Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”
If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.
By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:
- minimizing recovery time
- maintaining their daily structure and functioning
- reducing risk of chronic disability.
Table 1
Can a mentally ill patient work? 5 questions to consider
| What is the employee’s diagnosis? |
| What work can the employee do today? |
| To reduce risk of medical harm, what work should the employee not do? |
| Does an impairment prevent the employee from performing essential job functions? |
| What must occur to get the patient back to work? |
QUESTION 1: What is the employee’s diagnosis?
Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.
But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),1-4 and debilitating depressive symptoms can change from day to day.
QUESTION 2: What work can the employee do today?
Four capacities are needed to function in the workplace:
- understanding and memory
- sustained concentration and persistence
- social interaction
- adaptation.5
A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.
For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.
Table 2
Can your patient work? Assess work functions by required capacities
| Work function* | Capacity required to perform work function† |
|---|---|
| Comprehend and follow instructions | Understanding and memory |
| Perform simple and repetitive tasks | Understanding and memory |
| Maintain a work pace appropriate to a given workload | Sustained concentration and persistence |
| Perform complex or varied tasks | Understanding and memory; adaptation |
| Relate to other people beyond giving and receiving instructions | Social interaction; adaptation |
| Influence people | Social interaction; adaptation |
| Make generalizations, evaluations, or decisions without immediate supervision | Understanding and memory; adaptation |
| Accept and carry out responsibility for direction, control, and planning | Understanding and memory; adaptation |
| *Defined by the California Division of Industrial Accidents. | |
| †Analogous capacities developed by the American Medical Association and Social Security Administration | |
| Source: References 5 and 6 | |
Case continued: assessing capacity
To assess ability to comprehend and follow instructions, you could ask Ms. S to:
- take the yellow book off the bookshelf with her right hand
- turn to page 23
- set the book down on your desk.
To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.
It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.
Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?