Disability and the Concept of Return to Work

FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

This article discusses the return to work plan as a solution to the clinical and systemic problems arising from psychiatric disability. The systems that govern administration of “disability” benefits should be guided by:

1) Truth and resolution. The treating psychiatrist is relieved of the fear that if he or she acknowledges the truth, ie, the presence of (or potential for) preserved work capacity, his or her patient will suffer.

2) Work-reward relationship. The patient is supported for engaging in behaviors that are reasonably expected to culminate in restoration of the work-reward relationship and a healthy patient-psychiatrist-workplace system.

Among many problems inherent in the American disability system is the medicalization of work stress and its inappropriate conversion into psychiatric diagnoses, which implies impaired or loss of ability to function. This “medicalization” decouples the normal work-reward dynamic in a way that reinforces disability-seeking behaviors. Potential solutions to problems of disability require a multisystemic approach. In the psychiatrist’s office, solutions include the paradigm of “truth and resolution”; in practice, the re-coupling of work and reward as a goal, and support for disability reform (eg, the use of standardized functional assessments) but with careful consideration of its possible consequences.

Psychiatrists’ challenges to disability claims

There are challenges to the psychiatrist’s support of a patient’s claim for disability. While it seems obvious that a psychiatrist simply wants to diagnose accurately and make appropriate recommendations, the situation around disability is wrought with pitfalls and is quite complicated. The addition of an economic, potentially income-providing relationship forever changes the treatment dynamic. Supporting a disability claim could mean both administrative (in the form of documents initially justifying, then recertifying the claim) and legal (requiring other documentation or testimony related to the assessment) liabilities. Withholding support for disability benefits could lead to anger, violence, medical board complaints, negative online reviews, or litigation on the part of the patient. The psychiatrist might also feel burdened with significant counter-transference guilt.

A solution to this is “truth and resolution.” These best practices allow psychiatrists to conduct patient care in such a way that they can acknowledge the objective reality of return to work. It includes recognizing the pitfalls of misdiagnosis as well as potential excessive physical, emotional, and financial expense to the patient, the employer, family members, and medical specialists and administrators. These expenses can include unnecessary workups, treatment referrals, and cost to systems as benefits are paid and work production is lost, and the beginning of a process that can result in lifetime disability for a patient.

“Truth and resolution” as a treatment approach ensures that providers “first do no harm.” Importantly, it requires training in occupational assessment, which has been a noted weakness among psychiatrists. This training would include review of the difference between impairment and disability, discerning patient job requirements in interviews, consideration of somatic symptom disorders, and curricula that addresses the implications of a patient’s engagement with a disability system and prognostic factors affecting a return-to-work.

The work-reward relationship

The idea of promoting patient behaviors oriented toward restoring the work-reward relationship is an intuitive one which has been investigated in studies of disability and return-to-work across several medical specialties. Some approaches have focused on workplace accommodations. A 1998 review found that patients offered modified work after a workplace injury were about two times more likely to return-to-work than those who were not.¹ A 2005 systematic review found that the duration of disability for patients with musculoskeletal and other pain conditions was reduced by offers of work accommodations and communications between medical providers and employers.²

Other approaches to the return-to-work have considered stress and perception of support at work. A 2002 literature review found that a “non-supportive work environment” was associated with disability or retirement for cancer survivors.³ A later study found that “perceived employer discrimination” led to lower return-to-work rates for breast cancer survivors.⁴ Conversely, a 1998 prospective cohort study found that strong social support was a feature of patients who returned to work after lower extremity fractures.⁵ This suggests that interventions aiming to encourage actual or perceived support in the workplace could improve chances of a patient’s return.

Investigators have researched therapy when high work stress is identified. In a small Dutch study, patients with adjustment disorders were more likely to return to work and return to work earlier if they were treated with an activating, stress awareness training much like stress-inoculation training.⁶ Physician interventions in return-to-work and disability scenarios have also have some limits. Dasinger and colleagues⁷ found that a physician’s proactive communication consisting of understanding, questions, and recommendations about the patient’s work and workplace was associated with patients’ return to work within the first 30 days of disability for low back pain. Moreover, a physician’s explicit recommendation for returning to work was associated with a nearly 60% increase in return-to-work rates in patients with more than 30 days of disability. Unfortunately, these effects disappear in the first case and nearly lose statistical significance in the latter case when workers reported “high job strain” in the workplace.

Changes in assessment

In addition to changes in clinical approaches between doctor, patient, and employer, government systems have attempted systemic changes in assessments in attempts to reform disability systems. In this process, however, significant consideration must be paid to repercussions of changes made to vital disability benefit systems. In recent years, the United Kingdom has adopted a new functional assessment tool, the Work Capability Assessment (WCA). This tool has been used not only to assess new disability claimants, but also to reassess more objectively over 1 million claimants who had already been granted disability benefits.

Recently published research reveals that the WCA reassessment process was associated with increases in behavioral health symptoms, antidepressant prescribing, and completed suicides.⁸ To date, other nations conducting similar disability system reform (eg, the Netherlands, Australia) have not reported such trends. Still, the far-reaching social impact of such programs must be considered before the implementation of systemic disability reform.

Disclosures:

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Flinton is a Child and Adolescent Fellow in the National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, MD; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

References:

1. Krause N, Dasinger LK, Neuhauser F. Modified work and returns to work: a review of the literature. J Occup Rehab. 1998;8:112-139.

2. Franche RL, Cullen K, Clarke J, et al. Workplace-based return-to-work interventions: A systematic review of the quantitative literature. J Occup Rehab. 2005;15:607-631.

3. Spelten ER, Sprangers MAG, Verbeek JHAM. Factors reported to influence the return to work of cancer survivors: a literature review. Psycho-Oncol. 2002;11:124-131.

4. Bouknight RR, Bradley CJ, Luo ZH. Correlates of return to work for breast cancer survivors. J Clin Oncol. 2006;24:345-353.

5. MacKenzie EJ, Morris JA, Jurkovich GJ, et al. Return to work following injury: the role of economic, social, and job-related factors. Am J Pub Health. 1998;88:1630-1637.

6. Van der Klink JJL, Blonk RWB, Schene AH, et al. Reducing long term sickness absence by an activating intervention in adjustment disorders: a cluster randomized controlled design. J Occup Environ Med. 2003;60:429-437.

7. Dasinger LK, Krause N, Thompson PJ, et al. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. 2001;43:515-525.

8. Barr B, Taylor-Robinson D, Stuckler D, et al. “First, do no harm”: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Comm Health. 2016;70:339-345.❒