‘Depression and Anxiety’ in Income Protection

1. ‘Depression and Anxiety’ in Income Protection Dr Derek Lovell Consultant Psychiatrist WELLINGTON 11TH AUGUST 2006

2. INCIDENCE OF PSYCHIATRIC DISORDERS • DSM-IV • DEPRESSION AND ANXIETY : Diagnosis & Treatment • CASE STUDY: Income Protection Claim

3. Prevalence of Mental Disorder in Australia, 1997 Any anxiety disorder 9.7% • Panic disorder 1.3% • Agoraphobia 1.1% • Social phobia 2.7% • Generalised anxiety disorder 3.1% • Obsessive-compulsive disorder 0.4% Any affective disorder 5.8% Any substance-use disorder 7.7% Any mental disorder 17.7% Source: Australian Bureau of Statistics, Mental Health and Wellbeing: profile of adults, Australia, 1997.

4. Social Factors • 40% of relationships end within 5 years. • Extended families less common. • Only 60% of population are the ‘traditional family.’ • Less sense of community, e.g. fewer involved with church, community groups. • Greater use of childcare.

5. Work Factors • Labour market deregulation • Downsizing • Longer working hours • Many positions casual / part-time • Both parents working / children in day care. ACTU study of 10,000 workers: • Two-thirds complained of work stress • 24% had taken time off work for “stress.” Stress is not an illness.

6. Pharmaceutical Company Marketing During 2003, 700,000 Australians consumed 8.3 million scripts for antidepressants. • Zoloft - 2.5 million • Cipramil - 1.74 million • Efexor XR - 1.54 million • Luvox - 349,835 • Prozac - 349,190 This doesn’t necessarily mean these individuals suffer from a psychiatric illness.

7. Why so many SSRI prescriptions? • Aggressive marketing by pharmaceutical companies. • Limited time available to GPs to address psychosocial problems. • Patients want a “quick fix.” • Extensive community education about “depression.” • Easier to ascribe difficulties to an “illness” than to accept personal responsibility.

8. Definitions in Income Protection Disablement requires: • A psychiatric illness. • A partial or total inability to work which results from the psychiatric illness.

9. Definitions in Income Protection Income protection is not: • a vocational retraining benefit for career unhappiness • a “paid holiday” for “stress” • a parenting benefit • a spouse carer’s benefit • a substitute income for a failing business • benefit payable because of professional deregistration

10. What is psychiatric illness as opposed to stress, worry and unhappiness? There are no definitive tests and all psychological test results are based on patient self report or observations of the psychologist / psychiatrist.

11. DSM-IV-TR • Designed for research • Operational criteria - a cookbook or checklist • Multi-axial

12. Major Depression DSM-IV criteria for Major Depression At least five of the following symptoms for at least two weeks (symptom 1 or 2 must be present): 1. Depressed mood 2. Loss of interest or pleasure 3. Significant appetite or weight loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive guilt 8. Impaired thinking or concentration; indecisiveness 9. Suicidal thoughts / thoughts of death. MAJOR DEPRESSION IS HIGHLY LIKELY TO RESPOND TO ANTIDEPRESSANTS OR PSYCHOLOGICAL TREATMENT.

13. Problems with DSM-IV-TR • Not designed for medicolegal purposes • Symptoms can be learnt (sometimes badly): - Google search - Patient education material from pharmaceutical companies

14. Difficulties in Income Protection with Psychiatric Disorders • Overdiagnosed - relationship, social difficulties or work pressures are medicalised and responsibility taken away from the individual. • Pressure on general practitioners to prescribe by pharmaceutical companies. • Undertreated - e.g. subtherapeutic doses of medication only. • Supplier-induced demand of psychologist / treater. • Adopt “sick role” when life too difficult. • Psychological symptoms can’t be verified - no diagnostic tests. • Adverse publicity from the press when claim is denied by the insurer.

15. Major Depression • 1 in 5 people will meet criteria for Major Depression at some time in their life. • Untreated, the average episode lasts 10 months. • Average number of life time episodes is 5. • Treatable in 70 - 80% of patients.

16. Prognosis of Major Depression • 50% recover totally • 30% partially recover and resume employment • 20% have a chronic course • 15% suicide eventually • 60% of affected patients have a second episode • If two or more episodes, 90% chance of a further episode • only 15% have a family history { CLAIMS { UNDERWRITING

17. Difficulties in Income Protection with Major Depressive Disorder Treatment needs to be: • Proactive - Best Practice Guidelines • Supervised by a specialist psychiatrist wherever possible.

18. Red Flags: • Claim soon after policy inception • Medical, Legal or Insurance Background • An occupation susceptible to economic downturn, e.g. sales • Occupations where long hours worked, e.g. legal firms.

19. Red Flags (contd.) • A claim form which never changes month to month: “Depression Seeing psychologist Lovan 20mg” • with no specialist referral or no best practice treatment. • An ability to perform all leisure and educational activities with the exception of work.

20. Most people with depression will be treated in general practice. • For mild and moderate depression, there is little difference in relative effectiveness of treatments. • The best outcomes are likely when a good therapeutic alliance is formed between a healthcare professional and the patient, and adequate treatment is provided over a long enough period. • Drug treatment should continue for: • at least one year for a first episode of depression, and • at least 2 years for repeated episodes.

21. Mental State Examination in Depression • Generalised psychomotor retardation is the commonest sign, although agitation can also occur • Lack of attention to personal grooming and hygiene may be evident • Speech may be slow and monotonous • Affect is usually, but not always, depressed, and often anxious or irritable, with the patient easily moved to tears (in more severe depression the patient often describe being “beyond tears”) • Thought content reveals themes of hopelessness and helplessness, with a negative view of the self, world and future • Suicidal ideas and plans may be evident • Delusions may occur in severe depression, or even perceptual disturbances such as hallucinations • Cognitive function is intact, but may be hard to assess in severe depression.

22. Antidepressant Medications • Most patients do best with a combination of antidepressants and some form of psychological therapy. • A 4 - 6 week trial of an antidepressant is reasonable before trying a drug from another class of antidepressant. • Patients who respond to drug therapy should continue with the same dose for 4 - 9 months to prevent a relapse. • Consider maintenance therapy (ie, continuing treatment for two or more years) for those who have had three previous episodes of depression and those with two previous episodes (if such episodes were recent and severe).

23. Antidepressant Medications RECOMMENDED ORDER OF ANTIDEPRESSANT USE: First Line: Selective serotonin reuptake inhibitors (SSRIs), venlafaxine, moclobemide or mirtazapine. Second Line: Tricyclic antideperessants (desipramine or mortriptyline are preferred as they have fewer anticholinergic effects and are less sedating). Third Line: Irreversible monoamine oxidase inhibitors (MAOIs).

24. Antidepressants marketing in Australia since 1990 - dosage and adverse effects

25. Case Study: Major Depression • 48 year old female solicitor. • Practicing family law 50 hours a week. • One of 2 partners in a law firm for 15 years. • IP protection policy incepted at time of partnership. • No previous history of psychiatric treatment. • Married for 18 years. • Husband is 60 year old retired commercial lawyer. • 2 daughters, 15 and 13.

26. Case Study:Major Depression(contd.) Background • Eldest of 7 - took responsibility for younger siblings. • High achiever - Ba LLB over 6 years. • 5 years of articles as not confident. Then full-time practice in family law. • Enjoyed helping people. Encountered hostility from ex-partners of clients in regional centre • Distressed by child custody battles and child abuse.

27. Case Study:Major Depression(contd.) History of Stressors Described • November 2005, best friend (former bridesmaid) diagnosed metastatic breast cancer. • November 2005, younger brother diagnosed with terminal metastatic liver cancer (primary unknown).

28. Case Study:Major Depression(contd.) Symptoms Described • Fatigue and irritability. • Sleep disturbance, awake 2am - 4am • Tearful • Emotionally labile - would start crying when clients did. • Less confident in conferences and in mediation. • Anxious going to court. • Worried about letting people down. • Lost appetite and 5kg in weight. • Stopped regular walking and a professional women’s group.

29. Case Study:Major Depression(contd.) Treatment • Consults GP who suggests she cease work in Feb 2006. • Prescribed Cipramil 20mg. • Referred to a female psychologist weekly for one month then monthly appointments. Encouraged to exercise, walk and take a “break from work.”

30. Case Study:Major Depression(contd.) Progress • Acknowledges some improvement in her mood after 2 - 3 weeks. • States she can’t perform complex analytical tasks. • Sleep and appetite improved. • Will not consult a psychiatrist as knows them all socially in regional centre. • Medical Certificate states Major Depression in Partial Remission.

31. Case Study:Major Depression(contd.) Presentation • Articulate and neatly groomed. • No slowing of speech or thought. • No observable concentration difficulties. • Briefly tearful speaking of brother and best friend’s illness but otherwise emotionally reactive. • States doesn’t feel well enough to work and can’t handle conflict.

32. Case Study:Major Depression(contd.) Digging Around • Why is husband retired at 60? • Husband TPD at age 53 with fibromyalgia.

33. Case Study:Major Depression(contd.) Attitude to Family Law Work • “Draining” • “Problems all the time” • “Clients needy” • Avoids husbands of clients in supermarket. • Recent episode of having to leave a restaurant when a man started repeatedly shouting “lawyer, lawyer, lawyer” when out with girlfriend.

34. Case Study:Major Depression(contd.) WAS THERE AN EVENT THAT LED TO HER CEASING WORK IN FEBRUARY 2006? 13 year old daughter found to be self-mutilating her thighs - refusing to see a psychologist.

35. Case Study:Major Depression(contd.) DOES SHE STILL HOLD A PRACTICING CERTIFICATE? ARE THERE ANY ACTIONS AGAINST HER? WHAT ARE THE CONDITIONS OF THE PARTNERSHIP AGREEMENT? WHO IS DOING HER WORK? She reluctantly acknowledged she has sold her share of the partnership to the other principal on 30 June 2006 but added he had said she could work as a consultant if she wished.

36. Case Study:Major Depression(contd.) Detailed History of Daily Activities • All household tasks (cleaning lady let go) • Spending a lot of time with 13 year old daughter (feels guilty for previous long work hours).

37. Case Study:Major Depression(contd.) Current Situation • On IP claim for six months. • Sold partnership. • Guilt re daughter’s behaviour. • Feels better not working.

38. Case Study:Major Depression(contd.) Whilst initially high likelihood of Major Depression - currently, presentation is best described by: • Motivational problems. • Family responsibilities. • Lifestyle factors. • View that life is finite. LONG TERM CLAIM.

39. Case Study:Major Depression(contd.) • Early IME • Involvement of a psychiatrist, perhaps in another centre. • Encouragement to have daughter in psychological treatment and return to part-time work within one month or continue to work on with support • More aggressive pharmacological treatment early on, e.g. higher doses of antidepressant medication.

40. Case Study:Major Depression(contd.) • Claim will most likely go legal. • It will be argued she has a treatment resistant depression. With concentration difficulties. • Adverse outcome for insurer.

41. Anxiety Disorders • Generalised Anxiety Disorder • Panic Disorder and Agoraphobia

42. Generalised Anxiety Disorder Features: • Months of excessive anxiety and worry • The worry is out of proportion to the event, pervasive and excessive, difficult to control • Accompanied by muscle tension, hyperarousal and symptoms of the “flight or fight” response

43. Generalised Anxiety Disorder Psychological Treatment: • Education about nature of disorder • Progressive muscle relaxation • Structured problem solving • Graded exposure to difficult situations • Specialist referral to a cognitive behavioural program for non-responders • Drug therapies: • Benzodiazepines reduce the anxiety and worry symptoms but often lead to dependence. • Low dose sedative tricyclic antidepressants (eg, amitriptyline, doxepin, dothiepin) are also of use N.B. Many use alcohol to excess to “relax.”

44. Panic Disorder and Agoraphobia Features: • Sudden attacks of fear or anxiety in situations of little danger • Symptoms of the “flight or fight” response, complicated by hyperventilation and worsened by the fear of collapse or death • Avoidance, for fear of panic, of situations from which escape is not possible or help is not available, typically public transport, travelling alone, crowded places

45. Panic Disorder and Agoraphobia Psychological Treatment: • Education about nature of disorder • Hyperventilation control • Graded exposure to feared situations • Specialist referral to a cognitive behavioural program is recommended

46. Panic Disorder and Agoraphobia Drug Therapies: • Tricyclic antidepressants, monoamine oxidase inhibitors, high potency benzodiazepines like alprazolam and the selective serotonin reuptake inhibitors have all been shown to reduce panic frequency, anxiety, and phobic avoidance. • Introducing the antidepressant drugs is often difficult because these patients are sensitive to side effects. • Benzodiazepines can produce dependence. • Drugs relieve symptoms but do not cure the disorder.

47. Hyperventilation Control Technique If sufficiently mastered, this technique will control panic attacks. It has two parts: regular monitoring of respiration rate by the patient and the slow breathing technique to inhibit hyperventilation when anxious. Hyperventilation control needs to be automatic if patients are to be able to use it when they need it. SLOW BREATHING TECHNIQUES Using the second hand on a watch or clock: Take a deep breath and hold. Breathe in and out on a six-second cycle, saying the word “relax” as you breathe out. After one minute, hold your breath again, then continue to breathe on a six-second cycle. Repeat the sequence until anxiety has diminished.

48. Structured Problem Solving With the doctor’s guidance, the patient learns to appraise situations accurately and then develop appropriate coping techniques. After one or two crises handled in this way, patients can learn to carry out the techniques for themselves. STEP 1: WHAT IS THE PROBLEM / GOAL? STEP 2: LIST ALL POSSIBLE SOLUTIONS. STEP 3: ASSESS EACH POSSIBLE SOLUTION. STEP 4: CHOOSE THE “BEST” OR MOST PRACTICAL SOLUTION. STEP 5: PLAN HOW TO CARRY OUT THE BEST SOLUTION. STEP 6: REVIEW PROGRESS AND BE PLEASED WITH ANY PROGRESS. What has been achieved? What still needs to be done?

49. Income Protection & Anxiety Disorders Specific Issues: • Positive reinforcement occurs when anxiety levels are lessened by relief from deadlines and responsibilities. • Avoidance - Agoraphobia (role for surveillance). • Arguments that anxiety levels interfere with concentration and work capacity is limited. • Generally, anxiety disorders respond well to treatment and are not disabling.

50. What Constitutes a Good Psychiatric Report? • Concise and without jargon. • Careful history of psychological symptoms and treatment (including doses of medications) • Critical appraisal of history obtained in light of observations at clinical interview and the daily activities described. • A logical argument as to whether a DSM-IV diagnosis is present. • Is there consistency with the usual history, course and presentation of the condition? • An analysis of how the condition interferes with work capacity? • Recommendations regarding best practice treatment. • Rehabilitation prospects in light of occupational history. • Motivation and response to treatment. • A time frame for recovery.