J Occup Rehabil DOI 10.1007/s10926-014-9506-9

Mental Health Claims Management and Return to Work: Qualitative Insights from Melbourne, Australia Bianca Brijnath • Danielle Mazza • Nabita Singh Agnieszka Kosny • Rasa Ruseckaite • Alex Collie



 Springer Science+Business Media New York 2014

Abstract Purpose Mental health conditions (MHC) are an increasing reason for claiming injury compensation in Australia; however little is known about how these claims are managed by different gatekeepers to injury entitlements. This study, drawing on the views of four stakeholders—general practitioners (GPs), injured persons, employers and compensation agents, aims to describe current management of MHC claims and to identify the current barriers to return to work (RTW) for injured persons with a MHC claim and/or mental illness. Methods Ninety-three in-depth interviews were undertaken with GPs, compensation agents, employers and injured persons. Data were collected in Melbourne, Australia. Thematic techniques were used to analyse data. Results MHC claims were complex to manage because of initial assessment and diagnostic difficulties related to the invisibility of the injury, conflicting medical opinions and the stigma associated with making a MHC claim. Mental illness also developed as a secondary issue in the recovery process. These factors made MHC difficult to manage and impeded

B. Brijnath (&)  D. Mazza  N. Singh Department of General Practice, Faculty of Medicine Nursing and Health Sciences, School of Primary Care, Monash University, Building 1, 270 Ferntree Gully Rd., Notting Hill, Melbourne, VIC 3168, Australia e-mail: [email protected] A. Kosny  A. Collie Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia R. Ruseckaite  A. Collie Institute for Safety Compensation and Recovery Research, Monash University, Melbourne, Australia

timely RTW. Conclusions It is necessary to undertake further research (e.g. guideline development) to improve current practice in order to enable those with MHC claims to make a timely RTW. Further education and training interventions (e.g. on diagnosis and management of MHC) are also needed to enable GPs, employers and compensation agents to better assess and manage MHC claims. Keywords Australia  Insurance claims review  Mental health  Return to work

Introduction In Australia work-related mental stress is the second most common cause of workplace compensation claims after manual handling [1]. Mental stress can have a deleterious effect on an individual person’s physical and psychological health, work productivity and wider social relationships [2, 3]. Prolonged exposure to mental stress in the workplace— whether as a result of high work load, exposure to violence, bullying and/or harassment, trauma and other factors—can lead to mental illnesses, such as depression, post-traumatic stress disorder (PTSD) and anxiety, as well as physical conditions, such as increased blood pressure, migraines, and sleep disorders [4, 5]. In 2007 work-related mental health conditions (MHCs) were estimated to cost the Australian economy $14.1 billion with direct costs to employers in the vicinity of $10 billion [6]. Albeit high, these costs do not capture the full extent of the problem as a number of people (as many as 70 %) either do not apply for mental stress claims or have their claims rejected [7, 8]. Though the reasons for underreporting of MHC claims in Australia are not entirely clear, a Canadian study suggests that the fears of being

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viewed as mentally ill and a malingerer could deter many from lodging a claim [9]. For those who do make a successful claim, lengthy amounts of time off work and complex management is often involved in the process of recovery and return to work (RTW). From the perspective of compensation schemes, MHC claims are the most expensive and most difficult to manage of all the claims categories in Australia [2, 10]. This is also true in overseas settings; the literature shows a strong link between MHC claims, long-term absence from work and high rates of disability pensioning [11–14]. To improve mental health outcomes, reduce costs associated with MHC claims and facilitate timely RTW it is important to first understand the current barriers and facilitators to RTW for individuals with either a MHC claim and/or mental illness. The aim of this paper is to describe, from the perspective of four stakeholders—GPs, employers, compensation scheme agents and injured persons—the management of MHC claims and the barriers and facilitators that influence injured persons RTW following a MHC claim. We begin with a brief description on how injured persons enter the health and compensation systems before drawing on the literature to describe issues faced in MHC claims management, injury recovery and the RTW process. We then outline our methods and study findings and conclude with specific recommendations for improving current MHC management and directions for future research.

Entering the ‘System’ In the state of Victoria, where the present qualitative study was conducted, there are two statutory injury compensation authorities—WorkSafe Victoria and the Transport Accident Commission (TAC). If a person sustains an injury and decides to proceed with lodging a claim for compensation, they must do so at either WorkSafe (for work-related injuries) or the TAC (for vehicle-related injuries). An initial certificate of capacity must be completed by a medical practitioner and along with an injury claim form is submitted to the relevant compensation authority [15, 16]. For work-related injuries, these documents must be submitted by the injured person’s employer; for vehicle-related injuries the claim is directly submitted to the TAC by the injured person [15, 16]. Following assessment and acceptance of the claim compensation payments for lost income, medical and other expenses commence. There is an expectation that most persons will recover from their injuries and RTW in due course [15, 16]. During the treatment and recovery process there is also an expectation

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that the injured person, their compensation agent, employer and medical practitioner will be in regular communication with each other to facilitate recovery and safe RTW [15, 16]. In Australia most injured persons enter the compensation system by obtaining a certificate of capacity from their GP. GPs see about 96 % of injured workers [17] and approximately two-thirds of persons injured in motor vehicle accidents [18] and are therefore a critical gatekeeper to injury entitlements. GPs assessment of the nature of the injury and the person’s capacity to work often determines whether a compensation claim will be accepted. GPs also fulfil a number of other roles including providing repeat clinical opinions of injured persons physical and mental capabilities, recommending periods of time off work, giving advice on compensable medical and care treatments necessary for recovery and making decisions that impact on the liabilities of compensation agencies.

MHC Claims Management Research shows that when GPs are educated about work and health issues they report feeling more confident and are more likely to address these issues during their consultations [19]. They are more capable of identifying individuals at high risk of developing chronic pain/disability and poor mental health after injury and facilitating faster triage and appropriate referral [20]. They can also broker adequate and appropriate access to health services, develop stronger patient-provider relationships and be more empathetic towards individuals who experience distress as a result of injury; such practices improve treatment outcomes and help to alleviate depression and anxiety in injured persons [21, 22]. Similarly, studies show a respectful and supportive approach to managing MHC claims by compensation agents is more likely to promote feelings of empowerment in injured persons and facilitate RTW [23, 24]. Conversely, where there is diagnostic uncertainty, failure to diagnose underlying mental illness, conflicting medical opinions and poor communication between stakeholders, RTW rates are lower and outcomes poorer for injured persons [25–27]. Employment-related factors such as high job stressors, re-organisational stress, threat of unemployment, no worker’s insurance and poor supervisor-employee communication are also likely to delay RTW [28]. Unfortunately, recent certification data from the United Kingdom (UK) suggest that workers with MHC are more likely to be certified as being unfit for work compared to those with physical conditions [29, 30]. These findings resonate with our previous quantitative work [31]

J Occup Rehabil Table 1 Sample characteristics of injured persons Mean age (Standard deviation)

48 years (13.7)

Gender (number (n))

Men = 71 % (12)

Table 2 Sample characteristics of GPs, compensation agents and employers Group (n)

Mean age (SD)

Gender (n)

Mean years of experience in current job role (SD)

GPs (25)

52 years (10.2)

Male = 72 % (18)

24 years (11.8)

45 years (11.8)

Female = 28 % (7) Male = 36 % (9)

Women = 29 % (5) Primary injury type (n)

Musculoskeletal = 71 % (12) MHC = 18 % (3) Both = 12 % (2)

Development of secondary MHC in 12 MSK claims (n) Clients back at work (n)

Yes = 67 % (8) No = 33 % (4) Yes = 47 % (8) No = 53 % (9)

Time since injury (n)

Employers (EMP) (25)

Female = 64 % (16)

3–6 months = 29 % (5) 6–9 months = 0 [9 months = 71 % (12)

Weekly household net income (n)

$300–$600 = 12 % (2)

9 years (6.5)

Compensation agents (CS) (26)

34 years (9.4)

$600–$900 = 47 % (8) $900–$1,500 = 35 % (6)

Male = 15 % (4) Female = 85 % (22)

7 years (5.7)

[$1,500 = 6 % (1) Weekly household expenses (n)

\$660 = 35 % (6) $660–$1,000 = 53 % (9) $1,200–$1,500 = 6 % (1) [$1,500 = 6 % (1)

No. of dependents

None = 41 % (7) One = 24 % (4) Two = 24 % (4) Three = 12 % (2)

Nature of employment

Full-time = 94 % (16) Part-time = 6 % (1)

MHC mental health conditions; MSK musculoskeletal conditions

the four stakeholder groups. Semi-structured interviews were undertaken with GPs, injured persons, employers and compensation scheme agents. Interviews were used because it allowed us to explore the meanings and intricacies of individuals’ experience from his/her own perspective and to examine participants motivations, intentions and logics of behaviour in a way that would not be possible through closed-ended survey questions. This yielded a rich and diverse dataset that helped us to understand the meanings participants ascribed to particular phenomena and practices in context [32]. Sample and Recruitment

examining GP certification behaviour in the state of Victoria. In our analysis of compensation work claims data from 2003 to 2010 we found that MHC had the highest rate of ‘unfit for work’ certificates among six common categories of work-related conditions [31].This suggests that there remain unexplained issues as to why Victorian GPs who saw persons with work-related MHC claims did not issue modified duty certificates or fit for work certificates at the same rate as for other conditions. To understand why this discrepancy exists we draw on results from a larger qualitative study that investigated current and preferred practices of GPs with regards to RTW. In this paper we focus specifically on the current nature and complexity of MHC claims management and the barriers and facilitators that influence RTW following a MHC claim.

Methods We utilised an exploratory qualitative approach to understand the basic social processes and interactions between

Data were collected between September and December 2012 in Melbourne, Australia. Ninety-three participants were interviewed face-to-face; 25 GPs, 26 compensation scheme agents, 17 injured persons and 25 employers. Efforts were made to purposively sample all four groups in order to capture a diversity of work experience, injury types, duration of time off from work, locales (inner city/ suburban), employer size and work roles. Tables 1 and 2 give an overview of the sample. Universal inclusion criteria were that all participants had to be over 18 years of age and be able to speak, read and write English. Different methods were used to recruit the four groups. GPs were recruited from an existing research database comprising over 500 GPs in Melbourne who had consented to being contacted about ongoing research studies. Initially a fax advertising the study was sent to the practice. Those GPs interested in participating then contacted the research team and those who were eligible—i.e. they were currently or had previously treated persons with an injury compensation claim—were then interviewed. Efforts were made to

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purposively sample the GPs by their geographic practice area, gender, age, years of experience as a practicing GP and percentage of injured persons with WorkSafe and/or TAC claims seen per year. GPs were reimbursed $200 for their time because interviews were conducted during consultation hours and this sum reflects the average GP’s hourly rate. Compensation personnel were identified via the existing relations the research team had with WorkSafe Victoria and the TAC. Invitations with attached consent forms and reply paid envelopes were mailed to compensation agents and they were followed up by a phone call 1 week later. From there on snowball techniques were used to identify additional agents in a diverse range of roles until data saturation was reached. Compensation agents were not reimbursed for their time as interviews were undertaken during their workday and they were salaried staff. Employers and injured persons were recruited from the existing databases of current claims held by WorkSafe Victoria. Initially, WorkSafe sent a letter to approximately 200 employers and 200 injured persons advising them that the research team would contact them after 2 weeks to explain the study and invite them to participate. Those who did not wish to be contacted advised WorkSafe and their details were not provided to the research team. 2 weeks after the original letter was posted potential participants were contacted by phone and invited to participate. For those who agreed, standard procedures were then followed to obtain informed consent and the interview was scheduled at a later date. Recruitment continued in this fashion until data saturation was reached. This strategy had the dual advantage of facilitating swift recruitment and also mitigated potential identification of participants to WorkSafe as the organisation only knew who had initially opted out, not who eventually took part in the study. To further protect participant’s anonymity, we only included employers if they were part of medium to large businesses with more than 20 full-time equivalent staff and more than one claim in the previous 12 months. Similarly, we only included injured persons if their claims were current and related to musculoskeletal and/or MHC claims (the two most common claims categories). The decision to include these two common claims categories helped us to understand not only different treatment and recovery pathways but also how musculoskeletal and MHC co-morbidities could develop and compound the primary injury. Such information proved critical to understanding the management of a claim and where and how delays in RTW occurred. Injured persons received $20 gift vouchers for their time; employers were not compensated because interviews were undertaken during their workday and we only targeted those salaried staff directly involved in RTW (e.g. human resources personnel, RTW coordinators).

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Table 3 Examples of interview questions How do you feel when you are dealing with an injury claim? [probe on simple vs complex claims] How do you perceive your role in the claims process? [probe on what role should be] Tell me about the process of recovery? [probe on barriers and enablers to recovery] What has been your experience negotiating the health system? What has been your experience negotiating the compensation system? What do you think about RTW? [probe on benefits of RTW, stakeholder’s role in RTW process] How do you feel about GPs taking a stronger role in facilitating RTW? [probe on barriers and enablers]

Procedure Interviews were undertaken by two research assistants trained in semi-structured and in-depth interview techniques by qualitative methods experts in the team. Each interview lasted between 45 and 60 min. Building on overseas data [33, 34], participants were asked about their experiences negotiating health and compensation systems, their perceptions of the GPs role in managing injury and RTW, their role in RTW and the barriers and enablers of RTW (see Table 3). All interviews were audio-recorded and transcribed verbatim. Approval for this study was obtained by the Monash University Human Research Ethics Committee. Data Analysis Data were analysed via thematic coding that used inductive and deductive techniques [35, 36]. Over a number of meetings four team members independently and then collectively reviewed a sub-set of 10 transcripts. From this a set of codes emerged. Then in pairs, the four team members reviewed the remaining transcripts using the existing code set, adding new codes and modifying existing ones where relevant. In each dyad, the transcripts were independently coded and then cross-checked by another team member. Interpretive differences were resolved by consensus. After this process, the codes were clustered according to various topics and then thematically grouped. Themes were identified from the data as well as their relationship to the literature; in this way both inductive and deductive methods were applied [37]. Multiple strategies were used to compare, distil, link and conceptualise data, including incase and cross-case summaries, typologizing and theoretical memoing [38]. The entire team met to discuss and verify the final interpretation and then transcripts were entered into NVivo 10 (QSR International 2012, Melbourne) for further analysis and data storage. To ensure

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data rigor and reliability [39, 40] the following steps were undertaken: findings have been presented in their context; findings have been presented to illustrate how conclusions were reached and triangulated by comparing and contrasting the perspectives of each stakeholder within the data set and other findings in the literature; and findings were related to secondary literature sources to warrant credibility and validity of data. In this paper only those themes related to MHC claims are presented. Findings There were five key themes related to the management of MHC claims: (1) the visibility of the injury; (2) the role of the independent medical examiners; (3) the stigma associated with making a MHC claim; (4) the development of mental illness as a secondary issue; and (5) the complexity of managing MHC claims and RTW. Each theme is discussed below. Visibility of the Injury: ‘‘They Want to See the Proof’’ Both GPs and compensation personnel discussed the difficulties associated with assessing a MHC claim. As one GP said of the insurers, ‘‘They want to see the proof’’ and without evidence of visible injury, the claim was more complex to assess and accept. However obtaining proof was difficult for two reasons: first, there was a lack of identifiable measures that could be used to clearly demonstrate an injury and this complicated the assessment and diagnostic process. GPs and compensation agents often compared physical and mental injuries, lamenting the invisibility of the latter: Psychological injuries it’s very difficult, it’s very, very difficult and it can be very frustrating, you can’t measure the level of disability and it can be very debilitating for them [injured person] (GP#17, male (m), 31 years old (yo), 4 years experience (ye) in current role). The second reason it was difficult for MHC claims to be assessed and accepted was because of the challenges associated with delineating between mental illnesses developed as a result of work-related stress and pre-existing mental illness secondary to work (e.g. marital conflict, genetic predisposition and existing history). According to one employer, ‘‘The most difficult part of a stress claim is working out the validity of it to start with, whether work is a contributing or significant factor’’ (EMP#5, f,53 yo,7ye). Common causes of successful work-related MHC claims included harassment and bullying, working in high stress industries and/or difficult jobs and witnessing a traumatic

event. While the last two causes were not very problematic to assess and process, GPs reported that they were increasingly seeing MHC claims related to bullying and harassment and that these claims were difficult to assess and that they required further training to be able to confidently do so: You know I would really like some education on where bullying sits as a workplace injury. I find that very difficult to manage as a GP, you just accept from the patient that this illness might not have occurred if they were not in that workplace and write a Work Cover certificate (GP#1,m,62 yo, 40 ye). Independent Medical Examiners: ‘‘Their Independent Guy Says Differently’’ Typically in MHC claims second and even third medical opinions were sought by injured persons and their compensation agents. In some instances, due to multiple morbidities, complex case management was required and there were multiple providers contributing to the injured person’s treatment and recovery. Occasionally in these situations there could be conflicting medical opinions. Typically these conflicts were reported to occur between GPs and allied health professionals, GPs and medical specialists, GPs and independent medical examiners and between GPs and members on the compensation authority’s independent medical panel. Where these conflicts arose communication between the clinicians was often poor and the consequences for the injured person distressing. Timely RTW trajectories were often disrupted and people stayed off work for longer. As one GP reported: One patient that I saw yesterday had an examination by an independent medical examiner recently who said that he was opioid dependent and was suffering from a somatoform disorder … Now this was done by an orthopaedic surgeon. Now I don’t think an orthopaedic surgeon … has got any skills in being able to make the diagnosis of a somatoform disorder, far less to determine that a patient is opioid dependent. But that opinion won’t [matter] in this particular case because there’s no prospect for this guy returning to work ever (GP#10, m, 66yo, 38ye). For injured persons there was an implicit pressure on the one hand to ‘do the right thing’ by returning to work and on the other hand, to fully recover and look after themselves. This contradiction created anxiety as individuals wanted to be viewed as honest and hardworking and not as malingering or making false claims. For those whose cases went before an independent medical panel or an independent medical examiner the process was confrontational because many interpreted this event as the compensation authority

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questioning the validity of their claim and their honesty. However, only four injured persons in our sample reported having had an independent medical exam; three of these claims related to musculoskeletal injuries and one to a MHC. These individuals reported that though the prospect was daunting, they found the actual event fair and reasonable. One injured person (IP#8, m, 65yo) said, ‘‘The medical panel people were very fair,’’ and that he felt well represented in the exam: If you don’t win them over because you only just meet them face to face, they’ve got a dossier, I don’t know how long it is, that they might have spent 10 min reading before you got in the room […] I was walking out, the gentleman [medical examiner] who was letting me out of the place, as I went out the door, he said ‘‘You’ll be okay mate.’’ And I was relieved for that you know. GPs were much more circumspect about the role of the independent medical panel as the panel’s opinions were often sought in situations where the compensation agent felt that little headway was being made with the GP and/or the injured person about RTW. Oftentimes the results of these independent medical exams contradicted the GPs recommendations and this created friction. One GP said he felt ‘‘angry’’ and ‘‘upset’’ with the process and many reported either avoiding dealing with ‘WorkSafe doctors’ or counselling injured persons to avoid putting in for MHC claims due to the complexities associated with getting the claim accepted. This created additional conflict and roadblocks to RTW. A member of an independent medical panel said: You’ve got this awful situation where the worker doesn’t think they are being believed, the doctors being the advocate for the worker, you got the other side of the coin with independent medical examiners being branded ‘insurance doctors’ saying the other thing. And once you get into that situation you are on a merry-go-round and it’s very difficult to jump off (CS#18, m, 61yo, 4ye). Stigma and MHC Claims: ‘‘Do They Think That I’ve Been Putting it on?’’ There was considerable stigma associated with making a claim irrespective of the injury type. Injured persons feared being labelled a ‘bludger’ (lazy person), being viewed as ‘weak’ and ‘as putting it all on’ to exploit the compensation system and avoid work. Such perceptions created selfdoubt and anxiety in many. For those with a MHC claim there were additional factors that amplified the stigma of lodging a claim. These factors were the difficulties

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associated with GPs assessing and diagnosing mental disorders, as well as the stigma associated with having a mental illness. For some injured persons the claims process was as much about receiving recognition from their GP and compensation agents about the legitimacy of their claim as it was about seeking help to manage their injury and RTW: I felt guilty. I felt as if, I was questioning myself whether I was putting it all on, whether it was for real, whether you know maybe I should be back at work (IP#10, f, 61yo). I had a really legitimate concern and three independent doctors said I have a legitimate concern … but I was very anxious about them, someone acknowledging … it was legitimate (IP#16, m, 51yo). Injured person’s fears of being stigmatised and/or discriminated against were not unfounded. Many employers and compensation agents were sceptical, either about the validity of MHC claims, or about the severity of the illness. GPs were more equivocal, but all three groups had had previous encounters where there was doubt about the sincerity of the claim. He is just playing it up that he’s having mental problems and he’s having flashbacks and it’s like [sigh], ‘‘Oh god, it’s been going on for years for goodness sake. Come on, toughen up kid’’ (EMP#2, m, 64yo, 8ye). Sometimes clients are worded [advised], ‘‘Don’t get back to work. If you get back to work you get a reduction in your compensation. Play the game. Make yourself become sick or now tell them you got mental illness because it’s hard for anyone to see it and challenge.’’ And of course they play that role. And it’s sad (CS#1, f, 52yo, 12ye). In my experience 99 % of the people that come in are genuine. It’s very rare to have a malingerer or someone who’s just in it to make some money because getting a worker’s claim through is a hard road. You’ve got to be very committed (GP#12, m, 59yo, 30ye). Such attitudes contributed to injured persons and employers becoming more adversarial towards each other. Participants said that in the long term this resulted in poorer health outcomes for the injured person, lower rates of RTW and increased feelings of anger from both the employer and the injured person. For those with an injury there was the added fear that their claims would become common knowledge either at their workplace or at another place where employment might be sought. There was concern that this would limit job prospects and current and future working relationships. One injured person said:

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You don’t want them to know about your injury either. I’m worried because I sort of said to my return to work person […] I said to her, ‘You know … [crying on the tape] … I wouldn’t want to hire someone with a mental illness, if I knew about it’ (IP#1, f, 34yo). Mental Illness as a Secondary Issue In some cases mental illness also developed as secondary to a primary physical condition that was the focus of the initial compensation claim. This occurred in eight of 12 injured persons we interviewed with musculoskeletal claims. Compensation agents, GPs and employers explained that this was a common occurrence attributable to three inter-related factors: the nature of the original injury, the psychological resilience of the injured person and the systemic factors influencing recovery. If the original injury created significant functional impairment and chronic pain that required extensive rehabilitation and time off work, then there was an increased likelihood of mental comorbidities developing. Chronic pain was repeatedly mentioned by all groups as being a major risk factor for the development of secondary mental illness. Chronic pain is a huge issue. And that’s something that I think when things gets over medicalised and the person isn’t given the right information about their injury at the start. That’s when these thoughts starts popping in their head that they are never going to get better or you know no treatment’s going to help them. They can’t work or that kind of thing. So, if the GP doesn’t rein that in from the start, it does cause huge issues to the [RTW] track (CS#21, f, 25yo, 3ye). Factors influencing the mental illness-chronic pain nexus included over-medicalising, medical mismanagement and the injured person’s mindset. Over-medicalising refers to the practice of prescribing powerful, sometimes addictive, pain medications; medical mismanagement to the doctor’s failure to reinforce to the injured person the benefits of RTW and a positive attitude to recovery; and the injured person thus developing a negative attitude to recovery and RTW. GPs said that these factors were challenging to discuss in short consultations, hard to resolve and made injury management and recovery more problematic. If you’ve got injury where pain lasts for a long [time], after a while the brain does all sorts of funny things to that and some of the psychological stuff comes in. You know ‘Woe is me. I can’t work, I can’t earn an income, my children are starving, I have to take them out of their school or they won’t get Christmas

presents this year. Woe is me, it’s not fair’… all that kind of stuff comes in (GP#25, m, 50yo, 25ye). Injured persons, for their part, struggled with their original injury, chronic pain and opiate dependency. For some the experience was so debilitating that it eventually inculcated in them an attitude of hopelessness, victimhood and passivity. They were less inclined to take a more active role in their recovery, often unable to RTW and struggling to find quality of life. It still hurts me today, I can’t even wash my head, I have to rely on my wife to wash me, clean me, not that I wanted a nurse to come in but when you lose your independence you sort of … it’s frustrating, it’s bad sitting here looking at four walls, you can only look at so much TV and pop so many pills (IP#14, m, 54yo). Framing these individual issues were structural difficulties associated with the compensation and health systems. These difficulties, mentioned by all four groups, included inappropriate access to health care and conflicting or imperfect medical knowledge with regards to health systems and limited understanding of compensation system requirements and confusion about decision-making authority within compensation systems. Encountering these obstructions caused frustration for all stakeholders and also created financial problems for a number of injured persons. Delays and red-tape in the compensation system could exacerbate the risk of mental illness with financial instability, in particular, related to worsening mental health. One injured person said: The money I was receiving didn’t even pay my rent … So how was I supposed to survive? And because of all that, all the trauma they put me through, I’ve got severe psychological problems as well now and depression and I’m not half the bloke I used to be (IP#9, m, 62yo). Complexity of Managing Mental Health Claims Unsurprisingly the management of MHC claims were highly complex and very fraught. Nearly all the GPs, compensation agents and employers interviewed listed MHC claims as an example of a complex claim. Part of the difficulty associated with managing these claims was the uncertainty around predicting RTW. According to one agent (CS#14, f, 29yo, 3ye), ‘‘Whilst a fractured leg might heal in 6 weeks, some sort of PTSD or depression could take years and years to heal so it’s very, very, very slow.’’ Consequently many injured persons received compensation for extended periods of time and

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often they did not RTW, perceiving that the source/s of the stress remained either unaddressed or that the issue could not be resolved. These stressful sources could include supervisors, other colleagues or the nature of the work itself. In some cases alternative duties could be proposed but this was often harder for GPs to recommend and for employers to implement compared to modified duties for physical injuries where the same task could be performed but to a slower pace or lower level (e.g. lifting 5 kgs instead of 10 kgs). GPs were uncertain as to what kind of alternative duties to recommend and faced the added difficulty of balancing the injured person’s privacy with communicating to the employer outstanding issues, which could affect the claim and timely RTW. Without the injured person’s consent, employers could not be informed of all the details of the claim. One doctor said: It is quite difficult then to actually start to talk about depression to the employer if the patient doesn’t want them to know about it … So I sort of find myself sort of tiptoeing (GP#8, f, 53yo, 25ye). Compounding these difficulties was the fact that many treatments were not remunerated by the compensation authorities. With the exception of medication and counselling, nearly all other types of therapies shown to be beneficial in reducing stress (e.g. Tai Chi and yoga [41, 42]) were not covered and injured persons had to self-fund these therapies. In some cases even where treatments were remunerated some injured persons declined them. One such example was a refusal to see a psychiatrist or psychologist. Compensation agents could not compel injured persons to consult mental health professionals and many agents grappled with how forceful they should be in encouraging workers to RTW. The treatment as well, it’s not an exact science, so what might work for one person might not work for another and they are just all so different. So the claims staff are not really equipped well to deal with it. There’s also a level of anxiety out there about maybe being a little bit pushy on the phone (CS#10, f, 41yo, 10ye). All four groups were supportive of extra training for compensation agents, GPs and employers. Compensation agents and employers wanted more education on how to communicate effectively with injured persons; GPs wanted more training on MHC claims assessment and clinical management of mental illness and chronic pain. According to one employer: You’ve got to have some education yourself to be able to know what kind of support to give instead of

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getting angry […] I would guess that it would become very frustrating if you try and try and try but mentally the person is not quite ready, you can actually be not helping them in recovering and you will be going the other way (EMP#1, f, 42yo, 15ye).

Discussion This study examined the current nature and complexity of MHC claims management by four stakeholders in Australia and the barriers and facilitators that influence RTW following a MHC claim. Findings support and extend the literature in three ways: first, in line with the literature [25– 27], there is clinical uncertainty around MHC claims assessment and diagnosis. Such uncertainty can result in conflicting medical opinions about injury severity, management and RTW prognosis, which in turn affect timely RTW. Second, there are broader cultural stigmas around mental health and compensation claims that colours the claims process, inhibits communication, reduces helpseeking and RTW. This may explain why many MHC claims are not lodged and by extension why the true prevalence of MHC claims remains unknown. Third, diagnostic uncertainties and fear of being stigmatised does affect the management of MHC claims. GPs, employers and compensation agents are unsure of how to deal with the myriad of complexities that develop in MHC claims and there is need for guidelines and further training in a number of areas. Echoing the international literature [25–27], Australian GPs and compensation agents reported that there were numerous problems associated with the assessment and acceptance of a MHC claim. Unlike physical injuries where, for example, an x-ray could be completed to show a fracture or broken bone, for MHC claims there were neither visible injuries nor clear clinical guideline recommendations about management and recovery timelines. This impeded decisive judgement and management resulting in delays in accepting the claim, the independent medical panel sometimes being used to cross-check the claims and conflicting medical opinions. Such issues left their mark on injured persons and their GPs, influencing how both groups engaged in the longer term with the compensation authorities and employers. Often the scrutiny brought to bear on the veracity of injured person’s claims amplified existing anxieties and they grappled with the double stigmas of putting in a MHC claim and of living with mental illness. This finding resonates with previous Canadian data [9]. Injured persons with a MHC claim were fearful that their employers and colleagues would discover that they had a MHC and that this

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would diminish their current and future employment prospects. Such results provide a plausible explanation for why there is underreporting of mental injuries as a result of work thus extending the existing Australian compensation literature in this space [see 7, 8]. Injured person’s desire for both the legitimacy of their claim to be recognised and for their recovery to be supported is an important point of intervention in the RTW process. Compensation agents and employers recognised this and wanted further training on how to improve communication in this area. Such training could help alleviate the stigma injured persons encounter when making MHC claims as well as their fears of being viewed as mentally ill at work. This could have the added benefit of creating more open communication about RTW between the GP and employer if the injured person consented to their information being shared. GPs, for their part, identified MHC claims assessment and diagnosis, as well as chronic pain management, as areas for further education. Addressing these needs will help ensure greater consistency of care in general practice and reduce GPs anxiety when they feel that their clinical judgement is being questioned either by an independent medical panel or another health practitioner. Research shows conflicting medical opinions and poor communication between clinicians is a major barrier to RTW and can keep people off work for longer than necessary [25, 27]. Alongside poor communication between clinicians there are other health and compensation systems barriers such as slow referral, poor communication, red-tape and so forth, which can derail the RTW process and create secondary injuries such as depression and anxiety [34, 43]. As shown in our study secondary mental illness did develop in some cases and this further complicated existing management.

Conclusions To the best of our knowledge no other study has collectively gathered and analysed the views of GPs, compensation agents, employers and injured persons. The strengths of our study lie in the size and diversity of our sample and the rigorous approach we took to data collection and analysis. Through a granular and detailed analysis our work makes a significant contribution to current research in injury compensation, primary care and mental health highlighting the nature and complexity surrounding MHC claims and the barriers that can be addressed to facilitate safe RTW. Our study is limited by its focus only on one city in one state in Australia. There are different mandates governing injury compensation in other jurisdictions within Australia, which we did not examine, and other key players, such as

occupational physicians, psychologists and allied health, whose perspectives we did not include. Incorporating these diverse settings and stakeholder views might have yielded different results; however, the similarities between our findings and the international literature suggest that the barriers to MHC claims management and RTW pathways are persistent, pervasive and that systemic change is required. Facilitating such systemic change will be challenging not least because MHCs and RTW encompass compensation and health systems each with their own complexities and idiosyncrasies. Currently there are no gold standards for interventions for RTW in MHC claims and the evidence around efficacy of interventions in RTW for MHCs is weak [44]. Much more research is required. Future studies could focus on guideline and protocol development to improve GPs and other health professionals management of MHC claims as well as intervention trials on how to improve communication between stakeholders to minimise the risks associated with opioid dependency, functional impairment and negative thinking. Additionally, research could examine how to construct sustainable, meaningful modified jobs for workers with MHC claims on RTW. Ultimately there is a need for all parties involved in RTW to consistently deliver a message of resilience, recovery and the health benefits of work. This is an argument about economic and social justice. Research conclusively shows that irrespective of the injury, keeping people off work and not facilitating a RTW when it is safe to do so, can be detrimental to health, economic and social status [45–47]. It is imperative that the current paradigm is changed in order to facilitate a more timely return to safe work. Acknowledgments We gratefully acknowledge the technical advice and support of Ms Natalie Bekis, Ms Louise Goldman, Ms Tamara Fitzgerald and Mr Jamie Swann, from WorkSafe Victoria and the TAC, for their assistance with recruitment. We also thank Ms Amy Allen for assistance with data collection and analysis. Finally, we express our gratitude to the individuals who participated in the study. This project was funded by the Institute for Safety, Compensation and Recovery Research (ISCRR). ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash University.

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Mental health claims management and return to work: qualitative insights from Melbourne, Australia.

Mental health conditions (MHC) are an increasing reason for claiming injury compensation in Australia; however little is known about how these claims ...
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