Is your patient too sick to work?

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.