When an employee is off work due to illness or injury, the focus is usually on the primary reason for the absence. It may be an on-the-job injury covered by workers' compensation, or an employee may be on short-term disability due to a serious illness such as cancer, a chronic disease such as diabetes or a nonoccupational injury.
Throughout the process of evaluating the individual's case, providing appropriate treatment, and planning for the employee's eventual return to work, what may go unnoticed is a common secondary health issue: depression.
According to estimates, depression as a secondary health issue (also known as a comorbidity) affects 40 percent to 65 percent of cardiac patients, up to 27 percent of stroke patients, and 25 percent of cancer patients. Depression is also estimated to occur in 25 percent of individuals with diabetes, which is one of the most prevalent chronic, complex conditions in the workplace.
"One-third of all adult Americans have at least one chronic illness," says Kathleen Ward Douglas, president of K.A. Shannon Consulting LLC in Phoenix. "If they have a chronic illness, their ability to work may also be affected, which can result in an associated depression."
All too often, however, depression as a comorbidity is underdiagnosed due to a number of factors. Employees themselves may be part of the reason. They may be unaware that they suffer from depression, or they may rationalize their feelings of helplessness and sadness, believing they can handle it on their own. If they suspect that they have depression, they may be reluctant to admit it because of lingering societal stigmas about psychosocial issues. They may also have concerns about their insurance coverage for treatment of depression as it is most often under a separate benefit structure.
Being off from work due to an illness or injury can trigger depression because so much of a person's identity and self-esteem are linked with employment and being productive. "When that changes, it's as if part of their role and identity has been taken away," says Karen Provine, a supervising counselor for the New Mexico Division of Vocational Rehabilitation.
If not diagnosed and treated, depression can undermine the plan of care and treatment for the ill or injured employee and delay his or her return to work, because depression immobilizes a person's energy and self-care ability. It may exacerbate the problem to the point that the employee is unable to come back to work at all.
"One of the biggest issues with any disease or chronic condition is the individual's adherence/ compliance with the medication, diet or exercise program, and unfortunately clinical depression plays right into that," Douglas adds. "Depression ultimately affects the person's quality of life, reducing the person's ability to follow the medical care plan."
Fortunately, there are strategies that can help identify, respond to and treat depression in employees who are off work due to another illness, injury or health concern. This requires that care providers and other professionals--including case managers, occupational health nurses, rehabilitation counselors, and physical and occupational therapists--be on the alert for indications of depression as they do comprehensive assessments.
"Case managers should know their clients and be cognizant of changes in personalities, personal hygiene issues, and the effect of health issues on their lives," says Kim Schuetze, a hospital social worker at Kosair Children's Hospital in Louisville, Ky. "The case manager must be astute and assertive enough to address these changes and other difficult issues. They must not accept surface, easy answers.
They must offer support, encouragement and resources so that any mental health issue will not be perceived as a 'weakness' or necessarily permanent." Schuetze is a commissioner with the Commission for Case Manager Certification, a certifying body for case management professionals.
For case managers, who may be working with an employee who is already off work due to another health issue, there are several ways to appropriately identify depression, depending upon the case managers' practice setting and professional background, says Michael Garrett, vice president of business development for Qualis Health of Seattle.
For example, a case manager who has the competency can conduct his or her own depression screening to detect if there are serious depressive symptoms, and/or discuss the possibility of depression with the attending physician to see if the individual has been screened for it.
In addition, the case manager can also review medical records and other documentation to see if there are any indications of depression. A case manager also has an important role in educating clients and family members about the warning signs of depression.
"Most importantly, the case manager can communicate with the patient or client and family members to see if there are signs of depression," adds Garrett. "Once depression is detected, the case manager needs to make the appropriate referrals and other follow-up interventions in order to address the issue."
LOOKING AT THE "WHOLE PERSON"
Depression, as a stand-alone health issue, is already on many employers' radar screens. According to the National Mental Health Association, at any one time, one out of every 20 employees experiences depression. Further, depression ranks among the three top workplace problems, following family crisis and stress. Depression is one of the most common causes of short-term disability.
Yet when depression is a comorbidity, it can be overlooked because of the focus on the physical disease, chronic illness or injury affecting the individual. "Part of the responsibility of the case manger is not just to assess the primary disease process, but also to do a depression screening, which can be easily integrated into the physician's office visit or the case manager's assessment process. That can at least give a heads-up if there is potentially a depression issue,"
Douglas adds. By evaluating and addressing all of the comorbidities, including depression, outcomes can be improved.
The care plan for each ill or injured employee must look at the whole person, not just a specific disease, illness, injury or other health issue. This lends itself to a "disease management approach," whereby a specific population is identified and appropriate strategies are targeted. In this instance, the population includes employees who are off work due to illness or injury, knowing that they face a measurable likelihood of also having depression.
With this approach, depression is treated just like any other comorbidity that may occur among patients. Just as a patient who is hospitalized after a heart attack may also have an underlying condition such as hypertension or diabetes, the disease management approach recognizes that the individual may also have depression that needs to be addressed in order to facilitate optimum return to health.
Consider this scenario: In the course of discussions with an employee, a case manager, occupational health nurse or rehabilitation counselor suspects that the individual suffers from depression.
In this instance, the primary health care provider should be contacted immediately (assuming that the employee has authorized contact with the care providers regarding the care plan or other health issues).
Most likely, the primary care provider's specialty is related to the employee's primary health concern, such as oncology, orthopedics, endocrinology or neurology. If depression is diagnosed, the care plan can be expanded to include treatment of this secondary condition, and appropriate resources identified. According to health care statistics, 80 percent of depression is considered treatable.
With an understanding of the clinical and psychosocial needs of the employee, the case manager, care providers and other members of the treatment team can work together to provide the care and resources that will enable the individual to return to work. This, in itself, can be therapeutic for many people.
"The whole focus of rehabilitation is taking the person, where he or she is, looking at not only their work history and their disability, but their education and their psychological and support systems, and help that person get to a point of optimum heath," adds Provine. "Then they can feel productive again."
Depression as a comorbidity can only be addressed if care providers, case managers and other professionals take a holistic approach to treating an ill or injured employee. This requires a relationship with employees based on advocacy and trust, addressing physical and behavioral health issues through a comprehensive approach to treatment planning.
MINDY OWEN, RN, CRRN, CCM,
is the chairwoman-elect of the Commission for Case Manager Certification and principal of Phoenix HealthCare Assoc. LLC of Coral Springs, Fla.
DIANE L. HUBER, PhD, RN, FAAN, CNAA, BC, is the immediate past chairwoman of the Commission for Case Manager Certification and a professor at the University Of Iowa College Of Nursing.
July 1, 2005
Copyright 2005© LRP Publications