March 30, 2021 Workers' Comp

Mind Over Matter: Addressing Mental Health Comorbidity With Pharmaceutical Treatment

<p>“Mind over matter” is a familiar saying suggesting the potential of “will” to manage or overcome a physical challenge or to persevere beyond expectations. We understand our minds to be powerful agents of will, but how does mental health comorbidity play into a workers’ compensation or auto injury recovery? When a person struggles to cope with a physical injury and a host of other life issues, how might recovery be hampered? Alternatively, how can a healthy mindset help with recovery?</p>

“Mind over matter” is a familiar saying suggesting the potential of “will” to manage or overcome a physical challenge or to persevere beyond expectations. We understand our minds to be powerful agents of will, but how does mental health comorbidity play into a workers’ compensation or auto injury recovery? When a person struggles to cope with a physical injury and a host of other life issues, how might recovery be hampered? Alternatively, how can a healthy mindset help with recovery? Mental health is demonstrated to have a large impact on a person’s ability to cope with and recover from a workplace or auto injury—especially when pain is also involved. Let’s look at how mental state affects health and recovery outcomes and how your pharmacy program might aid in managing mental health issues.

The Mind-Body Connection

Disease comorbidity, or the presence of more than one disease or condition in one person at the same time, is generally associated with worse health outcomes, greater complexity of clinical management and related costs. Comorbidity of chronic pain and major depression is especially complex, often contributing to delayed recovery and increased costs. The operating crosswalk from pain or injury to depression and vice versa is clear in a study from Harvard Health. “People with chronic pain have three times the average risk of developing psychiatric symptoms—usually mood or anxiety disorders—and depressed patients have three times the average risk of developing chronic pain.” A similar study looking at the link between depression and chronic pain adds to this: “Clinical studies have revealed that chronic pain, as a stress state, often induced depression and that up to 85% of patients with chronic pain are affected by severe depression.” In an auto accident, rates of depression post-injury can be particularly prevalent. A study in the Social Psychiatry and Psychiatric Epidemiology journal states, “A review of psychiatric morbidity following motor vehicle injury found that the rates of depression across studies ranged between 21 and 67%.” Mental health comorbidity, like major depression and anxiety, are among the most frequently occurring with pain, significantly impacting full recovery and return to work. In a study of more than 7,000 workers’ compensation claims from Harbor Health Systems, depression and mental health comorbidity increased claim durations, medical costs, temporary total disability days and rates of litigation. Whether in a workers’ compensation or auto casualty claim, the relationship between mental health and recovery outcomes that these stats describe are particularly important to observe. Not only can the physical experience of pain cause mental stress and contribute to depression, but the recovery process, including new routines, life changes, financial burdens and PTSD can all exacerbate the perception of physical pain. Harvard Health states, “Pain slows recovery from depression, and depression makes pain more difficult to treat; for example, it may cause patients to drop out of pain rehabilitation programs.” Many other studies of patients with depression and comorbid pain also speak to diminished pain treatment success and prognoses. On the other hand, a positive or healthy mindset can also help with recovery from a physical injury. Compelling examples of the power of the mind-body connection exist in athletic performance optimization and its impact on placebo effect in clinical trials. First, there is a measurable impact of state-of-mind in the healing process (as was explored in the antithesis above). A NIH meta-analysis study on Optimism and Physical Health showed that, “optimism was a significant predictor of health outcomes or markers.” Additionally, there have been extensive studies on the benefits of mindfulness, cognitive behavioral therapy, and meditation to support positive mind-body healing and pain management. For example, “the recent evidence-based clinical practice guidelines from the American College of Physicians (ACP) gave a strong recommendation” for treating lower back pain with acupuncture and mindfulness-based stress reduction (NIH). It is believed that when stress is reduced, inflammation is also reduced—leading to healing. Secondly, the mind can have an impact on the intensity of the symptoms a person feels. In an interesting study using virtual reality gaming, burn injury pain was reduced by up to 50% more than drugs alone. According to Jeannie Sperry, a psychologist who co-chairs the division of addictions, transplant, and pain at Mayo Clinic, “’Acute pain is generated in the peripheral nervous system, which conducts danger signals to the brain. From there, the brain determines whether it’ll experience the pain signals or ignore them,’ Sperry said. ‘In the case of chronic pain, that system has gone awry,’ Sperry said. ‘Without training your brain to turn down the alarm system, the alarm keeps going off all the time.’” Luckily, as Harvard Medical School reports, “Research suggests that because pain involves both the mind and the body, mind-body therapies may have the capacity to alleviate pain by changing the way you perceive it.”

Can Pharmaceuticals Support Both Pain Management & Mental Health Comorbidity?

Treatment for pain and mental health comorbidity are necessarily complex and multi-layered. So how can we help support both by acknowledging the power of the mind-body connection and supporting the recovery process from all angles? Data from Mitchell Pharmacy Solutions suggests that antidepressant prescribing is on the rise in workers’ compensation, with utilization in retail and mail order settings increasing 12.5% from 2019 to 2020 and percent of total drug costs in claims rising to 11.3% from 10.5%. Interestingly, studies have suggested that drugs typically used for mental health management may be effective at treating pain, (e.g.  antidepressants—Duloxetine and Venlafaxine) and vice versa. This is likely because these conditions share biochemical “messengers” (neurotransmitters), anatomic and physiologic pathways. Harvard Health suggests, “Almost every drug used in psychiatry can also serve as a pain medication. Relieving anxiety, fatigue, depression, or insomnia with mood stabilizers, benzodiazepines, or anticonvulsants will also ease any related pain. The most versatile of all psychiatric drugs, the antidepressants have an analgesic effect that may be at least partly independent of their effect on depression since it seems to occur at a lower dose.” As always, medications should be considered on a claim-by-claim basis taking into account what is best for the patient. Other studies have found that opioids may have a limited positive effect on mental health comorbidity in treatment up to a certain point and in certain patients. However, opioids used for longer treatment courses are also linked to negative effects, especially with long-term use, with one study finding that “patients taking opioids for 31–90 days were found to be at an 18% higher risk for depression than those taking opioids for 1–30 days. Additionally, depression may prolong the duration of opioid use.” Studies of other “non-traditional” substances for use in mood disorders and pain, including ketamine, psilocybin, ayahuasca and others known to affect cognition, perception and mood are in early progress. Keep an eye out for our upcoming Drug of the Month article to learn more. Overall, no single treatment or “silver bullet” is apparent in the management of injury, pain and mood. Pharmaceuticals offer one important tool supporting relief of an injury in which treatment of the wounded spirit and wounded body helps injured patients recover. Learn more about other approaches here.

Mental Health Considerations for the Workers’ Compensation and Auto Casualty Industries

The complicated, working interrelationship of mind and body expressed simply by “mind over matter” reminds us that we are more than the sum of our parts. The best management of a workplace or auto injury for fullest recovery, return to work and living may be inextricably attached to the sum of externalities in one’s whole life picture. Viral pandemics, physical injury, loss of work, and financial and family stresses all contribute to a person’s ability to heal mentally and physically. Although many approaches to recovery focus on healing the physical injury, the inseparable mind-body connection in healing may, in some instances, necessitate a more holistic approach.

Craig Prince

Craig Prince is a clinical pharmacist for Mitchell Pharmacy Solutions, leading pharmacy communications, P&T Committee functions and operating clinical programs focused on opioid mitigation. Prince is an accomplished healthcare business professional, broadly experienced over his career in enterprise market development, national account management and clinical roles in the pharmaceutical, medical device and managed care industries as well as clinic settings.

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