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Clinical Consultation: Major Depression in Rehabilitation Care
Situation: M.J. is a 32-year-old female currently in an inpatient rehabilitation program. She was admitted 5 weeks ago S/P Motor Vehicle Accident. with a diagnosis of traumatic brain injury (TBI). The patient was engaged in the rehabilitation program and had progressed well until 2 weeks ago. Since that time, her appetite has decreased and she has lost 5 pounds. She reported feeling more tired and taking multiple naps during the day. She has been voicing more concerns about the hopelessness of her situation, has refused to go to therapy, and has denied that she is feeling sad. Nurses report that she has required more PRN pain control.
Consultation: Anne Gunderson, GNP CRRN-A, an assistant professor at the University of Illinois Chicago College of Medicine, Department of Medical Education, and John Tomkowiak, MD, associate dean of curriculum at Rosalind Franklin University Chicago Medical School, reply:
Major depressive disorder (MDD), referred to as simply depression, is a primary mood disorder. For many rehabilitation patients, depression is a common medical problem that affects the patient’s recovery. MDD, however, is often overlooked by healthcare providers and inappropriately (or inadequately) diagnosed for many patients who present with depressive symptoms. Numerous studies cite lack of time, lack of knowledge and skill, and the stigma associated with psychiatric illness as causes of this deficit.
In inpatient rehabilitation programs, depressed patients tend to use the program less effectively, make less progress, and have an increased length of stay. After discharge, depressed patients leave the house less often, do not become involved in recreational pursuits, and report having less contact socially (Wu, 1995). Patients and families often tend to minimize the depressive symptoms or treat the symptoms as something that is “expected” after a traumatic injury. With M.J., it could be easy for her family, and even healthcare providers, to brush off the symptoms as part of an appropriate response to a TBI. Depressed individuals are also less likely to be referred for, seek out, or successfully complete rehabilitation programs or to use adaptive devices (Horowitz, 2003). Rehabilitation providers must recognize the symptoms of depression and provide the necessary treatment for these patients as part of the overall treatment plan.
No clear anatomic or physiologic cause can directly explain depression. Most experts agree that it can be diagnosed on the presentation of clinical symptoms outlined in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition revised (DSM-IV; American Psychological Association, 1994). DSM-IV criteria for MDD require the presence of five of nine symptoms for a 2-week period or more (see Figure 1) and one of the nine symptoms must be a loss of interest in usual activities or a persistent depressed mood. Although M.J. denies feeling sad, she began experiencing the symptoms approximately 2 weeks ago, and they have presented daily.
Other mental health disorders that are similar in presentation to MDD and that should be considered when making a diagnosis are dysthymia, bipolar disorder, bereavement, anxiety disorders, and depression secondary to exogenous medications or substance abuse. These disorders often coexist and compound the difficulty in correctly diagnosing and treating MDD. M.J.’s medical history prior to the MVA could also help determine whether MDD is an appropriate diagnosis.
Standard treatment interventions include the use of antidepressant medications and psychotherapy; however, there is also a growing trend in the use of alternative medicine techniques such as massage, guided imagery, and bright-light therapy. Management plans for rehabilitation patients with MDD should be driven by medical and psychological assessment findings. Symptoms are important because they guide treatment (Cole, 1996). Although short-term psychotherapy is designed to assist patients with MDD in developing effective coping mechanisms, they have to have at least a minimal set of cognitive and memory function for this therapy to be effective. In the case of M.J., it is important to correctly assess her cognitive abilities before psychotherapy is started.
In the inpatient setting, medication adjustments can be made more rapidly because side effects can be monitored more closely than in the outpatient setting. The patient with MDD will probably not feel that he or she has significantly improved within the 2-week timeframe. Regular follow-up is very important. Although follow-up may occur on a 3-month basis, treatment should continue for a minimum of 6 months and could easily extend to years (Rakel, 1999).
In the outpatient rehabilitation setting, patients who have been diagnosed with MDD and have been started on medication, psychotherapy, or both should be seen again within 2 weeks of starting the medications and should be evaluated for side effects and effectiveness of the treatment plan. This evaluation should include whether and how much progress has been achieved toward therapy goals, and documentation of the resolution of depressive symptoms.
Indications that interventions have been successful for the patient include a restoration of a euthymic mood; sleeping, eating and activity patterns that return to normal; and resolution of other depressive symptoms (noted upon assessment). For M.J., appropriate diagnosis and treatment would include an increased appetite, weight gain, elevated mood, participation in therapy, improved sleep patterns, and continued progress toward her therapy goals. Without recognition of the depressive symptoms and the development of an appropriate treatment plan, it is likely that the progress M.J. will make in her recovery will be much less.
About the Authors
Anne Gunderson, GNP CRRN-A, is an assistant professor at the University of Illinois Chicago College of Medicine, Department of Medical Education. She can be reached at firstname.lastname@example.org.
John Tomkowiak is associate dean for curriculum at Rosalind Franklin University Chicago Medical School.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press, 1994.
Cole, S. A. (1996). Mood disorders. In J. Noble (ed.). Primary care medicine (pp. 1738–1747). St. Louis: Mosby-Year Book.
Horowitz, A. (2003). Depression and vision and hearing impairments in later life. Generations: Journal of the American Society on Aging, 27(1), 32–38.
Rakel, R. E. (1999). Depression. Primary care. Clinics in Office Practice, 26(2), 211–223.
Wu, P. B. J. (1995). Poststroke depression. Spinal Medicine. Retrieved on September 13, 2005, from http://www. spinalmedicine.com/articles/post_stroke_depression.html