Mental Injuries- Part 3: Implications for Disability Insurers and Workers’ Compensation

 

The apparent rise in mental disability claims is a significant issue for disability insurers and workers’ compensation systems. The observed rise in workers’ compensation claims for mental injury must be interpreted in context.

I accept the following as a fundamental principle for  workers’ compensation:

If work is the cause of injury and disability, then the compensation and treatment should be funded by the employer.

 Failure to recognize work as the cause externalizes costs to others including the worker, other workers, and the community at large.   

The cost of compensation and treatment, the main components of workers’ compensation premiums nominally paid by the employer, are properly reflected in the overall cost of production.

Handwringing over costs often misses this underlying premise.  The degree to which any statute results in work-related cases of mental injury being discouraged or denied shifts more costs from employers (the nominal payers of workers’ compensation premiums) to taxpayers (who fund social welfare), other workers (who fund social insurance), and insured (who fund some or all the costs for disability insurance).  Externalization of work-related mental disability costs to other insurers and workers amounts to a subsidy of the cost of production.

Even if workers’ compensation fully covered all work-related cases, workers suffering work-related mental injuries must still bear the burden of the harm, and with their families,  carry some of the financial loss. 

Recap

In earlier posts in this series, I provided data on the increasing numbers of accepted workers’ compensation and disability insurance claims for mental injuries.  Here is a brief recap of our discussion so far.  

Work-related mental injury and disability have always existed but not always identified, accepted,  or counted.  At least some and perhaps most of the observed increase in mental disability claims may be attributable to changes in definitions of mental injuries, refined coding practices, decreased stigma, increased advocacy and awareness, reduced barriers to filing mental disability claims, and changes in the broader work environment.

Greater identification and recognition of mental injuries allows for greater access to short and long-term disability funds; recognition of the work-relatedness of some mental injuries leads to a rise in mental disorder claims for workers’ compensation.  Disability insurance and workers’ compensation both have administrative imperatives that drive the need for improved access to diagnostic and treatment services. Disability insurers have an added incentive to ensure claims that are work related are properly attributed and compensated by workers compensation; workers’ compensation has statutory and fiduciary requirements to ensure that only claims within the scope of coverage are accepted.  

Financial support for working-age persons with mental disabilities is limited.  Welfare (social assistance) may be available to most and most of the employed labour force have access to social insurance for severe and prolonged disability. 

Private group and individual disability insurance plans generally offer greater financial support than social insurance but are only available to a minority of the employed labour force;  financial supports for work-disabling mental conditions are typically time limited. 

Workers’ compensation typically offers greater financial support than disability insurance; while covering nearly all workers, the path to an accepted claim for mental disability is challenging ( by virtue of the work-relatedness requirement, onus and standard of proof levels, diagnostic services access/availability, restrictive definitions and exceptions  that may apply). 

Greater recognition, changing definitions, and reduction in stigma may increase claims … and that trend is reflected in the data workers’ compensation and disability insurance data. 

What to keep in mind when looking at Workers’ Compensation Mental Injury  data

Understanding what is going on in the data is not simple.  What gets counted, what periods are involved, administrative backlogs, and even the coding practices will influence reported data. 

As noted in earlier posts, work-related mental injuries may arise after physical injury, occupational disease, or treatment.  Mental disabilities may also arise without physical injury or disease through workplace bullying, harassment, and overwork.  Data that differentiates the nature and source of mental injuries are important to understanding how mental disability claims are occurring and changing in a jurisdiction.

Mental-injury claims data must be well understood before attempting any comparisons within a jurisdiction over time or across jurisdictions.  Even if data in multiple jurisdictions report identical categories of data, underlying differences in definitions, coding practices and coverage context may inhibit meaningful comparison.

As you examine the data across jurisdictions, verify consistency of definitions, practices, and scope over the study or reporting period.  Confirm the process and terminology for claim reporting, consideration, and decision during the reporting timeframe.  These considerations are in addition to accounting for the usual factors such as differences in demographics, industrial mix, etc. 

In this part, we look at data and recent changes in one workers’ compensation jurisdiction to highlight the complexity in understanding reported data.  The example is one with a high degree of transparency around work-related mental injury.  We will then consider some of the implications for disability insurers in the long and short-term disability space.  

Mental Disorder Claims – WorkSafeBC Data

Few workers’ compensation authorities publish data on mental disability claims.  WorkSafeBC is an exception.

WorkSafeBC is the exclusive insurer for workers’ compensation in British Columbia, Canada.  Coverage extends to about 2.7 million workers (about 95% of the employed workforce) and 280,000 employers in a province of about 5.5 million people. 

WorkSafeBC’s public accountability and transparency regarding mental injuries is well documented. The 2023 Annual Report is titled “Toward psychological health and safety” [see https://www.worksafebc.com/en/resources/about-us/annual-report-statistics/2023-annual-report/2023-annual-report-2024-2026-service-plan?lang=en] and provides details on the current strategies.  The annual report notes a nearly 30% increase in psychological-injury-only claims over the last five years.

This tells only part of the work-related mental injury statistical story.  WorkSafeBC also publishes an annual Statistics report.  The numbers in the following table not only account for the psychological-only-claims but also existing claims or claims for other injuries that have mental disorders to be considered as part of the claim.  The following table comes from the Statistics 2022 publication, the most recent version available: [available at https://www.worksafebc.com/en/resources/about-us/annual-report-statistics/2022-statistics ]

This shows that Allowed claims for mental disorders have grown.  It also demonstrates the status or disposition of other claims reported. In workers’ compensation articles, claims are often described as either “accepted” or “denied”.  In practice, the claim process is not a simple binary categorization.

The above table reveals a more accurate portrayal with clearer definitions regarding the status and disposition of mental disorder claims considered:  

1.     Claim data for 2022 is as of October 23, 2023. Data for 2020 is as of January 31, 2021. Data for 2019 is as of January 31, 2020. Data for 2018 is as of January 31, 2019. Data for 2017 is as of November 30, 2018.

2.     Disallowed claims are those that do not meet the requirements of section 135 of the Workers Compensation Act.

3.     Claims that require no adjudication or are rejected may have been filed in error or be rejected if the worker does not have WorkSafeBC coverage.

4.     Suspended claims are often those where the worker does not respond to a request for additional information or withdraws the claim. Suspended claims may proceed at a future date.

 

Why Data from One Jurisdiction Varies from Source to Source

The data provided by WorkSafeBC  in the annual and statistics reports differ from those provided by the Association of Workers’ Compensation Boards of Canada (AWCBC) in its National Work-Injury Program (NWISP) report.  The NWISP 2020-2022 report notes: 

This report contains Lost Time Claims by calendar year of injury, or diagnosis in the case of disease, that have been accepted for payment during the year of the accident – or in the three-month grace period (January 1st–March 31st) immediately following the reference year.

The AWCBC NWISP definitions page (see https://awcbc.org/en/statistics/national-work-injurydisease-statistic-program-definitions/) notes that the Nature of Injury coding refers to the “principal physical characteristic of an injury/disease”.  For BC in the years 2020-2022, the NWISP report records the following accepted clams under Code 52 Nature of Injury [(year) count]:  (2020)1303, (2021) 1599, (2022) 1559.  Timing, reporting,  and coding differences account for the lower counts in the NWISP when compared to the same years in the annual and statistics reports.         

Changing legislation

Even this detailed table lacks another key contextual factor.  As with most jurisdictions, the issues of work-related mental injury and disability were of significant concern to workers’ compensation policy makers and stakeholders. 

The Royal Commission on Workers’ Compensation in British Columbia nicely summarizes the issues as they stood in the late 1990s [ see Volume 2 Chapter 4 in “For the Common Good : Final Report of the Royal Commission on Workers' Compensation in British Columbia”, 1999].  The heightened awareness of mental injuries was evident in the public hearings and research briefs received by the Royal Commission.  The work of the Royal Commission and other reviews urged changes to the workers’ compensation legislation. 

Bill 49, Workers Compensation Amendment Act, 2002 contained a provision for “mental stress” claims.  The provision was narrow and had restrictions but was a shift toward greater acceptance.   

Over the years, the term “mental disorders” replaced “mental stress”  and the section expanded in ways that allowed for greater acceptance of claims.  The current section of the Workers Compensation Act of BC , Section 135  [available at https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/19001_04#section135 ]   includes a presumptive clause for “eligible occupations” such as correctional officer, police officer,  and emergency medical assistant.  It also provided for additional occupations to be added to the presumption by regulation.      

Presumptions

I’ve mentioned presumptions in previous posts in this series. Although almost always rebuttable, presumptive clauses are more than symbolic gestures; they have real consequences. For example, presumptions:

• Shift the onus away from the worker having to prove work-relatedness
• Reduce stigma associated with filing claims.
• Speed processing time from consideration to decision (decrease individual case investigation, reduce processing times, may reduce suspended claims by lessening some evidentiary needs)
• May increase speed of access to needed treatment.
• May decrease worker appeals.

Presumptions change processes and operations of workers’ compensation insurers as reflected in the WorkSafeBC data. 

In 2018, a new mental-health presumption for municipal and federal firefighters, police, paramedics, sheriffs and correctional officers was established.

In 2019, additional occupations were added.  These included emergency response dispatchers, nurses, publicly funded health-care assistants, as well as forest firefighters, fire investigators and firefighters working for Indigenous organizations.

Effective June 2024, the presumption was expanded yet again, adding to the mental-health presumption community-integration specialists, coroners, harm-reduction workers, parole officers, probation officers, respiratory therapists, shelter workers, social workers, transition house workers, victim service workers and withdrawal-management workers.

The percentage of allowed claims adjudicated under presumptive clauses has typically increased in the years following the expansion of eligible occupations. 

Implications for Other Disability Insurers

In most jurisdictions, employment-based disability insurance plans (short and long-term disability known as STD and LTD) are not universal and those that exist do not always cover mental injuries.  Group disability plans are more common in unionized organizations, among larger employers, and in certain sectors such as healthcare.

In the BC context, disability insurance extends to about 1.3 million individuals, primarily through group plans.  If premiums are paid for in whole or in part by the employer, benefits are taxable.  Coverage ranges from about 50% to 70% of earnings. 

As noted in previous posts, disability insures have an incentive to control costs where another form of insurance is a first payer, or benefits can be coordinated.  Workers’ compensation is the first payer for work-related injury including mental injuries.  Many workers who would qualify for STD or LTD coverage may be required by their insurer to apply for workers’ compensation if there is a possibility of the mental injury being related to either a physical work injury or work-related occupational disease or a psychological only workers’ compensation claim. From the employee perspective, the benefit under workers’ compensation is generally greater than that from STD/LTD so there is an incentive to seek this coverage. Health care costs related to an accepted workers’ compensation claim may also increase the incentive to claiming . 

Changes in the presumptive clauses have three other important impacts for disability insurers.  The fact workers’ compensation may cover certain mental disorders raises the prospects of injured workers seeking benefits because of the increased awareness.  Increased numbers of people seeking benefits for mental disorders will increase the competition for diagnostic and treating mental health professionals—an already under-serviced provider segment.  The qualification difference between STD/LTD and workers’ compensation will result in cases started under a disability benefits plan being retroactively covered by a workers’ compensation claim, adding complexity to claims handling.  

Besides the direct cost and workload issues, workers’ compensation claims that are rejected or disallowed may well be subject to reviews and appeals, protracting the claim consideration.  We know that the iatrogenic effects of such processes may extend disability.   Increasing backlogs in handling workers’ compensation claims can have implication for disability insurer costs.

As noted in previous posts, access to diagnostic and treatment resources is critical but the availability of qualified professionals accepted by workers’ compensation and other insurers is limited.  Restricted access tends to drive up costs for services (such as consultation reports and on-going therapy) and length of disability.   

Final Thoughts

Many managers have had the experience of an employee with increasing absences.  The given and recorded reasons may be convenient (e.g., sickness, illness in family, etc.), low-hassle (sick leave, personal business day, vacation leave) alternatives to reporting a work-related mental injury or making a workers’ compensation or STD/LTD claim for mental injury or disability.  The motivations are obvious.  For the employer, the process is simple and easily managed like any other brief absence. For the employee, there is no stigma, little justification, and minimal hassle to access paid absence. Essentially, the costs of the work-related mental injury and disability are externalized to the worker and her family.

Many workers who cope with work-related mental issues on their own conceal disabling conditions under requests for sick leave and vacation time off until those avenues are exhausted; only then is a claim for  disability insurance, social insurance, or workers’ compensation claim reluctantly filed. 

The human cost to the worker/employee, their family and the community is the same regardless of where a claim is filed.  What may shift is the attribution of cause and funding consequences.    

It is too simplistic to say that the observed increases in workers’ compensation and disability insurance claims for mental injury reflect a deterioration in the mental health of the workforce or a worsening of exposure to causes such as work pressure/volume, harassment, or bullying.  To be clear, these are factors that need to be monitored and worthy of prevention.  The consequences of removing stigma and excessive barriers to filing disability and workers’ compensation claims for mental injury and disability are likely revealing more of what has been there all along.

It is also too simplistic to say “building resilience” is the solution to the rising claim counts.  While necessary, building a more resilient workforce is unlikely to change incidence but may well diminish severity.  More research is needed here. 

The human and social costs of mental injuries are immense and real.  Dismissing mental disability as a personal failing or weakness in the individual is a slap in the face to those experiencing the pain and consequences of mental injuries.   Fully recognizing work-related mental injuries and disabilities is essential to building the strategies and resources for primary prevention, early intervention, and increasing available supports for treatment.

The detailed claims analysis from WorkSafeBC and statistics from AWCBC,  SunLife, MunichRe, and SafeWork Australia quoted in this series are a first and important step in understanding workers’ compensation and disability insurance for mental disability.  Improved understanding through transparency and more investment in research are needed to better inform our policy decisions and foster improved outcomes.

 

Mental Injuries: Workers' Compensation and Disability Insurance Part 2

Last time, we outlined the growth in mental disorder/psychological injury claims in workers' compensation and related workplace insurance programs.

Despite data gaps, the trends in many jurisdictions show an increasing number and proportion of accepted work-related mental injury and disability claims; there is some evidence that mental disability claims in the broader social insurance environment may be a more consistent proportion of disability types. Greater acceptance of the work-relatedness of mental injuries and disabilities may be more reflective of an existing reality than a decrease in mentally healthy workplaces. 

In this part, we will explore the underlying changes that may be contributing to the observed trend, explain why comparison between jurisdictions is challenging at best, and  touch on initiatives for prevention and treatment.

Attitudes about mental injuries

In August 1943, General George S. Patton encountered Private Charles Kuhl in the 15th Evacuation Field Hospital at Nicosia (Sicily). The eighteen-year-old Kuhl had been pulled from battle suffering from "battle fatigue" as well as malaria and dysentery. Patton asked him about his injuries. "I guess I can't take it," Kuhl told the General. Patton grabbed the young soldier by the collar and slapped him with a leather glove, describing him later in writing as a "weakling". A few days later at an evacuation hospital in San Stephano, the general encountered Pvt. Paul Bennet, age 21, having been evacuated from the fighting for exhaustion and dehydration. Bennet told the general, "It's my nerves, I can't take the shelling anymore". The general struck Bennet and called him a coward.

The incidents of Patton slapping or deriding soldiers as cowards were covered extensively in the newspaper headlines of the day. Public and political leadership recognized that the General had gone too far. Not far enough for Eisenhower to order Patton's removal from command but enough to get Patton to apologize.

Our collective understanding of mental injuries has evolved, but there are persistent undercurrents of belief that any mental disability is the fault of the individual, an inherent weakness. "Toughen up!" is still the default response of many, but public acceptance towards the reality of mental injuries has improved. The Roper Center for Public Opinion Research notes on its Public Attitudes about Mental Health webpage [ https://ropercenter.cornell.edu/public-attitudes-about-mental-health ] :

Sixty-seven percent of the public believed that mental disorders were an extreme or serious public health problem.

Eighty-nine percent believed that physical and mental health were equally significant.

Attitudes have changed and are changing over time. That change has spurred policymakers to become more specific in creating avenues for the treatment of and compensation for mental injuries. That said, attitudes toward mental illness still vary  not only by jurisdiction but by industry,  and even by occupation or specific worksite.  The toughen-up attitude still exists.

On the disability insurance side, this shift has meant changes to policies and procedures. While not everyone has access to disability plans, insured parties want clarity of the coverage;  insurers need clear procedures to approve coverage. Disability insurers also want to limit their liability to non-work-related cases.

For workers’ compensation, growing recognition of the work-relatedness of mental injuries requires changes to legislation and policy allowing for compensation. Workers’ compensation is typically the first payer for temporary disability so decisions to accept or deny claims for mental injury need to be explicit and timely.

Just because a disability insurance policy or workers’ compensation law covers disability due to mental injury does not automatically mean an immediate and complete filing of such claims. There are many societal and process factors that may inhibit a worker with a work-related mental injury from filing one. The stigma associated with mental injury and mental illness more generally is a big one.

Stigma

The stigma associated with mental injuries may discourage those in need from seeking treatment or attributing disability to other causes to avoid real or perceived stigma. While measuring attitude assesses the societal or workplace environment, stigma is best assessed from the perspective of individuals experiencing mental illness or injury.

Those seeking help through the healthcare system report feeling patronized, punished, or humiliated (Christina Pellegrini, Mental illness stigma in health care settings a barrier to care, CMAJ January 07, 2014 186 (1) E17).

Public education programs and industry-specific initiatives to de-stigmatize mental injury will “reveal” underlying cases of work-related mental injury. It may increase claims for workers' compensation, but that does not automatically lead to increases in accepted claims.

Successful efforts to reduce stigma will increase claims statistic for work-related mental injury and disability in two ways. Those injured or suffering from mental conditions may seek help directly because of the mental injury and cases previously initiated for other causes may be recorded as having a primary or secondary mental injury component.

As with attitude, stigma levels vary greatly. Few local or workplace surveys assess stigma, but elevated levels of stigma are likely to suppress claims, prolong disability, and worsen outcomes.

Overcoming the stigma issue is just one step. Choosing to file a workers' compensation claim is quite another, one that involves processes that may be harmful or so onerous as to cause a worker to avoid reporting the mental injury altogether.

The following touches on just a few process issues.

Workers' compensation coverage for mental injuries

The mental injury category of work-related injuries is more complicated than most other injury categories. Keep in mind, each jurisdiction will have its own characteristics that make direct comparative analysis difficult.

The inter-jurisdictional differences in reporting requirements and coverage may influence the willingness of parties to report mental injuries. Even within jurisdictions, the reporting and coverage of mental injuries is subject to a lot of change.  The following highlight just a few sources of difference and how these may impact jurisdictional data over time and complicate interjurisdictional comparison.

Processes for filing and adjudicating claims

All workers' compensation claims are evaluated based on the connection between injury or illness and work. Legislation in each jurisdiction is specific to that jurisdiction and may include provisions such as exclusions and presumptions regarding mental injuries but operational processes can also have a big impact. 

Adjudicative practices directives, staffing levels and organizational factors can all influence how claims are processed and adjudicated. Some jurisdictions take a generalized approach while others have specialized adjudicative and administrative sections to manage mental injury claims.  The specialized structures tend to have specific training and procedures that may be more accommodating to those with mental injuries.

The adjudicative framework will also impact both the acceptance rate and the willingness to file a workers' compensation claim for a mental injury. That framework often depends on external definitions as well as internal applications (policy, practice, administration).

Changing definitions and the PTSD example

Definitions in legislation and associated with coding systems change over time. One example is  International Classification of Disease (ICD) system is commonly used to code claims. ICD-9 had 14,000 codes and was used for decades; its successor, ICD-10, has 70,000 codes and has been used broadly since around 2015. Other coding systems for nature of injury, industry and occupation are jurisdictionally specific and subject to change over time. And coding practices may or may not be consistent within or between jurisdictions over time.

Workers’ compensation systems rely on a medical diagnosis of the injury, then determine the "work-relatedness" of that injury before considering the extent and duration of any compensation. Changing definitions can play a role in the process and what is reflected in statistical data. Here is one example.

Post-Traumatic Stress Disorder (PTSD) is a recent term, but the condition this term describes has been around for centuries. While "shell shock", "battle fatigue", traumatic neurosis or hysteria were used in the military context in the 19th and first half of the 20th century, when the DSM was first published in 1952, it did not contain references to these terms or PTSD; that changed in 1980.

The original DSM-III (1980) description focused on external traumatic events, emphasized etiology, and had narrow exposure criteria. The DSM-5 (2013) changes broadened the exposure criteria and expanded symptom clusters. The changes reflect a growing understanding of PTSD.

I started working in vocational rehabilitation in the workers' compensation context in 1980. It was clear to psychologists I worked with that some of the workers we encountered were suffering from PTSD. I also recall that acceptance of claims for PTSD took effort and depended, in large part, on just getting the worker assessed by a qualified professional. Few cases were considered, fewer were accepted.

To be clear,  certain psychological disorders as sequelae to physical injury are accepted by workers' compensation systems in the US, Australia, and Canada because of a clear nexus between the direct physical traumatic and the mental injury. The recognition of a disabling condition in the absence of physical trauma is more recent.

The point here is that changing definitions may account for more cases considered and recorded as mental injuries. More practitioners recognize the harm, more legislation addresses the issue, more administrative systems record the data in the mental injury category either as a primary, secondary, or other diagnosis.

How common is PTSD?

Increases in mental injury statistics are not necessarily reflective of a worsening work environment. Definitions and criteria for PTSD have changed over time. Reduced stigma and increased awareness contribute to more cases being considered and identified. Better legislation, policy and practices will also contribute to the increase. That begs the question, will the level of PTSD and other mental injuries level off? If we are recognizing, adjudicating, and recording cases optimally, the levels will more closely reflect actual prevalence.

While most people will not develop PTSD as currently defined, the prevalence may be greater than you might expect. According to the US National Center for PTSD, about six out of every one hundred people (or 6% of the U.S. population) will have PTSD at some point in their lives—8% of women and 4% of men. [see “How Common Is PTSD in Adults?” at  https://www.ptsd.va.gov/understand/common/common_adults.asp ]. 

Of course, these data do not differentiate causes (for workers’ compensation) or numbers within the working population (for disability insurance, social insurance plans). With treatment, symptoms typically subside below the diagnostic threshold.

Exclusions and Presumptions

Disability insurance policies may exclude certain conditions or risks. Pre-existing conditions may preclude coverage of disabilities related to mental illness or disorder. Workers’ compensation systems may also have specific exclusions and presumptions.

Workers’ compensation legislation sets the parameters for the acceptance of mental injuries. Many laws have specific exclusions that further hinder direct inter-jurisdictional comparisons. For example, the Workers Compensation Act in British Columbia has an "employment exclusion" (section 135(1)(c)) that accepts mental disorders as compensable only if: "the mental disorder is not caused by a decision of the worker's employer relating to the worker's employment, including a decision to change the work to be performed or the working conditions, to discipline the worker or to terminate the worker's employment." While variations of the employment exclusion are common, other statutes include "presumptive" clauses that may be applied very narrowly or quite broadly. In 2018, Nova Scotia included a presumption for frontline and emergency response workers diagnosed with PTSD. The presumptive cause makes it easier for these workers because the condition is presumed to be work-related. [see PTSD Presumption for Frontline or Emergency Response Workers - Government of Nova Scotia, Canada]

Queensland's Workers' Compensation and Rehabilitation Act 2003 now includes Subdivision 3BA PTSD sustained by first responders and other particular persons and extends presumptive work causation to those whose "employment requires the person to experience repeated or extreme exposure to the graphic details of traumatic incidents by— (i) attending the scenes of traumatic incidents; (ii) experiencing traumatic incidents as they happen to other persons; (iii) investigating, reviewing or assessing traumatic incidents that have happened to other persons." Presumptive clauses remove the need for the worker to prove work-relatedness or the decision-maker to make complex and difficult inquiries into individual cases to determine causation. Most presumptive clauses are rebuttable if there is sufficient weight of evidence to the contrary.

Presumptions may increase claims filing, and exclusions may increase denial rates and suppress filing claims. These factors will vary by jurisdiction and within jurisdictions over time, making comparisons between jurisdictions or over time within a jurisdiction more difficult. The exact provisions for presumptions and exclusions can only be determined by workers’ compensation  authorities. It is no surprise that disability insurers often require their claimants to file workers’ compensation claims.

Varying onus and standards of proof

The onus of proof refers to the responsibility of presenting evidence to support a claim. Who bears that onus varies, and that can impact claim-filing behavior. It is common to encounter injured workers for whom the perceived obstacles to filing a claim result in their declining to even report serious physical or mental injury.

Inquiry-based jurisdictions, such as those in Canada and some US states, often place the onus on the adjudicator or the workers' compensation board. This approach recognizes the inherent imbalance of power between the claimant and the employer or insurer, and it aims to ensure a fair and comprehensive investigation of the claim. For instance, in Ontario, Canada, the Workplace Safety and Insurance Board (WSIB) has a statutory obligation to investigate and make decisions based on the merits and natural justice. The adjudicator is responsible for gathering relevant evidence, seeking expert opinions, and deciding based on the evidence presented.

In contrast, in more adversarial jurisdictions, the onus rests on the claimant. This is the case in many jurisdictions in the United States, where the claimant must provide substantial evidence to support their claim for mental injury. For example, in California, the claimant must prove that the mental injury was predominantly caused by actual events of employment, rather than by non-industrial factors.

The variability in reported incidence of mental disorders in workers' compensation may be due in part to variations in the standards of proof. The standard of proof refers to the level of certainty required to establish a particular fact or claim. Different jurisdictions may employ different standards of proof for mental injury claims.

The "causative significance" standard is used in some Canadian jurisdictions. Under this standard, if the work-related factors were a significant cause of the mental injury, even if other non-work-related factors also contributed, the claim is accepted.

The "balance of probabilities" standard is commonly used in many jurisdictions, including some states in the United States and some provinces in Canada. By this standard, the claim is accepted if it is more likely than not that work-related factors caused the mental disability.

The "predominant cause" standard is more stringent (for example,  New South Wales, Australia). Under this standard,  the claim is accepted if work-related factors are the primary or predominant cause of the mental injury, outweighing all other non-work-related factors combined.

More stringent onus and standards of proof factors may discourage claims rather than increase denial rates, which are rarely published by injury category. In any comparative analysis, understanding these factors is critical.

Limitations on Compensation and Disability Insurance

Mental injuries may take a long time to develop, diagnose, adjudicate, treat, and compensate. That passage of time, the complications of filing, effort in seeking claim acceptance on top of recovering from the mental disorder make it challenging. More than one worker has said, “Claiming is not worth the pain.”  This “hassle” factor is an inherent limitation in the process and leads to fewer claims being filed and more being abandoned.

As for the issue of permanent disability compensation for mental injuries, the application of proportional causation, particularly as used in California, is noteworthy. In California, if a mental injury is found to be compensable, but it is determined that both work-related and non-work-related factors contributed to the injury, the disability compensation may be proportionally allocated based on the degree of each factor's contribution. On one hand, this approach acknowledges the complex nature of mental injuries and ensures that claimants receive appropriate compensation based on the factors involved in causing their condition. On the other hand, apportioning causation is difficult, arbitrary, and counter to the no-fault principle fundamental to workers’ compensation.

Again, the process of obtaining the information needed to determine causation is intrusive and may discourage initial applications or increase abandonment of efforts to complete a claim.

In both the workers’ compensation and disability insurance domains, limitations may include certain age and duration restrictions for some or all benefits including those involving mental injury or disability. Common LTD benefits for mental illness last only 12 to 24 months. Integration with social insurance plans or other coordination of benefits may limit compensation and benefits. These limitations vary by jurisdiction and may alter the incentives and disincentives for claim filing.

Understanding the limitations and any change in legislation or policy that limits access or the amount of compensation is important to understanding the apparent mental injury claim rate.

Societal and Environmental Factors Play a Role

As noted in the attitudes and stigma sections, the societal environment is critical to understanding trends in work-related mental injury data. Here are a few other factors to consider.

Diagnosis and treatment of mental disorders are complex and complicated by the barriers that may exist in accessing mental health care professionals. Many jurisdictions have a shortage of qualified psychologists and psychiatrists—professionals often required to make the diagnosis that initiates a claim. Some jurisdictions are broadening the scope of practice of related professions to broaden access to treatment, typically under the direction of a supervising senior professional.

If the societal or operational expectation is for a manager to be available 24/7 or a factory worker to work 9-9-6 (nine AM to nine PM six days per week)—even if that is counter to official labor laws—workers may feel compelled to comply just to retain employment or secure advancement. Certain professions have a culture of just forging ahead despite knowing the health risks. These factors can impact the apparent data on mental injury claims and contribute to increased incidence of mental injury.

As with culture, attitudes, and stigma, other societal factors inherently influence the mental injury data. Although inter-jurisdictional comparisons can adjust for industrial mix and demographic factors, contextual social factors cannot be ignored.

What about Prevention?

While the focus of the statistics in this discussion is on injuries, fatalities through suicide are a terrible but real consequence of mental injuries. Primary and secondary prevention must be considered.

There are some obvious primary prevention initiatives that can reduce the incidence of work-related mental injuries. We may not be able to eliminate the inherent pressures in the unpredictable events in a first-responder's job, but controlling exposures to predictable stressors such as overwork is possible.

Building resilience and reducing the stigma associated with mental injuries takes some effort. BC First Responders' Mental Health conferences and workshops and Australia's Mates in Construction are examples of such efforts.

As noted, access to diagnosis and treatment is challenging. Certain interventions such as cognitive-behavioral therapy (CBT) have good evidence of effectiveness but are costly with limited professionals providing treatment. Expanding and expediting access to these resources may well reduce the number of disabling mental injuries and the duration of claims. Supports in the workplace for return-to-work are critical to this and may prevent worsening symptoms and outcomes. Effective vocational rehabilitation is also important where occupational change is necessary to achieving a safe, durable return to work.

Where Will the Trend Go from Here?

The research evidence has firmly established the work-relatedness of many mental injuries. More research is needed, particularly around risk factors, early interventions, and treatments. That research may impact the human and financial costs of work-related mental injuries.

Workers’ compensation jurisdictions are more accepting now of claims of mental injuries than twenty years ago. Workers' compensation jurisdictions and their appellate levels will continue to develop their laws, policies, and jurisprudence to recognize mental injuries. Those trends will also have consequences.

Recognition will logically lead to increased claims. Raising awareness will lead more individuals and their health-care professionals to make the link between work, injury, and disability. Destigmatization of mental injuries more generally in society will also contribute to increased workers' compensation claims. The scarcity of treatment options and the cost of treatments could contribute to increased claims; however, many workers have told me that the added stress of pursuing a workers' compensation claim is a huge disincentive to establishing a mental injury claim.

Despite the inherent barriers and “hassle factor” in filing a workers’ compensation claim, the growing recognition of the work-relatedness of many mental injuries may continue to drive disability insurers require filing of workers’ compensation claims as a condition of STD or LTD coverage wherever work be a factor.

For jurisdictions well along in the acceptance of work-related mental injuries, the trend lines may level off or decline. Mental injury from overwork, bullying, and harassment are amenable to prevention strategies, although awareness building may increase claims initially.

For jurisdictions early in this evolution, you are likely to see rising claims for a time before the proportion of work-related mental injuries stabilizes.

All jurisdictions should consider increased research investments. As with other work hazards, we know primary and secondary prevention can be effective, but knowing which interventions have the greatest benefit takes effort. Operationally, improved access to diagnostics and treatment is critical, particularly in reducing the severity and duration of disability arising from mental injury. Achieving that may involve greater inter-jurisdictional cooperation and investment in programs to develop and train more professionals and technologies.

The reality of work-related mental injury has never changed. Recognition of that reality is changing. Hopefully, the prevention, diagnosis, treatment, and rehabilitation can improve to address the real needs of the people and communities beyond the trend lines.