While Holidays bring out the best in many of us, mood disorders and depression are unfortunately extremely common. It is estimated that over one in four people that present to a doctor have depressive symptoms of varying degree. While grief and sadness may be normal physiologic responses to stressful situations, depression is not. Whether that depression translates into conditions that affect insurability or threaten a person’s well-being is always a difficult assessment for underwriter and clinician.
Depression can be genetic in origin, developmental in nature, or from psychosocial stresses (such as job loss or divorce for example). There are four categories of depression, and different causes and expression in each type. Symptoms may be common to all of the types, but treatment and prognosis can be quite different in each. Many present with physical or somatic symptoms, and it is the doctor’s job to rule out organic or systemic disease before concentrating on the mind as the etiology of the process.
Depression with adjustment disorders generally relate to a specific stressor or life event. It can be a grief reaction, a response to loss, or a reaction to a specific cause. The disorder usually occurs within months of the stressor and can range from general sadness and anxiety to major depression. Not every case has to be treated medically but, depending on the severity, many require some type of adjunct therapy.
Major depressive disorders can occur at any time and are not necessarily related to a stressor in life. Some are chronic and manifested by feelings of sadness, loss of interest and withdrawal from activities. Others may be true psychotic major depressions, with hallucinations, paranoia and agitation, and require hospitalization. Some may be physiologic, and postpartum depression is not uncommon in mothers shortly after childbirth. These may require medication as well and prompt attention.
Bipolar disorder is a mood shift, from manic and excited episodes to frank major depression. The swings can be marked, and there is a significant correlation with substance abuse as well. Manic episodes have increased irritability, flight of ideas, lack of sleep and exaggerated behavior that can include leaving a job, excessive spending, and ideas of grandeur that are regretted once the episode subsides. Significantly, the swing from “high” to the depths of a major depression can be very serious and require hospitalization for control as well.
Mood disorders from medications and illness are another category of problems. Chronic illness is associated with depression, as is cancer and end of life limitations. Alcohol dependency often coexists with depression. Certain medications given for other reasons also may cause depression as a side effect, ranging from hypertensive medications to ones for heart protection and Parkinson’s disease for example.
The biggest worry and most important complication of mood disorders is suicide. Certain categories, such as bipolar disease and those previously hospitalized for depression, are significant risks. Those with chronic illness (especially younger ages) and older patients with incurable disease are also elevated risks for suicide. The more severe depression is or was, the higher the chance of problems in the future. Those who actually have made plans for suicide are much more likely risks to try again to complete the task.
Many cases of depression are mild and respond well to antidepressants and psychotherapy. Ongoing medication used to preclude the possibility of a standard or preferred issue, but that is no longer the case. Cases where there is a documented stressor where that stressor has been dealt with have quite favorable prognoses. Depression where therapy is ongoing and the potential insured is working, having a normal family life and functioning well, have very favorable outcomes. Cases however where depression is profound, long lasting, interferes with normal life activities, and where any sort of a suicide attempt has been contemplated or actually attempted, present much more difficult problems. The strength and type of medication, the need for multiple medications, and the inability to improve despite medical intervention, represent unstable risks and cases are generally postponed or declined.
One problem unique to mood disorders and depression for underwriters is the inability to get detailed notes that adequately address the problem. Psychologists and psychiatrists tend to withhold what they feel is confidential information, even when it may benefit the application for insurance. Patients are likewise concerned that information may get into the wrong hands and are less likely to divulge or attempt to obtain it. It is important to stress to the potential insured that a lack of information can have the same effect as adverse information, and a separate note from the health professional that can be as specific to diagnosis and prognosis can keep any underwriter’s imagination from assuming the worst—especially when the information is beneficial to the case overall.
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1991. Goldstone does consulting full or part-time as well as on a fill-in basis for companies who need a medical director/physician. He can be reached by telephone at 949-943-2310. Emaill: [email protected]