Disease of the month: Depression and anxiety disorders

Incredibly common, yet little understood by the public, Fergus Bescoby investigates the insurance angle.

The word ‘depressed' is an everyday word, probably overused, often used along the lines of "I'm depressed" when in fact what they actually mean is "I'm fed up because I've had a row, I hate my boss or I've split from my boyfriend/girlfriend".

The medical profession over the past decade has tried to label all sufferers of mental health issues, no matter how minor, which can be evidenced by the huge increase in International Classification of Disease codes from about 20 to over 350.....all related to mental health conditions.

This article however, is written concentrating on the more severe end of the mental health spectrum because it is these conditions that are of most relevance to life and health insurance

Statistics show that 1 in 4 Britons will suffer from a mental health problem within any given year, with anxiety and depression being the most common combination. The cost to the economy is approximately £8.6bn a year.

This is thought to be due to the rising number of people who are reported as being unable to work due to their mental health status, but does not include the heavy burden placed on the NHS by depression and other mental health related conditions.

Research predicts that the cost of GP consultations to treat depression amounted to more than £33m in 2007-08, while treating depression in hospitals cost another £218m.

Depression and anxiety disorders are not the same, although at first glance they seem similar and commonly occur together. Not everybody who is anxious is depressed, but most depressed patients have some symptoms of anxiety.

Depression generates emotions such as hopelessness and despair and anger. Energy levels are generally low, sleep patterns are frequently disturbed and depressed people often feel overwhelmed by the day-to-day tasks and personal relationships which are so important to life.

A person with anxiety disorders however, experiences fear, panic or anxiety in situations where most people would not feel threatened or pressured. The sufferer may experience sudden panic or anxiety attacks without any recognised trigger and often lives with a constant nagging worry or anxiousness. Without treatment such disorders can restrict a person's ability to work, maintain a relationship or in some instances even leave the house.

Both anxiety and depression are frequently treated in much the same manner, which may explain why the two disorders are so often confused. Anti-depressant medication is often used for depression while behavioural therapy frequently helps people overcome both conditions.

Depression

With true depression, there is a low mood and other symptoms each day for at least two weeks. Symptoms can also become severe enough to interfere with day-to-day activities.

The exact cause is not known and anyone can become depressed. Some people are more prone to it, and it can develop for no apparent reason. There may be no particular problem or worry, but symptoms can develop quite suddenly.

An episode of depression may also be triggered by a life event. In many people it is a mixture of the two. For example, the combination of a mild low mood with some life problem, such as work stress, may lead to a spiral down into depression.

Women tend to develop depression more often than men. Particularly common times for women to become depressed are after childbirth (postnatal depression) and during the menopause.

Although not fully understood, it is felt that a chemical imbalance in the brain might be a factor. However, an alteration in some chemicals in the brain is thought to be the reason why antidepressants work in treating depression.

Depression can run in families. If there is one parent who has become severely depressed, there is about eight times more likelihood of a sibling also becoming depressed.

Doctors normally describe depression by how serious it is:
Mild depression has some impact on your daily life.
Moderate depression has a significant impact on your daily life.
Severe depression makes the activities of daily life nearly impossible. A small proportion of people with severe depression may have psychotic symptoms.

Anxiety
These disorders are amongst the most common mental health disorders with about 10% of the population suffering from anxiety to such a degree that treatment is required. Women are more frequently affected than men. The onset of the disorder is rarely after the age of 45.

Anxiety is a normal response to stress or danger. At times it is helpful because it can help prepare the body for action, and it can improve performance in a range of situations. Anxiety becomes a problem when it is experienced intensely and it persistently interferes with a person's daily life.

Anxiety can be experienced in a number of different ways, both psychological and physical and symptoms can include irritability, inner tension, fear of losing control, chest pain and tightness, palpitations and sweating.

Specific types of depression and mental health disorders

• Obsessive-compulsive disorder (OCD)
OCD is characterised by constantly recurring patterns of obsessive thoughts or compulsive actions which are always repeated in the same way and force themselves onto the patient despite being experienced as pointless. These thoughts or actions cannot be suppressed, and attempts to resist them result in severe internal tension and anxiety in the patient.

Obsessive-compulsive disorder (OCD) is a relatively rare disorder. While many people (14 per cent of the general population) have minor obsessional symptoms, OCD itself occurs in less than 1 in 1000 people (0.1 per cent) with both men and women being equally affected.

It is not to be confused with Obsessive Compulsive Personality Disorder (OCPD), which although similar has different traits such as a preoccupation with rules orderliness and control. OCPD sufferers tend to be high achievers but often find it difficult to complete tasks due their ‘over perfectionist' attitude. They also find expressing affection or praise extremely difficult

• Post-traumatic stress disorder (PTSD)
Symptoms tend to come on weeks, or even months, after a stressful event that was of an exceptionally threatening or catastrophic nature, which would cause distress in almost anyone. It can persist for years. Symptoms include flashbacks (vivid memories of the event), nightmares, avoiding anything associated with the stressful event and being on edge. In addition, sufferers often experience generalised anxiety, panic disorder, depression, guilt (of surviving) and blunting of their emotions.

• Bipolar disorder (manic depression) & Schizophrenia
This form of depression can be defined as an emotional disorder characterized by changing mood shifts from depression (low mood) to mania (high mood) which can sometimes be quite rapid. People who suffer from manic depression have an extremely high rate of suicide.It affects the same number of men and women and tends to run in families. Schizophrenia sufferers have delusions and hallucinations but do not have a ‘split' personality as once described

• Endogenous Depression
Endogenous means from within the body. This type of depression is defined as feeling depressed for no apparent reason.

• Situational Depression, Reactive Depression or adjustment disorder
Depressive symptoms developing in response to a specific stressful situation or event (e.g. job loss, death of family member). These symptoms occur within 3 months of the stressor and lasts no longer than 6 months after the stressor (or its consequences) has ended. Depression symptoms cause significant distress or impairs usual functioning (e.g. relationships, work, school) and do not meet the criteria for major depressive disorder.

• Psychotic Depression
Major depressive episode with psychotic symptoms such as hallucinations (e.g. hearing voices), delusions (false beliefs).

• Postpartum Depression
Pregnancy brings about many hormonal shifts. These dramatic shifts can sometimes affect mood. This is commonly known as the "baby blues." Postpartum depression can be more than just a case of the blues, however. It can range from mild symptoms that go away without treatment all the way up to postpartum psychosis, which left untreated, may be responsible for tragic murders of children.

Treatment
Depending on the severity, treatment usually involves a combination of drugs, talking therapies and self help. Hardly anyone with depression is admitted to a psychiatric hospital. Most get treatment from their GP and make a good recovery.

• Talking treatments
Cognitive behavioural therapy (CBT) normally consists of a fixed number of sessions - usually six to eight sessions over 10-12 weeks. CBT is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts - for example, being active to challenge feelings of hopelessness.

Interpersonal therapy (IPT) focuses on relationships with other people and on problems, such as difficulties with communication or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed.

• Antidepressant drugs
SSRIs (selective serotonin reuptake inhibitor) are as effective as the older TCAs (tricyclic antidepressants) and have fewer side effects. Fluoxetine, citalopram and sertraline are all examples of SSRIs. The drug increases the level of a natural chemical in the brain called serotonin, which helps lift the mood.

Underwriting implications
For the majority of disclosures of mild anxiety or depression, additional information will be requested in the form of a tele-medical questionnaire. This should ascertain the following: Type of disorder or symptoms, date of onset ,cause, number of episodes ,treatment ,time off work, any suicide attempts, suicidal thoughts or self harm and current mental state

A GPR may be required if the information on the tele-medical questionnaire indicates a more severe psychiatric condition.

Likely underwriting outcomes
Terms will depend on the following:
Whether it is a single event, recurrent or permanent
Whether the client has been referred beyond GP care
Whether the client is on treatment, the type of treatment, and whether they are compliant
Work absence and date of last episode

For Life Cover - anyone who is currently on treatment for mild anxiety but has no true depression and is healthy in all other respects is unlikely to be charged an extra premium. For those with depression, or who have had depression in the two years preceding the application, are likely to incur a small loading and a mood disorders exclusion will be applied to "own occupation" TPD.

If they have not been on treatment for at least two years then they are likely to be accepted at standard rates although this will depend on the severity of the initial episode and number of recurrences.

For serious illness cover and critical illness cover mild anxiety or depression is unlikely to incur a loading, but there will be a loading for more serious psychiatric illnesses.

Depression is one of the most common causes of disability claims and terms for Income Protection Cover are offered with this in mind. Anyone currently on treatment for depression is unlikely to be accepted for Income Protection Cover.

Where treatment has stopped and the condition has resolved, there will be a postponement period of up to two years depending on the severity of the initial symptoms and duration of the condition. Depression will then be excluded.

If treatment stopped more than seven years ago, then it may be feasible to accept Income Protection Cover at standard rates with no exclusions wherever possible, although this will depend on the previous history.

Fergus Bescoby is underwriting development manager at PruProtect

https://www.pruprotect.co.uk/adviser/