Physicians and insurers increasingly recognize value of biopsychosocial assessment with injured workers Since he began practicing more than 20 years ago, health psychologist Ron Carbaugh, PsyD, has witnessed a growth trend in biopsychosocial evaluation of injured workers. Carbaugh operates a private pain management practice in Denver. About 85 percent of his patients are in the Workers’ Compensation system. “Biopsychosocial evaluation is becoming much more accepted,” says Carbaugh. “Physicians are learning that there are “red flags” for delayed recovery-and that a psychological evaluation can shed light on these issues and help patients improve more readily. In the past, physicians might refer patients to me six to 12 months after the injury; now, I often receive referrals six to eight weeks after the incident.” In addition, Carbaugh notes that he now gets referrals not only from physiatrists who manage long-term rehabilitation cases, but also from Occupational Medicine doctors, who are the “front-line” practitioners in treating injured workers. Plus, Carbaugh sees increased acceptance from insurance companies in authorizing initial biopsychosocial evaluations—and in approving follow-up sessions to deal with identified issues, including psychotherapy, pain management sessions, and adjustments. “In some cases, the thinking among insurers used to be, ‘Oh no, if we get a psychiatrist or psychologist involved, they’re going to treat the person forever, which will add to the patient’s disability.’ Now insurers are recognizing that it can be very helpful to involve a mental health professional who will take a closer look at biopsychosocial factors that might impede recovery.” Industry guidelines contribute to growing trend Carbaugh observes that new treatment guidelines across the country also have helped promote the value of biopsychosocial evaluation. Some of these guidelines stipulate psychological assessment for chronic pain patients; some even recommend specific tests for use with this population. And, Carbaugh points out a more subtle way in which guidelines have fostered an increase in the psychological assessment of chronic pain patients. “Here in Colorado, we have treatment guidelines for physicians and other specialists who care for injured workers,” he says. “For every diagnosis, there are recommendations for types of treatment and amount of treatment. With the establishment of these boundaries, insurance companies are more prone to approve an evaluation; they are no longer as worried that patients will be receiving long-term psychiatric or psychological care that may not be justified.” With some patients, Carbaugh stresses, it may be appropriate to recommend treatment that extends beyond the guidelines. “In these situations, you must provide evidence to support your recommendations—and this is one of the benefits of objective biopsychosocial tests,” he says. “For example, the Colorado guidelines for chronic pain patients recommend six to eight sessions for pain management counseling as a general rule. But if the patient has a more severe depression or perhaps posttraumatic stress disorder, then six sessions will not be enough. With the results of a psychometrically sound test, I can show insurers that my recommendation for further treatment is backed up by objective data. The test results give me added credibility beyond my clinical observations.” Biopsychosocial tests help support clinical impressions Carbaugh equates the value of psychological tests to the value that physicians receive from doing a blood test, MRI, or CT scan. “Especially with complex cases, the results of biopsychosocial tests should be one of the factors in a practitioners’ decision-making process,” he says. “In meeting with a patient, I might know within 15 minutes that the person is really depressed but I’m still going to administer an objective test to confirm my diagnosis,” Carbaugh says. “Tests allow me to gather additional detail more efficiently than if I were to do three or four clinical interviews to get the same information.” Carbaugh has found several instruments to be particularly helpful, including the BHI 2 (Battery for Health Improvement 2), which assesses validity, physical symptoms, and psychological, character, environmental and social factors that can impact medical treatment. He uses the BHI 2 with delayed recovery patients because it includes features that are relevant to this population, such as a nationally standardized 0-10 pain scale that assesses multiple dimension of the pain experience, including level of pain in ten body areas, pain tolerance, pain range, and peak pain. “I also like that the BHI 2 contains Doctor Dissatisfaction and Job Dissatisfaction scales; research clearly supports that these are important issues with injured workers,” he says. In addition, the BHI 2 offers a Defensiveness scale that Carbaugh finds especially valuable in the Workers’ Compensation arena for a couple of reasons. “On the one hand, many injured workers approach testing in a very guarded manner,” he says. “They may under-report psychological problems because they’re afraid that if they disclose these issues, doctors will take their physical complaints less seriously. On the other hand, there are patients who exaggerate symptoms, perhaps because they feel no one will listen to them unless they dramatize the situation or perhaps to support a claim of disability. The BHI 2’s Defensiveness scale is very useful in helping to identify whether a patient has a tendency to minimize or magnify symptoms.” Carbaugh also administers the P-3 (Pain Patient Profile), a brief assessment of psychological factors most frequently associated with chronic pain. “A great advantage of the P-3 is that it’s normed on a chronic pain population in addition to a community sample,” he says. “It provides relevant information—and it gets right to the point. The P-3 only takes patients five or 10 minutes to complete, which is a real benefit to them.” Another test Carbaugh relies upon is the MBMD (Millon Behavioral Medicine Diagnostic) test, which helps measure psychosocial factors that may support or interfere with a chronically ill patient’s course of medical treatment. “What’s great about the MBMD test is that it identifies personality characteristics in terms of how the person is likely to deal with medical problems - as opposed to tests that are designed to assess psychopathology.” Earlier assessment, quicker resolution Carbaugh has been pleased to see an increased recognition of biopsychosocial issues affecting injured patients in recent years - among physicians, industry leaders, and insurers alike. “These days, we’re able to identify underlying issues much sooner in the process, which helps patients get better faster—and relieves the stress on the Workers’ Compensation system.” Editor’s note: A review of several published practice guidelines indicates that the use of psychological tests in evaluating workers’ compensation patients is gaining increased support. The American College of Occupational and Environmental Medicine (ACOEM) guidelines adopted in California specifically recommend that patients who are not showing normal recovery within the expected timeframe receive a psychological evaluation. The State of Colorado’s Division of Workers’ Compensation guidelines, which Dr. Carbaugh referred to, and the Official Disability Guidelines also support the use of psychological assessments.