Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

The post Everyone Needs Support first appeared on Back in Control.

The post Everyone Needs Support appeared first on Back in Control.

His tests and treatment were as follows:

• His lumbar MRI showed disc degeneration at every level but no instability.
• He had crippling anxiety including fairly frequent panic attacks.
• He was open to psychological care.
• I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
• I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

• The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
• I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
• It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
• The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

• We know that chronic pain increases anxiety and frustration, which exacerbates pain.
• Psychosocial stress is a better predictor of outcome than the surgical pathology.
• The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
• The patient has documented severe untreated anxiety.
• In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
• The state still will not pay for any mental health resources
• They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
• If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?

BF

The post It Really is Upside Down first appeared on Back in Control.

The post It Really is Upside Down appeared first on Back in Control.