Clinical guidelines for the diagnosis and management of work-related mental health conditions (Work-related Mental Health Guidelines) (CURRENT)
The Clinical Guidelines, Technical Report and Implementation Plans are now available Click here for more information
Funding: This project is funded by the Department of Employment and Comcare, Queensland Treasury-Department of Industrial Relations, State Insurance Regulatory Authority, ReturnToWorkSA, and WorkCover WA, via the Institute for Safety, Compensation and Recovery Research, $850,267.
Team: Professor Danielle Mazza, Dr Bianca Brijnath, Dr Samantha Chakraborty, Ms Jacinta Clements
The issue: Our previous research has found that GPs provide sub-optimal care for people with work-related mental health conditions. This work (see GP RTW Study) showed that 94% of initial GP certificates for mental health claims recommend patients as unfit for work. Some of the clinical challenges that GPs faced included initial assessment and diagnostic difficulties because of the invisibility of mental health injuries; establishing whether a mental health condition developed as a consequence of work; conflicting medical opinions between GPs and specialists, GPs and medical panels and GPs and patients about the cause, severity, treatment and prognosis of mental health conditions; the development of secondary mental health conditions after an initial compensable injury; and predicting when patients should return to work and recommending alternative duties. GPs themselves have expressed a need for more educational and training support about diagnosing and managing work-related mental health conditions.
Aims: We are developing a national clinical guideline to help GPs improve their diagnosis and management of work-related mental health conditions. A secondary outcome will be the creation of an implementation plan to support the uptake of the guidelines in practice.
This study used qualitative methods. Initially, telephone interviews were conducted with a pilot group of psychiatrists, general practitioners (who have treated worker compensation patients with a mental health injury claim within the past three years), and compensation scheme workers. 25 GPs psychiatrists and six compensation scheme workers were then interviewed as part of the study.
Participants were presented with two case scenarios and asked to respond to the management of the patient in each scenario, focussing on areas of difficulty for GPs. All interviews were transcribed and thematically coded. Findings were used to determine key guideline questions.
A Guideline Development Group (GDG) has been established to act as an advisory group to the project team. The GDG will provide advice about the strength of existing evidence and formulate recommendations for inclusion in the guidelines and will also:
- define the guideline scope and content area;
- evaluate the current evidence;
- create draft guidelines;
- release the draft guidelines for public consultation;
- refine and finalise the guidelines;
- develop an implementation and translation plan for embedding the guidelines into clinical practice;
- seek guideline approval from the National Health and Medical Research Council (NHMRC) and the Royal Australian College of General Practitioners (RACGP); and
- publish and disseminate the guideline within 16 weeks of date of NHMRC approval, in accordance with NHMRC publishing requirements.
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Funding: WorkSafeVictoria and the Transport Accident Commission via the Institute of Safety, Compensation and Recovery Research provided $42,181 to support this study.
Investigators: Danielle Mazza, Bianca Brijnath, Nabita Singh
The issue: Our previous research regarding sickness certificates that were written by GPs found that 74.1% of certificates stated that patients were unfit for work. In the UK, a growing body of work undertaken by Dame Carol Black and colleagues has found that certifying for incapacity has the potentially worsens patient outcomes. By contrast, certificates which focus on building existing capacity (e.g. by classifying patients as ‘fit to undertake alternative duties’, or ‘fit to work’) are linked with better patient outcomes and earlier return to work. Driven by this research, in 2013 WorkSafeVictoria and the Transport Accident Commission redesigned their sickness certificate to focus on capacity, thus producing a new ‘certificate of capacity’. Our team was tasked with evaluating the certificate – in particular the appropriateness of the certificate and its usability.
What we did: We conducted in-depth interviews with 10 GPs, 6 employers and 5 injured workers, and we conducted one focus group discussion with 8 compensation agents.
What we found: All participants felt that the new certificate was an improvement from the previous version. Nevertheless, GPs continued to certify injured workers based on incapacity, rather than capacity to work. All groups wanted more clarity about assessing patients with mental health conditions. GPs, employers and compensation workers also wanted the certificates to be available electronically.
What’s next: This study informs compensation schemes about how to create a certificate that is useful. In the long-term it would be useful to undertake an impact evaluation to see if the new certificate has improved the way that GP certify injured workers.
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Read more here:
Stakeholder perspectives on the new sickness certificate in Victoria: results from a mixed-methods qualitative study. Brijnath B, Singh N, Mazza D. Aust Health Rev. 2016 Feb;40(1):27-32
In 2013 the two statutory injury compensation authorities in Victoria, Australia, WorkSafe Victoria (WSV) and the Transport Accident Commission (TAC), redesigned their sickness certificates to focus on capacity. The aim of this study was to evaluate whether the new draft certificate was usable and whether the revised content and structure were appropriate. Four key stakeholder groups – GPs, injured workers, employers and compensation agents - participated in either individual interviews or a focus group discussion. All stakeholders said that the new certificate was an improvement on the previous certificate however groups differed in their understanding about the purpose of the certificate. All stakeholders wanted more information about mental health assessment to be included in the certificate and most stakeholders wanted the certificate to be available electronically.
Funding: Victorian WorkCover Authority (VWA) via the Institute of Safety Compensation and Recovery Research (ISCRR) provided $150,000 to support this project
Investigators: Danielle Mazza, Bianca Brijnath, Rasa Ruseckaite
The issue: Until now in Australia, there were few available studies on the role of healthcare providers in facilitating RTW and no studies explicitly focusing on the role of GPs in facilitating RTW. Yet the strategic role of GPs in the compensation system suggests that they have an important part to play in the RTW process. Using a mixed methods approach, our study aimed to explore the current knowledge, attitudes and practices of GPs, injured workers, employers, and compensation schemes in enabling GPs to facilitate injured workers to return to work.
What we did: We used a mixed-methods approach using (1) qualitative in-depth interviews with 93 participants including GPs, employers, injured workers and compensation scheme agents across metropolitan Melbourne, and (2) quantitative analyses of GP sickness certification data from the Victorian workers compensation system.
What we found: The number of certificates issued by GPs increased between 2003 and 2010. A small proportion of GPs (3.8%) were responsible for nearly a quarter of all injured worker certificates (24.8%). There were no differences in return to work outcomes according to GP caseload.
There are numerous reasons for the high rates of ‘unfit’ certificates issued by GPs. These include a lack of clarity about the GP’s role in return to work, heavy reliance on injured workers feedback on capacity to work and availability of alternative/modified duties, lack of communication and coordinated care between key health providers, high administrative burden, and the age and social circumstances of injured workers. Mental health claims were noted to be complex and were most likely to result in ‘unfit’ certificates for long periods of time.
What’s next: This landmark study has prompted changes in certification across Australia and has opened up a number of promising avenues for further research to build capacity across primary care.
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Factors associated with sickness certification of injured workers by General Practitioners in Victoria, Australia.Ruseckaite R, Collie A, Scheepers M, Brijnath B, Kosny A, Mazza D. BMC Public Health. 2016;16:298
The type of sickness certificate that a GP provides to an injured worker can have a long-term impact on the injured worker’s health and wellbeing. The aim of this study was to find out what factors may influence GPs when they are writing certificates for injured workers following a work-related injury. A retrospective population-based cohort study was conducted on compensation claims between 2003 and 2010. The investigators used logistic regression analysis to identify factors that influenced GPs to certify workers as either unfit-for-work versus fit to undertake alternative duties. A total of 119,900 claims were analysed. This study found that specific groups of injured workers (workers with fractures, older age workers, workers with mental health issues, and workers who live in rural areas) were less likely to receive certificates for alternative duties.
General practitioners and sickness certification for injury in Australia.Mazza D, Brijnath B, Singh N, Kosny A, Ruseckaite R, Collie A. BMC Fam Pract. 2015;16:100
Most people with compensable injuries in Australia are certified as ‘unfit to work’ by their GP. 93 GPs, injured workers, employers and compensation scheme agents from Melbourne, Australia participated in face-to-face semi-structured interviews about the factors that influence GP certification. Five themes were identified in this study: (1) divergent views from stakeholder groups about the GPs role in facilitating return to work; (2) communication between the four stakeholder groups; (3) conflict between stakeholder groups; (4) allegations of misuse of the compensation system by GPs and injured workers; and (5) the layout and content of the sickness certificate. This study highlights numerous opportunities for improvement of GP certification practices in Australia.
Mental health claims management and return to work: qualitative insights from Melbourne, Australia.Brijnath B, Mazza D, Singh N, Kosny A, Ruseckaite R, Collie A. J Occup Rehabil. 2014 Dec;24(4):766-76
In Australia work-related mental health claims are the second most common reason for workplace compensation claims, however little is known about how these claims are managed and how return to work following a mental health claim is facilitated. Ninety-three in-depth interviews were undertaken with GPs, compensation agents, employers and injured persons in Melbourne, Australia. This study found that mental health claims were complex to manage because of difficulties with assessing injured workers and diagnosing mental health conditions. Further education and training interventions are needed to help GPs, employers and compensation agents facilitate return to work for people with mental health claims.
Trends in sickness certification of injured workers by general practitioners in Victoria, Australia. Ruseckaite R, Collie A, Bohensky M, Brijnath B, Kosny A, Mazza D. J Occup Rehabil. 2014 Sep;24(3):525-32
This study looked at how GPs complete sickness certificates for injured workers in Victoria, Australia between 2003 and 2010. A retrospective population-based cohort study was conducted and sickness certification rates per 1,000 working population per annum were calculated. Most certificates were classified as unfit for work (74.1%), with alternative duties prescribed in 22.8% of certificates. Only 3.1% of certificates were classified as fit for work. GPs are increasingly classifying workers who have musculoskeletal injuries with alternative duties, however workers with mental health conditions continue to be classified as unfit for work.
Sickness certification of workers compensation claimants by general practitioners in Victoria, 2003-2010.Collie A, Ruseckaite R, Brijnath B, Kosny AA, Mazza D. Med J Aust. 2013 Oct 7;199(7):480-3
A retrospective analysis of the Victoria workers compensation database was conducted for all injured and ill workers between 2003 and 2010. 74.1% recommended that workers were unfit for work and 22.8% recommended alternative duties. Unfit-for-work certificates were issued to 94.1% of workers with mental health conditions, 81.3% of those with fractures, 79.1% of those with other traumatic injuries, 77.6% of those with back pain and strains, 68.0% of those with musculoskeletal conditions and 53.0% of those with other diseases.
Health Benefits of Safe Work Evaluation Plan: GP Partnerships and Engagement & Redesign Certificate of Capacity (COMPLETED)
Funding: Victorian WorkCover Authority (VWA) and the Transport Accident Commission (TAC) through the Institute of Safety Compensation and Recovery Research (ISCRR) provided $49,070 to support this project
Investigators: Danielle Mazza, Bianca Brijnath, Samantha Bunzli, and Ting Xia
The issue: The Health Benefits of Safe Work (HBoSW) program was designed to optimise General Practitioners (GP) management of compensable injuries and return to work outcomes. The program comprised of six arms and was conducted over the period 2013-2015. The team was tasked with evaluating three of the program arms: GP engagement in the HBoSW program, attitudes of GPs towards the redesigned Certificate of Capacity, and changes in GP certification of capacity for compensation claims following the introduction of the redesigned certificate.
What we did: The qualitative evaluation of the GP engagement in the HBoSW program and attitudes of GPs towards the redesigned Certificate of Capacity was conducted from July 2014 to July 2015. The quantitative evaluation of GP engagement in the HBoSW program and changes in GP certification of capacity for compensation claims following the introduction of the redesigned certificate began in August 2015 and closed in March 2016.
What we found: Findings from the evaluation of the Health Benefits of Safe Work program suggest that the reach of the program was limited. GPs and other practice staff who participated in the education intervention about the health benefits of safe work reported little change in their knowledge and attitudes towards return to work following compensable injury. Almost all GPs included in this study reported being aware of the health benefits of work prior to the intervention and change in certificate.
What’s next: Further specific and targeted education about the health benefits of safe work directed at GPs is not recommended. Rather these messages may be integrated into other programs targeting the areas of educational need identified in this study namely, clinical aspects of the management of mental health conditions and the administrative and legal aspects of compensable injury management.
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