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February 24, 2016 DOWNLOAD PDF

LTD Claims from Depression: What You Need to Know

Dr. Katherine Feleki

Dr. Katherine Feleki is a 1981 graduate of the University of Toronto School of Medicine. 
Dr. Feleki completed her family medicine residency at Queen’s University in 1983 and ran a general family practice from 1983 to 2013.  From 2014 to present Dr. Feleki has practiced as a G.P. Psychotherapy in Kingston.  She has been a friend of Eric Schjerning’s for nearly 35 years. 

General Facts at a Glance

Mental health problems are very common in family practice settings.   About one third of visits to a GP have a direct psychological component. (WHO).

Major Depressive Disorder (MDD) is the most common psychiatric illness.

In a given year, 5 - 8.2 % of the Canadian population experiences a major depressive illness. (CMAJ 2013)  The lifetime prevalence of a major depressive illness in Canada is 10.8%. (Statistics Canada 2002).

Only one third of people with depression seek help. (Mood Disorders Society of Canada, 2013).

Depression is often a recurrent condition with 56% of patients experiencing a single episode, 28.6% experiencing two episodes, and the remaining 15.4% experiencing three or more episodes in their lifetime. (Canadian Network for Mood and Anxiety Treatments - CANMAT).

Depression doubles the risk of alcohol abuse (Cavanagh JT, Carson AJ, Sharpe M. Psychological autopsy studies of suicide: a systematic review. Psychological Medicine 2003; 33).

Depressed individuals are at 25 times greater risk for suicide than the general population. (American Association of Suicidology, 2014).

After cancer and heart disease, suicide accounts for more years of life lost than any other cause of death. (CDC 2014).

MDD has recently been identified as an independent risk factor for heart disease. (Medscape, Feb 28, 2014 ).

The Burden For Employees and Employers

Depression has a negative impact on the individual, interpersonal relationships, workplace productivity, and physical health.

Depression is now the leading cause of disability in the world. (WHO fact sheet no. 369 October 2015).

Depression has a profound impact on occupational functioning, both as a result of missed work (absenteeism), and loss of productivity while attending work when unwell (presenteeism).

Depressed employees are more likely to become unemployed or miss time from work than employees with physical illness. (Journal of Affective Disorders, 2009).

The Canadian Mental Health Association estimates that workers who take time off work because of depression cost employers an average of $18,000 (Depression Snapshot, Doctor’s Review, January 2016).

Cognitive Impairment - What is it and why is it important? 

Cognition refers to the acquisition, processing, storing, and retrieval of information.  Cognitive impairment exists if there are deficits in any of these domains.

The majority of patients with MDD have symptoms of cognitive impairment.

Measures of cognitive functioning account more for variability in workplace functioning than does severity of depression.  (McIntyre RS et al Comprehensive Psychiatry 2015)

Many antidepressants will improve cognitive function indirectly by improving mood and symptoms of depression. None of the conventional antidepressants have, to date, shown strong, direct, pro-cognitive effects for depression. No medications are FDA approved to treat cognitive symptoms in MDD. (Towards a Better Understanding of Cognitive Disturbances in Depressed Psychiatric Patients, Medscape). Some antidepressants such as tricyclics and older antipsychotic agents may worsen cognitive function, especially in the elderly.  (Pharmacist’s Letter/Prescriber’s Letter May 2008).

Cognitive dysfunction often persists even in patients who fulfill the criteria for remission and contributes to impaired productivity in the workplace and decreased quality of life.  (Medscape 2014, Cognition in MDD: Improving Quality of Life).   These patients have trouble concentrating, remembering things, making decisions and performing tasks, even though they may no longer be depressed. (http://www.wsps.ca/Information-Resources/Articles/Depressions-prolonged-effects-CBOC-recommends-wor.aspx). However, this is not well recognized. 

Clinical trials are currently underway for the validation of the THINC-it Tool, an assessment tool to identify cognitive impairment in MDD in primary care settings.

As antidepressants have not shown strong efficacy in the improvement of cognitive effects in MDD, new treatment options that target cognitive dysfunction are needed.

Cognitive remediation refers to non-pharmacological methods of improving cognitive function in patients with mental illness.  It is a type of rehabilitation treatment aimed at improving attention, memory, language, and executive functions, which can be used to complement medication or psychotherapy.

Treatment of Depression

Medication

It generally takes 1 to 2 weeks before there is any improvement from an antidepressant, with good response requiring a minimum of six weeks of treatment.  It may take up to 14 weeks of treatment to reach remission.

The minimum recommended duration of treatment with antidepressants is 6 to 12 months.

Approximately 2/3 of patients will not respond adequately to the initial antidepressant prescribed.  In such cases, options include switching to another medication, adding either a second antidepressant or an augmenting drug to the first, or adding psychotherapy. (Journal of Affective Disorders 117, 2009)

There is a small group of patients who will not achieve remission with multiple trials of medication who are considered treatment resistant.

Approximately  33% of patients will discontinue their medications within 30 days, and more than 40% stop within 90 days. (Journal of Affective Disorders 117, 2009). The common reasons for discontinuation include side effects (nausea, vomiting, diarrhea, weight gain, sexual side effects being commonly reported) and perceived stigma. 

Psychotherapy

Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are as effective as medications in mild to moderate depression and can be used as first line treatments. (Canadian Network for Mood and Anxiety Treatments (CANMAT).

Patients who receive CBT have lower rates of remission than those who receive medication only.

Cognitive behavioural therapy (CBT) focuses on the interrelationship of thoughts, moods or emotions and behaviour.  The way we think or interpret a situation affects how we act and how we feel.  What we do impacts the way we think and feel. Our emotions or how we feel affects what we do and what we think.  As each of these parts interact with the others, small changes in any one domain can lead to changes in the others. In MDD, behavioural goals are centered on increasing productive and rewarding behaviours of patients.  Cognitive Interventions target maladaptive and negative thinking styles.

Interpersonal Therapy (IPT) focuses on various aspects of relationships with particular attention to four common areas of difficulty: Interpersonal role disputes, role transitions, grief, and interpersonal deficits.

Exercise

Many studies have shown that exercise is effective in reducing symptoms of depression.

Personal Perspective

Treatment of depression is challenging for multiple reasons. Patients often present with vague physical complaints and the diagnosis is not always obvious or readily accepted by the patient.  Stigma around mental illness is still common. Many patients discontinue medications prematurely, several patients require several medication trials before achieving remission, and patients in remission may still have cognitive impairment and do not do as well as expected upon returning to work. 

These factors make it very difficult to accurately predict prognosis for full recovery and return to work dates for depressed patients.  (a question that is asked on every disability form).

Work disability impacts on patients’ confidence, social interactions, family dynamics, and can be a source of financial stress.

Patients with depression should be encouraged to seek CBT (with or without antidepressant medication) to reduce risk of recurrence. Depressed patients should also be encouraged to exercise regularly.

The Mental Health Commission of Canada estimates that the prevalence of depression will continue to rise. (Depression Snapshot, Doctor’s Review, January 2016)Psychosocial stressors such as economic crises, unemployment, increased personal debt, depressed housing markets, increased numbers of people living in poverty, and family breakdown, all contribute to an increase in mental health problems. (Depression: A Global Crisis, World Mental Health Day, October 10 2012, World Federation for Mental Health)

Programs aimed at preventing depression are needed in schools, workplaces, and communities.

In addition to improving symptoms of depression, future treatments must also directly target cognition so that patients can have a full recovery.

In my experience, most patients with MDD are not malingers.  Most want to recover and return to work.  Disability insurance companies understandably also want claimants to return to work.  With depression, people tend to see themselves and others in a negative way.  Interactions with claims adjudicators can sometimes be perceived as intrusive and conflictual and this is not helpful to recovery.  Mental health training and a sensitive, empathic approach could ultimately benefit both the depressed individual and the insurance company.