A study of the relationship of the characteristics of injured workers receiving vocational rehabilitation services and their depression levels.

Depressive disorders affect approximately 19 million adults in the United States (National Institute of Mental Health [NIMH], 2002). Depression as noted by Schouten and Williams (2000) is both an important cause and consequence of disability, both as a primary disorder and in combination with other medical illnesses. The NIMH notes that stressful life events such as a work-related injury may contribute to recurrent episodes of depression in some individuals, while in others depression recurrences may develop without identifiable triggers. It is important to explore all treatment options for those suffering from refractory depression based on its potentially severe functional impairment, and the high cost associated with this disorder (Sajatovic et al., 1999).

A feature common to injured workers is a presentation of mild to severe major depression present in most, if not all of those referred for psychiatric evaluation (Williams, 1997). Schouten and Williams (2000) noted that major depression usually results from prolonged disability and unemployment. According to Williams (1997), stressful life events such as a work injury, pain, loss of wages, physical limitations, etc., have produced depression among injured workers. Moreover, Williams postulated that workers with psychiatric problems are in the same predicament as their hysteric, bipolar, obsessive compulsive disorder, borderline, and attention deficit hyperactivity disorder (ADHD) predecessors were five, fifteen, twenty-five, and one hundred years ago; poorly understood by most clinicians today, and often receive little or no treatment, or ineffective treatment.

Studies have examined the relationship between depression and gender (Barnow et al., 1970; Douglas, 2000; Narrow, 1998; NIMH, 2002), education (Blazer, Kessler, McGonagle, & Swartz, 1994; Easterday, Schau, & Martinez, 1997; Guth, 2000; Meich & Shannahan, 2000), income (Meertens, Scheepers, & Tax, 2003; Mutaner, & Barnett, 2000), age (Heithoff, 1995), ethnic status (Blazer et al., 1994; Williams & Harris-Reid, 1999), pre-injury psychological history (Polatin, Kinney, Gatchel, Lillo, & Mayer, 1993; Spencer & McDaniel, 1993; Williams, 1997), time away from the work force since injury (Green, 1996; Mason, Wardrope, Turpin, & Rowlands, 2002; Schouten & Williams, 2000; Tate, 1992; Weed & Field, 2001), severity of medical injury (Aronoff & Feldman, 2000; Nagumo, 2000), and job skill level (Brodwin & Brodwin, 2002; Hopp, 2002; Sanne et al., 2003; Zwerling et al., 2002). Although studies have investigated the association between depression and socio-demographics, there is a paucity of empirical research examining the interplay between depression and such socio-demographics among the injured worker population.

The purpose of this study was to investigate the relationship between socio-demographics and depression levels among injured workers. One might hypothesize that many customers with work injuries vary in their level of depression based on various socio-demographic variables such as gender, education, income, age, ethnicity, pre-injury psychological history, time away from the work force since work injury, severity of work injury, and job skill level. The literature on mental illness relating to the definition and general understanding of depression in the adult working population will be reviewed, as this construct will be used to operationalize depression levels. Further, a review of the literature on the findings on the relationship between certain demographic characteristics (e.g., gender, education, and age) and depression will define and clarify the relationship between these variables. Last, the Beck Depression Inventory, Second Edition (BDI-II) will also be reviewed in determining its validity and reliability as a measure of depressive levels.

Literature Review

Definition and Types of Depression

An NIMH panel (2002) concluded that there is a high degree of variation among persons with depression in terms of symptomatology, the course of illness, and each individual's response to treatment. This indicates that depression may have a number of complex and interacting causes. The panel notes that depression often co-exists with anxiety disorders, social phobia, or generalized anxiety disorder. They note that depression and these co-occurring illnesses can be diagnosed and treated. Depression can be subdivided into major depression, dysthymic disorder, and adjustment disorder with depressed mood (Conn & Kaye, 2001). Adams (2002) states that major depression is most often acute, readily treated, and does not tend to last for more than six months as opposed to a dysthymic disorder which may last for years.

A common misinterpretation is that a major depressive episode or major depressive disorder is somehow a more serious disorder. However, the DSM-IV-TR diagnostic criterion for dysthymic disorder among adults indicates that the individual has a depressed mood for most of the day, for at least two years [American Psychiatric Association (APA), 2000]. Dysthymia is also known as a low grade depression and in order to be diagnosed with dysthymic disorder, two or more of the following would be present: poor appetite, overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, difficulty in making decisions, or feelings of hopelessness. DSM-IV-TR notes that symptoms of dysthymic disorder, typically chronic and mild depression, must persist for at least two years in adults to meet the diagnostic criteria.

The last major psychological disorder related to work injury is adjustment disorder with depressed mood. As noted by the DSM-IV-TR, the major underlying theme behind this disorder is the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors (e.g., the impact from a work-related injury), within three months of the onset of the stressor(s) (APA, 2000). These symptoms or behaviors are evidenced by either of the following: (1) marked stress that is in excess of what would be expected from exposure to the stressor, or (2) significant impairment in social or occupational (academic) functioning, or in usual social activities including interpersonal relationships with others.

Demographics and Depression

Gender

Several studies have documented depression level differences between males and females. For example, Douglas (2000) conducted a study that revealed that females demonstrated a higher incidence of depression than their male counterparts. According to the NIMH (2002), women are nearly twice as likely (12%) as men (7%) to be affected by a depressive type illness each year. They also reported that at some time during their lives, as many as 20% of women have at least a single episode of depression that should be treated. In another study by Barnow et al. (1970) relating to the importance of psychosocial factors, gender and severity of depression, females were shown to possess more depressive syndromes than males. Narrow (1998) found similar results which suggested that women (6.5%) are twice as likely as men (3.3%) to suffer from a major depressive disorder in any given year. In a similar study, the World Health Organization (2002) reported that depressive disorders account for approximately 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among the male population.

Another study by Maciejewski, Prigerson, and Mazure (2001) was conducted to determine if women are more likely than men to experience an episode of major depression in response to stressful life events. They concluded that females were approximately three times more likely than men to experience depression in response to stressful life events. Dewa et al. (2002) found similar results with regard to the ratio level between men and women with depression in the workplace population. They found that women represented 3.9% of their study sample with depression and men represented 1.4% of the sample. Similarly, Lehtinen and Joukamaa (1994) reviewed world-wide studies between the years 1965 to 1992 and found that depressive symptoms varied between 10% to 19% in men and from 18% to 34% in women. When a diagnosis of major depression was made, they found that the range was between 2.6% to 5.5% for men, and between 6.0% and 11.8% for women.

Education

Education has also been identified as a significant contributor to differences on depression levels. For example, Guth (2000) investigated two groups: those with a high school education or less, and those with greater than a high school education, and found that those with less than a high school education were significantly more depressed. In that same year, Meich and Shanahan (2000) reported similar findings, although they concluded that the inverse relationship between education and depression varies to some degree with age. One year later, Jenkins (2001) reported findings consistent with those of many prior investigations that examined the relationship between education and depression. This author's study reported that the increase in education and income are inversely related to depression, that lower levels of education lead to higher levels of depression.

Two years later, Ettner and Grzwacz (2003) reported a positive relationship between levels of education and mental and physical health. They concluded that a higher level of education corresponds to higher levels of depression, which contradict the aforementioned findings. Injured workers with lower levels of educational achievement may be at risk for having maladaptive psychological coping strategies and pain beliefs that bode poorly for emotional adjustment (Roth & Geisser, 2002).

Income

Meertens et al. (2003) examined the longitudinal trend of depressive symptoms in the Netherlands between the years 1975 to 1996. They found that persons in low income brackets and the unemployed are more likely to suffer from depressive symptoms over time in comparison to persons in the higher income brackets. Mutaner and Barnett (2000) conducted a study consisting of 1,055 respondents between the ages of 18 to 64 years of age to examine the association between socioeconomic status (SES) and depression. They reported that depressive symptoms were inversely associated with higher socioeconomic status. That is, depression levels decreased as income levels increased, and depression levels increased as income levels decreased.

Age

As noted by an NIMH panel (2002), depression is not a normal part of the aging process. However, in any given year between one and two percent of those over the age of 65 who live in the community (as opposed to living in nursing homes or other institutions) suffer from major depression (NIMH, 2002). Roberts, Kaplan, Shema and Strawbridge (1997) conducted a study to assess the effects of age on major depressive episodes. They found that when the effects of age and other risk factors were controlled, there were no significant age effects on depression. Roberts et al. also found that the initial age effects were primarily due to functional impairment and health problems, and that what appeared to be age-related effects on depression were attributable to associated physical problems and related disability, and not age per se. Heithoff (1995) points out that major depressive disorders in persons in late life are obscured by conflicting evidence, and conducted a study whereby symptoms of depression attributed to physical causes were recoded to be the equivalent to those with a psychiatric cause. This researcher reported no disproportionate rise in diagnosable depression in the older age groups.

Ethnic Status

Persons from racially/ethnically diverse backgrounds are identified not as much on the basis of their smaller numeric size, but instead on the convergence of political and historical circumstances (Williams & Harris-Reid, 1999). Blazer et al. (1994) noted that major depression was lower for African Americans (11.9%) as compared to Caucasians (17.9%) and Latinos (17.7%). This study did not address major depression or depressive symptoms among Asian Americans or Native Americans. The authors noted that the disparity between lower depressive symptoms among African Americans may be due to their underreporting of depression, and not due to the fact that they are actually less depressed.

In another study by Jackson-Triche et al. (2000), ethnic group differences were examined with regard to prevalence of depressive disorders and health related quality of life in fee for service and managed care patients (n=21,504) that sought care in a general medical setting. The results before adjusting for demographic factors indicated that African Americans and Latinos had the highest rates of depressive symptoms. It was found that Asian Americans had the lowest rates of depressive symptoms. The U.S. Department of Health and Human Services Surgeon General's Report on Mental Health (2001) thoroughly reviewed the literature on ethnic minority mental health concerns with regard to culture, race, and ethnicity. The report concluded that persons from traditionally underserved racial and ethnic background have less access to mental health services, are less likely to receive needed mental health services, often receive a poorer quality of mental health care, and are underrepresented in mental health research. These findings indicate that more attention should be given to the disparities for persons from racially/ethnically diverse populations who have less access to mental health services.

Pre-injury Psychological History

The interplay between pre-existing personality disorders and depression levels following workplace injuries is complex (Williams, 1997). Research regarding psychological conditions in the chronic pain disability population with predominately back pain disability patients in the 1980's documented increased prevalence of depression, anxiety, substance abuse/dependence, somatization and personality disorders compared to the general population (Williams, 1997). It has been well established that emotions and pain are related clinically (Verma & Gallagher, 2000). Dersh, Gatchel, Polatin, and Mayer (2002) concluded that the prevalence of most psychiatric disorders was found to be elevated in the subjects only after the onset of musculoskeletal conditions. To lend support to this theory, Williams reported that chronic pain in injured workers more often precedes depression and causes psychological and social problems.

These same authors noted the presence of several psychopathological conditions, most notably major depressive disorders (MDD), drug abuse/dependence, and personality disorders. They found anxiety disorders were only slightly more common in their study subjects. Psychological variables that merit investigation include pre-injury personality characteristics of the employee (Spencer & McDaniel, 1993). In a study by Lustman, Velozo, Eubanks, and Montag (1991), psychiatric histories were obtained in 56 patients beginning rehabilitation following a work-related injury to establish the temporal relationship between the onset of psychiatric symptoms and the date of the work injury. They found that a high percentage of injured workers with depression had a predisposition (pre-injury) for depression as opposed to a reactive or situational depression. Polatin et al. (1993) reported that the majority of the subjects were found to have prior psychological disorders.

In a study identifying prior history of psychiatric problems involving 46 hotel employees injured as a result of a plane crashing into the hotel, Smith, North, McCool, and Shea (1990) examined the prevalence of four psychiatric disorders: posttraumatic stress disorder (PTSD), major depression, generalized anxiety disorder, and alcohol abuse/dependence. More than two-thirds of the cases of acute post-disaster psychiatric disorders were predicted by identifying the subjects who had pre-disaster psychiatric histories.

Time Away-from the Work Force Since Injury

Work-related injuries and the injured workers' return to work following the injury are increasing areas of concern at the national level (Tate, 1992; Weed & Field, 2001). Patients with workplace injuries are noted to frequently develop psychiatric disorders as a result of the traumatic losses associated with injuries on the job (Grant & Robbins, 1993). According to Schouten and Williams (2000), major depression is usually the result of prolonged disability and unemployment. Furthermore, depression following injury can result in loss of role status, loss of hope of recovery, activation of pre-existing low self-esteem, chronic pain, and loss of work as a means of sublimating aggression. Mason et al. (2002) conducted a survey study involving 154 work-related and non-work-related subjects and concluded that non-return to work was associated with psychological morbidity.

Several studies have investigated the relationship between length of time away from the workforce and depression among vocational rehabilitation customers. For example, Fierro and Leal (1988) found that depression and dependency scores were significantly lower, and self-esteem scores were higher for the groups referred earlier to employment settings when compared with the late referral group. Keogh et al. (2000) studied outcomes related to time lost from work of 537 workers who had suffered from work-related upper extremity cumulative trauma disorders. They concluded that 31% of the participants studied had depression with persisting symptoms. In another study examining the relationship between depression and time away from work since injury, Blackwell, Leierer, Haupt and Kampotsis (2003) determined that workers referred for vocational rehabilitation within six months of the injury were 1.52 times more likely to return to work as compared to those who were referred after six months. This lends support to the need for early rehabilitation intervention. According to Green (1996), the longer a worker is off duty due to an injury, the less chance of a successful return to work. Moreover, Green opined that powerful psychological factors affect the outcome of work of injured patients when return to work is not immediate. In that same year, Williams (1996) found that injured worker referrals to his psychiatric private practice setting developed major depressive symptoms between eight and fourteen months after the date of the industrial injury. It must be noted however, that the injured worker referrals were part of a suspected population of injured workers who needed psychiatric services based on prior assessment from the referring party.

Severity of Medical Diagnosis

Aronoff and Feldman (2000) reported that chronic pain was closely related with disability. They also cited that a central principle to chronic pain syndrome and related disability behaviors is a disability condition, and that because of chronic pain, one is unable to meet occupational, domestic, family and social responsibilities, or to engage in vocational and recreational activities. Nagumo (2000) conducted research related to low grade chronic depression, pain, and personality traits with spinal cord injury. He reported that 15% of participants met the criteria for low grade chronic depression, while 30% of the sample population consistently showed normal mood; however, age, sex, time since injury, levels of injury, and marital status had no relationship to depression. In contrast, only 9.5% of the general population suffers from a depressive illness in any given one year period (Robbins & Regier, 1990). Piccinelli, Patterson, Braithwaite, Boot, and Wilkinson (1999) found that severe injuries in combination with overall residual disability were strong predictors of anxiety and/or depressive disorders.

Job Skill Level

Sanne et al. (2003) investigated the relationship between depression and anxiety with regard to occupational job skill levels. They found a distinct and inverse association between job skill levels and depression, especially in men. They reported that those with lower job skill levels demonstrated higher depression scores on the Hospital Anxiety and Depression Scale HADS-D. By definition, unskilled workers are less educated due to lack of any required formal training. Zwerling et al. (2002) examined the factors associated with employment and persons with disabilities. They concluded that those persons with disabilities who were more educated were more likely to be working. As noted previously, Hopp (2002) stated that the attainment of education is a significant factor in returning to work, and conversely, the lack of education limits the injured worker to be able to return to work in a competitive marketplace. Education was found to be strongly associated with workforce participation. Blazer et al. (1994) noted the relationship between the occurrence of depressive symptoms and low levels of education. In this case one must logically consider the association between job skill level and the amount of education necessary to be prepared to meet the demands and the essential functions of a particular occupation or avocation.

Purpose of this Research

The purpose of this study was to analyze the relationship between certain socioeconomic variables and depression among injured workers. The variables analyzed included gender, educational level, income level, age, ethnic/minority status, severity of medical disability, antecedent pre-injury psychological history, time away from the workforce since injury, and job skill level among the injured worker study sample. The findings of this study are expected to assist rehabilitation counselors who provide vocational rehabilitation services to injured workers gain a greater understanding of the nature and extent of the interplay of the nine aforementioned demographic variables and depression. Rehabilitation counselors should be aware of those characteristics that are significantly associated with depression among injured workers in order to develop appropriate intervention strategies for this target population. The findings could help improve rehabilitation planning for injured workers and consequently improve their potential for achieving positive rehabilitation outcomes.

The research study focused on one question: Are client (a) time away from work since injury, (b) age, (c) pre-injury psychological history, (d) gender, (e) severity of work injury, (f) income, (g) education, (h) job skill level, and (i) racial/ethnic minority status significantly related to depression among injured workers? It is expected that numerous significant differences on the dependent variable (depression levels) will exist based on various demographic variables.

Method

Participants

The participants in this study consisted of 250 unemployed injured workers who were referred to a private practice vocational evaluation and testing center between March 17th 2002 and February 19th, 2004 for mandated vocational rehabilitation testing and evaluation services. The testing and evaluation results were subsequently used for adjudication purposes. Every participant possessed a disability resulting from a work-related injury that was categorized in severity ranging from mild to severe. A majority or 56% (n = 139) of the participants were males while females accounted for 44% (n=111) of the study sample. Seventy percent (n=176) of the participants possessed at least a high school education or GED high school equivalent compared to 30% (n:74) who did not. The majority of participants (n:164 or 66%) earned an annual salary ranging from $10,000 to $29,999, and 34% (n=86) earned $30,000 and above. Eighty percent of participants were Caucasians (n=201), and 20% (n=29) were ethnic minorities consisting of African Americans, Native Americans, and Latinos.

Instruments

Demographic form. Participants completed a demographic form. The form included: gender, level of education, yearly salary income, age, ethnicity, pre-injury psychological history requiring treatment from a qualified professional, time away from work since injury, work injury medical severity, and occupational skill level.

Beck Depression Inventory-II The Beck Depression Inventory-Second Edition (BDI-II) is a 21 item self-reported four point weighted Likert scale instrument for measuring the severity of depression in adults and adolescents aged 13 years and older (Beck, Steer, & Brown, 1996). It was developed for the assessment of symptoms that correspond to the criteria for diagnosing depressive disorders listed in the DSM-IV (Beck, Steer, & Brown, 1996). Over the past 35 years, the BDI has been recognized as one of the most widely accepted instruments for assessing the severity of depression in diagnosing patients and for detecting possible depression in normal populations (Archer, Maruish, Imhof, & Piotrowski, 1991; Piotrowski & Keller, 1992: Piotrowski, Sherry, & Keller, 1985).

Procedures

The State of Oklahoma Workers' Compensation Court, insurance carriers, third party administrators plaintiff and defense attorneys referred participants to a private practice vocational evaluation testing center where they received vocational rehabilitation services. Each participant was given informed consent and voluntarily participated. No compensation was provided for participation and individuals were free to withdraw at any time without penalty. After obtaining a signed consent form, the demographic questionnaire was given to participants. The questionnaire was written in non-technical language for comprehension/literacy to help identify demographic characteristics among participants as accurately as possible. Next, participants were asked to respond to items on the BDI-II which purportedly measured sadness, pessimism, past failure, guilty feelings, punishment feelings, etc. The participants were screened for their thoughts, feelings, and behavior resulting from being injured and off the job.

Statistical Analysis

The research question was analyzed following data collection. A forced multiple linear regression (MLR) analysis was employed to analyze the relationship between gender, educational level, income level, age, ethnic status, pre-injury psychological history, time away for the work force since injury, severity of work injury, job skill level and depression levels. The order of entry for the MLR analysis was dictated by presumed causal priority of the variable to level of depression. Causal priority was determined by an evaluation of the bivariate strength of association between each predictor variable and BDI-II scores entered by descending order in relation to correlation coefficient: (a) length of time away from work since injury, (b) age of client, (c) pre-injury psychological condition, (d) gender, (e) medical severity, (f) annual income at time of injury, (g) education, (h) occupational skill level, and (i) racial/ethnic minority status (see Table 1).

Results

Research Question

The research question to be addressed by the study was: Are client (a) time away from work following injury, (b) age, (c) pre-injury psychological history requiring treatment, (d) gender, (e) severity of work injury, (f) income, (g) education, (h) job skill level, and (i) racial ethnic/minority status significantly related to depression among injured workers? The statistical analyses for the linear relationship revealed the following result: Of the nine socio-demographic variables entered into MLR, time away from work since injury ([p.bar] < .05, [r.bar].sup.2]] = .05, [n.bar] = 250), age of client ([p.bar] < .05, [r.bar].sup.2]] .04, [n.bar] = 250), and prior psychological condition/history ([p.bar] < .05, [r.bar].sup.2]] .02, [n.bar] = 250) were identified as significant predictors (see Table 2). The first key finding suggests that individuals who spent the most time away from work following occupational injury possessed higher levels of depression as measured by BDI-II scores.

The findings also revealed that younger persons (i.e., under 50 years of age) possessed significantly higher levels of depression as reflected by BDI-II scores when compared to older injured workers. This predictor accounted for approximately 4% of the variance explained in the dependent variable/criterion; BDI-II scores. Finally, findings revealed that individuals with prior psychological conditions possessed significantly higher levels of depression as measured by BDI-II scores when compared to injured workers with no prior history of psychological conditions. This predictor accounted for approximately 2% of the variance explained in the BDI-II scores. Interestingly, the time away from work following injury variable accounted for the greatest amount of variance in BDI-II scores.

Discussion and Implications for Practice

The current study has generated several key findings regarding the importance and role of certain socio-demographic factors in the prediction of depression among injured workers. Specifically, three socio-demographic variables (i.e., length of time away from work following injury, age of client, and past psychological condition) were found to be significantly related to depression. The findings on the contributions of length of time away from work after injury corroborate previous research. For example, Blackwell, Leierer, Haupt and Kampotsis (2003) reported that workers referred for vocational rehabilitation within six months of injury were 1.52 times more likely to return to work when compared to those who were referred for such services after six months. Fierro and Leal (1988) reported lower self-esteem scores, which is directly linked to depression, among individuals who were referred to work at a later time than those referred earlier. Explanations for this finding are plentiful and consistent across the literature. The longer one remains unemployed, the more time to dwell on their loss of role status, hope of recovery, focus on pre-existing self-esteem issues, and loss of work as a sublimating aggression (Schouten & Williams, 2000). As noted by Lazarus and Folkman (1984), the prolonged period of employment is a chronically stressful state and even minor stressors could adversely impact one's mental health.

The findings in this study found that injured workers 50 years old and above possessed lower levels of depression when compared to workers under age 50. These findings concur with previous studies that depression does not increase with advanced age. For example, Roberts et al. (1997) concluded that advanced age and depression was not a significant contributor to depression, although they identified physical problems and related disability as significant predictors. Additionally, Heithoff (1995) reported no disproportionate rise in diagnosable depression in older age groups, and the peak of depression is centered around age thirty with gradual decline after age thirty. One possible reason for the current finding might be that older injured workers are more financially stable when compared to younger workers. Perhaps younger injured workers are more likely to possess multiple life stressors; such as dependents, children in the home under their care, less tenure, less job stability, fewer transferable skills by virtue of younger age, lack of credentials, lack of life experiences or maturity to deal with the impact of the work-related injury, and limited financial security. These factors might contribute to higher levels of depression and added stress among younger injured workers as they must continue to provide food, shelter and all other amenities.

The finding on pre-injury psychological history indicates that injured workers who had previous psychological conditions possessed higher levels of depression when compared to those with no prior psychological history. This finding is consistent with previous research results that have found a direct relationship between pre-injury psychological condition (presence versus absence) and depression levels. For example, Smith et al. (1990) found that pre-disaster psychiatric disorders predicted post-disaster psychopathology. This finding has several possible explanations, although one hypothesis stands out as postulated by Lustman et al. (1991): Typically injured workers with depression have a predisposition for depression as opposed to acquiring reactive or situational depression. Perhaps those persons with prior psychological conditions were more likely to have a predisposition for depression opposed to those persons with no prior psychological pathology. One might expect that added stressors associated with work-related injuries might be more likely to trigger depression among those with such predispositions.

Finally, several inconsistencies in the findings were noted between the current and previous findings in regard to the contributions of gender, education, income level, ethnic/racial status, severity of injury and occupational job skill level on depression. First, gender was found to be a non-significant contributor to differences on depression levels. This finding contradicts previous research (Douglas, 2000; NIMH, 2002) that suggests that females demonstrate a higher incidence of depression than their male counterparts, and that they are two to three times more likely to have depression than men.

The findings suggest that level of education is not significantly related to depression among injured workers. These conclusions contradict those of Blazer (1994) who reported that depression was more often noted among persons with lower levels of education when compared to persons with higher levels of education. The current findings also contradict previous findings on the role of income in predicting depression. Although the current study found no significant relationship between the two, Meertens, Scheepers and Tax (2003) found that persons with lower incomes and unemployed were more likely to suffer from depressive symptoms over time compared to persons with higher incomes.

The findings of this study concluded that race/ethnic minority status was not significantly related to depression of the injured worker. There needs to be a further investigation of the effects of race/ethnicity on depression to ascertain whether or not this study is in agreement with or a contradiction to the additional research. As previously noted, The United States Surgeon General's Report on Mental Health (2001) thoroughly reviewed the literature on ethnic minority mental health concerns with regard to culture, race, and ethnicity, and concluded that minorities have less access to mental health services, are less likely to receive needed mental health services, often receive a poorer quality of mental health care, and are underrepresented in mental health research. If indeed they are underrepresented in mental health research, no conclusion can be drawn at this time.

The severity of the medical diagnosis of the work related injury (surgical versus non-surgical) was not found to be significantly associated with depression among injured workers. The findings contradict previous research (Piccinelli et al., 1999), which reflects a direct relationship between severity of disability and depression. For example, Piccinelli et al. found that severity of injury was a strong predictor of anxiety and/or depressive disorders. Finally, occupational job skill level was also found to not be significantly associated with depression levels. Little current evidence exists to refute or corroborate this study's findings, and thus future research is needed to ascertain the "true" impact of occupational job skill level on depression.

Implications for Future Service Delivery

The results of this study identified that the time away from the work force, age, and pre-injury psychological history predictor variables were significantly related to depression among injured workers. First, regarding length of time away from the workforce after injury, rehabilitation counselors might consider incorporating these findings into their rehabilitation and vocational planning, while targeting those individuals who are at higher risk for depression as they might have a poorer prognosis for successful rehabilitation. Early participation for injured workers by rehabilitation and vocational counseling services may reduce the potential for depression, maintains self-esteem, independence, results in an earlier return to work, and the ability to earn an income sooner. Early referrals lead to early intervention, which could assist injured workers with job restructuring, accommodation, seeking alternative job titles with the same employer, new employment with a new employer, or retraining in a more compatible occupation based on new physical limitations and lack of transferable skills. Early referral services should include a vocational evaluation assessment of the worker's profile of physical abilities, interests, aptitudes, work history, transferable skills, physician medical information, residual functional capacities, family dynamics, geographic barriers, and personal needs in order to reach acceptable vocational goals at the earliest opportunity. The counselor should also provide individual counseling to empower and motivate clients to overcome their disability focused behavior and to refocus on their abilities, assets and strengths.

In addition, job placement and job development activities should be individually designed to meet the injured worker's return to work goals. The strategies should include preparing for the job search that would include job readiness training services. Such services are designed to prepare the injured worker in returning to the world of work; such as, resume preparation, reference list, portfolio preparation, interview skills training, networking, job search training, role playing, dressing for success, and motivational discussions to foster a positive mental attitude. Specific employment options should be created to match the injured worker's vocational profile and direct the client to seek gainful employment at the earliest opportunity. A specialized job search should be directed at job titles that fall within the client's physical restrictions and limitations. In addition, the injured worker's family should be incorporated in the rehabilitation strategy plan as soon as possible in order to draw from the strengths of the family dynamic.

When psychological overlay such as depression has been diagnosed, the rehabilitation counselor will have increased difficulty in returning the client back to the community and to gainful employment. Again, early intervention is the appropriate strategy. Therefore, rehabilitation education programs should continuously address these factors with regard to curriculum development. In addition, education of employers, employees, and multi-disciplinary treatment teams assisting the injured worker, may benefit from this knowledge, and incorporate early intervention strategies to address these issues for early service planning for more and greater successful outcomes. For example, rehabilitation counselors may want to utilize the conclusions drawn from this study to educate disability management participants, employers, and referring agencies of the importance of early intervention from rehabilitation counseling for injured workers.

Secondly, regarding age of the injured worker at time of injury, the rehabilitation counselor should be cognizant of the fact that younger persons (defined in this study as under the age of fifty) have significantly higher levels of depression when compared to older persons over age fifty. Rehabilitation counselors may wish to take this finding into account during the assessment phase of the rehabilitation counseling process. Screening tools such as the BDI-II, the CES-D, or similar screening tools should be utilized to determine depressive levels in their clients. The rehabilitation counselor should also recognize that other factors such as medical severity, time away from the work force following occupational injury, and prior psychological history, can have interplay in the outcome of the service planning. The rehabilitation counselor should be particularly aware of this finding regarding age and be sensitive to the needs of this at-risk group.

Finally, regarding those injured workers who have a pre-injury psychological or psychiatric history who are referred for rehabilitation counseling services, the counselor should recognize the impact of prior psychological history on future service planning. Again, the rehabilitation counselor should screen for the level of depressive symptoms with depression screening tools to better understand the current situation of the client. The rehabilitation counselor should utilize a therapeutic approach combined with empowerment strategies and techniques so that clients are made aware that they are the one ultimately in charge and capable of making decisions on their own about positive future outcomes. A solid alliance between the counselor and the client will help determine the best outcome for the client. The client should be made aware of the importance of their own self-determination for their choices in future planning. In addition, the rehabilitation counselor needs to be aware of other agencies that may provide additional services to serve each client in a unique way. Other agencies could include social services, employment service agencies, medical care, additional psychological treatment, and other various disciplines, which may be of great benefit in assisting the client in assuming greater responsibility in their choices for return to the community, to work, thereby minimizing potential risks for failure. In addition, the rehabilitation counselor should be continually updated on the types of medications the client may be taking including their benefits and side-effects. Rehabilitation counselors should recognize the challenges of their role in assisting clients with psychiatric or psychological problems, and they should be aware that persons with mental disabilities have the highest unemployment rates when compared to others without this disabling condition and should be able to meet these professional demands and challenges by utilizing these findings.

Implications for Future Research

This study could be replicated in other states with different socio-economic populations with the same sampling plan using the same statistical methods for purposes of consistency. If similar results are generated, cross validation would be achieved thereby enhancing the generalizability of these findings. Some demographic variables found to have a significant relationship in this study obtained from a sample population in Oklahoma might not have a similar result in another geographic location. Conversely, variables that were found to be non-significant predictors might be found to be significant in other similar studies conducted in other geographic locales. Thus, the limitations of this study might be greatly reduced.

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Dennis Carlton Stice

Amerihab Evaluation and Testing Center

Corey L. Moore

Langston University

Dennis Carlton Stice, Ph.D., CRC, CCM, Director, Amerihab Evaluation and Testing Center, P.O. Box 891436, Oklahoma City, OK. 73189-1436.

TABLE 1
Correlations Between Socio-demographics (n=250)

                              Subscale

                  Skill Lvl   Med Sev.        Time

Skill Lv1
Pear Corr                 1
Sig. (2-tailed)

Med Sev
Pear Corr              .083           1
Sig. (2-tailed)        .191

Time
Pear Corr              .007        .092           1
Sig. (2-tailed)        .912        .149

Prior Psy
Pear Corr              .051       -.038        .023
Sig. (2-tailed)        .425        .547        .714

R/E
Pear Corr             -.100       -.111       -.051
Sig. (2-tailed)        .115        .081        .418

Age
Pear Corr              .102       -.037        .115
Sig. (2-tailed)        .107        .556        .070

AI
Pear Corr              .269        .001       -.011
Sig. (2-tailed)        .000        .989        .865

LE
Pear Corr              .128       -.036       -.158
Sig. (2-tailed)        .043        .568        .012

Gender
Pear Corr              .050       -.095        .008
Sig. (2-tailed)        .433        .132        .898

                              Subscale

                  Prior Psy        R/E         Age

Skill Lv1
Pear Corr
Sig. (2-tailed)

Med Sev
Pear Corr
Sig. (2-tailed)

Time
Pear Corr
Sig. (2-tailed)

Prior Psy
Pear Corr                 1
Sig. (2-tailed)

R/E
Pear Corr             -.105           1
Sig. (2-tailed)        .098

Age
Pear Corr              .016       -.059           1
Sig. (2-tailed)        .801        .350

AI
Pear Corr              .058       -.082        .077
Sig. (2-tailed)        .365        .197        .224

LE
Pear Corr              .019       -.033        .023
Sig. (2-tailed)        .766        .603        .718

Gender
Pear Corr              .066        .106       -.040
Sig. (2-tailed)        .298        .093        .525

                              Subscale

                        AI          LE         Gen

Skill Lv1
Pear Corr
Sig. (2-tailed)

Med Sev
Pear Corr
Sig. (2-tailed)

Time
Pear Corr
Sig. (2-tailed)

Prior Psy
Pear Corr
Sig. (2-tailed)

R/E
Pear Corr
Sig. (2-tailed)

Age
Pear Corr
Sig. (2-tailed)

AI
Pear Corr                 1
Sig. (2-tailed)

LE
Pear Corr              .156           1
Sig. (2-tailed)        .014

Gender
Pear Corr             -.291        .121           1
Sig. (2-tailed)        .000        .056

Note. Skill Lvl=Occupational Skill Level, Med. Sev=Medical Severity,
Time= Time Away From Work Following Occupational Injury, Prior Psy=
Pre-injury Psychiatric History Requiring Treatment Prior to
Occupational Injury, R/E=Racial/Ethnic Minorities, Age=Age of
Participant at Time of Survey, AI=Annual Income at Time of Injury,
LE=Highest Level of Education Achieved, Gen=Gender.

TABLE 2
Summary Table for MLR Analysis for Demographic
Variables on Depression Scores Among Injured Workers

(Test of Linear Relationship) Coefficients

Demographic Variable       Unstdz'd Coef   Stdzd. Coef
                           (Std. Error)      (Beta)

Time Away From Work            5.821           .234
Age of Client                 -4.901          -.189
Pre-injury Psych History       3.579           .131
Gender                         1.514           .063
Medical Severity                .727           .027
Annual Income at Injury        1.226           .049
Level of Education             1.303           .050
Occup. Job Skill Level        -5.487          -.002
Racial/Ethnic Minorities        .234           .008

Demographic Variable         Sig.           [r.sup.2]

Time Away From Work        .000 *              .05
Age of Client              .003 *              .04
Pre-injury Psych History   .035 *              .02
Gender                     .342                .00
Medical Severity           .665                .00
Annual Income at Injury    .474                .00
Level of Education         .435                .00
Occup. Job Skill Level     .976                .00
Racial/Ethnic Minorities   .901                .00

* p < .05; denotes statistical significance