Get the best outcomes: the importance of mental and behavioral health within physical medicine and rehabilitation.

Peter Gunderson, an Icelandic mountain climber who suffered a terrible fall while hiking, found himself struggling to recover from a spinal injury. But he was determined to walk again. His first year in rehab yielded positive, gradual improvements. However, it was the second year that saw his greatest struggle: depression.

“He worked so hard, only to realize that what happened to him was permanent, that there would be no more improvement,” said Dr. Teresa Ashman, director of neurorehabilitation psychology at Atlanta’s Shepherd Center. “That second year after a traumatic injury is the real aftershock.”

Dr. Ashman spoke recently at Paradigm’s sixth annual Innovation Symposium and explained how emotional issues such as depression are just as impactful as the actual physical injuries. But treating depression requires a truly holistic approach that encompasses a variety of options. She noted that there is no cookie-cutter, one-size-fits-all treatment for any of these interventions.

“There is a high prevalence rate of post-injury depression within six years after spinal cord or traumatic brain injury — as much as 60%,” she said. She went on to explain how this high prevalence is related to suicidal thoughts, and that the risk of depression can increase as patients realize the real implications of their injuries and how hard it is for them to re-integrate into the community.

“Depression is just one of the diagnoses post-injury,” Dr. Ashman said. “There is everything from post-traumatic stress disorder and obsessive-compulsive disorder to substance abuse and sleep-wake issues.”

The successful treatment of post-traumatic brain injury depression has proven difficult to measure. There is a general lack of evidence, and results are often anecdotal or based on case studies. These include both pharmacological and non-pharmacological treatments.

“There was a recent clinical trial in which patients were given either Zoloft® or a placebo,” Dr. Ashman said. “Both groups saw some improvement with their depression and anxiety issues, and their quality of life.” The Zoloft group had slightly better results, yet despite the widespread use of these kinds of drugs to treat post-injury depression, there is little evidence to support their use.

In contrast, randomized clinical trials of psychotherapy for treating depression after a traumatic brain injury showed significant improvement in depression, participation and quality of life measures. It suggests a comprehensive biopsychosocial approach to treatment can improve outcomes.

Dr. Ashman pointed out that the role of neuropsychologists and rehabilitation psychologists is critical. They can restore patients to maximum premorbid functioning, help them regain functional independence and educate the patient and families about secondary prevention. A psychological and behavioral health assessment is the first step. It can help identify areas of emotional strengths and weaknesses, evaluate a patient’s social support systems and provide a more individualized treatment approach.

“Remember, patients and their loved ones are anxious, afraid and overwhelmed,” she said. “We can embolden them to ask for and accept help. Compassionate people who really care are so important to this holistic approach.” That approach includes increased therapeutic activities, environmental changes, relaxation and meditation techniques, nutrition, spirituality, coping skills and counseling. “Recovery doesn’t end at discharge,” Dr. Ashman said. “The most rapid recovery is in the first six months to two years, but recovery can and does continue throughout a patient’s life.”

Dr. Ashman concluded by saying that people do thrive and can be very resilient. They can’t be given up on too soon. “The power of the mind and the strength of the human spirit are so important,” she said. “Never say never. Amazing things happen, and these patients can get on a path to a better life.”