Portal de Periódicos da CAPES

Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury

2021; Volume: 27; Issue: 2 Linguagem: Inglês

10.46292/sci2702-152

1945-5763

Charles H. Bombardier, Casey B. Azuero, Jesse R. Fann, Donald D. Kautz, J. Scott Richards, Sunil Sabharwal,

Health Policy Implementation Science

Suicide is at least 3 times more common in individuals with spinal cord injury (SCI) than in individuals without SCI, and anxiety and posttraumatic stress disorder (PTSD) are at least twice as prevalent. Substance use is also significantly more prevalent. However, even though individuals with SCI usually have contact with health care professionals, these mental health disorders are often not recognized and therefore often not addressed optimally, perhaps because of the other more obvious physical health impairments caused by SCI and the stigma that surrounds mental health disorders.This clinical practice guideline (CPG), which has been in development for over 15 years, is long overdue. Fortunately, however, during this time, progress has been made in recognizing the extent of the problem and beginning to evaluate potential treatments. This CPG has been rigorously developed with the thought that implementable things can be done to improve the recognition and treatment of mental health disorders, specifically depression and anxiety, PTSD, substance use disorders, and suicide prevention. It is anticipated that this important and practical work will educate clinicians about the scope of the problems and raise awareness about the availability of the means to accurately diagnose and treat these disorders.We are fortunate to have the representation of all the various stakeholders in the development and peer review of this CPG, including all of the subspecialists who are impacted by these recommendations, ranging from experts in psychiatry and psychology to rehabilitation professionals. We hope that this wide-ranging representation will translate into uniform quality practice through the widespread use of this CPG to guide the detection and treatment of mental health and substance use disorders in all settings, which can only result in the best outcomes and least amount of morbidity and mortality for individuals who experience SCI.On behalf of the consortium steering committee, I want first to acknowledge the leadership of the Chair, Charles Bombardier, in guiding this panel inexorably through the seemingly unending development process over the past decade. Next to be commended are the panel members themselves for keeping to task, even as many have retired along the way, and the many reviewers who provided valuable feedback from all areas. All these people, including the panel Chair, have volunteered their time to help produce this superb document. In addition, I wish to acknowledge the ongoing support of the Paralyzed Veterans of America, especially President David Zurfluh, Executive Director Carl Blake, and Director of Research and Education Cheryl Vines, as well as the rest of the leadership team without whose support these guidelines would not exist.Thomas BryceChairConsortium for Spinal Cord MedicineThis clinical practice guideline (CPG) has had a long gestation period. We owe a great debt of gratitude to those who long ago envisioned and nurtured the idea of a broad psychosocial CPG that would further define and elevate standards of care for individuals with spinal cord injury (SCI). In March 2003, Lester Butt, PhD, presented a 5-phase proposal to the Consortium for Spinal Cord Medicine (“the Consortium”) to develop a psychosocial CPG. The proposal called for the establishment of a psychosocial workgroup led by Dr. Butt and joined by Helen Bosshart, LCSW, ACSW; Bob Sontag, MSW; Hugh Taylor, MSW; Pat Tracy, MSW; Chuck Bombardier, PhD; Scott Richards, PhD; and Dan Rohe, PhD. Don Kewman, PhD, and Romel Mackelprang, DSW, were identified as topic champions for the CPG. Dr. Butt and colleagues constructed a compendium of psychosocial issues from which the CPG topics could be chosen. They next developed 2 parallel surveys to identify the most important topics for inclusion in the CPG from the perspectives of individuals with SCI, as well as SCI physicians, psychologists, and social workers. Results of that survey were bundled into a CPG proposal that incorporated psychosocial comorbidities (e.g., pain, substance abuse, traumatic brain injury, diagnoses listed in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]), health/wellness/quality of life (e.g., coping, sexuality, family, aging, compliance), community reintegration, psychosocial treatment approaches, summary, and future directions. The proposed content was recognized by the Consortium as identifying important aspects of psychosocial care for individuals with SCI; however, the comprehensive nature of the proposal was felt by the Consortium to be overly ambitious and consequently impractical, given available time and resources. In 2005, the Consortium unsuccessfully sought support from the Agency for Healthcare Research and Quality, Evidence-based Practice Centers, to complete the literature reviews and evidence grading for the psychosocial CPG. In 2008, Don Kewman, Lester Butt, and I met to discuss potential ways forward. During that meeting, we decided to take a “Swiss cheese” approach and identify smaller, doable, but still meaningful psychosocial domains that could be the subject of several separate CPGs. The topic of sexuality had already been selected as a stand-alone CPG topic. Ultimately, the group decided to focus the second psychosocial CPG on common disorders in the American Psychiatric Association DSM-IV that were prevalent in SCI: depression, anxiety/posttraumatic stress disorder (PTSD), and substance use. We reasoned that these conditions were not only prevalent, but they were clinically important, clearly defined, and the subject of considerable research that could inform care and could benefit from a guideline to elevate and enhance current standards of care. In about 2010, I took over the leadership of the revised CPG. The Consortium approved of the more narrowly focused CPG proposal, but other new and revised CPGs were already in the pipeline and so a start date was deferred. The Great Recession, limited resources, and more urgent emerging priorities delayed the commencement of this CPG until 2016. Still, the Paralyzed Veterans of America (PVA) and their CPG directors and managers proved their mettle by sustaining the CPG program through difficult times and kept their commitment to see this CPG through to completion.I am deeply grateful to the PVA for financial and institutional support. I am especially thankful for the PVA staff who have guided and enabled the development of this CPG over the years: Kim Nalle, Lana McKenzie, Christina Arenas, Caryn Cohen, Kera Lawson, Rita Obi, and Cheryl Vines, as well as PVA consultant J. Paul Thomas. Consortium chairs Larry Vogel and Tom Bryce have been ardent supporters of psychosocial research and this CPG. The methodology team at the Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, led by Shelly Selph, MD, MPH, along with Jessica Griffin, MS, and Ryan C. Stoner, PhD, produced an excellent systematic review of the literature and responded to comments and additional requests in a very collegial manner. I am also thankful for the Veterans Administration/Department of Defense guidelines on treating depression, substance use disorders, tobacco use, PTSD, acute stress disorder, and suicide management, which we have quoted heavily. These and other guidelines have formed the basis for many of the recommendations that we have provided where relevant information from individuals with SCI is lacking.I also want to recognize at least a few of the pioneering researchers who embraced an empirical approach to understanding psychosocial aspects of SCI: Fiona Judd, Roberta Trieschmann, J. Scott Richards, Robert Frank, Timothy Elliott, Ashley Craig, Paul Kennedy, James Krause, Bryan Kemp, and Denise Tate. These individuals and their colleagues modeled evidence-based approaches and produced an early foundation of empirical support on which to base assessment and treatment practices. They inspired me and the next generation of psychosocial researchers to build on what they had discovered. No CPG provides final answers. May this CPG point us toward a higher standard of care for now, eventually to be challenged, updated, and replaced with better information, more effective methods, and improved standards of care. This is what individuals living with SCI deserve from us.Charles H. Bombardier, PhDPanel ChairParalyzed Veterans is proud to sponsor the development and dissemination of the SCI CPGs. For over twenty five years we have partnered with the Consortium of Spinal Cord Medicine in a shared mission to improve the health of individuals living with SCI. Today, hundreds of thousands of copies of the guidelines are used around the world by physicians and other medical professionals who provide care to individuals living with SCI at every level, from the emergency department to acute care, rehabilitation to community services.We thank Dr. Bombardier for his leadership and perseverance in guiding this important new guideline into practice. Sincere thanks is also extended to each of the panel members who worked tirelessly, without remuneration, to bring this project to fruition. Dr. Thomas Bryce and the members of the SCI Consortium have provided vision, leadership and support bring this and many other clinical practice guidelines to completion. Their efforts and those of the field reviewers assure the high quality of the recommendations.As with any project of this magnitude, many were involved in the process. Sincere appreciation goes to Dr. Shelly Selph and her team at the Pacific Northwest Evidence-based Practice Center, Oregon Health and Science University, who conducted the review of literature and methodology for this guideline.Within Paralyzed Veterans, work on this guideline benefitted from the efforts of nearly every department. But special appreciation goes to our graphic designers Jonathan Franklin and Kevin Johnson.Finally, it is only with the significant, mission-driven support of Paralyzed Veterans, our leadership and our members, that we are able to provide these services. Sincere thanks to Paralyzed Veterans President David Zurfluh, Past President Al Kovach, Executive Director Carl Blake and Deputy Executive Director Shaun Castle for their support.The overall objective of this guideline is to improve the care of individuals with SCI by guiding clinicians and policy makers with its recommendations. The following recommendations use available evidence and—where evidence is limited—panel experience and consensus. The panel based its evidence ratings primarily on research in which the focus of the study was SCI. This information was supplemented by using evidence from trials, guidelines, and expert opinions contained in the scientific literature of non-SCI populations.For individual patients, decisions are best made by considering these recommendations combined with clinical judgment, the latter based on specific knowledge about each patient’s risk factors, the potential for adverse effects, and the availability of various options within one’s center. The bracketed rating refers to the level of scientific evidence, the strength of the evidence, and the level of panel agreement with the recommendations (Tables 2–4).This guideline is the second Consortium for Spinal Cord Medicine clinical practice guideline (CPG) on mental health. The first mental health guideline, published in 1998, focused exclusively on depression after SCI. We now know that a number of mental health disorders and SUDs are prevalent and contribute to additional suffering and disability in individuals with SCI.3 Therefore, this guideline focuses on recognition and treatment of the most common mental health conditions in SCI: depression, anxiety, PTSD, and SUDs. The guideline also includes specific sections on detection and management of suicide because of the elevated risk of completed suicide among individuals living with SCI.This CPG was designed for SCI rehabilitation professionals who are not mental health specialists a well as for those who are. Therefore, we need to begin with foundational concepts such as how mental health disorders and SUDs are defined. According to the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the 5th edition (DSM-5) published in 2013, mental illnesses are “health conditions involving changes in thinking, emotion or behavior (or a combination of these). Mental illnesses are associated with distress and/or problems functioning in social, work or family activities.”4 SUDs occur when the use of substances (e.g., alcohol, tobacco, cannabis, inhalants, stimulants, hallucinogens, and opioids) cause significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.4 In the DSM-5, mild, moderate, and severe SUDs replace the diagnoses of substance abuse and substance dependence found in the 4th edition of the DSM (DSM-IV).5Mental health and SUDs are common in the general population and even more so in individuals with SCI. Each year, 1 in 5 Americans is affected by mental illness and 1 in 12 by an SUD. There is evidence to suggest that individuals with SCI are at greater risk of mental illness and substance use. Estimates of depression in the first year after SCI range from 20% to 40%.3,6 Estimates range from 13% to 40%7–10 for anxiety disorders following SCI. Between 25% and 96% of individuals with SCI used alcohol prior to injury and 32% to 35% used illegal drugs.11 Suicide is the cause of SCI in 0% to 6.8% of cases and is reported to be the cause of death in 5.8% to 11% of decedents with SCI.12 Comorbid mental illnesses and SUDs aversely influence SCI-related symptoms such as pain, as well as functioning, level of independence, community participation, quality of life, and mortality.3 Yet, mental health and SUDs seem to be underrecognized and undertreated in individuals with SCI.13,14 Under-recognition may occur because SCI is a catastrophic injury that blurs the lines between normal emotional responses and mental health disorders. Undertreatment may stem from poor recognition, as well as a failure to use rehabilitation as a window of opportunity to intervene in mental health and SUD conditions. Treatment of mental illness and SUDs is becoming more integrated into regular medical15 and trauma care.16 This is a trend that should be followed in SCI rehabilitation because it can be more effective17 and consistent with mental health treatment preferences in individuals with SCI.18 Consequently, we hope that consumers of this guideline—professionals, students, individuals with SCI and their loved ones—find a document that answers practical questions regarding the prevalence and risk factors for these disorders, how to screen for and assess these conditions, and what can be done to treat mental illness and SUDs, especially within rehabilitation settings.This CPG does not address other psychological concepts such as adjustment, grief, resilience, coping, and so forth except to the extent that these variables are related to the included mental health conditions. While these other psychological factors may be important, they were judged to be too expansive and to lack consensus definitions to be included in this CPG.The Consortium is a collaboration of professional and consumer organizations funded and administered by the Paralyzed Veterans of America (PVA). The Steering Committee, administratively supported by the PVA’s Research and Education Department, is made up of 1 representative from each Consortium-member organization. The Consortium’s mission is to direct the development and dissemination of evidence-based CPGs and companion consumer guides. This mission is solely directed to improving the health care and quality of life for individuals with SCI.The development of these guidelines involved the following major steps: creating a list of formal questions to be addressed, systematic searches of published literature related to these questions, critical appraisal of the quality of the retrieved studies, abstraction of relevant study results, creation of evidence-based recommendations, writing and revising of various drafts of text that explain the recommendations, and multiple reviews by panel members and outside organizations. The Consortium’s CPG development process also involved extensive field review and a legal review.A medical librarian searched Ovid MEDLINE (through August 22, 2016), PsycINFO (through July, 2016), the Cochrane Central Register of Controlled Trials (through July, 2016), and the Cochrane Database of Systematic Reviews (through August 17, 2016) by using search terms related to chronic SCI. See Appendix A for complete search strategies. We also attempted to identify additional studies through hand searches of reference lists of included studies and reviews. All citations were imported into an electronic database (Endnote X7, Thomson Reuters).Selection of included studies was based on inclusion criteria created in consultation with the PVA. Two reviewers independently assessed titles and abstracts of citations identified through literature searches for inclusion by using the criteria below. Full-text articles of potentially relevant citations were retrieved and assessed for inclusion by both reviewers. Disagreements were resolved by consensus. Results published only in abstract form were not included because inadequate details were available for risk of bias assessment; we did consider for inclusion those abstracts that had additional information available in the form of slide sets from conference presentations, or those that provided supplemental data from published studies. When the data were sparse, we included studies conducted in countries that are less similar to the United States (e.g., Iran, Taiwan) and studies with smaller sample sizes (e.g., less than 100). See Appendix B for a list of included studies and Appendix C for a list of excluded studies.In consultation with the PVA, we formulated 8 key questions. Key questions and inclusion criteria are as follows.We abstracted information on population characteristics, interventions, subject enrollment, prevalence, results for efficacy, effectiveness, and harms outcomes for trials, observational studies, and systematic reviews. We recorded intent-to-treat results when reported. Data abstraction was performed by one reviewer and independently checked by a second reviewer. Differences were resolved by consensus.We assessed the internal validity (risk of bias) of randomized trials, observational studies, and systematic reviews by using predefined criteria. These criteria are based on the U.S. Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination (United Kingdom) criteria;19,20 the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines;21 and the Quality in Prognostic Studies (QUIPS) tool.22We rated the internal validity of each randomized trial on the basis of the methods used for randomization, allocation concealment, blinding, the similarity of compared groups at baseline, loss to follow-up, and the use of intent-to-treat analysis. Observational studies were rated on nonbiased selection, loss to follow-up, pre-specification of outcomes, well-described and adequate ascertainment techniques, statistical analysis of potential confounders, and adequate duration of follow-up. For studies of risk factors, we used the QUIPS tool.22 This tool includes domains on study participants, attrition, measurement of the prognostic factor, statistical adjustment for confounding factors, and appropriate statistical analysis. Systematic reviews were rated on clarity of the review question, specification of inclusion and exclusion criteria, use of multiple databases and search for grey literature, sufficient detail of included studies, adequate assessment of risk of bias of included studies, and adequate summarization of primary studies.Two reviewers independently assessed the risk of bias of each included study and differences were resolved by consensus. Studies were rated as “low risk of bias,” “medium risk of bias,” or “high risk of bias” from the presence and seriousness of methodological limitations. Risk of bias assessments for included studies are listed in Appendix D.Studies that had a significant or “fatal” flaw were rated as having a high risk of bias, studies that met all criteria were rated as a low risk of bias, and the remainder were rated as a medium risk of bias. As the medium risk of bias category is broad, studies with this rating vary in their strengths and weaknesses. The results of some studies rated as having a medium risk of bias are likely to be valid, while others are only possibly valid. A fatal flaw is reflected by the failure to meet combinations of items from the risk of bias criteria. An example would be a study with high attrition (e.g., 60%) combined with inadequate handling of missing data, or one in which details of randomization and/or allocation concealment were lacking and there were baseline differences in important prognostic characteristics.We graded the quality of evidence by using the GRADE approach.23–27 Developed to grade the overall quality of a body of evidence, this approach incorporates 4 key domains: risk of bias (includes study design and aggregate risk of bias), consistency, directness, and precision of the evidence. It also considers other optional domains that may be relevant for some scenarios, such as a dose-response association, plausible confounding that would decrease the observed effect, strength of association (magnitude of effect), and publication bias.Table 1 describes the grades of evidence that can be assigned. Grades reflect the quality of the body of evidence to answer key questions. Grades do not refer to the general efficacy or effectiveness of treatments, for example. Two reviewers independently assessed each domain for each outcome and differences were resolved by consensus.The quality of the body of evidence was evaluated for each outcome by key question.We constructed in-text tables that show the study characteristics, risk of bias ratings, and results for all included studies. We reviewed studies by using a hierarchy of evidence approach, in which the best evidence is the focus of our synthesis for each question, population, intervention, and outcome addressed. When possible, we pooled study results with meta-analyses by using Stata 14.28The search and selection of articles are summarized in the literature flow diagram (Figure 1). Database searches resulted in 2,927 potentially relevant articles. After dual review of abstracts and titles, 624 articles were selected for full-text dual review, and 127 studies were determined to meet inclusion criteria and were included in this review.1.1 Integrate mental health professionals with education, training, and experience in spinal cord injury (SCI), as well as in general mental health and substance use disorders (SUDs) within comprehensive inpatient and outpatient SCI rehabilitation programs.RationaleMental health disorders and SUDs are common comorbid conditions in individuals with SCI.10 These conditions can contribute to the overall suffering and disability of individuals with SCI,29,30 adversely affect outcomes,3,13,29–31 increase the costs and reduce the efficiency of rehabilitation,32,33 and lead to premature death.34 It is widely recognized that mental health disorders and SUDs are undertreated generally,35,36 including within SCI rehabilitation. For example, a minority of individuals with SCI are treated for major depression when it is present.13,14 To address mental health treatment disparities, health care organizations are adopting care models wherein screening, assessment, and treatment for mental health disorders and SUDs are integrated into regular health care settings. A good example is the United States Department of Veterans Affairs (VA) Primary Care-Mental Health Integration (PC-MHI) program that has demonstrated increased access to care for mental health disorders and SUDs.37 Integrated mental health and SCI rehabilitation care is already the standard in other countries.38 People with SCI can be affected by multiple interacting comorbid conditions (such as traumatic brain injury,39 substance use disorder, other mental health disorders,40 and chronic pain41) as well as distinct adjustment patterns42 and the need to adopt many new SCI-specific health behaviors. Therefore, we recommend that mental health providers have education, training and experience in SCI rehabilitation and in as many of these other areas as possible.431.2 Routinely screen all individuals with SCI for mental health disorders, SUDs, and suicide risk as part of inpatient and outpatient rehabilitation.RationaleScreening all patients for common comorbid mental health and substance use issues is justified by the prevalence and impact of these conditions in SCI and by the availability of validated brief screening instruments.10,29,30 Routine screening is also critical to the integration of behavioral health care into other medical care and to overcoming undertreatment.11 Widely adopted effective programs for mental health integration such as collaborative care rely on universal screening for target problems.44 This CPG focuses on depression, anxiety, PTSD, SUDs, and suicide because there is evidence that these conditions are prevalent and disabling in individuals with SCI. Each section provides more specific recommendations regarding the timing of screening, screening measures, and responses to positive screening test results.1.3 Include current symptoms and pre-injury history in screening and assessment of mental health disorders and SUDs.RationaleWe also recommend that screening include preinjury history of mental health and substance use problems because individuals with SCI have high rates of pre-injury mental health disorders and SUDs, and a history of these disorders is predictive of post-SCI mental health.10 These investigators found that the odds of having a psychological disorder after SCI were 24 times greater if the individual had been treated for a psychological disorder before the SCI.101.4 Refer individuals who screen positive for a mental health disorder or SUD to a mental health professional for a diagnostic assessment and initiation of treatment, if indicated.RationaleAs noted above, mental health disorders and SUDs are undertreated. A national survey showed that only 32.7% of individuals with mental health disorders or SUDs received adequate treatment, and of the individuals with a SUD, only 28.6% received adequate treatment.45 The VA’s PC-MHI program demonstrated that integrated care resulted in increased access to care37 and treatment initiation.46 In primary care, the collaborative care model of mental health integration led to more than double the percentage of patients who experienced at least a 50% reduction in depression severity compared with those who were treated with usual care (45% vs. 19%).47 A study of depression treatment preferences in SCI showed that patients tend to prefer depression treatment provided in medical or rehabilitation settings rather than in specialty mental health settings.18 A randomized controlled trial (RCT) of collaborative care for depression, pain, and physical inactivity in outpatients with SCI resulted in significantly improved pain interference and reduced depression severity, as well as increased treatment satisfaction among those who received collaborative care versus those who received usual care.481.5 Use principles of shared decision making to involve individuals with a mental health disorder or SUD in treatment planning.RationaleConsistent with the 2001 Institute of Medicine report, Crossing the Quality Chasm,49 clinicians are encouraged to inform their patients regarding treatment options, expected outcomes, and what treatment is available in order to facilitate informed choice and a collaborative decision-making process. These processes are thought to result in better treatment plans and greater patient engagement.491.6 Systematically use reliable and valid measures of progress to inform care and adjust treatment for mental health disorders or SUDs.RationaleThere is a growing body of evidence showing that using repeated outcome assessment and decision rules to adjust treatment improves clinical outcomes, aids recognition of clinical worsening, and highlights residual symptoms that can be a risk factor for relapse.50–52 This approach, called measurement based care (MBC), can also enhance the therapeutic relationship and boost patient adherence and recognition of progress, especially early in treatment.50–52 The Joint Commission recommends the MBC standard (CTS.03.01.09). The VA has invested in MBC by creating a behavioral assessment software program and committing to the adoption of MBC.501.7 Refer to follow-up treatment and coordinate care upon discharge or transition to the next phase of care, if indicated.RationaleMental health conditions and SUDs are often chronic, relapsing conditions that require prolonged treatment, relapse prevention efforts, and ongoing monitoring or rescreening.53,54 Consequently, it is vital to plan for continued treatment across transitions in care such as from inpatient rehabilitation to outpatient rehabilitation.Anxiety is a normal reaction to SCI, but anxiety can become overwhelming and interfere with daily functioning, consistent with anxiety disorders. Anxiety disorders are characterized by anticipation or worry about future threat and are typically accompanied by symptoms such as muscle tension, vigilance, and cautious or avoidant behaviors. These disorders are persistent (typically lasting 6 months or more); o