The statistics prior to the Covid-19 pandemic indicated a significant increase in mental ill health, with one in four adults experiencing mental illness in each given year[1]. We have seen a particular increase in women presenting with mental illness. However, suicide is far more common in men and is in fact the biggest killer in men up to age 45 in the UK. According to NHS England, mental health problems are the largest single cause of disability in the UK. Those living in poverty, the unemployed and ethnic minorities are thought to be disproportionately affected by mental ill health. We don’t know what the long-term effect of the pandemic will be on the population in terms of mental health issues, but it is likely to be significant.
There has also been a surge in mental health problems in children and adolescents, including anxiety, depression, panic attacks, eating disorders and self-harm. The younger generation are facing new challenges relating to technological advances, such as problems with body image owing to social media pressures, online bullying, “revenge porn” and “sexting.” When considering cases involving PTSD symptoms and other psychiatric conditions, we should be mindful of these issues and look for pre-existing issues and vulnerabilities when reviewing the records.
PTSD – Who is vulnerable?
Even the most resilient of people can be significantly affected by trauma and, according to statistics, around 7 out of 100 people will develop symptoms associated with PTSD after experiencing a significant traumatic event[2]. The effects can be chronic and lifelong and there are multiple factors that can have an impact on whether someone will go on to develop PTSD after a traumatic event. Those factors can include: pre-morbid personality; the severity of the traumatic event; forensic history; social circumstances; and prior history of trauma (e.g. childhood abuse). Any such issues in a claimant’s medical records should therefore be recorded in detail and flagged with your team of experts for them to consider.
It is worth noting that PTSD is not particularly prevalent in older adults. However, it has been suggested that this is perhaps down to older individuals not wanting to admit symptoms associated with PTSD due to perceived stigma, and failing to report issues to their healthcare providers. Nonetheless PTSD in later life has been linked to significant physical health problems and disabilities, as well as reduced cognitive functioning[3]. When looking at PTSD in older adults therefore, close attention should be paid to any suggestion of impaired cognitive functioning in the records, as this may have an impact on how much an older adult will be able to benefit from learning based therapies. With older age also comes certain stressors, such as bereavement and medical problems, which are likely to exacerbate PTSD symptoms.
Gender is also an important factor to consider when looking at PTSD cases, as studies have revealed that women are approximately twice as likely as men to develop PTSD during their lifetime[4]. Men are most vulnerable to PTSD between the ages of 41 and 45 years, whereas women are most vulnerable at 51 to 55 years. When dealing with a potential PTSD case therefore, gender and age range can be red flags when profiling individuals more at risk of PTSD than others.
Treatment Options: What’s New?
We are all familiar with the traditional treatments for PTSD and other psychiatric diagnoses, such as talking treatments, Cognitive Behavioural Therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and psychiatric medication. There are also arts and creative therapies, as well as complementary and alternative therapies such as yoga, meditation, hypnotherapy, etc. There are, however, emerging therapies and more unusual forms of treatment that are in the pipeline that we could potentially see being recommended in our expert psychiatry reports in the not so distant future. Some of these are more radical than others.
Dialectical Behaviour Therapy (DBT)
DBT is a common treatment for Borderline Personality Disorder, however more recently, it has also been used to treat a range of other psychiatric conditions, including PTSD. The focus of CBT is to change unhelpful ways of thinking. The aim of DBT is to change unhelpful behaviours, but the difference is that at the same time, it focuses on the patient being able to accept who they are. The meaning of dialectics is to balance opposite positions and look at how they go together and DBT is about finding a balance between acceptance and change. This is something that we may start to see more of in the future.
Virtual Reality Therapy (VRT)
VRT uses a software to build a virtual vision of fears to be used as part of CBT treatment. Psychologists are trialling VRT for all kinds of conditions, from phobias to PTSD, to pain management. Essentially, the recipient enters a virtual reality world constructed to increase their exposure to negative stimuli, so it is a form of “exposure therapy” i.e. experiencing the very thing that triggers anxiety, whilst guided by a professional to help in terms of getting past that fear.
The therapist can recreate a scene that triggers the anxiety, e.g. being in a room full of people, travelling in a vehicle, etc. The US Military are in fact funding research into VRT for veterans with PTSD, as a battlefield setting can be recreated using the VRT software. The primary goal with this form of treatment in a PTSD case would be to build resilience and increase emotional strength. In a pain case, the focus would be on helping to shift a patient’s focus away from pain.
MDMA Assisted Therapy
The Multidisciplinary Association for Psychedelic Studies (MAPS) have been testing MDMA (the party drug commonly known as “Ecstasy”) assisted therapy for over 10 years. The US Food & Drug Administration (FDA) have approved Phase 3 trials of MDMA to treat chronic and delayed-onset PTSD, which is the final phase of validation to legalise it is as medicine. We know that CBT / EMDR is not always effective for lasting trauma but there is evidence that MDMA helps when used in conjunction with psychotherapy. The thinking is that prolonged exposure based therapy is much more tolerable with the drug, than without it.
A recent study looking at the long-term outcomes of this treatment found continued improvements in most patients for more than one year after the treatment ended. The data showed that 67% of patients no longer met the criteria for PTSD more than one year after the treatment ended[5] and therefore there is evidence of long-term positive outcomes.
We are not taking about “street” Ecstasy here – it would be a pharmaceutical grade with a known degree of the drug, which is actually being created in a high security factory in Dudley in the West Midlands. The drug would also only be administered in a licenced centre by a trained psychotherapist. The Phase 3 trials are expected to be complete in 2022, meaning that the treatment could be approved in the United States as soon as 2023. MAPS is also initiating Phase 2 trials in Europe, so this may be something we see in the UK in a few years.
Lysergic Acid Diethylamide (LSD)
It is not just MDMA that is being used in conjunction with therapy. Other psychedelic substances such as LSD are becoming increasingly recognised as potentially effective treatments for depression and PTSD. Research undertaken by a University in Barcelona investigated how LSD triggers changes in consciousness. Music listening was also introduced to see if it could boost the therapeutic effects of the drug. It was found that taking LSD whilst listening to music made the drug more effective at reorganising the brain and synchronising neural networks. It also found that changes in the brain were only temporary lasting a few hours, but evidence suggested that new brain networks, developed whilst under the influence of the drug, could become permanent.
It will be interesting to see how long it takes for these types of therapies to become commonplace (if ever) and to see whether we might see this type of therapy being recommended in years to come. It could be that, in time, insurers are going to be asked to fund these types of therapy but only time will tell.
PTSD and Life Expectancy
Mental and physical health are undoubtedly closely connected and according to the World Health Organisation, people with severe mental health disorders have a 10 to 25 year reduction in life expectancy[6]. So an issue to be aware of in cases involving PTSD and/or depression, is that there is a significant risk of early death from cardiovascular disease, respiratory disease, type II diabetes, accidents, suicide and other causes.
We therefore need to consider these statistics when thinking about future losses in cases where there is a psychiatric element / longstanding mental health issues. Life expectancy is also an issue we should be asking our experts to comment specifically on in their reports.
Conclusion
In conclusion, given that the reporting of mental health illnesses is on the increase, issues around pre-accident mental health issues and red flags around a claimant’s vulnerability to an adverse psychological reaction to an accident or injury are going to be more commonplace.
We also do not know what the long-term impact of Covid-19 is going to look like given that we are only just emerging from the pandemic. We must of course take our victim as we find them in accordance with the “egg shell skull” principle. However, it is anticipated that arguments around attribution and causation will increase in the coming years.
For more information, contact Rebecca Williams
[1] https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/
[2] https://www.psychologytoday.com/us/blog/understanding-ptsd/202006/how-ptsd-affects-the-quality-your-life
[3] https://www.psychiatrictimes.com/view/ptsd-late-life
[4] https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/1744-859X-9-32
[5] https://www.clinicaltrialsarena.com/comment/mdma-ptsd-treatment/?utm_source=Army%20Technology&utm_medium=website&utm_campaign=Must%20Read&utm_content=Image
[6] https://www.therecoveryvillage.com/mental-health/news/mental-health-impact-on-life-expectancy/
Rebecca Williams
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