Psychiatric Issues in Behavioral Health Disability
5.9 Treatment Outcomes: Strategies for Addressing Return to Work
The preceding sections have underscored the importance of the psychiatric func- tional assessment (see Sect. 5.3.3), coordination of treatment (see Sect. 5.2.2), avoiding medicalization (see Sect. 5.5.2), identifying and responding to malingering (see Sects. 5.6.2 and 5.6.3), and enhancing compliance (see Sect. 5.7.3). This chapter also emphasizes that true inability to work due to a psychiatric illness is a crisis warranting immediate and intensive intervention (see Sects. 5.2.2 and 5.4.3). While a psychiatrist may take all these to account and determine that the treatment of a patient follows evidence-based guidelines and is effective for that patient (see Sect. 5.7.1), it is not likely that the patient’s return to work will occur solely as a result of these efforts. Treatment should include an explicit and clearly communi- cated goal of return to work. Because inability to work is a crisis, return to work function should be a top priority goal.
It is very important for the psychiatrist to understand that illness and impairment can co-exist with adequate occupational function (American Psychiatric Foundation, Partnership for Workplace Mental Health, 2005). That is, a patient does not need to be 100% free of psychiatric symptoms, findings, or impairments in order to work.
As many disability case managers have found that “People may feel they need to be 100% in order to return to work. But in reality, they can’t really be 100% until they are back to work 100%” (Parker, 2009).
My colleagues and I have found several strategies helpful in achieving a return to work goal. When appropriate, we communicate to patients our belief that return to work is in the patient’s best interests and clarifythat it is our duty to advocate for those best interests. We engage patients in activities focused on the return to work goal, such as work hardening, communicating with the employer and human resources, etc. Work hardening, as defined by the American Physical Therapy Association, is a highly structured, goal-oriented, individualized intervention program designed to return the patient/client to work. Work hardening uses real or simulated work activities designed to restore physical, behavioral, and vocational functions (American Physical Therapy Association, 2009) (see Chapter 7). The psychiatrist can incorporate work hardening principles into mental health treatment by having a patient read successfully more challenging and technical material, complete email on a regular basis, or perform other tasks using the same abilities as those needed for his or her job. In discussing return to work, it is essential that the psychiatrist and the patient remain solution focused rather than barrier focused. For example, if a patient says that he or she cannot return to work until he or she feels 100% better, the psychiatrist can ask, “Did you ever work at less than 100%? What helped you then?” If a patient does not feel that he or she can return to the same boss or the same workload, the psychiatrist can engage the patient in a conversation on what the patient can do differently in terms of managing interactions, prioritizing the load, communicating his or her needs appropriately, etc. As a regular practice, we devote some of the face-to-face time to completing any forms required, to engage the patient in this process and as a practical time management approach.
While the psychiatrist can have significant impact on a patient-by-patient basis, and can play a role in improving the mental health disability process, he or she is one part of a much larger system that includes employers, insurers, and many others, all of whom can help to build a better system and processes. It may help the psychiatrist to know that he or she is not alone in improvement efforts. Toward this end, the American College of Occupational and Environmental Medicine adopted a guideline in 2006, based on the work of the College’s Stay-at-Work and Return-to Work Process Improvement Committee (ACOEM, 2006). The Committee examined current stay-at-work and return-to-work processes, made recommendations to improve the processes, and examined current best practices and initiatives.
Recommendations for insurers and employers included the following: revamp disability benefits systems to reflect the reality that restoring function is an urgent matter, given the short window of opportunity to normalize life; whenever possible, incorporate mechanisms into the stay-at-work and return-to-work process that prevent or minimize withdrawal from work; provide or pay for employee assistance and condition management services; inquire routinely into workplace social realities; develop and disseminate screening issues that flag workplace and social issues for investigation; perform prompt psychiatric assessments of workers with slower than normal recoveries; make payment for psychiatric treatment depending on evidence-based treatments with demonstrated effectiveness; educate health- care providers about the financial aspects that can distort the disability process;
compensate physicians for their time and effort in managing the stay-at-work and
return-to-work processes; encourage programs that allow employees to take time off work without requiring a medical excuse; encourage employers, insurers, and benefits administrators to use communication methods that respect physicians’
time; and standardize key information and processes.
Specific to psychiatry, in 2005, the Partnership for Workplace Mental Health convened a series of conferences with practicing psychiatrists, psychologists, employers, health plan representatives, members of the Social Security Administration, researchers, and other experts in the area of work disability/mental disorders to discuss the problem psychiatric occupational disability (American Psychiatric Foundation, Partnership for Workplace Mental Health, 2005). The Task Force made recommendations for clinicians and employers. Recommendations for employers included the following: establish policies and procedures to ensure that employees secure an accurate diagnosis and appropriate treatment plan, with an emphasis on a solid and objective assessment of the scope, range, and severity of functional impairment; require that their health/behavioral health/disability plan vendors use standardized functional assessment clinical tools (currently under pilot study; see Sect. 5.3.3); design their benefit plans in conjunction with their medical and disability providers to ensure that psychiatric conditions and disabilities, and physical disabilities with underlying psychiatric conditions, are treated by the appropriate mental health professional; intervene early in an employee’s disability absence; and use a team-based approach to work (including the employee, treating provider(s), employer, EAP, and disability plan representatives).
Currently, active discussions are taking place at the grass roots level. For example, The 60 Summits Project brings together physicians and other providers, employers, insurers, and others across traditional boundaries – to build a team approach to and to agree on specific new ways to collaborate – because they now see that the goal is to minimize the disruptive impact of illness and injury on life and work for employed people as well as their employers. Summit participants hope to increase the well-being, diversity, availability, and productivity of North America’s work- force by reducing avoidable lost workdays, presenteeism, benefit costs, job loss, and withdrawal from the workforce (60 Summits, 2009).
Acknowledgments Each of us has the privilege of leaning on the shoulders of others. In formu- lating this chapter, I have drawn deeply from the well of extensive research by many scholars and practitioners, to whom I am in great debt. Special thanks to Jennifer Christian, M.D., President and CMO of Webility Corporation, and Founder of 60 Summits Project and Jeffrey P. Kahn, M.D., CEO, WorkPsych Associates, Inc. for providing a wealth of foundational research; and to Jeffrey Segal, M.D., J.D., F.A.C.S., CEO of Medical Justice, for invaluable assistance in defining and articulating the forensic psychiatric role.
References
Summits (2009) Available at www.60summits.org
Allison, T. G., Williams, D. E., Miller, T. D., et al. (1995). Medical and economic costs of psycho- logic distress in patients with coronary artery disease. Mayo Clinic Proceedings, 70, 734–742.
American Academy of Psychiatry and the Law (2005). Ethics guidelines for the practice of forensic psychiatry. Available at www.aapl.org
American College of Occupational and Environmental Medicine (ACOEM). (2006). Preventing needless work disability by helping people stay employed. Journal of Occupational and Environmental Medicine, 48, 972–987.
American Physical Therapy Association (2009). Guidelines: occupational health physical therapy:
work conditioning and work hardening programs. Available at www.apta.org
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington, D.C: American Psychiatric Association.
American Psychiatric Association. (2006). Practice guidelines for the treatment of psychiatric disorders, compendium 2006. Washington, D.C: American Psychiatric Association.
American Psychiatric Foundation, Partnership for Workplace Mental Health (2005). Assessing and treating psychiatric occupational disability: new behavioral health functional assessment tools facilitate return to work. Available at www.workplacementalhealth.org
Barofsky, I. (1978). Compliance, adherence, and the therapeutic alliance: steps in the development of self care. Social Science and Medicine, 12, 369–376.
Barsky, A. J., Delamanter, B. A., & Orav, J. E. (1999). Panic disorder patients and their medical care. Psychosomatics, 40, 50–56.
Bartley, M. (1994). Unemployment and ill health: understanding the relationship. Journal of Epidemiology and Community Health, 48, 333–337.
Binder, L. M. (1993). Portland digit recognition test manual. Beaverton, OR: Laurence Binder.
Blackwell, B. (1976). Treatment adherence. The American Journal of Psychiatry, 129, 513–531.
Chodoff, P. (2002). The medicalization of the human condition. Psychiatric Services, 53, 627–628.
Conrad, P. (2007). The medicalization of society: on the transformation of human conditions into treatable disorders. Baltimore: Johns Hopkins University Press.
Druss, B. G., Rosenheck, R. A., & Sledge, W. H. (2000). Health and disability costs of depressive illness in a major US corporation. The American Journal of Psychiatry, 157, 1274–1278.
Egede, L. E. (2004). Diabetes, major depression, and functional disability among US adults.
Diabetes Care, 27, 421–428.
Eisenthal, S., Emery, R., & Lazare, A. (1979). Adherence and the negotiated approach to parenthood.
Archives of General Psychiatry, 36, 393–398.
Ekman, P. (1985). Telling lies: clues to deceit in the marketplace, politics, and marriage. New York:
Norton.
Fenton, W., Blyler, C., & Heinssen, R. (1997). Determination of medication compliance in schizo- phrenia: empirical and clinical findings. Schizophrenia Bulletin, 23, 637–6510.
Fishbein, M., & Ajzen, J. (1975). Belief, attitude, intention, and behavior. Massachusetts: Reading.
Frances, A. (2009). A warning sign on the road to DSM-V: beware of its unintended consequences.
Psychiatric Times, 26(8), 1–9.
Frederick, R., Sargaty, S., Johnston, J. D., et al. (1994). Validation of a detour response bias on a forced-choice test of nonverbal ability. Neuropsychology, 8, 118–125.
Garriga, M. (2007). Malingering in the clinical setting. Psychiatric Times, 24(3), 1–4.
Gerdtham, U. G., & Johannesson, M. (2003). A note on the effect of unemployment on mortality.
Journal of Health Economics, 22, 505–518.
Goldfinger, S. M., Hopkin, J. T., & Surber, R. W. (1984). Treatment resisters or system resisters?:
toward a better service system for acute care recidivists. New Directions for Mental Health Services, 21, 17–27.
Greenberg, P. E., Kessler, R. C., Nells, T. L., et al. (1996). Depression in the workplace: an economic perspective. In J. P. Feighner & W. F. Boyer (Eds.), Selective serotonin re-uptake inhibitors:
advances in basic research and clinical practice. New York: Wiley and Sons.
Hales, R. E., Yudofsky, S. C., & Gabbard, G. O. (2008). The american psychiatric publishing textbook of psychiatry (5th ed.). Arlington, VA: American Psychiatric Publishing.
Hall, J. A , & Dornan, M. C. (1988). What patients like about their medical care and how often they are asked: a meta analysis of the satisfaction literature. Social Science and Medicine, 27, 935–939.
Harris, I., Multford, J., Solomon, M., et al. (2005). Association between compensation status and outcome after surgery. Journal of the American Medical Association, 293, 1644–1652.
Haynes, R. B., Taylor, D. W., & Sackett, D. L. (1979). Compliance in health care. Baltimore:
Johns Hopkins University Press.
Horwitz, R. I., & Horwitz, S. M. (1993). Adherence to treatment and health outcomes. Archives of Internal Medicine, 153, 1863–1868.
Jin, R. L., Shah, C. P., & Svoboda, T. J. (1995). The impact of unemployment on health: a review of the evidence. Canadian Medical Association Journal, 153, 529–540.
Johnson, D. A. W. (1979). Further observations on the duration of depot neuroleptic maintenance therapy in schizophrenia. The British Journal of Psychiatry, 135, 524–530.
Kahn, J. P. (2008). Diagnosis and referral of workplace depression. Journal of Occupational and Environmental Medicine, 50, 396–400.
Kahn, J. P., & Aidinoff, S. (1999). Occupational psychiatry and the employee assistance program.
In J. Oher (Ed.), The employee assistance handbook. New York: Wiley and Sons.
Katon, W., Von, K. M., Lin, E., et al. (1990). Distressed high utilizers of medical care: DSM II diagnoses and treatment needs. General Hospital Psychiatry, 12, 355–362.
Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-of-onset distribu- tions of DSM IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.
Kessler, R. C., Greenberg, P. E., Mickelson, K. D., et al. (2001). The effects of chronic medical conditions on work loss and work cutback. Journal of Occupational and Environmental Medicine, 43, 218–225.
Krause, N., Frank, J. W., Dasinger, L. K., et al. (2001). Determinants of disability and return to work after work-related injury and illness: challenges for future research. American Journal of Industrial Medicine, 40, 464–484.
Kroenke, K., & Mangesldorff, A. D. (1989). Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. The American Journal of Medicine, 86, 262–266.
Langlieb, A. M., & Kahn, J. P. (2005). How much does quality mental health care profit employers?
Journal of Occupational and Environmental Medicine, 47, 1099–1199.
Lecrubier, Y. (2001). The burden of depression and anxiety in general medicine. The Journal of Clinical Psychiatry, 62(Suppl 8), 4–9.
Lepine, J. P. (2002). The epidemiology of anxiety disorders: prevalence and societal costs. The Journal of Clinical Psychiatry, 63(Suppl 14), 4–8.
Lerner, B. H., Gulick, R. M., & Dubler, N. N. (1998). Rethinking nonadherence: historical perspec- tives on triple-drug therapy for HIV disease. Annals of Internal Medicine, 129, 573–578.
Lustman, P. J., Griffith, L. S., & Clouse, R. E. (1997). Depression in adults with diabetes.
Seminars in Clinical Neuropsychiatry, 2, 15–23.
Moran, A. E., Freedman, R. I., & Sharfstein, S. S. (1984). The journey of sylvia frumpkin: a case study for policy makers. Hospital & Community Psychiatry, 35, 887–893.
Morgan H (2006) A conflict of roles: expert witness or treating physician? SpineLine July/August 2006: 27–30
National Institutes of Mental Health (2001). Depression can break your heart. Available at www.
nimh.gov
Norell, S. E. (1981). Accuracy of patient interviews and estimates of clinical staff in determining medication compliance. Social Science and Medicine, 15, 57.
Palardy, N., Greenberg, L., Ott, J., et al. (1998). Adolescents health attitudes and adherence to treatment for insulin dependent diabetes mellitus. Journal of Developmental and Behavioral Pediatrics, 19, 31–37.
Pampallona, S., Bolini, P., Tibaldi, G., et al. (2002). Patient adherence in the treatment of depres- sion. British Journal of Psychiatry, 180, 104–109.
Parker, J. (2009). Managing complex disability cases: a conversation about finding exceptions.
Back to Work: Disability Management and Return to Work Strategies in Canada, 13(3), 6–7.
Perkins, D. O. (2002). Predictors of noncompliance in patents with schizophrenia. The Journal of Clinical Psychiatry, 63, 118–1121.
Purcell, T. B. (2002). Factitious disorders and malingering. In J. A. Marx, H. S. Robert, & R. M. Walls (Eds.), Rosen’s emergency medicine: concepts and clinical practice (5th ed.). St. Louis: Mosby.
Reed, P. (Ed.). (2005). The medical disability advisor (5th ed.). Reed Group, Ltd, Westminster: CO.
Reid, W. H. (1993). Law and psychiatry: treating clinicians and expert testimony. Journal of Practical Psychiatry and Behavioral Health, 4, 1–3.
Rogers, R., Harrell, E. G., & Liff, C. D. (1993). Feigning neuropsychological impairment: a critical review of methodological and clinical considerations. Clinical Psychology Review, 13, 255–274.
Rosen, J., Mulsant, B. H., Bruce, M. H., et al. (2004). Actors’ portrayals of depression to test interrater reliability in clinical trials. The American Journal of Psychiatry, 161, 1909–1911.
Rossi, A. S. (2001). Caring and doing for others: social responsibility in the domains of family, work, and community. Chicago: University of Chicago Press.
Sajatovic, M., Davies, M., & Hrouda, D. R. (2004). Enhancement of treatment adherence among patients with bipolar disorder. Psychiatric Services, 55, 264–269.
Samuel, R. Z., & Mittenberg, W. (2005). Determination of malingering in disability determina- tions. Primary Psychiatry, 12(12), 60–68.
Schatzberg, A. F., Scully, J. H., Kupfer, D. J., & Regier, D. A. (2009). Setting the record straight:
a response to Dr Frances’ commentary on DSM-V. Psychiatric Times, 26(8), 1. 9–10.
Simon, G. E. (2003). Social and economic burdens of mood disorders. Biological Psychiatry, 54, 208–215.
Simon, G. E., Revicki, D., Heiligenstein, J., et al. (2000). Recovery from depression, work productivity, and health care costs among primary care patients. General Hospital Psychiatry, 22, 153–162.
Sleeth, J. (2009). Mental health, disability, and stress: what Selye and Mate can tell the human resources professional. Back to Work: Disability Management and Return to Work Strategies in Canada, 13(3), 8–9.
Soumerai, S., McLaughlin, T. J., Ross-Degnan, D., et al. (1994). Effects of limiting medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. The New England Journal of Medicine, 331, 650–655.
Starsburger, L. H., Gutheil, T. G., & Brodsky, A. (1997). On wearing two hats: role conflict in serving as both therapist and expert witness. The American Journal of Psychiatry, 154, 448–456.
Trueblood, W., & Schmidt, M. (1993). Malingering and other validity considerations in the neuropsy- chological evaluation of mild head injury. Journal of Clinical and Experimental Neuropsychology, 15, 578–590.
Trzepacz, P. T., & Baker, R. W. (1993). The psychiatric mental status exam. Oxford, UK: Oxford University Press.
Twaddle, A. C. (1979). Sickness behavior and the sick role. Cambridge, MA: Schenkman Publishing.
Unutzer, J., Patrick, D. L., Simon, G., et al. (1997). Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a four year prospective study. The Journal of the American Medical Association, 277, 1618–1623.
Weiden, P., & Olfson, M. (1995). Cost of relapse in schizophrenia. Schizophrenia Bulletin, 21, 419–428.
Weiden, P., & Rao, N. (2005). Teaching medication compliance to psychiatric residents: placing an orphan topic into a training curriculum. Academic Psychiatry, 29, 203–210.
133