Tag Archives: depression

Gene Testing: Time Is Ripe in Work Comp

Pharmacogenetic testing (PGT) has the potential to help clinicians improve outcomes for injured workers and reduce costs for payers. While research showing the clinical value of PGT continues to grow rapidly, evidence of the return on investment in the workers’ comp space is just beginning to emerge. Practitioners can benefit from the technology without falling victim to the hype of some proponents by becoming better educated about PGT and those providing it.

Because the use of PGT in the workers’ comp population is relatively uncommon, practitioners may find it challenging to realize the true value of the tests. “A few of our customers are trying PGT on select claimants,” said Dianne Tharp, pharmacist and executive clinical liaison for pharmacy benefit manager Healthcare Solutions, an Optum company. “This is a complex area; everything is evolving. It’s relatively new for the industry, and we are all still learning.”

One growing area of interest is in genetic tests that can identify injured workers most at risk for addiction and abuse. However, there are many challenges with such tests, including uncertainty about their predictive performance in clinical settings, which must be overcome before clinicians can use them to help identify whether an injured worker may misuse or abuse a prescribed opioid. While PGT could be a welcome tool, the science is not yet at a level where clinical application is appropriate.

“On the other hand, pharmacogenetic testing for drug response is often more — and in some cases highly — predictive,” said Naissan Hussainzada, senior director of genetics strategy and commercialization at Millennium Health. “For example, certain genetic variations can change how an individual metabolizes some opioid medications. Using this information, clinicians can identify patients at higher risk for medication failure and/or side effects, which may help them make more informed and tailored treatment decisions.”

Injured workers with preexisting conditions or those who develop comorbid conditions post-injury may especially benefit from PGT — as they may be receiving multiple medications that could potentially elevate their risk for drug-drug and gene-drug interactions. PGT information could also help the clinician better understand whether drugs prescribed for comorbid conditions will be effective.

“In the workers’ comp space, PGT could be used to help the clinician optimize medication prescribing and avoid trial and error,” Hussainzada said. “This has the potential to translate to faster recovery, less time away from work and shorter claim duration for the injured worker.”

See also: Genetic Testing: The New Wellness Frontier

Polypharmacy challenges

Multiple medication regimens and comorbid conditions are frequently present in workers who are injured on the job. The inability to work and the presence of pain can result in additional comorbidities, especially depression.

Metabolism can play an important role in how patients respond to medications, particularly antidepressants, opioids, certain anticoagulants and cardiovascular medications. Mental health providers, in fact, were among the first to recognize the value of PGT in guiding medication therapy and dosing.

“Mental health disorders are often assessed subjectively, and drug therapy can be lengthy, unpredictable and suboptimal,” Hussainzada said. “It may take several months to stabilize a patient on an effective antidepressant using trial and error.”

PGT can be especially useful for antidepressants. “There are actionable PGT results with good evidence for the antidepressants,” Tharp said. “That would be an instance where PGT may be useful [among injured workers].”

In addition to antidepressants, Tharp said PGT is also being used to help determine a patient’s ability to properly metabolize warfarin, which is used to prevent blood clots.

Drug-drug interactions

Individuals metabolize medications differently, partly depending on a person’s genetic makeup and partly on clinical factors, such as hepatic (liver) disease, lifestyle factors and administration of other medications. For example, introducing a new medication may change how existing drugs are metabolized, which can change their effectiveness or tolerability. Conversely, an existing medication may have an impact on the metabolism of a new medication.

“There are well-documented drug-drug interactions between opioid analgesics and certain antidepressants,” Hussainzada said. “This is because some antidepressants can inhibit or ‘turn off’ the enzymes responsible for metabolizing opioids. This can lead to the opioid becoming less effective, or in some cases, intolerable or potentially toxic. Making matters more challenging, there are some individuals that carry certain genetic variations that can make them more susceptible to a phenomenon called ‘phenoconversion,’ which can elevate their risk for certain types of drug-drug interactions. For injured workers receiving polypharmacy, PGT may help clinicians identify these higher-risk individuals and help mitigate some of the risks of phenoconversion.”

There are four categories of metabolizer type that correspond to how individuals may metabolize certain medications via hepatic enzymes. Individuals classified as “extensive” metabolizers possess fully functional enzymes and are able to metabolize medications normally. However, some individuals carry genetic variations that lead to reduced or significantly reduced enzyme function, and are classified as “intermediate” or “poor” metabolizers. Finally, some people may have genetic variations that lead to significantly increased enzyme function and are classified as “ultra-rapid” metabolizers. What that means is: Two people taking the same drug at the same dose can have very different responses because of their metabolizer status.

Individuals susceptible to phenoconversion can “switch” metabolism type, for example, from an intermediate or extensive metabolizer to a poor metabolizer. The trigger for these conversions is non-genetic extrinsic factors, such as administering a drug that inhibits the enzyme pathway. Certain metabolizer types are associated with higher risk of phenoconversion and risk of drug-drug interactions.

“Intermediate metabolizers may be at higher risk for phenoconversion compared to normal metabolizers,” Hussainzada said. “However, it can be difficult to identify these patients because they may display normal or typical response to a medication, even if they are metabolizing that drug at a reduced rate. However, if an inhibitor of the drug is added to their regimen, this can shift the individual from intermediate to poor metabolism and lead to medication failure and/or potentially serious side effects.”

For some claimants who take medications for pre-existing conditions, adding a pain medication can increase the risk for drug-drug interactions and phenotypic conversion. “So a claimant who has been taking antidepressants for years is now also prescribed an opioid because of his injury,” Hussainzada said. “If he is an intermediate metabolizer for the opioid, the antidepressant may convert him to a poor metabolizer. This could lead to inadequate pain relief, which may delay recovery and increase risk of poor outcomes.”

In another scenario, an injured worker who is taking opioids for his injury and who later develops depressive symptoms may be treated with concomitant antidepressant therapy. “In this case, the opioid may have been initially effective, but certain opioids would lose analgesic potency once the inhibitor, or antidepressant, is added,” Hussainzada said.

PGT can also help a clinician identify patients who may need to be started with atypical or non-standard doses of certain analgesics. One particular enzyme responsible for the metabolism of a large number of medications is cytochrome P450 2D6, or CYP2D6. Claimants who are reduced metabolizers for the pathway may not respond adequately to a standard dose of oxycodone.

“If you are a CYP2D6 poor metabolizer, standard doses of oxycodone or hydrocodone may not effectively control your pain,” Hussainzada said. “However, without knowing this type of genetic information beforehand, it may appear to the clinician that these individuals are drug-seeking if they continue to ask for higher doses.”

Some poor metabolizers may not get any pain relief, even with very high doses of a medication. Identifying these patients through PGT can lead the clinician to prescribe a different pain medication from the start, something that can be critical to getting an injured worker back to function.

According to a recent position paper from Healthcare Solutions, the rates of comorbidity and polypharmacy are on the rise in workers’ comp and can lead to increased medical costs, delayed returns to work and longer claim durations. Clinical depression is a common comorbidity, and the use of antidepressants is prevalent; however, both are associated with poor recoveries and outcomes.

“For patients taking multiple medications, there may be multiple enzymes that are recruited to metabolize and eliminate these drug combinations from the body,” Hussainzada said. “Some recent data indicates that when you look across multiple enzymes, genetic variation is much more common than when you look at a single enzyme. So for the claimant receiving polypharmacy, it may be even more important to understand how their genetics will contribute to their medication response since it is likely that at least one enzyme system may be variant.”

Clinicians can use PGT information at the beginning of a claim to optimize initial prescribing and dosing of opioids and other medications, which may hasten the recovery time. “In workers’ comp, the data are pretty clear: The faster we can facilitate post-injury recovery and get the claimant back to work, the better their overall prognosis,” Hussainzada said. “Particularly with opioid therapy, we want to use these drugs judicially and effectively.

See also: Urine Drug Testing Must Get Smarter

The future

Researchers and workers’ comp practitioners continue to monitor the clinical evidence for testing in an effort to help clearly identify those injured workers who would benefit most from PGT — in terms of better outcomes and lower costs. For now, there are several types of injured workers who may be good candidates for testing.

“A claimant taking multiple medications from several therapeutic classes, one who has failed several therapies and changing dosages or a patient on ultra-high daily morphine equivalent doses may be a good candidate for PGT,” Healthcare Solutions’ Tharp said.

Ultimately, proponents hope PGT can be a useful tool in getting the right medication at the right dose to each patient. If test interpretations are based on firm clinical evidence, PGT can provide clinicians with a road map for navigating prescribing decisions that can often be complex and subjective. However, providers are advised to become familiar with PGT and, especially, the companies marketing these services.

“Payers, clinicians and patients need to be aware that not all pharmacogenetic testing is equal. Ask questions about the evidence for specific genes and drugs and make sure there are clinical standards in place for how results are interpreted,” Hussainzada advised. “Some tests may not be ready for clinical use, so it’s important to be informed.”

Hope on Depression in the Workplace

There is a silent epidemic taking a toll on the American workforce. This illness affects 9.5% of the adult population and is to blame for 200 million lost workdays each year. Those lost workdays cost employers an estimated $17 billion to $44 billion. Despite these staggering statistics, only one-third of those affected by this common illness will ever seek professional help. What is this cause of disability, absenteeism and productivity loss? Depression.

There are many reasons an employee may keep concerns about his mental health private. Stigma, fear of losing his job and lack of awareness can prevent an individual from seeking help. Despite these hurdles, there are strategies employers can implement to not only connect their employees with the help they need but to also improve productivity. Employers that address mental health issues have happier, healthier employees and see increased productivity and profits.

Confidential online depression screenings are a proven way to reach those in need and help direct them to appropriate assistance. For more than a decade, the WorkplaceResponse program has worked with organizations to address mental health issues in the workplace. Developed by the nonprofit Screening for Mental Health, WorkplaceResponse is a mental health education and screening program that easily integrates into existing employee assistance programs or enhances existing wellness initiatives hosted by human resource departments or employee assistance programs.

The program offers screenings for common mental health concerns, including depression, bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, eating disorders and alcohol use disorders. Screenings are anonymous and engage employees in becoming active participants in their own well-being. Upon completion of a screening, employees are provided with immediate results and linked back to employee assistance program (EAP), local or company resources.

Health promotion programs can also have positive effects in the workplace. These programs serve as excellent tools to increase mental health awareness and educate workers on the signs and symptoms of depression. Managers and employees who can identify these symptoms can assist at-risk individuals with receiving the help they need.

National Depression Screening Day (NDSD), held annually on the Thursday of the first full week in October, is dedicated to raising awareness and screening people for depression and related mood and anxiety disorders. NDSD is the nation’s oldest voluntary, community-based screening program that gives access to validated screening questionnaires and provides referral information for treatment.

Oct. 8 marks the 25th year of the revolutionary campaign. This milestone allows for opportunities to begin the conversation about mental health in the workplace. Identifying workplace risk factors, taking action to reduce employee stress and initiating organizational wellness programs can be productive first steps.

Employers can make a difference by encouraging employees to take a quick, anonymous mental health assessment at http://helpyourselfhelpothers.org/ or by launching a 25-day wellness challenge. To encourage employees to take care of their mental health, a 25-day wellness challenge provides ideas and actions individuals can take to relieve stress, boost mindfulness and foster healthy behaviors. Examples include walking, cooking with family and taking a break from technology. Simple methods like the challenge can help increase awareness in the workplace.

It is time to address workplace depression. Effective screening tools are available, and treatment works. The early detection and prevention of mental health conditions can improve the lives of individual employees as well as the health of an organization.

6 Things to Do to Prevent Suicides

This year, for World Suicide Prevention Day, the theme is “Reaching Out to Save Lives” – a message all employers can use to let people know that everyone can play a role in suicide prevention. The National Action Alliance for Suicide Prevention’s Workplace Task Force members and the organizations they serve offer the top six things workplaces can do during the month of September to make prevention a health and safety priority:

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  1. Offer a Leadership Proclamation: “Not Another Life to Lose”

Members of executive leadership can take bold and visible positions declaring suicide prevention and mental health promotion critical workplace concerns. This proclamation can be in the form of a newsletter to employees or a video on a website.

  1. Highlight Mental Health Resources

Host a brown bag lunch program each day for the week. Invite employee assistance program (EAP) representatives or other local mental health professionals to offer educational session on stress, work-life balance, coping with depression or other related topics.

Offer a mental health fair where local suicide prevention, mental health or other wellness resources share more information and employees get a “passport” stamped for each one they visit. Completed passports go into a drawing for a prize.

Send resources to employees such as:

  1. Launch a Mental Wellness Task Force

A true comprehensive and sustained public health approach to prevention will take more than an awareness week or one-time training. To create significant change, a more strategic approach is needed. Start by pulling together a small group of stakeholders – people whose job titles reflect some level of relevance to this issue (i.e., wellness, HR, risk management, safety) and others who are passionate about prevention because it has touched their lives personally. Their task? To identify culturally relevant areas of strength and vulnerability for suicide within the organization and to develop a strategic approach to change.

Here are some resources:

  1. Leverage Social Media

During this week, companies can join the international conversation by posting on Twitter and Facebook.

  • Sample posts:
    • [Name of company or Twitter handle] makes #suicideprevention a health and safety priority #WSPD15
    • [Name of company or Twitter handle] We are doing our part to #preventsuicide during #NSPW. Everyone can play a role!
  • Hashtags:
    • National Suicide Prevention Week (Sept. 7-13)
      • #NSPW
      • #NSPW15
      • #SuicidePrevention
    • World Suicide Prevention Day (Sept. 10)
      • #WSPD
      • #WSPD15
    • Workplace
      • #WorkplaceMH
      • #WorkingMinds
    • Guidelines on social media and mental health.
  1. Honor Suicide Loss With Candle-Lighting Ceremony

How companies respond to the aftermath of suicide matters greatly. Grief and trauma support, thoughtful communication and compassionate leadership can help a workforce make the transition from immobilization to a bonded community.

Here are some resources:

  1. Donate to or Volunteer for Local or National Suicide Prevention Organizations

Engaging in community prevention efforts is a great way for employees to give back and to get to know the local resources available. Corporate investments in prevention programs and research will help us get ahead of the problem. Get involved!

Here are some resources:

Stigma’s Huge Role in Mental Health Care

The role of stigma for people who are in need of mental health treatment is both profound and devastating. According to a 2011 study by the Association for Psychological Science, only 60% of people diagnosed with mental health problems reported receiving treatment. That means 40% of the millions of people in the U.S. who need professional help are getting no treatment whatsoever. Social stigma, myths and stereotypes play a huge role in limiting both access to care and discouraging people from pursuing mental health treatment. The problem is multifaceted and complex and has a wide-reaching effects on people’s education, employment, health, well-being and relationships.

There are many forms of stigma and stereotypes. First, there is a widespread public perception that people with mental illness are dangerous, unpredictable and responsible for their own illness and not deserving of compassion and care. As a result, people in need of help are excluded from jobs, education and much-needed social interaction.

This problem also plays out in the professional medical setting, where negative stereotypes often lead medical providers to be less likely to focus on the patient rather than the disease and to not place the needed focus on recovery and referral for needed consultation and care.

Stigma in society and lack of awareness among medical providers also contributes to what is known as self-stigma. That is: People in need of help believe these stereotypes themselves and develop low self-esteem, which results in denial, attempts to hide problems, alcohol and drug abuse and a sense of hopelessness — they feel they are unable to recover, so why try? These are the people who make up the 40% not seeking treatment and consultation.

Stigma results in a double problem for many people. They have real underlying symptoms, which lead to an actual disability, while myths and misconceptions lead to stereotypes and prejudice. Too often, people turn against themselves. Depression, for example, has been referred to by mental health professionals as “rage turned inward.” This can lead to fear of rejection, isolation and hostile behavior. The result often is that the needed health care system is replaced by the criminal justice system.

How many people incarcerated today have an underlying untreated mental health condition? My guess is most, if not all. These are the people who did not pursue potential life opportunities for themselves but rather pursued illegal drugs or crime out of a sense of low-self-esteem and hopelessness. The overall result is both devastating to them and society as a whole.

Underlying mental health issues also have a huge impact on both healthcare and disability costs for private and public employers, health and disability insurers and both Medicare and Medicaid and the Social Security disability system (SSDI). How many people collecting private or public disability have an underlying, undiagnosed mental health problem? Nobody really knows, but many disability experts believe the number is staggering. The resulting costs to employers, insurers and taxpayers of untreated or undiagnosed mental health issues is in the billions of dollars.

In 2003, I helped conduct an unpublished study for a major U.S. corporation regarding its active employees out of work on full disability with a primary diagnosis of depression. The analysis cross-referenced these employees’ disability claim data with their health insurance data base. It was found that 80% of the primary treating providers in the healthcare benefit side had no mention whatsoever of a primary or secondary diagnosis of depression. This means that their primary treating provider or “family doctor” was either unaware of the underlying mental health issues or failed to acknowledge or consider the possibility.

What was not able to be studied in this research was how many workers out on disability or workers compensation for a “bad back” really had an underlying mental health issue. The study did determine the No. 1 and 2 co-morbidities for employees out on disability for depression was musculoskeletal conditions and gastrointestinal conditions. The overwhelming number of medical providers treating and submitting claims for these co-morbidities (80%) had no mention of an underlying mental health issue despite the fact that their patient was out of work on full disability with a primary diagnosis of depression. The healthcare and disability costs of these employees out on full disability with a primary diagnosis of depression was staggering and in the millions just to this U.S. corporation. Because this large employer was self-insured for healthcare, disability and workers’ compensation these costs go directly to its bottom line. These costs are then indirectly passed on to corporate customers and the general public purchasing the company’s products and needed services.

What needs to be done to address underlying and untreated mental health conditions?

I do not believe any new federal legislation is required at this time. The Affordable Care Act (ACA), the Americans with Disabilities Act (ADA) and the Mental Health Parity Act are all in place to help people receive needed mental healthcare access. There is no reason people should not seek professional help that they need.

As in most complex public health issues, the answer lies in awareness, education, outreach and research dollars. Educating the public is a very difficult task. As we have learned the hard way with overall prejudices, urban myths and misinformation in society, in general educating people can take generations. Medical authorities in leading medical schools and institutions have also stated that documented research and best practices based on evidence-based medicine can take 20 years to filter down to local medical practices, if ever.

People suffering with underlying mental health issues don’t have 20 years to wait for proper referral and treatment. Medical professionals on the front line need to be educated today to ask the right questions with their patients about potential underlying mental health issues and help reassure people that the overwhelming majority of mental health issues can be diagnosed and successfully treated.

As a society we can no longer allow people to hurt themselves or others when treatment is readily available for people who need help because of genetic and other environmental causes that are no fault of their own. How many of our major problems such prejudice and gun violence have a root cause in untreated mental health issues? Maybe all of them.

Breaking the Silence on Mental Health

Shh, it’s time for another round of “let’s discuss depression or suicide in the workplace.” That’s right, shh. After all, we aren’t supposed to discuss these issues. If we do, someone else may try to commit suicide. If we hush up the problem, maybe it will go away.

So, help me to understand why we tolerate this silence with mental illness and not with any other medical condition. I think it is because mental health is a bit more mysterious and scarier than most other conditions.

But mental health does account for a large percentage of the costs related to lost productivity ($51 billion). It generates direct costs of treatment of $26 billion a year[1] — and “absence, disability and lost productivity related to mental illness cost employers more than four times the cost of employee medical treatment.”[2]

We need to get over our fear and get the discussions out in the open. Only then will we have a chance to break the cycle.

The goal of breaking the silence is already occurring on the high school level and is showing results. I realize that this is a different population, teen-agers, but talking about it really does matter in prevention. This most recently occurred in a high school in Crystal Lake, Ill., after two teen-age friends took their lives. The school and community leaders made a point of getting information to other students about the warning signs so that they could possibly identify those in danger and encouraged parents to talk with their teens about their grief. Leaders also provided grief counselors onsite and gave the students different options for grieving, which included holding vigils, providing groups and allowing for other forums of expression.

This is an excellent model that can be adapted for the workplace in partnership with your employee assistance program (EAP). Here are some things employers can do for their workplaces after a suicide:

  • Openly discuss suicide and offer grief groups to anyone directly or indirectly involved with the people who took their lives. Make it okay to talk about the suicide. For more information on steps employers might take, go to “A Manager’s Guide to Suicide Postvention in the Workplace.”
  • Provide information about the warning signs so that employees can help identify others who might be at risk. Make sure that employees and their family members get information about resources that they can access for themselves, their family members or other co-workers. And stress the confidential nature of these sources. A great first step is the National Suicide Prevention Lifeline (800-273-TALK (8255)).

The best defense, however, is a good offense. To encourage prevention, I suggest the following:

  • Create a “mental health/wellness” friendly workplace that involves openly discussing mental health and stress and making sure that employees know that there is confidential help available.
  • Provide employees and managers with training on signs of depression, anxiety, etc. and encourage them to seek help if they or a colleague is showing any of these signs.
  • Have your EAP visible through consistent promotional efforts using print, email and social media.
  • Make sure that the company’s benefits plans have good mental health coverage.

I have been lucky enough to have spent the last 36 years in the field helping individuals and organizations become more open to dealing with psychological issues that may interfere with their professional or personal growth. And I have been amazed at how successful treatment can be when the issue is confronted head-on.

As leaders in the insurance industry, those of you who subscribe to this blog are trusted advisers to the leadership and decision makers in organizations of all kinds. I therefore implore you to use these relationships to encourage them to face mental health in an open and forthright manner. Only when people are able to openly seek out help for mental health related concerns in the same manner that they seek out medical treatment for other issues will we be successful.

[1] Managed Care Magazine (2006, Spring) Depression in the Workplace Cost Employers Billions Each Year: Employers Take Lead in Fighting Depression.

[2] Partnership for Workplace Mental Health, A Mentally Healthy Workforce—It’s Good for Business, (2006), www.workplacementalhealth.org.