Whether clinically depressed or temporarily depressed due to certain occurrences in their life, patients can regress or make poor progress in therapy. Depression can cloud a patient’s mind, interrupt their flow of thinking, and leave them feeling discouraged, confused, indecisive, irresponsible or ill-equipped to care even for their own children.

Depression affects every aspect of life. Patients often lack the physical vigor to proceed in therapy or fail to participate adequately in conversations. When asked “what’s the matter?”, they will likely find themselves unable to articulate their feelings, and say they do not understand why they are feeling this way. They may appear inattentive to their surroundings or slow to respond to verbal prompts, as well.

Many patients describe depression as living in a black hole or a feeling that there is no “light” at the end of the proverbial tunnel. It is the hopeless feeling that a person is held captive within a mental prison controlled by their negative thoughts – forever destined to be in a constant state of despair.

In healthcare, professionals often encounter patients with similar signs of depression – especially following a life-threatening diagnosis, a traumatic event, or a severe injury. It’s important to remember that pain and disappointments in life often breed depressive thoughts and can elicit a physical response.

Consider the Approach

In the therapeutic setting, it’s not uncommon for a patient to feel sad from time to time; they may be experiencing excessive amounts of pain, stress, disappointment, and frustration. Therefore, therapists must learn to identify the signs and symptoms of depression and confront the issue with patience.

“Many times pain, or the perception of pain, is a combination of actual painful processes, such as injury or trauma, and [also] how the brain processes this information,” says Michael C. Orefice, DC, LAc, from the Milford, Conn.-based Active Health & Wellness Center, LLC.

For example, one source of pain that is more physical in nature is an ankle sprain. Orefice suggests that the perceived pain is mostly from damaged tissue; however, there is also an emotional effect, caused from the patient being inconvenienced by the injury.

On the other end of the spectrum, Orefice says, a person suffering from fibromyalgia is going to have a larger emotional component. The injury experienced is severe to the patient but not as clearly clinically defined as a sprained ankle. A patient with these types of injuries or syndromes often suffers from increased stress and altered hormonal levels (e.g. increase in cortisol) – factors commonly seen in depressed patients.
 
“When treating patients on the acute injury spectrum, I focus more on determining why the injury occurred in the first place, and then reducing the level of pain. I use a combination of ‘medical acupuncture’ to regulate or reduce pain, ‘active release techniques’ to work on muscles tendons and ligaments to regain proper range of motion, and joint manipulation to restore function and motion to an involved joint. The focus of treatment is mainly on the local area of injury or trauma,” says Orefice.
 
When treating patients with depression or a similar emotional component, healthcare professionals need to determine what factors are causing the patient to experience this suffering. Orefice says that educating patients about their conditions and involving them in their treatment decisions is self-rewarding for them and can be very beneficial in the rehabilitation process.

Despite the underlying cause of the patients’ physical pain, it must be addressed properly. Physical pain can perpetuate emotional pain or an overwhelming state of depression. Signs of discontentment, hopelessness, and/or sadness can alter patient outcome in therapy if overlooked or not addressed properly.

Communication is Key

In regard to attitude, some people have a naturally sad or negative disposition, but there are times when a typically happy or positive patient can take a downward spiral during therapy and refuse to cooperate. This is one reason why patient assessments are crucial to therapists; they help them remain attentive to the ebb and flow of each individual’s attitude as a number of patients come in and out of therapy.

A large number of patients with a variety of physical ailments come to the Allentown, Pa.-based Good Shepherd Rehabilitation Network’s (GSRN) on a daily basis. Among 15 outpatient sites, GSRN therapists work to rehabilitate individuals who may have suffered a traumatic brain injury, stroke, or other type of physical injuries demanding medical attention.

When a patient comes in for a session with the GSRN therapists, clients are asked a number of questions to assess their current condition. They may come to a therapist with more than just a physical issue; it could be an emotional issue, such as depression, which may be unrelated to the injury.

Sue Golden, PT, regional director of neurorehabilitation at Good Shepherd says that it is not uncommon for patients to come in for a physical therapy session while also suffering with emotional issues. “We conduct a thorough intake at admission, and we start each session asking them questions,” says Golden. “ ‘Is there any history of depression?’ ‘Are you taking medications?’ ‘Are you having any problems at home [or other]?’ Allow them to vent if they need to.”

Basically, she says, “We want to get them to open up and start talking. Through communication, asking them how they are feeling, taking vital signs or simply asking how their days has been, it opens the door to assess the patient’s overall health and status in the rehabilitation process. It’s also important to ask the same or similar questions in the next session, and follow-up with them in regards to what they may have said last time to see if there is anything that may seem suspiciously wrong or unusual.”

Depression can take a physical form. An individual may feel extra tired or lethargic, anxious, numb or uninterested in the subjects that once interested them. Other common symptoms include constant headaches, muscle pains, and an increase in blood pressure.

Golden says, that in her experience, she has observed that some depressed patients need to be approached differently. For instance, when a person is unwilling to participate or show any interest in physical therapy exercises, it may not be depression, but possibly a fleeting period of discouragement.

Depressed, discouraged, happy or sad, patients all need to be treated appropriately. Golden says that patients come to therapists for help, and that they simply need to see some signs of success or improvement from time to time.

“You have to know your patient in order to know how to approach them,” says Golden. “Some may need a push; others may need a listening ear.” But despite the patients’ need, it’s crucial that therapists are mindful of each patient and how to approach them. Talking with patients, getting to know the patient’s personality, interests, daily routines, sense of humor, and more, provides therapists with the understanding necessary to work effectively with them.

Food and Mood

Asking a person, “How are you doing?” opens the door to other factors influencing the person’s wellbeing and is another reason therapists need to check up on a client’s mood or emotional status. For instance, some helpful questions include: “How is life at home?” and “Have you been getting enough rest and eating right?” In response, a patient may offer information that will give the therapist insight as to how they should approach them. And, it may allow the patient to identify whatever it is that is negatively influencing their attitude and performance in a therapy session.

A person’s mental and physical wellbeing are dependent on a number of factors that can alter the effect or success in therapy. For example, a client comes in looking worn out, tired or sad. They are asked: “How is life at home?” They may explain that they are having trouble putting food on the table – thus, they are not receiving the proper nutrition, which could be why they’re irritable during therapy sessions. Proper nutrition can influence a person’s energy, stamina, muscle growth, concentration, and more.

Depression is also influenced by the foods people eat. The American Dietetic Association (ADA) says that food and body chemicals interact to keep humans going. When someone’s mood changes, so do their body chemicals. Basically, this means that how people feel can often be a result of what they eat; in turn, this also means that what they eat can also be due to how they feel.

There are more specific ways people can manage the foods they eat when their moods take a turn for the worse. For instance, recovering from an injury, the birth of a child, or experiencing a traumatic event or the death of a loved one can lead to an increase of stress in the body, resulting in mood swings. There are a number of reasons why depression affects each person’s appetite or body differently.

Bonnie Taub-Dix, MA, RD, CDN, a national spokesperson with the ADA, says one reason is that there is the connection between mood and food. Specializing in psychology and weightloss, Taub-Dix says depression is often apparent in a person’s appetite for food. In her experience as a registered dietitian, she has seen a commonality between depressed patients and their food intake. “Sometimes, people will temper their moods with the foods they eat [and/or] foods they don’t eat,” she adds.

“An extreme weight loss or weight gain can indicate an emotional problem. When people are depressed, they may increase their food intake or eat more inappropriate food – such as sugary foods, or foods higher in fat content,” says Taub-Dix. She recommends some patients keep a food diary. Each day, the patient enters what they ate, how much, and how they felt throughout the day. But, Taub-Dix says you have to get to know your client – if they dislike writing, it may not be a good idea for them.

However, maintaining a food diary really helps some depressed patients and allows them to see what, when or why they may be consuming certain foods. Then, they can determine how this plays into their body image. Although a definite link between food and mood exists, Taub-Dix says that the reverse is true: Food can affect mood. For instance, foods that increase a person’s seratonin level make them feel happy.

Stress often leads to a craving for carbohydrates because they boost serotonin, which has a calming effect. Choosing more complex carbohydrates, such as whole-grain products, beans, and vegetables, can help patients increase the nutritional content of their meals and snacks.

Afternoon lows are often a result of poor meal timing or food choices. Nutritionists encourage patients to space meals three to four hours apart and choose low-fat protein and complex carbohydrates for their meals. For instance, many women may notice more urges to eat chocolate when they are feeling down or during a physically demanding or stressful period – breaking up with a boyfriend, losing a job, suffering from premenstrual syndrome, and more.

Another stressful time for a woman is postpartum. Most people associate having a baby with a time of happiness, but this is not always the case for new moms.

Just for Moms

A new mom can feel overwhelmed, tired and run-down, thinking “I am not ready for this”. And, “if they are not eating right, these effects only increase,” says Taub-Dix. It is a physically and emotionally demanding time; a time when hormones fluctuate, schedules change – and motherhood can feel like a slap of reality. For instance, there is now a crying baby in the house who needs to be fed, washed, cleaned, and changed, whereas for 9 months, a mother heard nothing from the under the belly.

While her body is trying to recuperate, a woman may notice a sudden drop in energy or mood, which is somewhat normal, especially if she is trying to lose the baby weight. Some chalk up this stage as a case of the “baby blues”, but Taub-Dix says healthcare professionals need to assure new moms that every woman’s body handles the change differently. They could be feeling pressure to lose weight – which can significantly impact their mood – or not eating enough to sustain them.

Feelings of despair or sadness may come and go due to a number of factors far deeper than weight or food. If not careful, baby blues may extend into the first year. If the sadness persists beyond the changes made in one’s food, diet, and exercise routine, then it could be more serious than food or weight gain.

They may be suffering with postpartum depression (PPD), a form of depression that can vary in length and severity. If this is the case, an RD may need to not only assess their diet and make some changes, but also refer them to a clinical psychologist.

“A key for mothers to remember is to maintain proper nourishment,” says Taub-Dix. “Just as they did during pregnancy, women have to monitor their food intake – for their own benefit and the baby’s, especially if and when they are nursing.” Some women may find it extremely tough to function and take on the full responsibility of motherhood, and, as a result, forget to eat. Because of this, Taub-Dix stresses the importance of proper nourishment.

In addition, new mothers may partake in breastfeeding, holding a child for prolonged periods of time, new household chores, and more. This is a lifestyle change that may contribute to overuse injuries, muscle aches, pain, sprains, and strains.

“I treat many mothers who present with a variety of different conditions that are caused from normal activities of daily living due to children being present in their lives [for the first time],” says Orefice.

He believes that stress plays a role in the perception of pain, which can lead to depression. “I believe most new mothers would agree that after having children, their stress levels have certainly increased.”

“Of course,” he adds, “stress doesn’t always have to be bad stress but, either way, it takes a toll on the body. I would say constant stress over prolonged periods of time can contribute to depression. That being said, stress on the body – physically and mentally – can contribute to depression or even cause depression,” says Orefice.

Although Orefice mainly focuses on relieving physical pain to help with stress or emotional component, if the emotional pain seems severe or increases with time, he says he would refer the patient to also seek psychological treatment.


Depressed Parents and Injured Kids
 
Every woman reacts differently to stress – whether it’s beneficial or debilitating stress, she may feel as if she is on an emotional rollercoaster. New fathers also react in their own way. Men may not wear their emotions on their sleeve as much or as often as their female counterparts, but their feelings may manifest in their actions or lack of participation. And, this may also need to be addressed in therapy.

Because parents play an important role in caring for their child’s needs, they can feel responsible if a child experiences pain, injury or trauma. In turn, they can be a positive or negative influence, and slow down the progress their child could make during rehabilitation.

Brent Reitz, PT, vice president of pediatrics at GSRN, says that although he does not work directly with mothers like Orefice, he has observed depression among parents of injured children.

Reitz has worked with children of all ages, ranging from premature babies to 21 years of age who are suffering with various medical conditions – such as head injuries, cancer, and more. He says, “every mother reacts differently, [and] there are several major types of reactions. Depression is the most obvious.”

He says, “Many parents are angry at everyone – because the medical field is the first stop for these families and healthcare is difficult to navigate, they take out much of their anger on their providers. Another presentation is denial – many mothers will show an unending drive to cure the child. These parents will push and push during therapy to find the new miracle treatment that will cure their child – but that just doesn’t exist for many children.”

Or, in other words, a child’s parent/s can feel emotionally or physically afflicted during the course of treatment. Signs or symptoms of depression may not surface emotionally in the child undergoing therapy, but depression could be emotionally or physically evident in their parent/s.

“From a treatment standpoint, the key is patience,” says Reitz. “Every parent is different, and you truly need to work to understand each one’s individual needs.”

He continues, “for example, for the depressed mother who has [emotionally and mentally] detached from the child, the best way to go about it is to try to find a connection for that mother. A mother of a newborn baby with cerebral palsy (CP) may think that their dreams of a perfect child are gone. As a therapist, you need to help them understand what little successes mean to the future of the baby so that they can paint a new picture. Sometimes, it means setting them up with a mothers support group or ‘accidently’ running into a cute, little 6-year-old with CP who lets them see what their child can actually become.”

–– Haley K. Jestice is a staff writer for Therapy Times. Questions and comments can be directed to hjestice@therapytimes.com.