The connection between the mind and body has long been debated by everyone from ancient philosophers to contemporary scientists.1 Though some healthcare practices still consider the two as separate entities, there is increasing research supporting a relationship. The World Health Organization affirms this idea, defining health as “a state of complete physical, mental and social well-being” and stating that mental health is an “integral and essential component of health.”2
Research shows there is also an explicit link between physical injury and mental health. In a review of 41 research papers on the relationship between mental health and injury, studies reveal that post-traumatic stress disorder (PTSD), depression, and anxiety were frequently associated with traumatic physical injury.3 Studies also demonstrate that psychological risk factors can explain as much as a 35% to 40% variation in how a person responds to an injury.4 Though not every injury results in mental health issues, many do.
This is especially apparent in the case of injuries tied to workers’ compensation claims. Injured workers have a higher likelihood of experiencing symptoms of depression, anxiety, and PTSD. In turn, these mental health concerns can increase claim costs and duration and result in delayed return to work – especially when left untreated.
A mental health disorder is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior.5 In addition to mental health concerns brought on through injury, workers sometimes bring with them factors that may have been present before the injury. These also impact recovery and claims.
Mental health disorders fall into many categories and can present individually or in combination with one another. Those that are most often connected to the workplace include:
Symptoms of stress, which is common in many occupations, include difficulty concentrating, irritability, headaches or body pains, upset stomach, trouble sleeping, loss of appetite, or overeating. Chronic stress can worsen pre-existing health problems and exacerbate mental health conditions.6
Workplace anxiety can be caused by many things, from giving a big presentation to working with senior leaders. During the COVID-19 pandemic, anxiety affected many healthcare professionals.7 Symptoms include excessive fear and worry and are severe enough to result in significant distress or impairment in functioning.8
Depression ranks among the top three workplace problems addressed by employee assistance professionals.9 Symptoms include feeling sad, irritable, or empty; a loss of pleasure or interest in activities; poor concentration; feelings of excessive guilt or low self-worth; hopelessness about the future; thoughts about dying or suicide; disrupted sleep; changes in appetite or weight; and feeling especially tired. People with depression are at an increased risk of suicide.10
The prevalence of PTSD is high in conflict-affected settings, such as healthcare or emergency response. Symptoms include intrusive memories; flashbacks or nightmares; avoidance of thoughts and memories of the traumatic event; avoidance of activities, situations, or people reminiscent of the event; and persistent perceptions of heightened current threat.11 Approximately 15% to 35% of patients with chronic pain also have PTSD.12
U.S. adults experience mental illness each year
U.S. adults experience serious mental illness each year
of U.S. adults with mental illness received treatment in 2021
average delay between onset of mental illness symptoms and treatment
In 2019, 1 out of every 8 people around the world were living with a mental health disorder, with anxiety and depressive disorders being the most common.14 By 2020, those numbers rose significantly due to the COVID-19 pandemic, with a 26% and 28% increase, respectively, for anxiety and major depressive disorders.15
Because of the inherent connection between physical and mental health, injuries often result in mental health concerns. In fact, injury is considered one of the leading psychological stressors for athletes and is typically associated with an increased risk of depression. In a study of Division I football players, 33% of injured athletes reported high levels of depressive symptoms, compared with 27% of non-injured athletes.16
The same trend applies to anyone who gets hurt on the job. Research shows statistically significant differences in the rates of mental health service use between injured and non-injured workers.
A study of workers who missed at least five days of work due to work-related musculoskeletal injuries showed that half frequently felt symptoms of depression in the year following their injuries, and almost 10 percent were diagnosed with depression at some point during that time.17
Another study matching one injured worker with three uninjured workers during a two-year period concluded that injured workers had a higher likelihood of seeking mental health care services during the six months after the injury.18
And a third study of Canadian workers concluded that the injured group had 6.56 times the rate of post-injury mental health hospitalizations and 2.65 times the rate of post-injury mental health physician claims as the non-injured group – with the greatest differences in rates of mental health service use occurring during the first 12 months following the injury.19
There are three categories of mental health injury when it comes to workers’ comp claims, all with different burdens of proof that vary by state of residence.
A mental health concern develops during or after a work-related physical injury. Qualifying for workers’ comp is usually straightforward because the mental injury is tied directly to the physical workers’ comp claim.
A mental health concerns develops due to stress or anxiety and leads to a physical problem, such as cardiovascular disease. Qualifying for workers’ comp by proving the link between mental health and work can be difficult.
Mental distress results from work, with no physical injury to the employee. Qualifying for workers’ comp can be difficult unless the employee was involved in a catastrophic event. Though some states don’t allow mental/mental health claims, others have specified the elements necessary to establish this type of claim.20 For instance, states cover mental health injuries such as PTSD for some occupations, such as first responders.
Mental health problems following an injury have a multi-faceted effect on workers’ comp claims.
The average major depressive disorder lasts for 26 weeks, making depression the single leading cause of disability in the workplace21 – and no doubt lengthening workers’ comp claim durations. As an example, the average duration for an injury diagnosis of low back strain is about 23 days, but if you take that same diagnosis and add a comorbid condition of depression, the duration increases to 42 days. If you add a secondary diagnosis of depression, the average duration is up to 90 days.22
Mental health concerns can also lengthen claim duration due to noncompliance with treatment plans. Studies show that patients who are depressed are three times more likely to be noncompliant with a treatment plan and to have a higher risk of physical illness.23
Return to work is also impacted. One 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.24
In a second study, symptoms of depression were also common among participants who were having trouble returning to work. Only 10% of workers who reported feeling depressed at 1 month, 6 months, and 12 months after the injury were able to return to work and stay at work. The remaining 90% never even attempted to return to work or tried to return but had at least one recurrence of work absence.25
A third effect of mental health concerns is an increase in overall claim cost. Mental health conditions are the most expensive health challenges in the nation behind cancer and heart disease. They are also the leading cause of disability in high-income countries.26
In fact, patients with a chronic disease and behavioral health comorbidity cost as much as 50% more than those without the behavioral health condition.27 Another statistic shows that an employee with one or more comorbid conditions – like a mental health condition – has work-related costs twice that of a healthy employee with the same primary diagnosis.28
Even when injured workers recover enough to return to work, the lingering effects of unidentified and/or ongoing mental health concerns can degrade work performance and lead to business losses. Combined with substance abuse, mental health disorders cost employers between $80 and $100 billion in indirect costs such as lost productivity and absenteeism.29
A survey of more than 34,000 employees at 10 companies revealed that individuals with any mental health condition experienced more absenteeism days per year than individuals with no conditions, at a ratio of 31 to 1. Absenteeism related to depression is estimated to account for around 2.5 days a month, with the work absence cost estimated at $3,540 per year for men and $4,600 for women.30
Presenteeism – diminished interest and productivity at work – is even more costly to businesses. Among all productivity losses, 81% of lost productivity time is due to presenteeism. A study among U.S. workers with depression found that presenteeism accounts for 4.6 times as many hours lost as absenteeism.31
Companies wanting to save their bottom line should invest in supports to create a more mentally healthy workplace. In fact, studies have shown that the indirect cost of mental health concerns – such as lost productivity – exceeds spending on direct costs like health insurance and pharmacy expenses.32
There are a variety of strategies employers and payers can use to reduce claim risk when it comes to mental health. Many of the detrimental effects on claims – like increasing duration and cost – can be alleviated with routine detection and treatment of mental health concerns. It is when these conditions go undetected and untreated that the downstream costs are highest.33 Unfortunately, early screening and identification of mental health concerns after traumatic physical injury is not consistent or routine during the hospital admission process.34
This may seem simple, but routine communication with the injured worker can make a big difference when it comes to diagnosing mental health concerns. Case managers and front-line providers should ask questions that reveal underlying behavioral issues.
These may include: How are you doing? Have you spoken to your employer? When do you see yourself returning to work?
Digital communications can play an important role here, as well – from text capabilities that connect the injured worker with their claims team, to mobile applications that help nurture touchpoints with the injured worker while delivering insights back to their team that may help identify yellow flags.
Once a problem is identified, claims handlers can begin to address psychosocial barriers with the injured worker. This doesn’t necessarily mean sending the worker for psychiatric evaluation, but rather providing support, life coaching, education, and self-help methods.35 When a higher level of intervention is needed, the case manager can make a referral for psychological evaluation and treatment.
In addition to the case manager, the injured worker’s supervisor and co-workers can also help offset the effects of mental health concerns by providing support. Studies have shown that benefits may be gained by increasing weekly reminders, developing daily schedules, and increasing follow-ups regarding work.36 Employers may also provide managers with training to help them recognize the signs and symptoms of stress and depression in team members.
The first six months following an injury is when most mental health symptoms arise – and it’s the ideal time to conduct mental health screening.37 This can be accomplished in the form of a confidential pain screening questionnaire administered to injured workers. Those who score higher – and are at risk for delayed recovery – may be asked to participate in a cognitive behavioral health coaching program.
Employers can enhance access to mental health services and supports in the workplace, such as providing Employee Assistance Programs that include mental health services, making mental health self-assessment tools available, or offering free or subsidized clinical screenings for depression. One example is the state of Nevada, which requires a state-administered mental health hotline and peer support program for first responders.38
Giving case managers access to consistent, accurate, and comprehensive health information on an injured worker is key to detecting mental health concerns. Decision aids and tracking tools are also important in helping the case manager to understand the data and make informed decisions. Oftentimes payers use multiple vendors for different services, making it difficult for case managers to see the whole medical picture – so the aggregation of data is critical to improving outcomes.
Cognitive behavioral therapy, talk therapy, and prescription antidepressants and anti-anxiety medications are common treatments for mental health conditions. Early intervention with antidepressants has been shown to shorten disability by three weeks and to improve work performance in 86% of employees.39
Exercise therapy has also been proven to improve both mental and physical health in patients with depression. For mild to moderate depression, the effect of exercise may be comparable with antidepressant medication and psychotherapy.40
Giving injured workers return-to-work strategies can ease the transition back to the workplace and may reduce the occurrence of absenteeism. These include working part-time, telecommuting, modifying work duties or schedules, and implementing reasonable accommodations.
In addition to reducing claim risk, treating mental health conditions simply leads to better health outcomes for injured workers. When left undetected and/or untreated, mental illness can have grave consequences. These include unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, poor quality of life, and suicide. In a study of 100,000 injured workers, lost-time injuries were associated with a 92% increase in the risk of deaths from suicide for women and a 72% increase for men.41
Tragic results like this can be avoided with routine identification and treatment of mental health conditions. Together, employers and payers can make a lasting difference and work toward better health outcomes for injured workers
If you or anyone you know is struggling with mental health, the National Mental Health Hotline can help. Call 866-903-3787 24/7 for confidential, free assistance.
Treating depression can be expensive – for both employers and payers. Research shows that the concurrent treatment of pain, depression, or anxiety and occupational injuries is associated with large increases in claim costs and delayed return to work.
A 2019 study looked at more than 22,000 indemnity claims over a five-year period. Those claims with anti-depressant, opioid, or benzodiazepine (anti-anxiety) prescriptions were 2.24, 1.14, and 1.38 times more likely to remain open at the end of the study, suggesting that the presence of anti-depressants in a claim had the highest independent impact on return to work.42 In addition, anti-depressant prescriptions were associated with the greatest increase in overall claim costs. Another study found that they were nearly three times as likely as other drug classes to result in a claim more than $100,000.43
