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Epidemiological and Prevalence of Psychosocialand Behavioral Health Concerns

Epidemiological and Prevalence of Psychosocialand Behavioral Health Concerns

In occupational medicine, the main problem with psychological and psychosocialissues is the treatment of workers with injuries or illness attributed to work and thustreated in the workers’ compensation system.

Workers’ compensation is a state or province program, and each state or provincehas its own laws and rules, although these are somewhat similar. Even when workerspresent with seemingly clear cut medical issues, psychological and psychosocialfactors still have a large impact.

Harris et al., (2005) reported a meta-analysis comparing the results of surgicaltreatment for conditions treated in a compensation setting (usually workers’ compensation)to the results of treating the same condition in a noncompensation setting(health insurance). Two hundred and eleven studies met the inclusion criteria, and 175found worse treatment results (outcomes) in the compensation patients compared tothe noncompensation patients. Thirty-five studies found no difference. For surgeriescommonly performed in the workers’ compensation system like shoulder acromioplasty,lumbar spine fusion, lumbar discectomy, and carpal tunnel release the odds ofa poor or unsatisfactory result were four times greater in the compensation patients.Similar findings have been reported in more recent studies on other diagnoses,like anterior cruciate ligament reconstruction in the knee (Barrett, Rook, Nash, &Coggin, 2000; Mobbs, Gollapudi, & Chandran, 2001). These studies do not show thatthe patients receiving workers’ compensation had more severe injuries or illness priorto surgery, and they did not find worse objectively measured outcomes in range ofmotion, neurologic deficit, etc. These studies did not document mental disorders orpsychosocial stressors, but logically, the reason for the poor outcomes in these studiesof workers’ compensation patients is that the outcomes were assessed by questionnaires on which the patients self-report symptoms and function. While these questionnaires(Oswestry Disability Index, DASH, Knee Society rating scale, SF-36, etc.) have beenvalidated in populations not seeking compensation, their use in compensationpatientpopulations has not been scientifically validated. Thus, something (psychosocial issues)other than biomedical issues causes the treatment results to be worse, as assessed bypatient self-report, in workers’ compensation patients.

Many workers’ compensation patients do not have significant psychosocialconfoundingissues, and these patients recover like the noncompensation patients. Thereis no postulated biological reason for delayed or poor recovery in these compensationpatients; therefore, logically, those patients with psychosocial confoundersare thosewho have delayed recovery and poor outcomes.

Compensation status also affects the outcomes of vocational rehabilitation efforts(Drew et al., 2001).This conclusion is supported by studies on the prevalence of psychosocial issuesin compensation patients. Dersh found that 64% of 1,595 patients in a tertiary rehabilitationprogram had major (Axis I) disorders (other than pain disorder associatedwith psychological factors), compared with 15% of the general population (Dersh,Gatchel, Polatin, & Mayer, 2002). In addition, 70% had a recognizable Axis IIpersonalitydisorder, compared with a literature estimate for the general population of6–14%. Psychological and personality factors are an important issue in those withupper limb work-related disorders. Ring and colleagues found that compared topatients with specific diagnoses, those with idiopathic arm pain had a much higherprevalence of psychological issues, and that upper extremity ill-health correlated withdepression (Ring, Kadzielski, Malhotra, Lee, & Jupiter, 2005; Ring et al., 2006).In summary, psychosocial confounders are common in occupational medicine inworkers’ compensation patients, and these issues seem to explain the pooreroutcomesnoted in treating these patients. This has recently been reviewed with aconclusion that comprehensive biopsychosocial treatment is more effective thanisolated traditional biomedical treatment (Vranceanu, Barsky, & Ring, 2009).

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