9/15/2016. Psychiatric Fitness-for-Duty: Navigating the Evidence. Disclosures. 30,000,000,000,000 synapses Image Source: Forbes

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1 OEMAC September 26, 2016 Psychiatric Fitness-for-Duty: Navigating the Evidence Charl Els MBChB, FCPsych (SA), MMedPsych (cum laude), Dip.ABAM, MROCC, DESS Associate Clinical Professor: Department of Psychiatry Adjunct: Division of Preventive Medicine, Department of Medicine Adjunct: John Dossetor Health Ethics Centre Disclosures No relevant financial or other disclosures The opinions expressed are those of the speaker Management of potential bias: N/A 30,000,000,000,000 synapses Image Source: Forbes 1

2 Top 10 Leading Disease/Disorder Categories Contributing to DALY s (2010) Murray CJ, et al. The state of US health, : burden of diseases, injuries, and risk factors. JAMA ;310(6): Proportion of Years lived with Disability Whiteford HA, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study. Lancet (2013), 382(9) Proportion of Years of Life Lost Whiteford HA, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study. Lancet (2013), 382(9)

3 Proportion of DALYs Whiteford HA, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study. Lancet (2013), 382(9) DALYs for each Disorder by Age Whiteford HA, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study. Lancet (2013), 382(9) Workplace Mental Disorders [1] Leading cause of disability in US & Canada: ages Economic cost: $16b annually More than $51 billion lost to the Canadian economy annually The World Health Organization The World Health Report 2004: Changing History, Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for Geneva: WHO. Mental health and substance use at work: Perspectives from research and implications for leaders Scientific Advisory Committee to the Global Business and Economic Roundtable on Addiction and Mental Health. Sources: Mental Health Works: Canadian Mental Health Association and 3

4 Workplace Mental Disorders [2] MH passed CV disease: fastest growing cost category for disability claims (Canada). Mental illness accounts for: 75% of all short-term disability claims 82% of long-term disability claims M. Wilson, R. Joffe, & B. Wilkerson. The unheralded business crisis in Canada: Depression at work. Global Business and Economic Roundtable on Addiction and Mental Health (2002) Watson Wyatt, Mental Health claims on the rise in Canada, Survey, (2005) Sources: Mental Health Works: Canadian Mental Health Association and Workplace Mental Disorders [3] 58% of EEs reported: Work-life conflict Being overwhelmed by their jobs, families or finances. Cost saving p.a.: ER, per EE, for those Rx: $5,000 - $10, 000 Mental Health Works. Mental Health Fact Sheet. Canadian Mental Health Association. Higgins C, et al., Exploring the Link Between Work-Life Conflict and Demands on Canada s Health Care System, Public Health Agency of Canada, (2004 Sources: Mental Health Works: Canadian Mental Health Association and ). Workplace Mental Disorders: Legal Risks Jurisprudence & legislative evolution: ERs increasingly responsible ERs potentially liable for psychological injury to EEs Shain M, What Do We Know? Best Advice on Stress Management in the Workplace, Health Canada, (2000) Sources: Mental Health Works: Canadian Mental Health Association and 4

5 Mental Disorders: Health Risks [1] 21% of all workers: physical health problems caused by stress, anxiety or depression. 20% experienced fatigue, sleeping problems, anxiety or depression. EEs with stress: more likely to report hypertension, anxiety or depression and obesity. Insurance Journal 2003 as cited by the Government of Canada in The Human Face of Mental Health and Mental Illness in Canada, 2006, pg. 41. Desjardins Financial SecurityHealth is Cool! 2006 Survey on Canadian Attitudes towards Physical and Mental Health at Work and Play. (2006) American Psychological Association. Americans engage in unhealthy behaviours to manage stress. (2006) Sources: Mental Health Works: Canadian Mental Health Association and Mental Disorders: Health Risks [2] 59%: could not keep up their usual pace - needed more rest. 37%) who reported experiencing physical problems, but did not take time off work, continued to work needed the income Desjardins Financial Security. Health is Cool! 2006 Survey on Canadian Attitudes towards Physical and Mental Health at Work and Play. (2006) US Department of Labor. Accommodation and Compliance Series: Employees with Mental Health Impairments. Job Accommodation Network. (2009). Common Mental Disorders Major depressive disorder Anxiety disorders Substance Use Disorders Bipolar disorder Schizophrenia 5

6 Depression (Major Depressive Disorder) Depression is a leading cause of disability, representing the 4 th most important cause of disability worldwide. Relationship between depression and occupational impairment: independent of other salient social influences / interpersonal stress & job stress related to work dissatisfaction. Murray, C. & Lopez, A.D. (Eds.). (1996). The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Disease, Injuries and Risk Factors in 1990 and projected to Cambridge, MA: Harvard University Press. Simon, G., et al. (2000). Recovery from depression, work productivity and health care costs among primary care patients. General Hospital Psychiatry, 22, Martin, J.K., et al. (1996). Subclinical depression and performance at work. Social Psychiatry and Psychiatric Epidemiology, 31, 3-9. Depression (MDD) [2] Persons with MDD: substantially more likely to report high levels of work impairment. Likely the result of the common symptoms of depression, including cognitive, behavioural, motor, and social impairments that may affect occupational capacity. Kessler, R.C., Dupont, R.L., Berglund, P., & Wittchen, H.-U. (1999). Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. American Journal of Psychiatry, 156, Depression (MDD) [3] Following traumatically stressful experience allegedly causing symptoms of MDD: No reliable dose-response gradient for such relationship. Absence of any reliable dose-response gradient provides additional evidence against claims of stressful occupational experiences resulting in the diagnosis of MDD. Tucker P, Pfefferbaum B, Doughty DE, Jones DE, Jordan FB, Nixon SJ. Body handlers after terrorism in Oklahoma City: predictors of posttraumatic stress and other symptoms. Am J Orthopsychiatry. 2002;72(4):

7 Depression (MDD) [4] Depression is a chronic construct. A person suffering from 1 episode: 50% chance of 2 nd. After 2 episodes, there is a 75% chance of having a 3 rd. After 3 depressive episodes: 90% chance of future MDE. Dubovsky, S.L., Davies, R., & Dubovsky, A.N. (2003). Mood disorders. In R.E. Hales & S.C. Yudofsky (Eds.), The American Psychiatric Publishing Textbook of Clinical Psychiatry (pp ). Washington, DC: American Psychiatric Publishing Inc. Rytsala, J.H., Melartin, T.K., Leskela, U.S., Sokero, T.P., Lestela-Mielonen, P.S., & Isometsa, E.T. (2005). Functional and work disability in major depressive disorder in Major Depressive Disorder. Journal of Nervous and Mental Disease, 193, Depression (MDD) [5] MDD, with psychotic features: disproportionately elevated risk - usually precludes any useful occupational functioning. MDD impairment / disability: equal / greater than other chronic medical illnesses, like diabetes or heart conditions Disability may persist even after improvement of depressive symptoms. Dubovsky, S.L., et al. (2003). Mood disorders. In R.E. Hales & S.C. Yudofsky (Eds.), The American Psychiatric Publishing Textbook of Clinical Psychiatry (pp ). Washington, DC: American Psychiatric Publishing Inc. Rytsala, J.H., et al. (2005). Functional and work disability in major depressive disorder in Major Depressive Disorder. Journal of Nervous and Mental Disease, 193, Depression (MDD) [6] Scientific findings suggests that, as is the case with most mental illness constructs, genetics play a dominant etiological role, and childhood experience also appears to play a compelling role. RE, Yudofsky SC, Gabbard GO, eds. The American Psychiatric Publishing Textbook of Clinical Psychiatry. 5th ed. Arlington, VA: American Psychiatric Publishing; Sadock BJ, Sadock VA. Kaplan and Sadock s Synopsis of Psychiatry. 10th ed. New York, NY: Lippincott Williams and Wilkins;

8 Early detection is vital: higher likelihood of recovery >50% of accommodations cost < $500 Most employers report benefits > $5,000 EEs (diagnosed with depression and Rx): save ER 11 days p.a. What does Rx look like? Benefits of Rx US Department of Labor. Accommodation and Compliance Series: Employees with Mental Health Impairments. Job Accommodation Network. (2009). What is the Role of Work? Scientific findings predominantly contradict claims that adult life experiences cause psychopathology. Melhorn MJ, Talmage JB, Ackerman WE, Hyman MH. The American Medical Association Guide to the Evaluation of Disease and Injury Causation, 2nd Edition American Medical Association [p. 490]. 8

9 Is work psycho-pathogenic? Work is scientifically established to be beneficial to mental health. More likely to demonstrate mental illness if she /he had never obtained employment. Talmage JB, Melhorn JM, Hyman MH. AMA Guides to the Evaluation of Work Ability and Return to Work. 2nd ed. Chicago, IL: American Medical Association; Barth RJ, Roth VS. Health benefits of returning to work. Occup Environ Med Rep. 2003;17(3): Waddell GE, Burton AK. Is work good for your health and well-being? London, England: The Stationery Office; Psychological Benefits of Work 1. Income and sense of security 2. Source of identity 3. Source of sense of purpose in life 4. Source of self-worth and self-esteem 5. Opportunity to develop skills and creativity 6. Autonomy and independence 7. Relationships outside the family 8. Structure 9. Defines leisure time and activities Gold LH, Shuman DW. Why we work: Psychological meaning and effects (Chapter 3), In: Evaluating Mental Health Disability in the Workplace. Springer p Waddell GE, Burton AK. Is work good for your health and well-being? London, England: TSO Research findings have reliably indicated that work is a protective agent in regard to MDD Gabbard GO. Gabbard s Treatments of Psychiatric Disorders. 4th ed. Arlington, VA: American Psychiatric Publishing; Sadock BJ, Sadock VA. Kaplan and Sadock s Synopsis of Psychiatry. 10th ed. New York, NY: Lippincott Williams and Wilkins;

10 Psychological Meaning of Work Are there any downsides to work? Assessing goodness-of-fit Factors that exert positive or negative effects o Constant effect determinants o Variable effect determinants Gold LH, Shuman DW. Why we work: Psychological meaning and effects (Chapter 3). In: Evaluating Mental Health Disability in the Workplace. Springer p Potentially Toxic Workplaces 1. Lack of cooperation 2. Lack of support 3. Intolerance 4. Exclusivity 5. Rigidity Gold LH, Shuman DW. Why we work: Psychological meaning and effects (Chapter 3). In: Evaluating Mental Health Disability in the Workplace. Springer p Estimated Disability and RTW 10

11 Mental disorders are leading causes of disability Work is therapeutic Summary: FTW and RTW determinations: What are the challenges and opportunities? 11