By Michael Lacroix, Ph.D., Medical Director, The Hartford
Teresa Williams published an excellent article on this site recently on the mental health impact of the coronavirus pandemic. Her recommendations were right-on. But two things stood out for me in her article. The first was that, on a website dedicated to Workers’ Compensation (WC), those two words (“Workers’ Compensation”) never appeared in the article. The second was her key recommendation that “Wise employers are paying close attention to taking care of their staff members’ mental health during this time…” Let me comment on the first of these, and then provide additional information that could assist with the second.
The reason I was struck by the absence of a reference to WC is because of the implicit assumption that readers would recognize that, regardless of the legislation and regulations in their particular state, mental health issues would obviously impact WC claims. This is something that is increasingly recognized. Studies show that mental health comorbidities, and depression in particular, result in significant delays in recovery from physical injuries, even minor injuries.1,2 While it is difficult to quantify the significance of psychological co-morbidities in WC because in most states these are not considered compensable claims, and often not even recorded, it is possible to get a sense of their importance by looking at the impact of anti-depressant and anti-anxiety prescriptions on the cost and duration of WC claims. In the California WC system in 2018, psychoactive medications accounted for 8.3% of all prescriptions.3 A recent study4 further quantified the impact of depression and anxiety on recovery times and cost for WC injuries. Having anti-depressants prescribed was associated with an additional $22,318 in medical cost and $50,911 in total claim cost, respectively. The effect on total paid WC costs associated with antidepressant prescription was greater in magnitude than all other drug classes. In fact, anti-depressant prescriptions were associated with a three-fold increase in the likelihood that the WC claim would cost more than $100K.
So, expect mental health issues to impact your employees, and also to impact your claimants, whether their claims are Covid-related or not.
On the second point, I fully support Ms. Williams’ suggestions for mitigating the impact of mental health issues on employees (and, by extension, on would-be claimants), but let me expand on her recommendations by reporting on the results of a study that we recently completed with UPS employees applying for leaves under the Family Medical Leave Act (FMLA) for mental health reasons. I have argued5,6 previously that there are more similarities than differences between Group Benefits Leaves and short-term disabilities (STD) on the one hand, and WC injuries on the other, and that it may be advisable for WC professionals to learn from strategies developed by their Group Benefits colleagues and vice-versa.
By way of background, FMLA is a federal leave entitlement for many American workers. If the eligible employee follows proper procedures, with few exceptions employers must approve the leave. Moreover, employers may not direct the employee’s care, such as requiring that they see a particular doctor or clinic to approve the FMLA leave. However, there is nothing in the FMLA law that prevents employers from making assistance available – which, of course, employees are free to accept, or not.
The present study was an expansion of a small proof-of-concept pilot7 in which we offered assistance to those employees who requested FMLA time off for a divulged mental health condition. The assistance consisted simply of providing these employees with information on how to access their employee assistance program (EAP) and other relevant available reference material. For those who accepted the information (referred here as those who Engaged), their FMLA durations turned out to be 18% shorter, and for those who subsequently filed STD claims, their STD durations were similarly shorter.
The Hartford has now completed a larger, follow-up study in partnership with a large multi-national employer client (UPS). Employees requesting FMLA on the basis of a mental health challenge were contacted early on by a behavioral health clinician offering assistance with finding helpful resources. Most FMLA requests were based on issues related to “stress / anxiety / panic,” with “depression” as the next most frequent basis. Overall, depression turned out to have a larger impact than stress. Employees filing for leaves associated with depression averaged 5 more days on FMLA than did those filing on the basis of stress. And those who subsequently filed an STD remained out of work twice as long for approved depression STD claims than those out of work for stress (50 vs 25 days.) This particular outcome is not surprising. Depression is usually more deeply ingrained, while stress is more often situational. We have found consistently that STD claimants with a primary physical diagnosis who also presented with depression as a secondary or co-morbid condition take longer to recover than those with anxiety or stress as a co-morbidity.
The impact of employee Engagement on FMLA durations in this study was similar to that in our earlier pilot: For employees with stress / anxiety / panic, Engagement with the clinician resulted in 3 fewer leave days (18%) on average, while there was no clear impact of Engagement on leave durations for depression.
However, the impact of employee Engagement grew more apparent over time, once a leave extended to an STD claim, and was much greater for absences associated with depression than stress. While 67% of non-engaged employees on leave for depression subsequently extended the leave to an approved STD claim, only 23% of their Engaged colleagues did so. For employees with stress leaves, Engagement with the Hartford clinician during the FMLA leave period resulted in those employees who transitioned to an approved STD leave returning to work 22 days earlier than those who did not engage during the FMLA leave period. However, Engaged employees out of work due to depression returned to work from STD leave an average of 31 days earlier, as compared to those who were Not Engaged group, a very significant improvement.
Mental health challenges often start out small, but then snowball into bigger problems if not addressed properly from the beginning. Many STD claims start out as leaves under the FMLA or related state leave law. Faced with a stressor, the employee initially tries to cope by taking a few hours or a few days off as needed – and then is forced to request longer periods of time off in terms of an STD claim if the stressor cannot be contained and their mental health deteriorates further. The same progression would be expected with WC claims. This suggests, and our results demonstrate, that intervening early may improve recovery time, or even prevent some conditions from developing to the point that more extended time off is needed for the mental health condition.
These results largely replicate our earlier, smaller pilot with a different employer. We conclude that even a very light touch from a behavioral health clinician very early in the “continuum of absence” can have a significant impact downstream on helping employees return to work sooner. Why would such a small measure (the primary information was how to contact the EAP) have such a large impact? While many employers offer generous benefit plans, employees are often busy such that, by the time they need the information, it may take some time and effort to find it. The required effort may be particularly challenging when they are under stress or depressed, yet that is when they need the information most urgently.
This logic also applies to WC cases. It has long been documented that the employers play a critical role in the recovery of their employees. Injured workers who feel supported by their employer get back to work much faster.8 Supervisors, in particular, can have an enormous impact.9,10
Take-Away: People are people, and in the course of life some “employees” become “claimants.” What applies to your employees also applies to your claimants. When supervisors call employees (and when adjusters call claimants) after an injury to inquire how they are doing, it would be advisable to add a few sentences to the conversation to make sure they know the EAP number to call if they feel increased stress, worry, fear, or depression as they progress through their recovery – which many of them will experience, particularly now under the pandemic. Sometimes the simplest, least costly solution is the one that works best.
1Richmond TS, Amsterdam JD, Guo W, et al. The effect of post-injury depression on return to pre-injury function: a prospective cohort study. Psychol Med. 2009;39:1709-20. doi: 10.1017/S0033291709005376
2 Kellezi, B et al. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology, 2016:52(7). doi:10.1007/s00127-016-1299-z
3Young B & Hayes S. California WCI Research Update. https://www.cwci.org/document.php?file=4190.pdf
4Hunt D et al. Association of opioid, anti-depressant, and benzodiazepines with workers’ compensation cost: A cohort study. J Occ Env Med, 2019: 61(5):e206–e211. doi: 10.1097/JOM.0000000000001585
5Lacroix, J.M. Workers’ Comp and Disability Insurance: Two worlds or one? Public Risk, April 2016:32(4), 14-18.
6Lacroix, J.M. Work Comp and Disability Insurance: Two Sides of One Coin. Presented at the annual meetings of the International Association of Industrial Accident Boards and Commissions, Chicago, September 2, 2015.
7This pilot was rewarded with a Decision Health Platinum award in 2018 and has been reported in a number of published and conference venues. See Marin, E., & Lacroix, J.M. Providing Early Mental Health Resources Makes a Difference. @Work, May 2019, Vol. 11, No. 3, P. 37.
8Butler RJ & Johnson WJ Loss reduction through worker satisfaction: The case of WC. Risk Management and Insurance Review, 2011: 14, 1-26.
9Shaw WS et al. A controlled case study of supervisor training to optimize response to injury in the food processing industry. Work, 2006:26, 107-114.
10Shaw WS et al. Employee perspectives on the role of supervisors to prevent workplace disabilities after injury. J Occ Rehab, 2003:13(3), 129-142.