Returning a patient to work

[ghost dog]

Hey folks,

I was wondering if I could get your feedback on how you approach patients with mood disorders in regards to a graduated return to work.

The reason I ask is I have a significant number of patients with both chronic pain and co-morbid depression (more so pain).

Studies show that the longer a person is off work, the less likely they are to return to the workforce. Of course, our role is to improve their mood and lessen pain, but of course an absolute elimination of symptomatology is not always possible / realistic.

I give my usual spiel that many people will sometimes feel better when they return to work ( even if on a part time basis), as this can sometimes lessen / or distract an individual from the above symptoms. Of course, a return to work is certainly influenced by occupational satifsfaction and other workplace factors.

Any pointers or related counseling given to pts would be much appreciated.

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[whopper]

A problem here is the workplace might be the reason why the person is depressed to begin with. There's a phenomenon known as a "toxic work environment." Think of it as a toxic residency. While it's not a DSM disorder, several studies have pointed out that for all intents and purposes, it's similar to PTSD except that the trauma was not life threatening. A theory is that it's repeated, every work day, and after several months or even years of it, it can have PTSD-like reactions. From observation from patients and reading several studies on it, I've come to a clinical opinion that in such cases the employee is placed in a setting where learned helplessness is experienced daily They see a problem that is upsetting to them, but they must re-experience it daily or else they can't work.


Another problem is malingering, and that in a clinical setting, you can usually only go on what the person tells you. How do you know it's the truth? (You usually don't). The person might me exaggerating problems just to get out of work. Another is that we can usually only go by what people tell us in an office setting. A real work-place evaluation asking for time off or disability is more on the order of a forensic evaluation where the evaluator may actually have to go to the person's place of work for days to see what it's like there and talk to multiple people such as the person's colleagues and employer.

Whenever a person asks me to fill out a form asking for time off, unless the evidence is more than what they tell me in the office, I write down that all of it is based on the person's own subjective reports to me, that the evaluation is not forensic-based, that a psychiatrist's ability to tell if someone is lying simply on clinical observation is no better than a layman, and that I have a clinical bias for my patient.

The companies that require forms be filed out often times don't know the standards by which we have to write these reports. Unfortunately most doctors don't either! I know doctors that'll fill out anyone's disability request for the right price. I often times get patients or employers then ask me for a forensic level evaluation, to which I respond, "Hmm, okay, that'll be about $350/hr for every hour spent working on this including the report that'll likely take at least 5 hours to write up, and I shouldn't be the one doing it since I'm the treating doctor. I can refer you to forensic psychiatrists that can do this." When that happens is both parties agree to drop it.

As for taking time off, you are correct. The more time a patient takes off, the more likely they are to not return to work. This can leave an nonspecific deadline of sorts because the longer this problem festers, the worse it can be.

 

[Therapist4Chnge]

If you see them before they leave work, you have a shot at getting them back. You can talk to the patient about making a plan of how to take a temporary leave, how to frame it in such a way it isn't a one-way ticket to long-term disability, get their job/family on board, etc. If you don't see them until after they go on disability/other, you are fighting an uphill battle.