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MasterClass: Treating major depressive disorder following
physical injury
Exploring strategies that help people become resilient and
manage depressive mood in people with injury and co-
morbidities such as chronic pain, fatigue and trauma
Dr Ashley Craig
Professor of Rehabilitation Studies
Kolling Institute of Medical Research
Sydney Medical School-Northern, The University of Sydney, NSW Australia
Senior Clinical Psychologist
1) To present a bio-psychosocial approach for treating depression
following traumatic physical injury
2) To present findings from recent research on prevalence of depression/
PTSD following physical injury in traumatic circumstances
3) To explore strategies that help people manage their depressive mood
and co-morbid problems like chronic pain and fatigue.
4) To illustrate the bio-psychosocial treatment for depression and
comorbid physical injury with case study examples
5) Questions and answers
Objectives
Biopsychosocial approach
Engel 1977
Integrates biological, psychological and social dimensions
important in the evolution of health outcomes
“The fate of integrated treatment: Whatever
happened to the biopsychosocial psychiatrist?” Glen O. Gabbard, M.D.
Jerald Kay, M.D.
Am J Psychiatry 2001; 158:1956–1963
Schotte, C.K., et al., (2006). A biopsychosocial model as a guide for
psychoeducation and treatment of depression. Depression and Anxiety, 23,
312-324.
1. Biological factors: age, sex, severity and type of injury,
chronic pain and fatigue, physical health, breath rate,
sleep, prior injuries, genetic predisposition, past and
current medications, recreational drug usage
1. Biological factors: age, sex, severity and type of injury, severity of
chronic pain and fatigue, physical health, breath rate, sleep, prior injuries,
genetic predisposition, past and current medications, recreational drug
usage
2. Psychological factors: style of thinking, coping skills,
cognitive capacity, emotional capacity and stability,
capacity to enjoy, pleasant life events activity, social and
relationship skills, assertiveness, prior psychological
morbidity
1. Biological factors: age, sex, severity and type of injury, severity of
chronic pain and fatigue, physical health, breath rate, sleep, prior injuries,
genetic predisposition, past and current medications, recreational drug
usage
2. Psychological factors: style of thinking, coping skills, cognitive
capacity, emotional capacity and stability, capacity to enjoy and pleasant
life events activity, social and relationship skills, assertiveness, prior
psychological morbidity
3. Social and environmental factors/triggers: traumatic
experiences, social support, social engagement, mobility,
compensation, financial status, employment status,
cultural and political factors
In my experience, a biopsychosocial approach has worked
best for me when treating/ managing depression in people
sustaining a physical injury (e.g. from a road crash, sporting
accident, or work related injury)
The benefits of this approach are:
(i) It provides a structure when confronted with complexity
(ii) It is flexible, allowing me to tackle different priorities at
different times (e.g. do I manage pain or mood first?)
(iii) The client becomes integral in the focus and direction of
the treatment
(iv) It encourages a multidisciplinary multifactorial approach
Before we discuss tips, let me introduce a handsome character
called Graham. He has physical features needed to survive a
motor vehicle crash
Graham was built by Patricia Piccinini, commissioned by TAC and in
conjunction with surgeon Dr Christian Kenfield and Monash University
Accident Research Centre crash investigator David Logan.
No neck, a helmet type head, with the same brain size, lots of liquid to
absorb the force.
His ribcage is fortified with organic airbags implanted
in between each rib.
What psychological features would he need?
Detecting psychological disorder in adults injured in a motor
vehicle crash who are engaged in compensation
Submitted paper
Rebecca Guesta, Yvonne Trana,b, Bamini Gopinatha, Ian D. Camerona, Ashley
Craiga
a John Walsh Centre for Rehabilitation Research, Sydney Medical School-Northern, The
University of Sydney, Kolling Institute of Medical Research, St Leonards, NSW
Australia. b Key University Centre for Health Technologies, University of Technology, Sydney,
Broadway, NSW, Australia
DSM-5 Diagnosis MDD
PTSD
Yes 58 (53.2%) 21 (19.3%)
No 51 (46.8%) 88 (80.7%)
Rates of major depressive disorder (MDD) and post-
traumatic stress disorder (PTSD) in participants who
have sustained mild to moderate physical injury and
in compensation using DSM-5 criteria.
The psychological impact of injuries sustained in
motor vehicle crashes: Systematic review and meta-
analysis
Craig, A., Tran, Y., Guest, R., Gopinath, B., Jagnoor, J., Bryant, R.A.,
Collie, A., Tate, T., Kenardy, J., Middleton, J.W., & Cameron, I.
BMJ Open 2016, 6, e011993. doi:10.1136/bmjopen-2016-011993
Whiplash/ whiplash associated disorder (WAD)
2,459 participants with WAD, with comparison to 61,037 controls
Large summary
effect size
Spinal cord injury
354 participants with SCI, with comparison to 231 able-bodied non-
MVC controls
Note the summary
effect size is
moderate to large
Tips and strategies that help people manage
their depressive mood and co-morbid problems
like chronic pain and fatigue
1. Remember you cannot help everyone
2. Be familiar with the peculiarities of the major
types of injuries such as TBI, SCI, musculoskeletal
injury (eg fractures, back injury, whiplash), and
burns, and the particular impairment and co-
morbidities arising from them
3. Know what medications they have been on and
are currently on. For me, it is critical I know this for
medications such as anti-convulsants (eg.Lyrica),
analgesics (like codeine or oxycodone, paracetamol),
and anti-inflammatories (like ibuprofen), hypnotics
and benzodiazapines, and so on. Have a drug guide
close by in the clinic.
Dworkin, R. H., et al. (2007). Pharmacologic management of neuropathic
pain: evidence-based recommendations. Pain, 132, 237-251.
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0013/231520/SC
IPAIN-Report-3-Dev-Sci-Pain-Navigator.pdf
4. Especially, know the anti-depressants and their
benefits/ side effects and especially those that have
independent pain beneficial effects (TCAs, SNRIs)
Marks, D.M., et al., (2009). Serotonin-norepinephrine reuptake inhibitors
for pain control: premise and promise. Current Neuropharmacology, 7,
331-336.
5. Educate about the nature of chronic pain: my clients are
often told it is all in their heads, and they become confused
or more depressed!
Louw, A., et al., (2011). The effect of neuroscience education on pain,
disability, anxiety, and stress in chronic musculoskeletal pain. Archives
Physical Medicine and Rehabilitation, 92, 2041-2056.
6. Chronic pain and depressive mood are highly associated
and self-efficacy mediates this relationship
Craig, A., et al., (2013). Developing a model of associations between
chronic pain, depressive mood, chronic fatigue and self-efficacy in
people with spinal cord injury. The Journal of Pain, 14, 911-920.
Craig, A., Tran, Y., Siddall, P., Wijesuriya, N., Lovas, L., Bartrop, R., & Middleton, J. (2013).
Developing a model of associations between chronic pain, depressive mood, chronic fatigue
and self-efficacy in people with spinal cord injury. The Journal of Pain, 14, 911-920.
-0.31 DEPRESSIVE
MOOD CHRONIC PAIN 0.50 TIME SINCE
INJURY
Chronic pain influences mood (and mood influences pain)
(Greater time since injury associated with lower pain)
-0.47
-0.31
-0.54
DEPRESSIVE
MOOD CHRONIC PAIN 0.32 TIME SINCE
INJURY
SELF-EFFICACY
Self-efficacy mediates/ buffers this effect of pain on mood
0.40
-0.47
-0.31
-0.54
0.52
DEPRESSIVE
MOOD CHRONIC PAIN 0.32 TIME SINCE
INJURY
SELF-EFFICACY
FATIGUE
However, self-efficacy has no influence on fatigue
Chronic pain and depressive mood related to higher fatigue (and vice versa)
7. Important to get the client to self-monitor over at
least one month
8. Treatment for depression in the physically injured
must target fear of pain and pain catastrophizing
Zale, E.L., & Ditre, J.W. (2015). Pain-related fear, disability, and the
fear-avoidance model of chronic pain. Current Opinion in Psychology,
5, 24-30.
Craig, A., Guest, R., et al., (2017). Pain catastrophizing and negative
mood states following spinal cord injury: transitioning from inpatient
rehabilitation into the community. The Journal of Pain, 18, 800-810.
9. Focus early on improving foundations of physical/mental
health: sleep, diet, physical activity, social support/engagement.
However, it may be harmful to just focus on healthy lifestyle
strategies (eg sleep, exercise, lose weight), as this may increase
chances of chronic depression
Psychological Distress Following a Motor Vehicle Crash:
Feasibility and Preliminary Results of a RCT Investigating Brief
Psychological Interventions
Submitted paper
Guest, R., Tran, Y., Gopinath, B., Cameron, I., Craig, A.
Traumatic distress/ depressive mood for those with diagnosis of MDD.
10. I believe activity pacing is crucial for managing pain, but
also for depression and fatigue, though more research is
required
Gill, J.R. & Brown, C.A. (2009). A structured review of the evidence for
pacing as a chronic pain intervention. European Journal of Pain, 13, 214-
216.
11. It is necessary to address perceived blame, injustice and
anger, especially towards self, the other driver, the employer
(if losing employment) and/ or insurer
Guest, R., Tran, Y., Gopinath, B., Cameron, I., & Craig, A. (2017).
Psychological distress following a motor vehicle crash: evidence from a
state-wide retrospective study examining settlement times and costs of
compensation claims. BMJ Open. 7, e017515.
We showed in people with a psychological disorder injured in a road
crash, costs of claim increased substantially (over 5 times) and time to
settlement tripled
12. Slow breathing and mood
Breathing is an integral component of interoceptive processing,
that is, how we perceive feelings from our bodies that
determine our mood, sense of well‐being and emotions.
Changes in breathing rate can be both the consequence of an
increased level of anxiety or depressive mood
Breathing rate is a useful physiological marker of poor mood
and anxiety and pain, and I find teaching slow breathing is
essential
Paulus, M.P., 2013. The breathing conundrum—interoceptive sensitivity and
anxiety. Depression and anxiety, 30(4), pp.315-320.
Zautra, A.J., et al. (2010). The effects of slow breathing on affective responses to
pain stimuli: an experimental study. Pain, 149, 12-18.
13. We have shown enhancing self-efficacy is crucial for
recovery.
Begin with easier tasks they can master. The goal is to increase
self-efficacy throughout treatment so that by end of treatment
they have robust perceptions of control
14. Help to resolve major problems such as financial
difficulties, family relationships, re-employment choices
Thank you