Monday, November 17, 2014

Evidence Based Mental Health

What a great weekend. 

N6641M took me on a visit with Mom on Saturday (she's doing great!), then to see my life long friend, TZ (we literally have been together since 2 years old) to go to the International Motorcycle Exposition at the Long Beach Convention Center, then a Sunday morning motorcycle ride up Angeles Crest Highway to Newcomb's Ranch for breakfast, and then a nice (but Santa Ana wind swept) bicycle ride in the afternoon followed by a delicious tri-tip dinner... My mental health yesterday peaked at an all time high.

Imagine that - what could be better than seeing loved family, wonderful life long friends, flying airplanes, drooling over and then riding motorcycles and bicycles, and filling the tummy with delicious wonderment - a life affirming, psychologically stimulating time important to mental health.

I'd been on a huge path to burn out prior to this weekend - the stress of numerous speaking engagements in November, the upcoming WorkCompCentral Comp Laude Gala, running a business and all the uncertainty and stresses, plus all of the other complications in life...

My wife texted, after seeing a picture of me that was sent to her, "you look extremely happy David," to which my son dutifully replied, "that's because motorcycles make one happy."

They're both right.

I'd say that this past weekend was a great experiment supporting all of the evidence out there that mental health is as much, if not more, important to good functioning than nearly anything else.
Happy - motorcycles do that.
The workers' compensation insurance and claims community is big on evidence-based medicine. We hear it all the time about supporting a treatment decision based on scientific evidence; that's what utilization review and independent medical review, treatment guidelines, etc. is supposed to be all about.

But there is a huge component of science the industry chooses to ignore: psychology typically makes up a larger component of outcomes than any physical treatment.

There are several professional medical organizations (such as the American Academy of Orthopedic Surgeons or the American Academy of Disability Evaluating Physicians) that have, for years, been espousing the science behind this concept - that an injured worker's mental health is as much, if not more, important to good outcomes than nearly anything else. There are numerous studies and peer reviewed papers published in credible medical journals supporting this.

And a pair of articles published in this month’s issue of The Spine Journal support this concept even further.

Researchers principally from University of Zurich in Switzerland conducted a review of previous studies and found that two psychological phenomena – catastrophizing and fear-avoidance beliefs – are associated with return to work and levels of pain among patients with lower back pain.

Catastrophizing is essentially a thinking pattern that elevates perceptions of problems to catastrophic levels. Fear avoidance is refraining from engaging in behaviors out of concern that it will increase pain.

There are two common methods used to determine a patient’s level of fear avoidance. A team of researchers led by Gordon Waddell, a professor at Glasgow, Scotland’s Western Infirmary, created a fear-avoidance belief questionnaire in 1993 that creates a number score. The questionnaire asks patients to agree or disagree based on a numbered scale with statements such as "I should not do physical activities which make my pain worse" and "my work might harm my back."

The Tampa Scale of Kinesiophobia, developed in 1991, is structured in a similar way and asks comparable questions to produce a score.

The score a patient gets based on those responses, according to the University of Zurich researchers, is associated with the outcomes patients had. Several studies included in the review found higher pain levels and fewer patients returning to work when they had higher scores. When patients went through interventions targeting those problems, they had better outcomes.

series of studies from the Workers Compensation Research Institute bolstered the evidence supporting that theory in June. The studies, which examined predictors of worker outcomes in eight states, surveyed more than 3,000 workers in those states. When asked whether they feared being fired because of their injury, 52% said they strongly disagreed, 9% somewhat disagreed, 12% somewhat agreed and 27% said they strongly agreed.

The survey was conducted in 2013, and the participants were all injured in 2010, meaning they had been in the workers’ compensation system for at least three years. Of those who said they strongly agreed that they might be fired because of their work injury, 21% weren’t working at the time of the interview. For those who strongly or somewhat disagreed, the number was 10%.

Further, the disability of those who strongly agreed lasted an average of 13 weeks, compared with nine weeks among those who disagreed that their injury might lead to being fired.

I can go on and on and on.

But here's the hypocrisy - while there is substantial, if not almost insurmountable evidence that taking care of an injured worker's head is critically important to desired workers' compensation outcomes, the claims community would rather not take on that can of worms.

And I can understand why - because insurance and claims management in particular isn't designed to do this; the actuaries didn't factor in the cost of correcting one's behavior and psychology when analyzing the cost of claims.

Nor did the business people that have the obligation of making money off of claims management factor that into their models; it's frankly cheaper to pay off a claim than to tackle the "long tail" of psychological therapy necessary to turn a person around. Indeed, that all may be for naught - there may never be a "turn around."

Because for all the rhetoric about an employer taking an employee as he or she is, and thus being responsible for whatever occurs on the job, there is very little ability to monitor, much less influence, one's psychological state.

So here's the deal - we can talk about mental health of a workers' compensation claim ad nauseum, but the business of workers' compensation is not about taking care of the whole person; it was designed only to take care of what happened specifically at work.

The best claims management can do with this information is be aware of the extent to which psychology plays a part in an injured worker's recovery and, if it looks like psychology is in the way of the desired outcome, then cut the claim chord off as quickly as possible.

It's a harsh reality, but that is the reality.

Kind of like when I told my wife that I finally decided on what new bike I needed to get after the motorcycle exposition - that part of the David-management system got cut off as quickly as possible.

Something about having one motorcycle is enough ...


  1. Mental Health also involves trust and honesty from all party's. In work Comp & our HMO's, if your Dr.s is omitting objective evidence so as to deny your claim, and you have a standard of care that says it's fine for Dr.s to omit the truth in your care,to deny care? Like we do in WA State. Then we are messing with folks mental health right out the gate..... if folks we're honoring the bargain & A Dr.s Duty to do no harm, & our civil rights, to start with, many folks mental health's may not be affected as bad. Possibly if we were not trying to cheat labor&Patients to start with in their care to deny care so as to cost contain,or pushing a personal bias moral agenda, we would not angst the "Patient's" Mental Health... for if you mess up a person's mental health by trying to deny the truth to them to start with? What does that do to the rest of the relationship? It's an oppressive relation ship, and that is never good for any patients mental health.... and we are "PATIENTS" First & foremost, we tend to forget that, in workers comp.

    As far as what makes each person mental health better? That is up to each an every one of us to seek out and find. for many it's exercise and the thrill of pushing life to it's limits, for others it may be as simple as making music, or nitting, or some other creative endevore. It's not a one size fits all fix for mental health, nor for many of our other physical conditions as well.

    But your right, if the mental health is not intact out the gate, then, it will hamper one's road to recovery, somewhat like our med tort laws hamper and hinder folks rights to sue in WC and our HMO's these days as well. The class war is not just happening in WorkComp, it's happening in our HMO and regular care as well.

    We the patients, need our little civil stingers back to hold this behavior to account in our regular care as well as our workers comp care.

    A Class War on all fronts in our health care and employment needs today. I think if we stopped this class war that's going on, folks mental health's would be less of an issue in workers comp and our our HMO care. So we just have to stop the class war, sounds easy enough hey?


  2. PS I came across this article and thought it kind of speaks towards what Im saying about mental health not being a one fix size fix for all. Peace

  3. Perhaps an alternative view would be to make treating the whole person the business of the work comp system. The evidence strongly suggests that psychological factors such as catastrophizing and fear-avoidance, among others, extend claim duration unnecessarily. The evidence is less clear that appropriately addressing those factors would shorten durations, but it both makes sense that it would and the evidence is pointing that way. If we could better demonstrate a positive financial impact from addressing psychological factors, then it could become the business of the work comp system.

    The fact that it's also the right thing to do would be a nice bonus, but it needn't be the only driving force.