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There is growing evidence that workers at jobs that involve face-to-face interactions with distressed or constrained populations, such as health care, retail services, and prison systems, face significant risk for workplace violence (WPV). Experiencing traumatic violent events at work can have serious mental health consequences, including the development of posttraumatic stress disorder (PTSD). PTSD can make it difficult to stay employed or be successful at work, notably when the workplace itself is a trauma trigger, therefore returning to work is an important recovery milestone.

 This retrospective cohort study compared PTSD recovery durations and medical care for workers’ compensation claims caused by WPV versus non-workplace violence (non-WPV) in a statewide, generalized population. Ten years of California data uncovered 3,772 claims with a PTSD diagnosis and no physical injury. Those with physical injuries were excluded to decrease confounding effects on recovery not directly related to PTSD. Claims were classified as WPV if the available free-text injury description contained words such as assault, gunpoint, harassed, intimidated, punch, threat, robbery, violent, or verbal abuse. Non-WPV cases included words such as crash, fall, stress, accident, or witnessed. 

 From this dataset, WPV accounted for 49% of the PTSD claims. A binary logistic regression analysis found that female gender, younger age, work in retail or finance, a sedentary/light job class, or an income of less than $25,000 per year were significant risk factors of experiencing WPV. While other studies have found high rates of WPV in health care and public administration (which includes the justice system), our study also found that high risk groups for WPV-related PTSD included retail and finance. These industries may need additional resources to protect employees from experiencing violence at work.

For those who were able to return to work at the same employer (68% of the WPV group, 58% of the non-WPV group), patients with PTSD from WPV were absent from work for longer periods with a median of 132.5 days versus 91 days for non-WPV, regardless of treatment type and despite tending to receive their diagnosis sooner. 
Both groups received similar counts and types of treatments. The most common services were cognitive behavioral therapy (CBT), psychological evaluations, and psychiatric assessments. None of the services provided went against clinical guideline recommendations. Concerningly, the median number of CBT sessions was two, which indicates that many patients did not receive a therapeutic dose of psychotherapy. 

Across the cohort, patients received a median of six prescriptions over the duration of the claim. The most common prescriptions were benzodiazepines and antidepressants. Three of the top five most frequently prescribed medications were administered against clinical guideline recommendations.

This study found that many treatments prescribed to PTSD patients are based on insufficient evidence: 60% of the top ten services and 50% of the top ten prescriptions. More clinical studies on available treatments are needed, particularly in generalized populations. 

Additionally, because of the consistently longer time away from work by the WPV group, this study supports the need for additional recognition of the cause of workplace PTSD to facilitate appropriate referrals to WPV or PTSD specialists to assist with return-to-work efforts.

Target Article

Rufa AK, Carroll KK, Lofgreen A, Klassen B, Held P, Zalta AK. "You're going to look at me differently": A qualitative study of disclosure experiences among survivors of military sexual assault. J Trauma Stress. 2022 Jun;35(3):901-913. doi: 10.1002/jts.22797. Epub 2022 Feb 26. PMID: 35218235.

Discussion Questions

  1. Did following guideline-recommended services or prescriptions likely increase, not change, or decrease recovery durations? Why do you think that is?
  2. Should people with PTSD caused by workplace violence receive different care than those with PTSD from other causes?
  3. Witnessing a traumatic event, such as a suicide or homicide, is currently not part of the workplace violence definition by OSHA. Do you think it should be included or excluded?

About the Authors

Kerri Wizner, MPH, is an Epidemiologist with experience in academic, industry, and government public health research. Her research focuses on using surveillance to inform and prevent occupationally acquired injuries and disease and recommend effective interventions. 

Katherine Cunningham, PhD, is a Suicide Prevention Psychologist that provides direct clinical care and is actively engaged in research that focuses primarily on understanding the role of emotion in suicide risk, nonsuicidal self-injury, and PTSD among military veterans.
Fraser W. Gaspar, PhD, MPH, is an Epidemiologist and Statistician working with health analytics and big data. His research focuses on using advanced analytics and modeling to predict risk factors for injury or illness, intervention effectiveness, and cost considerations. 
Carolyn S. Dewa, PhD, MPH, is a Professor in the Department of Psychiatry and Behavioral Sciences and Chair of the Grad Group in Public Health Sciences at the University of California, Davis. Her research focuses on work disability related to mental disorders, including access to mental health services.
Brad Grunert, PhD, is a practicing Clinical Psychologist and a Professor in the Departments of Plastic Surgery and Psychiatry and Behavioral Medicine at the Medical College of Wisconsin. He has extensive experience in returning injured workers to employment and is widely published in the field of PTSD and adjustment to injury.

References Cited