Best practice management of work-related psychological injuries

Interviewer:

Welcome to this educational webcast for Queensland general practitioners, proudly brought to you by the Office of Industrial Relations. This webcast will provide general practitioners with information as to the best practice management of patients presenting with workplace psychological injuries and will have a specific focus on post-traumatic stress disorder.

Interviewer:

Discussing and sharing their insights with me today is Doctor Andrew Khoo, consultant psychiatrist, member of the Medical Assessment Tribunal, and senior lecturer at the University of Queensland. Doctor Khoo has significant specialised experience in the diagnosis and management of post-traumatic stress disorder and other psychiatric conditions. Over the last five years, there has been a 12.5% increase in work-related psychological injury claims across the Queensland scheme. Based on Doctor Khoo's clinical experience, he can certainly echo this trend with respect to PTSD prevalence in Australia.

Interviewer:

Thank you, Doctor Khoo, for your time. To start things off speaking to the Queensland workers' compensation scheme, we know that GPs are central to promoting their patients' holistic recovery and play a major role in the management of psychological injury claims. How should GPs go about assessing and managing a patient with a work-related psychological injury claim?

Dr. Andrew Khoo:

Thanks very much for having me. Look, I think with the assessment and management of psychiatric disorders within general practice, there is no real mystery here. The really important points are, first of all, being able to engage the patient and then clinical history taken. The advantage for the GPs is that we know that they're the gatekeepers to general medical care, firstly. And secondarily, they often have these pre-existing relationships with patients which certainly makes it much easier to access information.

Dr. Andrew Khoo:

Now, in saying all that, it's easy for me to ask GPs to take better histories. But I realise that they're time-poor and this has practical implications. Therefore, it's really important for them to be aware that when looking at mental health problems, that there are quick self-administered or patient-administered tools that are available to them. They would all be aware of the K10, which assesses psychological distress. Another really good one that I would recommend is the DASS 21, which particularly assesses depression, anxiety, and stress.

Dr. Andrew Khoo:

One thing I would like to also really underline, that early diagnosis is key, which allows then, it's the gateway then, to early intervention. Part of early diagnosis, however, is then disseminating what your diagnosis is to what is eventually going to be the management or rehabilitation team. This requires, obviously, early completion of work capacity certificate, which informs WorkCover, or the WorkCover claims manager who is a, also, sorry, a central person in the management team. We have a management team from the beginning which involves, obviously, the GP who is core, then the WorkCover claims manager, the psychologist or psychiatrist that's in involved, and, obviously, any return to work coordinator.

Interviewer:

I think that's very important, Doctor Khoo. GPs need to recognise the support that's available to them in the management of a compensation claim and you've highlighted the key players in the process there. One thing I will mention to general practitioners is recently Monash University launched a clinical guideline for general practitioners specifically in relation to the diagnosis and management of all work-related mental health conditions in general practice. This guideline is available on the WorkSafe website, and I strongly encourage GPs to access that guideline either through the website or through their medical professional association. Doctor Khoo, can you tell us what are some of the important considerations in general practice management of workplace psychological injury?

Dr. Andrew Khoo:

Firstly, I'd like really underline the importance of early intervention, and that that intervention is guided by an evidence-based approach. For most mood and anxiety disorders, we are talking about from a very general point of view, we're talking about the prescription of an SSRI or other antidepressant and this happens around the core or the foundation stone of psychological management. Particularly, the greatest amount of evidence seems to be for cognitive behavioural therapy. However, there are other psychological sort of indices that we can use, as well, in terms of treatment. This, then, underlines the importance of early referral to a psychologist or a psychiatrist. I'll talk a little bit more about that in a second.

Dr. Andrew Khoo:

Aside from the biological or pharmacological management, as well as the really important psychological management that's used, we can't forget, also, about the importance of just lifestyle or general positive mental health behaviours that really tend to augment evidence-based treatment. These are things like regular exercise, maintaining a good diet and self-care, managing substances like alcohol and other drugs. Then the importance of an ongoing involvement in hobbies and activities.

Dr. Andrew Khoo:

We also want to really underline the contribution of maintaining function. By this I mean social function, so social connectedness to all the networks that you normally utilise. Domestic function, maintaining that as much as possible. Maintaining your academic function, if you have any of that. And certainly looking to or starting to plan towards, from the beginning, some kind of workplace rehabilitation or work function rehabilitation.

Dr. Andrew Khoo:

With regard to referral to psychological specialists, or specialists in psychological therapy, I just can't underline enough the importance of a therapeutic fit between the patient and their professional. Don't be afraid to prepare to refer someone to multiple people and try and find a fit that works best.

Dr. Andrew Khoo:

Also, the importance, I guess, of having your handful of therapists that you've used before for your patients that are very good in trying to maximise your access to them, as well. In saying that, I understand that sometimes waiting times are an issue. But really waiting for a good person is often better than trying multiple, less well known options.

Dr. Andrew Khoo:

I do, also, want to stress how vital it is to push towards functional rehabilitation. I mean, the outcome of somebody's mental health disorder in terms of treatment outcomes in the research is much more proportional to how they functionally improve more so than what they're outcome is from a compensation point of view. An individual needs a purposeful and meaningful role and this is way more important than the outcome of compensation.

Dr. Andrew Khoo:

What I'm trying to do is really separate out treatment from compensation. We really, I think, need to start having these discussions with patients early because we know that the evidence shows that ongoing compensation issues tend to worsen treatment outcomes. The corollary to this is even before a return to work can actually occur, the importance of goal-directed function is vital to the rehabilitating individual.

Dr. Andrew Khoo:

By this I mean regular exercise, planning for exercise, and achieving that daily planning and creating structure in one's day. And even before an actual graduated return to work occurs, the importance of getting out of the house and doing some voluntary work or hosting employment programs. Really from the beginning, the goal for the injured worker should be a return to or goal for optimal workplace functioning.

Interviewer:

Absolutely, Doctor Khoo. It's very important for GPs to embark on that journey with their patient from the very beginning, and to start to set goals, realistic goals, but with a clear focus on increasing functionality. Can you talk to us a little bit about the evidence-based treatment for PTSD, particularly given that is your specialty area, Doctor Khoo?

Dr. Andrew Khoo:

Okay, thanks. Look, obviously, firstly the evidence-based approach for the management of PTSD, just quickly, also involves making sure you get the diagnosis right and then intervening early, like for most medical and psychological conditions. The cornerstone for the management of PTSD revolves around psychological therapy at this point. The evidence for the efficacy of psychological therapy at this stage really considerably outweighs that of pharmaco therapy in this particular condition.

Dr. Andrew Khoo:

In terms of the psychotherapies, we are looking, at this stage, on what the literature says with trauma-focused cognitive behavioural therapy which involves modalities like prolonged exposure, EMDR, and cognitive processing therapy, as an example, as really the cornerstones of the psychological approach at this point.

Dr. Andrew Khoo:

However, I must stress that one size doesn't fit all and other people may need some other types of approaches. But what this underlines is, again, the need for early referral to a specialist who can provide these kind of therapies, either a clinical psychologist in most cases, or a psychiatrist that specialises in the area. These psych therapies can be delivered to an individual or on a group basis.

Dr. Andrew Khoo:

In terms of pharmacotherapy, we are looking at, in the first instance, an SSRI or antidepressant. Also, probably looking to manage things like sleep and associated depression, if we need to. Again, I need to stress the importance of positive mental health behaviours like exercise and, particularly within the PTSD space, there is growing evidence for things like meditation and particularly yoga has an evidence-base now.

Dr. Andrew Khoo:

We need to push socialization, because people with PTSD tend to avoid, and avoid everything. The more they avoid and the more isolated they become, and that's a one-way ticket to depression. It's really important that we push them out of the house and get them socialising and connected with their communities. Finally, like we've been saying before, functional recovery from the beginning is the goal, across all function. Particularly, in this case, goal-directed, purposeful activity, meaningful activity, and, in this case, that often means work-related activity.

Interviewer:

Thanks, Doctor Khoo. I'm actually quite interested in how you think a GP can manage that in a general practice setting, particularly around the fear avoidance of a patient with PTSD? You mentioned that we need to push this socialisation and this increased functionality. But for a GP, do you have any tips for them to overcome those challenges that a patient may bring to their rooms?

Dr. Andrew Khoo:

Okay, that's a good question. The first thing that I would say is that I don't expect GPs to be doing the psychological therapy. This is even specialised within specialists who provide these kind of therapies. They're not expected to know that. But what GPs still have is a really critical role in terms of maintaining their pre-existing relationship with the patient, or their current relationship with the patient, and encouraging the patient's involvement in psychological therapy and participating in any psychological therapy homework that they have. Certainly, this, again, underlines the importance of communication between psychological specialists, and the GP.

Interviewer:

Absolutely. And it's that coordinated approach that's required. Thanks, Doctor Khoo. In closing, are you able to give us a few key points for GPs to take away from today's webcast?

Dr. Andrew Khoo:

Okay, so, look, I've got three takeaway points. We've covered them but this is what I'm hoping that everyone can recall when they inevitably come across patients with these kind of psychological difficulties. The first is, again, the importance of rapport and engagement with the patient and maintaining that. Then early identification and intervention, very important.

Dr. Andrew Khoo:

Secondly, the early referral for psychological management and the incorporation of evidence-based treatment modalities. Finally, the vital cog of communication within the management team, remembering that GPs sit at the core of a management team that involves the psychological specialist, be that the clinical psych or the psychiatrist, the insurer's claim manager, the workplace itself, and the return to work coordinator.

Interviewer:

Fantastic. Three very important points for general practitioners. Once again, thank you very much, Doctor Khoo, for your time today. Thank you, everybody, for listening.

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