Monday, February 20, 2005

Dr. Adams’ Case Management Update
This is the 375th Weekly Issue 

This Week's Topic: “The Ones Mother Gives You Don't Do Anything At All." 

Q^uestion
“Do you think that depression is a "disease” and should be treated as such?"

A^nswer
Dr. Adams' replies: “No, and it represents a grave danger that we label every human condition or disorder a "disease" and then treat it as if it were.

It is a current “fashion” to see everything as a disease and every patient as the victim of that disease. 

• Therefore, adults are not merely inattentive, they have ADHD. 

• They are not conflicted about their relationship, they have erectile dysfunction. 

• They are not unmotivated, they have chronic fatigue syndrome. 

• They are not irresponsible, they have an addictive disease.

See the danger?  Then we treat them as victims. 

Depressed patients are treated as though they simply have a chemical imbalance in their brain.  It has gotten to the point where the patient is not asked questions beyond whether they have had a change in appetite and are sleeping poorly.  Once we establish that they are depressed, we assume that it is a chemical imbalance, a disease and we probe no deeper.

We then treat it as a disease, over-medicate them, and may them dependent rather than determining what they need in order to cope with their lives. And we do not look for the mistakes that they are making in managing their lives.  

This financially meets the needs of whoever is treating the patient as though this were a biological/chemical problem - charging for return and very brief visits just for medication refills and endless therapies without ever getting to the bottom line…the source of the problem.  

I cannot begin to count the number of patients I have seen who have been in “treatment for years”, treated with a cabinet full of medications, with the true problems never addressed.

Indeed, with this solely biological/disease model, there is no underlying problem. Since it is a “chemical imbalance,” nothing else matters.  

Here’s the contradiction:  If it is a chemical imbalance…a disease…then how is the injury related to it at all?

And if it is truly a biological rather than a psychological problem, then there are biological "damages."

It is all unnecessarily complex. 

Sometimes it is, indeed, the injury which triggered the depression, but just as often, it is longstanding resentment of the employer, boredom with the marriage, worry over the children and endless financial concern that gave rise to feelings of helplessness and resentment. The "chemical imbalance" is the result...not the cause. 

Pills may help with the symptoms, but they do not resolve the underlying emotional problems that persist and lie in wait.

Monday, February 13, 2005

This is the 374th Weekly Issue 

This Week's Topic: “When in Doubt...Just Cut it Out" 

Question: “I kind of understand pre-surgical examinations, but can you give me an example of the impact such an exam has? What I mean is...aside from the obvious, why would someone not be a good surgical candidate and how do you determine this?”  

Dr. Adams' replies: “That's a very important question, and I can answer it best by briefly outlining a recent case.

This is a middle-aged man who injured his lumbar spine lifting something at work while rotating at the waist.

This happened twice in one year, but it was only after the second injury that he sought help. The first time, his employer discouraged him from doing so. So he worked in, and became fearful of, pain.

He went through physical therapy was greatly improved but still had some pain.

When asked if he were still in pain, he simply said "yes." An MRI was ordered and revealed a significant lumbar bulge.

He was recommended to undergo surgery.

See? So far no problem.

However, this is what was not known:

• He was not taking, and did not require, any pain medication.

• When he had pain, it lasted only several minutes to a few hours and only occurred a couple of days per week.

• He could relieve pain merely my changing position.

• Even though his physical therapist felt that they had no more to offer, the patient felt that his pain was reduced by two-thirds when he was in P.T.

• His friends and relatives had told him that surgery on the back often/usually results in the need for "two or three more surgeries," and his "surgeon told me that there are no guarantees.”

• Add to this "I do not care if it is my back or my tonsils, I am virtually terrified of any and all surgery."

So ask yourself this: Since this patient functions very well when having brief physical therapy twice a week, and since he does not require medication, and since his pain lasts only several minutes and is most often relieved merely by briefly changing position, is he truly a surgical candidate?....is candidacy determined by MRI or by the individual's unique pain response?"

Monday, February 6, 2006

This is the 373rd Weekly Case Management Update

This Week's Topic: “Makes No Sense to Me"

Question: “OK, I have one for you…how can an injured worker be able to return to work and also need care? If they are released to return-to-work, then, by definition, they have completed all necessary care.”

Dr. Adams Replies: “If you go to work with a sore throat, that does not mean that you do not need to see your physician or require medication.

We all work with some degree of limitations. This may range from minor illnesses, minor injuries to fatigue, restlessness and personal problems.

Our presence at work does not mean that we do not need health care.

An injured worker may have may have neck, shoulder and head pain. He may be anxious and depressed. He may have financial and interpersonal problems.

Yet, he is able to work within reasonable and objective limitations.

If we wish him to consistently work, he may need continued care from his psychologist, orthopedist and physical therapy. He may need to take medication for his physical discomfort as well as medication for his anxiety and depression. He may need assistance adjusting to his pain and limitations.

It is most important that we do not complicate recovery by believing that (a) someone cannot work if they are in care…or (b) need no care just because they are able to return to work.”

Monday, January 30, 2006

This is the 372nd Weekly Case Management Update

This Week's Topic: “Sponge Bob Fat Chance"

Question: “Often regardless of what I do for some of my orthopedic patients, it is never enough. They expect more and more, and then abandon me even after I have met their needs. Care to comment?”

Dr. Adams Replies: “Many injured workers are impressively dependent. Sometimes this emerges from educational deficiencies or intellectual limitations. Often it emerges simply as part of a dependent personality disorder.

They accept any diagnostic or even invasive procedure (surgery) without question or complaint.

They also absorb, like a sponge, anything anyone does for them.

Any kindness, advocacy, assistance or special considerations are immediately absorbed and appreciation is short-lived and followed by an increased expectancy for more…and more.

I observed many years ago that highly motivated patients are very reluctant to telephone the office between appointments or after hours. Dependent patients, however, quickly form a habit of between-appointment calls. Their initial appreciation soon becomes a demand to be called back, even for minor concerns.

Patients who absorb efforts beyond the-call-of-duty are most often those least likely to mobilize, most likely to somatize (report symptoms which migrate to areas other than the site of injury) and also most likely to become angered and seek a change-of-provider. This soon becomes a habit pattern.

It is very important to determine which patient is unhealthily dependent and more likely to benefit from firm limits rather than limitless accommodations.”

Monday, January 23, 2006

This is the 371st Weekly Case Management Update 

This Week's Topic: “Children" 

Question: “I read that people heal more quickly when they are married. I wonder if an injured worker recovers more quickly if he/she is married and/or has children.”  

Dr. Adams Replies: “In my experience, children are an appreciable, and unfortunately, often negative factor in the recovery of injured workers. 

If there are young children in the household, it appears to add to the despair of the injured worker.  His/her role as a parent is compromised; the inability to be active with the children (or in the case of infants to even lift or care for them) leads to appreciable guilt and frustration. 

Often, the injured worker misperceives his own disappointments with those of the children. He looks for verbal and behavioral signs that the children are disappointed and grown impatient with their parent’s recovery.  

This, in turn, leads to morbid fantasies of abandonment.  It much like the fear of being abandoned by a spouse because intimacies are not currently possible. In both case, there is the almost paranoid perception that the spouse will find another partner, and the children will find another parent to replace the person who is injured.  

As you can imagine, this becomes a self-fulfilling prophecy:  If you repeatedly tell someone that you expect them to abandon you, you increase the probability that this will eventually occur.  If nothing else, they do get quite tired of listening to it.

The response of the spouse and children, and the patient’s perceptions of those responses can be critical areas in facilitating recovery.”

Monday, January 16, 2006 

This is the 370th Weekly Case Management Update 

This Week's Topic: “How It is Done" 

Question: “We see a lot of surgeons and pain management people prescribing antidepressants, but we do not see these drugs as working…what is your view.”  

Dr. Adams Replies: “They do work…for their intended purpose.  

Depression consists of two very different components: 

a.    The physical (neurovegetative symptoms) which include problems with sleeping, eating, irritability, concentration and decision making, etc.

b.    The emotional aspects (from a recent journal article) which include “a return to normal functioning rather than solely a relief from symptoms…the three most frequently judged to be very important in determining remission included the presence of features of positive mental health such as optimism and self-confidence; a return to one's usual, normal self; and a return to usual level of functioning 

The latter (b) are most often not addressed.  It is assumed that a patient in pain is depressed (or the patient complains of being depressed).  He/she states that she is “down in the dumps…not sleeping very well…tired…grumpy…forgetful…eating habits have changed.” 

They are prescribed someone’s favorite antidepressant, and they may, indeed, sleep better, have a more normal eating pattern and be less irritable. 

However, (as noted in this study) “patients indicated that the presence of positive features of mental health such as optimism, vigor, and self-confidence was a better indicator of remission than was the absence of the (physical) symptoms of depression. 

 Many patients will tell you that “oh, the medication helps somewhat, but it does not tell me how to solve all these problems.”

Monday, January 9, 2006 

This is the 369th Weekly Case Management Update

This Week's Topic: “Long & Winding Road" 

Question: “What we prefer to do is wait until the authorized treating physician feels that depression must be addressed…before then, we don’t want to rock the boat if you know what I mean.”  

Dr. Adams Replies: “Your goal needs to be to insure that depression does not interfere with the course of care for the physical injury. For that, you cannot wait. 

Depression after serious (and that's the key word - "serious") injury is to be expected.  It follows a specific path, but that path is not a direct one: 

1. The individual is injured, and with few exceptions, the person anticipates immediate and brief treatment. 

2. When the nature of the injury does not permit immediate recovery, the individual passively follows the course of care. 

3. After a period of several months, when it becomes clear that treatment will span several more months, the patient may become agitated and irritable. 

4. If that course of care then leads to multiple therapies, multiple providers and a life scheduled around appointments and medications, a sense of futility and helplessness is often seen. 

5. The first annual anniversary of the injury creates a sense of alarm, and the patient feels a sense of despair if not hopelessness, and depression becomes evident. 

**This is when a patient should be referred for psychological evaluation** 

6. Now irritable, forgetful, often gaining (or losing) substantial weight, sleeping poorly and unable to concentrate, remember or make important decisions, the patient becomes housebound, withdrawn and alienated from family and friends. 

**If the patient is not referred at this stage, numerous and substantial problems arise, compliance with care suffers, and there is now a decreased probability of returning to any employment within objective physical limitations** 

7. This path will spiral downward if not interrupted, and the case may span years without resolution 

8. If care is initiated at the point of early detection of depression, the patient becomes more compliant and begins to make viable future plans...even if such plans involve the acceptance that some complaints will be chronic and a return to work (or to the pre-injury type of work) may no longer be feasible.