Workers’ Compensation Claim for Mental Injuries Stemming From Work with Aggressive Patients

Facts of the Case

In 1979, the claimant, “Jane Doe,” began employment as a licensed practical nurse for the South Carolina Department of Disabilities and Special Needs (Department). She provided basic patient care in a Department facility that housed patients on various units. In 1997, the Department began downsizing the facility, resulting in a patient population change on Ms. Doe's unit. As higher functioning patients were moved to community homes, the remaining units were consolidated. Consequently, Ms. Doe's unit, which previously treated a passive patient population, changed to treating a mixed group of passive and aggressive patients.

Thereafter, the unit experienced a dramatic increase in violence. Aggressive patients attacked passive patients and Ms. Doe was forced to intervene. Injuries to both staff and patients rose sharply, and the number of incidents on the unit increased from 11 in March 1997 to 128 in May 1997. Ms. Doe suffered numerous minor physical injuries, including having feces smeared in her face. She began to complain of depressive symptoms following the spring of 1997. Eventually, she received medication and electroconvulsive therapy for depression and was hospitalized for psychiatric care in 1998. A medical expert opined that her severe depression was caused by her work situation.

Ms. Doe filed for workers’ compensation benefits, alleging that she had suffered stress-related mental injury as a result of the change in work environment. Initially, the commissioner denied the claim; and on review, the appellate panel of the Workers’ Compensation Commission upheld the commissioner's findings. However, the circuit court reversed the decision, holding that the commission's findings were unsupported by substantial evidence. Thereafter, the court of appeals reversed the circuit court's decision and reinstated the commission's denial of benefits. The matter was appealed to the South Carolina Supreme Court.

Ruling and Reasoning

The South Carolina Supreme Court reversed the court of appeals’ decision upholding the commission's denial of benefits and remanded the matter to the commission to award disability benefits for Ms. Doe's mental injury. The major question facing the court was whether there was substantial evidence to support the commission's denial of benefits based on lack of causation.

First, the court noted that mental and nervous disorders are compensable if the related stressors arise from unusual or extraordinary conditions of employment. In defining the legal standard for “unusual or extraordinary conditions,” the court cited its earlier decision in Shealy v. Aiken County, 535 S.E.2d 438 (S.C. 2000), holding that the standard was whether the work conditions were unusual compared with the employee's normal strains. Next, the court noted that the commissioner found no unusual or extraordinary work conditions in this case. The commissioner concluded that it was not unexpected that other patients would move onto the claimant's unit, that workers would face aggressive behavior, or that the amount of care needed by the patients would change.

In applying the standard set forth in Shealy, the court concluded that the findings of the commissioner and the Workers’ Compensation Commission's appellate panel were unsupported by substantial evidence. The court found that extraordinary and unusual conditions did exist because of an unexpected mix of passive and aggressive patients on the unit. It noted that Ms. Doe was inexperienced in managing a mixed population of passive and aggressive patients, that none of the Department facility's other units had a similarly mixed population, and that the mix increased behavioral problems due to a “domino effect” when aggressive patients acted out. Further, the court was swayed by the fact that the Department made changes after a Department of Health and Environmental Control survey criticized it for housing diverse patients together.

The court further pointed out that the court of appeals took out of context the testimony of Ms. Doe's coworkers in support of its finding that no extraordinary and unusual conditions existed. It observed that while this testimony indicated that it was not unusual for nurses to deal with aggressive patients or to experience changes in the type of patient, the testimony did not state that it was usual to deal with a mixed patient population. It noted that when taken in full context, the testimony of the coworkers supported Ms. Doe's allegations that the workplace environment had worsened significantly and became “pretty chaotic” due to the diverse patient population. Accordingly, it found that this testimony supported the conclusion that extraordinary and unusual conditions existed compared with the normal stresses of the claimant's employment.

Finally, the court addressed the court of appeals’ view that Ms. Doe had a pre-existing depressive disorder and other social stressors that affected her mental injury. On review of the record, it dismissed the conclusion that these factors caused or contributed to her disability. It found that the only evidence regarding causation was a medical expert's opinion that Ms. Doe's mental injury was caused by the stress of her employment. It also pointed out that pre-existing depression does not preclude workers’ compensation benefits for mental injury. Consequently, it reversed the denial of benefits and remanded the matter to the commission.

Discussion

Doe v. South Carolina Dept. of Disabilities is an important ruling for forensic and clinical psychiatrists to consider when evaluating patients claiming disability for workers’ compensation benefits. Psychiatrists must bear in mind, however, that the holding in this case is jurisdiction-specific. Since the legal treatment of workers’ compensation claims vary from state to state, it is critical that psychiatrists performing these evaluations be cognizant of the governing statutory and case law for workers’ compensation claims within their jurisdiction. The types of compensable injuries, types of compensable work-related stressors, and related legal standards of proof vary across state lines and directly affect whether an employee has a viable disability claim within a given jurisdiction.

A universal consideration in these cases, regardless of jurisdiction, is whether there is a causal relationship between the work-related stressor and the employee's claimed injuries. In cases in which pre-existing psychiatric disorders are present, establishing a causal relationship may be particularly difficult. Doe v. South Carolina Dept. of Disabilities, however, makes it clear that the presence of pre-existing psychiatric conditions and concurrent social stressors is not necessarily fatal to workers’ compensation claims, but that expert testimony establishing a causal nexus between the employment stressor and the claimed mental injuries is essential for a claimant to prevail.