Patients Who Can't or Won't Work: How to Assess Impairment

Work performance is a core indicator of both psychological functioning and treatment outcome, said Air Force Maj. Steven Pflanz, a psychiatrist who is the life skills flight commander and assistant chief of the medical staff at McGuire Air Force Base in New Jersey.

A thorough evaluation involves numerous questions, he said. How does the job affect the person's self-esteem? Why did she choose that job or that career? Does she hate her job but love her career? How does being laid off affect how he feels about himself as a person? How does work affect family relationships? Does the person socialize with peers from work? Military officers, said Pflanz, a career officer himself, typically find that work dominates their social networks.

If a patient says he can't work, Pflanz suggested, ask what specific tasks he can't do and why. Because employers today ask people to work longer and harder, he said, asking people whether they feel stressed is less useful than asking, “How are you coping?”

People who want to get out of their jobs, he observed, sometimes have accidents or manifest symptoms such as headaches. Some people use sickness to justify failure. Some complaints of cognitive impairment may require objective testing.

Physicians can't attest to the person's having been ill before they first saw that person, Pflanz said.

A treating psychiatrist can't determine whether a person is disabled with respect to a particular job, said Andrea Stolar, M.D., a consultant to MetLife Individual Disability Income Center in Tampa, Fla. “That's a claims decision,” she said. The psychiatrist can report, however, whether the person shows up in clean clothes and on time, remembers facts, and talks coherently.

Scott agreed. All that psychiatrists can communicate on a disability form, she said, are impairments of functions in multiple domains. You need to document how people are functioning in your office and their life, she advised, and what they need to get back to functioning well.

Scott recounted the case of a man who had obsessive-compulsive disorder and had worked at the same company for 30 years, steadily rising through the ranks. After his grown daughter left home, his illness worsened, and he spent most of his workday in the bathroom washing his hands. One night he went home early. Having misplaced his house key, he called his wife, who told him a key was under the doormat. He would not lift the mat, however, because he did not want to get his hands dirty. Conveying such details about daily life, Scott suggested, can help such patients get benefits.

Creative solutions, Stolar related, may enable some people to stay in their jobs. One woman used earphones to listen to music at her desk, thereby blocking out distractions. An emergency room nurse who found daily exposure to trauma too stressful switched to a job coding medical records. Some people can work successfully from home.

In contrast, Stolar noted, someone with an anxiety disorder that keeps her from participating in required large-group meetings won't be able to stay in that job.

Even patients who take time off from work benefit from continuing their usual daily activities, she added. That includes eating and sleeping at regular hours. Participating in outside activities reinforces staying in treatment. Day treatment programs, she said, sometimes can provide the needed structure.

For people who are not working, Stolar said, psychiatrists can assign homework with specific goals to accomplish each day. Helping those who have adopted a sick role improves their productivity, she asserted, and speeds their return to their prior level of functioning. ▪