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Abstract

Introduction

This focused review reports on the impact of self-management interventions on depression in people with a mobility disability.

Method

There were two phases to the search including a comprehensive scoping review of the literature examining multiple secondary conditions impacted by self-management programs (Phase 1) and a focused review of the literature detailing the impact of self-management interventions on depression (Phase 2). CINAHL, PubMed, and PsyclNFO were searched for articles published between January 1988 through August 2014 and studies were screened by the first author based on specific inclusion and exclusion criteria.

Results

Twenty-five studies met criteria with results, demonstrating a mixed effect of self-management programs on depression. Sixteen studies included an intervention and control/comparison group, of which eight (50%) had a significant effect on depression. A further nine studies did not include a control/comparison group and five found significant changes in depression and four found no change. Eighteen out of 25 studies (72%) were rated as having moderate-to-high bias and nine different outcome measures were used across studies.

Discussion

Based on the mixed findings and varied approaches adopted for intervention and outcome assessment, future research should adopt a more rigorous methodological approach to examine self-management interventions on depression.

Keywords

disability health self-care scoping review focused review

Introduction

Due to the complexity of mobility impairments (eg, spinal cord injury [SCI] multiple sclerosis), there is a recognized need for increased self-management support to reduce secondary and chronic conditions,^1–3 as individuals often have to self-manage diverse aspects of their health and health care. The importance of self-management is emphasized by the fact that disability increases an individual's risk of experiencing secondary (eg, pressure ulcers, urinary tract infections, bowel management issues, pain, depression) and chronic conditions (eg, diabetes, heart disease), with evidence suggesting that the issue is the greatest among people with mobility impairment.⁴ These secondary and chronic conditions have been documented to have a significant impact on an individual's quality of life, morbidity, and mortality. Despite this, it is important to recognize that secondary and chronic conditions are preventable if individuals are able to appropriately self-manage their health and health care.⁵ Therefore, clinicians and researchers are challenged to find ways to positively impact the health promoting behaviors of people with mobility impairments.^6–8

One secondary condition that has a significant impact on the health and function of people with mobility impairment is depression. In the general population in the United States, there is a lifetime prevalence of major depressive disorder of 19.1%, although this is higher in people with mobility impairment. For example, the prevalence of depression in people with multiple sclerosis has been reported at 50%,⁹ and it is estimated that this rate is 40% in people with SCI during acute rehabilitation.¹⁰ The high prevalence of depression in people with mobility impairment is compounded by the negative impact on other areas of functioning. Specifically, depression has been linked with reduced functional improvements, decreased mobility, and lower functional independence in people with SCI completing inpatient rehabilitation¹¹ as well as poor treatment compliance in people with multiple sclerosis.¹² Fortunately, depression can be modified and prevented through the use of self-management programs.^13–16

Thus, the purpose of this study is to provide a focused review of the literature on self-management programs developed to prevent or manage depression in individuals with mobility impairment.

Methods

Procedure

There were two phases to the current review. During Phase 1, we completed a scoping review of the literature examining the impact of self-management programs on secondary conditions in people with mobility impairments. The population of interest included people with a congenital or acquired (ie, disease, injury) health condition that impaired mobility. Six of the most prevalent secondary conditions experienced by people with mobility impairment^17–19 were used as search terms and included chronic pain, chronic fatigue; depression/mental health, urinary tract infections, bowel/ bladder issues, and pressure ulcer/sore. Self-management interventions focused on positively impacting one of these six secondary conditions were included in the scoping review. Phase 2 involved completing a focused review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)²⁰ as a guide. Specific inclusion and exclusion criteria were developed and are described in Froehlich-Grobe, Driver, and Sanches.²¹

Literature search

CINAHL, PubMed, and PsyclNFO were searched using a truncated algorithm in September 2014, for papers published between January 1988 and August 2014. Keywords included disability (disability^*), physical disability (disability^*), mobility impairment, self-management, self-care, self-regulation, lifestyle, self-control, secondary conditions, urinary tract infection, bladder/bowel problems, pain, chronic pain, fatigue, depression, and mental health. The reference lists of identified literature were also manually searched. The results of Phase 1 and 2 are outlined in Figure 1 and the process of identifying appropriate articles is described in Froehlich-Grobe et al.²¹ Ultimately, 25 publications focused on the impact of self-management interventions on depression as the primary outcome. The first author then recorded key components of the literature into Table 1.

Figure 1

PRISMA flow diagram. Adapted from Moher et al.²⁰

Table 1

Summary of studies included in the systematic review that assessed mental health/depression.

STUDY	SETTING	PARTS	INTERVENTION	OUTCOME MEASURES	TIME TO FOLLOW-UP	RESULTS	CONTROL/ COMPARISON CONDITION
Baranoff et al³²	Single group pre/post test; clinic-based; Australia	CP n = 186 Age = 43.5	CBT multidisciplinary program with group-based classes and diverse instructors, including a psychologist, physiotherapist, pain physician, and nurse. Components included appropriate exercises and activities, fear avoidance, cognitive restricting, relaxation training, goal setting, and education regarding chronic pain. Dose: 3 weeks	Depression and Anxiety Stress Scale (DASS-21)	BL, 3 wk, 3.75 mo	Between Group N/A Within Group Medium effect on depression observed at 3 weeks Changes in select processes (catastrophizing, acceptance) sig predicted changes in depression and anxiety	N/A
Barlow & Barefoot²⁸	Quasi-experimental design; Community setting, UK	Ankylosing spondylitis n = 52 Age = 42.34	Self-management course, which consists of information on AS; exercises in a hydrotherapy pool and on land; posture in everyday activities; home checks for monitoring mobility; and exercise motivation sessions. Dose: 12 hours over 2 days	Center for Epidemiological Studies-Depression Scale (CES-D)	BL, 3 wk, 6 mo	Between Group Sig improvement in depression at 6 months Within Group Sig improvement in depression among treatment group at 3 weeks	Guidebook with information on AS and a home exercise program
Gatchel et al³¹	Single group pre/post test; Community setting, US	CP n = 65 Age = 54.9	Interdisciplinary pain treatment program including medical and medication management, physical therapy (6-12 sessions), group counseling (coping, stress, social support: 10 sessions), and individual psychological management (CBT, biofeedback, stress management–-10 to 16 sessions).	Beck Depression Inventory (BDI) General mental health: SF-36	Pre-post program	Between Group N/A Within Group Sig improvement in depression and general mental health	N/A
Haworth et al⁴⁵	RCT; Community setting, UK	Acquired neurological impairment n = 42 Age = 41.63	Group-based education and exercise program. Educational component (2 sessions) provided information about the benefits and barriers to exercise, and promoted confidence in ability to exercise; four sessions involved participation in circuit-based exercises. Dose: 8 sessions over 4 weeks	Hospital Anxiety and Depression Scale (HAD) U-WIST Mood Adjective Checklist	BL, 6 wk, 12 wk, 24 wk	Between Group Within Group N/A	Standard care
Hewlett et al²³	RCT; Community-based, UK	RA n = 127 Age = 59.71	CBT-based self-management course with focus on fatigue self-management, problem solving, goal setting, self-monitoring of activity/rest, and energy management. Dose: 6 2-hr sessions	Hospital Depression and Anxiety Scale (HADS) Arthritis Helplessness Index (AHI)	BL, 6 wk, 10 wk, 18 wk	Between Group Sig decrease in depression and helplessness Within Group N/A	1-hr session on fatigue self-management information
Jensen et al⁴⁰	Single group pre/post test; Community, US	CP n = 141 Age = 44.7	CBT multidisciplinary program, included sessions with physiotherapist, psychologist, pain physician, and nurse. Content based on CBT principles and consisted of exercises and activity; cognitive restructuring, relaxation training, goal setting and education regarding chronic pain. Dose: 5.5 days/week for 3 weeks	Center for Epidemiology Studies Depression scale (CES-D)	BL, 3 wk, 6 mo, 12 mo	Between Group N/A Within Group	N/A
Kroenke et al³⁶	RCT; Clinic-based, US	CP n = 250 Age = 55.5	Intervention consisted of 3 months antidepressant therapy; followed by 6 sessions of pain self-management program delivered every other week during second three months; final six months was a continuation phase focused on relapse prevention. Included 5 in-person contacts (at baseline, 6, 12, 16 and 20 weeks) and 8 telephone contacts (1, 3, 9, 14, 18, 22 weeks and at 8 and 10 mos)	Depression: Hopkins Symptom Checklist (HSCL-20) Occurrence of major depressive disorder Generalized Anxiety Disorder Scale (GAD-7)	BL, 3 mo, 6 mo, 12 mo	Between Group Sig improved depression measures and anxiety Within Group N/A	Usual care
LeFort et al³³	RCT; Community setting, Canada	CP n = 110 Age = 39.48	Group-based psychoeducational program with group problem solving, mutual support, various cognitive behavioral self-management techniques, a workbook and relaxation tape, and education about pain, nutrition and walking. Dose: 6 2-hr weekly sessions	Short version of Beck Depression Inventory (SF-BDI) Mental health: Medical Outcomes Study (SF-36)	BL, 12 wk		Wait listed
Lorig & Holman²⁴	RCT; Community setting, US	RA and OA and Other n = 543 Age = 64	Group 1 Arthritis Reinforcement Course (ARC): developing and endurance exercise program, cognitive pain management, communication skills, and nutrition. Dose: two-hour weekly sessions for 6 weeks Group 2 Newsletter: bi-monthly newsletter on arthritis reinforcement course	Short version Beck Depression Inventory	BL, 4 mo, 8 mo, 20 mo	Between Group Sig improvement In depression at 20 months in both groups Within Group	Usual care
Lorig et al²⁶	Study 1 RCT; Home-based, US Study 2 RCT; Community-based, US	Study 1 OA and RA n = 1090 Age = 62.2 Study 2 OA and RA n = 341 Age = 65.2	Study 1 Mail-delivered, tailored print intervention consisting of personal letter, summary report, and suggested plan of action. Repeated every 4 weeks for 12 months based on individualized questionnaire completed. Participants provided with a handbook, tailored letter with exercise and arthritis behavior information, and relaxation tape. Study 2 Interactive small group sessions with lay leaders; topics included knowledge about arthritis, nutrition and medications, skills for improving function and reducing pain, use of cognitive restructuring tequniques, physical activity, improving communication. Dose: 6 2-hr weekly sessions	Center for Epidemiology Studies Depression scale (CES-D)	BL, 1 yr, 2 yr, 3 yr	Study 1 Between Group Within Group N/A Study 2 Between Group Within Group N/A	Study 1 Usual Care Study 2 Mail-delivered intervention from Study 1
Lorig et al²⁵	RCT; Community setting, US	RA, OA, undiagnosed Arthritis n = 219 Age = 62.50	Intervention included education on how to access care, importance of exercise, self-management techniques, relaxation techniques, problem solving, healthy behaviors, and goal setting. Sessions included participation in group exercise. Dose: 6 2-hr weekly sessions	Center for Epidemiology Studies Depression scale (CES-D)	BL, 4 mo, 12 mo	Between Group Sig improvement in depression at 12-months Within Group N/A	Usual care
McCracken et al¹⁹	Quasi-experimental; Clinic-based, UK	CP n = 219 Age = 46.30	Context cognitive behavioral therapy-based pain management course designed to increase psychological flexibility; included daily exercise education, skills training, and psychological sessions. Incorporated exposure, acceptance, cognitive de-fusion, mindfulness, and value-based methods. Dose: ~80-hrs over 3 weeks	Pain Anxiety Symptom Scale (PASS) Beck Depression Inventory (BDI) Psychosocial disability: Sickness Impact Profile (SIP)	BL, 3 wk, 3 mo	Between Group Sig improvement in depression and pain anxiety Large effect sizes for psychosocial disability and depressions Within Group Sig improvement in depression, pain anxiety and psychosocial disability among treatment group at 3 weeks	Usual care
Nicholas et al³⁸	Single group with pre/post test; Clinic-based, Australia	CP n = 567 Age = 44.0	Interactive group sessions based on cognitive-behavioral principles; included a focus on teaching self-management strategies, activity pacing, thought challenging, desensitization, goal setting, and stretch exercises. Dose: 15 eight-hour sessions over three weeks	Depression Anxiety Stress Scale (DASS) Fear and avoidance: Tampa Scale for Kinesiophobia (TSK)	BL, 3 wk	Between Group N/A Within Group Sig improvements in depression and fear and avoidance measures Those performing more self-management strategies experienced greater effects on depression	N/A
Nicholas et al³⁷	RCT; Community setting, Australia	CP n = 140 Age = 42.88	CBT-based intervention with intraoperative exposure (deliberately experiencing pain to reduce fear): included education, self-monitoring of sensations, repeated deliberate exposure to the pain, and engaging in activities expected to aggravate pain. Dose: three weeks	Depression Anxiety Stress Scales (DASS)	BL, 3 wk, 1 mo, 6 mo, 12 m	Between Group Within Group Sig improvement in depression at 1 year for o both groups	CBT-based intervention coupled with distraction (avoiding the pain) component
Nielson & Jensen⁴¹	Single group with pre/post test; Community setting, US	F n = 198 Age = 46.4	Program aimed at improving pain management skills and physical and psychological functioning. Includes physical and occupational therapy, group CBT, reduction of pain behavior, assertiveness and relaxation training, and tapering of medications when indicated. Dose: 5 days/week, for 4 weeks	Irritability, anxiety and overall mood: WHYMPI Affective Distress subscale Depression: Chronic Pain Coping Inventory scales (CPCI) Emotion: SOPA subscale	BL, 4 wk, 4 mo, 6 mo	Between Group N/A Within Group Sig improvements in depression, affective distress and emotions	N/A
Niemisto et al³⁴	RCT; Clinic-based, Finland	CLBP n = 196 Age = 37.09	Intervention included evaluation, treatment and exercise sessions with a focus on manipulation with muscle-energy techniques and stabilizing exercises aiming to correct lumbopelvic rhythm, included an educational booklet. Dose: 4 1-hr sessions over 4 weeks	Finnish Depression Questionnaire (DEPS)	BL, 5 mo, 12 mo	Between Group Within Group N/A	Physician's consultation, educational booklet, instructions regarding posture and 3-4 exercises intended to improve function and strength
Perry et al¹⁸	Comparative parallel, cohort design; Community-based, Australia	SCI-related CP n = 36 Age = 44.13	CBT-based pain management program, included: relaxation and desensitization skills, goal setting, pacing, upgrading activities, cognitive restructuring, rationalization of meds, ex, stretch, communication, and relapse prevention. Dose: 10 sessions, 45 hours contact time	Hospital and Anxiety Depression scale (HADs) SF-12 Mental Component Scale (SF-12 MCS)	BL, 6 mo, 7 mo, 15 mo	Between Group Sig improvement in anxiety and SF-12 MCS Within Group Sig improvement in anxiety and SF-12 MCS in treatment group	Usual care
Peters & Large³⁹	RCT; Clinic-based, New Zealand	CP n = 68 Age = 43.9	Group 1 Inpatient treatment: education about pain, behavioral pain management strategies (relaxation, biofeedback), promotion of adaptive cognitions via cognitive restructuring, visualization and imagery techniques, exercise, vocational counseling, and medication management.	Depression: Beck Depression Inventory (BDI)	1 wk, 4 wk, 12 mo	Between Group Sig difference GHQ measures, with Group 1 showing the most improvement	Usual care
			Dose: Group 2 Outpatient treatment: education, practical advice on exercising and achieving goals, medication and stress management. Dose: 1 2-hr session per week for 9 weeks	Psychological distress: General Health Questionnaire (GHQ)		Within Group Sig reduction in depression in all groups
Poole et al⁴⁴	Single group with pre/post test; Internet-based, US	Systemic sclerosis n = 16 Age = 52.2	Internet delivered intervention: specialized web site that translated self-management workbook content online, with feedback form to evaluate the program. Included: 10 modules, videos, worksheets, and resources. Dose: 10 week program	Center for Epidemiology Studies Depression scale (CES-D)	BL, 10 wk	Between Group N/A Within Group Sig decrease in depression with moderate effect size	N/A
Ruehlman et al³⁵	RCT; Internet-based, US	CP n = 330 Age = 44.93	Internet-based chronic pain management program with a custom learning plan, interactive learning modules, self-management tools, gradual increase in activities and social networking focus	Center for Epidemiology Studies Depression Scale (CES-D) Depression, Anxiety and Stress Scales (DASS)	BL, 7 wk, 14 wk	Between Group Sig decline in depression Within Group N/A	Usual care
Sauter et al⁴³	Quasi-experimental; Community setting, Austria	MS n = 32	Fatigue management and energy conservation program with topics covering the importance of rest, communication and body mechanics, environmental adaptions, personal priorities and standards, time management, and balancing self-care, work and recreational tasks Dose: 6 2-hr weekly session Group 1 Cognitive therapy, included: role of psychological factors, education about RA, challenging thoughts and underlying beliefs, management of flare-ups/high-risk situations, dealing with painful episodes, assertiveness, and communication.	Self-rating depression scale	BL, 6 wk, 8.5-10.5 mo	Between Group Sig decrease in depression, maintained through follow-up Within Group N/A	Usual care
	RCT		Group 2 Behavioral therapy, included: education about RA, relaxation training, goal-setting, pacing, problem-solving, management of flare-ups/high-risk situation.			Between group N/A
Sharpe & Schrieber²⁹	Community-setting, Australia	RA n = 104 Age = 56.2	Group 3 Cognitive-behavioral therapy, included all components listed above	Hospital Anxiety and Depression Scale (HADS)	BL, post, 6 mo	Within group No group change in depression but overall significant decrease	Usual care
Shigaki et al²⁷	RCT; internet-based, US	RA n = 106 Age = 50	Internet-based program with weekly educational modules for improving self-efficacy of RA self-management, plus tools for group interaction. Dose: 10 weeks	Center for Epidemiology Studies Depression scale (CES-D)	BL, 10 wk, 9 mo	Between group Within group N/A	Usual care
Slater et al³⁰	Quasi-experimental; Clinic-based, US	CLBP n = 34 Age = 44.70	Education about back pain and function, systematic increases in exercise, activity planning and contracting, contingent reinforcement for improving function and activity and non-reinforcement of pain behaviors, self-management and problem-solving training. Individualized components: medication and palliative tapering, family support, vocational problem-solving. Dose: Weekly 1-hr individualized treatment sessions for 8 weeks	Beck Depression Inventory	BL, 8 mo	Between group Within group N/A	Usual care
Turner et al⁴²	Single group, with pre/post test; home-based, US	MS n=41 Age = 52.59	Tele health monitoring system that obtained weekly scores from patients and transmitted to provider. Dose: 6 months	Self-rating depression scale	BL, 6 mo	Between group N/A Within group	N/A

Note: Results column with missing detail indicate no significant differences were reported.

Abbreviations: CP, chronic pain; CLBP, chronic low back pain; MS, multiple sclerosis; OA, osteoarthritis; RA, rheumatoid arthritis; SCI, spinal cord injury.

Review of Study Bias

The Cochrane Risk of Bias Tool²² was used to assess bias and included the evaluation of sequence generation, allocation concealment, blinding, incomplete outcome data assessed, and free of selective outcome reporting. Studies with all criteria met were classified as low risk of bias, >1 partially met were moderate risk, and >2 were high risk.

Results

Participants

Populations comprised individuals with arthritis (n = 7/rheumatoid and osteoarthritis),^23–29 back pain (n = 6),^30–35 chronic pain (n = 7/lower body),^19,36–41 and neurological disorders including SCI,¹⁸ multiple sclerosis,^42,43 systemic sclerosis,⁴⁴ and general neurological impairment (brain, spinal condition, or neuropathy).⁴⁵ Participant ages across these studies ranged from 36 to 65 years (mean age 49 years old) with sample sizes ranging from 16 to more than 1000. For studies that reported race, most included white participants (60%-98% white participants in sample),^{19,27,31,35,36,39–42,44} with only one study focusing solely on Spanish-speaking individuals.²⁵ Women comprised most participant samples and studies typically included three to four times as many women.

Settings

The majority of studies were completed in a hospital-based outpatient clinic setting^{18,19,23,28–33,36–38,40,41,45} with other settings including online/telehealth interventions,^27,35,42,44 and community (mail or small group).^24–26 One study compared the effect of an intervention between individuals in an inpatient and outpatient setting.³⁹ Thirteen studies were completed in the North America,^{24–27,30,31,33,35,36,40–42,44} six in Europe,^{19,23,28,34,43,45} and six in Australia/ New Zealand.^{18,29,32,37–39}

Intervention

All of the programs were multidisciplinary and combined cognitive (eg, restructuring thoughts), behavioral (eg, goal setting, utilizing social support, problem solving), physical (eg, therapy, exercise, relaxation), and medication therapy. Most studies formally included cognitive behavioral therapy (n = 11) into the self-management program.^{18,23,27,29,31–33,35–37,40} The programs were also delivered in different formats including individualized, small group, or online/telephonically. The length of the intervention ranged from being individualized,³¹ to three weeks^19,40,41 to monthly for one year.²⁶ Finally, social cognitive theory was the theoretical framework used to develop the respective interventions.^27,28,36,45

Outcome measures

Depression was measured with nine different outcomes assessments with the most commonly used assessments being the Center for Epidemiological Studies-Depression Scale,^{25–28,35,40,44} Hospital Anxiety and Depression Scale,^18,23,29,45 Beck Depression Inventory,^19,30,31,39 Depression and Anxiety Stress Scale,^32,35,37,38 and Short Version of Beck Depression Inventory.^24,33

Results

Of the 25 studies, results indicated a mixed effect of the intervention on depression; eight found a significant improvement in depression when compared to the control/comparison group,^{18,19,23,25,28,35,36,43} eight found no difference,^{26,27,30,33,34,40,42,45} and five studies designed without a comparison group reported a significant difference over time.^{31,32,38,41,44} Four studies also reported no significant differences between groups but reported a significant difference when all participants were aggregated.^24,29,37,39 In studies where a significant effect was reported, maintenance of changes varied from 3 weeks¹⁹ to 12 months.^34,36 The length/intensity of the intervention did not have a consistent connection with effectiveness of the intervention on reducing depression.

Study bias

Out of 25 studies, 18 (72%) had moderate-to-high bias (Table 2) with lack of blinding, allocation concealment, and sequence generation being the most prevalent issues, although many studies did not include enough detail to assess bias.

Table 2

Methodological quality of included studies (n = 25).

STUDY	SEQUENCE GENERATION	ALLOCATION CONCEALMENT	BLINDING	INCOMPLETE OUTCOME DATA ADDRESSED	FREE OF SELECTIVE OUTCOME REPORTING	RISK OF BIAS
Baranoff et al³²	No	NO	No	No	Yes	High
Barlow & Barefoot²⁸	No	NO	No	Yes	Yes	High
Gatchel et al³¹	NO	NO	No	No	No	High
Haworth et al⁴⁵	Yes	Yes	Yes	Yes	Yes	Low
Hewlett et al²³	Yes	Yes	No	Yes	Yes	Moderate
Jensen et al⁴⁰	NO	No	No	Yes	Yes	High
Kroenke et al³⁶	Yes	Yes	Yes	Yes	Yes	LOW
LeFort et al³³	Yes	Yes	Yes	Yes	Yes	LOW
Lorig & holman²⁴	Unclear	Unclear	Unclear	Yes	Yes	Moderate
Lorig et al²⁶	Yes	No	Partial	Yes	Yes	Low
Lorig et al²⁶	Yes	Unclear	Unclear	Yes	Yes	Moderate
McCracken et al¹⁹	NO	No	No	No	Yes	High
Nicholas et al³⁸	NO	No	No	Yes	Yes	High
Nicholas et al³⁷	Yes	Yes	Yes	Yes	Yes	Low
Nielson & Jensen⁴¹	No	No	No	Yes	Yes	High
Niemisto et al³⁴	Yes	Yes	Yes	Yes	Yes	Low
Perry et al¹⁸	No	No	No	Yes	Yes	Moderate
Peters & Large³⁹	Yes	No	No	Yes	Yes	Moderate
Poole et al⁴⁴	No	No	No	Yes	Yes	High
Ruehlman et al³⁵	Yes	Unclear	Unclear	Yes	Yes	Moderate
Sauter et al⁴³	Unclear	Unclear	Unclear	No	Yes	High
Sharpe & Schrieber²⁹	Yes	Yes	Yes	Yes	Yes	Low
Shigaki et al²⁷	Unclear	Unclear	Unclear	Yes	Yes	Moderate
Slater et al³⁰	No	No	No	Yes	Yes	Moderate
Turner et al⁴²	No	No	No	Yes	Yes	High

Discussion

This focused review suggests that there is a growing body of literature examining the effect of self-management interventions on depression in people with mobility impairment. This is emphasized by the fact that a greater number of the 25 articles identified have been published more recently (1980's = 1; 1990's = 5; 2000's = 8; 2010's = 10). Overall, results of the self-management intervention were mixed. For example, interventions were equally effective for all samples (ie, arthritis, back/chronic pain, neurological impairment). However, while the majority of studies included people with arthritis and chronic back pain/pain, few of the published interventions included people with SCI or multiple sclerosis, despite the recognized need.^1,3,10,46 This provides opportunity for future intervention efforts for these populations. The content of the intervention was also mixed (eg, exercise prescription, relaxation techniques, nutrition, self-talk), although cognitive behavioral therapy was the most commonly adopted approach. One result of note across studies that reported adherence was that people who completed more components of the intervention (eg, greater attendance and tracking of behaviors) experienced improved outcomes. This finding emphasizes the important role that participant engagement and consistent tracking of behavior has on self-management behavior.³⁸ Finally, participants benefited from short interventions with less dosage (eg, 12 hours over 3 weeks) as well as more intense and extended programs (eg, 45 hours over 15 months).

This variability may be due to methodological limitations common across studies. First, 72% of reviewed studies were determined to have moderate-to-high risk of bias, mainly as a result of a lack of blinding and concealing participant allocation to groups (although this is challenging with self-management intervention delivery). This significantly impacts the reliability and validity of results and ability to generalize findings between settings. Second, the variability of outcome measures (n = 9) used to assess depressive symptoms, substantially limits the ability to directly compare study findings. Third, few studies (only 4/25) used theory to guide intervention development,^27,28,36,45 although several studies incorporated theoretical components such as self-efficacy or cognitive behavioral strategies (eg, goal setting, self-monitoring). Fourth, the body of evidence lacks racial and gender diversity, as most studies included white females, with only one intervention modified to address the needs of a minority group.²⁵ Fifth, participants’ adherence to intervention components was rarely assessed and thus it cannot be determined whether non-significant findings were due to ineffective intervention or dose received.

Overall, this focused review suggests that a variety of different approaches are taken to self-management intervention delivery and measurement. While individual investigators may be systematic in their approach (see Kate Lorig's work) the field of self-management intervention research has greater variability in delivery (eg, intensity, duration, theoretical underpinning), setting, and outcome measures used. Sallis et al⁴⁷ introduced a behavioral epidemiological framework that suggests if research efforts are to effectively address public health issues, such as depression in individuals with disability, they must be completed sequentially. Specifically, the framework proposes five phases of research that build upon the evidence base sequentially and include (1) linking the health behavior (eg, depression) to outcomes (eg, return to work, quality of life, functional ability), (2) identifying tools to accurately measure the health behavior, (3) detecting mediators and moderators of the behavior, (4) developing evidence-based behavioral interventions, and (5) disseminating results to influence policy and programming. Based on the large differences found in approach, outcome measures, and results, there is a clear opportunity to adopt a more systematic approach to self-management research addressing depression in individuals with mobility impairment. Future efforts should be made to standardize factors such as setting (eg, clinic, community, telehealth), mode and timing of outcome assessments, and intensity, duration, and frequency of intervention.

Telehealth interventions (ie, telephonic, web-based) present clinicians and investigators with a unique opportunity to deliver an intervention while overcoming many transportation barriers faced by people with mobility impairment. Of the four studies that adopted a telehealth approach in the current review,^27,35,42,44 two reported a significant decrease in depression.

In conclusion, this review suggests that self-management approaches have successfully reduced depression among people with mobility impairment in about half of the published studies. Yet, it is also important to recognize that the evidence base is best characterized as having moderate-to-high risk of bias and relies upon self-reported data. Future efforts should include a systematic approach to self-management program delivery (ie, setting; mode and timing of outcome assessment; frequency, duration, and intensity of intervention), examine telehealth approaches, document intervention adherence, use randomized controlled designs, and standardized presenting results to include effect sizes to facilitate the ability to complete meta-analyses.

Author Contributions

Conceived and designed the experiments: SJD, KFG, KDS. Analyzed the data: SJD, KFG, KDS. Wrote the first draft of the manuscript: SJD. Contributed to the writing of the manuscript: SJD, KFG, KDS. Agree with manuscript results and conclusions: SJD, KFG, KDS. Jointly developed the structure and arguments for the paper: SJD, KFG, KDS. Made critical revisions and approved final version: SJD, KFG. All authors reviewed and approved of the final manuscript.

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Self-Management Interventions to Prevent Depression in People with Mobility Limitations

Abstract

Introduction

Method

Results

Discussion

Keywords

Introduction

Methods

Procedure

Literature search

Review of Study Bias

Results

Participants

Settings

Intervention

Outcome measures

Results

Study bias

Discussion

Author Contributions

References