‘Depression and Anxiety’ in
Income Protection
Dr Derek Lovell
Consultant Psychiatrist
WELLINGTON
11TH AUGUST 2006
 INCIDENCE OF PSYCHIATRIC DISORDERS
 DSM-IV
 DEPRESSION AND ANXIETY :
Diagnosis & Treatment
 CASE STUDY:
Income Protection Claim
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.
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.
Work Factors

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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.
Pharmaceutical Company Marketing
During 2003, 700,000 Australians consumed 8.3 million
scripts for antidepressants.

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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.
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.
Definitions in Income Protection
Disablement requires:
 A psychiatric illness.
 A partial or total inability to work which results
from the psychiatric illness.
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
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.
DSM-IV-TR
 Designed for research
 Operational criteria - a cookbook or checklist
 Multi-axial
Major Depression
MAJOR DEPRESSION IS HIGHLY LIKELY TO RESPOND TO
ANTIDEPRESSANTS OR PSYCHOLOGICAL TREATMENT.
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.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood
Loss of interest or pleasure
Significant appetite or weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Impaired thinking or concentration; indecisiveness
Suicidal thoughts / thoughts of death.
Problems with DSM-IV-TR
 Not designed for medicolegal purposes
 Symptoms can be learnt (sometimes badly):
- Google search
- Patient education material
from pharmaceutical companies
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.
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.
Prognosis of Major Depression
CLAIMS
UNDERWRITING
{
{




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
Difficulties in Income Protection with
Major Depressive Disorder
Treatment needs to be:
 Proactive - Best Practice Guidelines
 Supervised by a specialist psychiatrist wherever possible.
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.
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.

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.
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.
Antidepressant Medications

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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).
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).
Antidepressants marketing in Australia since 1990 dosage and adverse effects
Daily dose (mg)
DRUG
START
USUAL
MAXIMUM
Selective serotonin reuptake inhibitors (SSRIs)
20
20 – 40
Fluoxetine
20
20 – 40
Paroxetine
50
50 – 100
Sertraline
100
100 – 200
Fluvoxamine
20
20 – 40
Citalopram
80
50
200
300
60
Reversible selective monoamine oxidase inhibitor (RIMA)
300
300 – 600
600
Moclobemide
Serotonin-noradrenaline reuptake inhibitor (SNRI)
75
75 – 150
375
Venlafaxine
Case Study: Major Depression
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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.
Case Study:
Major Depression
(contd.)
Background

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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.
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).
Case Study:
Major Depression
(contd.)
Symptoms Described

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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.
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.”
Case Study:
Major Depression
(contd.)
Progress

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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.
Case Study:
Major Depression
(contd.)
Presentation

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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.
Case Study:
Major Depression
(contd.)
Digging Around

Why is husband retired at 60?

Husband TPD at age 53 with fibromyalgia.
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.
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.
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.
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).
Case Study:
Major Depression
(contd.)
Current Situation

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On IP claim for six months.
Sold partnership.
Guilt re daughter’s behaviour.
Feels better not working.
Case Study:
Major Depression
(contd.)
Whilst initially high likelihood of Major Depression currently, presentation is best described by:

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Motivational problems.
Family responsibilities.
Lifestyle factors.
View that life is finite.
LONG TERM CLAIM.
Case Study:
Major Depression

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
(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.
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.
Anxiety Disorders

Generalised Anxiety Disorder

Panic Disorder and Agoraphobia
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
Generalised Anxiety Disorder
Psychological Treatment:

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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.”
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
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
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.
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.
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.
Hyperventilation control needs to be automatic if patients are to be able to use it when they need it.
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?
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.
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.