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DSM-5 won’t increase mental health work claims – here’s why

The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) has copped the predicted criticisms since its release on the weekend. Most centre on the idea that more of us will…

The majority of diagnoses for depression, anxiety and PTSD are made by GPs who don’t use the DSM criteria.

The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) has copped the predicted criticisms since its release on the weekend. Most centre on the idea that more of us will be diagnosed with mental disorders, as the diagnostic thresholds are lowered.

Critics have also argued these thresholds will lead to an increase in claims for work-related disability or compensation, allowing more people to take extended sick leave. These claims could range from short periods of psychological distress or “not coping”, to serious and impairing illnesses such as recurrent depression or psychosis. Many systems provide income during this time off work, through tax payer-funded or organisational or personal insurance compensation.

However the DSM-5 is unlikely to increase such claims. Diagnostic thresholds for some mental disorders may be marginally lower in the new manual, but clinicians rarely rigorously apply the diagnostic criteria.

What’s changing under the DSM-5?

The DSM-5 includes small changes to the diagnosis of schizophrenia and bipolar disorder. These will have no significant effect on the workforce, as these conditions are rarely claimed to be caused by work in any compensation system.

The changes that may have significant effects on the working population are in depression and anxiety disorders, including post-traumatic stress disorder (PTSD). Contrary to popular belief, the majority of people with these disorders are employed.

The new manual includes a diagnosis for prolonged grief (depressive symptoms related to bereavement) and has a lowered threshold for PTSD. To be diagnosed with PTSD one no longer has to have experienced “fear, helplessness or horror… right after the traumatic event”. There are also some minor changes around symptom profiles – reckless or self-destructive behaviour, for instance, is now a symptom of PTSD.

How are work-related illnesses diagnosed?

The vast majority of diagnoses and treatment plans for depression, anxiety and PTSD are made by general practitioners who don’t use the DSM-5 criteria.

If anything, GPs use the World Health Organisation’s International Classification of Diseases criteria for primary care, or more commonly, rely on individuals scoring highly on the K10, which measures depressive and anxious symptoms. This measure is mandated as part of accessing a range of treatments, most notably Medicare-funded psychotherapy under the Better Access Scheme.

The psychologists they are referred to most often use another measure, the Depression Anxiety Stress Scales (DASS), to determine symptom severity.

Perhaps the most common diagnosis given to people seeking worker’s compensation for mental illness is an “adjustment disorder.” This diagnosis is incredibly easy to make, requiring an unspecified number of symptoms “such as anxiety, depression, worry, tensions and anger” which must merely be “more severe than expected” – although who decides this is moot. The DSM-5 equivalent is “mixed anxiety-depressive disorder” and is just as easy to diagnose.

More importantly, a review of WorkCover certificates shows doctors are most likely to use labels such as “stress”, “anxiety”, “burnout”, “bullying and harassment”, none of which are diagnoses. The DSM-5 will do nothing to change these labels or whether a doctor thinks a condition is or isn’t work related.

Rise in disability

For an increasing number of people, the end point of sick leave is a move onto longer-term government disability pensions. Access to these systems is generally the purview of doctors who have to determine whether the person meets a number of eligibility criteria: severity of illness, likelihood of returning to work, and so on.

Every country in the OECD has seen a gradual rise in the proportion of disability support payments attributable to mental illness, not because of any diagnostic changes but through changing patterns of work and who is working (fewer physical jobs, more women and older workers), lower levels of back pain claims (which many suggested were really “stress”), and greater recognition of depression by clinicians compared to a few decades ago.

The greatest determinants of the total numbers of disability claims are likely to be social and financial, which “push” people out of the workforce and “pull” them into benefits.

In the mid-1980s when then-UK prime minister Maggie Thatcher noted that disabled people received lower benefits than the unemployed, her right-wing government engineered a reversal of this. At the time, the UK had just over one million citizens on disability benefits and just over three million unemployed.

Following the payment changes there was a rapid rise to a peak of 2.8 million people claiming disability benefits in 2003-4 and 1.4 million unemployed; the same number of people were out of work but they were called something different and paid more. Australia had a similar change a few years later: people were “pulled” into benefits.

The likelihood that a disabled person would be unemployed compared to a healthy person has also been increasing, “pushing” disabled people out of the workforce. This “disability penalty” is highest for those with mental disorders and the trend towards short-term contracting and precarious employment has worsened this.

Last year, eligibility for disability support pensions for mental illness, which costs the Australian government some A$3.8 billion a year was changed to a new threshold. This is based on the presence of both a diagnosis, but more importantly, upon a certain percentage of whole body impairment through the use of the Psychiatric Impairment Rating Scale.

The only publicly available testing of these new scales, which impact hundreds of thousands of people, suggest that “41% of formerly eligible applicants became ineligible”. For people with psychiatric impairment there was “a comparatively high rate of downward movements” – in other words, even fewer people were eligible.

In terms of how we should weight our concerns about changes to workplace disability eligibility and claims, the actions of lawmakers and policy administrators in Australia have a far greater influence than a small group of psychiatrists across the Pacific who produced the DSM-5.

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18 Comments sorted by

  1. John Quintner

    logged in via email @bigpond.net.au

    It seems to me strange that psychiatric/psychological conditions can be rated for compensation purposes as being "impairments" through the use of a rating scale that is based on a purportedly objective assessment of "disability" whereas "chronic pain" has been deliberately excluded from assessment on the grounds that it is not an impairment. Would you care to comment on this use of "impairment" as a surrogate marker for "disability" but only in cases where there are diagnosable psychiatric/psychological conditions? Why do doctors go along with this blatant discrimination against those injured workers who experience chronic pain of disabling severity?

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    1. Henry Franceschi

      Director, NCD Treatment Centers

      In reply to John Quintner

      You raise a lot of the technical issues that have made the DSM-5 so controversial.

      • First, workers comp disability cases are not the same as clinical cases. The former are legal cases and they use actuarial instruments, developed by workers comp experts based on thousands of disability cases. Clinical cases are rarely legal cases that go to Court. The workers comp “rating scales” are similar to those used for insurance; they’re actuarial evaluations. That’s why a workers comp disability case…

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    2. John Quintner

      logged in via email @bigpond.net.au

      In reply to Henry Franceschi

      @ Henry. Two points:

      1) Please convince me of the objectivity you claim for 307.89 (“Pain disorder associated both with psychological factors and a general medical condition).” Sounds very subjective to me. Smoke and mirrors, perhaps?

      2) As rating scales are in fact "actuarial evaluations," why not simply train up people such as used car salesmen to administer them? In these times of shortage of doctors such a system change would free up many medicos for work that they have been trained to do - i.e. administer to the needs of their patients. Yes, I know I am being cynical but, like you, I have worked within these systems for many years.

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    3. Henry Franceschi

      Director, NCD Treatment Centers

      In reply to John Quintner

      1) That a Court rules in your favor is the best testament there is to objectivity. No different than a referee rules that there's been no foul. A legal case gets a positive legal judgment, what else could you ask for? Unless your disability is no serious to you.
      2) Once you know the WC method of evaluating the reports flow even easier b/c they're so structured. What takes time is that you're writing for the Court not just another colleague. You really have to watch what you say b/c there's a plaintiff…

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    4. John Quintner

      logged in via email @bigpond.net.au

      In reply to Henry Franceschi

      @ Henry.

      1) I remain unconvinced of your claimed objectivity for 307.89. Have I missed the point?

      2) The skills of used car dealers appear to be the modern equivalent of those possessed by the slave traders of old, who were able from experience to accurately assess the value on the slave market of any person, whether disabled or otherwise! Anyone want to kick this around?

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    5. Henry Franceschi

      Director, NCD Treatment Centers

      In reply to John Quintner

      On 1) Sounds like it. Disability is a legal medical case; the approach I take is based on observable, measurable impairment of functions that the patient personally defines (the best evidence there is in Court), and if any detectable tissue damage exists in any organ, body part, or system and a specialist in that area testifies in support of that evidence, then that's the way medical cases are won in Court. If you don't like scoring goals, I pass on that and 2).

      Dr. A-F

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    6. John Quintner

      logged in via email @bigpond.net.au

      In reply to Henry Franceschi

      @ Henry. Yes, perhaps I have missed the point. It seems to me from what you say that we are talking about different games. You have chosen to play a game where the rules have been set by bureaucrats and lawyers (who believe in the illusion of "objectivity"), which to me seem a long way from those that govern the ethical practice of Medicine.

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    7. Henry Franceschi

      Director, NCD Treatment Centers

      In reply to John Quintner

      Peoples' chronic disabling pain that was caused while faithfully working or on duty for a company or a military unit is not a "game" to the families whose disabled member can't work, take part in normal family activities, pay the mortgage, pay to keep the kids in school, and then is refused the financial help to which they believe they are entitled. They have their right to their day in Court plus the best support possible for their disability claim. You go ahead and talk philosophy to people in these circumstances. I prefer to give them the best support possible for their disability claim so they and their families can go back to living as much of a normal life as possible. Sounds like you're not qualified to see patients so you give yourself the arrogance of thinking of them as invisible while you philosophize. I have practical things to do from here forward. May you never get disabled.

      Dr. A-F

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    8. John Quintner

      logged in via email @bigpond.net.au

      In reply to Henry Franceschi

      @ Henry. In Australia, most people who are in the situations you mention never get their day in Court! The WC systems here are designed to exclude them from receiving fair "impairment" assessments on the grounds that being in pain rates 0%.
      I will ignore your ad hominem attack as my qualifications to practice in Pain Medicine and Rheumatology are not relevant to this conversation. If you are in doubt, I suggest you search for me on PubMed etc.

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    9. Henry Franceschi

      Director, NCD Treatment Centers

      In reply to John Quintner

      I hate ad hominem when done to me, so I extend my apology.

      Then as a colleague let me encourage you to take a different more winner view towards disability cases and simply decide that you're going to let the system win.

      After I had done enough disability cases to pick up WC's strategy to wear people down so they'll walk away from a valid disability claim, it became clear to me that I had to above all - once I had teased out of the case it's absolute scientific strengths - that i had to become…

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    10. John Quintner

      logged in via email @bigpond.net.au

      In reply to Henry Franceschi

      @ Henry. I take my hat off to you. Of course you are correct - we (i.e. the medical profession in Australia) allowed it to happen - a move from a system that assessed "disability" to one that purported to assess/rate "impairment". I say purported because by sleight of hand, psychiatric/psychological conditions were badged as "impairments" but assessed on a scale that is clearly that of "disability". I would love to hear a response from Nick on these very issues.

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    11. Nick Glozier

      Professor of Psychological Medicine, BMRI & Disciplne of Psychiatry at University of Sydney

      In reply to John Quintner

      Thank you all for your comments. A one of the authors of the WHOs international classification of function - the ICF I agree with the impairment -activity limitation- participation boundary problems and and have seen different systems deal with them differently. However this is not just an issue in the psychiatric system - look through many other body systems and there repeated cases e.g. symptoms that cannot be substantiated e.g. tinnitus allowing an extra 5%, self reported urinary frequency determining…

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    12. John Quintner

      logged in via email @bigpond.net.au

      In reply to Nick Glozier

      Thanks for your response, Nick. You have reminded me that the "wheels fell off the Ferrari" about 15 years ago when scientific research on "whiplash-associated disorders" rendered his hypothesis obsolete.

      The question of mine that remains without a satisfactory answer is - why would you discriminate against people in pain by not awarding them an "impairment" rating above 0% when psychiatric/psychological conditions are rated on the PIRS (which is unashamedly a scale that rates level of function). Surely the same rating scale could equally apply to people disabled by their pain.

      In my view, WC systems in Australia are to some large extent hamstrung by thinking that might have been appropriate to the 19th century. Perhaps they have now reached their use-by date and could be dismantled and replaced by more equitable systems of income support. I know this is a pious hope!

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    13. Sue Ieraci

      Public hospital clinician

      In reply to Henry Franceschi

      Henry - I hope, for patients' sake, that you don't treat people with psychiatric illness.

      Firstly, most of the mood disorders appear to be linked to neurotransmitters. What would your approach be to patient incapacitated with severe depression, who is not amenable to CBT or exercise, and feels suicidal?

      Secondly, about medications: it is not uncommon in mood disorders and some psychotic illness to rationally use more than one medication - such as adding lithium for mood stabilisation in a complex psychotic illness.

      Thirdly, personality disorders are not "disorders of lifestyle, personal choices and behavior."

      It's easy to be smug in an area that you are able to avoid. I don't see why you would want to, though. Do you have outstanding results in workers comp assessment?

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  2. Eoin Killackey

    NHMRC Fellow; Associate Professor; Director of Psychological Research, Orygen Youth Health

    Good article Nick, puts the focus back on where the issues are and not on the smoke and mirrors minor distractions.

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  3. John Quintner

    logged in via email @bigpond.net.au

    @ Nick. By the way, before you respond to my question, I do have a supplementary one. What if doctors diagnosed their patients disabled by chronic pain using the category of "Somatic Symptom Disorder" (yes, I know it is a stupid DSM 5 category)? Would their patients then be eligible to undergo an "impairment" assessment under the PIRS?

    These may not be important issues to the bureaucrats who administer the WC systems but it does appear to me to be an important ethical issue for those of my medical colleagues whose livelihood depends upon their willingness to prop up these systems that reinforce outdated Cartesian substance dualistic thinking.

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  4. Dr Ben Mullings

    logged in via Twitter

    Great article. You refer to 'push' and 'pull' forces across this article, making mention of the Better Access to Mental Health Care initiative, which is arguably the largest program through which the public receives psychological treatment in Australia.

    I agree with you that the way we structure policies makes more a difference as to whether more or less patients (a) meet diagnostic inclusion criteria, and (b) receive the right type and amount of treatment for their needs. Coming back to the…

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  5. soula mantalvanos

    logged in via Twitter

    Hello Nick and everyone else commenting,
    Thanks for this conversation. Please forgive my bitterness.
    I wish the companies funding your review would call me too. Does anyone ever ask the injured worker?

    My views (injured worker with unidentifiable injury currently on $0 support)

    1. 'the end point of sick leave is a move onto longer-term government disability pensions'
    2. 'Every country in the OECD has seen a gradual rise in the proportion of disability support payments'

    If the system…

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