None of us have gone untouched by the COVID-19 pandemic. This is especially true for frontline workers who care for the critically ill. So, in part three of our series on mental health’s impact on workers’ comp, we’re going to look at the psychosocial effects the pandemic continues to play on our society and how post-traumatic stress disorder (PTSD) has become a term used more often in our industry. Joining me today are our experts, Nikki Wilson, Tammy Bradly, and Mariellen Blue.
Tom Kerr (TK): So, Mariellen, to start us off, how has COVID impacted societal views on mental health?
Mariellen Blue (MB): Tom, there’s an old English proverb that says, “There is no great loss without some small gain.” And, from my perspective, if there are positives that have come out of the COVID‑19 pandemic, I believe one is most certainly an increased awareness of mental health issues in our society.
Really, particularly in terms of how changes in everyday routines that we take for granted such as going to work, going to school, socializing, even being able to hug our family and friends, have impacted our psychological well‑being.
According to the World Health Organization, the COVID‑19 pandemic has induced a considerable degree of fear, worry, and concern in the population at large and particularly among certain groups such as older adults, health care providers, and people with underlying health conditions. And measures such as quarantine that have impacted so many people’s ability to perform their usual activities, routines, or livelihoods can really result in higher levels of loneliness, depression, harmful alcohol and drug use, and even self‑harm and suicidal behavior.
The Centers for Disease Control has also addressed the impact of COVID‑19 pandemic on mental health in our society, saying that while public health actions such as social distancing are necessary to reduce the spread of COVID‑19, they can also make us feel isolated and lonely and it can increase stress and anxiety.
There was also an interesting survey conducted by the U.S. Census Bureau in December 2020. The intent was to evaluate the impact of COVID‑19 on mental stress. And researchers found that more than 42 percent of people surveyed reported symptoms of anxiety or depression, which was an increase from only 11 percent for the same survey the previous year which was pre‑pandemic.
So that shows COVID‑19 alone has really increased the amount of anxiety, depression, other mental health concerns, in just the everyday population. It’s important to remember, I feel, that we’re all at risk of mental health issues during our lifetimes, whether because of a physical injury, illness, adversity or, even now, a pandemic.
But I really feel that the psychological impact of COVID‑19 that many of us have experienced over the past year has also shed new light and understanding on the potential psychological impact workers’ compensation injuries can have on an individual. And, in turn, hopefully, this will open the door for earlier identification and intervention for those at risk.
TK: And, Tammy, can dig a little deeper into how COVID has brought more attention to mental health factors in workers’ comp and the need for treatment?
Tammy Bradly (TB): I think so, Tom. I certainly know that employers are taking notice and doing more on a preventive front to offer support and access to mental health intervention. Also, from a comp perspective, you were seeing a lot of either proposed or enacted regulations from many different states across the U.S. because they are beginning to take notice of the needs to re‑examine some of their regulations around the content stability of mental health conditions, particularly around those people that they define as first responders.
Every state has a little different definition of how and who they would include in that group of first responders, and while I think it’s getting attention in the industry. I believe that there’s still a general concern of opening Pandora’s box and offering interventions pre‑claim, such as crisis intervention services, which really can help reduce an employer’s exposure to mental health claims, particularly in the case of PTSD.
But, for those injured employees that have a primary physical diagnosis, identifying that issue earlier is really going to be key to resolving it in a timely and efficient manner. And, I think as an industry, we too have to acknowledge that we may have attached a stigma to people having a mental health diagnosis, and all those misconceptions that we talked about earlier. And we have to work past that because ignoring the problem is not going to make it go away.
TK: Tammy, since you had mentioned PTSD, let’s talk about that. Post-traumatic stress disorder is often a term people associate with those who have experienced the distressing events such as war, violent attack, those types of things. So, what does PTSD mean in workers’ comp cases?
TB: Yeah, you know, Tom, that’s very true. Would you believe that 90 percent of the U.S. population will likely be exposed to one or more traumatic events during their lifetime?
Historically, you’re right. PTSD was first identified in World War I and since then the study of PTSD, the treatment of PTSD, has certainly progressed. But, over time, we’ve come to see that you don’t have to be a soldier to experience PTSD. We are seeing that in our first responders. PTSD for police officers is estimated to be between 6 and 8 percent; even ambulance personnel is as high as 20 percent — people that have everyday jobs exposed to traumatic events, day after day after day.
As we get into the discussion of how this relates to work, two million American workers have reported being victims of workplace violence each year. Unfortunately, there are many more cases that probably go unreported. Research has identified that there are certain factors around work that may increase the risk of violence. For some workers and certain worksites, things like people who exchange money, work in the public, they may be working with volatile, unstable individuals. People that work alone or in isolated areas may also be at a higher potential for violent acts. Providing services and care and working around alcohol can also increase the likelihood of violence. Additionally, the time of day you work and the location that you work such as late‑night shifts, working in high crime areas, these are also risk factors.
And, if you think about the world of work, we have a lot of people that are going to fall into these types of categories. And, as a result of the pandemic, we’re seeing not just the traditional first responders — the police, the fire personnel, the EMT — but now, we’re seeing hospital workers, doctors, nurses, support personnel, and even long‑term care facility workers who have, day after day, been exposed to death, fear of exposing themselves, as well as fear of taking home the virus to their loved ones.
And, when this keeps going on day after day after day — also exacerbated by the fact many of these people are working long hours under really tough conditions — all of this is going to increase their likelihood of having stress, anxiety, and potentially even developing into PTSD, if not addressed.
TK: And how does PTSD present itself in workers’ comp cases?
TB: Prior to the pandemic, typically when we saw PTSD, it was really with those people who have typically either witnessed workplace violence, or a catastrophic injury where they saw a coworker that was catastrophically hurt or they themselves perhaps were catastrophically injured.
Certainly, you can have a physical injury and develop PTSD as well. But, as I said earlier, since COVID, PTSD is now showing up in hospital workers and these long‑term care facility workers as well. Any prolonged exposure to an ongoing adverse event, like these people have been experiencing now for a year‑plus, can certainly expose them or predispose them to PTSD.
Again, whether or not these cases are actually compensable, it’s obviously going to vary based upon jurisdiction or regulations because every jurisdiction looks at PTSD and mental health from a slightly different perspective. PTSD does start with exposure to a critical incident. Symptoms must last for 30 days or more and really must disrupt that person’s normal life pursuits.
Traumatic stress is our normal response to a traumatic event. And, if we leave it unattended, it can develop into what we call a psychological crisis, which can disrupt our psychological balance and our ability to cope with the situation.
TK: So then, how is PTSD being addressed in workers’ comp?
TB: Again, looking at it from a pre‑client perspective, you have many employers out there that are really taking a proactive approach to really addressing the problem today. They are engaging experts trained in what we call critical incident stress management or CISM, to intervene with their employees early and to provide these employees with an opportunity to — the technical term is debrief — but really, it’s as simple as talking openly with someone trained in critical incident stress management about the incident or the prolonged exposure that they may be having that is bringing on this traumatic stress.
The goal of crisis intervention really is to mitigate the impact of the trauma and to help accelerate that recovery for that individual. And we do this by providing education around stress and stress reactions. We have to reassure them that they’re going to recover from this. We have to give them education around the signs and symptoms that they can expect to see and ensure them that these things aren’t necessarily abnormal, and we help provide them with coping skills and what we call emotional venting because individuals do need the support.
Also, as a part of this process, we will be able to really identify individuals that may not be dealing with the incident well and make recommendations for referral for additional professional care, if needed.
So, this is a great opportunity again to intervene early. And if there is an issue that doesn’t look like it’s going to be resolved through some brief interactions, we can get them referred over to the professional care that they need to help us stabilize that individual, reduce their symptoms, and really help them function.
We’ve talked about the pandemic, crisis intervention or critical incident stress management is now being used for frontline workers, not just those first responders and EMT, but now we’re seeing it being used in hospitals and in these long‑term care facilities for the workers. Many hospitals are putting critical incident stress programs in place for their workers. Some training used internal resources. Some used external experts or even volunteers from the community.
I know on our crisis response team, we have one crisis response specialist who volunteers providing critical incident stress management to hospitals in her area. She meets with doctors, nurses, as well as all of the support staff — anyone who is needing to talk about their concerns. These individuals are experiencing a lot of stress and anxiety. Again, long work hours combined with the daily exposure to those critically ill patients, people dying and, again, that fear of exposure to themselves or even their loved ones.
So, I have to commend her for her volunteerism and as well as the hospitals for recognizing that they do need to offer this type of support, for their employees because, if left unattended, it could potentially develop into PTSD.
Another quick example is with nursing home workers. Many of their patients are there for a significant period of time. So, they develop relationships. So, if they see these people becoming ill and potentially dying, they, too, are experiencing a great deal of stress. And I know that we have done a good bit of telephonic debriefing and crisis intervention with these types of facilities, again, because they want to be there and support their employees in this critical time.
TK: Great information on those interventions, Tammy. Thank you. Nikki, what about pharmaceutical interventions? What types of medications are being used to treat PTSD in workers’ comp?
Nikki Wilson (NW): Yeah, so in addition to a lot of the things that Tammy talked about, just another lever you can pull, if we will, on the pharmaceutical side is to add a medication. We have really good evidence, fortunately, for which drugs that are out there that can be of benefit in a condition like PTSD.
And, in fact, we’ve got some workers’ comp specific guidelines support through the Official Disability Guidelines, or ODG, that point us to which drugs are first‑line. And generally, the first‑line drugs for this indication are antidepressants, particularly the SSRIs like sertraline, paroxetine, fluoxetine, and an SNRI drug that’s known as venlafaxine. Those drugs have really good evidence. The trial that should be started in a patient is recommended to be at least 12 weeks long before we switch the therapy. So, it’s not as straightforward. Again, it requires some individualization to find which drugs work the best. But they do really show some benefit in this condition.
And I think of note, too, is that people who have PTSD, as Tammy was describing, typically will also suffer from additional indications like depression or anxiety, etc. So those antidepressants could be having a dual benefit or sometimes triune benefit for that patient. So, they really are good ones to try.
Interestingly, I have to mention this because it’s just fascinating and there’s been some great research in the investigational drugs area, specifically with regard to PTSD, psychedelics have really started to come under some investigational study for mental health disorders in general. So, things that typically in the past have been used for their hallucinogenic effects or their euphoric effects recreationally — like ketamine, LSDs, psilocybin, which is the active compound in magic mushrooms — all of them are now being studied for things like anxiety, depression, even addiction.
And MDMA is one that is on the horizon. It’s basically the component that’s in Ecstasy or Molly, which are street drugs, of course, used for their euphoric and bliss‑inducing effects. But research‑grade MDMA is being looked at now in humans to treat PTSD. It works very much similar to the way that the antidepressants I just mentioned work. It promotes the release of those feel‑good chemicals in the body like serotonin, dopamine, norepinephrine. It elevates serum oxytocin, which is a natural hormone released in mothers and things like that that promotes that certain bonding feeling or that feeling of well‑being.
So, some of the things that they’re finding from that research is that MDMA in human patients they’re testing will result in decreased hypervigilance and anxiety, increased relaxation, enhanced mood. So much so, in fact, that the FDA has designated MDMA‑assisted therapy for PTSD as a breakthrough therapy. What that means is that they’ve given it a special designation so that it will expedite the developmental review of those drugs. They consider it to demonstrate substantial improvement over available therapy or potentially substantial improvement.
So right now, those drugs are undergoing Phase III clinical trials, which is the last step before being approved or denied by the FDA. So, it’s just really interesting. One of the potential benefits they’re finding there is that MDMA is only administered a few times unlike most mental health meds, which I mentioned take daily long‑term use in order to find their effects.
So, it has some potential. We’ll have to see what happens with that. We’ll learn more, I think, in the coming years. I think in general, though, pharmaceuticals are, again, one of the levers you can pull when it comes to treating PTSD. It’s important to approach any mental health disorder for optimal treatment consisting of a combination of psychotherapy along with medications. We can’t just apply drugs in a vacuum. In fact, they can enhance some of the things that Tammy had discussed to try to promote recovery in order to achieve our best outcomes.
TK: And when we speak of anxiety and COVID, I'd be remiss to not address concerns that some employees may have regarding the vaccines. There seems to be reluctance based on fears of uncertainty regarding their effectiveness and possible side effects. How do you think this will impact the workplace going forward?
NW: Yeah, this is such a hot topic. I cannot tell you how often in the past few months I have talked to friends, coworkers and family and they’ve all had questions about this. And certainly, in my age group -- I would consider myself still fairly young ‑‑ I think what we’re seeing that. I have to address first that there’s just been substantial misinformation circulated via social media where, I know for myself and a lot of my peers, it’s a primary news source these days.
So, there’s just a lot of misinformation circulating wrongly claiming that the use of the vaccine will alter a person’s DNA or that it’s not safe because it’s never been tested before. There are even things out there erroneously reporting the vaccine includes fetal tissue or there’s microchips in it that Bill Gates is using to track all of us [laughs]. There’s just a lot out there that needs to be addressed on top of the general fears that anybody might have with a new medication or a vaccine in general.
One argument that I’ve seen quite often involves the “recovery rate” argument. Proponents of this idea believe that if you’re healthy, you probably won’t suffer much from the disease itself and ask, “is it really worth getting the vaccine?” And I think what we need to look at is what is the efficacy rate? What is the safety rate, and what is the trade‑off from not getting the vaccine?
So, let’s say you’re concerned about taking time off of work to go get vaccinated. You’re concerned about lost time due to any side effects that might occur once the vaccine is administered. So, the good news is there aren’t a lot of side effects that have been uncovered. The most common is an injection‑site reaction. So, your arm’s generally sore for a few days and it might be a little bit painful, red. That is pretty typical of any vaccine as many of us know.
The thing that we are seeing sometimes, however, is some people feel pretty crummy after getting their first or second dose. Some have had to take off work, which is a reality. And it’s something to prepare for, but what I often tell people is that lost time is maybe a day … 72 hours at most.
But, if you contract the illness, you’re looking at an unknown amount of time that could knock you out for weeks, months. We also don’t know the long‑term negative health effects or consequences of contracting COVID. There’s a lot that we’re still learning. So, in my mind, it makes perfect sense to do everything we can to prevent beyond the general steps that a vaccine is a good tool in that fight.
So, just to address some of the things that I’ve been hearing and discussing with many that we’ve had this discussion with is the vaccines that are out there today, we’ve got the two that are messenger RNA vaccines or mRNA vaccines, those by Pfizer and Moderna, The two‑dose shots and really how those work. It’s so important to understand how they work to put any fears to bed. They get into the body and basically give instructions to our bodies on how to make the protein that’s present on the surface of the coronavirus. Then, our immune system basically practices recognizing that and producing antibodies against that protein. That’s all it is. It’s just a set of instructions.
And the efficacy is fantastic, so far. I mean, we don’t get this kind of results with most of the vaccines that are out there. The overall efficacy of both of those vaccines is over 90 percent, which is phenomenal. And, of course, we’re still gathering data, but that’s what we know today.
And they’re starting to put out the research and efficacy against the variants that we’re hearing so much about today. So, all that information is out there, if you’re interested and want to go look, look for a reliable source that can point to that.
It is true there have never been any mRNA vaccines before that have been approved before now, but there have been multiple studies over the last several years that have looked at this particular technology, and its potential place in treatment of multiple diseases. There are rigorous safety approval processes required before any drug is recommended for widespread use, and this one is no different. The vaccines did receive fast‑track approval through the FDA, but I think it’s important to understand what was fast‑tracked and what wasn’t. It’s really just a process designed to speed up the development and expedite review of those drugs that treat some serious condition. And so, in this case, the regulatory side, the paperwork housekeeping approval process, looking at the data analysis, the FDA review process, was all fast‑tracked.
What wasn’t fast-tracked is the clinical trial stuff — so the enrollment of patients, monitoring for side effects, the clinical setup, and the follow‑up. It went through tens of thousands of people getting tested around the world and gathering information along the way, and any adverse reactions and safety events continue to be monitored after approval.
So, I think just educating on what’s out there, the cost‑benefit of taking this type of treatment, how we can just really give ourselves a leg up on how to prevent long‑term follow‑up and adverse outcomes from COVID. These are important things to know. And I think making sure you have a really good source, talking to your health care provider, and doing your own research is important.
TK: Another round of great information from our subject matter experts. Thank you, all. In the fourth and final podcast of our series, we'll talk about best practices and new approaches to treating mental health and workers’ comp. It's one, you surely won't want to miss. Until then, take a more in-depth look at mental health and workers comp, by checking out the eBook, Strategies for Combating Mental Health Challenges in Injured Employees. Thanks for listening.