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 Mental disorders are increasingly recognized as major contributors to occupational disability and absence. This is particularly true for depression: the rate of depression-related disability in the workforce appears to be increasing, and the WHO projects it will become, by 2020, the second leading cause of disability in the developed world (1). Depression is already the primary source of disability in many occupational sectors and raises the risk for secondary physical and psychiatric illness, as well as for injuries and accidents. Lessons learned from appropriate management of depression-related disability are relevant for other psychiatric disorders. Much of the burden of managing mental health–related occupational disability will fall on the shoulders of primary care physicians because many patients with depression receive their care from general practitioners. Psychiatrists are typically involved, however, when cases are more severe and prolonged; many longer-term disability insurance benefits require assessment or treatment by a psychiatrist. Physicians are often confronted with issues concerning occupational function in patients they are assessing or treating. However, physicians are in an awkward position in that they are trained to evaluate and alleviate symptoms and distress rather than occupational function. The increasing demand to deal with issues of occupational function can be daunting and may also seem tangential to the primary focus of clinical intervention. Further, physicians often feel caught between the interests of their patients and the requirements of employers and insurers. Nevertheless, proper medical assessment and management of occupational disability are essential to a patient’s care and quality of life. We examine some basic issues in the pragmatic management of depression-related occupational disability and make suggestions for more effective practice. Impairment and DisabilityA crucial distinction is that between impairment and disability. Psychiatrists have expertise in assessing and documenting the former, whereas the latter is largely an issue for insurers, employers, and contract administrators. Impairment Impairment has been defined in various ways; the WHO defines it as “any loss or abnormality of psychological, physiological or anatomical structure or function” (2, p 14). The psychiatrist’s job is to delineate a patient’s impairment. In addition to providing a statement of diagnosis (generally using the DSM-IV TR system) and delineation of symptomatology, it is critical that the practitioner specify functional impairments arising from the condition. These may include reduced sustained ability to read, learning capacity, independent decision making, effective social interaction, or tolerance for unexpected stress. The American Medical Association’s Guides to the Evaluation of Permanent Impairment (3) provides a framework for evaluating functional deficits. In this framework, psychiatric impairment is determined by assessing 4 areas: activities of daily living; social functioning; concentration, persistence, and pace; and deterioration or decompensation in complex or work-like settings. Psychiatrists and the insurance industry often use the GAF index. Although this measure has poor reliability and validity (4), it remains a standard index of functional status. Careful determination of the GAF score can pay dividends to patients in terms of insurance eligibility; an insurer may lack confidence in a psychiatrist’s opinion if the patient’s listed symptoms and apparent functional limitations are inconsistent with the stated GAF. A useful approach for psychiatrists or occupational physicians carrying out disability assessments is to precisely describe how individuals typically spend their days: their bedtime, how long they need to fall asleep, number of nocturnal awakenings, timing and contents of meals, activities, how often they leave the house, how often they drive and for how long, number and duration of social contacts, what sort of material they read, or how long they take to read the paper. Realistically looking at activities of daily living is key to assessing a patient’s functioning. Psychiatrists need to be aware of appropriate language for describing functional deficits. For example, it is not meaningful to state that a patient cannot concentrate and cannot sleep: it is most unlikely that a patient suffers from depression to the extent that he or she is entirely unable to concentrate or sleep for any period of time. It is more appropriate to describe some degree of impairment, whether in terms of reduced capacity, time limits to sustained concentration, or specific difficulty with concentrating on several tasks at once. Disability There are legal and nosological components to the definition of disability, but the most practically relevant definition may be that of the insurance industry. After all, psychiatrists often encounter the occupational disability issue when they are asked to complete claims forms. If a psychiatrist does not understand the perspective of the employer and insurance carrier, results for the patient can be unnecessarily dire. The insurance carrier is typically represented by a case manager, also known as an adjudicator or claims analyst, who is bound by the terms of the existing contract with the patient (whether as an individual or as a member of a larger entity such as a union or professional group). Such contracts define the criteria that must be satisfied to qualify an individual as disabled. Contract terms vary considerably regarding the disability criteria and the qualifying period, as well as regarding whether the coverage applies only to the patient’s “own occupation” or to “any occupation,” even on a part-time basis or at a lower salary. Decisions about disability criteria are not personal and are not ultimately the psychiatrist’s responsibility. Failing to meet these criteria does not deny a patient’s illness, impairment, or suffering. The case manager compares the information provided by the physician with the criteria of the relevant contract and the nature of the workplace. This involves comparing the patient’s diagnosis, prominent symptoms, and degree of functional impairment with the particular position, essential and nonessential job requirements, and possibilities for flexibility or accommodation. The case manager usually has access to an experienced occupational psychiatrist on the insurer’s medical board, but it is the manager—not the medical board consultant—who is charged with formally determining the presence of a compensable disability. The psychiatrist’s written assessment must directly respond to the insurance carrier’s disability criteria. Simply writing that a patient cannot work owing to a medical condition is no guarantee that the patient will receive financial support during work absence. For example, if the medical assessment fails to show that a patient’s condition meets the criteria for coverage, the patient’s claim will likely be declined. Further, if there is delayed or inadequate communication between psychiatrist and insurer, the patient may not discover his or her lack of coverage until he or she has been off work for months. This not only results in undue financial hardship but also may rupture a therapeutic relationship or lead to an entrenched conflict with the insurer. Sick Leave, STD, and LTDPhysicians encounter patients at various stages of disability. The requirements for evaluating a patient at each of these stages are somewhat different. The Canada Labour Code generally protects employees for up to 12 weeks during work absence due to illness or injury. This maintains the security of their position and benefits, but it does not guarantee salary continuance. If an employee does have salary continuance, the amount and duration will depend on the employment contract, the accrued sick leave, and the nature of the illness or injury. An employer may require a note from a physician if an employee has been absent, or is expected to be absent, for an extended period of time. If sick leave has been used up and regular weekly income reduced by more than 40%, a qualifying employee may be obliged to apply for Employment Insurance. To receive Employment Insurance, the employee’s physician must submit a medical certificate. The medical practitioner is asked to confirm that the individual is currently incapable of working and to provide an estimated date of recovery; a diagnosis or specific disability is not usually required. STD coverage will pay benefits to the worker up to a specified time period. Contracts vary in their maximum STD coverage but often set the maximum at 3 to 6 months. For an STD claim, the type of information required varies among plans; most require a specific diagnosis and a clear description of current symptomatology, as well as an estimate of when the individual will be recovered sufficiently to return to work. If a physician thinks that a patient has a diagnosable disorder, it is preferable to state this fact rather then simply identifying stress or workplace problems as the reason for the claim. Employers and insurers will not accept the stress explanation as an appropriate basis for a disability claim: an inability to cope with family issues or changing workplace demands is not a disabling illness. In general, making a diagnosis such as adjustment disorder, accompanied by appropriate supporting evidence regarding symptoms and functional deficits, is more effective than simply referring to stressors in a patient’s life or workplace. LTD coverage will pay financial support to a patient for a variable length of time and at a proportion of prior income, depending on the contract. Most Canadian plans will pay until age 65 years if disability criteria continue to be met. More detailed information is typically required for an LTD claim, including diagnosis, symptoms, clearly specified functional deficits, and description of current treatments. Further, there is typically a requirement to reevaluate the patient’s diagnostic, functional, and treatment status at regular intervals. A warning sign to an insurer is apparent lack of clinical progress in the context of passive treatment, for example, an individual apparently too sick to work remaining for 6 months on the same type and dosage of medication and seeing his or her psychiatrist every 2 months for nonspecific supportive therapy. Form FillingFilling out forms is a notable requirement of disability assessment by psychiatrists. It can place psychiatrists in the awkward role of invoicing patients for this task if the pertinent disability contract makes no provision for reimbursement by the insurer. Rather than berating the insurance carrier, practitioners should inform themselves about items not covered by the carrier and, if necessary, arrange an acceptable payment plan with their patients. While acknowledging the frustration created by extra paperwork, we must emphasize that disability evaluation forms are the primary way for insurance case managers to obtain the information needed to perform their job effectively.
Thoughtful attention to completing the required documentation will reduce the likelihood that the physician will be asked for further information. A request for copies of clinical office notes indicates concern that the information provided thus far is inadequate for determining a patient’s disability. For example, the case manager may be seeking confirmation that the patient was, in the psychiatrist’s estimation, symptomatic and impaired when the work absence actually began. If the physician is confident that the patient is very ill and that the issue concerns information transmission to the insurer, telephoning the case manager to explain this and give the requisite details (with appropriate patient consent) can be considered. Most psychiatrists are not comfortable directly providing their notes under the generic consent given to the insurer by their patient; the Canadian Psychiatric Association clearly supports this stance for obvious reasons of confidentiality and to maintain the therapeutic alliance. Getting further direct guidance from the patient or taking a few minutes to censor personal issues in the notes and then getting patient approval for their distribution may be another option. Likewise, a narrative letter outlining the patient’s condition and impairments, along with details concerning onset and duration of the illness, may suffice. That being said, a letter providing nonspecific assurance that the patient is under the physician’s care and will be unable to work for a protracted period of time is unlikely to be considered sufficient by the insurance company. Recommending Work AbsenceThe decision as to whether an individual must take time away from the workplace has important consequences for the patient and deserves careful consideration. Typically, a psychiatrist will recommend disability leave from the workplace because an individual is judged to be incapable, owing to illness, of handling the demands and responsibilities of his or her job. The psychiatrist may base the recommended duration of absence on the projected time required to resolve symptomatology and recover function. For example, in most cases, it is realistic to expect substantial recovery from uncomplicated treated depression within 6 to 8 weeks. In estimating the likely duration of absence, the psychiatrist can consider whether the patient has had previous episodes of mental health–related disability absence. Such episodes may significantly extend the expected length of absence. This will be especially true if there have been one or several failed courses of treatment or failed work returns, which worsen the prognosis and increase the length of absence expected. This type of patient, of course, is the most likely to be under the care of a psychiatrist, rather than exclusively under the care of a primary care physician. Putting direct illness issues aside, estimated or recommended duration of absence is also influenced by the perceived costs and benefits of work absence for the patient. The benefits of work absence, from the perspective of recovery, include the following:
The costs of work absence include these:
We encourage a problem-solving approach, in which all concerned parties collaboratively look at the advantages and disadvantages of work absence: whether to go off work, specifically why, and for how long. It should never be assumed that a patient diagnosed with major depression, for example, needs to take several months of work absence to recover. There are advantages and disadvantages to remaining in the workplace while recovering from a disorder (with therapeutic support), compared with staying at home to await recovery. Further, participating in the workforce is often itself a potent and positive therapeutic factor. Marie Jahoda, a pioneer of the positive mental health movement, pointed out that work provides structure, meaning, and an opportunity for social interaction (6). Work also provides an income, which is good for one’s mental health. Establishing Realistic ExpectationsPsychiatrists will often be asked by their patients or by case managers to indicate the expected time needed to restore work function. This task can be frustrating, since there is more evidence available about reducing psychiatric symptomatology than about restoring occupational function. The relation between symptom reduction and functional recovery is a complex one. An early review concluded that functional recovery is a delayed impact of treatment, continuing to improve long after maximum symptom reduction (7). This conclusion implies that one should continue standard depression treatment well after symptom resolution to obtain functional recovery. Physicians could confidently inform patients and case managers that substantially more functional recovery could be expected after symptom improvement by continuing with the same treatment approach. However, subsequent and more sophisticated research has made it clear that functional recovery in patients with MDD does not lag behind symptom improvement (8–11). On the contrary, changes in symptoms and function are synchronized and reach their peak within the first few months of treatment (12). Psychiatrists can no longer be quite so confident in providing assurance that functional recovery will eventually occur: it may be that “what you see is what you’re going to get.” According to current evidence, failure to achieve functional recovery within several months of treatment for depressive illness suggests the need for a change in treatment or rehabilitation strategy. Further, well-designed research indicates that standard psychopharmacological treatment for MDD leaves a significant gap in functional recovery. For example, a recent study found that approximately 60% of individuals who have undergone a course of pharmacologic treatment for major depression continue to show at least moderate impairment of work function 1 year later (13). Standard treatments for major depression can be limited in regard to recovery of occupational function, and other types of intervention may be needed to augment them. One treatment response has been to add other psychopharmacological treatment such as antipsychotic, mood-stabilizing, or stimulant medications. However, the scientific evidence supporting these pharmacologic augmentation strategies for job-related functional improvement is still rudimentary. Ultimately, we do not yet know of consistently effective means to enhance the impact on functional recovery of standard treatments for major depression. Some evidence suggests that CBT has particular benefit with regard to functional recovery. First, studies indicate that CBT has a beneficial effect on work function above and beyond the impact of antidepressant medication (14,15). Another study found that CBT showed a specific advantage over antidepressant medication with regard to reducing disability and work absence, even though the treatments were equivalent in reducing depressive symptomatology (16). One researcher suggested that CBT has a direct effect on psychosocial functioning by focusing therapy on relevant issues, such as the building of social skills (17). In many disability cases, even after impressive symptom reduction, a patient may retain loss of confidence, may expect condescension or criticism by colleagues, may worry about competency in a changing workplace, or may have concerns about how to again handle a difficult coworker or supervisor. Adding CBT in such circumstances might well have a clinical benefit in helping this patient return to work successfully. CBT focuses on active goal setting, problem solving, and reengagement, all of which are characteristic of successful rehabilitation programs. Further research will be required to determine the optimal approach to enhancing occupational recovery in patients with major depression. For now, psychiatrists should consider recommending nonpharmacologic interventions such as CBT where standard pharmacologic treatment has not effectively achieved adequate recovery of occupational function. Note that case managers or insurers’ medical coordinators may be able to fund such additional treatment in cases where occupational recovery has been elusive. Direct contact with the insurer by the psychiatrist is often helpful in this regard. In addition, employees may continue to have access to some degree of coverage for psychological services through their extended health benefit plans. Fostering the Patient’s Role in RecoverySelf-management of chronic or recurrent disorders has received increasing emphasis in research literature and clinical guidelines over the past decade. It refers to involving the patient in collaborative care of the disorder:
This approach is perhaps idealistic, given the time constraints and other realities of usual clinical practice. Nonetheless, a collaborative approach that emphasizes self-management seems most likely to reinforce the patient’s sense of competence, autonomous decision making, and goal setting. These are crucial factors in enhancing functional recovery and supporting return to productive work. Assisting the patient toward some degree of self-management of the disabling disorder may be a useful intervention. First, it is useful to encourage the patient in active coping with difficulties in the work situation. Major depression is often triggered or strongly influenced by workplace situations involving changes in occupational demand, perceived lack of support, or interpersonal conflict (19,20). Thus encouraging the patient to identify workplace issues associated with the onset of depressive symptoms and to adopt a problem-solving approach is likely a helpful intervention. Second, the patient on disability leave can be encouraged to maintain lines of communication with the workplace rather than avoiding all contact out of shame at being unable to function. This provides the patient with potential sources of support (such as a supervisor, coworkers, human resources, or occupational health staff in the workplace) and increases the sense of a continued relationship with the workplace. Similarly, communication with the insurance company case manager regarding ongoing status is to be encouraged. Third, collaborative decision making concerning the appropriate duration of disability leave will maximize the patient’s sense of personal effectiveness. The psychiatrist can provide a helpful framework for work return by emphasizing the balance between reducing workplace exposure to assist symptom recovery and protecting the patient from work deconditioning and demoralization. The goal of returning patients to work should ideally be presented and discussed as a key component of treatment and symptomatic recovery. Monitoring this, and not allowing occupational functioning to be stripped or sidelined from the overall therapeutic process, allows for a more active and efficacious approach to the situation. Fourth, several research studies have shown that disseminating self-management material to individuals suffering from clinical depression that is mildly to moderately severe is associated with high rates of compliance and significant symptom reduction (21). More workers have mild depression than have severe depression, but mild depression is nonetheless associated with significant impairment of work function (22). A manual to enhance self-management of depression has been developed at the University of British Columbia and is available for free download from the Internet (23). ConclusionThe management of depression-related disability is challenging for all participants, although patients have the most at stake. A psychiatrist’s thoughtful evaluation of the patient’s functional status, careful response to the requirements of disability determination, and focus on functional recovery yield substantial benefits. References1. Mental health, disorders management, depression. Geneva (CH): World Health Organization. Available: www.who.int/mental_health/management/depression/definition/en/ Accessed: 2005 Dec 30. 2. International classification of impairments, disabilities and handicaps (ICIDH). Geneva (CH): World Health Organization; 1980. p 14. 3. Cocchiarella L, Andersson GBJ, editors. Guides to the evaluation of permanent impairment. 5th ed. Chicago (IL): American Medical Association Press; 2001. 4. Söderberg P, Tungström S, Armelius BA. Special section on the GAF: reliability of Global Assessment of Functioning ratings made by clinical psychiatric staff. Psychiatr Serv 2005;56:434–8. 5. Shrey DE, Lacerte M. Principles and practices of disability management in industry. Winter Park (FL): GR Press Inc; 1995. 6. Jahoda M. Current concepts of positive mental health. New York (NY): Arno Press; 1980. 7. Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry 1992;49:761–8. 8. Judd LL, Akiskal HS, Zeller PJ, Paulus M, Leon AC, Maser JD, and others. Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch Gen Psychiatry 2000;57:375–80. 9. Kocsis JH, Schatzberg A, Rush AJ, Klein DN, Howland R, Gniwesch L, and others. Psychosocial outcomes following long-term, double-blind treatment of chronic depression with sertraline vs placebo. Arch Gen Psychiatry 2002;59:723–8. 10. Berndt ER, Finkelstein SN, Greenberg PE, Howland RH, Keith A, Rush AJ, and others. Workplace performance effects from chronic depression and its treatment. J Health Econ 1998;17:511–35. 11. Sherbourne CD, Wells KB, Duan N, Miranda J, Unutzer J, Jaycox L, and others. Long-term effectiveness of disseminating quality improvement for depression in primary care. Arch Gen Psychiatry 2001;58:696–703. 12. Miller IW, Keitner GI, Schatzberg AF, Klein DN, Thase ME, Rush AJ, and others. The treatment of chronic depression. Part 3: Psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry 1998;59:608–19. 13. Simon GE, Revicki DA, Heiligenstein J, Grothause L, VonKorff M, Katon WJ, and others. Recovery from depression, work productivity, and health care costs among primary care patients. Gen Hosp Psychiatry 2000;22:153–62. 14. Sherbourne CD, Wells KB, Duan N, Miranda J, Unutzer J, Jaycox L, and others. Long-term effectiveness of disseminating quality improvement for depression in primary care. Arch Gen Psychiatry 2001;58:696–703. 15. Rost K, Fortney J, Coyne J. The relationship of depression treatment quality indicators to employee absenteeism. Ment Health Serv Res 2005;7:161–9. 16. Mynors-Wallis L, Davies I, Gray A, Barbour F, Gath D. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. Br J Psychiatry 1997;170:113–9. 17. Hirschfeld RM, Dunner DL, Keitner G. Does psychosocial functioning improve independent of depressive symptoms? A comparison of nefazodone, psychotherapy, and their combination. Biol Psychiatry 2002;51:123–33. 18. Improving Chronic Illness Care (ICIC). Self-management support. In: The chronic care model: model elements. Available: www.improvingchroniccare.org/change/model/smsupport.html. Accessed 2005 Dec 20. 19. Wang J, Patten SB. Perceived work stress and major depression in the Canadian employed population, 20–49 years old. J Occup Health Psychol 2001;6:28–9. 20. Niedhammer I, Goldberg M, Leclerc A, Bugel I, David S. Psychosocial factors at work and subsequent depressive symptoms in the Gazel cohort. Scand J Work Environ Health 1998;24:197–205. 21. Scogin F, Hanson A, Welsh D. Self-administered treatment in stepped-care models of depression treatment. J Clin Psychol 2003;59:341–9. 22. Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression. JAMA 2003;289:3135–44. 23. Bilsker D, Paterson R. Antidepressant skills workbook. Vancouver (BC): University of British Columbia; 2005. Available: www.mheccu.ubc.ca/publications [under Self-Care]. Accessed 2006 Jan 4. Author(s)Manuscript received and accepted October 2005. 1. Consulting Psychologist, Psychiatric Assessment Unit, Vancouver General Hospital, Vancouver, British Columbia; Clinical Assistant Professor, University of British Columbia, Vancouver, British Columbia. 2. Consultant Psychiatrist, St Paul’s Hospital, Vancouver, British Columbia; Psychiatric Consultant, The Great-West Life Assurance Company, Disability Claims Management, Vancouver, British Columbia; Clinical Assistant Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. 3. Consulting Psychologist, Gilbert Acton LePage, Vancouver, British Columbia. Address for correspondence: Dr D Bilsker, PAU, JPPN-G, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, British Columbia V5Z 1M9 e-mail: Dan.Bilsker@vch.ca
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