Jacquie Hetherton and David Bird

Foreword

One of the commonest Psychological Injuries is that of Depression. Most, if not all, Claimants will have voiced their distress and experience of being ‘fed-up’ as a result of the event and its consequences being litigated. However, one of the key medico-legal issues is whether this understandable dip in mood equates to a recognised psychological disorder such as a depressive disorder. Associated with this, is how to interpret quantify feelings and thoughts of helplessness often voiced. Jacquie Hetherton and David Bird share their experience of anxiety and treating depresses individuals.

Depressed individuals often present as ‘down in the dumps’, sad or discouraged. Whilst these emotions can be experienced when an individual is ‘fed up’, with, for example, everyday stresses, being ‘fed-up’ is typically a transitory experience. In contrast, individuals classified as having a depressive disorder have enduring experiences of these emotions which are disruptive to everyday living and functioning.

The essential feature of those classified as having a Major Depressive Disorder (using DSM-IV criteria), is depressed mood, most of the day, nearly every day, or marked loss of interest or pleasure in almost all activities, unremittingly for at least a two week period. In addition the individual will have at least four of the following additional symptoms:

1. significant weight loss (when not dieting) or significant weight gain;
2. insomnia or excessive sleeping;
3. psychomotor agitation or retardation (being slowed down) which is observable to others;
4. fatigue or loss of energy; feelings of worthlessness or inappropriate guilt (which may be delusional, i.e. having no basis in reality)
5. impaired ability to think or concentrate, or indecisiveness;
6. recurrent thoughts of death, including recurrent suicidal ideation with or without a plan, or a suicide attempt.

A Major Depressive Disorder can be “reactive” in that it is in response to a particular event, or “endogenous” where there are no identifiable triggers for the onset of the depression.

Whilst many individuals experiencing low mood can identify with the above symptoms, for this mood disturbance to qualify as a clinically significant depressed mood (that which would be classified being a disorder) it must be of an intensity which results in significant impairment in social or occupational functioning.

In personal injury litigation, clinically significant depressed mood often conforms more to a diagnosis of an Adjustment Disorder with Depressed Mood than a Major Depressive Disorder. In an Adjustment Disorder, the depressed mood is in response to a specific psychosocial stressor but the full criteria for a Major Depressive Episode are not met. Again the mood disturbance must significantly impair social or occupational functioning for the ‘disorder’ criteria to be met. An Adjustment Disorder with Depressed Mood is often viewed as more palatable by individuals uncomfortable with a diagnosis of depression yet who report having been ‘knocked sideways’ by the psychosocial stressor they experienced or are continuing to experience (e.g. chronic pain after a road traffic accident). There is an expectation that Adjustment Disorders will resolve naturally over time, and the DSM-IV specifies that this is normally within six months of the stressor being removed. This does not imply that such an adjustment reaction needs no treatment as the acute experience of depressive symptoms even in the short term can be very debilitating.
While each individual client’s self-report is valuable in establishing whether of not they are suffering from a disorder, it is not appropriate for clinicians to base their diagnoses solely on the client’s belief regarding the presence or absence of a disorder. It is common for individuals to describe themselves as being “depressed” when in fact they are “fed up”, perhaps because they are grieving a loss or because they have encountered significant stresses at work. Despite the fact that many individuals have the belief “I feel sad, so I must be depressed”, this is not necessarily accurate. These are normal responses to difficult life circumstances, and do not signify a disorder. Equally, many individuals who would not describe themselves as depressed (commonly because they equate “depressed” with “suicidal”), display all the other DSM-IV characteristics of having a major depressive episode.

Depression is linked to ‘learned helplessness’ (Seligman, 1967), a perception learned by individuals that efforts to alter their adverse circumstances are futile and unlikely to be successful. For example, an individual with depressed mood reactive to disruptive travel anxiety and chronic pain after a road traffic accident, may develop learned helplessness. This is particularly likely if their pain is unresponsive to the treatments they undergo and/or if their anxiety symptoms do not improve following efforts on their part. Learned helplessness manifests itself in beliefs that their symptoms will not improve; and behavioural passivity, both of which intensify depression. Furthermore having a depressed mood in the first place is likely to increase the possibility of such negative interpretations being made, establishing a vicious cycle. Learned helplessness is linked to pessimism and hopelessness i.e. about oneself and the future, which is associated with an increased risk of suicide.

In terms of treatment, this tends to comprise psycho therapy and/or medication. Depending on how the depression is experienced e.g. the individual having identifiable negative thoughts and engaging in maladaptive behaviours that maintain the depression, cognitive behavioural therapy is likely to be of benefit. This is of course dependant on the acceptability of such an intervention to the individual experiencing depression. With some depression, particularly endogenous depression, anti-depressant medication may be indicated. Some people are opposed to such an intervention however. This highlights that an important factor is that individuals have a positive (or at least accepting) attitude to at least some degree to the treatments they are offered.

References

Diagnostic and Statistical Manual of Mental Disorders (4th Edition-TR) (2000). Washington DC: American Psychiatric Association.

Seligman, M.E.P. and Maier, S.F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74, 1-9.