Depressive Symptoms and Clinical Depression and People with Disabilities: Treatment

BRIEFING SUMMARY

This briefing summary provides an overview of some of the treatments being used for depressive symptoms and clinical depression in people with disabilities.

Youth

According to the website of the National Institute of Mental Health (NIMH), depression in children and adolescents is a serious disease, causing significant problems at home, in school, and with peers, and putting youth at risk for substance abuse and suicidal behaviors. Major depression in youth should be adequately treated and include careful follow-up and monitoring. Psychotherapy seems to be a useful initial acute treatment for mild to moderate depression, according to practice parameters published by the American Academy of Child and Adolescent Psychiatry (1998). Psychotherapy is often accompanied by an early follow-up appointment to help establish the persistence of depression before it is decided to try antidepressant medications. Psychotherapies include “cognitive behavioral therapy” and “interpersonal therapy.”1

While medications, particularly the serotonin reuptake-blocking medications (SSRIs), have been shown to be of benefit in adults, concerns have been raised that antidepressant medications themselves may induce suicidal behavior and be ineffective in treating depression in youth. These concerns are based on a series of public health advisories issued by the Food and Drug Administration (FDA) cautioning physicians, their patients, and families and caregivers of patients about the need to monitor both adults and children with depression, especially at the beginning of treatment, or when the doses are changed with either an increase or decrease, and to avoid abrupt discontinuation of treatment. The FDA has been closely reviewing the results of antidepressant studies in children after an initial report on studies with paroxetine (Paxil) and subsequent reports on studies of other drugs which appeared to suggest an increased risk of suicidal thoughts and actions in the children given antidepressants. There were no suicides in any of the trials. On close examination of the initial reports, it was unclear whether certain behaviors reported in these studies represented actual suicide attempts, or other self-injurious behavior that was not suicide-related. The FDA is advising clinicians, patients, families and caregivers of adults and children that they should closely monitor all patients being placed on therapy with these drugs for worsening depression and suicidal thinking, which can occur during the early period of treatment. The agency is also advising that these patients be observed for certain behaviors that are known to be associated with these drugs, such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania, and mania, and that physicians be particularly vigilant in patients who may have bipolar disorder.2

According to the NIMH website, there is no way to tell who may be sensitive to an SSRI’s positive or adverse effects; some people may show marked improvement, some may see no change, and some may be vulnerable to adverse effects. An individual patient’s response to medication cannot be predicted with certainty from the kind of studies that have been done thus far. It is extremely difficult to prove whether SSRIs increase the risk of suicide, especially since suicide is already a significant risk in those who are depressed. Each child should be carefully and thoroughly evaluated by a physician to determine if medication is appropriate.3

Adults

Research on depression in the general population suggests that a combination of cognitive behavioral counseling and medication provides the best symptom relief, with many people being able to discontinue the medication at the conclusion of treatment.4 Several types of antidepressant medications used to treat depressive disorders include SSRIs, tricyclics, and monoamine oxidase inhibitors (MAOIs). Concerning people with disabilities, two studies have found sertraline, one type of SSRI, to be effective in the treatment of major depression in individuals with rheumatoid arthritis and of depressive symptoms in individuals with schizophrenia.5 6 Sertraline is only one of many medications that can be used, however. In terms of other treatments, one literature search revealed 16 case reports that suggest that electroconvulsive therapy (ECT) is both as effective and safe with mentally retarded persons as in the general population for treating affective disorders such as major depressive disorder.7 It is important to note that each individual case is different, and treatment decisions should be made with the help of a qualified physician, based on the individual’s particular diagnosis and severity of symptoms.

The Elderly

One study of a large and diverse population of older adults with arthritis (mostly osteoarthritis) and co-morbid depression involved treatment with antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). Not only was the treatment effective in reducing depressive symptoms, but it also decreased pain and improved functional status and quality of life.8 Another study of elderly patients with major depressive disorder and vascular morbidity, diabetes mellitus or arthritis found setraline to be an effective treatment.9

Alternate Interventions

These alternate interventions for adults and the elderly are mentioned with caution, since they are based on a small number of studies. While they are interesting to note, it is highly recommended that any of these interventions be discussed with one’s physician before implementing them. As well, they may only help in relieving depressive symptoms, but not major depressive disorder. Some studies have examined a link between depression and vitamin B deficiency. Two studies involving 151 patients with a diagnosis of depressive disorder assessed the use of folate in addition to other treatment.10 The studies found that adding folate reduced Hamilton Depression Rating Scale scores on average by a further 2.65 points, which suggests that folate may have potential benefit in supplementing other treatment for depression. However, it is unclear if this is the case both for individuals with normal folate levels, as well as those with folate deficiency.

There are treatment strategies other than medication and vitamins for dealing with depression. One study reviewed and described packaged (ready-to-use) arthritis self-management education and exercise/physical activity programs for individuals with arthritis and other rheumatic conditions. Several of the nine intervention programs (five self-management education programs, and four exercise/physical activity programs) helped participants.11 Another study examined and compared the effect of aerobic and resistance exercise on emotional and physical functioning among older persons with initially high or low depressive symptomatology. This study was a trial of 439 persons 60 years or older with knee osteoarthritis randomized to health education (control), resistance exercise, or aerobic exercise groups. When depressive symptoms and physical function (disability, walking speed, and pain) were assessed at baseline and after 3, 9, and 18 months, it was found that aerobic exercise significantly lowered depressive symptoms over time, compared to results for the control group. No such effect was observed for resistance exercise. The reduction in depressive symptoms with aerobic exercise was found both among the 98 participants with initially high depressive symptomatology and among the 340 participants with initially low depressive symptomatology.12

A third study involved people with disabilities due to idiopathic Parkinson’s disease who received lessons in the Alexander Technique, which is a way to understand coordination using one’s body and mind together, practiced by freeing posture and removing unnecessary tension. The group receiving 24 Alexander Technique lessons was comparatively less depressed post-intervention.13

Conclusion

Due to the high prevalence of depressive symptoms and major depressive disorder among people with disabilities, it is important to study effective ways of treating it in this population and to ensure access to treatment. Further studies of depression and individuals with different disabilities will add to understanding and lead to the effective treatment and improved quality of life of these individuals.

Endnotes

1 National Institute of Mental Health (NIMH) Antidepressant medications for children: information for parents and caregivers 2004 Apr 23.http://www.nimh.nih.gov/press/StmntAntidepmeds.cfm

2 FDA Talk Paper T04-08: FDA issues public health advisory on cautions for use of antidepressants in adults and children. 2004 March 22. FDA Talk Paper T03-70: FDA issues public health advisory entitled: reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder (MDD) 2003 October 27. FDA Talk PaperT03-43: FDA Statement regarding the anti-depressant Paxil for pediatric population 2003 June 19. http://www.fda.gov

3 National Institute of Mental Health (NIMH) Antidepressant medications for children: information for parents and caregivers 2004 Apr 23.http://www.nimh.nih.gov/press/StmntAntidepmeds.cfm

4 Blatt S, Zuroff D, Bondi C, Sanislow C. Short- and long-term effects of medication and psychotherapy in the brief treatment of depression: Further analyses of data from the NIMH TDCRP. Psychotherapy Research Vol 10(2) (Sum 2000): 215-234. Yale U, New Haven, CT, US.

5 Slaughter JR, Parker JC, Martens MP, Smarr KL, Hewett JE. Clinical outcomes following a trials of sertraline in rheumatoid arthritis. Psychosomatics. 2002 Jan-Feb;43(1):36-41. Department of Psychiatry and Neurology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA.

6 Mulholland C, Lynch G, King DJ, Cooper SJ. A double-blind, placebo-controlled trial of sertraline for depressive symptoms in patients with stable, chronic schizophrenia. J Psychopharmacol. 2003 Mar;17(1):107-12. Department of Mental Health, Queen’s University Belfast, Belfast, UK.

7 Kessler RJ. Electroconvulsive therapy for affective disorders in persons with mental retardation. Psychiatr Q. 2004 Spring;75(1):99-104. Adults and Children with Learning and Developmental Disabilities, Bethpage, New York, USA. kesslerr@acldd.org

8 Lin EH, Katon W, Von Korff M, Tang L, Williams JW Jr, Kroenke K, Hunkeler E, Harpole L, Hegel M, Arean P, Hoffing M, Della Penna R, Langston C, Unutzer J; IMPACT Investigators Effect of improving depression care on pain and functional outcomes among older adults with arthritis; a randomized controlled trial. JAMA. 2003 Nov 12;290(18):2428-9, Comment on:JAMA. 2003 Dec 3;290(21):2803, Center for Health Studies, Group Health Cooperative, Seattle, Wash 98101, USA. lin.e@ghc.org

9 Muijsers RB, Plosker GL, Noble S. Sertraline: a review of its use in the management of major depressive disorder in elderly patients. Spotlight on sertraline in the management of major depressive disorder in elderly patients. Drugs Aging. 2002;19(5):377-92. Adis International Limited, 41 Centorian Drive, PB 65901, Mairangi Bay, Auckland 10, New Zealand.demail@adis.co.nz

10 Taylor MJ, Carney S, Geddes J, Goodwin G. Folate for depressive disorders. Cochrane Database Syst Rev. 2003;(2):CD003390. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK, OX3 7JK. john.geddes@psych.ox.ac.uk

11 Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention programs for arthritis and other rheumatic diseases. Health Educ Behav. 2003 Feb;30(1):44-63. Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3724, USA. tob9@cdc.gov

12 Penninx BW, Rejeski WJ, Pandya J, Miller ME, Di Bari M, Applegate WB, Pahor M. Exercise and depressive symptoms: a comparison of aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology. J Gerontol B Psychol Sci Soc Sci. 2002 Mar;57(2):P124-32. Sticht Center on Aging, Department of Internal Medicine, Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.bpenninx@wfubmc.edu

13 Stallibrass C, Sissons P, Chalmers C. Randomized controlled trial of the Alexander technique for idiopathic Parkinson’s disease. Clin Rehabil. 2002 Nov;16(7):695-708. School of Integrated Medicine, University of Westminster, London, UK. stallic@wmin.ac.uk