrent controls
4. Nonrandomized studies with historic controls
5. Case series with no controls

Categories of the Strength of Evidence Associated with the Recommendation:

1. The recommendation is supported by scientific evidence from properly designed and implemented controlled trials providing statistical results that consistently support the guidelines statement
2. The recommendation is supported by scientific evidence from properly designed and implemented clinical series that support the guidelines statement
3. The recommendation is supported by expert opinion

None provided

The type of scientific evidence and the grade of the recommendation are identified with each recommendation (see "Major Recommendations").

Of the 15 major recommendations, one was based on large randomized trials with definite results; one was based on small randomized trials with uncertain results; one was based on nonrandomized studies with concurrent controls; four were based on nonrandomized studies with historic controls; and eight were based on case series with no controls.

One recommendation was supported category A evidence, scientific evidence from properly designed and implemented controlled trials providing statistical results that consistently support the guidelines statement.

Three recommendations were supported by category B scientific evidence or evidence from properly designed and implemented clinical series that support the guidelines statement.

Eleven recommendations were supported by category C evidence or expert opinion.

All recommendations had strong expert panel agreement and support.

• Depression following spinal cord injury. A clinical practice guideline for primary care physicians. Washington (DC): Paralyzed Veterans of America; 1998. 35 p. [112 references]

Not applicable: The guideline was not adapted from another source.

1998 (reviewed 2005)

Consortium for Spinal Cord Medicine - Private Nonprofit Organization
Paralyzed Veterans of America - Private Nonprofit Organization

Consortium member organizations include: American Academy of Orthopedic Surgeons, American Academy of Physical medicine and Rehabilitation, American Association of Neurological Surgeons, American Association of Spinal Cord Injury Nurses, American Association of Spinal Cord Injury Psychologists and Social Workers, American Congress of Rehabilitation Medicine, American Occupational Therapy Association, American Paraplegia Society, American Physical Therapy Association, American Psychological Association, American Spinal Injury Association, Association of Academic Physiatrists, Association of Rehabilitation Nurses, Congress of Neurological Surgeons, Insurance Rehabilitation Study Group, Paralyzed Veterans of America, U.S. Department of Veterans Affairs.

Administrative and financial support provided by Paralyzed Veterans of America.

Guidelines Development Panel

Names of the Committee Members: Jason Mask, LCSW (Chair); Kimberly Arlinghaus, MD; Helen Bosshart, LCSW; Lester Butt, PhD; Rebecca R. Clearman, MD; Mary J. McAweeney, PhD; Barbara Simmons, MSN, RN

Not stated

This is the current release of the guideline.

According to the guideline developer, this guideline is still considered to be current as of January 2005, based on a review of literature published since the original guideline publication.

None available

This summary was completed by ECRI on May 31, 1999. The information was verified by the guideline developer as of November 15, 2000. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.