Disability and Mental HealthThe Ties that Bind

Stephan Esser MD, USPTA

Disclosure

• None

Or?

Objectives

• Revisit the basic epidemiology of mental health disorders and disability

• Learn about the connection of mental health and disability status

• Identify risk factors for persistent disability

• Identify opportunities for change

• Develop conceptual approaches to improving QOL and function and reducing disability

• Define Disability?

– Dis = without

-Ability = a skill/proficiency/talent

Definitions• Disability:

– ADA: 3 part• has a physical or mental impairment that substantially

limits one or more major life activities • has a record of such an impairment• is regarded as having such an impairment

– SSA:• You cannot do work that you did before• You cannot adjust to other work because of your

medical condition(s)• Your disability has lasted or is expected to last for at

least one year or to result in death.

Consequence of diseaseICIDH 1976

• Something abnormal occurs within the individual

• Exteriorization: Someone becomes aware of such an occurrence

• Objectification: The performance or behavior of the individual is altered

• Socialization: Either the awareness or the alterations in performance/behavior place individual at a disadvantage

Definitions

• Impairment: any loss or abnormality of psychological, physiological or anatomical structure or function.

• Disability: any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.

• Handicap: a disadvantage for a given individual that limits or prevents the fulfillment of a role that is normal

Disability Definitions• Medical Model:

• disability as a feature of the person, directly caused by disease, trauma or other health condition, which requires medical care provided in the form of individual treatment by professionals

• Social Model: • disability as a socially created problem not an attribute

of an individual, demands a political response, it is due to unaccommodating physical environment brought about by attitudes and other features of the social environment.

WHO International Classification of Functioning, Disability and Health

Stats• WHO: 15% live with a disability, 2-4%

experience difficulty in function

• Mental Illness

Definitions

• DSMIII-IV:– Mental Health Disorder:• a manifestation of a behavioral, psychological, or

biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

Primary Classes

• Anxiety Disorders• Mood Disorders• Psychotic Disorders• Eating Disorders• Impulse Control/Addiction Disorders• Personality Disorders• Other

Depression

A Link

• Depression and Disability– Depression in:• Those with disabilities: 30-50%• Non disabled: 7%

National IRF Admits 2008-2010National IRF Admits 2008-2010

Case # 1

• A 26 y/o male 16 days s/p motorcycle accident with resultant C6 ASIA A Tetraplegia presents to your IRF. – Needs:• Bladder, Bowel, Skin, Nutrition, Pain Control, DVT

Prophylaxis, HO Prophylaxis, PT, OT, RT etc

• Psychology?, Psychiatry, Family Meetings, Clergy etc

• The Disability Dilemma

“A sick thought can devour the body's flesh more than fever or consumption.” Guy de Maupassant, Le Horla et autres contes fantastiques

“A sick thought can devour the body's flesh more than fever or consumption.” Guy de Maupassant, Le Horla et autres contes fantastiques

Case # 2

• 54 y/o male postal worker presents with low back pain. Pain is out of proportion to exam, MRI is relatively unremarkable except for an L5-S1 BBDB and facet arthropathy. The patient requests you fill out disability paperwork as he reports he is “ready to retire” and looks forward to traveling.

Case # 2.5

• A 65 y/o male former Marine presents with chronic knee pain requesting your assistance with paperwork. He comments he is 35% service connected for his knees and really thinks he should be 60% because that is what other friends have. His BMI is 32, and he smokes 1.5 ppd.

Case # 2.75

• A 45 y/o female presents on long term disability for fibromyalgia and her Type 2 diabetes. She has a BMI of 38.65, takes Oxycontin and percocet daily for her pain. She is on Celexa and nightime Ambien in addition to her T2D medications. She requests you complete paperwork to increase her long term disability for new onset low back pain.

• Crisis of Conscience……..or?

A Few Stats

• 2.8 million new Social Security Disability Insurance (SSDI) applications in 2012

• 29% higher than in 2007• 67% higher than 2002 levels• Individuals collecting disability (10.8 million) :

entirety of manufacturing (12 million).• There is now 1 person collecting disability for

every 12 in the workforce

Reflections

• Disability status is increasing• Are more people really “disabled”?• How “abusable” is the system?• Individuals and systems are imperfect

Is there something deeper?

• The Ties that Bind

Depression can seem worse than terminal cancer, because most cancer patients feel loved and they have

hope and self-esteem.David D. Burns

Depression can seem worse than terminal cancer, because most cancer patients feel loved and they have

hope and self-esteem.David D. Burns

Case # 3

• A 65 y/o male with 25 years of chronic low back pain presents to clinic for evaluation. He has CAD, HTN, T2D, HLD, Peripheral Neuropathies and is s/p 2 lumbar fusions. He takes Celebrex, Tramadol, Gabapentin and occasional Percocet 5/325 for severe pain. His wife died last August of Breast Cancer and his children live out of state.

Chronic Pain and Depression

• Single Central Nervous System– How much can it handle?

• Chronic Pain is more about the central nervous system and less about the peripheral– Central Sensitization

• Anxiety, Fear, Lack of understanding, inadequate support, underdeveloped coping techniques

• Depression and Disability

In Review• Increase Risk of disability:

• Excess body weight• Tobacco use• High risk activities or behaviors• Chronic conditions such as; diabetes, high blood pressure, back pain,

anxiety or depression, frequent alcohol consumption or substance abuse.

• Decrease Risk of Disability:• Maintaining a healthy body weight• No tobacco use• Healthy diet and sleep habits• Regular exercise• Moderate to no alcohol consumption• Avoidance of high risk behaviors including substance abuse• Maintaining a healthy stress level• Effective treatment of chronic health conditions.

Risk of Depression with DisabilityLazarus and Folkman (1984) and Haley and colleagues (1987)

• the number and nature of negative life events that a person faces

• the person’s view or appraisal of those events in terms of the perceived degree of threat to his or her future and current well-being

• the support that the person receives from other people, both instrumentally and emotionally

• the coping methods that the person uses to help deal with these stressors

• the person’s underlying personality

Depression and Function

• 5-year period• ADL decreased nearly twice as much for people who

were depressed compared to people who were not depressed.

• Kemp and colleagues (2004) assessed community activities and life satisfaction in people with spinal cord injuries who were depressed. • One-third the number of community activities

compared with the number for the nondepressed individuals, and their life satisfaction scores were 40 percent below those for people who were not depressed.

Where this has left me

• Disability is increasing

• The full picture is unclear

• The science supports the notion that mental health is an important predictor of disability status

• Depression can impair function/QOL and increase morbidity and mortality

Take Homes

• We all will work with “disabled” individuals• Identify risk factors• Look for the “Heart of the Matter”• Ask questions• Don’t make assumptions• You can’t always “see” disability• Love……….

Thank You!

Stephan Esser MD, USPTA