Employer-Provided and Self-Initiated Job Accommodations for Workers with Serious Mental Illness.

BACKGROUND: Many individuals with serious mental illness (SMI) are capable of employment in regular jobs (i.e. jobs paying at least minimum wage, not set aside for persons with disabilities, and not obtained with assistance from mental health services), but they may need job accommodations to be successful. The extant literature focuses almost exclusively on accommodations for workers with SMI who are receiving employment support, so we know almost nothing about the nature or frequency of accommodations needed by workers who are independently employed. AIMS: Drawing on survey data from a sample of workers with diagnoses of SMI who are capable of regular, mainstream employment, we aim to: (i) describe the nature and frequency of job accommodations workers requested from their employer or initiated on their own; and (ii) identify individual- and work-related factors associated with the probabilities of requesting or initiating accommodations. METHODS: The analysis sample includes 731 workers with diagnoses of schizophrenia, bipolar disorder, or major depressive disorder, who were employed in regular jobs post-onset of SMI. Workers identified any job accommodations requested from their employer, or initiated on their own. Summary statistics describe the nature and frequency of accommodations in four categories: scheduling, workspace, supervision, job modification. Logistic regression models estimate the relationship between workers' health- and job-related characteristics and the probabilities of requesting or self-initiating accommodations. RESULTS: Whereas 84% of workers in our sample self-initiated accommodations, only 25% requested accommodations from their employer. The most frequent accommodations of either type involved flexibility in scheduling (63% self-initiated, 24% requested), or modifications to the workspace (58%, 19%). Factors significantly correlated with the probability of requesting accommodations include: supportive workplace culture, longer job tenure, more severe cognitive/social limitations. Factors significantly correlated with the probability of self-initiating accommodations include: younger age, more severe social limitations, greater job autonomy. DISCUSSION: This is the first study of job accommodations among a cohort of persons with SMI independently employed in regular jobs. We identify a type of accommodation, self-initiated by the worker, that has not been studied before. These self-initiated accommodations are far more prevalent than employer-provided accommodations in our sample. Key factors associated with the probabilities of requesting/initiating accommodations reflect need (e.g. compromised health) and feasibility of implementation in a particular job. Limitations of the study include the cross-sectional design which limits our ability to identify causal relationships. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers who deliver vocational services for workers with SMI should be aware of the many ways these employees can accommodate their illness on their own, without the necessity of disclosing SMI to an employer. IMPLICATIONS FOR HEALTH POLICIES: Our results recommend workplace policies that support disclosure and employer-provided accommodations, as well as policies that create flexibility for employees to initiate their own accommodations. IMPLICATIONS FOR FURTHER RESEARCH: Given the prevalence of workers' self-initiated accommodations, it is imperative that research on job accommodations for workers with serious mental illness includes consideration of these types of accommodations.

Workplace Disclosure of Serious Mental Illness and Gainful Employment: Theory and Evidence.

BACKGROUND: This study provides the first systematic analysis of the association between workplace disclosure of serious mental illness (SMI) and the probability of gainful employment, among workers employed in regular jobs. By regular job, we mean one that pays at least minimum wage, is not set aside for persons with disabilities, and was not obtained with assistance of mental health services. By gainful employment, we mean a regular job with monthly earnings that exceed the maximum allowable earned income for receipt of Social Security Disability Insurance. AIMS: Among persons with SMI who are capable of working in regular jobs, we aim to identify: (i) what individual and work-related factors are associated with the decision to disclose mental illness at work; and (ii) how the decision to disclose is related to the probability of gainful employment. METHODS: The analyses are based on a theoretical framework in which workers choose a level of disclosure to maximize utility from the benefits of employment, subject to constraints associated with mental illness-related stigma. We specify a bivariate probit regression in which the probabilities of disclosure and gainful employment are determined jointly. The model is estimated with data from a national survey of 602 workers, with schizophrenia, bipolar disorder, or major depression, who were employed in regular jobs post-onset of illness. RESULTS: The results identify individual (e.g. younger age, less self-stigma, more severe cognitive limitations) and work-related (e.g. longer job tenure, supportive firm, administrative support occupation) factors significantly associated with the probability of disclosure. The results also indicate that disclosure has a significant positive association with the probability of gainful employment, when the empirical model controls for the endogeneity of disclosure in the employment function. Other variables that have a significant positive association with gainful employment include education, job autonomy, and employment in a white-collar occupation. DISCUSSION: The data support the hypothesis that workers with SMI make the decision to disclose their condition based on the probability of a positive response from their employer, and this rational behavior is likely the reason for the strong correlation between disclosure and the probability of gainful employment. However, a limitation of the study is that our retrospective survey design cannot identify causal relationships. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Work is an important recovery goal for many workers with SMI, so the disclosure decision is likely to be a significant topic of discussion between workers and their health care providers. IMPLICATIONS FOR HEALTH POLICIES: Amid the current focus on wellness in the workplace, policies aimed at reducing the stigma of mental illness at work, and promoting more tolerant and supportive workplace cultures, can improve the probability of gainful employment for workers with SMI. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed to design and implement workplace interventions that minimize the monetary/nonmonetary costs of disclosure for workers with SMI in regular jobs.

Workers' Perspectives on Workplace Disclosure of Serious Mental Illness and Their Employers' Responses.

Persons with serious mental illness are often reluctant to disclose their disability to an employer because of the intense stigma associated with their illness. Yet, disclosure may be desirable to gain access to employer-provided job accommodations, or to achieve other goals. In this article, we aimed to (1) describe the contexts in which workers in regular employment disclose a mental illness to their employer and (2) describe employer responses to disclosure, as perceived by the workers themselves. Semi-structured interviews were conducted with 40 workers, who were currently or formerly employed in a mainstream, regular job, post-onset of mental illness. Workers were asked to describe the circumstances that led to disclosure, and to describe their employers' responses to disclosure. Conventional content analysis was applied to identify common themes in the transcribed interviews. Analyses revealed five mutually exclusive disclosure contexts: seeking job accommodations, seeking protection, seeking understanding, responding to an employer's symptom-based inquiries, or being exposed by a third party or event. Analyses also revealed a wider range of employer responses-positive, negative, and ambiguous-than has been suggested by studies in which employers described their reactions to worker disclosure. Some themes were more prevalent among current versus former workers. Overall, the disclosure process appeared to be more complex than has been described by extant frameworks to date, and the linkages between disclosure contexts and employer response themes suggested that many workers did not receive the responses they were seeking from their employers.

The Three Cs of Disclosing Serious Mental Illness at Work: Control, Conditions, Costs.

This Open Forum describes a framework for analyzing factors that influence an individual's decision to disclose serious mental illness in the competitive workplace. The disclosure decision is multifaceted, organized in dimensions of control, conditions, and costs. Control refers to the extent to which a mental illness is concealable, so that a worker may choose whether to disclose. The conditions workers impose on disclosure determine when, to whom, and how much they choose to say. The costs, both monetary and emotional, are a manifestation of the pervasive stigma associated with mental illness. The framework described here can form the basis for rigorous empirical studies of the disclosure decision that will inform both workers' decisions to disclose and employers' responses to disclosure. The objective of this research is to improve labor market outcomes for the significant numbers of workers with serious mental illness who can engage in mainstream, competitive employment.

A Hierarchy of Stigma Associated with Mental Disorders.

BACKGROUND: Numerous studies have produced social distance rankings to identify differences in the intensity of stigma associated with various general medical and mental health conditions. All of these studies, however, treat "mental illness" as a single homogeneous condition, when in reality different diagnoses of mental illness may elicit different levels of stigma. AIMS OF THE STUDY: Within our samples, we aim to: (i) determine if there are significant differences in the intensity of stigma associated with different mental/behavior disorders; (ii) compare the intensity of stigma associated with mental/behavior disorders vs. physical/sensory disorders; and (iii) analyze the effect of familiarity with a person who has a mental/behavior disorder on the stigma associated with that disorder. METHODS: College students in the U.S. (n=213) and Republic of Korea (n=354) completed a survey of community attitudes toward persons with disabilities. Students were asked to rank 22 health conditions, including 10 mental/behavior disorders, according to the level of acceptance most usually accorded to persons with that condition in their society. Students also indicated, for each condition, whether they had close contact with a person who had that condition. RESULTS: Students in both countries indicated a lower mean level of acceptance for the group of mental/behavior disorders than for the group of physical or sensory disorders. Nevertheless, there were significant differences in the acceptability of different types of mental/behavior disorders, with schizophrenia and substance use disorders eliciting the most negative attitudes in both samples. Familiarity is correlated with greater acceptance for most, but not all, mental/behavior disorders. DISCUSSION: Mental illness-related stigma imposes costs on society in the form of productivity losses and increased rates of dependency. Reducing these costs requires an understanding of the negative stereotypes that are the source of stigma, and an appreciation of differences in the nature and intensity of stigma associated with different mental disorders. Limitations of the study include: lack of generalizability of the results; terminology which may have generated negative associations for some survey items; possibility of missing variables or data measured with error. IMPLICATIONS FOR HEALTH POLICIES: The findings with respect to familiarity underscore the importance of inclusive policies to combat mental illness-related stigma. Anti-stigma policies must, however, account for differences in attitudes toward different diagnoses of mental illness. Strategies that may be effective in reducing stigma for some disorders may be counterproductive for others. IMPLICATIONS FOR FURTHER RESEARCH: Many social distance studies rely on non-random samples, limiting generalizability of the results. Future research may be able to exploit web-based survey methods to obtain larger, more representative samples. Studies should include multiple diagnoses of mental/behavior disorders, instead of a single category of mental illness, and explore the ways in which familiarity affects intensity of stigma for different mental disorders.

Clinical Guidance on the Identification and Management of Treatment-Resistant Schizophrenia.

Treatment-resistant schizophrenia (TRS) occurs in approximately 30% of individuals diagnosed with schizophrenia. The identification and management of TRS in clinical practice are inconsistent and not evidence based. No established clinically relevant criteria for defining and treating TRS exist, although guidelines have been promulgated for clozapine use among TRS patients. This report summarizes the consensus from a roundtable that focused on defining and identifying TRS, pathways to treatment resistance, current treatments, unmet needs, and disease burden. Nine clinical experts in schizophrenia and TRS participated in a closed meeting on June 23, 2017, sponsored by Lundbeck, at which published literature in key areas of TRS research was reviewed. The findings from published studies were synthesized by experts in each area and presented to the group for review and discussion. It was agreed that inadequate response to 2 different antipsychotics, each taken with adequate dose and duration, is required to establish TRS. This recommendation is consistent with guidelines for clozapine use. For each trial, objective symptom measures should be used to assess treatment response, with medication adherence ensured. Once nonresponse is established (after ≥ 12 weeks for positive symptoms [2 trials of ≥ 6 weeks]), the treatment plan should be reevaluated and alternative pharmacologic or nonpharmacologic treatments considered. With increased awareness, those involved in the care of patients with schizophrenia will be able to identify TRS earlier in its course, thus supporting more informed treatment decisions by clinicians, patients, and caregivers to reduce the overall disease burden.

The impact of mental and substance-use disorders on employment transitions.

The cyclic nature of serious mental illness (SMI) and substance-use disorders (SUD) suggests that persons with these conditions may experience high rates of transitions among employment states (full-time, part-time, and no employment). This study uses longitudinal data from two waves of the National Epidemiologic Survey of Alcoholism and Related Conditions to examine employment transitions for persons with SMI/SUD relative to a no-disorder control group. Conditional on employment status in Wave I, we estimate conditional odds ratios and marginal effects of each diagnosis on the probabilities of part-time or full-time employment in Wave II, holding constant other characteristics that influence employment decisions. The results show transitions across employment states are common for all groups but more frequent for persons with SMI/SUD than the controls. Persons with SMI are less likely, and persons with SUDs more likely, to transition out of no employment than the controls. Part-time employment is a relatively transitory state, particularly for persons with SMI/SUD, but full-time employment brings a measure of job stability to all groups. After controlling for differences in observable characteristics, the marginal effects of SMI and alcohol disorders on employment transitions are largely significant, but the effects of drug disorders are not.

Job loss discrimination and former substance use disorders.

Persons with former alcohol or drug use disorders are protected from labor market discrimination by the Americans with Disabilities Act of 1990. They have been neglected, however, in empirical studies of labor market discrimination following implementation of the Act. We apply econometric techniques used to study other disabled groups to determine if there are significant differences in employment outcomes for persons with and without former substance use disorders and, if so, what part of these differences potentially can be attributed to employer discrimination. There are no significant differences in employment rates between persons with and without former substance use disorders, and among those who are employed no significant differences in rates of full-time employment. But persons with former substance use disorders report significantly higher rates of involuntary job loss within the previous year. Part of the differential remains unexplained after controlling for other factors that affect employment outcomes, suggesting employer discrimination may be one cause of poor job stability among this group. Certain identifiable subgroups with low levels of human capital are particularly susceptible to substance-related discrimination.

Patterns of sick-leave and health outcomes in injured workers with back pain.

Little is known about the sick-leave experiences of workers who make a workers' compensation claim for back pain. Our objective is to describe the 1-year patterns of sick-leave and the health outcomes of a cohort of workers who make a workers' compensation claim for back pain. We studied a cohort of 1,831 workers from five large US firms who made incident workers' compensation claims for back pain between January 1, 1999 and June 30, 2002. Injured workers were interviewed 1 month (n = 1,321), 6 months (n = 810) and 1 year (n = 462) following the onset of their pain. We described the course of back pain using four patterns of sick-leave: (1) no sick-leave, (2) returned to worked and stayed, (3) multiple episodes of sick-leave and (4) not yet returned to work. We described the health outcomes as back and/or leg pain intensity, functional limitations and health-related quality of life. We analyzed data from participants who completed all follow-up interviews (n = 457) to compute the probabilities of transition between patterns of sick-leave. A significant proportion of workers experienced multiple episodes of sick-leave (30.2%; 95% CI 25.0-35.1) during the 1-year follow-up. The proportion of workers who did not report sick-leave declined from 42.4% (95% CI 39.0-46.1) at 1 month to 33.6% (28.0-38.7) at 1 year. One year after the injury, 2.9% (1.6-4.9) of workers had not yet returned to work. Workers who did not report sick-leave and those who returned and stayed at work reported better health outcomes than workers who experienced multiple episodes of sick-leave or workers who had not returned to work. Almost a third of workers with an incident episode of back pain experience recurrent spells of work absenteeism during the following year. Our data suggest that stable patterns of sick-leave are associated with better health.

Self-reported severity measures as predictors of return-to-work outcomes in occupational back pain.

INTRODUCTION: We test an array of biopsychosocial, cognitive-behavioral, and work-related factors to identify the best predictors of work disability following a back injury. METHODS: We test the validity of alternative severity measures in predicting the likelihood of four distinct, mutually exclusive patterns of post-injury employment in the first year after onset of back pain. The study sample includes 959 participants in the ASU Healthy Back Study, a prospective cohort study of workers who filed claims for occupational back pain between 1999 and 2002. Self-reported severity measures include: NRS-101 measures of the intensity of back or leg pain, Roland-Morris scale of functional disability, and mental and physical components of the SF-12. RESULTS: All the severity measures have significant predictive power on return-to-work outcomes even after 1 year. Baseline physical functioning and overall mental and physical health status are more predictive of specific patterns of post-injury employment than pain intensity measures, possibly because there is considerable idiosyncratic variation in the pain intensity measures. The mental component of the SF-12, in particular, is relatively robust to alternate specifications, consistently statistically significant, and has the lowest probability significance level in explaining patterns of employment 1 year after injury.

Upper extremity disorders in the workplace: costs and outcomes beyond the first return to work.

BACKGROUND: Cumulative trauma disorders of the upper extremities (CTD) have become increasingly important in workers' compensation caseloads over the last two decades. Relative to occupational back pain, CTD have been much less studied. METHODS: We analyzed post-injury employment patterns and return-to-work probabilities for a sample of Ontario workers with CTD, for up to five years after injury. Results for workers with CTD are compared to results for workers with back injuries or fractures. RESULTS: Most workers with CTD return to work at least once, but a first return does not necessarily mark the end of work disability. Among workers absent at least once, 26% with CTD report a second injury-related absence, compared to 18% with back pain and 12% with fractures. After five years, focusing on first returns underestimates work-loss days associated with CTD by 32%. CONCLUSIONS: A substantial proportion of workers with CTD or work-related back pain experience injury-related absences after their first return to work. Focusing on the first return to work is misleading for both injury groups, but even more so for CTD, as they appear to be even more susceptible to multiple spells of work absence.

Perceived and measured stigma among workers with serious mental illness.

OBJECTIVE: This research analyzed the extent to which self-reports of job-related discrimination by persons with serious mental illness are associated with econometric measures of discrimination. METHODS: Data were from the 1994-1995 National Health Interview Survey-Disability Supplement. Data for workers with mood, psychotic, or anxiety disorders (N=1,139) were compared with data for those without such disorders (N=66,341). The main outcome measures were self-reports of wages and stigmatizing experiences in the workplace. RESULTS: After the analyses controlled for functional limitations and job characteristics, no significant difference in mean wages was found between workers with serious mental illness who did not report experiencing stigma and those with no mental illness. In contrast, for all types of mental disorders examined, mean wages for workers with serious mental illness who reported experiencing stigma were significantly lower than mean wages for those with no mental illness. CONCLUSIONS: Workers' self-reports of stigmatizing experiences in the labor market appear to be consistent with econometric measures of the effect of stigma on wages, suggesting that workers know when they are being discriminated against.

Early patterns of care for occupational back pain.

STUDY DESIGN: Cross-sectional analysis. OBJECTIVES: To describe the early health care utilization for occupational back pain. To identify factors associated with health care seeking and provider choice among persons with occupational back pain. SUMMARY OF BACKGROUND DATA: Back pain is the most prevalent work-related injury, yet little is known about patterns of care for occupational back pain. MATERIALS AND METHODS: The sample includes 1104 workers with incident episodes of low back pain. Outcomes measures include whether or not workers received care and the types of providers seen. Predictors of outcomes include demographics, injury severity, history of back pain, occupation, and employer. RESULTS: Eight percent of workers did not receive care in the first 4 to 16 weeks after filing a workers' compensation claim. Injury severity, gender, occupation, and employer were significant predictors of the decision to seek care. Almost 90% of workers who received care were treated by medical physicians, often in combination with physical therapists or chiropractors. Age, occupation, injury severity, and whether the employer or worker chose the initial health care provider were associated with the choice of provider. Employers selected providers for 78% of injured workers who received care. Medical physicians were the providers most often chosen by both employers and workers, but workers were more likely than employers to select chiropractors. CONCLUSIONS: A small but significant number of injured workers do not seek care for their back pain. Medical physicians treat all but a small fraction of the workers who receive care. The decision to seek care and the choice of providers is associated with injury severity, occupation, and employer actions.

Reducing the costs of work-related musculoskeletal disorders: targeting strategies to chronic disability cases.

Musculoskeletal disorders impose a significant direct cost burden on health care systems in the US and Canada and account for even greater indirect losses of productivity. The overall prevalence of musculoskeletal disorders is high, but a disproportionate share of costs is associated with a small number of cases with chronic pain. This is especially true for cases of occupational back pain, the single most common and costly musculoskeletal disorder in the workplace. A number of studies identify workplace characteristics associated with prolonged disability among cases of work-related back pain. These characteristics include: failure to receive job accommodations, receipt of disability benefit payments, and employment in high-risk industries or jobs that require heavy lifting. Research on the predictors of high-cost cases is limited, however, because of the lack of high-quality data and the need for a multidisciplinary approach. A new study, the Arizona State University Healthy Back Study, addresses some of these issues and promises new insights into effective strategies to reduce the proportion of high-cost claims.

Effects of provider networks on health care costs for workers with short-term injuries.

OBJECTIVES: This study examines the effects of preferred provider networks on health care costs and service utilization in the treatment of work-related injuries. RESEARCH DESIGN: A retrospective comparison of workers' compensation claims treated by network and non-network providers was conducted. Pairwise matches of individual cases are used to control for differences in case mix and severity of injury between network patients and a non-network comparison group. Cost differentials are separated into a price effect, the difference in costs attributed to network price discounts, holding services constant; and a utilization effect, the difference in costs attributed to differences in service utilization, holding prices constant. SUBJECTS: Data include approximately 87,000 workers' compensation claims, from California, Connecticut, and Texas, with injury dates between 1995 and 1997. The samples are restricted to five common injury types and work absences of less than 7 days. Workers treated solely by network providers are compared with a matched group of workers treated solely by non-network providers. RESULTS: Average health care costs are lower for network claims than for matched non-network claims. Price discounts explain a large part of the cost differentials for all injury groups studied, but differences in service utilization are also important for back cases and cumulative stress injuries. CONCLUSIONS: Networks bring the traditionally high costs of health care for work-related injuries closer to the costs of health care for off-the-job injuries. The network savings primarily reflect price discounts for the same services, thereby representing an increase in the cost-effectiveness of care.

Can workers' compensation health costs be controlled by managed care?

Three recent studies provide, for the first time, the information needed to evaluate objectively the cost savings, utilization, worker satisfaction, and productivity differences of network versus nonnetwork care in workers' compensation cases. The authors review these studies and analyze their findings.