Nick Glozier writes:
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 thatmore 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 theK10, 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.
** Nick Glozier is Professor of Psychological Medicine, BMRI & Discipline of Psychiatry at the University of Sydney. Nick has received funding from the NHMRC and ARC and is on the appeal panel of the NSW Worker’s Compensation Commission.