December 15, 2017

Dr. Steven Moskowitz: Invisible Obstacles: The Role Mental Health Plays in Recovery and Return to Work

By Steven Moskowitz, MD, Senior Medical Director, Paradigm Outcomes

Steven MoskowitzMental health is an element of claims management that is rightfully getting more attention in workers’ compensation. The mental health topic has been in the shadows because it can conjure up a frightful golem of high costs, added complexity and compensability issues. But beyond causation and coverage concerns lies the need to understand how an individual’s psychological and social characteristics affect recovery from an injury. Doing so can be a vital strategy for successfully resolving a complex injury or pain claim.

Research points to a strong correlation between physical and mental wellbeing. An effective mental health approach can not only improve recovery outcomes, but also optimize return to work and other claims management metrics.

Why Psychosocial Issues Are Often Overlooked
When a serious workplace accident first occurs, the focus naturally centers on saving the injured worker’s life. For less severe injuries or an illness, the primary goal centers on an effort to fix what is broken. Somewhere along the line, once the immediate biomedical needs are met, there emerges an individual trying to get back to the place he was at before the work injury occurred. Even when that place was not so great to begin with, it was familiar, he misses it, and may even begin to idealize it. This post-acute stage of recovery is when his psychosocial framework matters most.

The structure of the workers’ compensation system is such that we are often artificially blinded to an injured worker’s past medical and psychosocial history. But naturally, injured workers come to the table with all sorts of lifestyles, personal histories, comorbidities, hopes, expectations, habits and coping styles.

A plethora of personality traits can affect recovery. As an example, consider that the overall 12-month prevalence of a major depressive episode in the US is 6.6%, and even higher in 18-25 year olds and females. People with depression may consistently see the cup as half empty, be hard to motivate, voice hopelessness, or get stuck on how bad their life now seems. Similarly, the 12-month prevalence of an anxiety disorder is 10%. People with anxiety may worry excessively about such issues as their diagnosis, finances, their future, or making the wrong decisions. These two conditions alone can affect how an injured worker views his illness, copes or worries, and ultimately recovers.

Consequences of Ignoring Mental Health
Physicians commonly underestimate the degree of behavioral issues found in patients with pain complaints unless psychometric testing is used as part of the assessment. A study of spine surgeons illustrated this point.1 Failure to recognize or treat these mental health challenges can lead to poor outcomes. As evidence, consider a recently published study reporting that following rehabilitation gains for a musculoskeletal injury, those with high post-treatment scores on measures of catastrophizing and fear of pain were at increased risk of failing to maintain treatment gains at one year follow-up visits.2This is not news to those in the pain rehabilitation field, but it reaffirms that biomedical treatment will not resolve psychosocial issues.

Strategies to Address Psychosocial Issues
Being injured and dealing with the medical and insurance systems can be confusing and stressful. We must recognize that not everyone copes with stress and illness well, and some do it poorly. Unavoidably, the effects of an injured worker’s psychosocial issues often get comingled with a claim. Now we must ask, “What can be done about it?” I recommend a three-pronged approach to acknowledge and manage the influence of mental health on a claim.

First, Recognize when psychosocial issues may delay recovery. Delayed recovery itself may indicate the presence of psychosocial factors, especially when not clearly explained by medical testing or when someone’s symptoms worsen rather than improve over time. These two actions are key:

  • Identify past history that may include substance abuse, major psychological problems, prior work injuries and other medical disabilities.
  • Identify behaviors that indicate a psychosocial struggle such as frustration, anger, dramatic complaints or disability. Other factors like frequent phone calls or complaints, and crying or yelling may indicate non-physical drivers to a prolonged claim.

Next, determine how these psychosocial issues are affecting the injured worker’s recovery and claim resolution. Some of the questions you may need to consider include: Are the issues delaying return to work? Are they leading to poor clinical response? Are these behaviors misleading providers? Are they leading to medication escalation or inappropriate procedures? Are they making the injured worker dependent on the medical system? Are they leading to a more confrontational or litigious posture by the injured worker? Using techniques such as the trans-theoretical stages of change (readiness for change) assessment can be elucidating. Sometimes a formal psychosocial assessment or even psychological testing can clarify and quantify the effect of an individual’s maladaptive traits.

Finally, apply systematic interventions to untangle the psychosocial issues from the biomedical needs to help the injured worker’s functional recovery. When needed, engage psychosocial health services into a recovery plan. When used properly, techniques such as cognitive behavioral therapy (CBT) can facilitate recovery and assist returning the individual to work. One study suggests that “work-focused” CBT can significantly expedite return to work.3 The key is to provide a restorative psychosocial approach to recovery, not a justification for disability.

Some day-to-day strategies may help provide structure to injured workers whose lives may be chaotic or whose subjective experience of the compensation system feels disorienting or combative. Based on clinical psychologist and work disability prevention and occupational health consultant, Renée-Louise Franche’s, Ph.D., R. Psych, recommendations, I suggest the following interventions for use with all injured workers, particularly those with psychosocial issues, to hasten recovery:

  • Assist the individual with the insurance processes, humanize all communication with the injured worker clarify expectations and assist, when needed, with a structured way to fulfill their obligations.
  • Harmonize contradictory messages through a case management plan. It is particularly important to work with treating providers who may be promoting a biomedical approach when a biopsychosocial approach is needed.
  • Consider carefully selected, short-term cognitive behavioral services to focus on injury recovery and return to work, or liaison with non-compensable services for pre-existing psychosocial issues.
  • Integrate the workplace earlier rather than later, and realize there may be psychosocial barriers to returning to work masquerading as medial barriers.
  • In some cases, contrary to instinct, we may want to use utilization review (UR) and independent medical exams (IME) more sparingly. Though aimed at vetting questionable provider recommendations, some injured workers see it as aimed at them and become alienated or develop a sense of injustice when “denied” services they are told they need. This may push them toward a potentially ineffective treatment rather than away. They may respond better (though more slowly) to direct education and engagement earlier rather than later (and so may their physicians).

In summary, psychosocial issues commonly contribute to delayed or unsustained recovery in many cases. Identifying these causes early, and strategizing the best biopsychosocial claims approach can facilitate better clinical and claim outcomes.

Endnotes
1Clinical impression vs. standardized questionnaire: The spine surgeon’s ability to assess psychological distress. Daubs et al. J Bone Joint Surg Am. 2010;92:2878-83
2Catastrophizing and pain-related fear predict to maintain treatment gains following participation in a pain rehabilitation program, E. Moore et al.·1 (2016) e567 Pain Reports
3Work-Focused Treatment of Common Mental Disorders and Return to Work: A Comparative Outcome Study. Journal of Occupational Health Psychology. 2012, Vol. 17, No. 2, 220–234

About Steven M. Moskowitz, MD
Steven M. Moskowitz, MD, is the Senior Medical Director and supervisor of Paradigm Outcome’s pain program. Dr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain. He began his clinical practice in 1989 and currently practices at the Life Care Center of Nashoba Valley, MA. Dr. Moskowitz earned his medical degree from Tufts University School of Medicine, is certified in Managed Care Medicine, and he is a member of the American Academy of Pain Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American Pain Society.

About Paradigm Outcomes
Paradigm Management ServicesParadigm Outcomes is the nation’s leading provider of catastrophic and complex case management, Paradigm achieves 5x better medical outcomes and lowers total costs by 40%. Paradigm accomplishes this by bringing together nationally recognized doctors, the best providers in the country, and 25 years of clinical data to guide decisions. Paradigm is the only company designed and built specifically to address the needs of those with acquired brain injuries, spinal cord injuries, amputations, burns and chronic pain, and is the only company to stand behind their promises with medical and financial guarantees. Visit www.paradigmcorp.com to learn more.

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