Doing medicolegal assessments gives you a snapshot of the prescribing practices of GPs. Over the last year or two I have been astonished by the number of people being treated for anxiety by their GP with atypical antipsychotic medication, mainly quetiapine (Seroquel) and to a lesser extent olanzapine (Zyprexa).
I am an unashamed advocate of the use of benzodiazepines in anxiety. I have followed the professional literature for years and in the midst of the raging against their use there are a number of papers that continue to advocate for them on the basis of their safety and lack of serious side-effects.
Treatment recommendations for anxiety disparage benzodiazepine use.
For example :
The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines, despite a dearth of clinical research that shows this particular class of drugs is any more effective than others. Diazepam (Valium) and lorazepam (Ativan) are the two most prescribed benzodiazepines. Lorazepam will produce a more lengthy sedating effect than diazepam, although it will take longer to appear. Individuals on these medications should always be advised about the medications’ side effects, especially their sedative properties and impairment on performance.
Tricyclic antidepressants often are an effective treatment alternative to benzodiazepines and may be a better choice over a longer treatment period. (on PsychCentral.com 15 December 2014, quoting a 2004 paper)
The most recent edition of Therapeutic Guidelines 2013 states:
Anxiety and associated disorders
Psychological interventions should be used first-line for most anxiety disorders. However, sometimes adjunctive pharmacotherapy may be needed, usually with antidepressants rather than benzodiazepines. If short-term prescribing of benzodiazepines is necessary, consider the precautions given.
The BeyondBlue website states:
Benzodiazepines (sometimes called sedatives) are a class of drug commonly prescribed in the short term to help people cope with anxiety and panic attacks. Benzodiazepines reduce tension without making people drowsy but they are not recommended for long-term use as they can be addictive.
It appears to be a given that benzodiazepines are “bad”. Many papers attest to this and there are many papers about strategies that have been used to reduce the prescribing of benzodiazepines.
Benzodiazepine use by elderly patients is associated with adverse outcomes including increased risk of falls and fractures, motor vehicle accidents and cognitive impairment (CMAJ. Apr 1, 2003; 168(7): 835–839).
According to a paper in BMC Health Services Research 2010;10:321. doi:10.1186/1472-6963-10-321.
“Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide”
and
Benzodiazepines are used to treat various psychological disorders including sleep disorders, some neurological disorders and aspects of addiction and anxiety [1]. Utilization patterns show variation in the use of benzodiazepines over the last 2 decades. During the 1990’s there was much publicity around the harmful effects of long-term use of benzodiazepines in Australia, including new guidelines and efforts to increase community awareness. This resulted in a decrease in prescribing of benzodiazepines, however since the end of these campaigns, use has been continually rising, with a 21% increase in utilisation by concession beneficiaries in Australia (elderly, over 65 years of age, and those with a low income or receiving benefits) from 2000 to 2006.
There has been recent publicity about a number of deaths associated with combined use of opiates and benzodiazepines, there is no doubt that benzodiazepines can effect respiratory centres and may potentiate the respiratory depressant effects of opiates. In particular there is concern about recreational use of alprazolam. All that is understandable but most people with anxiety do not fit into this category.
In my clinical practice I have found benzodiazepines, used appropriately, sometimes long term, have proven to be far more useful in treatment of anxiety with far fewer side effects than antidepressants that often cause obesity and sexual dysfunction.
Here are two anecdotes about my involvement with benzodiazepines.
Some years ago I was involved with a GP training program in which I was a tutor doing telephone tutoring to a group of GPs interested in obtaining a diploma of mental health. The tutorials is proceeded well until we came to the topic of anxiety. I made some comments about use of benzodiazepines. I could not believe the hostile response. It was like I was prescribing poison. Their view was that all benzodiazepines are bad, if used they should never be used for more than a few weeks and that anything was preferable to their use. They confused dependence with addiction and did not acknowledge the relatively minimal side-effects of benzodiazepines compared with antidepressant medication. Within a short time I was asked to cease my involvement in that training program, possibly because of this unpleasant tutorial.
About 10 years ago a friend of mine developed breast cancer, I had never treated her. She had been using clonazepam for 20 years for treatment of panic disorder. Her panic disorder had been crippling to the extent that she had been housebound for three or four years. After using clonazepam her panic disorder became well controlled and she was able to go back to work as a teacher and became involved in a long-term relationship. She was using anywhere between 0.25 mg-2 mg of clonazepam a day.
Whilst in hospital after breast cancer surgery she developed an acute severe panic attack. She had mentioned that she had been using clonazepam but was not allowed to bring that to the hospital. After she was discharged I suggested that she be reviewed by a psychiatrist experienced in treating women with breast cancer. She saw the psychiatrist who was horrified that she had been using clonazepam and told her to stop using it and prescribed Aropax instead. She began using Aropax but developed weight gain, insomnia, sexual dysfunction and her panic attacks did not improve. She mentioned this to the psychiatrist who increased the dose of Aropax with a significant increase in side-effects but no improvement in her panic disorder.
She came to me in some distress “what can I do? I like my psychiatrist and it has been useful to talk about my cancer but my panic attacks are making it impossible for me to work and putting a lot of strain on my relationship.”
I suggested an option. She had two prescriptions for clonazepam at home and I suggested that she stop using the Aropax slowly and immediately start using clonazepam but not tell her psychiatrist what she was doing. She did so and her panic attacks settled. Her psychiatrist, rather smugly, said “I told you so, all you needed to do was to increase the dose!” Was I unethical? Possibly but any concern about that was outweighed by the improvement in my friend’s health.
So where are we with regard to anxiety disorder and medication. There have been many public health efforts and a great deal of money expended in trying to reduce benzodiazepine use. In Australia quetiapine is listed for treatment of Generalised Anxiety Disorder and most therapeutic guidelines recommend use of antidepressant medication as first-line treatment for anxiety.
There appear to be few people who have any neutral view about benzodiazepines. The accepted wisdom is that the BDZs are bad and that anybody who prescribes them is either incompetent or wicked and, their use must be reduced. It is noteworthy that education programs to reduce prescribing benzodiazepines by GPs have been totally ineffective. Nobody seems to have questioned whether or not the alternatives may be worse.
There is major concern about use of benzodiazepines long term but there appears to be little commensurate concern about long-term use of atypical antipsychotic drugs despite the strong possibility of long-term adverse side-effects. There appears to be little concern about giving antidepressant medication long-term for treatment of anxiety although we are all familiar with all the side-effects of that group of medications, including withdrawal symptoms.
At times I have wondered if the pharmaceutical companies have conspired to demonise benzodiazepines as they are no longer in patent and this allows them to profit greatly from use of newer antidepressant medications and atypical antipsychotics in treatment of anxiety.
The 2011 statistics from the Pharmaceutical Benefits Scheme give the following information.
Total cost of quetiapine $130 million, total number of prescriptions 820,620.
25 mg tablets (the usual dose used to treat anxiety by GPs) 294,062 prescriptions at a cost of $16,819,606. Each prescription cost $57.
Total number of prescriptions for diazepam; 2,258,000 237 prescriptions at a cost of $17,769,988. Prescriptions for 5 mg tablets totalled 1,977,635 at a cost of $15,533,180 giving a cost per prescription of $7.85.
Amitriptyline, total number of prescriptions 1,627,201 at a cost of $14,251,045. There were 555,169 scripts written for 10 mg tablets at a cost of $4,692,995 at a cost of $8.45 per prescription.
Paroxetine, commonly used for treatment of anxiety, total number of prescriptions 969,084 at a cost of $30,553,212 at a cost of $31.52 per prescription.
Sertraline, also used for treatment of anxiety in addition to treatment of depression, total number of prescriptions 2,774,837 at a cost of $74,698,325, cost per prescription $26.
My sanity was briefly restored when I read the following article. It was like hearing the first sounds of rain on a tin roof after a long drought.
The reappraisal of benzodiazepines in the treatment of anxiety and related disorders Expert Rev. Neurother. Early online, 1–12 (2014).
I urge you to read it. I will leave you with its introduction:
Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.
Some have requested information about the The American Board of Independent Medical Examiners. I see that a number of medicos in Western Australia and other states have this qualification. Some of the training appears to be quite generic and might be useful as a basis for commencing in medicolegal practice but there seems to be little to offer for psychiatrists. I was especially concerned by one module: “How to write winning reports”.
This group have provided some training in Adelaide and I would be interested in feedback from anybody who has gone through their training in October last year. For the moment I would be very cautious.
Options to add no-fault catastrophic injury cover to Western Australia’s Compulsory Third Party (CTP) Insurance Scheme.
The CTP Green Paper has been released by the State Government regarding the possible introduction of a no-fault catastrophic CTP personal injury insurance scheme.
The purpose of the Green Paper is to inform the community and seek feedback on the merits, costs and options for adding this additional insurance cover to the State’s existing CTP insurance scheme for people catastrophically injured as a result of motor vehicle accidents.
Submissions can be made from 15 October to 24 December 2014.
In early December 2014 a psychiatrist was convicted of WorkCover fraud in the Ringwood Magistrate’s Court. He was given a wholly suspended prison sentence and fined. This is a wake-up call to us all. We must be meticulous in our recordkeeping and ensure that what we charge is consistent with documentation such as appointment times. I can only feel sadness for the psychiatrist involved. Of course he did the wrong thing but at what a cost. He has destroyed his reputation and must have caused great distress to his family and friends.
Motorcyclists and accidents – do we see proportionately more motorcyclists than car drivers?
Statistics from the Victorian Transport Accident Commission demonstrate a vastly increased lethality due to motorcycle riding compared with driving a car.
In the last ten years, more than 430 motorcycle riders and pillion passengers have been killed, and close to 9,000 riders and pillions have been seriously injured on Victorian roads. This represents 14% of all road fatalities in the last ten years and 16% of all hospitalised claims.
Fatalities
Of the 243 people killed on Victoria’s roads in 2013, 41 were riders and passengers of motorcycles, representing 17% of the 2013 road toll.
Motorcycles represent less than 4% of the number of registered vehicles in Victoria, and account for around 1% of vehicle kilometres travelled*. Around 9% of Victorian licence holders hold a motorcycle licence.
Of the 41 motorcyclists and pillions killed in 2013:
I have written in other posts about changes to the Victorian TAC including the introduction of Joint Medical Examiners. Joint Medical Examiners are Independent Medical Examiners who see claimants and prepare reports for both the TAC and plaintiff’s solicitors. Since the JME process has been implemented there have been a number of disputes including the fee schedule, the lack of coordination between the two parties leading to excessive documentation and questions and the distaste many IMEs have for the requirement that they must complete TAC documentation and receive TAC accreditation before they can participate in the process. The other issue, of course, is the potential for the TAC to veto some examiners.
There have been a number of changes in position by the TAC; the initial fee schedule was $1368.79 (including GST) with an extra payment of $150 including GST in the transition period that was to expire on 1 January 2015. Subsequently since the legislation refers only to paying “a reasonable fee” the TAC agreed that JMEs could charge their usual fee until the end of the transition period. There was then consultation with a number of JMEs where complaints were made about several issues. This led to the establishment of the TAC/JME Reference Group, the transition period was extended to 1 April 2015 and rather than a single fee, a fee range was to be implemented. ($1231 -$1800 + GST).
The TAC/JME Reference Group has now met three times, it includes JMEs and representatives of the TAC and the Australian Lawyers Alliance. it has been agreed that the fee within the range above will be determined by the JME and will be paid automatically subject to the usual periodic reviews. There will be some leeway at the upper end of that range so that a fee that may be $300 or thereabouts above the top fee in the scheduled range will usually be paid automatically. JMEs will be provided with information about issues that are regarded as leading to complexity and the need for additional payments. This information will vary according to the different craft groups involved . There will be further meetings to explore cutting back on documentation, reducing document duplication and similarly cutting back on the number of questions asked.
Most of us have been surprised by the conciliatory stance taken by the TAC and are still crossing our fingers.
culminating in
This post has little to do with forensic psychiatry but is fascinating. Apart from “eat shit” being a term of abuse it has become a reality in the world of medicine, the latest New Yorker magazine has an article about faecal transplants.
This apparently simple procedure has been life-saving, in particular for people with Clostridium difficile infections due to use of prophylactic roared spectrum antibiotics, the article states that this afflicts more than 500,000 people each year, killing 15,000, almost all hospital patients who received antibiotics. A cottage industry has grown up with friends and neighbours providing the raw material. I was astonished to read that in our digestive tracts there are about as many as 100 trillion bacteria, fungi, viruses, and other tiny creatures and that 40% of faeces is composed of microbes. The first known account of faecal transplantation dates to a fourth century Chinese handbook but for years the only proponent has been Thomas Borody, a gastroenterologist in Sydney who has performed more than 5000 faecal transplants for a variety of conditions including people with autoimmune disorders including Crohn’s disease and multiple sclerosis. It is known that patients with Crohn’s disease have a gut microbiome that is less diverse than average and is lacking in key species of bacteria. A nonprofit organisation has set up an anonymous faecal transplant business with donors such as Vlaidimir Pootin and Dumpledore. The FDA has decided that faeces are a drug! This has the potential to shit on the whole process (excuse me, I couldn’t help it). The implication is that only major pharmaceutical companies with massive amounts of money will be able to fund the FDA requirements. One company is trying to produce an enema derived from faeces and has spent millions of dollars and is very opposed to the work of the nonprofit organisation.
I came across this paper recently and thought it might be of interest to you. It is a little out of date but the general information remains applicable. The last 2 tables are especially interesting with an overview of thresholds and an overview of methods.
Role of Impairment Assessment in Australian & NZ Injury Compensation Schemes
Andrew Fronsko and David Swift
ISCRR 1st Australian Compensation Health Research Forum
October 2011
The recent guideline # 19 Determination of a Recognised Psychiatric Diagnosis noted that the The Motor Accidents Authority Permanent Impairment Guidelines – Guidelines for the assessment of permanent impairment stated “The impairment must be attributable to a recognised psychiatric diagnosis in accordance with the Diagnostic Statistics Manual of Mental Disorders (4th Edition) [DSM IV], Internal Classification of Diseases (10th Edition) [ICD 10] or a substantial body of peer review research literature
1 The impairment evaluation report must specify the diagnostic criteria upon which the diagnosis is based.”
In May 2013 the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5) was released and in 2015 the Eleventh Edition of the International Classification of Diseases (ICD) is due to be released.
The Guideline stated that with the publication of the DSM 5 it may be unclear for Psychiatric Medical Assessors whether or not they can make a psychiatric diagnosis in accordance with DSM 5.
Preferred Approach
The DSM 5 may be considered by Psychiatric Medical Assessors as “a substantial body of peer review research literature.”(clause 7.13 MAA Guidelines) and apparently may be used together with DSM IV TR and ICD 10.
The Guidelines go on to state that any diagnosis based on DSM 5 must be clearly referenced and “must specify the diagnostic criteria upon which the diagnosis is based”,
However Psychiatric Medical Assessors were reminded that somatoform disorders, (Somatic Symptom and Related Disorders inDSM 5) are not assessed under the MAA Guidelines.
The guideline stated that the preferred interpretation is suggested to promote consistency of assessment and to assist the parties to understand the methodology behind the diagnosis of psychiatric injuries and associated impairment.
Whatever you may think of DSM 5 the question remains when and if should we use it. DSM 5, in particular, disparages the axial diagnosis scheme used in DSM IV and the GAF. The DSM 5 is poor with regard to persistent pain. However, de facto it clearly replaces DSM IV. I work in the medico-legal area where such a change has significant implications. The new South Australia impairment guidelines will specify use of DSM 5. There appears to be no direction from the College and, one may ask, is that the role of the College? So I have been using both in my reports, eg when dealing with claimants with persistent pain, but I prefer persistent depressive disorder DSM 5) to dysthymia (DSM IV). I believe that shortly I will have to make the transition complete. but it does seem a messy process. What are your thoughts.
According to The Age newspaper of 27 October 2014 The Transport Accident Commission has saved $142 million after the recent amendments in the Transport Accident Amendment Act that have defined severe long-term mental illness. I have written about this previously. The new definition requires people to prove that they have had significant symptoms for at least three years after a car accident despite treatment if they are to be eligible for common-law compensation. at the time we protested vigorously stating that few people with what we regarded as severe mental illness would meet the criteria. According to the newspaper the commission has not processed any claim for severe mental injury compensation under the new criteria since it was introduced in October 2013.
A letter obtained by Fairfax Media reveals that the Transport Accident Commission lobbied the government to 2 years for the change because it believed the old threshold for mental injury compensation was not financially sustainable. The commission’s chief executive, Janet Dore, wrote to former board members last month about its progress in the final year of the six year review of its finances. She said there had been a $142 million saving to the TAC scheme-this financial year, taking its total savings to $252 million, with no “hot spots” identified by actuaries for the first time in her tenure. “The cumulative result reflects significant erosion of the metal injury threshold, which was threatening long-term financial sustainability. It required two years of work to achieve legislative change to manage this issue,” she said.
Janet Dore confirmed she had written a letter saying “the TAC has a responsibility to ensure that the scheme remained accessible and financially viable into the future….
The commission made a $499 million profit this financial year down from its $973 million profit last year. When the law was changed the Victorian State government said it was not seeking to restrict access to compensation, but to ensure that compensation claims for mental injury were made “consistently”!
The government was talking bullshit, it is obvious that this was done to save money despite the TAC making a profit last year of $500 million. Dr Nigel Strauss was quoted as saying that most seriously ill psychiatric patients would miss out on compensation under the new criteria. John Voyage, head of Maurice Blackburn’s TAC Department estimated dozens of people were no longer eligible for mental injury compensation this year.
As I have already written, the fee schedule as from 1 July 2014 is increasingly irrelevent as JMEs have continued to charge their usual fee. We were told, in no uncertain manner that as from 1 January 2015 the fee schedule would definitely apply. Now the TAC has extended the transition period to 31 March 2015! The fee schedule will ( some scepticism here) be from $1231 – $1800 + GST), with complexity criteria to guide examiners billing within this range. There will be exceptions, examiners can contact the TAC to discuss circumstances where the reasonable cost for the service may be above the fee range when the transition period ends.
The Cost of Comorbidity to the Victorian TAC Scheme (Latest Research from the Institute for Safety, Compensation and Recovery Research, an independent Institute jointly funded by the TAC and the Victorian WorkCover Authority under the auspices of Monash University)
The conclusions were that comorbidity did not have a large impact on the overall injury recovery cost but certain health conditions did have a significant impact on hospital, medical and paramedical expenses. These conditions are mental disorders, diabetes, cardiovascular disease, recent surgery and (suspected) back pain. Mental health history, particularly pre-injury psychiatric attendance and GP visits in relation to mental health significantly added to the total claim cost, administrative, income, hospital and paramedical expenses especially considered over the full post-injury year.
56—Lump sum payments—economic loss
(1) Subject to this Act, if a worker, other than a seriously injured worker, suffers a work injury resulting in permanent impairment as assessed under Part 2 Division 5, the worker is entitled (in addition to any entitlement apart from this section) to compensation for loss of future earning capacity by way of a lump sum.
(2) An entitlement does not arise under this section if the worker’s degree of whole person impairment from physical injury is less than 5%.
(3) An entitlement does not arise under this section in relation to—
(a) a psychiatric injury or consequential mental harm
58—Lump sum payments—non-economic loss
(1) Subject to this Act, if a worker suffers a work injury resulting in permanent impairment as assessed under Part 2 Division 5, the worker is entitled (in addition to any entitlement apart from this section) to compensation for non-economic loss by way of a lump sum.
(2) An entitlement does not arise under this section if the worker’s degree of whole person impairment from physical injury is less than 5%.
(3) An entitlement does not arise under this section in relation to a psychiatric injury or consequential mental harm.
Stress Claims in Victoria as of June 30 2014 (adapted from The Age 21 October 2014)
The annual number of claims for mental disorders has risen by almost 470 in five years while the annual amount paid out in compensation has soared by 45 per cent to $273 million. Job-related stress is increasing in Victorian workplaces with 58 compensation claims for psychological injuries being accepted every week.
Victoria’s two biggest worker compensation categories – musculoskeletal complaints and major sprains and strains – have either fallen or remained steady in claim numbers over the same period along with most other physical injuries. For the first time, mental disorders have overtaken wounds to become the state’s third-leading workplace injury.
WorkCover data shows the average individual compensation payout for psychological injuries has ballooned from $73,000 in 2008-09 to almost $90,000 in the past financial year.
Mental health group Beyondblue attributes the rise in work-related mental stress claims to reduced stigma, heavier workloads and increasing job insecurity. But it was also being driven by a heightened recognition of the connection between the workplace and mental health, the group said, with a series of high-profile civil lawsuits ending in six and seven-figure payouts from employers found at fault.
Last month, former teacher Peter Doulis was awarded more than $1.3 million in damages for chronic depression after he was found to have been allocated an unduly heavy workload of a western suburbs school’s worst-behaved students.
“Cases like these get people thinking about their own workplace and conditions, and reflecting more objectively about situations they may be tolerating,” Beyondblue head of workplace policy Nick Arvanitis said.
With an estimated one in five workers taking time off work due to feeling mentally unwell in the past year, industry groups and health advocates have urged employers to treat the mental health of their staff as seriously as physical health and safety.
The data below gives a more comprehensive overview of those industries and workers more likely to make stress claims.
Mental Disorders in Victoria
Claims
2008/2009 2590
2013/2014 3056
Cost Estimate
2008/2009 $189.3m
2013/2014 $273.2m
All Injuries
2008/2009 28,805
2013/2014 26,508
Cost Estimate
2008/2009 $1,566.6m
2013/2014 $1,620.7m
The VWA have produced a new fee shedule backdated to 1 July 2014 “due to an administrative oversight”. When in doubt between conspiracy and stuffup, stuffup generally wins. I became confused about the fee schedule as there appeared to be items missing. I sought clarification that arrived promptly. In fact there are two fee schedules. There is a fee schedule for IMEs and a fee schedule for IIA, that is independent impairment assessments. I have been dealing with the system for a long time and it just goes to show how confusing all this is when I was unaware of these two different schedules.
Independent Medical Examinations 1 July 2014
| Psychiatrist | |||
| PCT100 First Examination and Report– Inclusive of conducting the examination, report writing, reading lime and any incidentals (such as postage, photography and faxing services)
– Diagnostic tests (such as x-rays) carried out as a necessary part of the examination are not included in the first examination and report item code and will be reimbursed in accordance with WorkSafe policies, the relevant Medicare Benefit Schedule item code and the WorkSafe’s Reimbursement Rates for Medical Practitioners. |
$833.77 | $83.38 | $917.15 |
| PCT150 Subsequent Examination and Report– Applies where a WorkSafe Agent requests a report within 12 months of the first examination and report for the same claim | $500.26 | $50.03 | $550.29 |
| Loadings additional to examination and report fee are subject to Work Safe Agent prior written approval only | |||
| PCT200 Report reading | $45.88 | $4.59 | $50.47 |
| – Flat rate for reading of all reports that accumulatively are greater than 20 pages | |||
| – This fee is payable once only per claim per WorkSafe Agent report request | |||
| PCT250 Urgent Examination and Report– Urgent request by a WorkSafe Agent to complete initial or subsequent exam and provide the report to the Agent within two business days | $94.33 | $9.44 | $103.77 |
| PCT300 Worksite visit | $817.55 | $81.76 | $899.31 |
| – Request by a WorkSafe Agent to complete a worksite visit and provide a report to the Agent | |||
| – Inclusive of worksite visit, report writing, reading time and any incidentals | |||
| PCT350 Travel to and from assessment (at Agent’s request) per hour | $423.98 | $42.40 | $466.38 |
| – Calculated in 15 minutes blocks | |||
| – Travel only paid when travelling to a location other than IMEs nominated practice location/s | |||
| – Travel for multiple assessments in the one location should be charged on a pro-rata basis for each claim | |||
| PCT400 Audiovisual Viewing | $212.01 | $21.20 | $233.21 |
| – Flat rate for the viewing of all audiovisual material | |||
| – This fee is payable once only per claim per WorkSafe Agent report request | |||
| PCT450 Supplementary report– Applies where a WorkSafe Agent provides information additional to that initially provided or to answer additional questions not initially asked and the IME has previously examined an injured worker in the past 12 months
– An IME is not required to conduct a re-examination (or re-contact) the injured worker in order to provide the additional information. |
$271.42 | $27.14 | $298.56 |
| PCT500 Interim report | $56.64 | $5.67 | $62.31 |
| – Request by a WorkSafe Agent to provide information prior to receiving the IME final written report | |||
| – The advice from the IME may be provided verbally (i.e. by telephone) or in writing (i.e. fax). | |||
| PCT550 Non–attendance on day of appointment– Non–attendance fee is applicable where an IME appointment is cancelled by the WorkSafe Agent on the day of the appointment or where the injured worker does not attend | $282.74 | $28.27 | $311.01 |
| IEO400 Assessment of Impairment as requested by Agent using AMA2Guide** | $155.21 | $15.52 | $170.73 |
Fee Schedule 1 July 2014 regarding Independent Impairment Assessments
Note 1 A Dual Purpose Referral refers to those requests for an assessor’s opinion regarding BOTH liability AND impairment within the one referral, examination, assessment and report request. Dual Purpose Referrals will only be requested of those assessors who are both an Independent Impairment Assessor and WorkSafe approved Independent Medical Examiner. This loading only applies subject to Agent request at referral. |
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The question has been raised about whether or not we should be using DSM 5. (See my blog from August 2013) In general psychiatry it is of little consequence but in the forensic area there are potential minefields. Recently a finding of the Victorian Medical Panels was challenged on the basis that the diagnosis made was a “somatisation disorder. On page 489 of DSM IV TR it states “by definition, all individuals with somatisation disorder have a history of pain symptoms, sexual symptoms and conversion or dissociative symptoms. Therefore if these symptoms occur exclusively during the course of somatisation disorder, this should not be an additional diagnosis of pain disorder et cetera.”
The diagnosis was challenged on the basis that it was a DSM IV TR diagnosis and should have been a DSM 5 diagnosis.
My own view is that the DSM 5 deals poorly with pain. It is interesting to note that the word “pain” does not appear in the index! Somatisation disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder had been removed from DSM 5. They are merged under the term “somatic symptom disorder. “Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain.” (My emphasis).
I prefer the DSM IV TR term of Pain Disorder, and you will notice that it is actually in the index.
This is a significant issue for us and leaves us open to challenge, I can imagine the dialogue “so doctor did you use DSM IV TR or DSM 5 for your diagnosis. Could you explain why you chose to use DSM IV TR when it has been superseded by DSM 5? What would your response be?
I have commented on DSM 5 previously. The other areas where I believe the changes are significant include changing the term dysthymia to persistent depressive disorder that I think is a plus. I was once asked in court “Dr Epstein, you have diagnosis man with dysthymia that he would have to agree that there is no evidence that he has any problems with his thymus gland.”
Panic disorder has been separated from agoraphobia, this seems to be not a big issue. There have been changes to the qualifiers with regard to acute stress disorder that are now explicit as to whether the stressor was expressed directly, witnessed or experienced indirectly. Criterion A2 has been eliminated (the one related to experiencing “fear, helplessness, or horror”.)
Adjustment disorders have been rejigged as stress response syndromes rather than a residual category for those who have clinically significant distress but whose symptoms do not meet the criteria for a more discreet disorder.
DSM 5 criteria for PTSD are said to differ significantly from the DSM IV TR criteria with criterion A being more explicit with regard to events that qualify as “traumatic” experiences”. I am pleased about that as too often I read that somebody has PTSD because they have had a negative assessment or because they have fallen over a chair or some other relatively minor trauma. You will note that criterion A2 had been eliminated as described above. There are now 4 symptom clusters clusters, re-experiencing, avoidance, persisted negative alterations in cognition and mood, alteration in arousal and reactivity including behavioural changes such as angry outbursts and reckless or self destructive behaviour. All these are of some value. I am not sure if any other changes are of great significance.
I would be interested if you can see any other DSM 5 diagnoses that are of value in terms of the work we do.
Nevertheless the initial point raised was whether or not we should be using DSM 5 or DSM IV TR and who decides. We have had no guidance from the College. DSM 5 does not make it explicit that it replaces DSM IV TR but by implication it must do so, the question is when does it do so, when it was published?
Which one do you prefer?
On 3 September 2014 the NSW Government introduced a number of changes to workers compensation entitlements. These changes are said to better support injured workers to return to work, with the commencement of the Workers Compensation Amendment (Existing Claims) Regulation 2014. These changes do not apply to workers injured after 1 October 2012, the New South Wales Workers Compensation Legislation Amendment Act 2012 then applies.
These regulations, in effect restore the situation for workers injured prior to 1 October 2012 her situation had changed following the the 2012 Amendment act.
Those eligible workers will now receive weekly payments for a maximum of 12 months after reaching the retiring age and if they have an impairment of greater than 20% they have continuing access for medical, hospital rehabilitation expenses until retiring age and for certain expenses they have continuing access regardless of their percentage impairment.
Key reforms
The recent changes only apply to those workers who made a claim for compensation before 1 October 2012.The changes made in respect of these entitlements allow:
a) is directly consequential on earlier surgery
b) affects the same part of the body affected by earlier surgery
c) is approved by the insurer within two years of approval of the earlier surgery
d) is reasonably necessary treatment as a result of the injury and is pre-approved by the insurer.
Insurers have been instructed to identify relevant claims and contact workers who may have an entitlement that is affected by these changes.
There is a Questions and Answers fact sheet and a Workers Compensation Changes fact sheet. These fact sheets and general information about the regulation are available on the WorkCover website at www.workcover.nsw.gov.au.
There are obvious advantages to having a uniform WorkCover system, interstate companies not having to deal with nine different systems(think about it, Western Australia, South Australia, Northern Territory, Queensland, New South Wales, ACT, Victoria, Tasmania and Comcare!), unions with workers in different states, the amount of bureaucracy, duplication and cost shifting is mind-boggling. It is also a nightmare for IMEs assessing people who have been injured in different jurisdictions.. Like much that we have I often think it would be best if we scrapped the whole thing and started afresh but of course that’s not going to happen.The question of a uniform WorkCover system raises further questions. Why should there be a uniform system for people who are injured at work but totally different system so people injured in transport accidents and loosely no system for people who are injured in other situations. Maybe we should go the New Zealand route and have a uniform accident compensation system for all accidents. One of the advantages of a non- federal system. The political and financial implications however are mind-boggling. Nevertheless the various WorkCover authority’s in each state and territory do have an organisation looking at doing precisely this..
I think there are 4 major problems with a uniform system.
1.The situation is complicated by a number of factors. Most states have moved to AMA 5 except Victoria and the Northern Territory. There is general satisfaction with AMA 4 in Victoria and a large amount of money has been spent in training IMEs. The feedback I have received suggest there will be no change in the near future.
2.The second point is that WorkCover schemes as opposed to motor accident schemes, have powerful constituencies especially unions and employers but also lawyers. This adds to the general unwillingness for either side to sponsor change that may disadvantage their clients.
3. The third issue is a specific issue with regard to psychiatry There are three systems of measuring psychiatric impairment that are incompatible with each other. Comcare uses a rudimentary table, most states use the Psychiatric Impairment Rating Scale about which I’ve written scathingly and Victoria uses the GEPIC (see article). Does this matter? Well, in fact it has great significance because the various thresholds for claiming permanent injury are different according to the method of psychiatric impairment used. For example in New South Wales it is 15% and in Victoria it is 30%. Bearing in mind that the psychiatric impairment has to be impairment that does not result from physical injury. AMA 6, from a psychiatric point of view is a disaster although it is used in the Northern Territory for motor accident claims.
One of the reasons we don’t want change in Victoria is that the GEPIC is used for WorkCover claims, transport accident claims and civil liability claims. This makes impairment assessment much easier and more understandable, it would bring a system into disrepute if a person had both WorkCover claim and a transport accident claim and the impairment assessment produced startling different figures.
There is an answer although not for the foreseeable future. The answer is that the authors of the chapter on mental and behavioural disorders in the American Medical Association Guide produce something worthwhile instead of what has been produced since AMA 2.
4.The unwillingness of individual states and to give up their own power and potential source of income to embrace a national model
A new member of the website, an occupational physician has started a blogging site called ‘Insult & Injury’ www.workcoverobservertas.wordpress.com with a focus on the damage that can result to claimants from the claims management system. He has some very interesting thoughts. In particular he is a proponent of a uniform system throughout Australia (see my thoughts). He like most of us has seen claimants regarding claims in other states and it can be something of a nightmare navigating the system. This is especially so with regard to doing impairment assessments. I urge you to have a look at the site. It gives you a different perspective on the damage to claimants when you see comments on various websites. There are two websites that you might be interested in checking. The first called WorkCover Victims Diary is very much about how people have been done over. The second, based in New South Wales Injured Workers Support Network seems to me a little more evenhanded.It will do you good to see how much we can be hated!