Mental Health Breakout

Transcription

1 Mental Health Breakout David Sones, M.D. (moderator) Robert Larsen, M.D., M.P.H. Valdimir Bukarius, M.D. Claude Munday, Ph.D. Robert Raasp, Esq. Hon. WCJ Mark Romano 31 st Annual CSIMS Mid Summer Seminar Sand Diego, California

2 Robert C. Larsen, M.D., M.P.H. CSIMS 2016 Mid Summer Seminar

3 Causation Causality The act of causing or producing an effect. The relation of cause and effect. The principle that everything has an effect.

4 Injury A (physical) harm or damage. A wrongful action or treatment.

5 L.C.3208 Injury includes any injury or disease arising out of employment.

6 L.C Specific injury One incident/exposure causing disability &/or need for treatment. Cumulative injury Resulting from repetitive mentally, physically traumatic events.

7 L.C Compensable Psychiatric Injuries 6 months employment (typically) required. Predominant cause threshold applies. Acts of violence: substantial cause threshold applies. Exclusion for lawful personnel actions. Claims after 1/1/2013: Requires catastrophic injury for increase in p.d. from psychiatric condition.

8 Causation Arenas Biologic/genetic Psychological/emotional Environmental/social/cultural/spiritual/beliefs

9 Case 1 45 y.o. male automotive worker with preexisting, controlled BAD with 40% TBSA 2 nd degree burns referred for suspected recurrent major depression. Biologic/genetic; preexisting pathology

10 Case 2 45 y.o. fire captain with 20 year history of exposure to structural fires, mva s, & gas line explosions. Episodes of panic begin after unsuccessful CPR effort on 6 y.o. girl resembling grandchild. No history of psych rx. Psychological; C.T. injury

11 Case 3 35 y.o. Thai female bank teller robbed at gunpoint. PTSD dx d. Past hx of coerced employment as sex worker in homeland for 6 years. Cultural/psychological; violent act; preexisting stressors

12 Case 4 25 y.o. clerk who reports harassment by 2 male coworkers who are fired. She continues working until several months later she s let go for artificial nails and tardiness due to inability to read an analog clock. Rx record demonstrates primary focus on partner s imprisonment for her attempted murder & her own conviction for assault of a female family member. Psychological/social; personnel actions

13 Case 5 27 y.o. construction worker who falls off scaffolding with multiple fractures, TBI & depression. Employed 4 months at time of accident. Evaluations by neuro, ortho, neuropsychol, psych. Biologic/psychological; violent act; catastrophic injury

14 1. The Labor Code 2. DSM 5 3. Causation of Injury and Causation of Impairment 4. Establishing WPI Pursuant To The 2005 PDRS 5. Rebutting a GAF WPI Rating 6. The WHODAS? By: Robert G. Rassp, Esq. rrassp@cs.com

15 The Labor Code (a): A psychiatric injury shall be compensable if it is a mental disorder which causes disability or need for medical treatment, and it is diagnosed pursuant to procedures promulgated under paragraph 4 of subdivision (j) of Section or, until these procedures are promulgated, it is diagnosed using the terminology and criteria of the APA s Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, or the terminology and diagnostic criteria of other psychiatric diagnostic manuals generally approved and accepted nationally by practitioners in the field of psychiatric medicine.

16 The Labor Code Section 139.2(j)(4) [The AD shall adopt regulations concerning the following issues]: Procedures to be used in determining the compensability of psychiatric injury. The procedures shall be in accordance with Labor Code Section and shall require that the diagnosis of a mental disorder be expressed using the terminology and criteria of the APA s Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, or the terminology and diagnostic criteria of other psychiatric diagnostic manuals generally approved and accepted nationally by practitioners in the field of psychiatric medicine.

17 Title 8 CCR 9726 Applies to psychiatric injuries occurring prior to 1/1/05 and adopts the eight work function impairments Those work function impairments can also be found on page 365 of the AMA Guides, Section 14.4d! Title 8 CCR 9805 AD adopts the 2005 PDRS which implicitly includes the GAF WPI conversion table. and it shall be amended every five years..

18 The DSM 5 DSM first published in 1884 by the American Psychiatric Association based on institutionalized mental patients The DSM IV Text Revision was published in 2000 The DSM 5 was adopted by the APA on May 10, 2013 The law is over 10 years behind science. In medicine, 13 years of research is an eternity.

19 The DSM 5 The purpose of the DSM is to provide a diagnostic classification system for psychiatrists, other physicians, and other mental health professionals that described the essential features of the full range of mental disorders. The current DSM 5 builds on the goal of its predecessors of providing guidelines for diagnoses that can inform treatment and management decisions. See DSM 5, page 6.

20 The DSM 5 The DSM 5 is mostly based on the bio medical model of mental disorders and de emphasizes psycho social aspects of mental disorders. The emphasis is on pathology. Why? $$$$$$$$ = medications Just like the AMA Guides, we are seeing the politics of medicine

21 The DSM 5 DSM 5 eliminates Pain Disorders DSM 5 modifies the classification of and diagnostic criteria for PTSD, adjustment disorders, depression, anxiety disorders DSM 5 eliminates Axes I through V of the DSM II, III, and IV

22 The DSM 5 DSM 5 eliminates Pain Disorders Now included in new category called Somatic Symptom and Related Disorders Patient has somatic symptoms associated with significant distress and impairment The diagnosis is made on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to those symptoms) rather than the absence of a medical explanation for somatic complaints. See DSM 5, pg. 309

23 The DSM 5 DSM 5 eliminates Pain Disorders Objective explanations of chronic pain do not apply here, e.g. failed lumbar syndrome, CRPS If there is a somatic component (as opposed to an objective explanation or in addition to one) for chronic pain, then the somatic component adds severity and complexity to depressive and anxiety disorders and results in higher severity, functional impairment, and even refractoriness to traditional treatments. See DSM 5, pg. 310

24 The DSM 5 DSM 5 on chronic pain: Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate. See DSM 5, pg. 813 DSM 5 on PTSD: 20% of returning soldiers from Iraq and Afghanistan have this diagnosis. That means 300,000 people. PTSD can be diagnosed in the absence of a physical injury

25 The DSM 5 PTSD and Adjustment Disorders are now under a single category: Trauma and Stressor Related Disorders and is no longer under Depression. PTSD is associated with high levels of social, occupational, and physical disability, as well as considerable economic costs and high levels of medical utilization... In community and veteran samples, PTSD is associated with poor social and family relationships, absenteeism from work, lower income, and lower educational and occupational success. See DSM 5, pp

26 The DSM 5 Depression is now a stand alone disorder and does not include Bipolar disorder which also has a separate section Generalized Anxiety Disorder, Substance/Medication Induced Anxiety Disorder, and Panic Disorder are all under Anxiety Disorders and are no longer under Depressive Disorders.

27 Causation of Injury vs. Causation of Disability Two separate analysis. In all versions of DSM, once a person has a DSM diagnosis, that diagnosis never goes away, even if the condition is in remission. Research indicates that once a person meets the diagnostic criteria for a mental disorder, it will either have active symptoms or will go into remission with a high probability of recurrence during the person s lifetime.

28 Causation of Injury vs. Causation of Disability

29 Causation of Injury vs. Causation of Disability

30 Causation of Injury vs. Causation of Disability

31 Which One Best Describes Donald Trump?

32 Causation of Injury vs. Causation of Disability

33 Causation of Psychiatric Injury Rolda vs. Pitney Bowes, Inc. (2001) 66 Cal. Comp. Cases 241 (WCAB en banc decision) Is there a DSM diagnosis? Actual events of employment predominantly cause injury Are employment events the result of good faith, lawful, nondiscriminatory personnel actions Were personnel actions substantial cause of psyche condition? See Sonoma State University vs. WCAB (Hunton), (2006) 142 Cal. App.4 th 500, 48 Cal. Rptr. 3d 330, 71 Cal. Comp. Cases 1059 Requires analysis of dual diagnosis if part is work related and other is not

34 Apportionment of Psychiatric PD Escobedo and Gatten cases apply: See Marlene Escobedo vs. Marshalls (2005), 70 Cal. Comp. Cases 604 (WCAB en banc decision); E.L. Yeager Construction vs. WCAB (Gatten) (2006) 145 Cal. App. 4 th 922, 52 Cal. Rptr. 3d 133, 71 Cal. Comp. Cases 1687; Benson vs. WCAB (2009) 170 Cal. App. 4 th 1535, 74 Cal. Comp. Cases 113. What if a case involves orthopedic, psyche, and internal injuries? Can the psyche simply say I agree with apportionment as stated by Dr. X, the orthopedic AME? Radiator, Inc. vs. WCAB (Kang) 80 Cal. Comp. Cases 79 (2015)

35 The DSM 5 and GAF DSM 5 eliminates Axes I through V of the DSM II, III, and IV The original purpose of these were to evaluate a person s personal, occupational, and social functioning a the beginning of treatment, during treatment, and upon discharge from treatment. The APA got rid of Axis I through V because of its conceptual lack of clarity (including symptoms, suicide risk, and disability in its descriptors) and questionable psychometrics in routine practice. See DSM 5, page 16.

36 The DSM 5 and GAF DSM 5 eliminates Axes I through V of the DSM II, III, and IV Instead, DSM 5 adopts the WHODAS (World Health Organization Disability Assessment Schedule) which is based on the International Classification of Functioning, Disability and Health (ICF) for use across all of medicine and health care. The WHODAS is evidence based, peer reviewed, and accepted internationally for use in determining psychiatric disability

37 The DSM 5 and GAF DSM 5 eliminates Axes I through V of the DSM II, III, and IV The WHODAS has 6 categories: cognition(understanding and communicating); mobility (getting around); self care; getting along with people; life activities such as household chores, work, and/or school activities; and participation in society. Each of the 36 questions are answered on a scale of 1 to 5 with 1 (no impairment), 2 mild impairment, 3 moderate impairment, 4 severe impairment, 5 extreme or cannot perform. WHODAS test can be found at follow the links to Online Assessment Measures and Disability Assessments

38 The DSM 5 and GAF DSM 5 eliminates Axes I through V of the DSM II, III, and IV Can the WHODAS rebut the GAF WPI rating of the 2005 PDRS? Each of 6 domains rate out on an average of 3, then 18/36 = a 50% disability? The physician would have to explain how a rating was obtained and within the framework of the WHODAS: Step 1: Add the scores within each of 6 category Step 2: Add up all six category scores Step 3: Convert the summary score into a metric ranging from 0 = no disability to 100 = total disability See page 746 of the DSM 5.

39 Rebutting the GAF The elimination of Axis I through V may make it easier to rebut a GAF WPI rating under the 2005 PDRS: Method #1: Evaluate work function impairment from page 365 of the Guides Evaluate ADL functioning using Table 1 2 on page 4 of the Guides Use Table 14 1 to determine impairment classes for work and ADL Use Table 13 8 for overall impairment rating

40 Page 365 AMA Guides

41 Page 365 AMA Guides

42 Page 365 AMA Guides

43 Table 1 2 AMA Guides

44 Table 14 1 AMA Guides

45 Table 13 8 AMA Guides

46 Table 13 8 Mental and Behavioral Impairments 72% WPI rating results in 100% disability when adjusted for DFEC (Rank 8 DFEC adjustment and GAF score of 27) for DOI before 1/1/13 72% WPI rating also results in 100% disability when adjusted by adjustment factor [1.4 x 72] for DOI on or after 1/1/13 But cause of psychiatric condition cannot be from physical injury unless the injury is catastrophic.

47 The elimination of Axis I through V may make it easier to rebut a GAF WPI rating under the 2005 PDRS: Method #2: Evaluate work function impairment from page 365 of the Guides Evaluate ADL functioning using Table 1 2 on page 4 of the Guides Use Table 14 1 to determine impairment classes for work and ADL Use Tables 13 5 (Clinical Dementia Rating CDR) and 13 6 Criteria for Rating Impairment Related To Mental Status

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49 Claude Munday, Ph.D.

50 Apportionment Go Your Own Way (but know why) Vladimir Bokarius, M.D.

51 Questions Thank You! 51