The petitioners appeal from the judge’s determination  that the employee’s April 30, 2002, work injury  did not cause, aggravate or accelerate the employee’s  bipolar disorder, leading to her suicide.  We affirm.

The employee had a long history of mental illness dating back to at least 1990.^[1]  Throughout the years the employee had been diagnosed with various disorders, including major depressive disorder, obsessive compulsive disorder, anxiety disorder, trichotillomania (hair pulling), body dysmorphic disorder, and bipolar disorder.  She sought treatment from a variety of psychiatrists and  psychologists and was prescribed numerous medications to treat her conditions.  Periodically, she would stop taking her medications on her own accord.  In 1990, the employee attempted suicide by ingesting an overdose of amitriptyline and was hospitalized for two weeks.

The employee began working for Allina/United Hospital [the employer] in 1992, as an LPN.  She continued to receive treatment from a variety of psychiatrists, whose records reflect that she periodically had suicidal thoughts.  In addition, she was hospitalized at Abbott Northwestern Hospital in December of 1998 because of a suicidal plan to stab herself, and, in January of 1999, the employee told one of her doctors that she had attempted to suffocate herself.

In September of 1999, the employee sustained a work-related injury to her neck, for which she had two surgeries.  She also treated for mental health issues both before and after this injury.

On December 19, 2001, the employee was seen by psychiatrist Dr. Paul Warner.  Her “presenting illness” at that time was described as depression since age 22, and she reported, “I wish I wouldn’t wake up.”  She returned to Dr. Warner on January 9, 2002, reporting that she felt numb, depressed, was sleeping a lot, and had severe obsessive thoughts.

The employee returned to her therapist, licensed psychologist Mary Beth Scanlon, on January 15, 2002.  Dr. Scanlon’s records reflect that she had not seen the employee for a couple of months.  At that time, the employee continued to be depressed and considered herself to be in a crisis over her partner talking about moving out.

The employee was seen by Dr. Warner again on April 2, 2002.  At that time, she reported having missed many days at work and that she was in trouble at work for that reason.  She also reported that she had stopped her medication Luvox.

On April 30, 2002, the employee sustained a work-related injury to her low back. Initially, she sought treatment for this injury at United Family Practice, where she was given Vicodin and Celebrex and was prescribed physical therapy.  The employer admitted liability and paid temporary total disability benefits on May 2, 2002, May 7, 2002, and continuing from May 11, 2002.

The employee was seen by neurologist Dr. Richard Foreman on May 22, 2002, complaining of persistent low back pain.  In his report of that date, Dr. Foreman noted that a recent MRI showed a small disc bulge at L4-5 and degenerative disc problems at other levels.  He opined that “her clinical story is not that of any single radiculopathy but more of an acute lumbar strain problem,” and he continued her on physical therapy.

The employee was apparently seen in the United Hospital emergency room on June 6, 2002, at which time she was hypomanic.  She was offered admission, but declined.  Concern was raised over whether the employee’s symptoms were related to her use of steroids for back pain, and Dr. Foreman agreed to discontinue prednisone.  The employee was advised to increase her intake of Klonopin for anxiety.

The employee was brought to United Hospital by the police on June 10, 2002, and presented as overtly manic with suggestions of being dangerous to herself or others.  She was admitted on a 72-hour hold with the understanding that she would be transferred to a different medical facility as soon as a bed became available.^[2]

On June 11, 2002, the employee was transferred to Fairview-University Medical Center and again placed on a 72-hour hold.  The next day, on June 12, 2002, she was examined by Dr. Daniel Stein, who noted that she appeared to have normal range of motion of her back and moved about the unit without obvious discomfort.  Dr. Stein recommended Celebrex for back pain.  By June 17, 2002, the employee was more organized in her thinking, was medication-compliant, and was discharged from the hospital.

On July 16, 2002, the employer filed a Notice of Intention to Discontinue [NOID], seeking to discontinue benefits based on the employee’s failure to provide medical support for her continued time off work.  The following day, on July 17, 2002, the employee was seen by Dr. Foreman, who released her to return to work without neurological limitations.  It was agreed that the employee would return to work with the employer on July 20, 2002.  However, on July 19, 2002, the employee was seen again by Dr. Scanlon, who noted that the employee felt that she had gotten the run around about her workers’ compensation claim.  “Anytime she thinks about United or Allina or goes there she reports becoming ill. . . .  She feels that she could work and carry out duties.  She just does not feel that she can do it there.”  Dr. Scanlon then indicated that the employee was not able to return to work with the employer or any Allina facility, and the employee did not return to work for the employer.

An August 23, 2002, Order on Discontinuance allowed discontinuance of benefits.  In response, the employee filed an objection.

The employee treated with Dr. John Dowdle for back pain in August, October, November, and December of 2002.  When last seen by this doctor, the employee was released to return to work with restrictions, and Dr. Dowdle indicated that he wanted to see a psychological evaluation due to his concern that there was a psychogenic component to the employee’s illness.

Dr. Jon Boller performed an independent psychological examination of the employee on October 1, 2002, at the request of the employee’s attorney.  In his report of October 17, 2002,  Dr. Boller opined that the employee was experiencing a conversion disorder superimposed on a legitimate chronic pain problem, with no indication of secondary gain.  He also noted that the employee “is emotionally traumatized by the manner in which her employer has responded to her work-related injuries, i.e., treating her as though she was either faking her pain, or that she had some other secondary gain in mind.”  While he felt that the employee was able to work from a psychological standpoint, he believed “that enough hard feelings have passed between her and her employer that she would be ill-advised to return to that employment.”  It was also his opinion that the employee’s hospitalization in June of 2002 was the result of a reaction to the prednisone that the employee had been taking for her back condition.

On November 20, 2002, the employer filed a notice of benefit reinstatement, reinstating temporary total disability benefits retroactive to July 30, 2002.  The employee then withdrew her objection to discontinuance.

On December 4, 2002, Dr. Thomas Gratzer performed an independent psychiatric evaluation on behalf of the employer.  In his report of that date, Dr. Gratzer noted that the employee’s back pain was improving with physical therapy.  It was his opinion that the employee was suffering from bipolar disorder, then in remission, and mixed personality traits.  He did not think that her June hospitalization was related to the prednisone she had been taking for her low back symptoms, and he did not think that the employee was suffering from a conversion disorder.

When seen by Dr. Scanlon on December 6, 2002, the employee was “much more fed up with the [employer] than in September.  She again feels that they are not treating her well.  She doesn’t feel respected.  She doesn’t feel that anyone is working to get her back to work.”  On December 10, 2002, Dr. Scanlon issued a letter stating that, while the employee was psychologically able to work, she would be ill-advised to return to work for the employer.

In January of 2003, Dr. Dowdle released the employee to return to work subject to a restriction against lifting more than 50 pounds on an occasional basis.  The employee obtained a job as an LPN with Metropolitan Urology that was to begin on approximately January 20, 2003.^[3]  However, she did not start that job as expected because, on January 13, 2003, she was admitted to Regions Hospital after taking an entire bottle of Klonopin.^[4]  The employee denied that this was a suicide attempt.  At that time, it was also noted that the employee had been spending excessive amounts of money that she did not have, that she had not been taking her medications consistently, and that she had been calling family members and friends nonstop, leaving messages.  An admission worksheet listed the following “current stressors”:  “lives alone, holidays, new job, workmen’s comp injury, financial, evicted from home.”

On January 14, 2003, Regions Hospital petitioned for the judicial commitment of the employee and for authorization to impose intrusive treatment with neuroleptic medication.  A case worker, Deb Strasser with Mental Health Resources, Inc. [MHRI], was assigned to the employee.  On January 23, 2003, an agreement was reached whereby the employee agreed to commitment and to obtain voluntary treatment under a Stayed Order of Commitment.  She also signed an agreement to the administration of neuroleptic medications.  That Stayed Order was filed on January 24, 2003.

During her hospitalization, the employee’s comments regarding her back varied.  On January 17, she reported intermittent low back pain.  On a couple of days, she was noted to use hot pads and a TENS unit for low back discomfort.  The record from January 18 indicates “some c/o back pain noted.”  On January 23, the employee reported, “my back is killing me,” and the next day she was given Tylenol for pain and reported some relief.  Other times she reported “relief from low back pain,” or “back pain mild.”  The employee also complained of shoulder pain during this hospitalization and was given Naprosyn.  At the time of her discharge on January 27, 2003, she reported “back pain tolerable.”  Regions records also reflect that the employee was somatically preoccupied.

Case manager Strasser maintained regular contact with the employee while she was hospitalized and after  her release.  Ms. Strasser’s records reflect that the employee was frustrated with insurance and work issues.

A psychiatry staff progress note from Regions indicates that, during her hospitalization, the employee had expressed concern about “reporting requirements with regard to nursing licensure,” and Regions staff apparently filed a report with the Health Professionals Services Program [HPSP].^[5]  On January 28, 2003, HPSP personnel contacted the employee and offered participation in their program, in lieu of a report being filed with the Board of Nursing.  The employee elected to participate in the program.

Also on January 28, 2003, the employer filed a NOID based on the employee’s refusal of a job offer within her limitations. She was to be paid through January 24, 2003.

On February 4, 2003, after her release from the hospital, the employee was seen for psychiatric follow-up by Donna Peterson, R.N., M.A., L.P., at Regions.  At that time, the employee listed her symptoms, in part, as “feel I’m coming out of my skin,” “anxious,” “ feeling stressed - not working - have bills.”  The employee was described as “marginally stable,” and it was noted that she did not have a counselor/therapist at that time.^[6]

HPSP case note records of February 5, 2003, indicate that the employee had come to their office on that date and that she was “nearly pain free since receiving physical therapy for her back but she has lifting restrictions.”  Those notes also reflect that, although she did not agree with the need to be monitored for her mental illness, the employee did sign the participation agreement.  That agreement provided, in part, that she could not return to work until authorized by HPSP, that she would disclose her mental illness to all future employers, and that she would identify a work-site monitor who would provide work quality assessments addressing overall work performance.  Later that day, the employee called HPSP expressing concern that she might not be able to obtain a job if she disclosed her mental illness.

On February 6, 2003, the employee called the telephone triage at Regions to request a letter authorizing her to go back to work.  She also stated that she was still having crying jags and questioned whether the lithium was working.  She was told that, after her evaluation on February 19, 2003, consideration would be given to her request.

A MHRI note for February 7, 2003, states that the employee “appeared anxious and was worried about a lot of things (getting a job, her cat’s ear, getting MA and getting her prescriptions re-filled and lack of things to do with her time).  Depression/anxiety seemed apparent.”  On February 10, the employee reported frustration with her current life/work.  On February 19, the employee’s caseworker discussed goal plans and progress with the employee’s brother, Mark Mikel, and he indicated that the family endorsed plans for the employee to file for bankruptcy.

On that same date, the employee was seen again by Ms. Peterson.  Ms. Peterson’s assessment of the employee at that time included poor coping and insight.  The employee was told that Dr. Harris^[7] would be contacted regarding the employee’s request for an anti-depressant and also for a letter stating that she could return to work.  According to a later notation, Dr. Harris indicated that the employee’s lithium level would be tested on February 20, 2003, and that consideration of an anti-depressant would be made after that.  On February 21, 2003, the employee was notified that the requested medications were available for pick-up.

Also on February 21, 2003, the employee underwent a diagnostic assessment at Ramsey County Mental Health Center [RCMHC].^[8]  At that time, the employee indicated that she “has been depressed partly because of not being able to work for sometime now” and because of financial concerns.  She reportedly became quite upset when told that it might be more than three weeks before she was seen by a doctor for medication assessment.  The intake worker talked to his supervisor and agreed to put the employee on the “waiting list for severe cases needing medication assessment.”  They agreed that she would be seen within a three-week time frame.  Individual therapy was suggested, but the employee said she could not return to her former therapist because of insurance issues.  The caseworker that attended that intake with the employee noted that the employee was preoccupied with concerns over how the involvement of  HPSP would impact her ability to obtain a job.

On February 24, 2003, the employee committed suicide.  A note found in her waste basket read, in part, “This is just too much.  The day I got injured is when all this started!”

The employee’s parents [petitioners] filed a claim petition for dependency benefits or payment to estate on August 16, 2006, and the matter proceeded to hearing on August 9, 2007.  In a findings and order filed on October 4, 2007, the compensation judge found, in part, that the June 2002 manic episode was not caused or aggravated by the employee’s use of steroid medication, that the employee’s April 30, 2002, personal injury did not cause or aggravate the employee’s preexisting bipolar disorder, that the bipolar disorder and the employee’s anxiety over being required to disclose her condition to prospective employers were the principal causes of her suicide, and that the petitioners failed to prove a direct and unbroken chain of causation between the employee’s low back injury and her suicide.  The petitioners appeal.

On appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.”  Minn. Stat. § 176.421, subd. 1 (2008).  Substantial evidence supports the findings if, in the context of the entire record, “they 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).  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

Self-inflicted injuries are generally not compensable.  Minn. Stat. § 176.021, subd. 1.  However, in Anderson v. Armour & Co., 257 Minn. 281, 101 N.W.2d 435, 21 W.C.D. 78 (1960), the Minnesota Supreme Court recognized as compensable a death by suicide.  Subsequently, in Miels v. Northwestern Bell Telephone Co., 355 N.W.2d 710, 37 W.C.D. 164 (Minn. 1984), the court held that the issue in such cases is whether the employee’s compensable work-related injury caused or was a contributing cause of his suicide in the medical or psychological sense, a fact issue to be decided on a case-by-case basis.  Id. at 714, 37 W.C.D. at 167.

In the present case, the petitioners first contend that the judge committed reversible error by accepting the opinions of Dr. Gratzer, in that he was an employee of the employer and his expert opinion was therefore biased.  We are not persuaded.

We note initially that no objection was raised to Dr. Gratzer’s reports or deposition testimony, and the issue of bias was not raised at trial.^[9]  When issues are not raised at the hearing level, they may not be raised for the first time on appeal.  Moreno v. Advertising Unlimited, slip op. (W.C.C.A. Jan. 3, 2001).  Furthermore, at no time did Dr. Gratzer testify that he was employed by the employer, only that he had “hospital privileges” at United Hospital, Regions Hospital, and Fairview University Medical Center.^[10]  The petitioners’ claim that “[t]he relationship between the Employer and Dr. Gratzer was too direct, too conflicted and the obligation to support the Employer’s position against Ms. Mikel, too large” has no support in the record.

The petitioners also contend that Dr. Gratzer’s opinions lacked foundation, suggesting that Dr. Gratzer did not review records from the employee’s January 2003 hospitalization or those of her case worker, Deb Strasser.  Dr. Gratzer’s addendum report of May 7, 2007, however, details many of the records from the January 2003 hospitalization, and, in his deposition of July 11, 2007, he testified that he had reviewed those records.  While there is no evidence as to whether Dr. Gratzer reviewed Ms. Strasser’s records, those records do not provide evidence of the “recurring and frequent complaints of back pain” that the petitioners allege was contained therein.^[11]

Dr. Gratzer is a board-certified psychiatrist who has a full-time inpatient practice at Regions Hospital and also an outpatient practice, primarily at United Hospital.  He regularly treats people with depression and/or bipolar disorder, employing the medical approach to mental illness,  including the prescribing of medications.  Dr. Gratzer reviewed the employee’s medical and psychological records going back to 1992, and he met and evaluated the employee on December 4, 2002.  Subsequent to the employee’s death, he reviewed medical records generated after his examination.  Clearly Dr. Gratzer had foundation for his medical opinions.

The petitioners further contend that the employee’s manic episode in June of 2002, which Dr. Gratzer testified put the employee at risk to relapse six to nine months later, was the result of a reaction to the prednisone that the employee was taking for her back injury.  Therefore, petitioners allege, the January relapse and February suicide were also causally related to the work injury.  The judge found, however, that the June 2002 manic episode was not caused or aggravated by the employee’s use of medications, and that finding has substantial support in the record.

Medical records reflect that the employee took prednisone from approximately June 1 to June 6, 2002.  When the employee was seen in the emergency room of United Hospital on June 6, 2002, the decision was made to discontinue prednisone on the theory that the medication might have led to the manic episode.  However, no doctor at that time opined that the prednisone had in fact led to the employee’s manic symptoms.  Moreover, four days after discontinuing the prednisone, the employee was brought to the hospital by the police with continuing, and apparently worsening, manic symptoms.  She was admitted at that time.  While a possible connection between the employee’s condition and her use of prednisone is mentioned in records from that hospitalization, again, no doctor opined that it was related.  The judge then had two opinions to choose from.  Dr. Boller opined that the employee’s hospitalization in June of 2002 was related to a reaction to prednisone.  But, as the judge noted, Dr. Boller provided no specific qualifications for rendering an opinion regarding reactions to prescription medications, and he is a psychologist, not a psychiatrist.  Dr. Gratzer, on the other hand, who is a psychiatrist who prescribes medications, opined that the employee’s manic symptoms and the hospitalization in June of 2002 were not the result of a reaction to prednisone, and he explained his reasoning on that issue.

A judge’s choice between medical experts is generally upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence.  Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).  We find no basis to overturn the judge’s choice of expert opinions here.

The petitioners also allege that various stressors connected to the employee’s work injury led to her suicide.  In this regard, they mention the employee’s time off work because of pain from her back injury, physical restrictions that prevented her from returning to work in her former occupation, financial difficulties related to being on and off of workers’ compensation benefits, the loss of her apartment, and the stress of having her deposition taken.  Further, they allege that, but for the work injury, the employee would  not have taken an overdose in January 2002, would not have been committed to Regions Hospital, and would not have been reported to HPSP.  According to the petitioners, “Cumulatively, all of these events exacerbated Ms. Mikel’s bipolar disorder and depressive episode, and were factors that substantially contributed to causing her to end her life.”  However, there is no medical opinion identifying these specific stressors as substantial contributing causes of the employee’s mental derangement or her suicide.

Dr. Boller identified “the stress in her life” as the source of the employee’s frustration.^[12]  And Dr. Hoistad identified “the severe pain and inability to get appropriate intervention” as the trigger event and substantial contributing aggravation of the employee’s bipolar disorder.  Dr. Gratzer, however, opined that the employee was experiencing a recurrent depressive episode of her bipolar disorder in January and February of 2003.  He testified that bipolar relapses can occur in the absence of psychosocial stressors and that mild back injuries do not aggravate bipolar disorder, type I.  Also, as the compensation judge pointed out, the employee had social, financial, and vocational stressors prior to her work injury.  Psychiatric and psychological records from the five-month period before the employee’s injury reflect that the employee had indicated, “I wish I wouldn’t wake up,” that she was depressed, and that she was worried about her job because she had missed many days from work.

The petitioners also contend that it was reversible error for the judge to adopt the opinions of Dr. Gratzer because of the doctor’s alleged “error in his assumptions” that the employee’s back pain was resolving in early 2003.  However, the compensation judge specifically found that the employee’s low back pain was improving in early 2003, and substantial evidence supports that finding.  That evidence includes Dr. Dowdle’s release of  the employee to work with a 50-pound lifting restriction in January of 2003; the employee’s indication on January 27, 2003, that her back pain was tolerable; the lack of medications for back symptoms upon the employee’s release from Regions, or after; and the February 5, 2003, notation in the HPSP records that the employee was nearly pain-free.^[13]  In contrast, the opinions of Drs. Boller and Hoistad rest on the assumption that the employee was living with constant pain.^[14]  Dr. Hoistad described the employee’s “severe pain and inability to get appropriate treatment for it” as a trigger that exacerbated her preexisting bipolar disorder and led to her suicide.  We have affirmed the judge’s finding that the employee’s back pain was improving, and there is no evidence that the employee had been unable to obtain appropriate treatment for her back.

Bipolar disorder is a biological disorder involving a chemical imbalance in the brain.  Bipolar disorder, type I, is a debilitating condition that affects individuals vocationally and personally.  Bipolar individuals suffer recurring episodes of depression and episodes of mania, and Dr. Gratzer testified that the period between episodes is often six to nine months.  Dr. Gratzer further testified that 10% of people with bipolar disorder are prone to commit suicide.  Of note, he was the only doctor to discuss the employee’s preexisting bipolar disorder.  It is undisputed that the employee suffered from bipolar disorder, type I, prior to the 2002 work injury.^[15]  Her medical records reflect  periods of depression and periods of mania prior to the work injury.  She suffered from a manic episode in June of 2002.  When seen by Dr. Gratzer in December of 2002, she was neither manic nor depressive, but, by January 13, 2003 (seven months after her manic episode), the employee was suffering from depression again.

The petitioners also argue that the employee’s suicide note, standing alone, establishes the employee’s belief,

Dr. Hoistad opined that the suicide note “is a compelling factor” in his opinion that the 2002 work injury was causally related to the employee’s suicide.^[17]  He explained that the note was “an important statement made at the end of her life summarizing the pain that she struggled with and her inability to control or be able to accommodate it in a meaningful way.”  However, given Dr. Hoistad’s other comments in his report, it was reasonable for the compensation judge to assume that Dr. Hoistad was referring to physical pain, and, again, the judge reasonably found that the employee’s back pain was getting better in early 2003.

In contrast, Dr. Gratzer opined that the note was evidence of the employee’s lack of insight into her bipolar disorder and her attempt to blame something else for her social, vocational, and financial difficulties, difficulties that existed prior to the work injury.  The medical records and the opinion of Dr. Gratzer provide support for the judge’s conclusion that the work injury and its consequences did not substantially contribute to the employee’s development of “a mental derangement of such severity that it overrode normal, rational thinking and judgement,” and that the petitioners did not prove “an unbroken chain of causation between the work-related injury, the mental derangement, and the suicide,” as specified by Miels.^[18]

This is a most tragic and difficult case, and we acknowledge that some of the evidence would support alternative findings.  However, the issue on appeal is not whether there is evidence that supports alternative findings but rather whether substantial evidence supports the findings of the compensation judge.  Concluding that the record as a whole reasonably supports the judge’s decision, we affirm that decision in its entirety.