Psychological treatment complex, but critical

Problems could impact return to work

By Pamela A. Warren, PhD
Clinical Psychologist, Urbana, IL

Mental health issues often are factors in occupational medicine and are essential to treat since they interfere with physical recovery. A recent study by Dersh, et al. (2002) reported that 64% of all occupational medicine patients experience at least one psychological disorder, compared to the 15% prevalence rate of the general population.1 Therefore, it is crucial that occupational physicians and clinicians are aware of the high occurrence of psychological disorders in their patients. It is equally important to utilize mental health professionals who practice in occupational psychology or psychiatry to assess and stabilize the individual in order to facilitate a full recovery and a return to work.

Of note, the National Institute of Occupational Safety and Health recently reported that the lost productivity and absenteeism occurring from all mental health concerns resulted in approximately $312 billion dollars annually.2 This high cost negatively impacts overall health care costs. As a clinical psychologist who practices in occupational psychology and disability management, I regularly observe numerous issues and make several recommendations to assist the occupational medicine professional in navigating the psychological treatment process effectively in an occupational medicine setting.

Here are a few recommended guidelines:

• Determine if an appropriate psychological diagnosis has been made. Stress, anxiety, and depression are the most common psychological diagnoses observed in file reviews or disability evaluations. However, stress is not a true psychological diagnosis. It is important to examine what stress is, vs. what stress is not. Stress is a normal, inherent part of life. It comprises both positive and negative components. Examples of positive stress are birthdays, marriages, or packing to get ready for vacation. Examples of negative stress are death of a loved one, losing one’s job, or diagnosis of a life-threatening illness. Stress is subjective and dependent on the individual’s repertoire of coping techniques, internal beliefs, and ability to view stress as temporary vs. permanent (individual resiliency).

Stress is not permanent, but is cyclic in nature. It is not impairment, since it is a part of everyday life; nor is it a disability. Therefore, stress is not a reason to apply or to file a disability claim. If a diagnosis of stress is provided by the employee or by other treating providers, it is an important clue that a potential psychological concern is occurring that hasn’t been appropriately identified according to professional psychological criteria.

• Define the actual psychological diagnosis. Specifically, it is essential to determine the factual reasons that the employee believes s/he cannot work or complete one’s defined workplace duties. This information must be objective, not subjective. An example of subjective information that is commonly seen is: "My patient cannot work at all because of workplace issues." Most insurance companies and employers do not ask for objective information on their applications. Therefore, it isn’t supplied by the applicant or to the treating health professional.

The occupational health professional should examine the clinical data received. Look for objective data versus subjective opinions. For example, is the employee anxious or depressed? This is a psychological diagnosis and therefore determines what type of information needs to be gathered from the employee and from the treating occupational medicine professional.

• Obtain a written copy of the actual workplace duties for the employee. It is the employer’s responsibility to define the actual workplace duties the employee completes so that duties match the written job description. Ideally, a written job description is completed for each paid position to define specific workplace duties. After it is signed and dated by the employee, it should be kept on file at the workplace. In the application for disability process, a copy of the signed job description should be sent to the occupational medicine professional in order to understand what actual workplace duties are required of the employee. By utilizing this information, issues of functional impairment can be determined in a factual manner.

• Obtain appropriate documentation from employers and insurance companies. Most employers and insurance companies do not generally have forms that allow health professionals to provide factual general or mental health information. For example, it is rare to see insurance forms that ask the health professional to provide the Diagnostic and Statistical Manual of Mental Disorders multiaxial diagnosis (e.g., Axis I-V). Yet, these are the professional criteria that all mental health professionals employ to make a diagnosis. Lack of appropriate documentation leads to health professionals relying on subjective information from the employee. This creates a miscommunication cycle about the appropriate questions to ask, as well as understanding what objective professional documentation is necessary to assess a claim.

• In the majority of cases, a diagnosis of Anxiety or Depression is not permanent. It is essential for the occupational medicine professional to express in objective terms why a short-term leave is necessary and what evidence-based treatment should occur in order to return the employee to work. Unfortunately, this is rarely the case when mental health or nonoccupational concerns arise during occupational medicine treatment. Frequently, employees are placed open-ended, long-term leave because of the individual indicates s/he isn’t "better yet." Therefore, occupational medicine professionals, insurance companies, and employers must ask for regular documentation of an evidenced-based treatment plan, coupled with clinical evidence of objective progress made. The evidenced-based treatment plan must have specific goals to return the individual to work. With a short-term leave from work, a graduated plan for return to work should be a part of the treatment plan.

• It is essential to ensure that the employee is receiving treatment and is complying with treatment recommendations. The occupational medicine professional, insurance company and employer must ensure that the employee/applicant is actually receiving and complying with treatment. It is startling how frequently in file reviews the applicant is not receiving regular, appropriate treatment and/or is not complying with treatment recommendations.

If a disability leave is approved, then the employee has a responsibility to follow the stated requirements for the leave. For example, if an individual is depressed and has an approved leave, then, it is important for occupational medicine professionals, insurance companies and employers to indicate in the application process that the employee is responsible for obtaining treatment and for providing regular documentation of treatment in order to maintain a leave. For an acute mental health diagnosis, there needs to a reasonable evidence-based treatment plan being utilized, such as clinical appointments one to two times a week or inpatient hospitalization if the symptoms are severe, to ensure that the employee is becoming stabilized and improving. Once-a-month appointments denote a lesser degree of professional care. If improvement is not occurring, then it is important to ask why not and obtain a second opinion.

• Ask other treating health professionals to provide objective evidence to support a psychological diagnosis. Ask what standardized psychological tests have been given to assess the severity of the employee’s stated concerns. It is inappropriate to make a diagnosis on the basis of an evaluation alone or on psychological tests alone. The professional standard is to complete both to reduce bias.

• Obtain training or work closely with an occupational mental health professional to become educated regarding current standards of treatment. It is crucial for occupational medicine professionals, insurance companies, and employers to familiarize themselves with current standards of treatment in order to accurately assess mental health claims. Otherwise, arbitrary decisions can and are made all too frequently which end up making mental health claims extremely expensive and antagonistic for all involved parties.

In closing, it is important to be aware that not all physicians are comfortable diagnosing or treating mental health concerns and therefore, only with pressing, will render a diagnosis. It is also essential to realize that mental health professionals do not receive professional training in disability management regarding the application of the clinical evaluation data and development of a reasonable treatment plan to assist employees in returning to work.

Therefore, it is imperative to first find a mental health professional with actual training and is practicing in the disability field to facilitate appropriate treatment and to return the employee to work. These professionals are rare.

References

1. Dersh J, Gatchel RJ, Polatin P, et al. Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability. JOEM 2002; 44(5):459-468.

2. National Institute of Occupational Safety and Health; 2003.

For additional information, contact:

• Pamela A. Warren, PhD, Clinical Psychologist, Carle Clinic Association, 602 W. University, Urbana, IL 61801. Telephone: (217) 383-3442.