GEPIC. An Introduction to Guide for the Evaluation of Psychiatric Impairment for Clinicians. Dr Michael Duke Senior Forensic Psychiatrist

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1 GEPIC An Introduction to Guide for the Evaluation of Psychiatric Impairment for Clinicians Dr Michael Duke Senior Forensic Psychiatrist

2 What is psychiatric impairment? A psychiatric impairment is any loss of psychological or mental function. Mental function impairment includes: Speech Perception Judgment Mood Thinking Intelligence Behaviour

3 What use is made of the MSE? Correlate GEPIC descriptors to MSE Use GEPIC method to find Whole Person Impairment (WPI) Subtract impairment unrelated to accident Subtract impairment due to consequential mental harm

4 Why do we assess psychiatric impairment? Statutory schemes as a: Threshold trigger Means for determining level of benefits A reliable means of measuring psychiatric percentage impairment is critical for users, tribunals and claimants. If there is no reliable method then psychiatric injury may be excluded from statutory schemes. This has happened in NZ and in SA for WorkCover lump sum benefits All jurisdictions treat mental injury adversely compared with physical injury:? due to prejudice and fears of cheating (can t people make up symptoms and fool the assessor?) Potential cost blowouts

5 Reasons for Measurement of Psychiatric Impairment the Victorian Experience Gate-keepers Victorian Accident Compensation Act To determine serious injury To determine compensation for non-economic loss Victorian Transport Accident Act To determine impairment benefits To allow for common law claims Threshold for personal injury claims re Victorian Wrongs Act (Civil Liability legislation)

6 Any sensible method of measuring psychiatric impairment must Appear to measure impairment Be based on the MSE Be easily and rapidly administered Produce a percentage score Reliable; different examiners produce similar results Be resistant to cheating Equitable seems fair and not designed to force claimants below a threshold. Have broad acceptance as fair and reasonable Be defensible in court and tribunal settings Impairment: reduction or loss of a physical/mental function and is determined by clinicians Disability: reduction in ability arising from an impairment and is determined by the courts

7 Compensable Psychiatric Impairment There usually needs to be a diagnosable psychiatric disorder. The disorder must lead to impairment. There has to be a clearly established link between the accident and the psychiatric disorder. The psychiatric disorder is not secondary to physical injury, in South Australian terms 'consequential mental harm.

8 Problems with measuring psychiatric impairment No 'gold standard Blurring of impairment and disability Relies on self-reporting Overlap between neurological injury and psychiatric injury Pain disorders

9 Principles of Psychiatric Impairment Assessment 1. The mental state examination as used by consultant psychiatrists, is the prime method of evaluating psychiatric impairment. 2. Diagnosis among the factors to be considered. 3. Consider other factors - educational, financial, social and family situation. 4. Character and value system of the individual of considerable importance. 5. Motivation for improvement is a key factor in outcome. 6. Review all treatment and rehabilitation methods. 7. Final judgement when history of illness, treatment, rehabilitation and of current mental and physical status and behaviour considered.

10 An example of one of the 6 factors Mood (descriptors only indicative) Mood - a pervasive lasting emotional state Affect is mood noted during the period of the mental state examination. Affect has a number features, including: Range: Variability of emotional expression over a period of time, i.e., if only one mood is expressed over a period of time, the affective range is restricted. Amplitude: Amount of energy expended in expressing a mood, i.e., a mild amplitude of anger is manifested by annoyance and irritability. Stability: Slow shifts of mood are normal. Rapid shifts (affective lability) may be pathological. Appropriateness: The fit (or congruency) between the affect and the situation. Quality of Affect: Suspicious, sad, happy, anxious, angry, apathetic. Relatedness: Ability to express warmth, to interact emotionally and to establish rapport.

11 Class Impairment Description Mood 1 0-5% Normal to Slight - relatively transient expressions of sadness, happiness, anxiety, anger and apathy; - normal variation of mood associated with upsetting life events % Mild - mild symptoms: some or all of the below mild depression; subjective distress leading to some mild interference with function; reduced interest in usual activities; some days off; reduced social activities; fleeting suicidal thoughts; some panic attacks; heightened mood; - may experience feelings of derealisation or depersonalisation.

12 Mood (cont) % Moderate Impairment - moderate symptoms: some or all of the below: frequent anxiety attacks with somatic concomitants; inappropriate self-blame and/or guilt; persistent suicidal ideation or suicide attempts; marked lability of affect; significant lethargy; social withdrawal leading to major problems in interpersonal relationships; anhedonia; appetite disturbance with significant weight change; psychomotor retardation/agitation; hypomania; severe depersonalisation % Moderately Severe - cannot function in most areas constant agitation; - violent manic excitement; repeated suicide attempts; - remains in bed all day; extreme self neglect; extreme anger /hypersensitivity; - requires supervision to prevent injury to self or others. 5 Over 75% Severe - severe depression, with regression requiring attention and assistance in all aspects of self care; - constantly suicidal; - manic excitement requiring restraint.

13 The GEPIC Table

14 GEPIC Severity Ratings

15 The GEPIC Table with Severity Ratings

16 Determining Whole Person Psychiatric Impairment 6 mental functions in 5 classes Each function is allotted a class consistent with the MSE. e.g MSE no perceptual problems yet Class 2 in GEPIC! Determine the median class; the median number is the middle number , the middle number is , the middle number is , the middle number is 2. The final percentage lies within the range of the median class. Class 2 is between 10-20%. Use severity ratings to locate impairment in class

17 Overlap Between Psychiatric and Neurological Impairment Acquired brain injury: impairment involves two disciplines, neurology and psychiatry. Cognitive Dysfunction and Behavioural Disturbance can be measured using Chapter 4 AMA 5 and/or the GEPIC Strong likelihood of overlap. Behavioural disturbance best measured using Chapter 4 Behavioural disturbance may be a manifestation of physical injury and is consequential mental harm. It may be counted using the GEPIC if there is no TBI.

18 How does GEPIC rate as an impairment guide? Does it measure impairment: YES Easily and rapidly administered?- YES Obtains a percentage score? YES Reliable?- POSSIBLE Cheating?-UNLIKELY Equitable YES Controversial - NO Defensible in court and tribunal settings- YES Does it seem to do the job YES

19 Differentiating pure mental harm from consequential mental harm The equivalent terms in Victoria are impairment secondary or consequential to physical injury Annotations for Determining Non Secondary Psychiatric impairment: Dr Michael Epstein & Dr Nigel Strauss were recruited to assist with this process. Categories

20 Impairment unrelated to the injury Impairment unrelated to the accident includes: Pre-existing impairment present at the time of the impairment assessment (e.g. a chronic schizophrenic disorder) Pre-existing impairment - no longer present at the time of the impairment assessment (e.g. a major depressive disorder that was successfully treated and for which there has been no ongoing treatment or symptoms) Pre-existing impairment present at the time of the impairment assessment exacerbated by the accident (e.g. a chronic anxiety disorder) Impairment arisen since the injury and unrelated to the injury (a non-injury related assault leading to the development of a post traumatic stress disorder) Injury from another trauma

21 Stability Stability is defined as impairment that will not vary by more than 3% in the next 12 months (American Medical Association Guides to the Evaluation of Permanent Impairment). The issue of stability is very important. The whole person impairment can usually only be finalised when the claimant s condition is considered stable. If the injury is not considered to be stable the claimant is left in limbo.

22 Stability II The condition is usually stable if: The claimant s accident injury occurred some years previously. If the claimant has had a variety of treatment with no change in symptoms. If the above 2 conditions apply it is unlikely a pain management program will bring about significant change. Although psychiatric or psychological treatment may have been beneficial at some time it is now unlikely to bring about much change (but may prevent further deterioration).

23 FAQs 1. Why are there gaps between the percentage levels? 2. What about people who don t speak English or who can t speak? 3. Do people need to have a psychiatric diagnosis to be assessed? 4. What is the situation with children? 5. Can people fool the assessor? 6. Why do the Guides use the median rather than average scores? 7. Why doesn t GEPIC use a list of typical symptoms eg. flashbacks 8. Why is it only used by psychiatrists 9. Is there much consistency between assessors? 10. How long does an impairment assessment take?

24 Conclusions 1. Measurement of psychiatric impairment is an important part of all benefits schemes 2. Psychiatric illness can arise from a number of causes including work injury and motor accidents 3. The Guides for the Evaluation of Psychiatric Impairment for Clinicians and its precursor has been used extensively in Victoria since 1997 with ready acceptance. 4. The GEPIC is now required to assess psychiatric impairments for RTW Claims in South Australia. 5. Training of psychiatric assessors in the use of GEPIC will commence soon.

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