Psychiatric Annals

CME Article 

Is Separation from the Workplace a Psychiatric Emergency? The Role of the Clinician and the Consultant

Greg P. Couser, MD, MPH; David Evan Morrison III, MD; Andrew O. Brown, MD; Gaurava Agarwal, MD

Abstract

Separation from the workplace is generally disruptive. Although weathered well by some, it can result in a literal lethal outcome for others. Psychiatry in general would benefit from greater awareness and understanding of how and when separation from work becomes a psychiatric emergency. Psychiatrists are well versed in handling psychiatric emergencies of possible harm to self or others. However, there is less training regarding how to address problems that are at high risk for occurring whenever a patient leaves work. Psychiatrists are in an ideal position to prevent disability and adverse health outcomes associated with unemployment. This article explores the health hazards of unemployment (including increased risk of death), positive consequences of working, and the important role psychiatrists play in setting appropriate expectations. Psychiatrists best serve patients and their employers by sustaining employment and helping their patients navigate workplace challenges and improve their work, which also likely to improve their self-efficacy. [Psychiatr Ann. 2021;51(2):58–63.]

Abstract

Separation from the workplace is generally disruptive. Although weathered well by some, it can result in a literal lethal outcome for others. Psychiatry in general would benefit from greater awareness and understanding of how and when separation from work becomes a psychiatric emergency. Psychiatrists are well versed in handling psychiatric emergencies of possible harm to self or others. However, there is less training regarding how to address problems that are at high risk for occurring whenever a patient leaves work. Psychiatrists are in an ideal position to prevent disability and adverse health outcomes associated with unemployment. This article explores the health hazards of unemployment (including increased risk of death), positive consequences of working, and the important role psychiatrists play in setting appropriate expectations. Psychiatrists best serve patients and their employers by sustaining employment and helping their patients navigate workplace challenges and improve their work, which also likely to improve their self-efficacy. [Psychiatr Ann. 2021;51(2):58–63.]

Patients frequently enter the offices of their primary care providers or psychiatrists with a myriad of issues affecting their ability to work. Because of our caregiving nature and because we are measured according to our patients' ratings, an eagerness to please is a trap compounded by often having limited time with our patients. It can be easy to suggest time away from work as a solution to our patients' problems. However, making such a determination at times may not help and could actually harm patients.

Work is central to our identity as people. Erikson,1 as he explores what is the essence of health, acknowledges Freud as the origin of the oft quoted maxim: “to be healthy is to work and to love.” We love our friends and family, yet our daily routine and socialization greatly revolves around work. When we are not working, an important part of who we are is missing, so our lives may suddenly unravel.

Psychiatrists are trained in psychotherapy and in treating issues related to love and relationships. At the same time, there is little focus on that other pillar of our mental health—work. This article reviews the factors that can turn a patient's simple request for disability into a serious psychiatric emergency.

Unemployment as a Health Hazard

Unemployment in general is a health hazard. Not working has been associated with adverse health outcomes2–4 and greater morbidity and mortality.3,5–8 Unemployment has been associated with decreases in mental, family, social, and economic well-being3,5–8 and may even be worse for mental well-being than divorce or marital separation.9

Unemployment has been associated with some specific adverse mental health outcomes. There are some data to show that job loss increases the risk of hospitalization due to alcohol-related conditions, (near 20% increased adjusted risk in men and near 40% increased adjusted risk in women), and in men it increases the risk of hospitalization from traffic accidents (near 40% increased adjusted risk) and self-harm (near 25% increased adjusted risk).10 One study showed the average number of people with psychological problems (ie, mixed symptoms of distress, depression, anxiety, psychosomatic symptoms, subjective well-being, and self- esteem) among those who are unemployed was 34% compared to only 16% among people who are employed.11 For those with depression, another study found that those who returned to work within 6 months of becoming unemployed had more pronounced improvement in depressive symptoms than those who went back to work after a longer period.12

There are many theories why unemployment is a health hazard. Proposed mechanisms include less income,13,14 negative impact on subsequent employment patterns,13 loss of self-esteem,13,14 social isolation,13,14 and social stigma.14 Although sickness can sometimes cause unemployment, the converse situation of unemployment causing sickness (ie, among healthy persons who would otherwise not be at risk for increased morbidity) is a frequent serious problem that can be anticipated, proactively addressed, and prevented. Data analysis of the US Panel Study of Income Dynamics (a longitudinal survey of American families) showed that even in cases of job loss due to establishment closure, the odds of fair or poor health were increased by 54%; and among respondents with no preexisting health conditions, it increased the odds of a new likely health condition by 83%.7

In cases of separation from work due to physical injury, workers are faced with navigating complex systems that may reinforce a feeling of learned helplessness. For example, when workers' compensation claims are denied or discontinued, there are a number of consequences, including financial strain, family tensions, subsequent health concerns, and negative employment experiences.15 In injury situations, attributing fault to another has been associated with greater financial and recovery worry. This makes sense given blame is associated with external locus of control and use of nonproductive coping strategies.16

Regardless of injury or illness, stigma and discrimination in mental health conditions may have an impact on expectations of return to work and associated outcomes.17 Furthermore, the label of disability connotes marginality and stigma.18 When some workers found they would no longer be able to work in their previous jobs, they described subsequent feelings such as loss of identity or loss of purpose.13,19,20 For older workers these feelings may be especially problematic due to reduced opportunities to return to the work force, leading to lower social and mental engagement, lower control, and low self-esteem.19

Unemployment has even been associated with premature aging. In one study, among men, unemployment exceeding 500 days over a period 3 years (compared to continuously working) was associated with having shorter leukocyte telomere length (a potential biomarker of aging) at follow-up.21 It naturally follows that unemployment has been associated with increased risk of death2,3 (Table 1).

Adverse Health Consequences of Unemployment

Table 1:

Adverse Health Consequences of Unemployment

Increased Risk of Death with Unemployment

Increased risk of death with unemployment has been shown in the literature. For example, a large study of middle-aged men who experienced unemployment in the 5 years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed.22 Another study showed that unemployment significantly increases the risk of death at the end of follow-up by nearly 50% (from 5.36% to 7.83%).23 In that study, there was no noted increased risk for death by motor vehicle accidents or homicides; however, there was an increase in suicide-specific mortality and risk of dying from disease other than cancer or cardiovascular disease.23 Thus, unemployment may also have an impact on the mechanism of death.

Age at becoming unemployed appears to be a factor influencing risk of death. One study matching employment earnings data of workers in Pennsylvanian to Social Security Administration death records found that for high-seniority male workers, mortality rates in the year after displacement were 50% to 100% higher than would otherwise have been expected. This effect of unemployment on mortality hazards declined over time from initial displacement, but there was still a 10% to 15% increase in annual death hazards even 20 years after displacement.24 Unemployment has similarly been associated with increased mortality risk for those in the early to middle stages of their career but less so for those in the late stage of their career.25

Even when looking at retirement as the means of entering the ranks of the unemployed, relatively healthy men have been shown to have increased risk of mortality compared with men who remained continuously employed.22 A large Greek study showed retirees (compared to those still employed) had a 51% increase in all-cause mortality. Also, a 5-year increase in age of retirement was associated with a 10% decrease in mortality. Theories of why this was the case included lower finances, less healthy habits, and psychosocial consequences.6 In another study of petrochemical industry employees, retiring at age 55 or 60 years was not associated with better survival than retiring at age 65 years, and mortality was higher in employees who retired at age 55 years than in those who continued working.8

Positive Consequences of Working

Although unemployment has been associated with poor health and increased risk of death, the converse is also true—that is, return to work has been associated with positive outcomes. A 2012 systematic review found return to work benefited financial status and health in a variety of populations, times, and settings.26 Evidence shows work is generally good for physical and mental health and well-being.3

In a more specific example regarding physical health and return to work, a large cohort of workers with low back pain saw pain and function improve more rapidly with an immediate or early return to work.27 Similarly, a specific mental health example was shown in a study in which returning to work within the first 6 months after job loss served to resolve post-job loss depressive symptoms. The authors suggested that programs could be geared to early return to work and efforts to strengthen confidence, motivation, and efficacy.12 Furthermore, a 2014 review found strong evidence for a protective effect of employment on depression and general mental health.4

In the authors' clinical experience, work as treatment makes sense. Work is a stabilizing part of a routine, a source of satisfaction for accomplishment, an important aspect of identity or sense of self, and a pillar for meaningful relationships. We also find as people are separated from work they are often anxious about the stigma of being away and not being a productive member of the work team. Until work is introduced into the treatment plan, it is our experience that patients on disability rarely get better; therefore, consideration of separation from work should be given very serious thought with a default of staying at work.

Imperative to Stay at Work

It is imperative for front-line clinicians and psychiatrists consulting to employers to recognize that keeping patients at work has the best outcomes (Table 2).

Why Stay at Work?

Table 2:

Why Stay at Work?

Studies have shown that the odds for return to full employment drop to 50/50 after 6 months of absence. Even less encouraging is the finding that the odds of a worker ever returning to work drop 50% by just the twelfth week.28 Yet, the decision to take patients off of work is usually a completely medically discretionary decision. A study found that 60% to 80% of lost workdays attributed to medical conditions in the United States involved time off from work that was not really required by the condition itself.5 People can generally work at something productive as soon as there is no specific medical condition to keep them from working.28 Furthermore, the Americans with Disabilities Act allows employees to request reasonable accommodations to keep them working.

From a psychiatric standpoint, there are few absolute indications for medical absences. In the case of high risk for suicidal or homicidal behavior, or possibly severe active substance use disorders, these can be incompatible with work until the risk is mitigated. In most other cases, the designation of “medically required absence” greatly depends upon the extent of symptoms and whether or not the symptoms directly affect functioning important to the essential job functions. In other words, it is important to know what your patient does for a living and whether or not the opportunity exists to stay at work with restrictions and/or accommodations. The default for psychiatrists according to the evidence should be to keep patients working and not separate them from their jobs unless there is a clear plan in place to return patients quickly to full functioning.

At the same time, patients can also be understandably anxious about working, particularly when they are not feeling well in the context of possible performance and/or interpersonal issues. Frequently identified factors related to later return to work include depression, anxiety disorders, burnout, comorbid mental health problems, older age, low education, history of previous sick leave, high job stress, reorganizational stress, threat of unemployment, and part-time work.29 Similarly, factors related to an earlier return to work include higher self-efficacy, active problem-solving coping strategies, lower age, frequent communication with supervisor, and quality and continuity of occupational care.29 As psychiatric clinicians and consultants identify the most critical factors that can affect later or earlier return to work, they can appropriately set expectations both for patients and the companies for which they work (Table 2).

Setting Expectations Is Paramount

Psychiatrists are unique in their knowledge of human behavior, assessing persons in crisis and risk of harm, interpersonal dynamics, and expectation setting. With a skilled interview, psychiatrists can easily learn about barriers to staying at work and formulate plans to address these barriers before making a decision to keep a patient away from work. Asking whether a worker expects to recover and return to work, especially at the outset, can help identify those at high risk for delayed return to work.17 Similarly, a person's level of work-related self-efficacy at the start of the sickness absence is an adequate predictor of time until actual return to work.29 Psychiatrists can strive to improve self-efficacy in their patients, as ultimately the patient's behavior determines the extent of his or her future recovery.5

Improving self-efficacy does not need to be complicated at the decision point of keeping a patient at work or taking the patient away from work. Normalization and validation are sometimes all that is needed for patients to gain confidence. It is normal for patients to think their situation is unique or that they must be completely symptom-free to keep working. However, having symptoms does not equate to impairment or true loss of functioning. Sometimes psychiatrists may be tempted to take patients away from work when they are symptomatic when a simple temporary accommodation may help the patient stay at work. Table 3 gives some potential ideas the authors have used for accommodations in different symptom scenarios.

Typical Psychiatric Symptom Scenarios with Ideas for Accomodations

Table 3:

Typical Psychiatric Symptom Scenarios with Ideas for Accomodations

Often, patients are the only ones noticing they are not working at full speed, and their co-workers or supervisors may not even recognize a problem is there. It can be helpful to ask about performance reviews. If the patient has only had positive feedback about performance, it is possible that work self-efficacy is low. Reassurance and encouragement done in a realistic manner (corresponding to work requirements) can go a long way to boost self-efficacy.

Reassuring patients about work also means validating their fears about staying at work. There is potential peril in medicalizing nonmedical issues such as workplace conflict, job dissatisfaction, or family disruption.5 In cases in which there are difficult workplace and/or home dynamics, it may be worth psychiatrists spending extra time with their patients to troubleshoot these issues. Psychiatrists can help by empowering their patients to actively problem solve rather than using avoidance as a coping strategy. This may involve direct therapy and guidance and/or referral to a therapist to address these issues. It is important to normalize emotions, focus on what the patient can do (ie, rather than what they cannot do), and let them know you are there to support them.

As clinicians we know how important co-workers are to enjoying, or even tolerating, work. Even though work is generally positive, we acknowledge work can also be stressful, particularly when there are difficult workplace dynamics with coworkers and/or a supervisor. We find it helps patients to validate that the workplace is not always an easy place to return. Some changes at work are truly challenging in new and potentially overwhelming ways. Table 4 is a list of pertinent factors regarding work and mental health that the authors recommend psychiatrists consider as they help their patients navigate difficult workplace situations.

Pertinent Factors Regarding Work and Mental Health

Table 4:

Pertinent Factors Regarding Work and Mental Health

In general, we recommend encouraging patients to see themselves as the center of initiative. Supporting patients may include confrontation of avoidant behaviors. It is also recommended psychiatrists make an effort to understand the workplace dynamics better, ideally by an on-site visit if possible. The most accurate understanding of all the realities of the work demands is ideal for navigation of the question of staying at work or taking time off. We strongly encourage setting a return appointment soon after work re-entry to further reassure and accurately debrief what happened at work.

Staying at work need not be an all- or-nothing proposition. It is important to leverage your unique experience as a psychiatrist. Depression and anxiety can be fatiguing, and so short-term restrictions such as limited work hours (eg, maximum of 4 or 6 work hours per day) or work days (eg, no more than 2 consecutive days without a day off to allow a day for recovery and focus on self-care) might be appropriate if it helps improve chances to gain confidence and stay connected to the workplace. Other potential work restrictions (discussed elsewhere in this issue) could be considered. However, regardless of staying at work with or without restrictions, psychiatrists can help by reinforcing the understanding that work is a normal part of functioning and an important factor of sustaining mental health.

Conclusion

Psychiatric clinicians and consultants can educate their employee-patients and the companies they work for about work issues. As they are formulating plans to support their patients in staying at work they ought to consider (1) separation from work is an urgent situation that has been associated with poor health and even increased risk of death; (2) working is a normal part of our daily functioning and an important source of relationships, pride, and identity; (3) when people are kept away work, their odds of returning to work at all decrease over time; and therefore, (4) the default decision for psychiatrists would be to keep their patients working as part of their treatment.

A request from a patient for disability or time away from work is an important time to stop, fully assess the situation, and formulate a plan. This may take additional time, but it is worth it given the potential adverse consequences of work separation. Psychiatrists are in an important position to educate organizations about health while helping employed workers improve self-efficacy so they stay at work. As people continue to work, they experience the health benefits of working, a deepening sense of meaning and sense of self, and the satisfaction of a job well done.

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Adverse Health Consequences of Unemployment

<list-item>

Greater morbidity3,5–8

</list-item><list-item>

Family issues/tension3,5–9

</list-item><list-item>

Increased risk of hospitalization10 <list-item>

Alcohol-related conditions10

</list-item><list-item>

Traffic accidents (men)10

</list-item><list-item>

Self-harm (men)10

</list-item>

</list-item><list-item>

More psychological problems11

</list-item><list-item>

Depressive symptoms12

</list-item><list-item>

Decreased economic well-being3,5–8

</list-item><list-item>

Loss of self-esteem13,14,19

</list-item><list-item>

Social stigma and isolation13,14,17,18

</list-item><list-item>

Learned helplessness15,16

</list-item><list-item>

External locus of control16

</list-item><list-item>

Loss of identity13,19,20

</list-item><list-item>

Premature aging21

</list-item><list-item>

Increased risk of death2,3 <list-item>

Increased suicide23

</list-item><list-item>

More pronounced if younger whenunemployed25

</list-item>

</list-item>

Why Stay at Work?

<list-item>

Better financial status26

</list-item><list-item>

Improved physical health3,27

</list-item><list-item>

Benefits for mental health3,4,12 <list-item>

May help depressive symptoms4,12

</list-item>

</list-item><list-item>

Increased confidence and self-efficacy12

</list-item><list-item>

Stabilizes routine20

</list-item><list-item>

Important part of identity1,13,19,20

</list-item><list-item>

Odds for returning to work drop the longer someone is away from work28

</list-item><list-item>

Most time away from work is not medically required5

</list-item><list-item>

Increased symptoms do not necessarily mean poor functioning/inability to work5

</list-item>

Typical Psychiatric Symptom Scenarios with Ideas for Accomodations

Symptom scenario Potential accomodation ideas
Fatigue More frequent breaks; allow more flexible hours to do work when person has the most energy
Sleep disturbance Limit rotating and/or night shifts; coordinate work hours with sleep schedule
Panic attacks Allow for up to 5-minute break per hour on short notice
Irritability Focus on projects; limit work directly with people
Hallucinations Allow use of headphones
Poor concentration Instructions verbally and in writing; allow more time to learn; limit distractions; use of checklists; well-defined priorities
Worry about work Allow more flexible hours to do work when worry is less; scheduled brief meetings with supervisor to debrief regarding concerns and clarify expectations; time away for appointments to debrief with mental health provider

Pertinent Factors Regarding Work and Mental Health

<list-item>

Health promoting factors <list-item>

Benefits from employers <list-item>

Health insurance

</list-item><list-item>

Income

</list-item><list-item>

Retirement income

</list-item>

</list-item><list-item>

Structure/predicatability

</list-item><list-item>

Source of identity (pride)

</list-item><list-item>

Professional support (colleagues and allies)

</list-item>

</list-item><list-item>

Health undermining factors <list-item>

Poor work conditions

</list-item><list-item>

Excessive hours

</list-item><list-item>

High demands

</list-item><list-item>

Low control

</list-item><list-item>

Underemployment

</list-item><list-item>

Bullying (cruel/sadistic bosses, taunting co-workers)

</list-item>

</list-item>
Authors

Greg P. Couser, MD, MPH, is a Consultant Physician, Psychiatry and Occupational Medicine, Mayo Clinic. David Evan Morrison III, MD, is an Assistant Clinical Professor of Psychiatry, Chicago Medical School. Andrew O. Brown, MD, is the Department Psychiatrist, Boston Police Department; and a Consulting Psychiatrist, public and private sector organizations. Gaurava Agarwal, MD, is an Associate Professor, Departments of Psychiatry and Behavioral Sciences and Medical Education, Northwestern Feinberg School of Medicine; and the Director of Physician Well-Being, Northwestern Medicine Medical Groups.

Address correspondence to Greg P. Couser, MD, MPH, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; email: couser.gregory@mayo.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20210105-02

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