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By Peter Rousmaniere

The newly injured patient brings to the initial medical encounter all of his or her fears, hopes, strengths and maladies. These may include symptoms of a serious mental health disorder.

Discussions with three doctors about mental health disorders reveal that experienced occupational medicine doctors can detect and respond to mental health problems ranging widely in nature and severity.

The doctors agree, though, that it is appropriate to refer a patient with a nonwork-related mental health disorder to a mental health professional outside the workers' compensation system.

Dr. Douglas Benner, an officer at San Jose, Calif.-based, EK Health, said that about 5 percent of physically injured workers have a "significant complicating psychological diagnosis such as depression."

However, as many as one in four workers can have behavioral patterns or a personality disorder that can complicate their treatment, recovery and return to work.

At the Mayo Clinic in Rochester, Minn., occupational psychiatrist Dr. Greg Couser sees injured workers who are referred by his colleagues. Couser said that "around 5 percent" of physically injured workers could end up with a mental health disorder diagnosis.

But "The presence of mental health symptoms," Couser said," does not necessarily mean there [should be] a psychiatric diagnosis."

Some workplace conflicts can result in stress that is purely work-related and doesn't indicate a preexisting or permanent condition.

"The important point here is to be thorough in taking a history, both in the history of present illness and in other aspects of history, such as social history, that might give some insight into functioning," Couser said.

Physicians will most usually see "clinical syndrome disorders of mood, such as some level of depression, also anxiety disorders with acute stress being a more common type," Benner said. He also said that personality disorders will crop up during a physical evaluation, noting that "their behavior traits can be quite challenging to recovery."

The experienced occupational physician also needs to be able to tell work-related from nonwork- related mental health conditions.

"Some conditions such as depression and personality disorders can be determined by the first patient history to be pre-existing, and thus not work related," Benner said. "Others such as acute stress disorders and post traumatic stress disorder can clearly be determined by history to be caused by an acute and traumatic work injury."

Maja Jurisic, a Milwaukee-based physician and assistant vice president at Concentra, has seen commercial drivers who sank into profound emotional upheaval due to a fatal vehicular accident, leading to post traumatic stress disorder.

The most common occupational mental health problem, according to Jurisic, is adjustment disorder, when a patient is at the end of her or his coping skills, or resilience is low, and the work injury pushes the worker "over the edge."

Jurisic is careful about how she records her findings. Employers are entitled to any information about the work injury, but not to medical information about nonwork problems. Then she may simply note that an unspecified underlying problem is creating a barrier to recovery.

If the condition stems primarily from the work injury, such as post traumatic stress disorder, she would "document it less obliquely, as the employer could then be privy to all of the information about that, especially if I were making a psychiatric referral."

These doctors said that mental health disorders, light or severe, fall within the scope of the occupational medicine specialist's competence.

September 12, 2011

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