Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Second Wave Depression

“There are two times when depression emerges in the case of work-related injury:

1. The patient feels the injury “ruined my life and no one cares.” This arises, as discussed, when there is insufficient education, training, job skills and, sometimes, motivation to perform or even seek out alternate work within permanent limitations.

Unfortunately, aside from the family, it is rare for this depression to be noted by those treating or managing the patient. The specific tissue damage is addressed, time is spent seeking authorization for care (including tests, medication and surgical procedures). And if the patient is irritable, sullen, displaying weight change, sleep problems and withdrawal, it is either not noticed, dismissed or attributed to the impact of pain or medication used to treat pain.

Most patients referred to me will deny that they are depressed by saying, “I am not sure I would call it exactly depressed” and then go on to describe classical symptoms of clinical depression.

Those that know that they are depressed will have reported this to several involved in their care; they may have even asked for a referral for treatment, and authorization for that comes even more slowly.

2. There is, however, a second tier or wave of depression that occurs as patients reach the “goal” of settlement. While individuals will accelerate their activities to reach a positive goal, they will pull away as they reach an end point that they consider to be negative. This is called “the goal gradient.” (For example, most will become very excited and motivated as a wedding approaches; others will become so alarmed at the prospect that they run-away at the last moment.)

Injury claim settlement is the same way. If an individual perceives that settlement is a solution to the problems that have spanned the last many months (or years), they will invest in their FCE, look at the concept of reducing their medication, be talking to people about employment and making viable future plans.

Since many injured workers are unable to conceptualize a future plan, know that they are to be released, know that they may always have pain and limitations, they feel helpless, a degree of hopelessness, and they become depressed once again.

Do not be certain that this depression-at-the-time-of-settlement is truly case building when, in fact, it may be a dread of the only future they see remaining for them.

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