Psychiatric Annals

CME Article 

Bridging the Gap from Symptoms to Disability: Returning to Work from Psychiatric Illness

Vladimir Bokarius, MD, PhD

Abstract

Psychiatric illness is a substantial and growing cause of disability and financial burden in the United States and around the world. Many clinicians experience difficulties in substantiating disability claims and understanding the different options of returning patients to the workforce. This article offers a simple algorithm for a clinical evaluation of psychiatric disability for mental health care providers who are not proficient in medico-legal examinations. It defines the challenges that clinicians face and discusses definitions and differentiation among symptoms, impairment, impairment in functioning, and disability. Examples of psychiatrically driven work restrictions and accommodations are provided. Finally, the article focuses on the importance of a timely return of patients to the workforce with appropriately defined restrictions/accommodations, aiming to help patients' recovery, improve their overall level of functioning, and prevent further disability. [Psychiatr Ann. 2021;51(2):64–69.]

Abstract

Psychiatric illness is a substantial and growing cause of disability and financial burden in the United States and around the world. Many clinicians experience difficulties in substantiating disability claims and understanding the different options of returning patients to the workforce. This article offers a simple algorithm for a clinical evaluation of psychiatric disability for mental health care providers who are not proficient in medico-legal examinations. It defines the challenges that clinicians face and discusses definitions and differentiation among symptoms, impairment, impairment in functioning, and disability. Examples of psychiatrically driven work restrictions and accommodations are provided. Finally, the article focuses on the importance of a timely return of patients to the workforce with appropriately defined restrictions/accommodations, aiming to help patients' recovery, improve their overall level of functioning, and prevent further disability. [Psychiatr Ann. 2021;51(2):64–69.]

Every psychiatrist who has gone through 4 years of residency training is well versed in recognizing the signs and symptoms of mental illness and establishing a diagnosis and a treatment plan. However, when a patient comes to the appointment with disability paperwork in hand, many clinicians feel hesitant and uncomfortable completing it. This is understandable because few providers were trained to deal with disability determinations. The disability forms, although seemingly simple, do not provide any guidance on completion nor indicate what type of information would best support a claim. Treating psychiatrists face many challenges in evaluating disability, including payers who do not like to see the word “disabled;” patients who do not want to return to work while symptomatic; health care professionals hired by the payers to review disability claims who only read progress notes, without ever seeing the patient, and call the treating provider to challenge their findings; claims may initially be denied if progress notes do not explicitly describe impairment in functioning; job descriptions and list of possible accommodations are rarely sent along by the employer; and forms appear daunting and tedious to complete.

To further complicate things, the terminology used by different entities in the process of disability determinations is not uniform. Many terms are used interchangeably and mean different things depending on the state and venue of the claim.

This article explains how to discern symptoms from impairment and from disability, how to document them all, and how to provide work restrictions and accommodations that facilitate return to work.

Definitions

Symptom

A symptom is any deviation from baseline perceived by a patient. Symptoms can be acute or chronic, intermittent or constant, or light or pervasive, and can be rated as mild, moderate, or severe.

Impairment

An impairment is an anatomical, physiological, or psychological loss or dysfunction of any part of the body, organ, or system. “Loss” includes loss of limb, resection of the stomach, loss of vision, or loss of memory or emotions. Examples of impairment include a decreased range of motion of a limb, gastroesophageal reflux, reduction in vision acuity, decreased attention, or insomnia. Impairment may be temporary or permanent. It can be mild, moderate, and severe. In psychiatry it is based on a combination of symptoms and evaluator findings including history, mental status examination, and, if necessary, psychological/neuropsychological testing.

Impairment in Function

An impairment in function is the inability to adjust to an impairment resulting in the failure to perform a function or deficiency in that performance, whether the function is an activity of daily living (ADL), a social activity, or an occupational activity. It can be rated as mild, moderate, severe, or quantified with a specific number (eg, percentage of whole person impairment, Global Assessment of Functioning score).

Disability (Related to Work)

A disability related to work is a complex concept that entails evaluation of impairment in functioning, age and occupation of the patient, and the resultant loss in earning capacity. This is a multidisciplinary assessment that involves vocational and legal entities in addition to a physician.

Disability may be partial or total, temporary, or permanent. It may be assessed regarding usual and customary occupation or about the entire labor market.

Restriction

A restriction is the recommended limitation of work activities to allow the patient to continue healing while concurrently working.

Accommodation

An accommodation is an adjustment to a job or work environment that makes it possible for an individual with a disability to perform their job duties. Accommodations may include specialized equipment, modifications to the work environment, or adjustments to work schedules or responsibilities.1

Of note, symptoms do not necessarily constitute an illness, prompt a diagnosis, or result in impairment. Illness, diagnosis, or impairment does not necessarily cause disability.

Most disability claims are focused on the patient's inability or decreased ability to perform an occupational activity. As such, the payers are not interested in symptoms or impairments alone, but in how these will affect occupational functioning. Therefore, the term disability is used in this article to reflect occupational limitations only.

Evaluation

A comprehensive psychiatric evaluation provides information clinically necessary to form a diagnosis and treatment plan based on reported symptoms, mental status examination, and pertinent history. Clinicians are well-versed in completing evaluations and this will not be discussed further.

Impairment

Once the evaluation is completed, the impairments are already identified, but need to be extracted and outlined separately from the symptoms. Table 1 is a list psychiatric impairment examples, organized by domains. Many impairments share names with symptoms.

Psychiatric Impairment Examples

Table 1:

Psychiatric Impairment Examples

Impairment in Functioning

One or more of the impairments in Table 1 may result in a limitation or complete inability to perform some or all functions that are essential to the patient's job. If this is the case, it supports a finding of impairment in functioning, which may lead to partial or total disability. However, the next level of assessment is to identify whether the patient could perform the job if restricted from certain activities or provided with a set of accommodations.

Work Restrictions/Accommodations as a Meaningful Reflection of Impairment in Occupational Functioning

For the physician working in the trenches with patients every day, documenting work status is straightforward. Once you understand how symptoms are impairing a person's performance in the major mental health domains outlined above, review these impairments in the context of that patient's job. For instance, a patient with emotional and behavioral impairment may have difficulty functioning in a customer-facing role, whereas a patient with impaired cognition may struggle with data entry. Once the areas of impairment are identified, they can be reviewed in the context of a Mental Residual Functional Capacity Assessment. This assessment is based on the following four domains of occupational functioning and is widely accepted: (1) ability to perform ADLs; (2) social functioning; (3) concentration, persistence, and pace; (4) deterioration or decompensation in work or work-like settings. The Social Security Administration and the American Medical Association Guides both use it as the basis for determining level of impairment in functioning. Independence, appropriateness, and effectiveness of activities should be considered.2

A short form, the Mental Residual Functional Capacity, which looks at these domains of occupational functioning in a more expanded fashion is available.3 Completing this form assists with determining what restrictions or accommodations may be necessary for the person to continue or return to employment.

Table 2 and Table 3 provide examples of psychiatric restrictions and accommodations, respectively, and are organized according to major domains of mental health. Please note that impairment in different domains may result in the same restrictions. The restrictions and accommodations should be individualized, based on the patient's job description and the individual circumstances of the work environment and mental illness.

Psychiatric Restrictions According to the Major Domains of Mental Health

Table 2:

Psychiatric Restrictions According to the Major Domains of Mental Health

Workplace Accommodations According to the Domains of Mental HealthWorkplace Accommodations According to the Domains of Mental Health

Table 3:

Workplace Accommodations According to the Domains of Mental Health

Disability

Determination of disability is complex and usually multidisciplinary. The combination of functional impairment and work restrictions/accommodations is the closest that a physician can come to about determining disability. This determination is a medical one and other factors of disability are outside the scope of medical practice and outside the scope of this article.

With that said, the disability forms provided by patients to physicians for completion can vary. They require documentation of diagnoses, treatment rendered or planned, and reasons why the patient is unable to perform work functions, but each agency has its own set of questions, and some request that medical records be attached. Temporary disability forms usually require specification of factors disabling the patient and the anticipated duration of disability. Although some forms are specific to mental health, most are generic of specialty. In those cases, mental health professionals should place relevant findings into the form fields and mark the rest not applicable.

Regarding physical examination findings, pertinent findings on the mental status examination should be listed. Under work restrictions, physical limits (lifting/bending/stooping) should not be addressed by mental health professionals; instead, psychiatric restrictions/accommodations should be listed under “Other” or attached as a separate list.

Note that payers will not generally rely on certifications of disability for extended periods of time; leave of 6 months to 1 year may not be honored and more frequent examinations and disability status reports may be required. Acceptable timeframes vary between claim administrators, but generally range from 30 to 90 days. It is also not advisable to put words such as “indefinite” or “until further notice” into the disability end dates. Physicians are encouraged to provide an estimate and then issue an update based on additional examination.

Total disability is the inability of a person, due to sickness or injury, to perform most of their usual occupational duties. Partial disability means that, due to sickness or injury, a person is unable to perform one or more of the majority of work-related duties on a full-time basis.4

As such, the explanation related to either partial or total disability needs to reflect which impairments caused by the mental health condition are causing the patient's inability to perform functions of their regular occupation. For example, an accountant who has impairment in concentration is unable to engage in material occupational duties as these require persistent focus and accuracy; therefore, the accountant would be considered totally disabled. An accountant who has an impairment in mood and affect may be partially disabled, with a restriction of not interacting with customers for the duration of the temporary disability but is able to continue engaging in the other essential functions of the job.

Disability forms typically take between 15 minutes and 1 hour to complete, depending on the extent of clinical documentation available in the patient's chart. Some payers will pay a fee toward reimbursing physician time spent on the paperwork, whereas some will shift the burden of payment onto the patient. Regardless, physicians are not expected to do this for free. The algorithm for medical determination of disability is illustrated in Figure 1.

Alogrithm for medical determination of disability.

Figure 1.

Alogrithm for medical determination of disability.

Return to Work

Payers like to have work status updated on a regular basis. For a patient who is taken off work completely, the payer may be responsible for paying up to 100% of the employee's usual income, which drives the desire to limit periods of temporary total disability. This is the same factor that at times motivates patients to stay on disability longer than is medically necessary. Ultimately, it is up to the health care professional to determine when it is time for a patient to return to work, with or without restrictions or accommodations. Research shows that the longer patients remain on disability, the less likely they are to return to their baseline level of functioning.4 Quite often, returning to work (with or without restrictions or accommodations) is therapeutic and the ultimate cure for a patient.

Many payers will assign “nurse case managers” to the claim and ask people to attend treatment appointments, promote treatment compliance, and encourage physicians to return the patients to work as soon as it is feasible. Many employers have “return to work” offices, which are responsible for accommodating employees with restrictions. These employers have a variety of jobs available with variable degrees of responsibilities, which provides flexibility for the patients who are motivated to improve their level of functioning.

Illustrative Case

A 45-year-old woman employed as an administrative assistant for a medical testing laboratory was assaulted by a customer. She was hospitalized for 3 days due to physical injury after the assault and had been certified off work by an orthopedic surgeon for 1 month; she was released back to work (before she saw the psychiatrist) with no restrictions from an orthopedic standpoint after that time.

She presents at the outpatient psychiatric clinic (after she was released to go back to work) with complaints of anxiety and fear, anhedonia, insomnia, frequent nightmares, distressing unwanted memories of the assault, flashbacks, avoidance of triggers causing anxiety attacks, feelings of guilt that she did not prevent the assault, feeling distant from her family and friends, increased startle response, and hypervigilance.

At the conclusion of the patient's examination, it is clear to the psychiatrist that she has impairment in the following areas: emotional (mood reactivity, anxiety, anhedonia); cognitive (decreased attention and concentration); thought content and process (intrusive distressing thoughts about the assault); perception (flashbacks); behavioral (self-isolation, fear of returning to work); ADLs (insomnia and nightmares, decreased contact with people).

These impairments affect her ability to function socially or return to work. She is afraid of returning to work where the assault occurred; she is afraid that she cannot talk to other people who will inevitably ask questions about her experience; and she is fearful that she will not be able to keep up with the demands of the job due to poor concentration, flashbacks, and distressing thoughts that interfere with her functioning even at home. At the same time, she misses her job and the feeling of being productive.

The diagnosis was posttraumatic stress disorder, and treatment was trauma-focused cognitive-behavioral psychotherapy, sertraline (50 mg in the morning), and prazosin (1 mg at night time) for nightmare reduction and sleep stabilization. Her work status was for 30 days off work at the initial evaluation (ie, temporary total disability), pending initiation of treatment and review of job description.

At the 4-week follow-up appointment, the patient reports improvement in sleep, decrease in nightmares, and better control of anxiety with techniques learned in psychotherapy. Despite improvement in some symptoms, she still has the same fears related to returning to work. Her treatment was to continue psychotherapy, continue prazosin (1 mg at night time), and increase sertraline (to 100 mg in the morning).

The patient's work schedule is 8 hours a day, 5 days per week. Some of her work-related responsibilities include greeting customers, checking them in for appointments, obtaining insurance information, processing incoming mail, processing laboratory orders, and processing payments. As a result, her return to work included the following restrictions/accommodations: restricted from working at location where assault occurred; restricted from front desk duties; requires accommodation of 1.5 times the regular time allotment to complete tasks; requires accommodation of up to three unscheduled breaks of up to 10 minutes each to use learned techniques to regain composure; and requires schedule flexibility to attend psychotherapy. The patient is now temporarily partially disabled.

After 6 months of regular treatment visits, the patient returned for follow-up. In the interim, sertraline was tapered off and prazosin stopped. She has completed the course of psychotherapy. The only symptoms that remain are rare nightmares and rare distressing thoughts related to the assault. She has no problems fulfilling the back-office duties at work and is not using extra time or unscheduled breaks anymore. She is still triggered when passing by the job location where she was assaulted and was unable to get rid of the fear of working with customers. No treatment is indicated currently, and the patient may continue to work with the following restrictions: restricted from working at location where the assault occurred and restricted from working with customers in person.

The patient's psychiatric condition is permanent and stationary (which means that it is unlikely to improve or deteriorate to any significant degree in the foreseeable future, usually 12 months). Her status is permanently partially disabled.

Conclusion

Understanding the difference between symptoms, impairment, functional impairment, and disability allows clinicians to facilitate not only treatment, but also a successful return to the workforce. In cases of total disability, proper documentation of functional impairment allows patients to either obtain total disability benefits or re-train for a new career path. When returning a person who is partially disabled returns to work, it is vital to understand the limitations and properly document the required restrictions and accommodations for the employers.

References

  1. U.S. Department of Labor. Job accommodations. Accessed January 6, 2021. https://www.dol.gov/general/topic/disability/jobaccommodations
  2. Gunnar BJA, Cocchiarella L, eds. AMA Guides to the Evaluation of Permanent Impairment. 5th ed. American Medical Association; 2006.
  3. Social Security Administration. Mental residual functional capacity assessment. Accessed January 13, 2021. https://secure.ssa.gov/apps10/poms.nsf/lnx/0424510060
  4. US Department of Labor, Office of Disability Employment Policy. IMPAQ International, LLC. Transition back to work: policies to support return to work after illness or injury. Accessed January 6, 2021. https://www.dol.gov/odep/topics/pdf/PAP_Transition%20Back%20to%20Work%20FINAL_2017-09-07.pdf

Psychiatric Impairment Examples

Domain Impairment
Emotional Changes in mood, affect, avolition, anxiety
Cognitive Changes in level of consciousness, orientation, memory, attention/concentration
Thought content and process Circumstantiality, tangentiality, flight of ideas, derailment, intrusive/distressing thoughts, paranoid ideation, delusions, suicidal/homicidal ideation, thoughts of self-harm
Perception Auditory/visual hallucinations, illusions, flashbacks, derealization
Social/behavioral Crying, laughing, expressing anger, aggression, compulsions
Activities of daily living Sexual dysfunction (libido, erection, orgasm), sleep dysregulation (insomnia, hypersomnia, parasomnias, nightmares, night terrors), appetite dysregulation, changes in energy level
Judgment and insight Lack of judgment and/or insight

Psychiatric Restrictions According to the Major Domains of Mental Health

Emotional <list-item>

No tight deadlines

</list-item><list-item>

No public speaking

</list-item><list-item>

Restrict supervision by specific person/gender/ethnicity (if victim of assault/abuse)

</list-item><list-item>

Restrict from working in specific places (for patients with PTSD, specific phobia, agoraphobia)

</list-item>
Cognitive <list-item>

No tasks requiring high accuracy of data entry/processing

</list-item><list-item>

No tasks requiring extensive memorization

</list-item><list-item>

No tasks requiring persistent focus for more than 60 minutes without a break

</list-item><list-item>

No multitasking responsibilities

</list-item><list-item>

No work with high hazard potential

</list-item>
Thought content and process <list-item>

No work requiring interaction with general public

</list-item><list-item>

No supervisory responsibilities

</list-item>
Perceptual <list-item>

No work in proximity of or in collaboration with others

</list-item><list-item>

No work in highly hazardous settings

</list-item><list-item>

No work requiring operation of heavy machinery/driving

</list-item>
Social/behavioral <list-item>

No interaction with customers

</list-item><list-item>

Limited communication with peers

</list-item><list-item>

No supervisory responsibility

</list-item><list-item>

Restriction from working with specific people or at specific places

</list-item>
Activities of daily living <list-item>

Restriction from working during night hours

</list-item><list-item>

Restriction from working longer than 4-hour days/3-day weeks

</list-item>
Judgment and insight <list-item>

No supervisory responsibility

</list-item><list-item>

Restriction from safety/hazard decision-making

</list-item>

Workplace Accommodations According to the Domains of Mental Health

Emotional <list-item>

Reduce distractions in work environment

</list-item><list-item>

Provide to-do lists, written instructions, and reminders

</list-item><list-item>

Allow time off for treatment

</list-item><list-item>

Provide clear expectations of responsibilities and consequences

</list-item><list-item>

Provide sensitivity training to co-workers

</list-item><list-item>

Allow unscheduled breaks to use stress management techniques

</list-item>
Cognitive <list-item>

Reduce distractions in work environment

</list-item><list-item>

Provide to-do lists, written instructions, and reminders

</list-item><list-item>

Prioritize job assignments and provide structure

</list-item><list-item>

Allow flexible work hours and a self-pace workload

</list-item><list-item>

Provide memory aids (schedulers, organizers)

</list-item><list-item>

Direct supervision with/without written instructions

</list-item><list-item>

Break complex duties into smaller, simple tasks

</list-item><list-item>

Allot more time for completion of tasks (specify the time)

</list-item>
Perceptual <list-item>

Provide sensitivity training to coworkers

</list-item><list-item>

Facilitate access to direct supervision

</list-item><list-item>

Allow unscheduled breaks

</list-item><list-item>

Allow time off to attend treatment

</list-item>
Social/behavioral <list-item>

Separate workspace

</list-item><list-item>

Single point of supervisory contact, allowing for approach to obtain direction

</list-item>
Activities of daily living <list-item>

Periodic rest breaks away from the workstation

</list-item><list-item>

Flexible work schedule and flexible use of leave time

</list-item><list-item>

Allow work from home

</list-item>
Judgment and insight <list-item>

Provide consistent supervision and direction

</list-item>
Authors

Vladimir Bokarius MD, PhD, is the Medical and Research Director, Center for Occupational Health.

Address correspondence to Vladimir Bokarius MD, PhD, Medical and Research Director, Center for Occupational Health, 2970 Hilltop Mall Road, Suite 101, Richmond, CA 94806; email: bokariusv@workerscompdoc.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20210106-01

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