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MSD-related injuries lead to depression, rehab failure: report

By Stefan Dubowski
| www.cos-mag.com

Montreal-based IRSST has released a new study highlighting the effects of depression among workers with musculoskeletal injuries undergoing rehabilitation. Research indicates the chances for successful return-to-work is reduced as injured workers become depressed.

A new study indicates that as many as 40 per cent of people sent to rehab for work injuries are also depressed — and depression makes it less likely that they’ll return to work.

One of the researchers behind the study says it’s time for a new approach to treating depression.

Tracking 225 people with musculoskeletal injuries, the researchers found that depressed patients were more likely to drop out of rehabilitation. And a year after treatment, the researchers found that depressed patients were less likely to return to work.

In a study published by the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST) — a Montreal-based scientific research organization — the researchers described a terrible Catch-22: depressed patients sometimes lack the motivation to complete rehabilitation treatment. Yet, rehabilitation treatment seems to help some patients tackle depression.

“Depression is associated with pessimistic views of the future, low expectancies for positive outcomes, motivation deficits and general withdrawal from social, recreational and occupational activities,” the report reads. “It is possible that depressed individuals might have difficulty mobilizing the motivational resources to maintain involvement in activities that could potentially improve their recovery.” 

In other words, if the depressed patients could be motivated to complete rehab, they might find themselves less depressed at the end of the treatment. But the challenge is motivating depressed people to complete the rehab in the first place.

So what’s the solution? According to the researchers, it may not have to do with traditional depression treatments. Pharmacological intervention (read: drugs) for depression might help in some ways — but in others, it could make things worse.

“Side effects of certain antidepressant medication can impede an individual’s ability to participate fully in physical rehabilitation programs (e.g., nausea, drowsiness, fatigue),” the report says.

And some patients might chafe at the idea of visiting a psychiatrist or a psychologist, says Michael Sullivan, Canada research chair in behavioural health at the Departments of Psychology, Medicine and Neurology at McGill University, and one of the report’s authors.

“There is the concern that clients will react defensively to being referred to a mental health professional shortly after injury due to the implication that the pain ‘is all in their head,’” Sullivan says.

The OT answer

He says the solution might lie with occupational therapists, because they’re trained in psychosocial interventions, but patients might be more open to receiving treatment from them than psychiatrists or psychologists.

“Our experience suggests that [occupational therapists] can be trained to deliver standardized interventions to target depressive symptoms,” he says. “Since the occupational therapist is not a traditional mental health professional, we hope that clients will not have the same defensive reactions as if they had been referred to a psychologist.

“Our next step is to work with the IRSST to develop a pilot project to test this type of intervention,” Sullivan says.

Musculoskeletal experts say they get the IRSST research paper’s message.

Tom Miller is a physiatrist (a physical medicine and rehabilitation specialist) and a professor in the Faculty of Medicine and Dentistry at the University of Western Ontario in London, Ont. He says physical rehabilitation and mental health are strongly linked.

Athletes unable to compete due to physical injury can suffer from depression. “That extends right out into the workplace as well,” he says, noting that depressed workers have difficulties performing their jobs.

Erika Pond Clements is an occupational therapist in Kitchener, Ont., who helps people who aren’t working because of depression. She said some patients prefer occupational therapists for support such as cognitive behavioural therapy and goal-focused interventions.

“The focus of occupational therapy in general is looking at people’s meaningful activities in their lives,” she says. “We’re helping people identify the activities that are most meaningful to them, and to explore how their thoughts and feelings impact on their ability to participate in those things.”

She also says depression and injuries often go hand in hand.

“When somebody is dealing with a temporary or permanent disability, it affects their ability to feel like they’re participating meaningfully. That affects their self esteem, their satisfaction, and their quality of life.”

But she also finds that occupational therapy can help patients who are wary of psychiatry and psychology.

“Some people are very open and prefer to see a psychiatrist or psychologist, especially if the issue that feels most difficult to them is depression,” Pond Clements says. “But people are sometimes reluctant because they have ideas about what it means to see a psychiatrist or psychologist, that they’re not believed, that it’s all in their head.”

Occupational therapy also makes sense for some patients because they draw a connection between the name of the profession and their desire to return to work – although Pond Clements points out that occupational therapy has to do with occupations beyond the workplace as well, including recreational activities.

How the study was conducted

Report R-675,

Pain, Depression, Disability and Rehabilitation Outcomes

was written by Sullivan, Maureen Simmonds of McGill’s School of Occupational Physical Therapy, and Ana Velly from McGill’s Community Epidemiology and Biostatistics department. The researchers took a sample of 225 individuals with musculoskeletal injuries and checked them for depression at the beginning of treatment, mid-treatment and at discharge over a four- to seven-week rehab period, as well as follow-up interviews by phone.

In addition to the link between depression and rehabilitation outcomes, the research team found – referencing other studies — the link between injuries and costs to businesses.

“Persistent musculoskeletal pain is currently the most expensive non-malignant health condition affecting the North American working-age population,” they say. “In 1998, the cost of lost production due to disability associated with musculoskeletal disorders in Canada was estimated to be in excess of $12 billion.”

They point out that they are not the first team to draw the line between depression and rehab. “Surveys indicate that approximately 20 per cent to 50 per cent of individuals with musculoskeletal conditions show evidence of elevated depressive symptoms. Individuals with pain-related musculoskeletal conditions with elevated depressive symptoms have sick-leave duration that is twice as long as individuals with musculoskeletal conditions who do not have depressive symptoms. Depressive symptoms in individuals with musculoskeletal conditions have also been associated with longer duration of wage replacement benefits following work injury or surgical intervention.”

But the McGill team isn’t covering old ground.

“To date, the relation between depressive symptoms and rehabilitation outcome has been studied only in individuals whose musculoskeletal condition has already become chronic. Little is currently known about the relation between depressive symptoms and rehabilitation outcomes for individuals with acute or sub-acute musculoskeletal conditions.”

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