The Psychiatric Patient at Work DAVID B. ROBBINS, MD, ARNOLD J. KAMINER, MD, THEODORE SCHUSSLER, MD, JD, AND ISIDOR H. POMPER, MS
Abstract: Psychiatric consultations and job performance of 135 IBM employees were studied. Psychiatric referrals were made by management and the company medical department or were self-referred. The consulting psychiatrist conducted interviews, met with management, personnel representatives and other physicians to coordinate treatment with job requirements. Every effort was made to retain employees and improve performance. After a two-three year follow-up period, 82 employees (61.7 per cent) were with the company; ten
were rated outstanding, 38 exceeded job requirements, 25 were meeting job requirements, and four were not. Performance data for five employees were not available. Forty-nine of 83 employees (59.0 per cent) rated unsatisfactory in job performance at the initial referral were performing satisfactorily at follow-up. The results support an optimistic attitude toward the working patient-with psychiatric disease and highlight the value of a full-time medical department with consultation facilities leading to secondary and tertiary prevention. (Am. J. Public Health 66:655-659, 1976)
In recent years, the vocational rehabilitation of psychiatric patients has received increasing attention.'-6 From the vantage point of an individual patient, successful return to gainful employment is not only an economic necessity but also a critical area of resocialization in the community.7 Psychological benefits of employment include group participation, a focus on reality problems, and increased self-confidence derived from successful coping and mastery. Adverse effects of unemployment, in patient and nonpatient populations, are resentment, anger, depression, and loss of self-esteem.8 From the community point of view, vocational rehabilitation of psychiatric patients reduces disability benefit expenditures, diminishes unemployment, returns needed skills to the work place, and counteracts institutionalism, custodial care, and excessive hospital costs. Despite the obvious benefits of vocational rehabilitation, systematic investigations are rare, particularly in a business setting. Most large-scale work-adjustment studies begin with a hospital population and follow the subjects into a variety of industrial settings.8'3 Cole and her co-workers have followed a cohort of employed patients for several years, but
these subjects work in various businesses and industries with diverse personnel policies and rating systems.14-8 By retrospectively analyzing the medical records of a single geographic area for a large business-machine manufacturer we hoped to answer such questions as: 1. What are the success-failure rates for vocational rehabilitation of a psychiatric patient population? 2. How are success rates affected by diagnosis, education, job level, length of service, and referral process?8' 18 3. How well do psychiatric patients perform on the job? Are they contributing fairly to the corporate effort?
From the International Business Machines Corporation, Medical Department, White Plains, NY. Address reprint requests to Dr. David B. Robbins, Medical Department, IBM Corpor., 1000 Westchester Avenue, White Plains, NY 10604. This paper, submitted to the Journal August 8, 1975, was revised and accepted for publication March 23, 1976. Portions of the information in this paper were presented at the American Psychiatric Association Annual Meeting in Hawaii, May 1973.
AJPH, July, 1976, Vol. 66, No. 7
Methods and Material The study is based on an evaluation of employees seen by the consulting psychiatrist at a headquarters location of the IBM Corporation. Since our population consists of divisional and corporate headquarters, it is deficient in entry-level and blue collar positions and skewed toward clerical, administrative, managerial, and professional personnel. The study group consists of all employees seen by the consulting psychiatrist during an 18-month period. The status of these employees was re-evaluated two to three years later. During the study period, approximately 7,500 employees were in the employee population with more turnover in some job categories than others. An on-site industrial medical department supplied occupational medical services to these employees. The consulting psychiatrist was available to the medical department 15 hours per week (three hours per day). 655
ROBBINS, ET AL.
All employees were seen by the same board certified psychiatrist. In addition to his own judgment, the consulting psychiatrist utilized hospital records, consultations with the employees' personal physicians and psychiatrists, and information available in the medical charts. The re-evaluation was based on a review of the medical chart and written performance appraisals by management. An appraisal and counseling session is conducted by management on at least a yearly basis for all employees in accordance with personnel policy. Performance data are derived from written appraisal forms and do not reflect estimates or ratings by the authors. Employees are referred to the consulting psychiatrist in a variety of ways. Employees can request consultation on their own for personal or family problems. Management or the personnel department may request evaluation by the medical department when they suspect a medical problem is affecting performance at work; in this situation the employee is usually first seen by an internist in the medical department. Employees may be seen in the medical department for other reasons (return to work after illness, first aid, etc.) and referred to the consulting psychiatrist after evaluation by the internist. The psychiatrist does not see all employees with psychiatric illness. An employee, in private psychiatric treatment, who is performing adequately would not be referred to the medical department or the consulting psychiatrist. Employees may have problems that can be handled through consultation with the internist in the medical department without psychiatric referral. Some employees will reject psychiatric consultation. All employees are entitled to refuse medical evaluation; their performance appraisal will determine appropriate managerial action. Psychiatric consultation is handled with the same ethical standards as any other medical department visit. The consulting psychiatrist provides an initial evaluation, and makes recommendations to the employee, including referral for treatment, if necessary. Through periodic follow-up visits the consulting psychiatrist acts as liaison between the treating psychiatrist, management, and the patient-employee. If there is no problem with performance at work there is no feedback to management. When illness is impacting job performance or a job is contributing to illness, management is given, on a need-to-know basis, the information and recommendations which will best serve the needs of the employee and the company. The consulting psychiatrist, with rare exceptions, does not provide formal treatment; some exceptions are acute psychiatric episodes at work or psychiatric disease that is almost entirely job-related. Every effort is made to retain the employee with psychiatric disease. The intervention techniques included followup visits and consultations within the medical department, outside treatment largely paid for by the company, and recommendations to management concerning selective job placement and restrictions. Although an employee may be released for nonperformance, company policy precludes release on the basis of a psychiatric diagnosis per se. 656
TABLE 1-Method of Referral by Diagnosis For Employees Seen by Consulting Psychiatrist Means of Referral
SelfReferral
Diagnosis Schizophrenia Manic Depressive Paranoid Psychosis Neuroses Personality Disorders Alcoholism Drug Dependence Heroin Physical Disorders of Psychogenic Origin Stuttering Transient Situational Disturbances No Psychiatric Disease TOTAL
1 4 2 -
Manager or Personnel
7 2 1 18 6 7
1
Medical
Dept.
TOTAL
5 3 21 8 5
12 5 2 43 16 12
2 2
3 2
10
1 6
6
1 22
9 27 (20.0%)
6 54 (40.0%)
2 54 (40.0%)
17 135
Results Population A total of 135 employees, 90 men and 45 women, was seen by the consulting psychiatrist during the study period. This represents a referral rate to the psychiatrist of 1.2 per 100 employees per year. The means of referral by diagnostic category is presented in Table 1. In 54 cases, management or the personnel department were the first to note signs of illness and made the initial referral to the medical department. In an additional 54 cases, referral to the consulting psychiatrist was initiated by a staff internist or nurse. Twenty-seven employees were selfreferrals. Occupations of the 135 employees are presented in Table 2. As some of our patients were referred for multiple, concurrent reasons, we tallied 308 initial complaints as reasons for referral (Table 3). Twenty-four and four-tenths per cent of these were directly connected with performance problems. The 135 employees had a total of 731 visits with the psychiatrist (Figure 1). Twenty-five employees with 11 or more visits accounted for 61. I per cent of all psychiatric visits. The employees in the study group made extensive use of TABLE 2-Occupational Category of Employees Seen by Con-
sulting Psychiatrist
Occupation
Clerical Maintenance & Facility
Computer Operations Professional TOTAL
40 (29.6%) 12 (8.9%) 12 (8.9%) 71 (52.6%) 135
AJPH, July, 1976, Vol. 66, No. 7
PSYCHIATRIC PATIENT AT WORK
per cent) were still with the company (Table 4). This is below
E
NUMBER OF PEOPLE
=
TOTAL PSYCHIATRIC VISITS
180
TABLE 4-Status of 135 Employees at 2-3 Year Follow-up*
160
With Company Outstanding Performance Exceeding Job Requirements Meeting Job Requirements Not Meeting Job Requirements No Recent Appraisal Not With Company Voluntary Resignation Separation by Mutual Agreement Fired Early Retirement Military Leave Educational Leave Total Disability Died In Jail Reason Unknown
140 120
100 80
60 40
20
82 (61.7%) 10 38 25 4 5 51 (38.3%) 14 8 6 5 1
1 13
TOTAL 1
2-5
610
11-15
1620
*Two lost to follow-up
20+
VISITS / PERSON
FIGURE 1-Frequency of Visits to Consulting Psychiatrist
nonpsychiatric medical department services: internist, nurse, x-ray technician, etc. These 135 employees accounted for 17.0 per cent of all medical department visits. Follow-Up The status of the study group was evaluated two to three years after the initial contact. Eighty-two employees (61.7
133
the expected retention rate.* Of these 82 employees still with the company, all but four were meeting the requirements of the job. Management appraisals indicated that 38 employees were exceeding the requirements of the job, and an additional 10 were considered to be outstanding performers. Fiftyone employees had left the company, including 14 who resigned voluntarily for personal reasons, i.e., not separated by management directive. Table 5 shows the retention rate in relation to perform-
TABLE 5-Retention Rate in Relation to Performance at Time of Initial Referral TABLE 3-Initial Reasons for Referral of Employees Seen by
Consulting Psychiatrist
75 (24.4%)
Performance Related Task Performance Attendance and Punctuality Problems with Other Employees Problems with Superior Lacking in Initiative Family Problems Marital Problems Other Family Problems Medical Complaints Depression Hospitalized Because of Problems Anxiety or Tension Acute Psychiatric Episode Physical Complaints Alcoholism Attempted Suicide Drug Abuse Sexual Problems Other
29 26 7 7 6
Failing to Meet Job Requirements Meeting Job Requirements TOTAL REFERRALS
184 (59.7%)
67 38 32 13 13 12 4 3 2
Number
Number Not
w/Company
w/Company
Total
49 (59.0%)
34 (41.0%)
83
33 (66.0%)
17 (34.0%)
50
82(61.7%)
51 (38.3%)
133*
*Two lost to follow-up (p - 0.02 chi square)
32 (10.4%/6)
12 20
ance. At the time of the initial referral, 83 of the employees were failing to meet job requirements. Of these initially unsatisfactory employees, 59.0 per cent were still with the company at the time of the follow-up. Of the employees who were performing adequately at the time of the initial referral, 66.0 per cent were with the company at the time of followup.
17 (5.5%)
TOTAL
AJPH, July, 1976, Vol. 66, No. 7
Performance at Time of Initial Referral
308
*Company retention rates are considered confidential and are not available for publication. 657
ROBBINS, ET AL.
Some of the parameters that might affect retention rate were evaluated for the 83 initially inadequate employees. Thirteen employees out of 19 with psychoses, 22 of 28 with neuroses, and eight of 12 with alocholic problems were still with the company (Table 6). The combination of either a per-
to the consulting psychiatrist (Table 9). This may reflect acceptance of disease and need for therapy. TABLE 9-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Number of Psychiatric Visits Number of Visits
TABLE 6.-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Diagnosis Number
Diagnosis
w/Company
Psychoses Schizophrenia Paranoid State Manic Depressive Neuroses Personality Disorders Alcoholism Drug Abuse (Heroin) Other Personality Disorders Transient Situational Disturbances
13 (68.4%) 8 1 4 22 (78.6%) 12 (48.0%) 8 0 4
2 (18.2%) TOTAL 49 (59.0%)
Number Not w/Company
1-5 Total
19
6 (31.6%) 4 1 1 6 (21.4%) 13 (52.0%) 4 3 6
28 25
9 (81.8%)
11 83
34 (41.0%)
Prognosis for retention improved significantly with length of time with the company (Table 7). A strong relationTABLE 7-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Years With the Company
0-5 6-10 10+ TOTAL
Still
Left
w/Company
Company
16 (41.0%)
13(72.2%) 20 (76.9%) 49 (59.0%)
Total
39 18, 26 83
23 (59.0%) 5 (27.8%)
6-(23.1%) 34 (41.0%)
ship was found between occupational category and retention (Table 8). Retention rate increased with the number of visits TABLE 8-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Occupational Category
Clerical Maintenance and Facilities Computer Operations Professional
TOTAL (p _ 0.01 chi square)
658
Total
23 (52.3%) 9 (60.0%) 17(70.8%) 49 (59.0%)
21 (47.7%) 6 (40.0%) 7(29.2%) 34 (41.0%)
44 15 24 83
Discussion In an effort to answer several basic questions about the work adjustment of employees with psychiatric problems, we retrospectively studied the medical and personnel records of 90 men and 45 women. In this phase of our study, control groups were not employed and data on comparable nonpatient population were not available to us. All functional diagnostic categories are represented in our population. The distribution of diagnosis is skewed toward neuroses and personality disorders reflecting the young age of our population and work demands which exclude the
chronically incapacitated. Most of our patients work in headquarters locations for large corporate divisions. The population at risk has an unusually large number of managers, professionals, and clerical employees. Our study group reflects this demographic bias and, in terms of job levels, is not strictly comparable to the cohorts investigated by Cole,14-'7 Brown,9 and others. We were impressed with our follow-up data, especially job appraisals and retention. Retention rates of identified psychiatric patients vary considerably with different reported series,8 from a low of 23.0 per cent13 to a high of 91.0 per cent. 16
*Five left by early retirement (p - 0.001 chi square)
Occupation
TOTAL
Not w/Company
(p s 0.01 chi square)
sonality disorder, or transient situational disturbance with poor performance carried a grave prognosis.
Years w/Company
6-10 11+
Still w/Company
Still
Not
w/Company
w/Company
Total
8 (40.0%) 2 (33.0%)
12 (60.0%) 4 (67.0%)
20 6
3 (37.5%) 36 (73.4%) 49 (59.0%)
5 (62.5%) 13 (26.6%) 34 (41.0%)
8 49 83
The least favorable retention prognoses were associated with drug dependence, personality disorders, and transient situation disturbances. Other diagnostic groups performed well, particularly the psychoneuroses; a finding which is in agreement with the Utah studies.14-'7 The retention rate is somewhat better for those patients who were meeting job requirements at the time of the initial referral (66.0 per cent versus 59.0 per cent). Failure to meet job requirements usually leads to a formal appraisal, a period ofclose observation, and, if performance does not improve, separation from the company. Therefore, most of the 83 patients who were not initially meeting job requirements would have been separated from the business if extensive intervention by management, medical and personnel departments had not been available. We think this study supports an optimistic approach to psychiatric rehabilitation and occupational mental health. Psychiatric consultation in an industrial medical department provides a genuine opportunity for tertiary and secondary prevention. With Powles19 and other occupational mental AJPH, July, 1976, Vol. 66, No. 7
PSYCHIATRIC PATIENT AT WORK
health workers, we believe that secondary prevention is an important function for an industrial medical department. As communication with management continues to develop, primary prevention should become increasingly feasible. We have shown that most patients can continue to work effectively, and some can perform at a superior level. Further research is under consideration, including the use of control groups, prospective studies, and an enlarged population to allow for more refined statistical investigations.
9. 10.
11. 12.
13.
REFERENCES 1. Editorial: The decline of industrial psychiatry. Psychol Med 3:405-10, 1973. 2. Cohen, R. R. Preventive industrial psychiatry. J Occup Med
3. 4.
5. 6. 7.
8.
11:674-677, 1969. Longaker, W. D. The fulltime psychiatrist in industry. J Occup Med 14:216-219, 1972. Cole, N. J. Psychiatrists, employees, and information exchange. Arch Gen Psychiat 25:381-384, 1971. Modlin, H. C. The occupational physician and the psychiatrist. JAMA 226:50-55, 1973. Erskine, J. F. Report on a two year experiment in cooperation between an occupational physician and a consultant psychiatrist. Trans Soc Occup Med 21:53-56, 1971. Simmons, 0. G. Work and mental illness. Eight case studies. New York, Wiley, 1965. Veterans Administration: Restoration of the mentally ill to the world of work-a critical survey of vocational rehabilitation of
14. 15. 16.
17. 18. 19.
the psychiatric patient. Background Paper 61-1, Psychiatric Evaluation Project, Washington, DC, 1961. Brown, G. W., Bone, M., Daltson, B., et al. Schizophrenia and social care. London, Oxford University Press, 1966. Rennie, T. A. C., Burling, T., Woodward, L. Vocational rehabilitation of psychiatric patients. N.Y., Commonwealth Fund, 1950. Schooler, N. R., Goldberg, S. C., Boothe, H., et al. One-year after discharge. Community adjustment of schizophrenic patients. Amer J Psychiat 123:986-995, 1967. Cooperman, I. G., Sonne, T. R. The employment adjustment of veterans with histories of psychosis and psychoneurosis. Dept. of Veterans Benefits, Veterans Administration, Washington, DC, Technical Report TR 22-1, 1963. Walker, R., McCourt, J. Employment experience among 200 schizophrenic patients in hospital and after discahrge. Amer J Psych 122:316, 1963. Cole, N. J., Shupe, D. R., Allison, R. B. Work performance ratings of former psychiatric patients. J Occup Med 8:1-4, 1966. Cole, N. J., et al. A comparative study of the work performance ratings of former psychiatric patients and their controls. Hosp Comm Psychiat 17:175-178,1966. Cole, N. J., McDonald, B. W., Jr., Branch, C. H. A two-year follow-up study of the work performance of former psychiatric patients. Amer J Psychiat 124:1070-1075, 1968. Cole, N. J., Shupe, D. R. A four-year follow-up of former psychiatric patients in industry. Arch Gen Psychiat 22:222-229, 1970. Shupe, D. R., Cole, N. J., Allison, R. B. Specific characteristics of work performance related to psychiatric diagnosis. Hosp Comm Psychiat 17:178-180, 1966. Powles, W. E., Winslow, W. W., Rubin, E. E., et al. Motivation problems related to secondary prevention in industrial mental health. Amer J Psychiat 123:297-302, 1966.
STATISTICAL METHODS COURSE OFFERED BY GEORGIA INSTITUTE OF TECHNOLOGY A two week continuing education program in Statistical Methods will be offered by the Georgia Institute of Technology, July 12-23, 1976. Topics to be covered include statistical estimation, decisions from statistical data, the design of statistical studies and experiments, analysis of variance, regression techniques, graphical tools, survey sampling techniques, and a number of related and supporting topics. The course has been designed for those in industry, business and government who need a working knowledge of statistical methods. Assumptions underlying the methods presented will be carefully explained, and an emphasis will be placed upon the systematic approach to formulating and analyzing statistical problems. Problem and discussion sessions provide an opportunity to apply the methods presented to a variety of selected problems taken from industrial, business, and government settings; and participants will use a time-shared computer system to solve a variety of these problems. The fee for the course is $475. A background which includes algebra is required for all participants. Inquiries should be directed to the Department of Continuing Education, Georgia Institute of Technology, Atlanta, Georgia 30332. Telephone: (404) 894-2400.
AJPH, July, 1976, Vol. 66, No. 7
659
Abstract: Psychiatric consultations and job performance of 135 IBM employees were studied. Psychiatric referrals were made by management and the company medical department or were self-referred. The consulting psychiatrist conducted interviews, met with management, personnel representatives and other physicians to coordinate treatment with job requirements. Every effort was made to retain employees and improve performance. After a two-three year follow-up period, 82 employees (61.7 per cent) were with the company; ten
were rated outstanding, 38 exceeded job requirements, 25 were meeting job requirements, and four were not. Performance data for five employees were not available. Forty-nine of 83 employees (59.0 per cent) rated unsatisfactory in job performance at the initial referral were performing satisfactorily at follow-up. The results support an optimistic attitude toward the working patient-with psychiatric disease and highlight the value of a full-time medical department with consultation facilities leading to secondary and tertiary prevention. (Am. J. Public Health 66:655-659, 1976)
In recent years, the vocational rehabilitation of psychiatric patients has received increasing attention.'-6 From the vantage point of an individual patient, successful return to gainful employment is not only an economic necessity but also a critical area of resocialization in the community.7 Psychological benefits of employment include group participation, a focus on reality problems, and increased self-confidence derived from successful coping and mastery. Adverse effects of unemployment, in patient and nonpatient populations, are resentment, anger, depression, and loss of self-esteem.8 From the community point of view, vocational rehabilitation of psychiatric patients reduces disability benefit expenditures, diminishes unemployment, returns needed skills to the work place, and counteracts institutionalism, custodial care, and excessive hospital costs. Despite the obvious benefits of vocational rehabilitation, systematic investigations are rare, particularly in a business setting. Most large-scale work-adjustment studies begin with a hospital population and follow the subjects into a variety of industrial settings.8'3 Cole and her co-workers have followed a cohort of employed patients for several years, but
these subjects work in various businesses and industries with diverse personnel policies and rating systems.14-8 By retrospectively analyzing the medical records of a single geographic area for a large business-machine manufacturer we hoped to answer such questions as: 1. What are the success-failure rates for vocational rehabilitation of a psychiatric patient population? 2. How are success rates affected by diagnosis, education, job level, length of service, and referral process?8' 18 3. How well do psychiatric patients perform on the job? Are they contributing fairly to the corporate effort?
From the International Business Machines Corporation, Medical Department, White Plains, NY. Address reprint requests to Dr. David B. Robbins, Medical Department, IBM Corpor., 1000 Westchester Avenue, White Plains, NY 10604. This paper, submitted to the Journal August 8, 1975, was revised and accepted for publication March 23, 1976. Portions of the information in this paper were presented at the American Psychiatric Association Annual Meeting in Hawaii, May 1973.
AJPH, July, 1976, Vol. 66, No. 7
Methods and Material The study is based on an evaluation of employees seen by the consulting psychiatrist at a headquarters location of the IBM Corporation. Since our population consists of divisional and corporate headquarters, it is deficient in entry-level and blue collar positions and skewed toward clerical, administrative, managerial, and professional personnel. The study group consists of all employees seen by the consulting psychiatrist during an 18-month period. The status of these employees was re-evaluated two to three years later. During the study period, approximately 7,500 employees were in the employee population with more turnover in some job categories than others. An on-site industrial medical department supplied occupational medical services to these employees. The consulting psychiatrist was available to the medical department 15 hours per week (three hours per day). 655
ROBBINS, ET AL.
All employees were seen by the same board certified psychiatrist. In addition to his own judgment, the consulting psychiatrist utilized hospital records, consultations with the employees' personal physicians and psychiatrists, and information available in the medical charts. The re-evaluation was based on a review of the medical chart and written performance appraisals by management. An appraisal and counseling session is conducted by management on at least a yearly basis for all employees in accordance with personnel policy. Performance data are derived from written appraisal forms and do not reflect estimates or ratings by the authors. Employees are referred to the consulting psychiatrist in a variety of ways. Employees can request consultation on their own for personal or family problems. Management or the personnel department may request evaluation by the medical department when they suspect a medical problem is affecting performance at work; in this situation the employee is usually first seen by an internist in the medical department. Employees may be seen in the medical department for other reasons (return to work after illness, first aid, etc.) and referred to the consulting psychiatrist after evaluation by the internist. The psychiatrist does not see all employees with psychiatric illness. An employee, in private psychiatric treatment, who is performing adequately would not be referred to the medical department or the consulting psychiatrist. Employees may have problems that can be handled through consultation with the internist in the medical department without psychiatric referral. Some employees will reject psychiatric consultation. All employees are entitled to refuse medical evaluation; their performance appraisal will determine appropriate managerial action. Psychiatric consultation is handled with the same ethical standards as any other medical department visit. The consulting psychiatrist provides an initial evaluation, and makes recommendations to the employee, including referral for treatment, if necessary. Through periodic follow-up visits the consulting psychiatrist acts as liaison between the treating psychiatrist, management, and the patient-employee. If there is no problem with performance at work there is no feedback to management. When illness is impacting job performance or a job is contributing to illness, management is given, on a need-to-know basis, the information and recommendations which will best serve the needs of the employee and the company. The consulting psychiatrist, with rare exceptions, does not provide formal treatment; some exceptions are acute psychiatric episodes at work or psychiatric disease that is almost entirely job-related. Every effort is made to retain the employee with psychiatric disease. The intervention techniques included followup visits and consultations within the medical department, outside treatment largely paid for by the company, and recommendations to management concerning selective job placement and restrictions. Although an employee may be released for nonperformance, company policy precludes release on the basis of a psychiatric diagnosis per se. 656
TABLE 1-Method of Referral by Diagnosis For Employees Seen by Consulting Psychiatrist Means of Referral
SelfReferral
Diagnosis Schizophrenia Manic Depressive Paranoid Psychosis Neuroses Personality Disorders Alcoholism Drug Dependence Heroin Physical Disorders of Psychogenic Origin Stuttering Transient Situational Disturbances No Psychiatric Disease TOTAL
1 4 2 -
Manager or Personnel
7 2 1 18 6 7
1
Medical
Dept.
TOTAL
5 3 21 8 5
12 5 2 43 16 12
2 2
3 2
10
1 6
6
1 22
9 27 (20.0%)
6 54 (40.0%)
2 54 (40.0%)
17 135
Results Population A total of 135 employees, 90 men and 45 women, was seen by the consulting psychiatrist during the study period. This represents a referral rate to the psychiatrist of 1.2 per 100 employees per year. The means of referral by diagnostic category is presented in Table 1. In 54 cases, management or the personnel department were the first to note signs of illness and made the initial referral to the medical department. In an additional 54 cases, referral to the consulting psychiatrist was initiated by a staff internist or nurse. Twenty-seven employees were selfreferrals. Occupations of the 135 employees are presented in Table 2. As some of our patients were referred for multiple, concurrent reasons, we tallied 308 initial complaints as reasons for referral (Table 3). Twenty-four and four-tenths per cent of these were directly connected with performance problems. The 135 employees had a total of 731 visits with the psychiatrist (Figure 1). Twenty-five employees with 11 or more visits accounted for 61. I per cent of all psychiatric visits. The employees in the study group made extensive use of TABLE 2-Occupational Category of Employees Seen by Con-
sulting Psychiatrist
Occupation
Clerical Maintenance & Facility
Computer Operations Professional TOTAL
40 (29.6%) 12 (8.9%) 12 (8.9%) 71 (52.6%) 135
AJPH, July, 1976, Vol. 66, No. 7
PSYCHIATRIC PATIENT AT WORK
per cent) were still with the company (Table 4). This is below
E
NUMBER OF PEOPLE
=
TOTAL PSYCHIATRIC VISITS
180
TABLE 4-Status of 135 Employees at 2-3 Year Follow-up*
160
With Company Outstanding Performance Exceeding Job Requirements Meeting Job Requirements Not Meeting Job Requirements No Recent Appraisal Not With Company Voluntary Resignation Separation by Mutual Agreement Fired Early Retirement Military Leave Educational Leave Total Disability Died In Jail Reason Unknown
140 120
100 80
60 40
20
82 (61.7%) 10 38 25 4 5 51 (38.3%) 14 8 6 5 1
1 13
TOTAL 1
2-5
610
11-15
1620
*Two lost to follow-up
20+
VISITS / PERSON
FIGURE 1-Frequency of Visits to Consulting Psychiatrist
nonpsychiatric medical department services: internist, nurse, x-ray technician, etc. These 135 employees accounted for 17.0 per cent of all medical department visits. Follow-Up The status of the study group was evaluated two to three years after the initial contact. Eighty-two employees (61.7
133
the expected retention rate.* Of these 82 employees still with the company, all but four were meeting the requirements of the job. Management appraisals indicated that 38 employees were exceeding the requirements of the job, and an additional 10 were considered to be outstanding performers. Fiftyone employees had left the company, including 14 who resigned voluntarily for personal reasons, i.e., not separated by management directive. Table 5 shows the retention rate in relation to perform-
TABLE 5-Retention Rate in Relation to Performance at Time of Initial Referral TABLE 3-Initial Reasons for Referral of Employees Seen by
Consulting Psychiatrist
75 (24.4%)
Performance Related Task Performance Attendance and Punctuality Problems with Other Employees Problems with Superior Lacking in Initiative Family Problems Marital Problems Other Family Problems Medical Complaints Depression Hospitalized Because of Problems Anxiety or Tension Acute Psychiatric Episode Physical Complaints Alcoholism Attempted Suicide Drug Abuse Sexual Problems Other
29 26 7 7 6
Failing to Meet Job Requirements Meeting Job Requirements TOTAL REFERRALS
184 (59.7%)
67 38 32 13 13 12 4 3 2
Number
Number Not
w/Company
w/Company
Total
49 (59.0%)
34 (41.0%)
83
33 (66.0%)
17 (34.0%)
50
82(61.7%)
51 (38.3%)
133*
*Two lost to follow-up (p - 0.02 chi square)
32 (10.4%/6)
12 20
ance. At the time of the initial referral, 83 of the employees were failing to meet job requirements. Of these initially unsatisfactory employees, 59.0 per cent were still with the company at the time of the follow-up. Of the employees who were performing adequately at the time of the initial referral, 66.0 per cent were with the company at the time of followup.
17 (5.5%)
TOTAL
AJPH, July, 1976, Vol. 66, No. 7
Performance at Time of Initial Referral
308
*Company retention rates are considered confidential and are not available for publication. 657
ROBBINS, ET AL.
Some of the parameters that might affect retention rate were evaluated for the 83 initially inadequate employees. Thirteen employees out of 19 with psychoses, 22 of 28 with neuroses, and eight of 12 with alocholic problems were still with the company (Table 6). The combination of either a per-
to the consulting psychiatrist (Table 9). This may reflect acceptance of disease and need for therapy. TABLE 9-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Number of Psychiatric Visits Number of Visits
TABLE 6.-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Diagnosis Number
Diagnosis
w/Company
Psychoses Schizophrenia Paranoid State Manic Depressive Neuroses Personality Disorders Alcoholism Drug Abuse (Heroin) Other Personality Disorders Transient Situational Disturbances
13 (68.4%) 8 1 4 22 (78.6%) 12 (48.0%) 8 0 4
2 (18.2%) TOTAL 49 (59.0%)
Number Not w/Company
1-5 Total
19
6 (31.6%) 4 1 1 6 (21.4%) 13 (52.0%) 4 3 6
28 25
9 (81.8%)
11 83
34 (41.0%)
Prognosis for retention improved significantly with length of time with the company (Table 7). A strong relationTABLE 7-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Years With the Company
0-5 6-10 10+ TOTAL
Still
Left
w/Company
Company
16 (41.0%)
13(72.2%) 20 (76.9%) 49 (59.0%)
Total
39 18, 26 83
23 (59.0%) 5 (27.8%)
6-(23.1%) 34 (41.0%)
ship was found between occupational category and retention (Table 8). Retention rate increased with the number of visits TABLE 8-Retention Rate for 83 Initially Unsatisfactory Employees in Relation to Occupational Category
Clerical Maintenance and Facilities Computer Operations Professional
TOTAL (p _ 0.01 chi square)
658
Total
23 (52.3%) 9 (60.0%) 17(70.8%) 49 (59.0%)
21 (47.7%) 6 (40.0%) 7(29.2%) 34 (41.0%)
44 15 24 83
Discussion In an effort to answer several basic questions about the work adjustment of employees with psychiatric problems, we retrospectively studied the medical and personnel records of 90 men and 45 women. In this phase of our study, control groups were not employed and data on comparable nonpatient population were not available to us. All functional diagnostic categories are represented in our population. The distribution of diagnosis is skewed toward neuroses and personality disorders reflecting the young age of our population and work demands which exclude the
chronically incapacitated. Most of our patients work in headquarters locations for large corporate divisions. The population at risk has an unusually large number of managers, professionals, and clerical employees. Our study group reflects this demographic bias and, in terms of job levels, is not strictly comparable to the cohorts investigated by Cole,14-'7 Brown,9 and others. We were impressed with our follow-up data, especially job appraisals and retention. Retention rates of identified psychiatric patients vary considerably with different reported series,8 from a low of 23.0 per cent13 to a high of 91.0 per cent. 16
*Five left by early retirement (p - 0.001 chi square)
Occupation
TOTAL
Not w/Company
(p s 0.01 chi square)
sonality disorder, or transient situational disturbance with poor performance carried a grave prognosis.
Years w/Company
6-10 11+
Still w/Company
Still
Not
w/Company
w/Company
Total
8 (40.0%) 2 (33.0%)
12 (60.0%) 4 (67.0%)
20 6
3 (37.5%) 36 (73.4%) 49 (59.0%)
5 (62.5%) 13 (26.6%) 34 (41.0%)
8 49 83
The least favorable retention prognoses were associated with drug dependence, personality disorders, and transient situation disturbances. Other diagnostic groups performed well, particularly the psychoneuroses; a finding which is in agreement with the Utah studies.14-'7 The retention rate is somewhat better for those patients who were meeting job requirements at the time of the initial referral (66.0 per cent versus 59.0 per cent). Failure to meet job requirements usually leads to a formal appraisal, a period ofclose observation, and, if performance does not improve, separation from the company. Therefore, most of the 83 patients who were not initially meeting job requirements would have been separated from the business if extensive intervention by management, medical and personnel departments had not been available. We think this study supports an optimistic approach to psychiatric rehabilitation and occupational mental health. Psychiatric consultation in an industrial medical department provides a genuine opportunity for tertiary and secondary prevention. With Powles19 and other occupational mental AJPH, July, 1976, Vol. 66, No. 7
PSYCHIATRIC PATIENT AT WORK
health workers, we believe that secondary prevention is an important function for an industrial medical department. As communication with management continues to develop, primary prevention should become increasingly feasible. We have shown that most patients can continue to work effectively, and some can perform at a superior level. Further research is under consideration, including the use of control groups, prospective studies, and an enlarged population to allow for more refined statistical investigations.
9. 10.
11. 12.
13.
REFERENCES 1. Editorial: The decline of industrial psychiatry. Psychol Med 3:405-10, 1973. 2. Cohen, R. R. Preventive industrial psychiatry. J Occup Med
3. 4.
5. 6. 7.
8.
11:674-677, 1969. Longaker, W. D. The fulltime psychiatrist in industry. J Occup Med 14:216-219, 1972. Cole, N. J. Psychiatrists, employees, and information exchange. Arch Gen Psychiat 25:381-384, 1971. Modlin, H. C. The occupational physician and the psychiatrist. JAMA 226:50-55, 1973. Erskine, J. F. Report on a two year experiment in cooperation between an occupational physician and a consultant psychiatrist. Trans Soc Occup Med 21:53-56, 1971. Simmons, 0. G. Work and mental illness. Eight case studies. New York, Wiley, 1965. Veterans Administration: Restoration of the mentally ill to the world of work-a critical survey of vocational rehabilitation of
14. 15. 16.
17. 18. 19.
the psychiatric patient. Background Paper 61-1, Psychiatric Evaluation Project, Washington, DC, 1961. Brown, G. W., Bone, M., Daltson, B., et al. Schizophrenia and social care. London, Oxford University Press, 1966. Rennie, T. A. C., Burling, T., Woodward, L. Vocational rehabilitation of psychiatric patients. N.Y., Commonwealth Fund, 1950. Schooler, N. R., Goldberg, S. C., Boothe, H., et al. One-year after discharge. Community adjustment of schizophrenic patients. Amer J Psychiat 123:986-995, 1967. Cooperman, I. G., Sonne, T. R. The employment adjustment of veterans with histories of psychosis and psychoneurosis. Dept. of Veterans Benefits, Veterans Administration, Washington, DC, Technical Report TR 22-1, 1963. Walker, R., McCourt, J. Employment experience among 200 schizophrenic patients in hospital and after discahrge. Amer J Psych 122:316, 1963. Cole, N. J., Shupe, D. R., Allison, R. B. Work performance ratings of former psychiatric patients. J Occup Med 8:1-4, 1966. Cole, N. J., et al. A comparative study of the work performance ratings of former psychiatric patients and their controls. Hosp Comm Psychiat 17:175-178,1966. Cole, N. J., McDonald, B. W., Jr., Branch, C. H. A two-year follow-up study of the work performance of former psychiatric patients. Amer J Psychiat 124:1070-1075, 1968. Cole, N. J., Shupe, D. R. A four-year follow-up of former psychiatric patients in industry. Arch Gen Psychiat 22:222-229, 1970. Shupe, D. R., Cole, N. J., Allison, R. B. Specific characteristics of work performance related to psychiatric diagnosis. Hosp Comm Psychiat 17:178-180, 1966. Powles, W. E., Winslow, W. W., Rubin, E. E., et al. Motivation problems related to secondary prevention in industrial mental health. Amer J Psychiat 123:297-302, 1966.
STATISTICAL METHODS COURSE OFFERED BY GEORGIA INSTITUTE OF TECHNOLOGY A two week continuing education program in Statistical Methods will be offered by the Georgia Institute of Technology, July 12-23, 1976. Topics to be covered include statistical estimation, decisions from statistical data, the design of statistical studies and experiments, analysis of variance, regression techniques, graphical tools, survey sampling techniques, and a number of related and supporting topics. The course has been designed for those in industry, business and government who need a working knowledge of statistical methods. Assumptions underlying the methods presented will be carefully explained, and an emphasis will be placed upon the systematic approach to formulating and analyzing statistical problems. Problem and discussion sessions provide an opportunity to apply the methods presented to a variety of selected problems taken from industrial, business, and government settings; and participants will use a time-shared computer system to solve a variety of these problems. The fee for the course is $475. A background which includes algebra is required for all participants. Inquiries should be directed to the Department of Continuing Education, Georgia Institute of Technology, Atlanta, Georgia 30332. Telephone: (404) 894-2400.
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