It’s been well established that mental and behavioral health conditions – whether occurring after an injury or already present – can lead to longer recovery times and poorer health outcomes1. In fact, 47% of workers’ comp stakeholders said they see psychosocial/mental/behavioral health as a barrier to recovery for injured workers.2
Mental health comorbidities also had a stronger association with smaller functional recoveries than physical health comorbidities, according to a study of workers receiving physical therapy for low back pain.3 A second study concluded that depression is an important predictor of recovery, with increasing levels of depression scores at one month associated with significantly reduced odds of recovery at 12 months.4
In addition to impacting recovery, mental and behavioral health may also affect the course of a claim and cost. When it comes to claim complexity, the number one concern for workers’ comp stakeholders is mental health conditions.5 What’s more, costs are 75% higher for people diagnosed with both behavioral health and other common chronic conditions than for those without a co-occurring behavioral health diagnosis.6
However, diagnosis of a mental health condition is not the only circumstance in which intervention may be beneficial or even needed in the overall management of an injured worker. Among injured workers, there are often psychosocial factors at play. These “yellow flags” are characteristics that shape an individual psychologically and/or socially and act as barriers to recovery from physical injury.
In a benchmarking survey, nearly 85% of organizations reported that psychosocial risk factors contribute to musculoskeletal disorders – the most common workplace injury – in their workplace.7 And in another example, the average lost-time claim costs 3.5 times more when words such as “fear” and “afraid” are recorded in adjuster conversations.8
Addressing these concerns early – starting with behavioral health screenings within a few weeks of injury – can positively affect a claim and health outcomes. For example, Cognitive Behavioral Therapy (CBT), a type of psychotherapy, has proven to be effective in reducing the length of sick leave and facilitating return to work.9
There are a variety of screening tools11 for psychosocial risk factors. In workers’ compensation, they may be used by treating providers, physical therapists, nurses, vocational counselors, and mental health providers. Guidelines recommend screening two to six weeks after a claim is opened.12
Screening tools for psychosocial risk factors include but are not limited to:
A 25-item self-reported questionnaire addressing six psychosocial factors that focuses on prediction of work disability. There is also a shorter 10-question version, the OMPSQ-10, that is reported to have similar predictive power but takes less time to administer.
A nine-item self-reported questionnaire designed to assist primary care physicians in making treatment decisions.
A six-item survey that screens for pain interference with activities, pain sites, recovery expectation, fear avoidance, and work accommodations.
In workers’ compensation, behavioral health treatments are typically brief and time-limited, with therapy lasting around six to eight weeks.13 Sessions usually borrow aspects from different treatment approaches. Note: Treatments vary depending on the specific psychosocial factors present or medical diagnosis in each case. Not all treatments are appropriate for every situation.
Cognitive Behavioral Therapy refers to a group of psychotherapies that focus on modifying maladaptive associations between cognition, emotion, behaviors, and physical symptoms. In workers’ compensation, CBT is the most used intervention to address psychosocial risk factors as well as mental health conditions.14 It is recommended for chronic pain as well as PTSD, depression, traumatic brain injury, and substance use disorders.
In a study of workers who experienced mild head trauma, treatment using CBT demonstrated favorable outcomes. The timeframe of recovery and return to work was reduced from a mean of 10 months prior to referral to a mean of seven weeks after neurocognitive screening evaluation and work-focused CBT, which focuses on work-relevant solutions that can help reduce lost time from work.15
Acceptance and Commitment Therapy is a newer form of CBT that focuses on accepting pain experiences, relying on increasing psychological flexibility to overcome difficult situations. ACT is recommended for the treatment of chronic pain, depressive disorders, work stress, psychotic symptoms, obsessive compulsive disorders, mixed anxiety, and substance use disorders.
ACT has proven to be an effective intervention treatment for psychological stress and burnout among healthcare staff. According to one study, 48% of participants who received ACT intervention showed reliable improvements in psychological distress at four weeks post-intervention.16 Another study focused on nurses and nurse aides working in long-term care residential settings. Participants receiving group-based ACT intervention reported significantly fewer days missed due to injury and a significant reduction in mental health symptoms compared to the control group.17
Biofeedback is recommended for the treatment of chronic pain and teaches patients self-awareness and self-regulation skills, so they have greater control over bodily processes. It uses sensors attached to the body to measure key functions. A review of the clinical effectiveness of neurofeedback, a type of biofeedback, shows that compared with no treatment, there is a statistically significant improvement in symptoms in patients with PTSD or generalized anxiety disorder.18
Digital health interventions are apps that help injured workers to self-manage their conditions and communicate with their care teams and case managers. They offer the potential to address the gap in care for depression and anxiety among people with chronic conditions. One review of digital health interventions found modest evidence that they have a positive impact on health-related outcomes in the workplace.19
While some payers are offering their own digital health applications, others are looking at opportunities to incorporate third-party evidence-based tools into their programs. Using one such tool, patients with disabilities experienced shorter total claim durations.
Eye Movement Desensitization and Reprocessing is a form of psychotherapy used to treat PTSD and traumatic brain injury. It involves making the patient recall specifics of the trauma while simultaneously focusing on an external stimulus. EMDR has been proven to improve PTSD diagnosis, reduce PTSD symptoms, and reduce other trauma-related symptoms.20
EMDR also shows promise as an effective treatment for depressive disorders. In a study of people receiving inpatient care for depression, 68% of those receiving EMDR showed full remission after treatment. They also had fewer relapses and depression-related concerns at follow-up over a year later.21
Functional restoration is one of the earliest biopsychosocial treatment programs for chronic pain.22
Implemented by a multi-disciplinary team and led by a supervising physician, this program takes a patient-centered approach to addressing chronic occupational musculoskeletal disorders. There are two components: an exercise program and a multimodal disability management program to address psychosocial issues.
In a study comparing the effects of FR versus physical therapy alone, the mean number of sick-leave days was significantly lower in the FR group, which included intensive physical training, occupational therapy, and psychological support.23 FR programs have also demonstrated effectiveness for patients with chronic lower back pain.24
Of note, by some accounts, the cost of FR programs is high compared to other psychosocial treatments. However, one study concludes that “such perceptions are misguided and incorrect in terms of the potential long-term cost savings of such a program.”25 Another study notes that early rehabilitation using FR is more likely to be a cost-effective solution “compared to cases that progress >8 months and receiving FR as a treatment of ‘last resort.’”26
Mindfulness therapy is a type of talk therapy that focuses on increasing awareness of the thoughts, feelings, and actions that hinder progress. It is recommended for the treatment of depressive disorders and is often combined with other therapies, such as CBT or ACT.
A review of 16 articles suggests that mindfulness interventions within the scope of occupational therapy practice are helpful for patients with musculoskeletal and chronic pain disorders and possibly certain neurological disorders.27 And a study of patients with spinal cord injury found that mindfulness may be particularly effective for improving symptoms of depression and anxiety.28
Pain Reprocessing Therapy is an emerging treatment recommended for alleviating chronic back pain. It focuses on changing patients’ beliefs about causes and threat value of pain and is based on the premise that the brain can generate pain in the absence of injury or after an injury has healed.
A recent study shows that PRT is a viable treatment for those with mild to moderate chronic back pain for which no physical cause could be found. After four weeks of PRT, 66% of participants reported being pain free or nearly pain free, and treatment effects were maintained at a one-year follow-up.29
The Progressive Goal Attainment Program is a standardized community-based approach of reactivation and cognitive behavioral techniques used to address psychosocial risk factors. The focus is return to work rather than pain management. PGAP training workshops are designed to equip rehabilitation professionals – such as occupational or physical therapists – with skills in psychosocial intervention strategies so that they are better able to assist their clients in overcoming the challenges associated with debilitating health and/or mental health conditions.
In a study of individuals referred for the rehabilitation treatment of disabling back pain, PGAP led to a higher likelihood of individuals returning to work. Half the sample was enrolled in a physiotherapy intervention characterized by a functional restoration orientation (e.g., mobility, strengthening exercises) while half the sample was also enrolled in PGAP. Participants in the PGAP group were more likely than participants in the purely physiotherapy group to have returned to work.30
Virtual Reality Exposure Therapy is an emerging treatment for PTSD. It works by immersing the patient within a computer-generated simulation that includes multi-sensory stimuli tailored to a patient’s individual trauma. According to a systematic review and meta-analysis, VRET could produce significant PTSD symptom reduction.31 And in clinical trials, a type of VRET called VR-based Graded Exposure Therapy (VR-GET) has also been shown to be beneficial in ameliorating PTSD symptoms.32
The U.S. Food and Drug Administration has also authorized the use of a VR device for chronic pain reduction. The prescription device employs the principles of CBT and other behavioral therapy techniques. In a clinical study of participants with lower back pain, 66% of device participants reported a greater than 30% reduction in pain, compared to 41% of control participants. At a one-month follow-up, all participants in the device group continued to report a 30% reduction in pain.33
In workers’ compensation, there is often some stigma associated with adding psychosocial services to a claim because these services may increase claim complexity and cost.34 However, studies show there is a direct correlation between physical injury and mental health.35 When it comes to treating injured workers, it’s difficult to separate one from the other; healing means treating the whole person, including any mental health concerns.
In fact, health outcomes are worse and downstream costs are often higher when these mental health concerns go undetected and/or untreated. Injured workers who experience negative mental health side effects have the potential for absenteeism or delayed return to work. Even more concerning, studies have shown that those with depression may be at greater risk of problematic opioid use.36 By adding psychosocial services to a claim in the early stages of injury, overall claim duration can be shortened and many poor outcomes avoided.
