Depression and Disability

[erg923]

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1. T4C recently posted a cite to Marty Rohling paper on depression and cognitive deficits that should, I think, settle the matter that in an otherwise healthy person, Depression does NOT produce actual deficits in cognitive functioning once effort is taken into account? Right? Which leads to the conclusion, I would suppose, that the cognitive deficits perceived in depressed individual are really just suboptimal engagement secondary to anhedonia and avolition? Nothing neurologically-based and completely reversible wit treatment, right? Would this be accurate?

2. When do we perceive depression to actually be "disabling," so much so that a person qualifies for disability insurance for a specified time period through their private policies or from SSDI? Depression with psychosis seems like a given seeing that there is a safety factor involved there. But when else? I have a little more info and opinion on the issue due to my current work, but I would really like to see how big the range of opinion is among young professionals.

 

[AcronymAllergy]

1. That's my current take on the matter, at least until (if) compelling evidence comes out to the contrary.

2. Tough question. I have to run right now, but will try and come up with some type of response a bit later.

 

[erg923]

1. That's my current take on the matter, at least until (if) compelling evidence comes out to the contrary.

2. Tough question. I have to run right now, but will try and come up with some type of response a bit later.

Note that I did not define "disability," as I would like to see how opinions run before we through in definitions created SSA and the larger commercial insurance industry. 🙂

 

[A Blue Duck]

Which leads to the conclusion, I would suppose, that the cognitive deficits perceived in depressed individual are really just suboptimal engagement secondary to anhedonia and avolition? Nothing neurologically-based and completely reversible wit treatment, right? Would this be accurate?

Maybe I'm misunderstanding. Your conclusion is based on the presumption that, because something does not have a proven neural basis and could potentially be reversed through treatment, it should not be considered a disability. How is this sound reasoning and where does it come from? If someone is experiencing pervasive loss of pleasure/decreased reward sensitivity and lacks motivation for completing daily tasks that impairs their ability to function in the real world... they are not really disabled because...it's possible that they could get better if we treated them (which there's totally a readily available universal treatment for these depressive symptoms that works for everyone /s)? And/or we don't have substantial evidence of a physical etiology of the disease in this specific individual?

In the real world there is no cutoff point for severity. We unfortunately operate under a DSM and insurance policies that require boxed categories when what we have in reality are spectrums of illness. It wouldn't be fair to make cutoffs strictly based on associated symptomology, such as psychosis, IMO. I would think it would have to be an idiosyncratic assessment of global functioning.

 

[erg923]

Maybe I'm misunderstanding. Your conclusion is based on the presumption that, because something does not have a proven neural basis and could potentially be reversed through treatment, it should not be considered a disability. How is this sound reasoning and where does it come from? If someone is experiencing pervasive loss of pleasure/decreased reward sensitivity and lacks motivation for completing daily tasks that impairs there ability to function in the real world... they are not really disabled because...it's possible that they could get better if we treated them (which there's totally a readily available universal treatment for these depressive symptoms that works for everyone /s)? And/or we don't have substantial evidence of a physical etiology of the disease in this specific individual?

In the real world there is no cutoff point for severity. We unfortunately operate under a DSM and insurance policies that require boxed categories when what we have in reality are spectrums of illness. It wouldn't be fair to make cutoffs strictly based on associated symptomology, such as psychosis, IMO. I would think it would have to be an idiosyncratic assessment of global functioning.

Well, I dont know about all that...

Its a provocative question, and its an interesting blend of clinical and medico-legal thinking...which sometimes don't agree, or could be completely contradictory of each other, right? Would you care to actually answer the question?

 

[A Blue Duck]

Ok...I never said it wasn't provocative.

1. No. I would not consider that accurate. For the reasons I stated in my main paragraph above regarding the logic leading to your conclusion.

2. There are assessments of global functioning. You should use assessments of functioning to assess disability level. Not just assume disability (or no disability) based on (the now former Axis 1 and 2) symptomology. The GAF has been replaced with the WHODAS. A WHODAS will give you an account of the patient's disability as it relates to their ability to function.

 

[erg923]

Ok.

1. What what conclusion then do you draw from Rohling paper about then nature of cogntive complaints in individuals with depression. Please note, I never said that this provides a reason for denying "disability." I simply brought it up to illustrate that assessment that does NOT assess effort provides little compelling evidence for this determination since there is such an incentive to exaggerate of feign deficits in this situation.

2. Is there any solid research on WHODAS in determining return to work status?

 

[A Blue Duck]

1. I'm not sure what specific paper you are referencing. I'd be happy to take a look and let you know. I'm familiar with some of Rohling's work on subjective complaints of cognitive deficits not matching empirically tested deficits but won't comment on something I may or may not have seen yet. I was commenting on your proposed conclusion from said work.

2. I do not know. I do know that the WHODAS is used throughout the literature to assess functioning and disability. Also a quick search shows that the WHODAS incorporates work status into its score. Other than that I can't really answer this.

 

[erg923]

1. I'm not sure what specific paper you are referencing. I'd be happy to take a look and let you know. I'm familiar with some of Rohling's work on subjective complaints of cognitive deficits not matching empirically tested deficits but won't comment on something I may or may not have seen yet. I was commenting on your proposed conclusion from said work.

2. I do not know. I do know that the WHODAS is used throughout the literature to assess functioning and disability. Also a quick search shows that the WHODAS incorporates work status into its score. Other than that I can't really answer this.

1.Rohling, M.L., Green, P., Allen, L. & Iverson, G.L. (2002) Depressive symptoms and neurocognitive test scores in patients passing symptom validity tests.

Seems to refute, quite strongly and compellingly, the notion the depression causes suppression/deficits in cognition. Thus, claiming cognitive impairment due to my depression (the "due to" is important in medico-legal assessment of disability) seems inaccurate. This get complicated by the fact that although changes in mood do not seem to cause cognitive deficits that manifest in the well controlled, distraction free environments in which we test, its doesn't mean those with mood disorder function as adequately in the real world, where time is of the essence and distractions abound. Trust me, i am trying to go somewhere with this conversation, and I also would like to use it in order to help me in some of my review side work.

2. Symptoms and functioning are of course important to factors in making a disability determination. I would disagree strongly that we should be using a scale that is not validated for this purpose in helping make that determination. I think that would get me in load of hotwater in an deposition, no?

 

[PsyDr]

The AMA Guidelines outline impairment rating very nicely. OTBM fits quite nicely with this.

IMO, the WHODAS is ridiculous. The WHO changed their entire definition of disability making it useless on any other level than conceptual.

 

[erg923]

The AMA Guidelines outline impairment rating very nicely. OTBM fits quite nicely with this.

IMO, the WHODAS is ridiculous. The WHO changed their entire definition of disability making it useless on any other level than conceptual.

Since you also do alot of forensic junk, apparently, care to weigh-in a bit more on this issue to help out us newbs?

 

[A Blue Duck]

1.Rohling, M.L., Green, P., Allen, L. & Iverson, G.L. (2002) Depressive symptoms and neurocognitive test scores in patients passing symptom validity tests.

Seems to refute, quite strongly and compellingly, the notion the depression causes suppression/deficits in cognition. Thus, claiming cognitive impairment due to my depression (the "due to" is important in medico-legal assessment of disability) seems inaccurate. This get complicated by the fact that although changes in mood do not seem to cause cognitive deficits that manifest in the well controlled, distraction free environments in which we test, its doesn't mean those with mood disorder function as adequately in the real world, where time is of the essence and distractions abound. Trust me, i am trying to go somewhere with this conversation, and I also would like to use it in order to help me in some of my peer review side work.

2. Symptoms and functioning are of course important to factors in making a disability determination. I would disagree strongly that we should be using a scale that is not validated for this purpose in helping make that determination. I think that would get me in load of hotwater in an deposition, no?

Of course. I come here very occasionally (usually passively) for interesting conversations regarding mental health and psych science. I hope you don't think I'm trying to do anything else. I'm just offering perspective from someone who studies the cognitive features of depression. I'm not trying to pretend I know the scope of disability assessment and filing with insurance companies or what have you. That being said...here's my perspective.

1. The WHODAS isn't a validated measure? Validated by whom? This is potentially getting into a specific issue I'm not aware of as I alluded to before but...it has certainly been validated in the eyes of most research and clinical communities (http://www.ncbi.nlm.nih.gov/pubmed/20482853)

2. One of the first things I do with any article is look at the generalizations it is making. As far as I can tell, this paper investigated differences in memory functioning in depressed versus non-depressed individuals. I don't feel the need to generalize, then, to all neurocognitive issues, nor would I like to generalize all neurocognitive issues to disability in depression. Should an assessment of disability be based solely on cognitive functioning? No..of course not. What I'm saying is that if we take the thesis and subsequent generalization of this paper as truth, that depression does not impair cognitive functioning, is impairment in affective perception or experience, sleep disturbance, nutrition, and social/occupational activities not constitute or at least contribute to an individual being rightfully disabled?

3. So they used memory tests to screen out people for subsequent memory testing? And then go on to say, "Failure on such tests suggests that a patient might have (a) intentionally performed poorly, (b) produced invalid results to obtain compensation for their alleged injuries or medical conditions, (c) or produced invalid results for some other reason, such as preoccupation with suicidal thoughts."

So, in regards to C. They *potentially* screened out persons whom may have scored badly on these tests because they are suffering from suicidal thoughts (or, more importantly, other depression related features) as a result of their depression.

wat

And I think your point about the ecological validity of the study is excellent. 🙂

Edit: Also just a heads up I have to run but will check up on this thread later.

 

[WisNeuro]

ion for their alleged injuries or medical conditions, (c) or produced invalid results for some other reason, such as preoccupation with suicidal thoughts."

So, in regards to C. They *potentially* screened out persons whom may have scored badly on these tests because they are suffering from suicidal thoughts (or, more importantly, other depression related features) as a result of their depression.
.

This doesn't change the interpretation really though. Unless you expected some singular effect of suicidal ideation on cognitive functioning you should still expect to see a dose response base don severity and/or chronicity of depression course. To my knowledge, not a single paper that has also oncluded effort as an indicator has found an effect of depression on cognitive functioning. The old literature of X disorder causes X cognitive impairment is severely flawed (not as a fault of the researchers, PVT/SVT use has only really become standard within the past decade or two) and we're seeing a lot of studies refuting these earlier studies once you account for effort/secondary gain.

 

[AcronymAllergy]

As was mentioned, RE: the Rohling article, the idea is that depression in and of itself does not seem to cause/be associated with significant cognitive impairment. That is, folks with even moderate to severe depression have the potential to score within normal limits on cognitive tests, which is unlike what might be said for, say, Alzheimer's or Lewy Body Disease where there are verifiable cognitive deficits and associated neuropathology.

That being said, I do think the anhedonia, insomnia, and concentration/decision making difficulties are likely to be some of the more debilitating symptoms in a professional and social functioning sense, which is where I start to gather my definitions of disability. That is, regardless of what impairments there are associated with a condition (e.g., depression), disability doesn't come into play until there's an activity/participation limitation. This is one of the reasons I actually like the current WHO ICF material, particularly relative to what they had outlined in the previous iteration (caveat--I've never seen, let alone used the WHODAS). One example a supervisor has used previously is near-sightedness. Prior to the invention of corrective lenses, the condition would've been both a dysfunction/impairment at the level of body structure and function, and would have also resulted in disability due to impairments interacting with the surrounding world. Nowadays, however, the condition--while still associated with dysfunction at the level of body structure/function, generally doesn't result in much disability.

With depression, I can see how it could be a disabling condition, yes. I wouldn't say it's the norm, but I wouldn't say it's outside the realm of possibility, either. What the threshold of disability would be, for me, would entail determining if the symptoms of depression are directly and significantly impairing an individual's ability to participate in work-related activities. The sticky part, though, entails determining the threshold for the point at which that becomes compensable, and the stipulations of said compensation. Although that could all directly relate to the specifics of the condition itself. That is, someone with a "less-severe" severe depression may still be able to work part-time, while someone with a "more-severe" severe depression may not.

Edit: to speak to a point that (I think) was brought up earlier, I certainly don't think that because a condition is treatable/reversible that it's incapable of causing disability, and I would imagine pretty much everyone here would agree. Look at moderate head injury, for example. After a year or two, many/most folks are able to return to work, and it's not uncommon for this to be at a level commensurate with pre-injury functioning. However, in those first 3-6 months post-TBI, the condition is most definitely disabling. Same could be said for numerous other medical conditions (e.g., liver failure in a pre-transplant patient vs. functioning post-transplant; recovery from multiple compound orthopedic injuries following a motor vehicle collision; etc). Unfortunately, it just becomes a more complex situation with many mental health conditions, because the recovery trajectory is so varied, and it can be more difficult to directly measure/ascertain the degree of disability.

 

[PsyDr]

The WHO used to define disability as any decline in functioning secondary to an illness/disease/injury. In or around 2009, the WHO changed their entire classification of disability to a social construct in which society had not adjusted stuff to accommodate illness/disease/etc. Called participant restriction. So in the ICF classification, changes disability from an illness impact to the degree society has not changed to accommodate illness. IMO, this is idealistic.

The AMA publishes the Guidelines to Permanent Disability, with ratings on diagnostic category, body part, and whole body. In mental illness, there are impairments spheres including adls, concentration, etc with corresponding rating per.

 

[PsychBiker]

I know someone who "was" permanently disabled; this was determined by both a physician and psychologist about a year ago - saw his SSA Disability Determination paperwork. However, he is currently able to physically run, live independently, and cognitively able to do graduate level work, and fortunately he stopped accepting the financial support offered by the federal government. Admittedly, this individual's recovery was somewhat out of ordinary (miraculous even), but shouldn't permanent mean permanent? I mean, for at least a year right?

I have no commentary (yet) beyond this, just sharing my personal experience.

 

[WisNeuro]

There is no question that there are people on disability/SSDI/Service connection who are not in fact disabled in an unemployable sense. There are also people who are mayhaps temporarily disabled, and if we give them the label/identity, it can become permanent. There are also people who are legitimately disabled who get turned down for benefits. It's a ****ty system, we just have to find the way to help out or patients as best we can given the brokenness of the system.

 

[AcronymAllergy]

There is no question that there are people on disability/SSDI/Service connection who are not in fact disabled in an unemployable sense. There are also people who are mayhaps temporarily disabled, and if we give them the label/identity, it can become permanent. There are also people who are legitimately disabled who get turned down for benefits. It's a ****ty system, we just have to find the way to help out or patients as best we can given the brokenness of the system.

This is always one of my biggest concerns. While ideologically, I agree with the concept of a disability compensation system, when you give folks money for something (even if that something is not being able to do things), you're of course reinforcing it and running the risk of directly/indirectly altering their recovery. I've not been able to come up with a good solution for that, even in a completely hypothetical sense, in the (admittedly small) time I've tried to work it out in my head.

 

[PsyDr]

Allow svts/pvts in SSDI claims. Require 6 month re-evals. Maintain the level of SSDI payment. Pay a living wage for workers. Increase vacation time to eu standards. Mandate employees only work 40hrs, like Germany.

 

[Therapist4Chnge]

I won't do an eval (disability or otherwise) without svts/pvts. Interpreting data starts w establishing adequate effort.

 

[A Blue Duck]

I won't do an eval (disability or otherwise) without svts/pvts. Interpreting data starts w establishing adequate effort.

It's possible that for the populations you work with this is an acceptable practice. However, it almost seems as if your decision operates under the assumption that anyone who fails an svts is malingering, and that's not the case.

Other possible reasons for SVT failure:
True brain dysfunction
Disinterest in being assessed
Somatitizational or hysterical features
Psychiatric/emotional symptomology
Transient physiological features
-sleep deprivation
-acute pain of a severe nature
-oversedation of a severe nature


How many of those align with severe depressive symptomology? I count several.

But as others have said, this is sort of a, making sure we help those who really need it while remaining conscious of the fact there are many who do present in similar fashions yet do not.

 

[AcronymAllergy]

It's possible that for the populations you work with this is an acceptable practice. However, it almost seems as if your decision operates under the assumption that anyone who fails an svts is malingering, and that's not the case.

Other possible reasons for SVT failure:
True brain dysfunction
Disinterest in being assessed
Somatitizational or hysterical features
Psychiatric/emotional symptomology
Transient physiological features
-sleep deprivation
-acute pain of a severe nature
-oversedation of a severe nature


How many of those align with severe depressive symptomology? I count several.

But as others have said, this is sort of a, making sure we help those who really need it while remaining conscious of the fact there are many who do present in similar fashions yet do not.

I didn't get that read (i.e., that the post is saying that a failed SVT = definitive malingering), but rather that validity testing in disability evaluations in particular is not only prudent, but part of clinically-informed practice. That's just my take on what was said, though.

I would also contend that if someone fails an SVT (for whatever reason), then the SVT is probably doing it's job, and the associated data is likely not a valid representation of true functioning. Finally, I'd contend that many of the features/conditions you've mentioned (e.g., sleep deprivation, pain, and even much psychiatric/emotional symptomology) generally don't interfere with performance to the degree that would be needed to not do well on SVTs in the absence of other contributing factors. This is also where the role of the clinician comes into play in integrating all of the available data.

 

[WisNeuro]

I would also contend that if someone fails an SVT (for whatever reason), then the SVT is probably doing it's job, and the associated data is likely not a valid representation of true functioning. Finally, I'd contend that many of the features/conditions you've mentioned (e.g., sleep deprivation, pain, and even much psychiatric/emotional symptomology) generally don't interfere with performance to the degree that would be needed to not do well on SVTs in the absence of other contributing factors. This is also where the role of the clinician comes into play in integrating all of the available data.

Seconded. The level of sleep deprivation/pain necessary to "force" a PVT failure would be so severe that the person would be nigh untestable in the first place. And, the research would suggest that psychiatric factors do not lead to PVT failure outside of a secondary gain context.

 

[A Blue Duck]

I didn't get that read (i.e., that the post is saying that a failed SVT = definitive malingering), but rather that validity testing in disability evaluations in particular is not only prudent, but part of clinically-informed practice. That's just my take on what was said, though..

Very possible I overinterpreted that.

And, the research would suggest that psychiatric factors do not lead to PVT failure outside of a secondary gain context.

There's peer reviewed research that contends the entire spectrum psychiatric factors does not and can not lead to genuine PVT failure? Sorry, but I'd enjoy reading that.

Something broader about this topic that's been bothering me. And call me idealistic if you feel that way. Why are we so quick to jump to the conclusion that is someone fails a test based on their volition, that this is the same thing as malingering or secondary gain? Avolition is itself a common symptom of many forms of psychopathology.

Also I'd like to add I've learned a lot from this discussion so far and am enjoying it. I feel like I'm a bit in the minority here so just want to state I'm not purposefully attempting to be antagonistic or anything.

 

[WisNeuro]

There's peer reviewed research that contends the entire spectrum psychiatric factors does not and can not lead to genuine PVT failure? Sorry, but I'd enjoy reading that.

There is for depression and PTSD, two that have incorrectly presumed to cause cognitive problems. There is no evidence suggesting that psychiatric factors lead to PVT failure. Can genuine memory impairment lead to failure? Of course, but usually these are individuals who are in nursing home facilities needing around the clock care. Someone who is able to manage their own ADL's should not fail these.

 

[A Blue Duck]

There is for depression and PTSD, two that have incorrectly presumed to cause cognitive problems.

Another question then. If depression causes avolition, and avolition causes deficits in cognitive functioning (e.g. in reward learning or cognitive control), does it not follow that depression is the origin of these cognitive deficits?

 

[WisNeuro]

Another question then. If depression causes avolition, and avolition causes deficits in cognitive functioning (e.g. in reward learning or cognitive control), does it not follow that depression is the origin of these cognitive deficits?

I think we have to separate measurable objective deficits on cognitive testing (i.e., memory testing) and neurochemical changes. You can pick up subtle differences (with evidence that they are reversible) with certain paradigms, at the millisecond level. But, to have a deficit at the level to cause PVT failure, one needs to very seriously impaired. These are apples and oranges comparisons.

 

[AcronymAllergy]

Very possible I overinterpreted that.



There's peer reviewed research that contends the entire spectrum psychiatric factors does not and can not lead to genuine PVT failure? Sorry, but I'd enjoy reading that.

Something broader about this topic that's been bothering me. And call me idealistic if you feel that way. Why are we so quick to jump to the conclusion that is someone fails a test based on their volition, that this is the same thing as malingering or secondary gain? Avolition is itself a common symptom of many forms of psychopathology.

Also I'd like to add I've learned a lot from this discussion so far and am enjoying it. I feel like I'm a bit in the minority here so just want to state I'm not purposefully attempting to be antagonistic or anything.

To speak to the bolded comment/question, I don't think anyone here (or any responsible clinician pretty much anywhere) would assert that failure of a validity measure = malingering/secondary gain. Both of those latter concepts are separate but related matters, neither of which is directly and ultimately determined by a validity measure. Rather, the validity test tells us simply if the data we have is valid. That's it. If it's likely to be invalid, it's then on the clinician to ascertain the possible reasons for that (e.g., secondary gain), and to determine if all of this is directly and causally related (ala malingering).

 

[A Blue Duck]

I think we have to separate measurable objective deficits on cognitive testing (i.e., memory testing) and neurochemical changes.

I would agree. My main concern here isn't actually who and who can't genuinely fail an svt/pvt (although I realize we've been talking about it), but with cognitive functioning more generally. It's with blanket statements such as

There is for depression and PTSD, two that have incorrectly presumed to cause cognitive problems.

when, it seems to me, the evidence on which we are leaping to that conclusion is specific (e.g. memory testing; disregard of all the other components of cognitive functioning) and confusing a causal pathway (depression-avolition-failure) for a false correlation (depression doesn't directly cause memory problems, therefore it doesn't cause cognitive issues).

 

[Therapist4Chnge]

It's possible that for the populations you work with this is an acceptable practice. However, it almost seems as if your decision operates under the assumption that anyone who fails an svts is malingering, and that's not the case.

As a treating provider (my role in a non-forensic setting) is to evaluate and make recommendations for treatment, return to work, etc. Establishing a level of cognitive functioning is paramount, and to do that I need accurate data. Using svts/pvts helps me better insure valid data. Failed svts/pvts provides me with a flag (actually multiple flags) that the data may not be representative of the person's actual level of functioning. It isn't my job to ascribe intent, instead it is to make sense of the data within the context of the case. I typically provide the most common reasons as to why this could happen (citing the appropriate research), which includes secondary gain factors and related. Given that these are non-forensic evaluations, I still make recommendations for treatment and follow-up interventions that could lead to re-assessment to attain more accurate data.

As for your list of reasons for SVT failure….most have washed out once other factors are controlled for in the research studies.

Also I'd like to add I've learned a lot from this discussion so far and am enjoying it. I feel like I'm a bit in the minority here so just want to state I'm not purposefully attempting to be antagonistic or anything.

I don't read your posts as antagonistic. I'm glad that there is a dialogue about this because there are many people in the field (students through senior clinicians) who would benefit from such a discussion, as much has changed in the past 5-10 years in regard to validity assessment and what we know about actual cognitive impairment due to XYZ.

 

[WisNeuro]

Fair enough. I will say that I was focusing on a definition of cognitive issues as being those that are detected based on cognitive testing, since that is applicable to clinical practice. Within this definition, there is no evidence that these psychiatric factors cause demonstrable impairment in memory.

 

[Therapist4Chnge]

There are some exceptions to certain assessments, but that is why multiple measures should be used and should include standalone and embedded measures. Sometimes sensitivity and/or specificity isn't as good on one particular measure for a given dx, but taken as a whole with 3 or more measures interpretation of the data becomes much more viable.

From a practical point of view…if I am evaluating someone who completed their ADLs, drove themselves here, and navigated the campus/hospital to find me….their failure on a measure that can be successfully completed by moderately ******ed children and also moderately demented adults raises a red flag. I shouldn't jump to, "they are obviously malingering", but I do consider their performance to be incredibly far outside of their expected performance, and I need to account for that deviation. Many patients could have impairments, but are concerned that they won't be detected so they exaggerate, others may purposefully provide wrong answers as an act of non-compliance, while others may truly not understand the directions.

 

[erg923]

Avolition can cause lack of enagment in some situations that results in cogintive deficits. Avolition itself does not cause cognitive deficits.

 

[A Blue Duck]

From a practical point of view…if I am evaluating someone who completed their ADLs, drove themselves here, and navigated the campus/hospital to find me….their failure on a measure that can be successfully completed by moderately ******ed children and also moderately demented adults raises a red flag.

Ha. I see your point there.

 

[WisNeuro]

Exactly. I had a patient with a MASSIVE right MCA stroke. The stroke and accompanying damage destroyed about 80% of the right hemisphere, there is only CSF there at the moment. He scored perfectly on the PVT's I administered. The vast majority of individuals should not fail these tests.

 

[A Blue Duck]

Avolition causes lack of enagment that results in cogntive deficits. Avolition itself does not cause cogntive deficits.

So...the pathway just becomes depression-avolition-lack of engagement- cognitive deficits. What's the difference in a causal sense?


I keep thinking of the prototypical patient who formerly was active in a variety of activities and now lies in bed for 16 hours a day. Some would argue this is because they no longer experience previously enjoyable activities as rewarding. Some would argue their lack of engagement results in a lack of rewarding experience. Either way, this person is displaying an issue with reward learning.

 

[IT514]

1. T4C recently posted a cite to Marty Rohling paper on depression and cognitive deficits that should, I think, settle the matter that in an otherwise healthy person, Depression does NOT produce actual deficits in cognitive functioning once effort is taken into account? Right? Which leads to the conclusion, I would suppose, that the cognitive deficits perceived in depressed individual are really just suboptimal engagement secondary to anhedonia and avolition? Nothing neurologically-based and completely reversible wit treatment, right? Would this be accurate?

2. When do we perceive depression to actually be "disabling," so much so that a person qualifies for disability insurance for a specified time period through their private policies or from SSDI? Depression with psychosis seems like a given seeing that there is a safety factor involved there. But when else? I have a little more info and opinion on the issue due to my current work, but I would really like to see how big the range of opinion is among young professionals.

For #1: I would say this is accurate as long as one is careful to not over-apply the findings, particularly, to an older adult population. Also, need to know your SVTs/PVTs, and various ways to approach the effort question. Not all SVTs/PVTs or approaches are the same. I'm sure you (OP) realize this, but not everyone does. People naturally want what amounts to premature closure on this, so folks seem to make this topic simpler than it really is.


For #2: I dont know, tough question. I would consider age of onset, # of depressive episodes (I know this can be tough), level of function/work, and current severity. One of the things that frustrated me when I was brefly involved in some SSDI evals was a lack of treatment history or a long history of weak "supportive therapies." Otherwise, in a perfect world, if they have had a solid go at one or two EBTs, med trials, and still present like Eor with poor day-to-day function, then I would say with reasonable certainty that this is a depression that is disabling.

My unprofessional response is: given what you know of this person, their work hx, and the nature of their depression, would YOU want to work with them? Perhaps an extreme example, but I would not want a neurosurgeon with severe depression cutting into my brain.

 

[aequitasveritas]

The question becomes, disabling from what? If a neurosurgeon can no longer operate effectively in his chosen profession due to depression, should society's response be one where he is categorized as "disabled? "; or should he find another, related or unrelated, manner of working?

 

[erg923]

The question becomes, disabling from what? If a neurosurgeon can no longer operate effectively in his chosen profession due to depression, should society's response be one where he is categorized as "disabled? "; or should he find another, related or unrelated, manner of working?

For SSA, it requires not being able to sustain work even in fields/jobs other than the current one or most recent one.

For some commercial carrier policies, its from the present job duties/description.

 

[aequitasveritas]

For SSA, it requires not being able to sustain work even in fields/jobs other than the current one or most recent one.

For some commercial carrier policies, its from the present job duties/description.

I understand that. My question is whether we should operate that way as a society.

 

[Sendtrees]

Getting paid to be sick creates such a perverse incentive to stay sick that it is hard for me to take seriously the idea that any real, motivated treatment will follow. Disability pays people poverty wages to believe their problems are due to "depression" rather than that they have been crushed by social and economic forces. I know a lot of people who have received short-term disability for short-term medical and emotional stressors, but the open-ended designation is what worries me.

 

[Therapist4Chnge]

Disability pays people poverty wages to believe their problems are due to "depression" rather than that they have been crushed by social and economic forces.

The depression is most likely there, but it has not been adequately addressed and/or it manifests in other ways that are less clear to the patient and agency. It really should be a high bar for someone to be deemed not able to work, though many find their way on to disability and have little to no chance of getting back off. I'd argue that it'd be far less likely for someone to NOT be depressed after life has knocked them down and made it near impossible to get back up w/o significant intervention.

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In regard to depression presenting following a physical injury….I see it quite frequently in my out-pt practice, patients come in with legitimate medical conditions, but they over identify with somatic complaints and minimize psychological factors, so they are stuck trying to "feel better" because they aren't addressing what is actually contributing to their regression in functioning.