Condition
Lifetime prevalence (%)
Major depression
13–20
Bipolar disorder
2–4
Panic disorder
3–7
Social phobia
12–25
Obsessive-compulsive disorder
2–7
Generalized anxiety disorder
5–14
Post-traumatic stress disorder
7
Alcohol abuse/dependency
10–26
Cannabis dependency
4–18
Schizophrenia
1–2
Attention deficit/hyperactivity disorder
7–10
Intermittent explosive disorder
5
Non-EtOH drug abuse
10
Psychiatric Disorders in Rehabilitation Populations
Psychiatric disorders are also common in a number of rehabilitation populations, including traumatic brain injury, spinal cord injury, stroke, and chronic pain. These populations have not been studied as rigorously as in the large multisite surveys noted above, but findings include:
- 1.
Traumatic Brain Injury (TBI) [3]:
▪ Depression —there is often a delay in depression onset by weeks or months following injury, but 22–77 % of TBI patients develop depression within 1 year of injury. Depression worsens functional outcomes.
•Occupational impairment or cannot work occurs in 50 %
▪ Mania —Up to 9 % of patients develop a manic episode following TBI
▪ Pain —30 % of patients have pain at 1-year following TBI, and depression was eightfold more common in those with persisting pain [4]—this emphasizes the need for a holistic approach , i.e., treating pain and psychiatric issues together
▪ Suicide—risk of suicide is increased fourfold in TBI patients
- 2.
Spinal Cord Injury (SCI) [5–7]:
▪ Depression —12 % of SCI patients have major depression at 1-year post-injury, and 10 % at 5 years
▪ Suicide—suicide is at least three times more common after SCI and in one large study of over 9000 patients [7] was the leading cause of death for SCI patients with complete paraplegia
Practical Applications
- A.
Assessment
- 1.
First, evaluate psychiatric diagnostic criteria
Criteria for 6 of the most common disorders seen in rehabilitation patients requiring assessment and treatments are highlighted below:
- a.
Major Depressive Disorder (MDD)
Symptoms lasting 2 or more weeks and a change from previous functioning. At least one symptom is: (1) feeling depressed most of the day more days than not, or (2) markedly decreased interest. May also include increased or decreased sleep, appetite and motor activity, guilt, decreased energy and concentration, thoughts of death or suicide
Are the symptoms recurrent? That is, are there 2 separate episodes with at least 2 months of no depression between them?
Does the patient have psychotic features? These increase risk of suicide and usually require addition of an antipsychotic medication to antidepressant medication for adequate response (response rates drop to <30 % with just an antidepressant medication in psychotic depression)
○ Psychosis = impaired reality testing with either:
- a)
abnormal content of thought (hallucinations, delusions, paranoia) and/or
- b)
abnormal process of thought with slowed thinking, paucity of thought (or as in mania, with rapid or disorganized thought)
- a)
NOTE: DSM-V observes the following: “Responses to a significant loss [such as] serious medical illness or disability may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss that may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered” [8, p. 125–126]. Studies show significant improvement in mood, even with prolonged bereavement with antidepressants; therefore, caution against under-treating patients who might benefit.
Evaluation for bipolar illness in every patient meeting criteria for a depression is important. The presence or history of a hypomanic or manic episode overrides diagnosis for MDD and instead warrants diagnosis of a bipolar disorder rather than MDD.
- b.
Bipolar Disorders
First, assess for hypomania (which requires less severity than full mania) to see if bipolar II might be present. Hypomania is “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity and energy, lasting at least 4 consecutive days and present most of the day, nearly every day” [8, p. 132]. If three of the following symptoms are present during the mood disturbance and represent a noticeable change from usual behavior, then bipolar II might apply: Distractibility, Racing thoughts, Speech rapid, Grandiosity, Agitation-goal directed activity, Sleep need decreased (e.g., rested with 3 h), excessive involvement in Pleasurable activities with painful consequences (“DRS GASP”). Bipolar II patients also must have experienced a current or past major depression to meet diagnostic criteria. If patient has full mania, i.e., the symptoms last a week and cause marked impairment in social or occupational functioning, or necessitate hospitalization, or are associated with psychotic features, then the patient has a bipolar I disorder.
- c.
Panic Disorder (PD)
Recurrent unexpected panic attacks, involving “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which four or more of the following are present”: palpitations, sweating, trembling, shortness of breath, choking, chest pain or discomfort, nausea/gastrointestinal distress, dizzy/light-headed, chills/hot sensations, paresthesias, derealization, fear of losing control/going crazy, fear of dying [8, p. 208]. At least one attack has been followed by either 1 or more months of persistent worry about additional attacks, or a significant maladaptive change in behavior related to the attacks, such as avoiding exercise or unfamiliar situations.
NOTE: Unlike DSM-IV, DSM-V PD stands as separate diagnosis from agoraphobia, which is now listed (if present) as a separate diagnosis.
- d.
Acute Stress Disorder (ASD) and Post Traumatic Stress Disorders (PTSD)
(Summarized here—for full criteria see DSM-V): Exposure as a victim or witness to actual or threatened death, serious injury, or sexual violation:
ASD —presence of 9 or more of the following 14 symptoms from any of five categories of intrusion, negative mood, dissociation, avoidance, and arousal: recurrent intrusive memories, dreams, flashbacks/dissociative reactions, intense psychological distress, inability to feel positive emotions, altered sense of reality, inability to remember important aspects of the event, efforts to avoid distressing memories or thoughts about it, efforts to avoid external reminders like people or places associated with the event, sleep disturbance, irritable behavior, hypervigilance, problems with concentration, exaggerated startle response. Duration for Acute ASD is 3 days to 1 month.
PTSD —the patient must have symptoms from each of the four categories of intrusion, negative mood, avoidance, arousal (dissociation is coded separately as a modifier) lasting at least 1 month causing clinically significant distress or impairment in relationships.
- e.
Intermittent Explosive Disorder
Recurrent behavioral outbursts representing a failure to control aggressive impulses manifested by EITHER: (1) Verbal aggression—temper tantrums, tirades, arguments, or fights—or physical aggression toward property, animals or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property or physical injury to animals or others; OR (2) Three behavioral outbursts involving damage or destruction of property and/or physical assault involving injury against animals or people within a 12-month period. The magnitude of aggression is grossly out of proportion to any provoking stimulus, is not premeditated, causes marked distress or psychosocial impairment or financial-legal consequences, and is by someone at least 6 years old.
NOTE: The above diagnoses are not given but are modified if the disorder is thought to be due to the use of a substance or directly related to the physiological effects of a medical condition, e.g., “substance/medication induced ‘x’ disorder” or “‘x’ disorder due to another medical condition.”
- f.
Neurocognitive disorders
Major Neurocognitive Disorder—evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: (1) concern of the individual or a knowledgeable informant or the clinician that there has been a significant decline in cognitive function, and (2) a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing, or, in its absence, another quantified clinical assessment. Cognitive deficits interfere with independence in everyday activities (at a minimum requiring assistance with complex activities of daily living (ADL) such as paying bills or managing medications), and is not due to delirium or better explained by another mental disorder such as major depression or schizophrenia. Specify cause: Alzheimer’s disease, TBI, Parkinson’s disease, human immunodeficiency virus, vascular disease, multiple etiologies, or another medical condition.
Mild Neurocognitive Disorder —the cognitive decline is “modest” and does not interfere with capacity for independence
- a.
- 2.
Second, consider medical causes or contributors
- a.
Medications can cause depression, mania, anxiety/panic, and cognitive impairment. For instance, beta-blockers often make patients tired or feel “flat”; muscle relaxants and neuropathic pain medications like gabapentin or pregabalin often cause cognitive impairment or fatigue; antibiotics (rarely) cause depression; steroids frequently cause hypomania or even manic psychoses; opiates impair alertness and can cause not only euphoria, but also memory impairment, dysphoria, irritability, and depression. Effects of anticholinergic medications are additive and can impair not only bowel motility and saliva formation but also make patients feel tired and “hazy or spacey” cognitively. Thus, sometimes “less is more” and the first step can be to simplify the patient’s medical medications before adding psychotopics.
- a.
- b.
Sleep deprivation can drive depression, worsen pain, and impair cognition and participation in daytime rehabilitation tasks (e.g., due to frequent bed checks, breakthrough pain, nocturnal procedures, hospital noise, or restless roommates)
- c.
Other medical causes of mood problems :
▪TSH and free t-3 and free t-4 (central hypothyroidism is not uncommon so a lone TSH to assess thyroid status is inadequate as the TSH might be low or normal due to pituitary hypo-function even in the presence of a hypothyroid state)
▪B12 and folate and magnesium abnormalities in patients with alcoholism or dubious nutritional status
▪HIV or other studies for patients at risk for sexually transmitted infections
▪Pain may drive depression as does sleep deprivation. Adequate treatment of both sometimes resolves psychiatric symptoms
- 3.
Third, obtain the patient’s psychiatric history
Information from previous providers/family members can help to better understand the patient’s diagnosis and history of treatment response. Many rehabilitation patients have communication or cognitive/memory problems and obtaining collateral data from family or care providers can be extremely helpful .
- 4.
Fourth, obtain the family psychiatric history
Most psychiatric conditions have a familial/genetic contribution, and diagnoses and medication responses tend to run in families. Suicide also runs in families and this history should lower the clinician’s threshold for careful and repeated assessment of the patient’s suicide potential.
- 5.
Fifth, consider the psychosocial context
Family dynamics are powerful and may drive depression, hopelessness, and suicidality. Conversely, and more commonly, families represent a bastion of support that can be used to help patient get past the acute distress caused by their illness or injury and proceed toward recovery. Thus, providing support to and problem-solving with families as they cope with the ramifications of the illness or injury can augment and strengthen the rehabilitation process.
- 6.
Sixth, assess suicidality
Don’t be afraid to ask about this; you won’t “give the patient ideas.” Suicidal thinking is on a continuum: determine if the patient is thinking about being dead or wishing they had died (ideation). Has the patient considered ways to do this (any plan) and if so, what are those? Does the patient have the means available in the hospital or at home to execute the plan? (If so, try to eliminate means—have family remove guns from the home if possible). Does the patient really want to die/making plans to do so (intent)? In general, it is best for patients with active and unremitted mood, anxiety, impulse control, or psychotic disorders not to have access to guns (suicide by shooting kills the victim in 80 % of attempts vs. a 1–2 % fatality rate with overdose). Two-thirds of gun fatalities in the USA are suicides, not homicides [9].
- 1.
- B.
Treatment
Consider non-pharmacological treatment alternatives first. Psychotherapy, exercise, meditation, family meetings/work, and use of sitters (with agitated patients) can often obviate the need for or at the very least complement pharmacological approaches. Electroconvulsive therapy and rapid transcranial magnetic stimulation are effective options for very severely depressed patients who cannot tolerate medications.
- 1.
Antidepressant Medications
“Antidepressants” is a shorthand term for a group of drugs that are not only first-line agents for depression, but also first-line agents for anxiety disorders such as panic, PTSD, and generalized anxiety disorder. All antidepressants are roughly equally efficacious, with the exception of Wellbutrin (bupropion), which does not generally help anxiety or panic and can make those worse, but has special efficacy for smoking cessation and may help ADHD symptoms in some patients. However, some patients respond to one antidepressant medication but not another, others may respond to both of those antidepressants, so one can conceptualize drug response as overlapping (Venn diagrams) groups of patients. Positive response rates for depression are 70–80 %, but complete resolution of symptoms with a given drug occurs 20–30 % of the time; therefore, sequential trials and augmentation strategies are often necessary. Panic disorder response is in the 60–80 % range, but OCD only responds positively about one-third of the time with partial improvement in another one-third. Cognitive behavior therapy (CBT) augments the response to antidepressants in MDD, panic, and OCD, and meditation augments response in MDD. Selective Serotonin Reuptake Inhibitors (SSRI) enhance neuroplasticity and improve recovery after stroke even in the absence of depression . All antidepressants confer a small but real risk of pushing a patient into hypomania or mania (rate is about 1/100 patients overall; but up to 10 % of patients with very severe depression). Antidepressants also all carry a risk of seizures in approximately 1/200 patients. Some antidepressants and their properties are listed in Table 6.2.
Table 6.2
Properties of antidepressant medications
Generic name
Trade name
Half-life (h)
Dose range (mg)
Comments
SSRI medications
Citalopram
Celexa
35
10–40
Use ≤40 mg/day due to QTc prolongation found in OD; approved for MDD
Escitalopram
Lexapro
27–32
5–30
Approved for MDD and GAD
Fluoxetine
Prozac, Sarafem, (part of Symbyax)
90–250Related posts:
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