Depression can have a devastating effect on a person's daily life. It makes work difficult and strains relationships. For someone who has had a major illness or injury, it can be even more damaging. Depression can delay the healing process and hinder the patient's ability to move forward.

Body Image

One aspect of disease or injury that can cause a patient to become depressed is a change in appearance or body image. Many conditions lead to such changes, including traumatic injury, cancer treatment or the loss of a limb from diabetes. According to EJGH Social Worker Roxane Foto, patients who become depressed over a change in their appearance are often unable to progress and learn the skills they need to care for themselves. This is especially true, Roxane says, for patients who require a colostomy or urostomy after surgery for cancer, Crohn's disease or other disorders. These patients must learn how to use new medical equipment, spot signs of infection, and other skills related to self-care.

"Patients who are depressed are often unable help themselves," Roxane says.

Cancer treatment may also cause changes in appearance. Women with breast cancer may face mastectomy. Others may be forced to deal with the loss of a limb or other body part. Patients undergoing radiation or chemotherapy are subject to hair loss and skin changes. Combined with the fatigue and other symptoms associated with these treatments, patients who see something different in the mirror can easily become depressed.

According to Roxane, support groups can be very helpful for patients coping with these issues. Look Good... Feel Better, a group sponsored by the American Cancer Society, is a good example. Participants learn from volunteer cosmetologists how to minimize and cope with the appearance related side effects of radiation or chemotherapy. They use makeup, hats, scarves and wigs to help improve the women's appearance and sense of well being.

Changing Abilities

In addition to changing a person's appearance, major illness or trauma can change a patient's physical abilities. They may have to learn new ways of doing routine things, a challenge if depression has eroded their motivation.

Occupational Therapist Suzanne Levy says she often sees patients who are struggling with depression. Regardless of the nature of their disability - fracture, stroke or heart attack for example - their ability to succeed in rehabilitation is hindered by their state of mind. She says that depression affects more than just mood. Focus and memory also suffer, making it difficult to learn new skills.

The Inpatient Rehabilitation department uses weekly team meetings to help identify patients suffering from depression. These meetings include therapists, physicians, nurses and hospital chaplains, all of who see the patient in a different context. Together, they can develop a more accurate picture of the patient's emotional wellness. For patients showing signs of depression, the team will bring in a social worker to complete a detailed assessment. Depending on the results, medications or psychiatric counseling might be the next step.

In their daily sessions with patients, Suzanne says therapists try to engage patients to keep them motivated. They ask what the patient wants to accomplish in therapy and try to place goals in a context that is meaningful to the individual. She points to one of her patients who met his goal of progressing from walking with a walker to walking with a cane. It might not seem like a significant accomplishment to most of us, but to him it was a major victory. To him, the walker was a symbol of disability and dependence. With the cane, he felt more independent and found the motivation to continue with his therapy.
Therapists encourage their patients as much as possible, but Suzanne says they can only do so much. "The patient must have the desire within to get better," she says. "We can't make them participate in therapy."

It is especially difficult for patients who have suffered an unexpected injury or illness, such as a stroke, because they lose their abilities so quickly. For patients recovering from hip or knee replacement, the experience is often easier. Most of these patients have chosen to undergo the surgery and have received preoperative education through the EJGH Total Joint Program.

"It's definitely easier if the patient knows what the surgery and rehabilitation will be like," says Suzanne. "If they're informed and they're having the procedure by choice, it's a very different situation."

Suzanne says that when depression gets in the way of a patient's rehabilitation, it may affect the therapist, too. Therapists work so closely with their patients that they often can't help but feel some of the same frustration and despair. Many therapists find themselves thinking about their patients long after their shift has ended.

Loss of Independence

Many patients who have experienced sudden trauma or illness know that disability may cost them their independence. This can be a source of anxiety and fear, which gets in the way of successful rehabilitation. Patients often worry so much about who will take care of them that they can't focus on their rehab program. Their worst fears can come true if they can't progress to the point where living independently is safe. The rehab team is then left with no option other than to transfer the patient to an assisted living facility or nursing home.

While depression is a problem in patients of all ages, it is especially prevalent in seniors. Seniors are more likely to experience stroke or a debilitating hip fracture, which can take a huge toll both physically and emotionally. Studies show that patients with depression who have had a stroke are 3.5 times more likely to die than stroke patients who are not depressed.

According to Lorry Ridge, a social worker and community educator with the EJGH Geriatric Behavioral Health Unit, physical and mental health go hand in hand. Therapy and antidepressant medications have been shown to improve rehabilitation outcomes in depressed patients who have had a heart attack or stroke. It's important that caregivers recognize and address depression as soon as possible.

"If depression is fought on the front end, soon after the incident, there's a better chance that rehab will be successful" she says.

Lorry says depression is especially problematic for seniors because they are already experiencing changes in the brain that occur naturally with aging. Add a physical injury, and the potential for depression is intensified. Often the depression is situational, meaning it is tied directly to the illness or injury, and may not require anything more than support and counseling for treatment. In other cases, depression has deeper roots and may respond to medication.

Whatever the cause, Lorry stresses that depression is a serious issue for seniors. Left untreated, depression can lead to thoughts of suicide. Someone over the age of 65 succeeds in suicide every 90 minutes, or 16 deaths per day. Twenty percent of all suicide victims are seniors, but those 65 and over only account for twelve percent of the population.

What Can We Do?

If your friend or family member seems to be experiencing illness or injury-related depression, it is important to show as much support and encouragement as you can. The person has to want to succeed at recovery, but your encouragement can help them find that motivation. Make sure the patient knows that he or she is needed and that you want them to regain their physical health and continue to be a part of your life.

Simple Ways to Show You Care

It's important for a patient in rehabilitation to know they are not alone or forgotten. Isolation and boredom can quickly lead to depression. The following are some of the ways you can offer encouragement to a recovering loved one.

• Send flowers or gifts. A surprise gift makes anyone's day, especially if they're in the hospital. Talk to the patient's nurses to find out what types of gifts are most appropriate.
• Have grandchildren, nieces or nephews draw pictures or make cards. It's hard not to be cheered by a child's colorful creation.
• Make signs to hang in the patient's room. Something that says 'way to go,' 'great job,' or 'we love you' can help the patient find motivation.
• Send postcards or notes. Just a line or two will remind the patient that you are thinking about him.
• Bring photographs of family, friends or pets to display in the patient's room. If the person has a special keepsake, it might also help to make the patient's room more comfortable.
• Visit as often as you can. Ask the nurses on the unit when you can and should visit. If you can't get to the hospital, make a phone call.
• Bring the newspaper when you visit. Talk about what's happening on the news. Keeping up on current events can help the patient stay in touch with the outside world.
• Participate in family conferences and therapy observations. Your involvement in therapy will help the patient both physically and emotionally. This is especially important if you will be one of the patient's caregivers after discharge.
• Celebrate holidays. If the patient is hospitalized over a holiday or birthday, bring a small celebration to him.