Monday, April 29, 2024

Mental Injuries: Workers’ Compensation and Disability Insurance Part 1

 “Every day we respond, and we attach ourselves to the worst day of somebody’s life.” [see Phil Melnychuk, “Online program gives firefighters some advance notice about the trauma and tragedy they’ll face”, Delta Optimist, March 20, 2024]


That’s the way Captain Ben Lewis recently described the nature of a firefighter’s job. Extracting a car crash victim, saving multiple lives at a fentanyl overdose scene, recovering the charred body of a child from a house fire. Attending the worst day of somebody’s life every day, day after day, can take its toll on firefighters and other first responders serving our communities.

The apparent rise in mental injuries

First responders are not the only workers at risk of mental or psychological injuries. Many workers’ compensation jurisdictions and work-disability insurers have noted increasing mental disorder (also called psychological injury, mental injury) claims over time. 


In this post, we survey some of the data reflecting this increase.  We will explore some of the reasons for the increase. In a later post, we will look more closely at the drivers behind current trends.  We will also discuss some of  the challenges in comparing data across jurisdictions and prevention strategies that might impact the trajectory of future trends.



Important note on Terminology

This is intended as a general discussion document and will use several different terms.  This requires a caution with respect to terminology.


Certain terms may carry negative connotations, confer a sense of blame, or infer a flaw in an individual. The terms used in this post are reflect the terms most often used in diagnostic, policy, coding, statistical and legislative data being discussed.


Psychological injury, mental disorder, mental illness, mental impairment, mental health injury, and other terms used here often have specific meaning or legal definitions that apply to in specific  jurisdictions.   There are also other terms that I have not used in this discussion but may be included in the categories discussed here. For example, operational stress injury and military sexual trauma are terms specific to certain armed forces. Legislation, policy, and coding standards use various terms to address this topic.  Similar terms in different jurisdictions may or may not carry the exact meaning or definition.


In the general context of work-related claims, my preferred terms are “psychological injury”  and “mental health injury” .  Mental health condition, mental health injury, psychological injury, mental health challenge, and similar terms are used in cited material.   Diagnosis or criteria in the DSM-5-TR,  ICD-11,  and equivalent classification systems are not always the same as those used in practice, policy, or legislation.  Certain mental health disorders including PTSD do appear in these references and generally have specific meanings that are consistent across jurisdictions but may not be consistently applied or reflected in statistical reports. This variation in terms makes interjurisdictional comparison more difficult.

Tracking mental injury statistics in Workers’ Comp and Disability Insurance

Workers’ compensation recognition of the relationship between work and psychological injury, particularly in the absence of physical trauma, has lagged the scientific acceptance.   Where short and long term disability (STD and LTD) insurance or social security disability  insurance plans (SSDI in the US) are available, they are often accessed before (or instead of) filing a  workers’ compensation claim. The threshold for STD, LTD and SSDI is “disability” from employment while workers’ compensation claims must first establish a work-related cause before considering the issue of disability. 


The Canadian data [from the Association of Workers’ Compensation Boards of Canada – National Work Injury Statistics Program] reflect a rising  trend in accepted work-related mental disorder claims (7,378 in 2022). While the overall trend in work-related time-loss injuries was declining (at least until the COVID-19 pandemic), time-loss claims involving mental disorders or syndromes have trended upward.



In Australia, mental health conditions accounted for 9% (11,700) of all serious workers' compensation claims, 7% of all work-related injuries and illnesses. [see Safe Work Australia, Data insights - Snapshot: Psychological health and safety in the workplace, February 2024]. While the index of all other serious injuries has remained flat, the index for serious claims involving mental health conditions has doubled.


The shape of the  index line for mental health conditions in the Australian data reminded me of a Munich Re study that looked at the relative increase in sick leave due to mental disease over a similar period, [See Munich Re, Mira Risk Review: Munich Re’s Mental Health Calculator, 2022 at https://www.munichre.com/content/dam/munichre/contentlounge/website-pieces/documents/MunichRe-MRRP-Menthal-Health-Calculator_en.pdf]  Munich Re notes:

  "Mental health conditions are an increasing challenge globally, but most noticeably in industrialized countries.

… the rise in incidence is reflected in higher numbers of life insurance applicants disclosing mental diseases as well as increased numbers of claims

…most mental health conditions are considered chronic or recurrent and have a high correlation with other health issues, despite good treatment.

…complexity in managing mental health conditions is the rule, rather than the exception.”

"

 


Sun Life Canada reports 24% of all new short-term disability (STD) claims and 32% of new long-term disability (LTD) claims are for mental illness.  The greater complexity and longer duration of these claims account for a disproportionate 45% of claim costs. (See SunLife, Changing Times: evolving the approach to disability management, 2021 at Changing times: evolving the approach to disability management | Sun Life). 


Social Insurance mental injury data

Social insurance generally covers a wider population than workers’ compensation but may reflect trends that are felt by workers’ compensation and disability insurance. The following table highlights aspects of the Australian Disability Support Pension (DSP), US Social Security Disability Insurance (SSDI), and Canada Pension Plan – Disability.


 

 

 

US Social Security provides benefits to workers for certain disabilities.  Looking only at the subset of Social Security Disability Insurance (SSDI) for workers who have filed for workers’ compensation or public disability benefits,  musculo-skeletal diagnosis dominate.  Note, however, that the diagnostic categories involving mental disorders are significant:


Changes in coding definitions make a time series using this subset of SSDI data difficult but it appears that the representation of mental disorders in this subset has fallen between 2010 and 2022.  Looking only at this medical category of SSDI claims, and using only table 34 in the Annual Statistical Report on the Social Security Disability Insurance Program for each year, the combination of “Depressive, bipolar, and related disorders”  or “Mood Disorders” with the “Other” category have fallen from about 14.1% (2010) to 9.3% (2022) of beneficiaries who have filed for workers' compensation or public disability benefits.


The Canada Pension Plan Disability (CPP-D)   system covers persons with contributions to the plan who suffer a “severe and prolonged” disability. Unlike  in the US SSDI, I could find no data isolating just those who had also filed workers’ compensation claims.   The following are based on December counts of benefit cases paid each year 2011(325,620 cases)-2023 (305,679 cases) and isolating mental disorders and all other classes of principle diagnosis : 



 

Australia Department of Social Services (DSS) provides data on the demographics of Disability Support Pension (DPS) recipients quarterly. I’ve selected December data reports and created an index by primary medical condition isolating the psychological/psychiatric  category and all others (excluding the psychological / psychiatric category):



About 37%  of the total 783,625 case were included in the Psychological/psychiatric category in 2023, up from about 33% in 2015.  


I could not find a study quantifying overlaps and possible substitution of sick leave, social insurance for workers’ compensation mental injuries. It is possible that workers’ compensation and other forms of disability compensation (including employer provided sick leave, short-term disability, and long-term disability) are experiencing similar patterns. 


These data suggest mental disorders are a significant issue for workplace participants, workers’ compensation, social insurance and disability insurance plans.   

Mental Injuries Are Not Always Associated with Physical Trauma

Most workers encounter a workers’ compensation claim because of work-related physical trauma. Mental injuries and disorders may well develop following physical injury, but that is not always the case. SafeWork Australia found that more than half of mental disorder serious injury claims arose from work-related harassment, bullying, and workplace pressure.


Safe Work Australia,  Data insights - Snapshot: Psychological health and safety in the workplace, February 2024


The Canadian data illustrate the distribution of claims by the nature of the disorder. Post-traumatic Stress Disorder (PTSD) tops the list but occurs in combination with other disorders and physical injuries. With PTSD, adjustment disorder, stress, and anxiety contribute to making up the majority.



 

While the range of descriptions noted is wide, recall that these data are for accepted time-loss claims.  That means the adjudicative authority has determined the work-relatedness of the loss.  Many cases of a similar nature may be denied for mental disorders or injuries.  More on  the standard and burden of proof in the next part of this series. 


Employees with employer provided  or employee group plans for short or long-term disability may seek coverage through those plans. As noted in earlier posts, many STD and LTD carriers will require claimants to file claims with workers’ compensation or social insurance plans as a condition of coverage under LTD or STD. 

Who suffers mental disorder injuries?

The following table lists the top 15 Canadian time-loss claims coded for mental disorders by occupation (Minor grouping level, first four digits of National Occupational Classification- Canada) by the number of accepted time-loss claims from 2020 to 2023: 

  


Please note that most of these occupations have something that might not be immediately obvious:  high levels of unionization. This may contribute to greater awareness of health and safety issues as well as better advocacy supports that contribute to greater success in claim filing.  The relatively lower numbers of accepted mental disorder claims among retail clerks may be more reflective of lower levels of unionization than lower exposure to harms. 


Australian workers’ compensation  data are grouped more by industrial sector but reflect a similar industrial distribution. The “Public administration and safety industry” includes police services, investigation and security services, fire protection, other emergency services, and correctional and detention services. The following figure appears in Safe Work Australia’s data report on “Psychological health and safety in the workplace”:


How Representative Are These Data?

Both the Canadian and Australian workers’ compensation data have gaps and inconsistencies that likely understate the extent of work-related mental disorders in the workplace.  Data for all jurisdictions in either country are not reported in all years.  There are no corrections or adjustments for changes in legislation that may occur over reported periods of time.  So, these data may not fully represent what is happening in either country’s workers’ compensation system.


Direct comparisons between countries are further complicated by differences in classification systems and coding practices.  At best, these data likely reflect broader trends.


That said, trends for individual jurisdictions over time are further complicated by changes in definitions, interpretation, diagnostic methods, adjudicative practice, mix of industries, and a host of other issues  within the jurisdiction.  Factors such as growing recognition of the reality of work-related mental injuries and declining stigmatization of mental disorders will likely impact reported claims but are difficult to assess.


To be clear, work-related mental injuries are real and despite the shortcomings in the available data, what we have available provides a good indication the reality of work-related mental injury is being somewhat (if not fully) recognized. 


Whether because of physical injury, a complication of treatment, or work-place conditions, workers are being harmed. That harm is significant and as life-altering for the bullied construction worker as it is for the burned-out air-traffic controller or the PTSD afflicted first responder.

Summary

Data from multiple sources show:

·       Mental disorders are a significant issue for workers’ compensation, disability insurers and social insurance entities

·       Increasing proportion of workers’ compensation claims in at least some jurisdictions

·       Increasing associated costs

 

Next time

These data on  of mental disorders demonstrate the significance of the issue.  They also illustrate some of the key challenges in comparing data across jurisdictions. 


In Part 2, we will explore some of the differences in the determination of claim acceptance in workers’ compensation programs and consider initiatives for prevention and treatment.