O - EMOTIONAL WELL-BEING
O.1.1
Integrate mental health professionals with education, training, and experience in SCI, as well as in general mental health and substance use disorders (SUDs) within comprehensive inpatient and outpatient SCI rehabilitation programs. (PVA-EWB 2020, p.160; Level C)
O.1.2
Routinely screen all individuals with SCI for mental health disorders, SUDs, and suicide risk as part of inpatient and outpatient rehabilitation. (PVA-EWB 2020, p.160; Level C)
O.1.3
Include current symptoms and lifetime history in screening and assessment of mental health disorders and SUDs. (PVA-EWB 2020, p.160; Level C)
O.1.4
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. (PVA-EWB 2020, p.160; Level C)
O.1.5
Engage individuals with a mental health disorder or SUD in shared decision-making for their treatment. (PVA-EWB 2020, p.160; Level C)
O.1.6
Systematically evaluate valid and standardized measures of progress to inform care and adjust treatment (measurement-based care) for mental health disorders or SUDs. (PVA-EWB 2020, p.160; Level C)
O.1.7
Refer to follow-up treatment and coordinate care upon discharge or transition to the next phase of care, if indicated. (PVA-EWB 2020, p.160; Level C)
O.1.8
Clinicians should consider referring individuals with SCI to peer support networks or to outpatient psychological consultations prior to discharge. Small group cognitive behavioural therapy-based treatment programs should be used to decrease depressive symptoms following SCI. (CAN-SCIP 2020, p.160; Level C)
O.2.1
Use a brief, valid measure that has good sensitivity to screen all patients for general anxiety and panic disorders:
- early during the initial inpatient hospital or rehabilitation stay
- as a repeat screen if indicated to assess persistence of symptoms or change in status
- at the first post-discharge follow-up point
- at future time points, depending on risk stratification factors such as prior positive anxiety screening results or preinjury history of psychological disorder.
O.2.2
Refer patients with positive screen results or those suspected of having an anxiety disorder to a mental health provider for a diagnostic assessment to assess for conditions such as generalized anxiety disorder or panic disorder. Rule out the possibility that the symptoms are better explained by the effects of the medical condition, medications, drugs, the environment, or other factors. (PVA-EWB 2020, p.160; Level C)
O.2.3
To minimize anxiety, support anxious patients with specific and nonspecific therapeutic strategies provided by all health care professionals (physicians, nurses, therapists, psychologists, social workers, and others) who work with them. (PVA-EWB 2020, p.160; Level C)
O.2.4
Treat generalized anxiety disorder, panic disorder, or other clinically significant anxiety by using pharmacological and/or nonpharmacological interventions on the basis of salient clinical considerations and patient preferences. (PVA-EWB 2020, p.160; Level C)
O.2.5
Consider pharmacological treatment for anxiety, if indicated. (PVA-EWB 2020, p.161; Level C)
O.2.6
Consider nonpharmacological treatment for anxiety. (PVA-EWB 2020, p.161; Level C)
O.3.1
Screen all individuals with SCI for major depression by using a brief, valid measure that has good sensitivity and specificity:
- early during the initial inpatient hospital or rehabilitation stay
- as a repeat screen if indicated to assess persistence of symptoms or change in status
- at the first discharge follow-up point
- at least annually or more frequently, depending on risk stratification factors such as prior positive screening results and chronic pain.
O.3.2
Refer patients with positive screen results or those suspected of having a depressive disorder to a mental health provider for diagnostic assessment and treatment. (Adapted from PVA-EWB 2020, p.161; Level C)
O.3.3
Follow up on positive screening test results by using a valid diagnostic assessment to confirm conditions such as major depressive disorder or adjustment disorder (including sufficient persistence of symptoms and interference with rehabilitation or role functioning) and rule out the possibility that the symptoms are better explained by the effects of the medical condition, medications, drugs, the environment, or other factors. (PVA-EWB 2020, p.161; Level C)
O.3.4
Follow up on positive screening test results by using a valid diagnostic assessment to confirm conditions such as major depressive disorder or adjustment disorder (including sufficient persistence of symptoms and interference with rehabilitation or role functioning) and rule out the possibility that the symptoms are better explained by the effects of the medical condition, medications, drugs, the environment, or other factors. (PVA-EWB 2020, p.161; Level C)
O.3.5
Treat major depression by using pharmacological and/or nonpharmacological approaches on the basis of clinical presentation (e.g., comorbid conditions), treatment efficacy, and patient preferences. (PVA-EWB 2020, p.161; Level A)
O.3.6
Consider pharmacological treatments for major depression. (PVA-EWB 2020, p.161; Level A)
O.3.7
Consider nonpharmacological treatments for major depression. (PVA-EWB 2020, p.161; Level A)
O.3.8
Clinicians should consider prescribing cognitive behavioural therapy as a treatment option for individuals with SCI and caregivers to reduce depressive symptoms. (CAN-SCIP 2020; Level A)
O.4.1
Screen all patients for common substance use disorders:
- Before discharge into the community, use a brief, valid measure that has good sensitivity to screen for lifetime use of and problems with alcohol, other (illicit) drugs, tobacco, marijuana, and nonmedical use of prescription medications
- depending on initial screening results and other risk factors, rescreen patients for recent substance use in outpatient rehabilitation or primary care.
O.4.2
Refer patients with positive screen results or those suspected of having a substance use disorder to a mental health provider for a diagnostic assessment and treatment of substance use disorder criteria. (Adapted from PVA-EWB 2020, p.161; Level C)
O.4.3
Support patients with substance use disorder with nonspecific and substance use disorder -specific relationship skills, used by all health care professionals (physicians, nurses, therapists, psychologists, social workers, and others) who work with them. (PVA-EWB 2020, p.161; Level C)
O.4.4
Treat substance use disorders within rehabilitation to the extent possible by using pharmacological, nonpharmacological, and community-based approaches on the basis of clinical presentation (e.g., comorbid conditions), length of stay, treatment efficacy, and patient preferences. (PVA-EWB 2020, p.161; Level C)
O.4.5
Use medication-assisted treatment for substance use disorders, including opioid use disorders and alcohol use disorders, when indicated. (PVA-EWB 2020, p.162; Level C)
O.4.6
Consider nonpharmacological treatments for substance use disorders. (PVA-EWB 2020, p.162; Level C)
O.4.7
Consider referral to community-based substance use disorder treatment programs and self-help resources. (PVA-EWB 2020, p.162; Level C)
O.5.1
Screen all patients for ASD within 1 month of SCI and for PTSD after the first month. Screening should occur:
- early during an initial inpatient hospital or rehabilitation stay
- as a repeat screen if indicated to assess persistence of symptoms or change in status
- at the first post-discharge follow-up point
- at future time points beyond 6 months, depending on risk stratification factors, such as being a veteran or other trauma-exposed professional or having subthreshold symptom severity on prior screening examinations.
O.5.2
Refer patients with positive screen results or those suspected of having ASD or PTSD to a mental health provider for a diagnostic assessment of ASD or PTSD criteria. (PVA-EWB 2020, p.162; Level C)
O.5.3
Support patients with PTSD with nonspecific and PTSD-specific relationship skills used by all health care professionals (physicians, nurses, therapists, psychologists, social workers, and others) who work with them. (PVA-EWB 2020, p.162; Level C)
O.5.4
Treat ASD and PTSD within rehabilitation to the extent possible by using pharmacological and nonpharmacological approaches on the basis of treatment efficacy, clinical presentation (e.g., comorbid conditions), length of stay, and patient preferences. (PVA-EWB 2020, p.162; Level C)
O.5.5
Offer patients with brief, evidence-based psychological interventions to treat ASD and prevent PTSD within the first month after injury. (PVA-EWB 2020, p.162; Level C)
O.5.6
Offer patients with PTSD evidence-based, trauma-focused psychological treatment. (PVA-EWB 2020, p.162; Level C)
O.5.7
Offer patients with ASD pharmacological treatment if trauma-focused psychotherapies are not available or not preferred. (PVA-EWB 2020, p.162; Level C)
O.5.8
Offer patients with PTSD pharmacological treatment if trauma-focused psychotherapies are not available or not preferred. (PVA-EWB 2020, p.162; Level C)
O.6.1
Formally screen individuals with SCI for suicidal ideation by using a brief, standardized, evidence-based screening tool. Screen for suicidal intent and behaviour in individuals who report suicidal ideation. Screen:
- early during the initial inpatient hospital or rehabilitation stay
- as a repeat screen if indicated to assess persistence of symptoms or change in status
- at an early discharge follow-up point, and
- at least annually or more frequently depending on risk stratification factors.
O.6.2
Recognize warning signs for suicide and expedite the evaluation of such signs by a trained professional. Take immediate follow-up action for anyone who displays direct warning signs for suicide (e.g., suicidal communication, preparation for suicide, and/or seeking access to or recent use of lethal means). (PVA-EWB 2020, p.162; Level C)
O.6.3
Stratify suicide risk on the basis of severity and temporality (acute or chronic) to determine appropriate therapeutic interventions and care setting. (PVA-EWB 2020, p.163; Level C)
O.6.4
Facilitate comprehensive assessment by a trained professional to integrate information about suicidal intent and behaviour, warning signs, ability to maintain safety, and factors that impact the risk of suicidal acts. (PVA-EWB 2020, p.163; Level C)
O.6.5
Hospitalize individuals with high acute risk for suicide to maintain their safety and aggressively target modifiable factors. Directly observe them in a secure environment with limited access to lethal means (e.g., kept away from items with sharp points or edges, cords/tubing, toxic substances). (PVA-EWB 2020, p.163; Level C)
O.6.6
Address chronic increased risk for suicide in the context of long-term outpatient therapy with established providers, adjusting the frequency of contact on the basis of risk level. (PVA-EWB 2020, p.163; Level C)
O.6.7
Establish a treatment plan for high-risk individuals that fosters therapeutic alliance with mental health professionals and includes evidence-based suicide-focused psychotherapies. (PVA-EWB 2020, p.163; Level C)
O.6.8
Optimize treatment for coexisting mental health and medical conditions that may impact the risk of suicide. (PVA-EWB 2020, p.163; Level C)
O.6.9
Educate the at-risk individual, family, and caregivers about suicide risk and treatment options. Provide information on suicide prevention resources, including crisis lines and services (e.g., the Canada Suicide Prevention Service number 1-833-456-4566). (Adapted from PVA-EWB 2020, p.163; Level C)
O.6.10
Establish a safety plan for individuals considered to be at high risk for suicide. Limit access to lethal means (e.g., restricting access to firearms, making use of gun locks, limiting medication supply). (PVA-EWB 2020, p.163; Level C)
O.6.11
Augment personal and environmental protective factors that may mitigate suicide risk. Enhance coping skills. (PVA-EWB 2020, p.163; Level C)