What are the psychological consequences of road traffic accidents, and how can we help?
Are you a personal injury lawyer? Want to understand how you can benefit your clients who may have sustained a psychological condition as a result of a road accident?
Then you’re in luck. In this article, we:
- review the extent of the problem
- refer to a well-established guidelines for their clinical management
- examine how well these guidelines work in practice.
The results should be to the overall benefit of your clients.
What’s the scale of the problem?
Road accidents are very common. The Department for Transport estimates that in 2014 around 740,000 people had been road casualties in Great Britain[1]. Incidentally, this figure’s much higher than annual estimates based purely on police data – because it’s believed that some incidents go unreported. Police data alone shows that there were 194,477 casualties of all severities reported in 2014.
What most people don’t know is that a high proportion of these casualties will develop one or more psychological conditions as a direct result of the accident. How do we know this? Because of the work of Professor Mayou and his colleagues at Oxford. He followed up more than 1,400 patients who attended an A&E department following a road accident. He was looking specifically for definable conditions, namely for post-traumatic stress disorder (PTSD), travel anxiety, generalised anxiety and depression.
When does psychological injury show itself?
About a third of patients had developed one or more of these clinically defined psychological conditions one year after the accident. Despite the passage of time, these conditions persisted in their clinical effects up to three years after the accident – regardless of physical injury or ongoing litigation[2]. If we take these figures as representative of people injured on the road, it means that every year over 150,000 people acquire a definable psychological condition as a result of a traffic accident – that’s over 3,000 a week. As a personal injury lawyer, you’ll most likely encounter some of patients!
What are the possible psychological conditions acquired as a result of road accident?
Although most people involved in a road accident are not psychologically affected, others may have one or more definable psychological conditions. These could be:
- acute stress reaction
- general anxiety disorder
- travel phobia/anxiety
- PTSD
- PTSD symptoms, not amounting to PTSD
- adjustment disorder
- depression
- chronic pain
What are the indicators of psychological ill health following a road accident?
How do we know if a client (either adults or children) might be developing a psychological condition? There are frequent symptoms that might draw your attention to this possibility. So, what are the questions to ask clients for clues to a potential condition?
Questions to ask adult clients:
- Since the accident have you had any problems sleeping, such as:
- difficulty getting off to sleep
- waking up in the middle of the night
- waking up earlier than you usually do and difficulty falling back to sleep
- nightmares or distressing dreams?
- Do images, thoughts or upsetting memories about the accident come into your mind spontaneously? If yes, when?
- Do you now avoid any activities since the accident? If yes, what?
- Has your mood changed since the accident? If yes, how?
(for example, irritability, numbness or feeling cut off?) - Are you lower in mood or more tearful now than before the accident?
- How do you cope with being a driver or passenger in a car?
Questions to ask about children involved:
- Do they have any problems sleeping in their own beds?
- Are they ‘clingier’ since the accident?
- Do they act out the accident when they are playing?
- Have they started bedwetting?
What are the approaches to managing psychological ill health?
A reactive approach
If you’ve come across a diagnosis in a medico-legal report, you may decide to consult the Judicial Studies guidelines for the assessment of general damages. While this is a reasonable step, you might be missing an opportunity to improve the psychological condition of your client.
A proactive approach
Many solicitors will chose a more proactive approach to possible psychological injury in their clients. There are really only two elements to this approach: establishing a diagnosis, then arranging appropriate treatment based on that diagnosis.
- Step 1: Establishing a diagnosis
Clearly, psychological conditions are best diagnosed by a psychologist – not a psychiatrist.
Psychological reports are designed to precede treatment and they’ll normally be written under the terms of the Rehabilitation Code of Practice. You’ll often see a variety of objective psychometric measurements (such as HADS, GHQ or IES) in these written reports. Importantly, they’ll assess the client’s motivation for a psychological intervention. This is a key factor in a successful psychological intervention, unlike many physical conditions where the patient’s recovery isn’t determined by their motivation.
- Step 2: Available treatments
Established a psychological diagnosis? Good. The next step is to decide a rational treatment. Recent decades have brought massive improvements in mental health treatments – usually not via drugs, but by the increased use of techniques such as Cognitive Behaviour Therapy (CBT), which bring real benefits to a range of psychological conditions.
What is CBT, though? It’s often defined as a type of therapy based on the theory that psychological symptoms are related to the interaction of thoughts and behaviours that may be perpetuating the condition. A key component of CBT is ‘homework’ and how committed a patient is to making this approach successful.
Fortunately, the National Institute for Health and Care Excellence (NICE) has come up with a series of very specific recommendations.
| NICE recommended treatments for specific psychological conditions (abbreviated) | ||||
| Condition | Year of recommendation | Clinical Guideline number | Recommended treatment | Number of weekly sessions |
| Depression (mild to moderate) | 2009 | 91 | CBT | 9-12 |
| Generalised anxiety disorder | 2011 | 113 (replaces 22) | CBT | 12-15 |
| PTSD | 2015 | 26 | CBT | 8-12 |
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As we can see from this, CBT forms a significant component of the recommendations. NICE recommends that all ‘those with PTSD should be offered treatment, regardless of when the traumatic event happened’. Starting this quickly often means fewer treatment sessions are needed. Delaying psychological treatment doesn’t necessarily benefit the client and it’s important to note that physical and psychological treatments can run concurrently.
What are the results of trauma-focused psychological treatment in clients with psychological conditions following road accidents?
CBT is recommended by NICE of course, but it’s been shown that it does work very well in practice. How do we know? Take as an example the outcome of 692 consecutive cases that had psychological symptoms after a road accident.
Treatment was only started on average 21 months after the accident and they had the spectrum of expected psychological conditions (mainly PTSD). All patient cases had the NICE-recommended weekly sessions of either CBT and/or EMDR. Those patients with PTSD took, on average, 11 sessions to be restored to their pre-accident state and slightly fewer therapy sessions.
But what’s the human impact of this? Subjectively, the majority felt they benefitted from their treatment. This was supported objectively by an improvement in three psychometric scores – the General Health Questionnaire (GHQ), Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES). Where there had been abnormal scores in these prior to therapy, they had reverted to normal levels by the time of discharge.
What are the factors affecting successful treatment?
Gender, age or physical injury tended not to have any bearing on treatment success. However, poor results were associated with some common factors, such as:
- patients repeatedly not turning up to their therapy sessions
- reluctance to complete homework tasks
- a negative change in employment status
What about travel anxiety?
Mayou described in his research that travel anxiety occurred in about one in seven of victims three years after the accident, making it a fairly common complication. Somewhat legally intangible, this condition is not in the Guidelines, but does have its own code (300.29) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V). Therapy in particular can alleviate travel anxiety, typically taking around eight sessions to resolve.
What does an RTA-induced psychological condition cost to treat?
The JSB tables from 2010 show that the cost of the psychological intervention (assessment plus therapy sessions) stands at around £2,000. Compare this to the minimum awards by the courts for PTSD, which range from £10,000 to £70,000. It really is a drop in the ocean when compared to the quantum of damages for the value of the whole claim.
What’s your role as a personal injury lawyer?
If you think your client has possible psychological conditions, you can act as an effective advocate for them. How would you go about doing this? Well, it all starts with looking, holistically, past the claim value, at the person behind it. Supported by the NICE recommendations, you can identify clients with possible problems and so insist that they receive correct and timely psychological interventions. Consider the possibility of interim payments in this situation, too.
We as PI solicitors should take a proactive approach to managing road accident-related conditions, since there’s strong evidence that most post-traumatic patients will respond well to appropriate treatments. Our unique position enables us to lobby modern therapeutic tools to the benefit of our clients, whilst providing plenty of professional satisfaction to ourselves.
[1] Department for Transport, Reported Road Casualties Great Britain: 2014 Annual Report (2015) p14.
[2] Mayou R and Bryant B ‘Outcome 3 years after a road traffic accident’, Psychological Medicine (2002) vol32, p671-675.
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