Is Psych a 4-Letter Word in Workers’ Compensation?
At the 2016 PRIMA Annual Conference, Dr Michael Lacroix, Director of Behavioral Health Services with Coventry Workers’ Comp Services, presented a session examining questions on the presence, role and the impact of psychological factors on the susceptibility to, the reaction to and the recovery from workers’ compensation injuries.
Back in 1977 a study published by Engel talked about the bio-psycho-social model of disease and that these factors were something that needed to be considered when evaluating patients. This study was ahead of its time and was not widely accepted at the time it was published. Over time, this study has become the foundation for the bio-psycho social model which is now a big part of standard medical practice.
Stress is the 2nd largest occupational disease after musculoskeletal conditions. 90 million lost work days annually are attributed to stress. Mental disorders account for 9% of medical absences, and 35% of SSDI recipients have a mental disorder. Mental illness accounts for around 15% of cost of disease. About 25% of adults experience some type of mental disorder each year. The issue of mental illness is something that cannot be ignored in the treatment of patients.
Without question, a workers’ compensation injury can have psychological consequences. Loss of income, loss of status as the breadwinner, change of routine, and loss of fitness are some of the areas that can lead to mental stress. Other elements that can lead to mental stress include anger (at employer, co-workers, insurer) and fears (associated with treatment and job loss). Other complicating factors that can impact the case are marital difficulties, medication dependency, or even post-traumatic stress. Over time the patient can develop a chronic pain cycle, focus on secondary gain issues, and develop a disability identity.
One question often asked is whether the work injury triggered the psychological disorder or was that pre exiting and possibly dormant until after the injury.
- A study done by Dersch, et al showed that there was a significant increase in psychological problems following a work injury particularly in the area of depression. However they also pointed out that about 37% of the population had preexisting psychological issues.
- A study done by CDC showed in the three months following injury workers were 44% more likely to develop depression than the control group.
- The Integrated Benefits Institutes study in 2009 found only 30% of patients with depression was getting treatment. The study also found that if there was depression then the medical costs were higher.
Does the presence of a psych condition impact recovery from a workers’ compensation injury?
- A study done by Wasan et al found patients with psychological comorbidities had diminished pain relief.
- Dersch et al did a study that showed poor claim outcomes associated with opioid dependence and depression.
- Perceptions play a huge rule on patient recovery. Many studies have shown that if a patient has a disability mindset and an obsession with their symptoms it leads to significantly poorer outcomes. The single biggest predictor on return to work is whether the patient believes they will return to work.
These studies illustrate the importance of identifying psycho-social issues early on the in the claim so that these issues can be addressed timely before they have the opportunity to complicate the claim and drive up costs.
The problem is long-standing reluctance from adjusters to bring psych into a claim because of concern that condition will become the driver of the case. In addition, there is stigma from patients to admit they have psych difficulties. Physicians are also reluctant to diagnose psych problems. While depression may be common in workers’ compensation, it is seldom diagnosed or treated.
Solutions:
- Nurse triage can be an effective tool to evaluate the presence of co-morbidities at the time of injury. They can also help to prevent unnecessary medical care.
- Case management nurses can become acquainted with the real lives and barriers to return to work that the injured workers are dealing with. The nurses should have training with basic psych techniques.
- We need to do a better job with mental health integration. Because of ACA, more employers have mental health coverage now through their group health plan. Rather than just denying care under workers’ compensation we need to be directing the injured worker to the benefits available under their group health coverage.
- The message from the employer is critical. The happier you are with the employer and the treatment you receive for your claim the more likely you are to have a good outcome on the claim. Workers who enjoy their jobs are going to want to get back to work quickly.
- WCRI did a study that showed low trust in the work relationship was a strong predictor of the outcome. If the worker was concerned they would be fired after the injury they were twice as likely to remain off work.
- The employer can also consider psycho-social issues in job accommodations. Things like flexible scheduling, modified job duties, slight changes to the work environment, and changes in supervision.