Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Bipolar Affective Disorder, Depressed


Related Terms

  • Affective Bipolar Disorder
  • Affective Bipolar Disorder with Rapid Cycling
  • Affective Bipolar Disorder with Seasonal Pattern
  • Bipolar I Disorder
  • Bipolar II Disorder
  • Depressed Bipolar Disorder
  • Manic-depressive Illness Depressed Type

Differential Diagnosis

  • Cyclothymic disorder
  • Dysthymic disorder
  • Major depressive disorder
  • Mood disorder due to a general medical condition
  • Personality disorders
  • Psychotic disorders
  • Substance-induced mood disorder

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Anxiety disorders
  • Eating disorders
  • Panic disorder

Factors Influencing Duration

As in unipolar depression, factors influencing length of disability in individuals diagnosed with one of the depressed subcategories of bipolar affective disorder include the severity of the illness, presence of complicating factors such as substance abuse or suicide attempts, type of occupation, and response to therapy. This may translate from almost no time lost from work to a major leave of absence. Only the most severe cases of bipolar illness result in total and permanent disability. Most individuals should be restored to near normal functioning within a few months. If appropriate allowances and monitoring are provided, individuals may return to work sooner. Substance abuse also complicates and delays response to treatment. If a manic episode results from therapy, recovery will be significantly slowed as this condition may be even more serious than the initial depression.

Medical Codes

ICD-9-CM:
296.50 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; Unspecified
296.51 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; Mild
296.52 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; Moderate
296.53 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; Severe, without Mention of Psychotic Behavior
296.54 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; Severe, Specified as with Psychotic Behavior
296.55 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; in Partial or Unspecified Remission
296.56 - Bipolar I Disorder, Most Recent Episode (or Current) Depressed; in Full Remission

Overview

Although bipolar affective disorder is classified as a mood disorder, the condition also affects cognition and behavior and frequently is complicated by psychotic symptoms (e.g., delusions, hallucinations, disorganized thinking). As many as two-thirds of bipolar patients have a lifetime history of psychosis (Rivas-Vasquez). Bipolar affective disorder is a disturbance of the brain characterized by major mood swings. When the condition is severe, an individual may experience episodes of extreme highs (mania) and extreme lows (depression) several times a year. These episodes may last between a few days to a few months. The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) adds the suffix "rapid cycling" to the diagnosis if the individual experiences four or more mood episodes (depression, manic, or mixed) during a twelve month period. The suffix "with seasonal pattern" applies to bipolar affective disorder when the depressive component is temporally related to the season of the year (i.e., fall or winter). Several subcategories of bipolar affective disorder are characterized by depression as the predominant or most recent symptom.

According to DSM-IV-TR, bipolar I disorder is characterized by the occurrence of one or more manic or mixed episodes. When the most recent episode is a major depressive episode, the diagnosis is bipolar disorder, most recent episode depressed. DSM-IV-TR characterizes bipolar II disorder as a condition characterized by one or more major depressive episodes accompanied by at least one hypomanic episode. Episodes of depression last from a few days to a few months and are characterized by morbid preoccupation, hopelessness, and apathy.

There is no single proven cause but it is thought to be a biochemical problem related to lack of stability in transmission of nerve impulses in the brain. This biochemical imbalance makes individuals with bipolar affective disorder more vulnerable to emotional or physical stress.

Incidence and Prevalence: Of the subcategories of bipolar affective disorder where depression predominates or a depressive episode is most recent symptom: Lifetime prevalence of bipolar I disorder is estimated to range from 0.4% to 1.6%, and lifetime prevalence of bipolar II disorder is approximately 0.5% (DSM-IV-TR 385).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Studies indicate that first-degree biological relatives of individuals with bipolar I disorder have elevated rates of bipolar I disorder, bipolar II disorder, and major depressive disorder. Other research suggests that individuals with a first-degree biological relative with bipolar II disorder have increased rates of the condition (DSM-IV-TR 385). Women are more frequently diagnosed with the subcategories of bipolar affective disorder where depression is predominant (Thase).

Source: Medical Disability Advisor



Diagnosis

History: Although the history is of greatest importance in establishing the diagnosis, a physical exam and laboratory tests should be done in every new case of suspected bipolar or depressive illness. A thorough history is vital in making the diagnosis of bipolar affective disorder. The actual criteria for the depressed phase of bipolar illness are the same as for major (unipolar) depression or major depressive episode. The only difference is a history of manic or near-manic episodes not attributable to medications, drug abuse, or physical illness.

For a DSM-IV-TR diagnosis of one of the depressive subcategories of bipolar disorder, the criteria for a major depressive episode must be met. These include feelings of sadness, hopelessness, and loss of interest in life activities or relationships must be present for at least 2 weeks making it difficult for the individual to function. Diagnosis must also be associated with at least four of the following: thoughts of death or suicide, trouble sleeping or sleeping too much, poor appetite or overeating, difficulty concentrating and making decisions, feeling slowed down or too agitated to sit still, feeling worthless or guilty with low self-esteem, and loss of energy or feeling tired all the time.

Whenever possible, corroborative history from friends, family members, or employers is useful as is any family history of mental illness or suicides. A careful, nonjudgmental inventory of substance abuse should be made in every case. Not only can bipolar illness be confused with substance abuse, but the abuse will require specific treatment measures of its own. Severe depressive episodes may be associated with seeing visions (hallucinations), hearing voices, or having false beliefs (delusions).

Physical exam: Even with a clear-cut history of bipolar illness, physical causes capable of producing symptoms of depression, such as hypothyroidism, cancer, or any chronic illness need to be excluded. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to diagnose the illness.

Tests: Psychological testing used in establishing the diagnosis may also provide a means of assessing severity and response to treatment. Laboratory testing, including thyroid function tests, or brain imaging studies may be necessary to exclude causes other than mood cycling. MRI brain scans may help predict outcome, as a recent study showed that those individuals with abnormalities deep in the brain (subcortical white matter lesions) had a worse outcome than those individuals without these abnormalities.

Source: Medical Disability Advisor



Treatment

Medications are the mainstay of treatment, with psychotherapy a useful supportive tool. Medications consist primarily of mood stabilizers, such as lithium and valproic acid, that moderate the intensity of mood swings. The most extensively studied mood-stabilizing agent is lithium, which is often the first choice of treatment for bipolar affective disorder. Anticonvulsant medications, such as valproic acid and carbamazepine, have increasingly been employed as important pharmacotherapeutic alternatives, either as a primary pharmacotherapy or as augmentation to lithium. Newer anticonvulsants such as lamotrignine are also considered as a treatment option. When present, psychotic symptoms such as paranoid delusions need to be targeted specifically with antipsychotic medications. Antipsychotic medications such as olanzapine and clozapine may be used. Recently the FDA has approved risperidone, quetiapine, and ziprasidone as primary and as adjunct therapies for the treatment of bipolar affective disorder.

Antidepressants may also be necessary. Some antidepressants are thought to be associated with a risk of precipitating a manic episode making the long-term course of bipolar illness worse. Care must be exercised when choosing the type and duration of antidepressant therapy.

Augmentation of pharmacotherapy with various psychotherapeutic techniques is recommended by most authorities. Psychotherapy added to treatment during the depressed phase may ensure that the individual remains safe until improvement occurs and that family integrity is supported. In some instances, the risk of self-harm or personal neglect is so great that psychiatric hospitalization is warranted.

A primary goal of psychotherapy is reducing the high rate of medication discontinuation and overall noncompliance with the pharmacological regimen. Other risk factors associated with mood instability also serve as psychotherapy objectives. Psycho-educational classes, support groups, and cognitive behavioral therapy groups lend themselves well to adjunctive treatment of bipolar disorder, and spouse and family involvement can also be helpful. Integrated dual diagnosis treatment for individuals suffering from coexisting mental illness and substance addiction helps to comprehensively address both disorders at once.

Some cases of depression are treatment-resistant. No combination of medications or psychotherapy seems to provide adequate relief for these individuals. In this circumstance, electroconvulsive therapy (ECT) is the treatment of choice and is both safe and effective.

Source: Medical Disability Advisor



Prognosis

Most episodes of depression in the context of bipolar illness get better within several weeks. Although improvement is accelerated by treatment with medications, most individuals take up to 4 to 6 weeks to respond clinically to antidepressants. Up to 60% of individuals with bipolar disorder obtain some relief from lithium, although the response rate among those with rapid cycling is only 20% to 40%. As more new medications continue to become available, there is a greater chance of finding one that is effective for a given individual. The long-term course of the illness is highly variable. Left untreated, however, it may get worse with time and tend to become resistant to treatment, leading to permanent disability with poor social function.

Source: Medical Disability Advisor



Complications

The same complications seen in unipolar depression may be present in bipolar depression. The most serious complication is suicide. Other complications include psychotic symptoms such as hearing voices (hallucinations) or having strange beliefs (delusions) that are usually paranoid in nature. These may put the individual at risk for accidents or lapses in judgment. Malnutrition may complicate prolonged depressive episodes when loss of appetite is prominent. The most common complication is substance abuse especially alcohol and affects about one-half of those with bipolar illness. Another dangerous complication is the presence of a mix of both manic and depressed symptoms. There is always the risk that an episode of mania may follow depression and/or emerge partly as a result of antidepressant therapy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Highly stressful situations should be avoided as well as those demanding high levels of concentration and alertness. Irritability and low frustration tolerance can be major problems and should be considered in the work environment.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of bipolar affective disorder (depressed) confirmed?
  • Even if there is a clear history of bipolar illness, have the history, physical exam, and testing excluded other possible causes of symptoms?
  • Does medication and drug history reveal use of beta-blockers, sedatives, or other prescription medications or street drugs that could cause symptoms resembling those seen in depression?
  • Does brain MRI show deep white matter abnormalities associated with poor outcome?
  • Does evidence exist of rapid cycling defined as four or more episodes of mania, excitement with moderate behavior change (hypomania), or depression in any 12-month period? Because it responds poorly to treatment, could failure to improve be linked to rapid cycling?
  • Because low blood levels of thyroid hormone are more common in individuals with rapid cycling than in other bipolar individuals, were thyroid function tests performed before and during treatment?
  • Is there a history or current evidence of substance abuse that may make an individual more prone to cycling with shorter episodes than usual?

Regarding treatment:

  • Does individual fit criteria for rapid cycling? Is individual being treated with lithium even though the response rate among those with rapid cycling is considered only 20% to 40%?
  • Is thyroid replacement therapy warranted based on thyroid function tests?
  • Has use of antidepressants precipitated hypomania, warranting discontinuation or change in medications?
  • Does individual have substance abuse? Could it be responsible for limiting the effectiveness of lithium or reducing compliance with dosing regimen? How successfully is the substance abuse being addressed? In the meantime, what plan is in place to ensure compliance with medication regime?
  • Although not officially a treatment for bipolar disorder, was carbamazepine considered as a supplement or alternative to divalproex sodium and lithium?
  • If combinations of medications and psychotherapy have not provided adequate relief, is electroconvulsive therapy (ECT) warranted at this time?
  • If self-harm or personal neglect puts individual at risk, is psychiatric hospitalization warranted?

Regarding prognosis:

  • Considering that individuals with severe depression have a high suicide rate, does individual display any tendency toward self-harm or suicide? What preventive safeguards are in place?
  • Is illness interfering with self-esteem, friendships, social supports, and career goal achievements?
  • Would individual benefit from one-on-one psychotherapy based on interpersonal, cognitive, or behavioral approaches?
  • Is individual involved in a support group?
  • If no improvement occurs after 6 to 8 weeks or if symptoms worsen, is it time to try another treatment approach or another medication or get a second opinion from another healthcare professional?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Rivas-Vasquez, R. A., et al. "Current Treatments for Bipolar Disorder: A Review and Update for Psychologists." Professional Psychology: Research and Practice 33 2 (2002): 212-223.

Thase, M. E., M. Bhargava, and G. S. Sachs. "Treatment of Bipolar Depression: Current Status: Continued Challenges, and the STEP-BD Approach." Psychiatric Clinics of North America 26 2 (2003): 495-518.

Source: Medical Disability Advisor






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