I am not sure why some think that I’m opposed to getting referrals to a mental health professional.  My position is the of opposite of that.  I feel that every injured worker should have access to some level of mental health support.   I work with a veteran pain psychologist who is wonderful.  90% of her practice is caring for my patients.  If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder.  On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability.  Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner?  What is even more worrisome to me is the patient who puts down a zero for all three.  He or she is just a time bomb.

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition what the referral trigger should be.  What is the definition of a “diagnosable” mental health disorder?  As there is not a concise definition, I am in a continual battle with worker’s comp to persuade them to “buy” a psychiatric diagnosis.  While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

The other comments are all ones that reflect my position and add a few pertinent dimensions.  I am just advocating that all of us take off the labels and listen to each other as human beings at every level.

I saw a patient a few months ago who is a young mother.  I have known her for years.  She developed quite severe axial back pain.  We had a short but direct conversation about stress and pain.  She came in a couple weeks later with her back pain feeling moderately improved but seemed upset.  I had a little extra time to talk to her.  She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children.  It turns out that he had been regularly beating her.  It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK.  If you met her, you would be more than upset.  She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition.  She really did not know what direction to go.  Her mother was helping out the best she could.  I did email my pain psychologist and although she had no funds, she was able to be helped out.   On top of that, her husband has chronic pain from failed back surgery.

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress.  Basic tools would be helpful in dealing with these matters.

Every injured worker needs to have access to at least a group that teaches these type of skills as well as offering support.  Individual referrals can be figured out more easily in that setting.  Psychology and psychiatry resources should be readily available.  Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single.  It is much worse if you are the breadwinner of a family. When would you not need some level of mental health support?  I am not even considering the added stress of dealing with worker’s comp.

A major concern and obstacle to accessing mental health support is our tendency to label people.  Injured workers quickly become labeled.  This is particularly true if they make the mistake of complaining too loudly or express their frustration.  They become “difficult” and “manipulative.”  If their stress becomes higher they may have more pain and ask for more meds.  Now they are “drug seekers.”   The list goes on.  If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and that problem is “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist.  Meanwhile months have passed and often their lives have unraveled.

The other comments by the group are also relevant.  The person’s whole life, including their mental state, must be acknowledged from the minute they are injured. Every person that comes in contact with them makes a difference.  Even the acknowledgment of their suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis.  If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful.  Because of our methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.  My whole staff is involved in the process, and that is what makes my job so enjoyable.

BF