Guidelines for spinal cord injuries don't go far enough

New clinical practice guidelines recommend that primary-care physicians routinely screen patients with spinal cord injuries for depression and refer patients to mental health professionals for treatment when necessary. But some psychologists say the guidelines don't go far enough in outlining the efficacy of psychological interventions in treating patients with spinal-cord injuries.

The 18-member Consortium for Spinal Cord Medicine, whose members include APA, the American Spinal Injury Association and the Paralyzed Veterans of America, developed the guidelines. While the guidelines recognize that assessing, diagnosing and treating depression in people with spinal-cord injuries is often complicated by biological, psychological and social factors unique to their injuries, the value of psychotherapy isn't emphasized as clearly as that of medication.

The role of psychologists and psychotherapy is implied but not explicit, says Timothy Elliott, PhD, an APA member who was involved in initial discussions about the guidelines.

Primary-care physicians, for instance, are encouraged to assess psychological factors that may contribute to depression. This includes looking at patients' coping styles, whether they blame themselves for their injuries, any unresolved conflicts from previous traumas, any pre-injury psychological impairments, patients' cognitive styles, and grief caused by the injury.

But the guidelines don't list specific psychosocial interventions for treating depression. Instead, they provide detailed information about antidepressants and their recommended dosages. Although, says Elliott, there have been several empirical studies about the efficacy of psychological interventions for patients with spinal cord injuries, there have been no empirical studies on the use of antidepressants for patients with spinal cord injuries.

"While the sophisticated reader would see the need for psychological services to treat people with spinal cord injury and depression, many primary-care physicians might just prescribe medication and not refer the patient to a mental health professional, leaving out an important psychosocial aspect of treatment," says Elliott, associate professor and psychologist in the department of physical medicine and rehabilitation at the University of Alabama at Birmingham.

The guidelines, he says, could have a greater effect on public policy and program decisions because they were also sent to health-care service providers, HMOs and insurance companies. These groups could use the guidelines to determine what treatments insurance should pay for and what would be considered reasonable care, says Elliott.

--L. Rabasca



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