Mental health articles

Determining Current Psychiatric Functioning: Strengthsand Weakness Within Occupational Medicine

One barrier to the recognition of psychosocial issues within the workers’ compensationsystem is the workers’ compensation system itself. Most states have “fee schedules”that determine how much physicians are paid for seeing patients in the office. For apractice to be economically viable, physicians must budget appointment timecommensurateto what they are paid for the visit and the expenses to the practice ofproviding the care. Exploring psychosocial issues takes time to build the necessaryrapport, and this exploration of psychosocial issues is in addition to the time requiredfor the purely biomedical aspects of injury or illness treatment. The expense to thepractice to treat a workers’ compensation patient is considerably higher than theexpense incurred by the practice to treat any other type patient (Brinker, O’Connor,Woods, Pierce, & Peck, 2002). This is because of extra paperwork detailing causationand work status, obtaining treatment authorization, resolving collection disputes,rebilling, etc. Thus, workers’ compensation patients really need more physician timeto permit the biopsychosocial issues to be addressed, and yet these are the verypatients for whom the physician has the greatest economic incentive to limit the timespent in the exam room. There is evidence that insurers paying physicians more toprovide quality care improves outcomes (Atcheson et al., 2001).

A second issue in the workers’ compensation system is that workers’ compensationinsurance companies many times have a strong bias against having any psychiatricdiagnosis recognized. In the workers’ compensation system, diagnoses that arerecognized as work related are eligible for free medical treatment (possibly lifetimemedical treatment), and in many systems they are also eligible for lump sum or monthly payment financial awards for diagnoses that are permanent impairments.

Thus, workers’ compensation insurers may have a financial interest in directingcases to doctors who do not recognize psychological issues. In addition, in somestates workers’ compensation systems do not recognize “mental-mental” claims(psychological disorders with psychosocial stressors, but no physical workplaceinjury). This may predispose both the patient and the physician to “medicalize”stressors, by labeling them as if they were physical disorders.

A third issue is that patients in a compensation setting have been shown to failto accurately reveal their past history of psychiatric/psychological illness. Don andCarragee (2009) found that 68% of motor vehicle accident victims seeking care forneck or back pain denied having any preexisting history of spine pain, drug oralcohol abuse, and psychological diagnoses, but these problems had been documentedin their prior medical records. In those seeking compensation for the motorvehicle accident, the rate of false reporting of preexisting problems was 80%.Lees-Haley, Williams, and English (1996) found that workers’ compensationclaimants describe their preinjury function on questionnaires as significantsuperior to average individual’s function, again suggesting that being in thecompensation system changes patients in a way that makes it harder for physiciansto obtain the needed information about psychosocial issues to be able todeal with these issues. (Lees-Haley et al., 1996 and 1997). The reluctance ofpatients to admit to preexisting psychological or alcohol or drug use disordersmakes the use of self-report questionnaires problematic in detecting theseissues. Nonforensically oriented psychologistsand psychiatrists may havetrouble detecting these issues if they use the traditional nonforensic mentalhealth professional approach of accepting whatever the patient says and tryingto work within the patient’s conception of reality.

Thus, the current system incentivizes the patient to conceal, consciously or unconsciously,the existence of psychosocial factors so that the injury or illness is acceptedas compensable; the current system incentivizes the physician to spend less time withthe patient than with patients with other funding sources; and the insurer has financialincentives to steer patients to doctors who ignore the psychosocial issues.Obviously, one way to determine current psychiatric or psychological functioningis to refer the patient for formal evaluation by a mental health professional. Simplerways to screen for psychosocial issues exist.

Physicians frequently note symptoms and exam findings that are out of proportionto the objective findings (e.g., Waddell’s signs and Waddell’s symptoms for back painpatients) in cases of biologically unexplained delayed recovery (Waddell, 2004).This should suggest the need for the assessment of psychosocial issues. Waddelldeveloped these signs and symptoms lists to help physicians recognize when apsychosocialproblem exists in addition to a biological problem. These signs may alsobe present in malingering, but malingering is much less common than are psychosocialconfounders that delay or prevent recovery.

When recovery is occurring as predicted by the biologic model, the exploration ofpsychosocial factors is usually neither done nor needed. When recovery or outcomeis inconsistent with the biomedical model and tolerance for symptoms, not risk of harm or objectively documented lack of capacity is the issue (Sect. 6.8), physiciansshould recognize that unevaluated and untreated psychosocial issues are present.Asking opened ended questions that screen for psychosocial issues may reveal“yellow flags” suggesting that psychosocial issues are present (Kendall, Burton, Main, &Watson, 2009). Examples of these questions would be:

• What do you think is the cause of your pain?

• Do you worry that something bad is causing your pain, but has not been found?

• When your pain increases, do you think you are harming yourself, and you muststop what you are doing?

• Do you think you will never get better?

• Have you been feeling stress or depressed lately?

• What tasks do you do at work?• What do you like about your job, and what do you dislike about your job?

• Are there parts of your job you fear you will never be able to do again?

• When do you think you will return to work?

• What could your employer do to help you return to work?

Another method of assessment is to have the physician’s office staff to havepatients complete pain drawings or questionnaires that screen for psychosocialissues. Pain drawings that show symptoms in places that are not easily explainedbiomedically are an indication for the assessment of psychosocial factors(Mooney, Cairns, & Robertson, 1976). A fear avoidance beliefs questionnaire(FABQ) (Waddell, Somerville, Henderson, Newton, & Main, 1993) and DistressRisk Assessment Method (Main, Wood, Hillis, Spanswick, & Waddell, 1992) arequestionnaires the patient can complete before the physician enters the examroom. These are easily scored, and they help make physicians aware of psychosocialissues. Another “yellow flag” questionnaire is contained in the NewZealand Acute Low Back Pain Guide (http://www.nzgg.org.nz/guidelines/0072/acc1038_col.pdf).

Tags: Occupational Medicine