Evaluating Mental Health Disability in the Workplace: Model, Process, and Analysis

Liza Gold, an occupational psychiatrist, and Daniel Shuman, a legal scholar, have written a book that will be very helpful for professionals evaluating psychiatric disability, requests for accommodation under the Americans with Disabilities Act, and fitness for duty. For many, it will be a resource to be consulted regarding specific topics, such as the legal aspects of disability evaluation or the rules about Americans with Disabilities Act, both of which may be unfamiliar to many psychiatrists. Read in its entirety, the book offers a useful perspective on work and mental health to general psychiatrists as well as to disability specialists.

The book begins with a rich discussion of the ethical issues involved in disability evaluations and invites each of us to consider our own belief systems about the ability or inability to work. For example, are we fearful of malingering? Do we see the employer as the noncaring oppressor? Do we believe that stress is invigorating or damaging? The first half of the book continues with a complex interweaving of legal, psychiatric, emotional, and social considerations in the study of work and disability. The authors address each area in turn and provide a rich assessment of each, which allows psychiatrists to make informed decisions in ways in which they are comfortable responding to questions about their own patients seeking disability status. The book may also help psychiatrists feel more comfortable participating in work-related evaluations for nonpatients. The second half of this text presents a clearly described set of practice guidelines for mental health disability evaluations. The authors provide excellent descriptions of variations in the definitions of disability, functionality, and level of proof required among the various types of disability assessments (Social Security, private insurers, and workmen's compensation). The final two chapters address the special issues of accommodation under the Americans with Disabilities Act and fitness for duty examinations, delineating the ways in which mental health examinations and reports differ from those required for physical disability.

Most psychiatrists, even those who never provide a third-party independent medical examination, are asked by patients to provide information for a disability claim, medical leave, accommodation at work under the Americans with Disabilities Act, or fitness for return to work. Psychiatrists rarely have had any formal training in performing disability assessments or in writing reports that may be evaluated by both physicians and nonphysicians. Although work generally occupies a significant part of each patient's day and may directly or tangentially be the focus of many psychotherapy sessions, most psychiatrists do not include a work history in their patient intake. Even when one knows the patient's profession, the patient's actual daily work activities, including physical, intellectual, and emotional demands, may remain hazy to the psychiatrist. Most of us were taught to conduct a child psychiatric evaluation, which includes a detailed developmental history and specific questions about functioning at home and school and with friends. However, we are unlikely to systematically evaluate similar functioning in adults. Thus, when work problems emerge, we may have little sense of the full context in which they occur.

When psychiatrists are asked to send patients' records to Social Security or another disability program or attest to the need for a patient to go on medical leave or return from leave, they may not fully consider the ethical and legal ramifications of simply fulfilling these requests. They may or may not consider the effect on the doctor-patient relationship in giving data to third parties, nor may they discuss these issues with patients before sending a report. Only occasionally will a psychiatrist suggest to his or her patient in ongoing treatment that the patient might be better served by obtaining a third-party independent medical examination from a nontreating psychiatrist rather than involving the patient's own psychiatrist, especially if the matter may end up in litigation.

Gold and Shuman adeptly lay out these complex problems in a way that provides clear information to the practitioner without oversimplifying any of the issues. In addition, they offer a firm foundation of well-researched information that will enable the psychiatrist to perform better mental health assessments and more confidently write reports in a systematic, reliable manner.