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Guideline Summary
Guideline Title
Mental illness & stress.
Bibliographic Source(s)
Work Loss Data Institute. Mental illness & stress. Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Work-related stress, major depressive disorder, post-traumatic stress disorder (PTSD), and other mental disorders

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Utilization Management
Guideline Objective(s)

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Target Population

Workers with occupational stress, major depressive disorder, and other mental disorders

Interventions and Practices Considered

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

  1. Acceptance and commitment therapy (ACT)
  2. Antidepressants, for treatment of:
    • Major depressive disorder (MDD)
    • Post-traumatic stress disorder (PTSD)
  3. Aromatherapy
  4. Causality (determination)
  5. Cognitive therapy for:
    • Depression
    • Panic disorder
    • Post-traumatic stress disorder (PTSD)
    • General stress
  6. Cognitive behavioral stress management (CBSM) to reduce injury and illness
  7. Computer-assisted cognitive therapy
  8. Depression screening
  9. Dialectical behavior therapy
  10. Disease management (programs)
  11. Distractive methods (to reduce acute stress)
  12. Duloxetine (Cymbalta®)
  13. Electroconvulsive therapy (ECT)
  14. Exercise
  15. Expatriate employee adjustment support
  16. Exposure therapy (ET)
  17. Eye movement desensitization and reprocessing (EMDR)
  18. Fish oil
  19. Group therapy
  20. Hospital length of stay
  21. Hypnosis
  22. Imagery rehearsal therapy (IRT) 
  23. Kava extract (for anxiety)
  24. Light therapy
  25. Major depressive disorder (mild, moderate, severe, and psychotic presentations)
    • Diagnosis
    • Initial treatment
  26. Mind/body interventions (for stress relief)
  27. Minnesota Multiphasic Personality Inventory (MMPI)
  28. Music (for relaxation/stress management)
  29. Office visits
  30. Opioid antagonists (especially naltrexone) for alcohol dependence
  31. Optimism (and its effect on schema-focused therapy)
  32. Patient education (to reduce stress related to illness)
  33. Peer support (for postpartum depression)
  34. Psychodynamic psychotherapy
  35. Psychological evaluations, intrathecal drug delivery systems (IDDS) and spinal cord stimulators (SCS)
  36. Psychosocial adjunctive methods (for PTSD)
  37. Psychotherapy for:
    • Major depressive disorder (MDD)
    • PTSD
  38. Return to work
  39. Selective serotonin reuptake inhibitors (SSRIs) for PTSD
  40. Spiritual support
  41. St. John's wort (for depression)
  42. Stress inoculation training
  43. Stress management, behavioral/cognitive and physical (interventions)
  44. Virtual reality (VR)
  45. Weaning of medications (antidepressants)
  46. Work/activity restrictions
  47. Yoga

The following interventions/procedures are under study and are not specifically recommended:

  1. Acupressure
  2. Acupuncture
  3. Antidepressants – selective serotonin reuptake inhibitors (SSRIs) versus tricyclics (TCAs)
  4. Brain wave synchronizers (for stress reduction)
  5. Depression, effect on:
    • Heart health
    • The gene factor
  6. Folate (for depressive disorders)
  7. Magneto-encephalography (MEG) for PTSD
  8. Psychosocial/pharmacological treatments (for deliberate self harm)
  9. Reiki
  10. SAMe (S-adenosylmethionine)
  11. Stress and:
    • Atherosclerosis (effect)
    • Blood pressure (effect)
    • Depression (effect)
    • Physiology/mental performance (effect)
    • Heart-related interventions
  12. Tension headaches (pharmaceuticals vs. behavioral therapy)
  13. Therapeutic touch (TT)
  14. Transcranial magnetic stimulation (TMS)
  15. Vitamin use (for stress reduction) including
    • Vitamin B6
    • Vitamin B12

The following intervention/procedure was considered, but is not recommended:

Psychological debriefing (for preventing post-traumatic stress disorder)

Major Outcomes Considered

Effectiveness of treatments in reducing stress and anxiety

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in the "Methodology Outline" and "Appendix A. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Ranking by Type of Evidence

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial - Randomized (RCT) or Controlled
  3. Cohort Study - Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review
  6. Nationally Recognized Treatment Guideline (from www.guideline.gov External Web Site Policy)
  7. State Treatment Guideline
  8. Other Treatment Guideline
  9. Textbook
  10. Conference Proceedings/Presentation Slides

Ranking by Quality within Type of Evidence

  1. High Quality
  2. Medium Quality
  3. Low Quality
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Recommendations

Major Recommendations

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of February 24, 2011. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the Work Loss Data Web site External Web Site Policy for the most current version available.

Refer to the original guideline document for the outline of treatment planning and introductory discussion of claims of mental illness within workers compensation.

Major Depressive Disorder

Major Depressive Disorder (MDD), Definition

The American Psychiatric Association's diagnostic manual (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision) defines Major Depressive Disorder (MDD) as a mental illness that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (some details that will help to provide an understanding of what this definition means are provided below). This mental illness is typically manifested in phases – the person is mentally ill for a period of time, and is then typically free from the symptoms of the mental illness for a period of time, but will probably develop additional episodes of symptoms in the future.

The "major depressive episodes" to which the above definition refers are the phases when the symptoms are present. These episodes are defined as: (1) a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities; (2) the individual also experiences at least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep disturbance, psychomotor agitation or psychomotor retardation, decreased energy, feelings of worthlessness or guilt, difficulty thinking/concentrating/making decisions, recurrent thoughts of death or suicidal ideation/plans/attempts; and (3) the symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks.

The portion of the definition which reads "without a history of Manic, Mixed, or Hypomanic Episodes" serves to separate Major Depressive Disorder (MDD) from the Bipolar and Cyclothymic Disorders.

Major Depressive Disorder (MDD), Diagnosis

The essential core of the diagnostic evaluation is the protocol provided in the American Psychiatric Association's diagnostic manual. The diagnostician should compare the claimant's presentation to all of the information in that protocol, including diagnostic features, associated features and disorders, course, and differential diagnosis.

The following examples of issues from that protocol are not intended to serve as a substitute for the full protocol. These examples are only being provided in order to give readers some idea of what the protocol involves, and to at least partially convey the complex nature of the protocol.

MDD is characterized by a history of one or more Major Depressive Episodes. These episodes are phases when the symptoms are present for most of the day, nearly every day, for at least 2 consecutive weeks.

Diagnostic features for such major depressive episodes include:

  • A period of at least 2 weeks during which there is:
    1. A depressed mood, and/or
    2. The loss of interest or pleasure in nearly all activities
  • At least four additional symptoms drawn from a list that includes:
    1. Changes in appetite or weight
    2. Sleep disturbance
    3. Psychomotor agitation (e.g., observable restlessness) or psychomotor retardation (e.g., observably moving more slowly than usual)
    4. Decreased energy
    5. Feelings of worthlessness or guilt
    6. Difficulty thinking/concentrating/making decisions
    7. Recurrent thoughts of death or suicidal ideation/plans/attempts

Course: This mental illness is typically manifested in phases – the person is mentally ill for a period of time, and is then typically free from the symptoms of the mental illness for a period of time, but will probably develop additional episodes of symptoms in the future.

Differential Diagnosis: The person with this disorder has not experienced any Manic, Mixed, or Hypomanic Episodes, (which would push the diagnosis toward the Bipolar and Cyclothymic disorders, instead of MDD). The symptoms cannot be attributed to any other mental illness, or to any general medical condition.

Psychological Tests (e.g., current editions of the Minnesota Multiphasic Personality Inventory, Battery for Health Improvement, Millon Clinical Multiaxial Inventory, Structured Interview of Reported Symptoms) can be used as an important adjunct to the diagnostic process, specifically for the purpose of introducing an objective element to a process that is otherwise completely subjective.

Thorough Review of Claimant's History can ideally involve an examination of records from the claimant's entire life, and collateral reports. This thorough type of approach is preferable to relying on the report of the claimant, because scientific findings have consistently revealed that an examinee's report of his or her history is not a credible basis for clinical decision-making.

Any such diagnostic evaluation (and associated treatment planning) should take place on an independent basis. If the evaluation does not take place on an independent basis, then the clinician must avoid any discussion regarding forensic issues such as work-relatedness, disability, etc.

Stress

Initial Evaluation

Focus on identifying possible red flags or warning signs for potentially serious psychopathology that would require immediate specialty referral. Red flags may include impairment of mental functions, overwhelming symptoms, signs of substance abuse, or debilitating depression. In the absence of red flags, the occupational or primary care physician can handle most common stress-related conditions safely.

In talking to the patient, it is important for the physician to get him or her to try and explain or pinpoint incidents or reasons for the stress, rather than to just generalize (i.e., "I hate my job," "Everything makes me stressed out," etc.). The physician may have to ask more specific questions about work or home life if the patient is initially unwilling or unable to address specific issues.

Occupational stress usually stems from one of three common models:

  1. Person-environment fit model: Poor job fit, such as a mismatch between the skills of the individual and the demands of the job, or a disparity between the individual's career-related desires vs. actual opportunities presented, is a leading cause of workplace stress.
  2. Demand control model: Jobs that place high demands on the worker but give him or her little control or opportunities for decision-making lead to high job strain, a source of stress that is consistently linked as a contributor to physical conditions such as cardiovascular mortality, heart disease, and hypertension. Consideration should be given to the influence of the individual's occupational and personal history, which may have an effect on how this model applies to his or her situation.
  3. Effort-reward model: Shows that stress is often the result of high effort without social reward. Like the demand control model, this model points out that a low ratio of effort to reward leads to sustained autonomic arousal and can cause physical effects such as high blood pressure or myocardial infarction.

Exploration of how and if the patient's stress follows the path of one of the above models will be helpful in determining treatment.

More specific sources of stress include bereavement, illness, familial changes or disorder, or other common and/or traumatic life changes. Time off work may be helpful, although the ultimate goal should be to preserve the patient's ability to function both occupationally and socially. Time off should not be so excessive that the employee loses his or her sense of function and appreciation at work and at home.

Initial Therapy

  1. Pursuing the patient's thoughts on how his or her stress relates to the above models may help determine the source of stress and cultivate ideas on how to eliminate or cope with the stress. Patient education and understanding about stress is necessary for effective stress management to take place.
  2. Other common treatment pathways include the use of one or more of the following:
    1. Relaxation techniques (such as meditation)
    2. Exercise (aerobic exercise has been shown to positively influence mood)
    3. Behavioral training (such as time management, anger management, assertiveness, or conflict resolution training)
    4. Stress inoculation therapy
    5. Cognitive therapy
    6. Modified work
    7. Organizational interventions
  3. Pharmaceutical therapy (limited, short-term use of anti-anxiety agents to improve function—anything else should be used in conjunction with a specialty referral)

Follow-up visits are an important part of treatment and should be conducted by a mid-level practitioner in person or via phone every three or four days, depending on the severity of the case, while a path to recognizable treatment is established and followed. Failure to improve or make significant progress after several months may indicate the need for psychiatric assessment or counseling.

Post-traumatic Stress Disorder

The concept of post-traumatic stress disorder (PTSD) was created by the American Psychiatric Association in 1980 to serve as a diagnosis for presentations of mental illness by people who have experienced an "extreme traumatic stressor." According to the current version of the American Psychiatric Association's diagnostic manual, the diagnosis of PTSD involves at least nine elements, which are outlined below: (1) The person witnessed death, a threat of death, or physical danger; (2) The person responded to that experience with intense fear, helplessness, or horror; (3) The person has symptoms which involve "re-experiencing" item #1 (example: repeating memories of item #1, with those memories being perceived as intrusive, and with those memories causing distress); (4) The person demonstrates avoidance of things that remind them of item #1; (5) The person experiences a "numbing of general responsiveness" (example: the person is unable to have loving feelings); (6) The person experiences symptoms of "increased arousal" (example: difficulty falling or staying asleep); (7) The involved distress or impairment is "clinically significant"; (8) The symptoms typically begin within the first three months after item #1, and typically resolve within a few months of onset; (9) The symptoms last for more than a month after item #1.

Refer to the original guideline document for Summary Tables for PTSD pharmacotherapy and PTSD psychotherapy interventions.

Official Disability Guidelines (ODG) Return-To-Work Pathways

Senile and Presenile Organic Psychotic Conditions (see original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)

Not severe, medical treatment: 0 days
Severe, specially designed, limited modified work: 7 days
Severe, regular work: indefinite

Senile Dementia with Delusional or Depressive Features

Severe, specially designed, limited modified work: 7 days
Severe, affecting fellow worker productivity & safety: indefinite
Severe, regular work: indefinite

Alcohol Withdrawal Delirium

Without hospitalization: 1 to 7 days
Including rehab, substance abuse professional (SAP) evaluation: 28 days
Including rehab, SAP evaluation, job safety issues: 42 days

Drug Withdrawal Syndrome

Without hospitalization: 0 to 5 days
With hospitalization, without suicidal ideation: 7 days
With hospitalization, with suicidal ideation: 21 days

Paranoid and/or Hallucinatory States Induced by Drugs

Without hospitalization: 1 to 3 days
With hospitalization, without threat of harm: 7 days
With hospitalization, with threat of harm: 21 days

Transient Organic Psychotic Conditions

14 days

Paranoid Type

Without hospitalization, no job safety issues: 0 to 7 days
With hospitalization: 42 days or by report

Unspecified Schizophrenia

Without hospitalization, no job safety issues: 0 to 7 days
With hospitalization: 16 to 42 days

Major Depressive Disorder, Single Episode

Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 21 to 42 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days

Major Depressive Disorder, Recurrent Episode

Outpatient therapy, without symptoms affecting work: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 14 to 28 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days

Bipolar Affective Disorder, Depressed

Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0 to 21 days
With hospitalization: 21 to 42 days

Bipolar Affective Disorder, Mixed

Without hospitalization: 0 to 14 days
With hospitalization: 21 to 42 days

Paranoia

Without hospitalization: 0 to 14 days
With hospitalization: 14 to 21 days

Depressive Type Psychosis

Without hospitalization: 0 to 56 days
With hospitalization: 21 to 64 days

Anxiety States

Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0 to 7 days
With hospitalization: 14 to 21 days

Panic Disorder

1 to 14 days

Generalized Anxiety Disorder

14 to 21 days

Hysteria

Without hospitalization: 0 days
With hospitalization: 7 to 14 days

Obsessive-Compulsive Disorders

Without hospitalization: 0 days
With hospitalization: 10 days

Personality Disorders

0 days

Alcohol Dependence Syndrome

Without hospitalization: 1 day
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization, including rehab: 14 to 28 days
Safety sensitive position: as determined by the SAP

Acute Alcoholic Intoxication

1 to 2 days
Also treated as rule violation absence

Opioid Type Dependence

Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization, including rehab: 14 to 38 days (10 days post-discharge)
Safety sensitive position: as determined by the SAP

Barbiturate and Similarly Acting Sedative or Hypnotic Dependence

Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 21 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP

Cocaine Dependence

Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 28 days
Safety sensitive position: as determined by the SAP

Cannabis Dependence

0 to 2 days

Amphetamine and Other Psychostimulant Dependence

Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP

Hallucinogen Dependence

Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP

Alcohol Abuse

1 day

Cocaine Abuse

Without hospitalization: 0 to 1 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days

Amphetamine or Related Acting Sympathomimetic Abuse

Without hospitalization: 1 day
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days

Acute Reaction to Stress

Without hospitalization (on-going counseling/drug therapy): 1 day
With hospitalization: 10 days

Unspecified Acute Reaction to Stress, Post-traumatic Stress Disorder

Without hospitalization (on-going counseling): 1 day
With hospitalization: 10 days
Chemical dependence comorbidity: 28 days

Adjustment Reaction

Without hospitalization: 1 to 6 days
Outpatient care: 1 to 6 days
With inpatient hospitalization: 14 to 28 days

Post-concussion Syndrome

Mild: 1 day
Severe: by report

Depressive Disorder, not Elsewhere Classified

Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work or other job issues: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 21 days
Outpatient therapy, with serious job satisfaction issues: 28 to 42 days
With hospitalization, non-cognitive/modified work: 28 days
With hospitalization, cognitive work: 42 to 56 days

Attention Deficit Disorder

1 day

(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary of the original guideline document)
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related stress, major depressive disorder, and other mental disorders.

Potential Harms
  • From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed.
  • While selective serotonin reuptake inhibitors (SSRIs) are better tolerated than tricyclic antidepressants (TCAs), they have their own specific problems, such as the aggravation of sexual dysfunction, interaction with co-administered drugs, and for many, a discontinuation syndrome.
  • The risk of suicidal behavior after starting antidepressant treatment is similar among users of amitriptyline (a tricyclic) and fluoxetine (an SSRI).
  • Despite the relative low prevalence of side effects associated with SSRIs a significant minority of older people find these drugs intolerable and experience nausea, vomiting, dizziness and drowsiness.
  • Postmarketing reports of hepatic injury (including hepatitis and cholestatic jaundice) suggest that patients with preexisting liver disease who take duloxetine (Cymbalta) may have an increased risk for further liver damage. The new labeling extends the precaution against using Cymbalta in patients with substantial alcohol use to include those patients with chronic liver disease. It is recommended that Cymbalta not be administered to patients with any hepatic insufficiency.
  • Antidepressant medication (fluoxetine/Prozac) has been found to compromise the success of smoking cessation efforts.
  • Hypomania as a potential adverse effect of light therapy needs to be considered.
  • Because exposure therapy (ET) may increase distress and post-traumatic stress disorder (PTSD) symptoms in the short term, it is not well accepted by all patients, some of whom may drop out of treatment.

Contraindications

Contraindications
  • The following are current suggested exclusionary criteria for the use of an implantable pain treatment: (a) Active psychosis; (b) Active suicidal ideation; (c) Active homicidal ideation; (d) Untreated or poorly treated major depression or major mood disturbance. Depression in and of itself in reaction to chronic pain does not disqualify a patient from implantable treatment, although moderately severe to severe depression should be treated prior to trial. Anxiety/panic disorder should also be stabilized; (e) Somatization disorder or other somatoform disorder involving multiple bodily complaints that are unexplained or exceed that could be explained by the physical exam; (f) Alcohol or drug dependence (including drug-seeking behavior and/or uncontrolled escalated use); (g) Lack of appropriate social support; (h) Neurobehavioral cognitive deficits that compromise reasoning, judgment and memory. Other "red flags" include: a) unusual pain ratings (for example, the pain rating never changes from 9-10); b) unstable personality and interpersonal function; c) non-physiological signs reported on physical exam; d) unresolved compensation and litigation issues.
  • There are a number of contraindications for using traditional hypnotic techniques in the treatment of post-traumatic stress disorder (PTSD): (1) In the rare cases of individuals who are refractory or minimally responsive to suggestions, hypnotic techniques may not be the best choice, because there is some evidence that hypnotizability is related to treatment outcome efficacy; (2) Some PTSD patients may be reluctant to undergo hypnosis, either because of religious belief or other reasons. If the resistance is not cleared after dispelling mistaken assumptions, other suggestive techniques can be tried, including emotional self-regulation therapy (ESRT), which is done with open eyes and uses sensory recall exercises rather than a hypnotic induction; (3) For patients who have low blood pressure or are prone to fall asleep, hypnotic procedures such as "alert hand," which emphasize alertness and activity rather than relaxation, may be substituted.
  • Contraindications for exposure therapy (ET) have not been confirmed in empirical research, but may include health problems that preclude exposure to intense physiological arousal: current suicidal ideation, substance abuse not in stable remission, co-morbid psychosis, or lack of motivation to undergo the treatment.

Qualifying Statements

Qualifying Statements
  • The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.
  • The definition of major depressive disorder provided in the guideline is a highly summarized definition that is not intended to provide a full understanding of major depressive disorder. It is instead simply intended to provide readers with a simple overview.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Work Loss Data Institute. Mental illness & stress. Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 (revised 2011 Feb 24)
Guideline Developer(s)
Work Loss Data Institute - For Profit Organization
Source(s) of Funding

Not stated

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, Jr., MD, together pilot the group of approximately 80 members. See the ODG Treatment in Workers Comp Editorial Advisory Board External Web Site Policy.

Financial Disclosures/Conflicts of Interest

There are no conflicts of interest among the guideline development members.

Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Methodology outline is available from the Work Loss Data Institute (WLDI) Web site External Web Site Policy.
  • Appendix A. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Methodology description using the AGREE instrument. Available from the WLDI Web site External Web Site Policy.
  • ODG for eReader. Treatment and disability duration guidelines are available for purchase from the WLDI Web site External Web Site Policy.
Patient Resources

The following is available:

  • Appendix C. ODG Treatment in Workers' Comp. Patient information resources. Electronic copies: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on April 4, 2005. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on October 20, 2005, following the U.S. Food and Drug Administration advisory on Cymbalta (duloxetine hydrochloride). This NGC summary was updated by ECRI on January 30, 2006, November 13, 2006, April 2, 2007, and August 29, 2007. This summary was updated by ECRI Institute on October 31, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This NGC summary was updated by ECRI Institute on January 28, 2009 and May 26, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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