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
Why work is important to patients’ mental health
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.The longer a person is away from work with an injury or illness, the less likely he or she will return:
- 50% of persons off work for 8 weeks will not return.
- >85% of persons off work for 6 months will not return to long-term employment and are at risk for long-term disability.1
Unemployment increases mortality rates, physical and mental illness, and use of medical services.2 The unemployed may be more likely than the employed to visit physicians, take medications, or be admitted to hospitals.3
A disability mindset can develop after only 2 to 4 weeks off work, even in capable workers. An estimated 60% to 80% of time away from work is medically unnecessary.4 Returning to work as soon as possible after an illness or injury maximizes health outcomes and ability to function.
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.