Depression and Spinal Cord Injury

Introduction

Adjusting to a spinal cord injury (SCI) and changes in your body and life can take a while. During this time, short periods of sadness, feeling hopeless, or intense feelings of loss are normal. The up and down emotions associated with adjustment are different from major depression. In major depression, a person feels down or depressed or loses interest in usual activities most of the day, nearly every day, for 2 weeks or more. If your mood is consistently down or you no longer get pleasure from previously enjoyable activities, it may be worth finding out whether you are experiencing an episode of major depression.

About 8.3% of adults in the United States, or 21 million individuals, have at least one episode of major depression in their lifetimes. Depression can run in families, which means it can have a genetic component. But it can also stem from things that have happened in your life, like relationship problems, job loss, or money problems. Traumatic events that lead to major life changes, such as SCI, can also cause depression. Depression is one of the most common mental health problems for people with SCI. In the first year after an SCI, an estimated 12% to 40% of people experience depression. Among people with an SCI who live in the community, about 15% to 30% experience depression, or about one in four people.

Depression is not something to be ashamed of. It is not caused by personal weakness, laziness, or a lack of willpower. Treatment may help reduce symptoms of depression; it may also help to shorten the length of a depressive episode.

What Is Major Depressive Disorder?

Major depressive disorder is the diagnosis people usually refer to when talking about depression. It is different from adjustment issues and grief in terms of the types of symptoms one experiences, length and intensity of symptoms, and impact on your life. Grief is a common response to the loss of a loved one, whereas an adjustment disorder is the experience of significant emotional or behavioral problems occurring within 3 months of a specific stressful event. Major depression has a different pattern of symptoms than an adjustment disorder and often has more severe symptoms. Symptoms of major depression are usually severe enough to affect how a person functions at work, school, or at home.

Symptoms of major depression can include:

• Feeling down, depressed, or hopeless;
• Loss of interest or pleasure in activities or things that you usually enjoy;
• Reduced appetite that leads to weight loss (or the opposite, increased food cravings that lead to weight gain);
• Problems sleeping too little or too much;
• Fatigue or lack of energy;
• Feeling physically slowed down, or the opposite, feeling restless like you can’t keep still;
• Feeling excessively guilty or worthless;
• Trouble with thinking or concentrating, or with making decisions; and
• Repeated thoughts of death, thoughts of suicide, or suicide attempts.

These symptoms cause significant distress or affect the person’s daily functioning at home, work, socially, or in other areas.

Depression Quick Screen

The Patient Health Questionnaire-2 below is a screener for depression. For each of the items listed below, circle the number (0–3) that reflects how often that problem has bothered you over the last 2 weeks.

Risk Factors for Depression

Research shows that your genes, certain things in your environment, mental factors, and substance misuse may play a role in depression. Trauma early in life and physical problems like chronic pain may also contribute. You may also develop depression after an injury, such as an SCI.

Stress and Coping After SCI

There is no doubt that coping with SCI can be stressful. You may need to do your daily activities differently if you can’t move around as well as you used to. Your relationships may change or become strained, leading to less social interaction or isolation. You may be less independent, limiting your ability to do activities you once enjoyed. These changes can lead to financial strain, job loss, and less physical activity.

People are less likely to become depressed if they see SCI as a challenge, not a threat. This means that they see SCI as a health problem they can learn to manage and even grow from. To protect against depression, the challenge is to balance hope and acceptance, manage problems related to SCI, and rely on yourself as much as you can. People who find ways to take part in pleasant or meaningful activities are less likely to become depressed. Joining a support group of people with SCI who can share their experiences can help alleviate feelings of depression. Regular physical activity is an effective way to reduce the risk of depression or to reduce the severity of depressive symptoms.

Depression Can Be Treated Successfully

It is important to treat depression. Treatment reduces the symptoms of depression such as poor concentration, low mood, poor energy, lack of interest, poor sleep, and negative thinking. It can also help you feel less disabled by your SCI. Counseling and antidepressants are about equally as effective. Roughly 60% of people who are treated can expect to improve significantly and about 40% improve enough that they are not depressed at all after treatment. Treatment may take 4–6 weeks to begin to have an effect and 12 weeks or more to achieve the full benefit. Combining counseling and antidepressants is more effective than either treatment alone. Therapies delivered online plus antidepressants also appear to be effective, although it can be a trial-and-error process to find an antidepressant that works for you. Doing regular exercise or physical activity by itself can improve your mood as can adding it to psychotherapy or antidepressants.

Psychotherapy Can Help

There are many kinds of psychotherapy. Cognitive behavioral therapy, or CBT, is an evidence-based approach that helps reduce depressive symptoms. It can help you learn coping skills and how to use them to deal with your emotions and tough situations. CBT helps you be aware of how your thoughts and beliefs affect your feelings, actions, and emotional state. A therapist helps you to uncover ideas and beliefs that are not helpful and learn different ones. A therapist will also help you to identify activities that are enjoyable and meaningful for you and help you get back to doing those activities to the extent you can.

Other types of psychotherapy may help, too. One type is known as acceptance and commitment therapy. This type of therapy helps you accept difficult situations and negative emotions as a normal part of life. The therapist helps people identify their core values and commit to living out those core values flexibly in the ways they can. Other forms of therapy include dialectical behavioral therapy, a type of talking therapy that helps people learn to manage intense emotions and make positive life changes. Another type of therapy that may be helpful is mindfulness-based therapy, which emphasizes awareness of the present, meditation, and breathing exercises. You can attend psychotherapy alone (individual therapy) or with others (group therapy) or via telehealth options that allow you to participate in therapy from home. You may need to try more than one type of therapy or multiple therapists to find what works best for you.

How Do Antidepressants Work?

There are many types of antidepressants. Most of them work by increasing chemicals in your brain that regulate mood. As with counseling, antidepressants often take 4–6 weeks to have a noticeable effect and 12 weeks or more to have a maximal effect, so stick with them. Your prescriber may want to gradually increase the dose. If you are not seeing a positive effect after 6–12 weeks, your provider may want you to try a different antidepressant. Thus, it could take a couple tries to find the best medication. Medication side effects tend to go down over time while the benefits of the medication tend to increase gradually. Talk to your provider about the risks and potential side effects before starting any medication. Take the medication as prescribed and talk to your health care provider about how your medication is or isn’t working. Don’t just stop taking these medications on your own. Discuss it with your provider.

Antidepressants can help in many ways. First, they can reduce the symptoms of depression. Second, they can prevent future episodes of depression. Third, they can reduce the risk of suicide. Fourth, they can help you reengage in activities and your social life. Fifth, antidepressants may improve chronic pain. Finally, they can help you function better at home and at work. Antidepressants are not addictive but stopping them all at once can have negative effects.

Where to Find Help

There are many types of health care providers who can treat depression. You can ask your primary care physician to make referrals to these specialists. Treatments include medication and therapy. Providers who can prescribe antidepressants include primary care doctors, psychiatrists, neurologists, and some clinical psychologists and nurse practitioners. These providers have a medical degree or a license to prescribe medications. Other providers, including clinical social workers, clinical psychologists, and licensed counselors, provide psychotherapy. Ask a new therapist if they have treated people with SCI. Try a few therapy sessions to see if there is a good fit. If not, find a different therapist.

What You Can Do Now

• Take a depression self-test like the one shown in Table 1. Answer the questions honestly. Then, add up your score and see where your score falls. If your score is 3 or higher and you have been feeling this way for more than 2 weeks, seek help. Contact a doctor, a psychologist, a psychiatrist, or a counselor who has experience treating depression.
• Tell those around you how you are feeling. They can support you and help keep you safe while you go through this tough time.
• If you have thoughts of suicide or of harming yourself, contact your health care provider or a mental health specialist right away. You can also call or text the Suicide and Crisis Lifeline at 988. You can start a chat at 988lifeline.org to speak to someone now. You can also call 911 or go to your local emergency department if you are in imminent danger of hurting yourself.
• Build routine physical activity into your schedule. Exercise, or just getting outside in nature, helps improve well-being and mood.
• Socializing may seem hard but engaging with others can often help to improve your mood.

Depression is not a necessary or inevitable part of living with SCI. Depression is nothing to be ashamed of. It is not a personal failing or weakness. There are effective treatments that can help.

Authorship

Depression and Spinal Cord Injury was developed by Allen Heinemann, PhD; Sharon Parmet, MS; and Charles Bombardier, PhD, in collaboration with the Model Systems Knowledge Translation Center.

Source: The content in this factsheet is based on research and/or professional consensus. This content has been reviewed and approved by experts from the Spinal Cord Injury Model Systems (SCIMS) centers, funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The content of the factsheet has also been reviewed by individuals with SCI and/or their family members.

Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider about specific medical concerns or treatment. The contents of this factsheet were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPKT0009) and by the Craig H. Neilsen Foundation (project 724833). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this factsheet do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.

Recommended citation: Heinemann, A., Parmet, S., & Bombardier, C. (2024). Depression and spinal cord injury. Model Systems Knowledge Translation Center (MSKTC). https://msktc.org/sci/factsheets/depression-and-spinal-cord-injury.

Copyright © 2024 Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.