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“…(in) chronic work-related musculoskeletal pain disability...A
majority (64%) of patients were diagnosed with at least one current
(mental) disorder, compared with only 15% of the general
population...Such findings suggest that clinicians treating these
patients must be aware of the high prevalence of (mental) disorder and
be prepared to use mental health professionals to assist in
identifying and stabilizing these patients…” (Journal of Occupational
& Environmental Medicine 2002; 44: 459-468)
The Psychological Seminar Series for 2003, launched on September 1,
2002, addresses the very frequently seen association of injury-related
chronic pain and concurrent (e.g. co-morbid) depression. This
association is often poorly understood with regards to both cause and
treatment. Poorly understood is the extent to which depression is an
exacerbation of a pre-existing psychological problem versus resulting
proximally from the injury itself.
CHRONIC PAIN
Contributing to depression among chronic pain
patients is their perception that they are
helpless to
control the experience of pain, and that science lacks the ability to
help them. As a consequence, many feel their plight is
hopeless.
Four out of 10 people with moderate to severe chronic pain have yet to
find adequate relief and say their pain is out of control, according
to a new survey by the American Pain Society, the American Academy of
Pain Medicine and Janssen Pharmaceutica.
DEPRESSION
An untreated depression can last at least six
months. The chances in a lifetime of having a depressive disorder are
about fifteen percent, and only a quarter of those people receive
proper treatment. Society has stigmatized mental illness for so long
that people with depression, and sometimes their families, feel
ashamed. A further complication is relegating all of depression to a
brain chemistry imbalance which shields the patient from
responsibility for their disorder.
CHRONIC PAIN and DEPRESSION
A recent study included 254 chronic pain patients
(identified as those whose pain had lasted at least six months). The
group was examined in terms of age, marital status, whether or not
they were employed, race, and whether they were involved in workers'
compensation litigation.
The strongest single predictor of depression was work
status. Employment is heavily weighted in an adult's self-esteem which
is impacted when the chronic pain sufferer believes that he/she can no
longer perform the duties the job demands.
For those unemployed patients involved in litigation,
the prospect of money was a consolation which unfortunately wore off
quickly once the reality of the long term implications of chronic pain
were confronted.
Among the employed, those pursuing litigation were
most likely to be unhappy, due to the awkward position of suing their
employer while still working.
Those less schooled were more vulnerable to
depression since they had few resources to understand their condition
or to find alternate employment. The unmarried were less able to cope
with their suffering than those who had a partner who could provide
support.
It was found that among women, depression declined
with age, while among men it worsened. Thus, among those under 40,
women were most affected, but among workers over 40, it was men who
had the highest depression scores. This is in contrast to depression
studies not involving chronic pain sufferers.
Of all the other variables, such as the degree and
strength of the chronic pain, the number of surgical interventions,
the number of drugs taken, none had the effect on the level of
depression as much as the
duration
of the pain. The longest-suffering patients, by far, exhibited more
depressive symptoms.
In conclusion, depressed chronic pain patients are
less likely to respond to treatment for their pain.
Since pain is harder to treat than depression,
psychological care including antidepressant therapy is often the best
first step on the road to treating chronic pain.
TYPES OF DEPRESSION
While there are numerous mood disorders, including BiPolar Disorder
(Type I, Type II and Cyclothymic Disorder), those which are associated
with work injury appear to be a specific three:
1. Major
Depressive Episode (or Disorder):
For at least two
weeks, the individual has been depressed or shown loss of interest, as
well as weight change of at least 5%. Additionally, nearly every day,
there may be sleep disorder, fatigue, worthlessness and/or guilt,
motor agitation or retardation, and problems with concentration.
2. Dysthymic
Disorder:
Depressed mood, most of the day and for most days, spanning at least
two years, accompanied by appetite changes, sleep changes, low energy,
low self-esteem, poor concentration, hopelessness, and never without
these complaints for more than two months.
3. Adjustment
Disorder with Depressed Mood:
Marked distress in excess of what would be expected in response to a
stressor in which the predominant symptoms are those such as depressed
mood, tearfulness or feelings of hopelessness. Chronic adjustment
disorder may extend beyond six months in duration when the stressor
has not abated.
A common
misinterpretation is that Major Depressive Episode or Major Depressive
Disorder is somehow a more serious disorder.
In reality, it is most often acute and readily treated and does not
tend to last >6 months. By contrast, Dysthymic Disorder, which may
span years, presents more of a challenge to treatment, partially
because it usually involves more than one factor or precipitating
event.
All three types of depression may arise in response to injury. All
respond well to cognitive behavioral psychotherapies and some of the
newer antidepressant medications. Those medications are designed to
enable a balance of brain chemistry while the patient works on those
problems giving rise to the depressive thoughts and self-limiting
behaviors.
It must also be noted that there is an often overlooked interaction
between narcotics and mood regulation. The intent of strong narcotics
is to relieve acute and severe pain, but too often, patients with
chronic conditions are prescribed addicting narcotics. These, in turn,
can create side effects of increased irritability and mood swings
which can be mistaken for a true depressive disorder. Physical side
effects such as constipation, rebound headaches, decreased appetite
and sleep disruption may also complicate recovery.
DEPRESSION, PAIN & PERSONALITY
Personality Disorders, a developmental defect of inner
experience and behavior that effects thought, mood, social functioning
and impulse control, is often a powerful foundation which gives rise
to recurrent depressed mood and to poor management of pain.
Personality Disorder does not arise from injury but may determine
response to the injury and subsequent pain.
The
dependent
personality passively allows
others to assume responsibility for treatment of pain. The
avoidant
personality is fearful of
failure and rejection and withdraws from care. The
histrionic
personality melodramatically
exhibits the experience of even minor pain. The
borderline
personality has
self-destructive behaviors including drug abuse which complicates
treatment after injury. The
paranoid
personality is easily prone to
distrust their doctor. The
antisocial
personality
will vary pain complaints and describe behavior solely
for purposes of tangible gain.
RED FLAGS
When looking at a case, there are numerous warning signs that should
be investigated. Among those are: A. The patient fears the condition
is worsening or falsely believes that there will be complete recovery,
each without verification from the treating physician. B. The patient
who was briefly employed now resists re-employment. C. The patient
refuses second opinions or is noncompliant with current care. D. The
patient who self– or over-medicates. E. The patient whose care is
orchestrated by others, often a spouse; a particular problem since
that relationship will not be easily altered.
By far, the most critical red flags are seen in those patients who
FEAR
their condition, who are
ANGRY
as to how their injury occurred, who are
RESENTFUL
of many involved in their treatment
process, and who perceive the future, not as an opportunity, but as a
THREAT.
DISABILITY VS. REHABILITATION
Neither an injury nor a disorder is per se a
disability,
and patients who are frightened, depressed, and angered by their
symptoms will thwart care designed to mobilize them. Work itself can
be therapeutic, and when transitional or alternate duty is available,
the patient who resists a return to productivity must have this
behavior examined and reflected back to them.
TIMING, DIAGNOSIS & TREATMENT
The patient who does not respond to adequate and
appropriate care, has diffuse and varying complaints, is irritable,
sometimes accusatory, inconsistently compliant, who demands much but
participates little, needs to be psychologically examined to determine
if there is co-morbid (whether injury-consequent or pre-existing)
depression. If it is determined that the patient is depressed, the
physical complaints are likely to be more effectively treated if the
depression is addressed as soon as it can be detected.
CRITICAL FACTORS OVERLOOKED
Pain and depression are common co-existing factors that slow or
completely obstruct the return to work. Depression is a primary rather
than a secondary concern; it must be aggressively addressed.
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