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Tuesday, 21 June 2011

Does LTD Make Depression Worse?

Depression has become one of the chief reasons that people in North America are home receiving Long Term Disability (LTD) benefits.  Why is this?

One answer, of course, is that depression appears to have become steadily more common over time.  The reasons for this are numerous and best left to other posts.

Another is a shift in what we might call health culture:  the belief-based practices that become common among health practitioners in the absence of evidence.

Send a dozen people to their healthcare practitioners with instructions to recite standard symptoms of mild to moderate depression.  When they return, count how many have been encouraged to take time off work.  “I’ll write you a note.”

What happens when we send depressed people home on leave?

The fantasy is that they will use all of that extra time to take care of themselves.  Self-care will become the new, and temporary, full-time job, and recovery will be much faster as a result.  The person will snap back and return to work invigorated and rested.

I’ve looked and I can’t find any evidence suggesting that this actually works.  Perhaps I am looking in the wrong places.  But I suspect there isn’t any.

The treatment for depression, in most instances, is an enhanced engagement with life.  Exercise, structure, tasks to complete, social contact, a reason to leave home in the morning.  Sure, we can all benefit from an examination of our distorted thinking, the resolution of childhood traumas, a consideration of our ultimate values.  But eventually the task is to re-engage.

Does stress leave or long term disability promote these goals?

By sending people home, we remove perhaps the biggest element of structure in their lives.  We take away the need to go to bed and get up at a regular time.  We alleviate the necessity of getting oneself cleaned up, organized, and out of the house.  We eliminate most of the contact with other people.  In effect, we give free rein for the depression to become the person’s master.

The symptoms of depression are problematic in part because they spiral.  I don’t sleep at night, so I catch up with a long nap in the afternoon, which makes it more difficult to sleep the next night.  My energy level is low, so it’s hard to pull myself together to get out of the house, so I stay home, bored, ruminating, and chastising myself for being lazy.

Without any external need to get going, my activity level is dictated entirely by my will, motivation, and self-discipline – all of which are impaired by the depression.

So what am I supposed to do?  If this is my first time on leave, I may automatically use my existing understanding of what it means to be off sick.  What is a sick person supposed to do?  Stay home, preferably in bed, and do relatively little.  But this is how to make depression worse, not better.

I may actually fear leaving the house, doing the shopping, seeing my friends, doing volunteer work, taking cross-country ski lessons – all of which are reasonable therapies for depression.  What if someone sees me?  “I thought you were off sick.  You must be faking.”  Far from encouraging anti-depression activity, sick leave makes it more difficult.

There are two additional problems.  First, getting sent home from work can get interpreted, by the depressive mind, as further evidence of one’s failure, incompetence, and worthlessness, thus reinforcing the problem.

Second, the prospect of eventually returning to work becomes a fearful barrier in itself.  “Will I be able to do it?”  “Will they think less of me now that I’ve proven I can’t take it?”  “Will everyone I work with grill me about the reason I was off?”  “Will they be looking for reasons to fire me?”

In other words, stress leave can be an iatrogenic cause of even deeper depression.  We worsen the problem we intend to solve.

I’m not suggesting that we want seriously depressed individuals on the job as air traffic controllers.  But most of us are not in such sensitive positions.  Most can benefit from cutting back a bit on responsibilities and working to enhance life balance.  Sending people home “sick” for six weeks (or longer) is often counterproductive.

Depression exists, independently of long-term disability.  And LTD can be a useful tool.  But it is used far too readily, and often produces more problems than it solves.

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