1

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