A study of psychiatric referrals for fitness for work

Abstract

Background:

There are very few Indian studies regarding the psychiatric evaluation of state government workers referred for psychiatric fitness for work.

Aim:

This study aimed to examine the reasons for referral, psychiatric diagnosis, and outcome of psychiatric referrals for fitness for work at a tertiary-level referral government hospital.

Materials and Methods:

The study evaluated consecutive psychiatric referrals at a tertiary-level referral government hospital with their informed consent utilizing a specially prepared pro forma, Kuppuswamy's Socioeconomic Status Scale and the Mini International Neuropsychiatric Interview plus. Psychiatric diagnoses were based on the International Classification of Diseases 10th Edition Diagnostic Criteria for Research.

Results:

The study included 67 male and 8 female psychiatric referrals with a mean age of 39.5 years. Most of the psychiatric referrals were married (82.6%), Hindu by religion (97.3%), from urban areas (80%), belonged to upper middle class (46.7%), and had rotating shifts or emergency duties (50%). Psychiatric referrals were usually made for a single reason (57%), most commonly absenteeism (84%) followed by undisciplined behavior (38%). A past history of disciplinary action taken against them was given by 56% of the referrals. The most common psychiatric diagnosis was psychoactive substance-use disorder (21.3%) followed by psychotic disorders (20%) and mood disorders (14.7%). No psychopathology was detected in 18.7% of the referrals. Most of the psychiatric referrals (68%) were fit for work, though 22.67% were declared unfit for work (permanent invalidation). Psychiatric referrals with multiple reasons for referrals, longer duration of psychiatric illness (>5 years), and diagnosis of organic mental disorder or psychotic disorder received invalidation (permanent unfitness) on psychiatric grounds.

Conclusions:

Psychiatric referral for fitness for work is most commonly for absenteeism. The most common psychiatric diagnosis was substance-use disorder followed by psychoses. The majority (68%) were found fit for work after treatment though 22.6% required invalidment from service.

“Work is at the very core of contemporary life for most people, providing financial security, personal identity and an opportunity to make a meaningful contribution to community life.”

-National Alliance for the Mentally Ill

Mental ill health and work involve many areas such as human resources, medicine, law, occupational psychology, epidemiology, rehabilitation, and psychiatry.[1,2] Psychiatric disorders are an increasing cause of disability and work-related problems.[1,3] They lead to decreased performance, violent behavior, suicide, frequent mistakes, accidents, early retirement, frequent, and long-term absenteeism.[4,5] Out of the total working population, 25%–30% have minor work-related problems such as occupational stress and 10% have major psychiatric disorders such as psychoses, depression, and substance-use disorders.[1,6,7]

Psychiatric fitness for work is the ability of workers to perform their work without risk to themselves or others.[3,8] It mainly involves two areas: the recruitment of new staff and the return of those who have been sick back to work.[9] For employers, human resource personnel and for occupational health staff the concerns are the performance of a job adequately, health issues, safety risk, future sick leaves and anti-discriminatory laws which have come into effect and are meant to “enable” the “disabled.”[1,10] Some psychiatric referrals are at times pressured by authorities to undergo psychiatric evaluation for administrative reasons. This may be due to conflicts at the workplace, to discredit or even to terminate services on psychiatric grounds.[11] A psychiatric referral may rarely be used to humiliate or punish the individual by sending for psychiatric evaluation. A psychiatrist should be aware of such a possible misuse of psychiatric evaluation.[12,13]

According to the Maharashtra Civil Medical Code 1976 and Bombay Civil Service Rules 1959, “Medical boards” are established to examine candidates being recruited for government service, sick government employees, and others who have applied for leave on medical grounds, commutation of pension, invalidation, and other situations where evaluation for work is required.[14,15,16] In addition, special “Standing Medical Boards” have been established at Pune, Aurangabad, Nagpur, and two at Mumbai. Any case referred to the medical board for evaluation for fitness for work has to be examined initially by the president of the medical board or the superintendent. If a psychiatric opinion is required, the case is sent to the head of the psychiatry department. In this study, a “Psychiatric Referral” is a case referred to the department of psychiatry by the superintendent, medical board, or standing medical board of government hospital for psychiatric evaluation and certifications regarding fitness for work.

A psychiatric referral is usually evaluated as an indoor admission to facilitate observation and evaluation. The psychiatrist first records the history from the relatives and then does the mental status examination. The psychiatric social worker arranges to get all work-related records of the psychiatric referral from the source of referral. The work-related records contain information regarding the job profile, the service record, the leave record, and the reasons for the referral. The psychiatric referral may be sent for psychometric testing to a psychologist or to the other departments if necessary. The psychiatric referral is evaluated in light of the above findings for fitness for work. Once the psychiatric evaluation is complete, a certified report with the result of the evaluation is submitted to the president of the standing medical board. The psychiatric referral may receive an outcome which may make him/her fit, provisionally fit, or unfit for work. Those referrals that are provisionally fit are called back for re-evaluation after 3 or 6 months with the work record of that period. On some occasions, the referral may be recommended leave and on some rare occasions invalidated on psychiatric grounds (permanent unfitness for work). The psychiatric referral may also be recommended a change in job or modified work.

At present, there is no systematic Indian study or guidelines available regarding psychiatric referrals for fitness for work.[17,18] This study will examine the sociodemographic characteristics, the reasons for referral, the psychiatric diagnostic categories, outcome, and associations, if any, of the psychiatric referrals for fitness for work. This will help to provide better services for psychiatric referrals for fitness for work and in planning further research in this neglected area.

MATERIALS AND METHODS

This cross-sectional study was conducted at a large tertiary-level referral government hospital attached to a medical college during February 2011–January 2012. The study protocol was approved by the Institutional Ethics Committee.

Sample

The sample of the study consisted of 75 consecutive individuals referred to the department of psychiatry of a tertiary-level referral government hospital for psychiatric evaluation for fitness for work. They were given information about the nature of the study and then written informed consent was taken from the individual and/or relative.

Inclusion criteria

1. Psychiatric referrals sent for evaluation for fitness for work

2. Psychiatric referrals who gave consent to participate in the study

3. Psychiatric referrals with proper records.

Exclusion criteria

1. Psychiatric referrals sent for reasons other than fitness for work

2. Psychiatric referrals who were prisoners.

Tools

Kuppuswamy's Socioeconomic Scale (revised 2010)

Kuppuswamy's Socioeconomic Status Scale is a popular tool in hospital- and community-based researches in India. This scale takes into account the education, occupation, and income of the family to classify the study groups into high, middle, and low socioeconomic status.[19,20]

Mini International Neuropsychiatric Interview Plus

Mini International Neuropsychiatric Interview (MINI) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the US and Europe, for International Classification of Diseases 10^th Edition (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders-IV psychiatric disorders. The administration time is approximately 15 min. It was designed to meet the need for a short but accurate structured psychiatric interview for multicentric trials and epidemiological studies. It is used as the first step in outcome tracking in nonresearch clinical settings.[21,22] The MINI. Plus is a more detailed edition of the MINI. The symptoms which are better accounted for by an organic cause or by the use of alcohol or drugs should not be coded positive in the MINI. The MINI. Plus has questions that investigate these issues.[21,22,23]

Methodology

The individuals referred for psychiatric evaluation for fitness for work were selected after they met the inclusion and exclusion criteria. The detailed history of psychiatric referrals was recorded and their mental status examination was done. The Kuppuswamy's Socioeconomic Scale and the MINI Plus were administered to the patients. Psychiatric diagnoses were made according to the ICD-10 diagnostic criteria for research.[24]

Statistical analysis

Statistical analysis of data was performed using Statistical Package for the Social Sciences SPSS (IBM, USA). Categorical variables were analyzed with the Chi-squared tests and the Fisher's exact test. Significance levels for all analyses were set at P = 0.05.

RESULTS

Sociodemographic details of the patients referred for fitness for work are summarized in Table 1. The age range of the referrals was 20–59 years. The mean age of the referrals was 39.5 years. Majority (97.33%) were Hindu, 1.33% each was from Muslim and Sikh communities. The duration of service ranged from training period of 2 months to 44 years of service. Nearly 50.67% (n = 38) had duties in rotating shifts. None of the psychiatric referral was from the lower class of Kuppuswamy Socioeconomic Scale. Reasons for referral and psychiatric diagnoses of the patients are shown in Table 2. A past history of disciplinary action such as memos, notices, suspensions, demotion, fines, or past medical board examination was given by 56% of referrals. Mental and behavioral disorders due to psychoactive substance use were diagnosed in 21.33% (n = 16) of patients, including 20% (n = 15) related to alcohol and 1.33% (n = 1) related to poly-substance use. Psychotic disorders (20%; n = 15) included schizophrenia (16% [n = 12], brief psychotic disorder (1.33% [n = 1]), and schizoaffective disorder (2.67% [n = 2]). Mood disorders (14.67%; n = 11) included bipolar affective disorder (8% [n = 6]), followed by major depressive episode (5.33% [n = 4]) and dysthymia (1.33% [n = 1]). Neurotic, stress-related, or somatoform disorders (12%; n = 9) included adjustment disorders (5.33% [n = 4]), panic disorder (2.67% [n = 2]), posttraumatic stress disorder (2.67% [n = 2]), and generalized anxiety disorder (1.33% [n = 1]).

Table 1.

Sociodemographic characteristics of referrals for psychiatric fitness for work (n=75)

Table 2.

Reasons for referral of psychiatric referrals, disciplinary actions, psychiatric diagnosis, and outcome of referrals for psychiatric fitness for work (n=75)

Associations of sociodemographic data and reason for referrals

All the referrals with administrative reasons were from younger age (20–39 years). Absenteeism, frequent mistakes, and undisciplined behavior were the most frequent reasons for referral in older age group (40–59 years) than younger age group (20–39 years) [Table 3]. Frequent mistakes, undisciplined behavior, and administrative reasons were more common in male psychiatric referrals. Absenteeism was the most common reason for referral in females. None of the females were referred for administrative reasons. Only workers from the upper socioeconomic status (upper + upper middle class) were referred for administrative reasons. Absenteeism, frequent mistakes, and undisciplined behavior were the most common reasons for referral in group with lower socioeconomic status (lower middle + lower class) [Table 3].

Table 3.

Association between reasons for referral and diagnoses with age, gender, education, socioeconomic status, and occupation of the referrals for psychiatric fitness for work (n=75)

Associations of sociodemographic data and diagnostic categories

Psychiatric referrals from the younger age group (20–39 years) had more referrals without active psychopathology. Referrals from the older age group (40–59 years) had more referral with organic and neurotic disorders [Table 3]. Only male psychiatric referrals had substance-use disorder. Substance-use disorder was more common in referrals with lower educational level (<higher socioeconomic class [HSC]). Neurotic disorders and those without psychopathology were more common in referrals with higher educational level (≥HSC). Neurotic disorder, mood disorders, and those without psychopathology were more common in the HSC. Organic mental disorders, substance-use disorders, and psychosis were more common in the lower socioeconomic class.

Associations between sociodemographic data and outcome of referral

A significant association was found between multiple reasons for psychiatric referrals, organic mental disorders, psychotic disorders, and long duration of psychiatric illness with invalidation on psychiatric grounds [Table 4 and Figure 1].

Table 4.

Association between sociodemographic and clinical variables with outcome of referrals for psychiatric fitness for work (n=75)

Figure 1.

Associations between psychiatric diagnosis and outcome of referral

DISCUSSION

Our study evaluated the sociodemographic data, reasons for referral, diagnostic categories, outcome, and their associations in 75 psychiatric referrals attending a tertiary-level referral government hospital.

Sociodemographic data

The sociodemographic profile of our study sample is comparable with few earlier studies. Elsayed et al. studied 116 referrals and the mean age was 34.5 years. Out of these, 64.7% were males and 35.3% were females and the male:female ratio was 1.8:1. A total of 67.2% were married and 32.8% were unmarried. Most (50.8%) had high school level of education. As compared to our study, they had a larger sample size, more females, and more unmarried referrals, which can be explained by the cultural and occupational differences in the two countries. The educational levels of both the studies were comparable. They did not comment on the socioeconomic classes and occupational categories.[3] Greenberg et al. studied 76 cases, of which 45% were males and 55% were females and the male:female ratio was 0.8:1. They had a similar sample size and a greater number of females, which can be explained by the cultural differences in the sample. They did not report about the age, marital status, and socioeconomic class of the referrals.[25] Gopala Sarma et al. studied 23 referrals over a period of 6 years (1986–1992), of which 73% were males and 27% were females and the male:female ratio was 2.7:1. They had a smaller sample size with a greater number of females. They did not report about the age, marital status, and socioeconomic class of the cases.[26]

Our study compares with the hospital-based Indian studies which had a smaller sample size and a greater male:female ratio.[26,27] Our study contrasts with the general population; industrial and armed force studies that had larger sample sizes; and the specific population studies on teachers, drivers, call-center workers, and industrial, security, and military workers which had smaller sample sizes.[28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48] The industrial, general population, and physician studies had referrals from the older age groups, whereas studies on military personnel, executives, and call-center workers had younger age groups as compared to our study.[28,29,30,31,32,33,34,35,37,40,41,42,43,44,45,46] Most of the foreign studies did not report about socioeconomic data. Our study included only psychiatric referrals from government service and none were from a private setting.

Diagnostic categories

Our study findings with regard to diagnostic categories and comorbid disorders compare with the following studies: Elsayed et al. used MINI and ICD-10 criteria and found that 2.6% had organic mental disorders, 20.7% had substance abuse disorders, 14.7% had psychosis, 18.1% had mood disorders, 38.4% had neurotic disorders, 8.6% had personality disorders, and 6.9% were malingers. Comorbid mental and physical illness was found in 42.2% of cases. Compared to our study, they had less organic and psychotic disorders and more neurotic disorders and a similar number of mood and substance-use disorders. They also found a similar number of medical comorbidities as in our study.[3] Greenberg et al. used ICD-10 criteria and found that 2.63% had organic mental disorder (dementia), 19.1% had psychosis, 45% had mood disorders, 14% had anxiety disorders, 1.3% had eating disorders, and 18% did not have any psychiatric disorder. As compared to our study, they found less organic disorders; more psychotic, mood, and neurotic disorders; and a similar number of referrals with no psychiatric diagnosis. Surprisingly, there were no substance-use disorders.[25] Gopala Sarma et al. found that 65.2% had psychiatric diagnosis similar to our findings and 26.1% did not have any psychiatric disorder, but they did not report the diagnostic categories. They attributed such a high number of psychiatric referrals without any psychiatric problem to nonpsychiatric reasons such as irregularities and undisciplined behavior at work.[26]

We used ICD-10 diagnostic criteria for research along with MINI Plus similar to that of Elsayed et al.[3,25] One hospital-based study used ICD-9 criteria.[26] Some studies did not specify the diagnostic criteria used.[27,28,29,30,34] The diagnostic categories of our study compare with the hospital-based Indian studies but not with the community-based studies, industrial studies, and the special population-based studies done on teachers, physicians, executives, call-center workers, and drivers.[3,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48] Studies on executive, call-center, and social workers found only minor psychiatric disorders.[25,34,39] Studies on armed force personnel had more substance-use disorders and neurotic disorders.[47,48]

Reasons for referral

Two earlier studies reported that 61.3% and 65.2% of the referrals for psychiatric fitness occurred following acts of indiscipline. As compared to our study, they had more of such referrals probably as they included absenteeism and frequent mistakes under indiscipline.[3,26] Greenberg et al. did not mention the reasons for referrals in their study.[25] The reason for referrals of our study compares with the hospital-based studies.[3,26,27] None of the general population and industrial, executive, call-center, physician, social worker, security force, armed force personnel or driver studies had mentioned the reasons for referral.[28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48] Teachers were mainly referred for a past history of psychiatric illness or inability to cope with work.[36]

Outcome of referral

In our study, the majority of the psychiatric referrals were declared fit for work and few were advised modified work in the form of unarmed or nondriving work. In our study, many employment agencies had expressed their inability to provide modified work; hence, a less number of referrals were recommended modified work. Our study compared with few earlier studies. Elsayed et al. found that 52.5% were fit for work, 11.2% were unfit, 9.48% were fit for modified work, 18.10% were temporarily fit, and 8.6% were temporarily unfit for work. As compared to our study, they had more referrals declared fit for modified work. They found a similar number of referrals as unfit for work (temporary and permanent) as compared to our study.[3] Greenberg et al. found that 34% of referrals were fit and 58% were advised temporary unfitness and further treatment. Compared to our study, they found less referrals fit for work.[25] Gopala Sarma et al. found that 39.1% were fit for work and 52.2% were unfit for work. As compared to our study, they found that less referrals were fit for work and a greater number of referrals were unfit for work, which can be explained by more referrals for indisciplinary action.[26]

The outcome of our study compares with that of the hospital-based studies of Elsayed et al. but not with Greenberg and Gopala Sarma probably due to different criteria of fitness for work.[3,25,26] Studies on teachers, executives, call-center workers, social workers, industrial workers, armed force personnel, and general population had a comparable number of cases fit for work, but studies on drivers had less cases fit for work, probably due to their specific job and different criteria of fitness for work.[28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]

Associations

We found a significant association between a long duration of psychiatric illness (>5 years), psychiatric referrals with multiple reasons, and organic mental disorders with invalidation on psychiatric grounds. A significant association was found between psychotic disorders and unfitness. All the psychiatric referrals without any active psychopathology were made fit for work.

Similarly, Elsayed et al. also found associations between unfitness for work and a long duration of illness, diagnosis of schizophrenia, organic mental disorders, and medical comorbidities. They found that referrals with substance-use disorders were made fit for modified work, whereas we found them to be fit for work, probably due to differences in culture, occupation, and attitude toward substance-use disorders.[3] None of the other hospital-based studies had mentioned an association between various parameters.[25,26,27,28]

The hospital-based, general population, and industrial and executive workers' studies found an association between a diagnosis of psychosis and a long duration of illness with invalidation on psychiatric grounds, which is similar to our study.[3,28,29,30,31,32,33,34] In contrast, the military studies found that young and single referrals with a short duration of service were associated with invalidation on psychiatric grounds, which was independent of sex. In both the military studies and our study, the diagnosis of psychosis was associated with invalidation on psychiatric grounds.[43,46] In all studies, shift workers were found to be associated with sleep disorders and those working in high stress areas had more psychiatric illness.[3,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]

Limitations

This study was conducted over a limited period of time on a small group of state government workers, at a single tertiary-level government hospital. This may not be representative of all workers from the state of Maharashtra or the country. A larger multicentric study of state government workers referred for psychiatric evaluation needs to be undertaken. There were a less number of female state government workers. Those government workers who were not referred and those who left the job because of psychiatric problems by themselves were also not studied.

Implications

This study had important implications for mental health services, training of mental health professionals, and further research in the field of occupational health in India.

Mental health services

The study highlights the importance of evaluation of work in the overall management plan of all psychiatric referrals as work provides financial security, independence, and a meaning to life. It will help in planning suitable targeted interventions for psychiatric referrals suffering from psychiatric disorders. It will help in the early detection and proper treatment of psychiatric disorders of psychiatric referrals. It will help to enable those psychiatric referrals who are disabled by psychiatric illness by providing suitable modified work and rehabilitation. It is recommended that there should be a special occupation liaison service for such psychiatric referrals with psychiatric disorders.

Training

Psychiatrists are increasingly being called to certify and report about patients in connection with work, related to administrative, legal, and welfare procedures. The assessment of mental fitness for work should be performed with great competence and objectivity; otherwise, it may lead to administrative, legal, and social problems. We should strike a proper balance between fitness for work and safety risks posed by individuals with psychiatric disorders. With the enforcement of labor laws and other anti-discriminatory laws, we should have clear guidelines regarding fitness for work, unfitness for work, and recommendations for modified work. It highlights the importance of having proper criteria for prerecruitment fitness, fitness for work, invalidation, and modified work.

Research

This study highlights the need for further research of psychiatric referrals for fitness for work, which is a neglected area. Research needs to be done in areas such as prerecruitment fitness, ongoing psychiatric fitness for duty, criteria for invalidation on psychiatric grounds, and criteria for modified work. Standardized, validated, and reliable screening tools for evaluation of work in psychiatric referrals need to be designed to improve the quality of evaluation. Research is also required to be done on preventive methods to reduce stress at work and improve occupational health through recreational and stress reduction techniques.

CONCLUSIONS

The most common reasons for psychiatric referral for fitness for work were absenteeism (84%), undisciplined behavior (38%), and frequent mistakes or accidents (26.7%). A few (5.3%) referrals were made for administrative reasons. A past history of disciplinary action taken against them was present in 56% of patients. The common diagnostic categories were psychoactive substance-use disorder (21.3%) and psychotic disorders (20%), followed by mood disorders (14.7%); neurotic, stress-related disorders (12%); organic mental disorders (10.7%); and mental retardation (2.7%). Nearly 18.7% of the psychiatric referrals did not have any psychopathology. Most of the psychiatric referrals (68%) were fit for work, though 22.67% were declared permanently unfit for work. Factors associated with permanent unfitness on psychiatric grounds included multiple reasons for referrals, psychiatric illness of more than 5 years' duration, and a diagnosis of organic mental disorder or psychotic disorder.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.