Assessing Psychiatric-Related Work Disabilities in Primary Care Practice

Mental illnesses and substance use disorders are among the most common causes of long-term disability in the United States, preceded only by musculoskeletal disorders, cancer, and pregnancy.(1) Primary care physicians (PCPs) play a significant role in the determination of psychiatric-related work disabilities, because more adult Americans receive mental health treatment from PCPs than from psychologists or psychiatrists.(2) PCPs often lack the time, training, and resources, however, to explore their patients’ psychiatric-related impairments and the effects of psychiatric disorders on their patients’ ability to perform at work.(3)

Denied Claims

Because it may be difficult for PCPs to make a compelling case for a psychiatric disability, it is not surprising that about one-third of initial claims for all causes of long-term disability are denied by private insurance companies.(4) The most common reason is that the information requested by the insurance company was not received or is inadequate. Although it is not known how the rejection rate for individuals with mental illnesses compares with the overall rate, taking into account physically based claims, mentally ill individuals often have a particularly difficult time obtaining disability benefits. Apart from inadequate or missing information, there may be diagnostic and preexisting condition limitations in insurance policies, and symptom variability in psychiatric patients makes it very difficult to predict treatment outcomes and project a date when the patient may return to work.

When insurance companies make disability determinations, whether for mental health claims or non–mental health claims, they typically request office progress notes and collateral information contained in primary care medical records (e.g., consultations, lab results, and imaging studies). Primary care medical records may or may not contain valuable information about the patient’s mental status and psychosocial functioning. Nevertheless, insurance companies rely heavily on primary care medical records for psychiatric disability determinations. (Of course, records of psychiatrists and psychologists also are requested and reviewed, if available.)

Performance Deficits

Disability benefits are awarded based on the impact a condition has on an individual’s ability to perform activities essential for a defined job. Insurance companies not only send written requests to PCPs for their medical progress notes, but typically send forms that ask questions such as “Why is your patient unable to work at present?” and “What specific activities or tasks is your patient unable to perform that affect his or her ability to work?” The PCP must have some knowledge of the tasks involved in the patient’s job to answer those questions.

Document review may reveal misrepresentations by healthcare providers due to bias or attempts to justify diagnostic and therapeutic interventions.

Any patient may report that a mental disorder prevents him or her from working. However, such statements must be medically verified. If the medical record or responses to the insurance company’s inquiries do not contain documentation corroborating that the patient actually is unable to perform work-related activities, then the odds of that patient qualifying for a mental health disability are low. Furthermore, document review may reveal misrepresentations by healthcare providers due to bias or attempts to justify diagnostic and therapeutic interventions. Thus, accurate assessment of the validity of the clinical presentation and other validity considerations is taken into consideration during claim file reviews.

PCPs usually are able to document information related to their patients’ temperaments and aptitudes as a proxy for work ability and impairment. For example, they can provide information about the patient’s ability to think clearly and articulate facts and ideas. They can discuss whether the patient can follow specific instructions, as well as direct, control, and plan activities. Patients with mental health disabilities usually demonstrate severe limitations understanding, remembering, or applying information, as well as adapting to change and interacting with others. A mental health disorder affecting a patient’s ability to interact and cooperate with others, handle conflicts, and respond to suggestions and correction may be indicative of psychiatric-related work disability.

Although patients with personality disorders often demonstrate interpersonal conflicts, the notion that work and experiences at work are the relevant causative factors for any manifestations of distress or impairment is ambiguous, at best. Personality disorders are, by definition, relatively fixed ways of behaving that arise in childhood or adolescence, long before an adult workplace event. Patients with borderline personality disorder, in particular, are very sensitive to environmental circumstances, especially at work. Yet, most patients with borderline personality disorder rarely meet insurance company criteria for a mental disability.(5)

Sources of Information

The psychiatric insurance claim file usually contains medical records submitted by a psychiatrist, psychotherapist, PCP, and sometimes other physicians and healthcare providers (e.g., physician assistants, nurse practitioners, and physical and occupational therapists). Insurance companies may request supplemental information on insurance company forms designed to capture important information not found in the medical records. Occasionally, insurance companies ask patients to undergo independent medical evaluations by expert physicians who are not involved in their treatment.

Inconsistent documentation among caregivers regarding a patient’s mental health functioning, such as differences in opinions and diagnoses, incorrect or contradictory information, or information that cannot be substantiated, will cast doubt on the issue of genuine, severe psychopathology. It also will damage the credibility of the patient’s statements to his or her providers or the providers’ accuracy in reporting the patient’s symptoms, such that a functionally impairing psychiatric condition cannot be established with certainty. The presence of significant inconsistencies will lead insurance companies to consider the possibility of secondary gain or exaggeration of the patient’s psychological dysfunction.

Symptom Severity and General Functioning

Because psychiatric disabilities are the result of significant symptomatology, symptoms should manifest as severe and beyond mild to moderate in intensity for an individual to be considered incapable of working. To be sure, rating the severity of symptoms is a subjective process. Rating scales for conditions typically associated with mental health disabilities, such as depressive and anxiety disorders and posttraumatic stress disorder, may be useful in gauging the severity of symptoms, as long as the testing contains objective validity scales to assess the patient’s current symptoms.

Because symptoms are indicators of the severity of the patient’s mental health conditions, it is crucial that the frequency, intensity, and duration of specific symptoms be documented. Documentation in the medical records should reflect that the symptoms are severe enough to interfere with the patient’s occupational role and responsibilities. Table 1 outlines specific mental functions that most commonly disrupt an individual’s capacity to sustain work.

Stress

A common misconception among caregivers is that patients should qualify for time off from work due to stress. However, realistically, no job has ever been stress-free, and there is no individual whose personal life has always been free of stress. Stress-related problems in living usually do not justify a finding of mental health disability, including financial stress due to unemployment and social hardships, as well as stress compounded by the actual denial of a disability claim.

When assessing the relation between stress and work performance, the PCP should determine whether an underlying mental illness is the cause of work-related impairment, or whether stress from work is the cause of psychiatric symptoms. If the latter, insurance companies are unlikely to approve the claim, because workplace stress and dissatisfaction are common and not, in themselves, an indication of mental illness or impairment.

A bad fit between an individual and a workplace does not constitute a mental health disability.

Complaints that derive from issues such as conflicts with a supervisor or coworker, heavy workloads, or a wish to take time off from work for personal reasons, must be separated from symptoms due to mental illness. A bad fit between an individual and a workplace does not constitute a mental health disability. When disgruntled individuals seek employment elsewhere, their job search may be considered prima facie evidence that psychiatric impairments and limitations do not preclude work.

Referrals

Although PCPs are adept at providing counseling and psychotropic medication for uncomplicated psychiatric patients, more seriously ill individuals usually require a referral to a psychiatrist or psychologist, or both. Insurance companies look to see if a referral has been made. If there is no documentation that the patient currently is receiving treatment by a mental health professional, it may signal that the PCP’s treatment, although appropriate, lacks the intensity of therapy considered prerequisite for a disabling mental illness. Insurance companies generally expect that a patient will have required intensive outpatient therapy or “partial” or inpatient hospitalization for a condition causing a major psychiatric-related work impairment.

Activities of Daily Living

Until proven otherwise, it is assumed that patients are capable of eating, bathing, dressing, grooming, and performing other routine activities related to personal hygiene and self-care—the so-called activities of daily living (ADLs). More complex skills, such as managing finances and medication, preparing meals, driving, and utilizing a computer and personal digital assistants, are known as instrumental activities of daily living (IADLs). Both ADLs and IADLs should be documented in the medical records as intact, or not.

It would be expected that a mental disorder severe enough to prevent performance of all work activities also would cause notable impairments in most or all other life activities, often referred to as a global psychiatric impairment. It is very unlikely that a mental disorder severe enough to preclude work would not affect ADLs and IADLs.

Work Restrictions and Return to Work

After careful consideration of the patient’s psychiatric and medical diagnoses, mental status examination, performance deficits, cognitive abnormalities, severity of symptoms, intensity of treatment, global assessment of functioning, ADLS/IADLs, and other factors, PCPs should be able to decide whether psychiatric-related work restrictions are medically necessary. Such decisions may result in life-changing events and, therefore, should be given very serious consideration.

Comprehensive restrictions such as “no work” and “permanently disabled” usually are not supported by insurance companies, because those terms are overly broad and too vague, and they are not correlated with specific clinical impairments and limitations. Reasonable psychiatric restrictions may include the following:

• Low project responsibility;

• Minimal supervision of others;

• Reduced or flexible work hours;

• Minimal interaction with the public; and

• No handling of dangerous machinery.

PCPs should limit their restrictions to the functional impact of the psychiatric disorder. Any restrictions indicated by comorbid medical conditions should be made separately. For example, in an individual with depression and low back pain, restrictions related to sitting, standing, walking, reaching, lifting, carrying, climbing, and stooping usually are not relevant to the psychiatric component of the disability.

Some mental illnesses may warrant driving restrictions, although this is a controversial issue.(6) Driving usually is considered a privilege unrelated to the capacity to work. Patients who should not be driving for psychiatric or medical reasons, or who should be driving only under certain circumstances, should be informed by their physicians. However, driving restrictions due to medical and psychiatric conditions preclude only employment as the operator of a motor vehicle, not all gainful employment,.

Risk Factors

The major risks of returning a mentally ill individual to work are acting out in aggressive or violent ways, and possibly harm to self or others due to inattention or poor judgment. The potential for cognitive impairment leading to harm to self or others requires close scrutiny of individuals who use dangerous machinery or are employed in the healthcare profession and are at risk to make medical mistakes.

Workplace violence, an all-too-common event on the nightly news, is essentially unpredictable. However, a personal history of violence or repeated violence is a significant risk factor for future violence. Risk factors for violence specific to work include feeling isolated or picked on by supervisors and being treated unfairly or particularly inhumanely at termination.(7)

Work Environment

It is undisputed that changes in the work environment can lead to significant improvements in worker well-being. The responsibility for disability management does not rest solely on the insurance carrier or claims administrator; rather, it is shared with the employer. The employer is expected to create an environment of awareness, support, and tolerance to ensure that workers lead more successful and productive lives, whether or not they have a mental disorder. Employers must foster an overall culture of wellness that is reinforced by senior leadership. Organizations increasingly are turning to chief wellness officers to promote worker well-being. Studies(8) have shown that modifiable work-related risk factors such as low job control and high job strain are important targets in efforts to reduce mental afflictions and disability claims.

The longer a patient remains on disability, the less likely he or she is to return to work.

Prevailing (and stigmatizing) views that mentally ill patients cannot or should not work are unfounded. Research has demonstrated that working does not have an adverse effect on mental illness in the overwhelming majority of cases.(9) To the contrary, work tends to have a salutary effect on individuals with mental illnesses. Working enhances psychological health and well-being, promotes a connection to the broader social and economic community, and also provides a means for individual satisfaction and accomplishment. Conversely, the loss of work has been associated with a variety of mental health ailments and societal problems, including crime, substance abuse, and family dissolution. Thus, early return to work should be a priority for patients on disability leave.

In addition, the longer a patient remains on disability, the less likely he or she is to return to work. Fear of relapse upon reintroduction of stable or recovering patients into the workforce usually does not warrant medically necessary work restrictions, because, as stated earlier, most psychiatric disorders are attenuated or ameliorated by work. Staying at work or returning to work is almost always in the patient’s best interest.

Appeal Process

Insurance company claims managers are trained to decide disability benefits based on the clinical data and accounts contained in the medical records, as well as medical opinions solicited from insurance company physicians and independent physicians, when requested. Benefit decisions must be aligned with the provisions set forth in insurance policies. PCPs and patients understandably can become angry and upset when a decision is unfavorable. Appealing insurance claim denials can be a complicated and frustrating process that often is difficult to understand and navigate.

Both the patient and the PCP may submit additional information to consider during an appeal. The same documentation standards apply—that is, to submit objective and detailed mental status and behavioral observations and findings related to global functioning. Clinical updates sent to insurers, whether documented in progress notes or written on the PCP’s letterhead, should emphasize the most recent events that substantiate the medical need for work restrictions.

Information submitted on appeal is scrutinized by insurance company personnel who have varying backgrounds and, therefore, should be written in non-technical terms for a general audience. In all instances, the tone of progress notes, evaluations, letters, and other correspondence should be professional, without hyperbole, rancor, or ranting. The newly submitted material should be free of bias and grounded in medical findings and observations.

Conclusion

PCPs are the vanguard to the evaluation of work ability and return-to-work decisions. Psychiatric-related work disabilities are characterized by: (1) psychiatric symptoms that cause global impairments; (2) impairments that result in functional limitations; and (3) performance deficits specifically related to psychiatric impairments and limitations. When all three conditions are met, medically necessary work restrictions usually are appropriate.

The most effective disability assessments focus on identifying the precise work-relevant impairments and limitations; explain why the recommended restrictions are necessary; and discuss how treatment can be reasonably expected to reverse the impairment and, in doing so, return the patient to work within a reasonable time frame.

References

1. Council for Disability Awareness. Disability Statistics. https://disabilitycanhappen.org/disability-statistic/ .

2. Reiger DA, Goldberg ID, Taube CA. The de facto mental health services system: a public health perspective. Arch Gen Psychiatry. 1978;35:685-693.

3. Taiwo OA, Cantley L, Schroeder M. Impairment and disability evaluation: the role of the family physician. Am Fam Physician. 2008;77:1689-1694.

4. American Council of Life Insurers. www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/public-comments/1210-AB39-2/00186.pdf .

5. Skodol AE, Gunderson JG, McGlashan TH, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry. 2002;159:276-283.

6. Holoyda BJ, Landess J, Scott CL, Newman WJ. Taking the wheel: patient driving in clinical psychiatry. Psychiatr Ann. 2018;48:421-426.

7. Resnick PJ, Kausch O. Violence in the workplace: role of the consultant. Consulting Psychology Journal: Practice and Research. 1995;47:213-222.

8. Harvey SB, Sellahewa DA, Wang MJ, et al. The role of job strain in understanding midlife common mental disorder: a national birth cohort study. Lancet Psychiatry. 2018;5:498-506

9. Blustein DL. The role of work in psychological health and well-being: a conceptual, historical, and public policy perspective. Am Psychol. 2008;63:228-240.