Do you sign off on medical LOA or accommodation forms?

[Atreides]

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I'm getting a steady stream of patients recently from a specific employer. Many of these patients are asking me to sign paperwork for psychiatric LOA or accommodations forms. I'm wondering what the general consensus is from other outpatient psychiatrists. Do you guys sign these forms? During residency, the rule of thumb we had was that if your symptoms are severe enough to need a leave of absence from work or school, they're severe enough that you need to be in an IOP or PHP at least. And they would handle the paperwork. On the accommodations front, I'm very averse to filling these out as they mostly seem to be for anxiety and facilitate avoidance behaviors at best. I've signed a few that I think are reasonable for ADHD (providing written instructions rather than just verbal) and bipolar (avoiding night shifts) but I'm turning down 90%+ of them

 

[splik]

Yes to reasonable accommodations to keep people at work. I don’t charge for it either but do complete during appt.

No to signing people off work. If they aren’t well enough to work, they need IOP/PHP/ECT/TMS/residential etc and they can complete the paperwork. patients typically get worse when not working if they aren’t receiving intensive treatment. I do sometimes see pts for multiple times per week treatment and might consider filling out stuff then.

 

[allantois]

It is so bizarre that employers need a form signed to provide written instructions to their employees or other forms of accommodations

 

[TexasPhysician]

I probably sign FMLA and STD 99% of the time, but I have requirements:

1. These are completed in monthly intervals. This means that 3 months off would require me filling these out 3x, 1 per month.

2. I require a level of care that is at least seeing me every 3 weeks and meeting with a counselor weekly. My requirements may be more intensive but not less. The goal is to return to work. Failure to meet requirements means I don’t continue paperwork requests.

3. Paperwork is done in appointments or requires a fee. If done in appointments, these appointments are in addition to the min of being seen q3 weeks or more frequent.

My policy is mainly because I believe the barrier to get good mental healthcare should be low. Many employers are strict on time off and availability to get help. That said, I expect those that take leave to be active in their recovery, take it seriously, and then return to work.

 

[Stagg737]

Agree with the above. I don't currently sign paperwork like this due to the nature of my clinic, but when I worked in continuity clinics I almost always had the policy that if I was signing paperwork for extended time off that the patient needed to be actively receiving a higher level of care than seeing me every 8-12 weeks.

In residency, our clinic let the residents decide if they wanted to fill out this paperwork but had a general guideline that no one should fill out paperwork if the patient had not been a patient of the clinic for at least 6 months.

 

[liquidshadow22]

This is a large part of outpatient psych

Lots of people just have workplace conflicts and don't want to go back to work.

I'm fairly liberal with std forms. What do you do with the Patirnts thst have exhausted std and then are you asking you to fill out long term disability forms? They may say that want one year off or they request for ssdi?

How do you respond to these? I usually tell them it's against professional guidelines for me to fill out. But am I supposed to have them pay a forensic psych $1000s to get an IME done? It's an odd situation to be in.

 

[Sushirolls]

If people aren't enrolled in PHP/IOP I don't sign for FMLA.

If certain populations are will likely crash during coming off meds in order to complete an MSLT, I'll sign FMLA time off for that, if they are willing to endure to get answer of MSLT/narcolepsy, etc.

Never LTD.
Never do SSD forms. Except for schizophrenia patients, or MRDD, etc. Depression? no. Anxiety? no.

And if patients push, or persist in requests, I let them know I can fill things out ... but it will not be favorable to what they want.

I don't spell out what accomodations should be for ADHD. That's up to the school/university. I do my part and write a letter saying diagnosis XYZ if necessary.

 

[claypigeon]

This is a large part of outpatient psych

Lots of people just have workplace conflicts and don't want to go back to work.

I'm fairly liberal with std forms. What do you do with the Patirnts thst have exhausted std and then are you asking you to fill out long term disability forms? They may say that want one year off or they request for ssdi?

How do you respond to these? I usually tell them it's against professional guidelines for me to fill out. But am I supposed to have them pay a forensic psych $1000s to get an IME done? It's an odd situation to be in.

I take a similar approach. Short term disability / FMLA is typically an earned benefit. Long term disability is something they have to prove via a system outside my office. I’ll quote AAPLs guidelines on not serving dual roles, refer for for an IME, but let them know I’m happy to send records. I’ve found setting expectations ie SSI is an 18+ month process, and referring to a disability lawyer, stops these borderline disability cases from pursuing this.

 

[psychma]

I write letters of accommodation for ADHD and autism. I keep them very specific to the person’s needs, which upsets some people. A letter of accommodation is not a blanket recommendation to work remotely and avoid life, which is what some people want but don’t get. I look at specific responsibilities, areas where they struggle and accommodations that can keep them at work.

 

[calvnandhobbs68]

I take a similar approach. Short term disability / FMLA is typically an earned benefit. Long term disability is something they have to prove via a system outside my office. I’ll quote AAPLs guidelines on not serving dual roles, refer for for an IME, but let them know I’m happy to send records. I’ve found setting expectations ie SSI is an 18+ month process, and referring to a disability lawyer, stops these borderline disability cases from pursuing this.

Yeah I don't get this that much in child now but with adult patients who would bring up "getting on disability" (in terms of LTD) all of them seemed to have no idea the length of the process....I've had a homeless schizophrenic patient who clearly couldn't function outside of a long term facility who took multiple applications for disability.

I'm more liberal with FMLA but that's mostly because I'm filling it out for parents these days to bring their kids to appointments...remember there's a bunch of options on FMLA and something you could probably check is that they have a chronic medical condition that will require X number of appointments a month/year. FMLA is only entitling you to UNPAID leave so there's less of an incentive anyway to abuse it, it's basically so people don't lose their jobs while off. I don't think I've ever filled out FMLA or any similar type of thing on the first visit though.

If it's more of a psychiatric LOA or STD type thing, then yes absolutely they need to be in IOP or PHP or seeing you AND a therapist (kind of in between IOP/PHP) weekly while getting into a program.

I have written for work accommodations (and school accommodations all the time of course) but only after I've known the patient for a while. I also fill that out during the appointment with the patient so they know exactly what I'm writing on it (comes up with college accommodations all the time).

 

[Candidate2017]

This is a large part of outpatient psych

Lots of people just have workplace conflicts and don't want to go back to work.

A large part of outpatient psych is patients seeking inappropriate things. It's not our job to rubber stamp them.

They may say that want one year off or they request for ssdi?

How do you respond to these? I usually tell them it's against professional guidelines for me to fill out. But am I supposed to have them pay a forensic psych $1000s to get an IME done? It's an odd situation to be in.

Not my circus, not my monkeys. I'm not supposed to do anything other than practice psychiatry.

I generally don't get involved in 95% of these things, which boils down to a patient trying to get me involved in extracting money out of a third party (employer, insurance, and/or government) in an inherently adversarial context. That's not my job. The patient can get their own disability lawyer who will review their med records, advocate for them if they deem the case legit, and get a cut of the proceeds.

The other side is sometimes an employer wants me to do a duty for fitness eval, i.e., extract free work from me as well as shift liability on to me. No, sorry. I don't work for you, and I won't assume personal liability for you because you are too cheap to have your HR assess or retain someone to assess your employee.

 

[allantois]

I've seen patients be fired from their jobs.. because their accommodation requests were well.. unreasonable. Like if you want a remote job - apply for remote jobs; don't expect that your employer is going to accommodate you. People treat us like a get out of jail free card. I've tried to train staff that if anyone mentions anything legal as the reason for their appointment to turn them away. Those people can go to a chiropractor to get that stuff filled out.

 

[comp1]

Long term disability is also a no for me pretty much outside of refractory schizophrenia and if the person is well enough to be asking for it themselves, it may not be indicated. The times I filled it out, family members asked. FMLA or any other short term disability leaves are SOLELY to get a person enrolled in a PHP/IOP, we're talking 3 days. After that, the PHP/IOP will handle the leave requests. I wouldn't sign off on any other sort of leave. I call other types of leave "Price is Right therapy" and it has no clinical basis. There are some people who need FMLA for weekly hourly talk therapy and that seems very reasonable, although it's pretty rare as standard sick leave is generally used.

 

[FlowRate]

Because of how our system is set up I generally end up approving the FMLA for the duration of the IOP/PHP. Things just flow way more smoothly that way. My MA does 95% of the paperwork anyway and she's really efficient with it so it's not like it takes me any time.

I also generally only do 1 month at a time. You can always update FMLA/LOA paperwork.

 

[comp1]

I don't think it's unreasonable to do the whole leave yourself if you know a patient is going to be doing an IOP or PHP, but in most systems it probably makes more sense to have the program do it.

 

[pyrrion89]

I used to be against filling FMLA, but essentially it is just a form stating they need unpaid time off and cannot be fired for taking this time off (at least not until they come back from leave). If it's clearly an avoidance mechanism related to anxiety, then no, I won't fill it, but otherwise I don't see the harm. But I only fill these out during the appointment. I don't sign it for more than 3 weeks; I figure by then they can find a PHP/IOP, and they need to agree to see me weekly until they find an IOP.

If they want STD then they need to be in IOP or PHP.
I never do LTD

 

[FlowRate]

Found this while browsing and wanted to add that I’ve started asking for a release to speak with HR or the school’s disability office before signing anything. It clears up what they’re actually asking for and keeps me from being the one making workplace decisions. Anyone else doing this, or do you stick strictly to symptoms and functional limits?

Not a perfect response to your question but, after reading up on the evidence base around school accommodations, I've started specifically putting "pause the clock breaks" rather than "extra time" recommendation for ADHD. Apparently extra time usually overaccommodates, especially 50% extra time that a lot of the college around here like to give reflexively for any student with any degree of ADHD.

For workplace accommodations, it really depends on the condition and the requested accommodation. Sometimes you do have to suggest a specific accommodation. (e.g. screen reader and dictation program for dyslexia.)

Also somewhat related, see: 40% of Students at Stanford Have a "Disability"

 

[Sushirolls]

Read that article.
So disheartening, the justification of everyone is cheating, so we too need to cheat.

 

[clozareal]

Not a perfect response to your question but, after reading up on the evidence base around school accommodations, I've started specifically putting "pause the clock breaks" rather than "extra time" recommendation for ADHD. Apparently extra time usually overaccommodates, especially 50% extra time that a lot of the college around here like to give reflexively for any student with any degree of ADHD.

For workplace accommodations, it really depends on the condition and the requested accommodation. Sometimes you do have to suggest a specific accommodation. (e.g. screen reader and dictation program for dyslexia.)

Also somewhat related, see: 40% of Students at Stanford Have a "Disability"

High prevalence doesn't necessarily mean fraud or cheating. Those who get into Stanford are likely to be better well off socioeconomically, so they'll probably have more access to healthcare and diagnosis and therefore accommodations than public/community colleges where these disabilities may be underdiagnosed.

This article has a lot of anecdotes, rumors, perceptions, and just bad mental health literacy. "I knew she didn't have a disability and I knew she knew it too." How does she know? A well managed mental illness from adequate medication and environmental/academic support is supposed to look like someone is doing fine because it alleviates the impairment.

She also says ADHD and anxiety are "less severe ailments." We know that ADHD results in lower graduation rates, especially when diagnosed in adulthood. I've treated so much school and social avoidance in teens because of anxiety and working through exposures and medications but unless those are constantly used/practiced in a system that supports it, then they may return causing avoidance again.

Then she criticizes someone's religious dietary restrictions as "gaming the system" for disability accommodations. The language is pretty inflammatory and misleading although it seems like it's working if it's shared often.

 

[Orgone]

High prevalence doesn't necessarily mean fraud or cheating. Those who get into Stanford are likely to be better well off socioeconomically, so they'll probably have more access to healthcare and diagnosis and therefore accommodations than public/community colleges where these disabilities may be underdiagnosed.

This article has a lot of anecdotes, rumors, perceptions, and just bad mental health literacy. "I knew she didn't have a disability and I knew she knew it too." How does she know? A well managed mental illness from adequate medication and environmental/academic support is supposed to look like someone is doing fine because it alleviates the impairment.

She also says ADHD and anxiety are "less severe ailments." We know that ADHD results in lower graduation rates, especially when diagnosed in adulthood. I've treated so much school and social avoidance in teens because of anxiety and working through exposures and medications but unless those are constantly used/practiced in a system that supports it, then they may return causing avoidance again.

Then she criticizes someone's religious dietary restrictions as "gaming the system" for disability accommodations. The language is pretty inflammatory and misleading although it seems like it's working if it's shared often.

If 40% of matriculants at Stanford have a "disability", I will humbly suggest considering that, as used, the word "disability" no longer has any meaning.

 

[Merovinge]

High prevalence doesn't necessarily mean fraud or cheating. Those who get into Stanford are likely to be better well off socioeconomically, so they'll probably have more access to healthcare and diagnosis and therefore accommodations than public/community colleges where these disabilities may be underdiagnosed.

This article has a lot of anecdotes, rumors, perceptions, and just bad mental health literacy. "I knew she didn't have a disability and I knew she knew it too." How does she know? A well managed mental illness from adequate medication and environmental/academic support is supposed to look like someone is doing fine because it alleviates the impairment.

She also says ADHD and anxiety are "less severe ailments." We know that ADHD results in lower graduation rates, especially when diagnosed in adulthood. I've treated so much school and social avoidance in teens because of anxiety and working through exposures and medications but unless those are constantly used/practiced in a system that supports it, then they may return causing avoidance again.

Then she criticizes someone's religious dietary restrictions as "gaming the system" for disability accommodations. The language is pretty inflammatory and misleading although it seems like it's working if it's shared often.

I agree with what you are saying but also 38% of the incoming class at one of the best universities in the world? These kids are the 0.1% of college applicants, making a face validity argument with the raw data. Why would their numbers be 2x that of Harvard? I assure you the people getting into Harvard are better off socioeconomically as well.

I am open to other hypothesis, but I think the culture at Stanford is one of ultimate system optimization and that's leading to what is happening with the disabilities. We have continued from pure competition into ultra competition. From products to en****ification. Stanford is the holy grail of capitalism universities and we are see what late stage capitalism produces.

 

[Stagg737]

High prevalence doesn't necessarily mean fraud or cheating. Those who get into Stanford are likely to be better well off socioeconomically, so they'll probably have more access to healthcare and diagnosis and therefore accommodations than public/community colleges where these disabilities may be underdiagnosed.

This article has a lot of anecdotes, rumors, perceptions, and just bad mental health literacy. "I knew she didn't have a disability and I knew she knew it too." How does she know? A well managed mental illness from adequate medication and environmental/academic support is supposed to look like someone is doing fine because it alleviates the impairment.

She also says ADHD and anxiety are "less severe ailments." We know that ADHD results in lower graduation rates, especially when diagnosed in adulthood. I've treated so much school and social avoidance in teens because of anxiety and working through exposures and medications but unless those are constantly used/practiced in a system that supports it, then they may return causing avoidance again.

Then she criticizes someone's religious dietary restrictions as "gaming the system" for disability accommodations. The language is pretty inflammatory and misleading although it seems like it's working if it's shared often.

I also get your sentiment, but this kind of post is why people don't take the ivory towers seriously. You have people openly admitting in this article that they don't think their condition is a real disability, but they're claiming that status because they can. You have them openly stating they were given extra accommodations that they not only don't need but think are excessive to the extent the graduate "Callie" who was interviewed felt guilty about getting some of those accommodations.

To the first bold point, the author said it was one of her friends. I would assume that they've probably talked about it, especially if she's writing that in a major international publication. Sure, there are some bad assumptions and ignorance like you said (specifically about anxiety and ADHD's potential severity), but there's multiple examples of people feeling they shouldn't qualify or were given extra exceptions that were unfair to others. As someone with a "disability" who doesn't use accommodations, your post misses the point of the article that people who don't need accommodations shouldn't be encouraged to abuse the system, not that those with legitimate need shouldn't get them.

 

[FlowRate]

High prevalence doesn't necessarily mean fraud or cheating. Those who get into Stanford are likely to be better well off socioeconomically, so they'll probably have more access to healthcare and diagnosis and therefore accommodations than public/community colleges where these disabilities may be underdiagnosed.

This article has a lot of anecdotes, rumors, perceptions, and just bad mental health literacy. "I knew she didn't have a disability and I knew she knew it too." How does she know? A well managed mental illness from adequate medication and environmental/academic support is supposed to look like someone is doing fine because it alleviates the impairment.

She also says ADHD and anxiety are "less severe ailments." We know that ADHD results in lower graduation rates, especially when diagnosed in adulthood. I've treated so much school and social avoidance in teens because of anxiety and working through exposures and medications but unless those are constantly used/practiced in a system that supports it, then they may return causing avoidance again.

Then she criticizes someone's religious dietary restrictions as "gaming the system" for disability accommodations. The language is pretty inflammatory and misleading although it seems like it's working if it's shared often.

Do you not see this clinically? I see it all the time. Patient reports perfect control of ADHD symptoms with medications but then later wants accommodations because they're told they're entitled to extra time on tests (and forgiveness of late assignments and school-provided note taking) and know it'll give them a performance advantage.

 

[clozareal]

Yes I see this frequently. The amount of 4.0 students who get straight A's and doing 10 extracurriculars feels like they cannot manage all of it, refuse to give up any external obligation, and then comes to my office for an ADHD evaluation because of their "impairment" from being able to get the resume into an ivory tower. I treat a lot of these high school and university students so I'm very familiar. It's my bread and butter to not diagnose ADHD in the worried well.

Not sure the difference between Harvard (20%) or Brown (also 20%) and Stanford but Amherst is 34%. It might be due to more permissiveness or a lower threshold of some places to allowing a definition for disabled. It may be due to ivory tower selection being so much more competitive that only the most neurodivergent savants have the resume to be admitted to such a school. It may be that it's so normalized that it's expected to do it for any sort of difference you have.

If you read down lower in the article, it says that 24% of students actually get academic/housing accommodations despite 38% of them having a disability. However, this is not data, but rather an opinion though. There is no report, evidence, or way we can review the data. It seems like it was pulled out of thin air from an opinion piece on The Atlantic who interviewed one of the Stanford disability task force members. What kind of disabilities, how does it track over time, and what types of accommodations? These are all left unanswered.

 

[calvnandhobbs68]

Yes I see this frequently. The amount of 4.0 students who get straight A's and doing 10 extracurriculars feels like they cannot manage all of it, refuse to give up any external obligation, and then comes to my office for an ADHD evaluation because of their "impairment" from being able to get the resume into an ivory tower. I treat a lot of these high school and university students so I'm very familiar. It's my bread and butter to not diagnose ADHD in the worried well.

Not sure the difference between Harvard (20%) or Brown (also 20%) and Stanford but Amherst is 34%. It might be due to more permissiveness or a lower threshold of some places to allowing a definition for disabled. It may be due to ivory tower selection being so much more competitive that only the most neurodivergent savants have the resume to be admitted to such a school. It may be that it's so normalized that it's expected to do it for any sort of difference you have.

If you read down lower in the article, it says that 24% of students actually get academic/housing accommodations despite 38% of them having a disability. However, this is not data, but rather an opinion though. There is no report, evidence, or way we can review the data. It seems like it was pulled out of thin air from an opinion piece on The Atlantic who interviewed one of the Stanford disability task force members. What kind of disabilities, how does it track over time, and what types of accommodations? These are all left unanswered.

You’re talking about two different things though.

This isn’t talking about new evals who don’t have ADHD, this is talking about 38% of the INCOMING class having a “disability” of some sort and 24% having accommodations. So more along the lines of someone who’s done just fine in AP classes in high school on their stimulant but now insists they need extra time for tests in college just cause.

Just like all the other various “hacks” people have picked up, I get kids definitely coming saying their friends got a letter saying they should get extra time or extended deadlines so they want one too.

On the other hand, I also have kids who are straight up bombing high school/college classes who refuse to use their accommodations (cause they don’t want to be the kid who tests in a different room) or go to the accommodations office or I have to remind they even have accommodations….as with most things in psychiatry, level of insight tends to be a pretty reliable predictor of severity.

 

[Stagg737]

You’re talking about two different things though.

This isn’t talking about new evals who don’t have ADHD, this is talking about 38% of the INCOMING class having a “disability” of some sort and 24% having accommodations. So more along the lines of someone who’s done just fine in AP classes in high school on their stimulant but now insists they need extra time for tests in college just cause.

Just like all the other various “hacks” people have picked up, I get kids definitely coming saying their friends got a letter saying they should get extra time or extended deadlines so they want one too.

On the other hand, I also have kids who are straight up bombing high school/college classes who refuse to use their accommodations (cause they don’t want to be the kid who tests in a different room) or go to the accommodations office or I have to remind they even have accommodations….as with most things in psychiatry, level of insight tends to be a pretty reliable predictor of severity.

Interestingly relevant new application for the old inpatient “rule of opposites”.

 

[yomike333]

I'm getting a steady stream of patients recently from a specific employer. Many of these patients are asking me to sign paperwork for psychiatric LOA or accommodations forms. I'm wondering what the general consensus is from other outpatient psychiatrists. Do you guys sign these forms? During residency, the rule of thumb we had was that if your symptoms are severe enough to need a leave of absence from work or school, they're severe enough that you need to be in an IOP or PHP at least. And they would handle the paperwork. On the accommodations front, I'm very averse to filling these out as they mostly seem to be for anxiety and facilitate avoidance behaviors at best. I've signed a few that I think are reasonable for ADHD (providing written instructions rather than just verbal) and bipolar (avoiding night shifts) but I'm turning down 90%+ of them

LOA is not automatically IOP level. Some patients are just decompensating in a bad work setup. Short term leave can prevent IOP if you catch it early. I do sign when there is objective impairment, missed days, panic at work, clear functional decline. I do not sign just because the job is stressful. For accommodations, I focus on functional limits, not diagnosis. If they cannot tolerate rotating shifts because of bipolar sleep instability, that is concrete. If it is just general anxiety about presentations, I push therapy and skills first.

 

[comp1]

I have to strongly disagree about IOP. If a patient is so impaired that they need time off work beyond that offered by the employer as standard, they need to be using that time formally and in a structured way to prevent it from happening again. If you are saying that you just write for 2 hours a week leave to go to weekly therapy, sure, but if you are writing for full days, those full days should be used for more than time at home.

 

[Taddy Mason]

I have to strongly disagree about IOP. If a patient is so impaired that they need time off work beyond that offered by the employer as standard, they need to be using that time formally and in a structured way to prevent it from happening again. If you are saying that you just write for 2 hours a week leave to go to weekly therapy, sure, but if you are writing for full days, those full days should be used for more than time at home.

Check @yomike333 ’s post history - joined 3 months ago and has purported to be a pharmacist, anesthesiology resident, and psych resident in that time period. I’d take whatever he/she has to say with a rather large grain of salt.

 

[Merovinge]

Check @yomike333 ’s post history - joined 3 months ago and has purported to be a pharmacist, anesthesiology resident, and psych resident in that time period. I’d take whatever he/she has to say with a rather large grain of salt.

Yomike333 is clearly going through some things, but this is still a really good reminder about what the criteria for HLoC are. Comp1 is spot on the money, and I see a lot of psychiatrists that had very little training around PHP/IOP. I have seen people get extensive leave authorized with NO structure which I would argue is actually doing harm to patients. Really sad to see.