AUBREY BELL, Employee, v. INDEPENDENT SCHOOL DIST. #625, and ASU RISK MGMT. SERVS., LTD., Employer/Insurer-Appellants, and HEALTHPARTNERS, ST. CROIX ORTHOPAEDICS, PA., and ALLINA BEHAVIORAL HEALTH, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
JUNE 1, 2005
CAUSATION - PSYCHOLOGICAL INJURY; CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence of record, including expert medical opinion, supports the compensation judge=s finding that the employee=s depression and related medical treatment are causally related to his work-related injury to his low back.
Determined By: Rykken, J., Johnson, C.J., and Stofferahn, J.
Compensation Judge: Danny P. Kelly
Attorneys: Thomas J. Davern, Davern, McLeod & Mosher, Golden Valley, MN, for the Respondent. Mark A. Fonken and Matthew P. Bandt, Jardine, Logan & O=Brien, Lake Elmo, MN, for the Appellants.
MIRIAM P. RYKKEN, Judge
The self-insured employer appeals the compensation judge=s finding that the employee=s medical expenses related to psychological treatment were causally related to the employee=s admitted work injury. We affirm.
The employee, Aubrey Bell, has worked for Independent School District No. 625, the employer, since 1977. On February 11, 1983, the employee sustained an admitted low back injury while working as a custodian for the employer, which was self-insured for workers= compensation liability. He has continued to receive medical treatment for his low back from the time of the injury to the present. The employee testified that his pain has worsened over the years and that he has had difficulty sleeping, has lost weight, and has been diagnosed with depression.
According to the medical records in evidence, the employee first treated for depression in April 1992 with Dr. Robert Karol, Ph. D., LCP, at the Institute for Low Back Care, to whom he was referred by one of his treating orthopedists, Dr. Alexander Lifson. The employee reported to Dr. Karol that he continued to experience significant pain, that he had felt quite pressured on his job to accomplish his work, and that, because his recently-revised work restrictions prevented him from performing his job, he had last worked in February 1992. The employee also reported being depressed because he was unsure whether the employer would offer him a new job within his restrictions and also reported that he was frustrated with the workers= compensation system. Dr. Karol recommended that the employee and his QRC consider the Backs at Work program at the Institute for Low Back Care, a program Dr. Karol described as having Aa combination of physical and psychological reactivation elements.@ He also suggested that the employee later undergo a vocational evaluation. At Dr. Karol=s referral, the employee consulted Dr. Wyatt Moe, M.D., a psychiatrist, to whom the employee reported that he felt depressed, forgetful and unable to concentrate or sleep well. He was treated by Dr. Moe from 1992 through 1994 with medication. Although there are occasional references to depression and anxiety in the employee=s medical records from 1999, he evidently sought no further psychiatric treatment until 2001. The employee eventually returned to work for the employer, although it is unclear from the record when the employee resumed working.
In September 2000, the employee sought treatment for his low back pain with Dr. Kirkham Wood, an orthopedist at Fairview University Medical Center. Dr. Wood prescribed anti-inflammatory medications and recommended that the employee undergo physical therapy. By December 2000, Dr. Wood advised the employee to reduce his work hours to six hours per day. X-rays taken on May 23, 2001, indicated severe disc disease at the L5-S1 level and mild disc disease at the L2-3 level. Dr. Wood took the employee off work for six weeks until he could complete physical therapy. In September 2001, the employee reported increased symptoms in his low back. Dr. Wood discussed surgery as an option. An October 3, 2001, MRI scan of the lumbar spine indicated degenerative changes and mild to moderate central canal stenosis at the L4-5 level, mild bony neural foraminal stenosis on the right at the L4-5 level and bilaterally at the L5-S1 level. Dr. Wood discussed treatment options in November 2001, including epidural injections, medication, and surgery, but the employee declined surgery at that time. The employee again consulted Dr. Wood in May 2002, and reported continued symptoms and trouble sleeping. By June 2002, Dr. Wood restricted the employee to four-hour work days, in the hope that this would aid his sleep and improve his daytime concentration.
From May 2001 through July 2004, the employee was treated for depression at the River City Clinic, Behavioral Health Services, and HealthPartners Clinic, for a total of ten visits. The employee saw a therapist at River City Clinic who recommended a psychiatric evaluation. The employee was assessed at Behavioral Health Services in July 2001, by Dr. Ramesh Sairam, psychiatrist, to whom he reported that his chronic pain had increased in the last few years and that he was having difficulty obtaining proper treatment through workers= compensation insurance for his back injury. By then, the employee had started physical therapy which he reported was helpful. Dr. Sairam assessed the employee as having mild to moderate depressive symptoms in the context of chronic back pain arising from a work-related injury.
The employee was later treated at HealthPartners for his depression, where it was noted that his physical health had deteriorated and that he had become increasingly depressed. The employee reported depression, feelings of isolation and anger, sleep difficulties, loss of energy, and interests, labile mood, and difficulty with concentration and memory. He reported that he had struggled with depression since approximately 1990, and that he had taken antidepressant medication, off and on, for at least the past nine years. In a report dated August 24, 2004, Marc Schiappacasse, M.A., the employee=s treating psychologist, diagnosed major depression, generalized anxiety disorder, obsessive compulsive disorder, and psychological factors affecting his medical condition. He recommended that the employee undergo a psychiatric consultation for further evaluation of his overall functioning and for a review of his medication. Dr. Schiappacasse also recommended a relaxation tape for the employee, and encouraged the employee to pursue obtaining further physical therapy in order to improve his level of functioning. In a letter report dated August 24, 2004, Dr. Schiappacasse concluded that the employee=s low back pain was a substantial contributing cause of his depression.
On May 13, 2003, the employee was evaluated by Dr. John Rauenhorst, psychiatrist, at the employer=s request. The employee reported that he had constant low back pain, with some radicular pain, and that several times each month he also had episodes of more severe pain lasting about 2-3 days. He advised Dr. Rauenhorst that he had Abouts of depression@ because he could not function as he used to. The employee asserted that his depression resulted from the combination of his low back pain and his inability to do the things he formerly was able to do. Dr. Rauenhorst diagnosed the employee with depressive disorder and anxiety and concluded that the employee has had long-term, nonspecific, suicidal ideation. Dr. Rauenhorst determined that the depression was not causally related to the employee=s work injury since he had not treated for depression until nine years after his 1983 injury, and since other family members may have had some mental health problems which could indicate the employee=s predisposition to a depressive disorder. Dr. Rauenhorst also stated that the employee was taking medications, unrelated to his work injury, which could cause depression.
In February 2003, the employee filed a claim petition for payment of medical expenses related to low back treatment and for treatment of depression, and also requested appointment of a QRC since the employee apparently had been told he would be laid off from his employment in the following summer. A hearing was held before a compensation judge on August 25, 2004. At the hearing, the employer advised that it would pay the medical expenses for treatment of his low back. Also, the employee indicated that he had withdrawn the rehabilitation issue since he had not been laid off from his employment. The remaining issue addressed at the hearing was whether the expenses related to the employee=s psychological and psychiatric treatment were causally related to his 1983 low back injury. Those expenses included reimbursement to the employee for prescription payments and medical mileage incurred between 2001 and 2004, and also included intervention claims for reimbursement for medical services provided to the employee. The employer denied liability for payment of the medical expenses for treatment of the employee=s depression, arguing that the work injury was not a substantial contributing cause of the employee=s depression. The compensation judge found that the employee=s depression was causally related to the employee=s work injury and ordered payment of the medical expenses incurred for treatment of that condition. The employer appeals.
The employer appeals the compensation judge=s finding that the employee=s depression and need for psychological treatment are causally related to his 1983 work injury. Where a work‑related physical injury causes, aggravates, accelerates, or precipitates a mental injury, that mental injury is compensable. See Hartman v. Cold Spring Granite Co., 243 Minn. 264, 271, 67 N.W.2d 656, 660, 18 W.C.D. 206, 212 (1954) (Atraumatic neurosis is compensable if it is the proximate result of the employee's injuries and results in disability"). See also Dotolo v. FMC Corp., 375 N.W.2d 25, 38 W.C.D. 205 (Minn. 1985) (depression that was causally related to a work-related condition of tinnitus was held to be compensable). In order for a mental injury to be compensable, it is not necessary that the work‑related physical injury that caused it is its sole cause; it is sufficient if the work‑related physical injury is a substantial contributing factor. See Miels v. Northwestern Bell Tel. Co., 355 N.W.2d 710, 715, 37 W.C.D. 164, 170 (Minn. 1984).
In this case, the employee=s depression was diagnosed after his work-related injury. That factor is not determinative, however. Where healed injuries have not impaired an employee's ability to work and other possible causes of the emotional distress are present, some medical opinion causally relating the emotional distress to the physical injuries is required before the mental distress can be found compensable under the workers' compensation system. See Rindahl v. Brighton Wood Farms, Inc., 382 N.W.2d 855, 38 W.C.D. 473 (Minn. 1986).
The record contains conflicting medical opinions and evidence on the issue of causation. The employer argues that there is substantial evidence that the employee=s depression was caused by factors other than his work injury. The employer cites Dr. Rauenhorst=s opinion that the employee=s depression was not causally related to his 1983 work injury since he was not treated for depression until about nine years after that injury, other family members reportedly had mental health problems, and the employee was taking medications, unrelated to his work-related low back injury, which could cause depression. The employer also argues that the employee=s frustration in dealing with the workers= compensation system was a factor in the employee=s depression rather than the injury itself.
The employee relies on the opinion of his treating psychologist, Marc Schiappacasse, who concluded that the employee=s low back pain was a substantial contributing cause of his depression. In addition, the employee argues that his medical records contain multiple references to his chronic low back pain and his depressed mood, anxiety, and insomnia resulting from his ongoing pain. The employee=s treatment for depression came after his renewed treatment for low back pain and his reported increase in low back pain.
Questions of medical causation fall within the province of the compensation judge. Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994). In addition, it is the compensation judge's responsibility, as trier of fact, to resolve conflicts in expert testimony. Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985). The compensation judge accepted the opinion of the employee=s treating psychologist concerning the causal relationship between the employee=s work injury and his depression. The judge outlined the history of depression and chronic pain that the employee reported since at least 1992, and outlined the employee=s psychological and psychiatric consultations and treatment since 1999. The compensation judge found that,
It has been established by a preponderance of the evidence that the psychological treatment provided by HealthPartners Primary Care Providers, HealthPartners Mental Health, Allina Behavioral Health Services, and River City Clinic are causally related, reasonable and necessary to cure and relieve the effects of the February 11, 1983 personal injury.
The issue on appeal is whether there is adequate evidence in the record to support the compensation judge=s resolution of this factual issue. This court must determine whether the findings of fact and the order are clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted. Minn. Stat. ' 176.421, subd. 1. Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Under this court=s standard of review, a compensation judge=s findings of fact should not be disturbed unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole. Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 229 N.W.2d. 521 (1975). Upon review of the record as a whole, we conclude that the compensation judge=s finding on causation for the employee=s depression had adequate support in the record, from both expert medical opinion and the employee=s medical records. We therefore affirm.
This conclusion was apparently based upon the employee=s history, provided to Dr. Rauenhorst, that at least two maternal aunts may have had some psychiatric disorder, although the employee did not know if they had undergone treatment, and also upon the employee=s history that two of the employee=s brothers may have had a problem with alcohol. Dr. Rauenhorst commented that A[I]ndividuals who have had close relatives with psychiatric disorders, or with problems with alcohol, are at a significantly increased risk for developing depressive disorders themselves. Such appears to be the case with Mr. Bell.@