Sick leave and work absence Part 2 Returning to work after prolonged sickness absence a psychiatrists perspective





C Grobler


Nelson Mandela Metropolitan University, Faculty of Health Sciences; Consultant Psychiatrist at Elizabeth Donkin Hospital, Port Elizabeth, South Africa


Correspondence: Prof. Christoffel Grobler, Elizabeth Donkin Hospital, Forrest Hill Drive, Port Elizabeth, 6001, South Africa. e-mail:

Keywords: psychology of working, work ability, return to work, sickness absence, impairment, disability


Work is an integral part of modern life, and employment is the means of obtaining economic resources that are essential for material gain and participation in society.1 Work gives life meaning for most individuals and provides income for life’s necessities – food, shelter, clothing and medical care.2 Working is also intimately linked to our evolutionary past, as our survival was dependent on our ability to locate food, find shelter, and develop a community for mutual support.3 Loss of work, on the other hand, has been linked to problems such as interpersonal conflict, reduced self-esteem, substance abuse, and other mental health problems.4

Due to the fact that many healthcare professionals, including the treating psychiatrist, believe that it is their duty to advocate on behalf of the patient, it is the experience of the author that they avoid discussing the benefits of returning to work with their patients. Usually, the reason for this is that the workplace may have been a contributing factor to the patient’s mental illness; hence the discussion is avoided. This paper will address the barriers to returning to work as well as assessment of work ability. Workplace interventions will be addressed in a follow-up paper.

There is a growing body of research demonstrating the harmful effects to health following prolonged certified work absence.5 Doctors need to take cognisance of their roles in managing problems associated with sickness certification, considering present-day findings about the benefits of work.1 Many doctors appear to be unaware of the potential harm that medically-excused prolonged time off work can cause.6 Recovery is said to be faster and more successful if people can do some work while recovering.5

Longitudinal studies reveal that, once a person commences certified work absence, they commonly start sliding down a slippery slope that leads to long-term ‘worklessness’, as work absence tends to perpetuate itself. In other words, the longer someone is off work, the less likely it becomes that they will ever return.7 According to the American Medical Association (AMA) Guides to the Evaluation of Work Ability and Return to Work, 50% of people out of work for eight weeks will not return to work, and 85% of people out of work for six months or more will never return to work on a sustained basis.2

The effects of work absence, according to Dunstan,8 are a progressive deterioration in physical and psychological health, a six-fold increase in the rate of suicide, interpersonal relationship problems, loss of identity and self-worth, financial hardship, and a general erosion of quality of life. In their review, Waddel and Burton1 found unemployment to be associated with increased rates of overall mortality and, specifically, increased mortality from cardiovascular disease and suicide; poorer physical health; lung cancer; susceptibility to respiratory infections; higher rates of medical consultation; medication consumption and hospital admission; poorer mental health; and psychological wellbeing and disability. In a sense, one can equate long-term worklessness with a slow and painful death.

Being booked off for sick leave could, in some cases, lead to temporary impairment which would mean that the person is unable to work for a period of time, usually three to six months. It is around this time that insurance cover will become an issue if the person or their employer has taken out insurance for such an eventuality. The treating doctor may then be called upon to submit reports to the insurance company and therefore needs to be proficient in the ability to assess work ability and impairment objectively.



There appears to be a common, naïve belief amongst South African psychiatrists that being away from work will, in itself, ‘allow the medication to work and the patient to heal’ in an atmosphere of reduced stress.6

Studies have shown that older doctors and those consulting at a higher rate per hour issue more certificates, and doctors with high levels of postgraduate training issue fewer certificates.9

The doctor’s ability to give quality advice to patients, regarding fitness for work, is largely dependent on their skills in managing the clinical areas involved, and in addressing the relevant occupational factors.5,10 There are several factors that doctors should consider when advising patients on fitness for work.11 These factors, together with the skills required, are listed in Table 1.


Table 1. Clinical knowledge and skills relevant to sickness certification



It is not uncommon for patients, after being booked off for some time, to be faced with obstacles to returning to work.12 These include:

•  Stigma and discrimination by employers and the public: disabled people regularly put employers’ negative attitudes high on their lists of barriers to working. This is particularly the case for people with mental health problems.13

•  The benefits trap: disabled people may be reluctant to return to work and give up their benefits in case they cannot manage in their ‘old’ job. Disabled people also report difficulty with accessing appropriate information about in-work benefits.5

•  Loss of motivation, confidence and skills: keeping motivation, self-confidence and self-belief are all factors considered to be important indicators of staying employed. In this context, relatives’ and friends’ attitudes and expectations are also important.14



In the preface to the first edition of the AMA Guides to the Evaluation of Work Ability and Return to Work, the editor, James Talmage, makes the following pertinent points about return to work after sick leave:2

“The healthcare provider is often looked to by other parties for guidance with regard to approaches to return to work. However, it is not a subject about which physicians receive extensive training in their medical education. Patients, employers, and disability insurers believe physicians have the necessary knowledge and experience to answer disability certification questions scientifically, not realising that few physicians actually have had any formal training in such certification.

The editors and authors of this handbook have a firm belief, supported by science and consensus, that work is good for man and that it is the physician’s role to encourage work and return to work as part of treatment.”

The American College of Occupational and Environmental Medicine, the American Academy of Orthopaedic Surgeons, and the Canadian Medical Association strongly recommend that physicians return patients to their usual work roles as soon as possible.2 A similar view is taken by the AMA, encouraging physicians to advise their patients to “return to work at the earliest date compatible with health and safety” and, through the care of the physician involved, facilitate a patient’s return to work.15

Fitness for work is a dynamic concept because of the changing nature of two variables, namely work and health conditions. Therefore knowledge of both is required.16

There are three matters to consider when a doctor is asked about a patient’s ability to return to work, viz. risk, capacity and tolerance. Risk refers to the chance of harm to the patient, co-workers or the general public if the patient engages in specific work activities. Capacity refers to concepts such as strength, flexibility and endurance, and is measurable with a fair degree of scientific precision. Tolerance, however, is a psychological concept. It is the ability to tolerate sustained work or activity at a given level. The patient might have the ability to perform a certain task but not the ability to do it comfortably, hence tolerance is not scientifically measurable or verifiable.2 The employer also has a responsibility to provide reasonable accommodative measures in cases where the employee is still impaired, upon returning to work.17,18

In terms of assessing work ability, the AMA Guides2 suggest using an organised approach, asking the following questions:

1. What is the job in question?

2. What is the patient’s medical problem?

3. Is there significant risk of harm with work activity?

4. Is the patient physically able to do the job?

5. Does the patient have the ability to do their work at an acceptable risk?

6. Does the patient want to work?

7. Can the patient tolerate the work, considering the side effects of the medication, e.g. sedation or poor concentration and cognitive problems related to the mental illness?

Physicians assessing a patient for return to work should be aware of the important supporting role occupational therapists can play in the decision-making process through functional capacity assessments (FCAs), specifically. FCA is a method for assessing the residual capacity of the injured worker for return to work. The process usually involves an assessment of the match between the demands of the worker’s job or workplace and the residual functional capacity of the worker, the results of which guide interventions to address any mismatch.19



In the United Kingdom, general practitioners (GPs) often feel that managing work and health issues per se goes beyond their role. Research has identified four main factors that influence GPs in their attitudes to the management of return-to-work issues: the doctor-patient relationship, patient advocacy, pressure on consultation time, and limited occupational health expertise.20 In South Africa, no literature currently exists regarding this issue amongst psychiatrists. However, in conversations with fellow psychiatrists, the author believes the same to be true for them.

A qualitative study by Cohen in 2009 explored GPs’ perceptions of the management of individuals in receipt of long-term incapacity benefits.21 There was consensus among participants that the management of long-term worklessness was not the GP’s role. GPs did not feel that discussion about work-related issues with their patients was of high importance, or their responsibility and, as a consequence, did not routinely enquire about work or attitudes about returning to employment. Some GPs felt that having a return-to-work discussion with a patient already on temporary or permanent disability was not their responsibility as they were not the ones who had said that the person was incapable of working. Others said that they avoided having the discussion altogether.

Some doctors said they were aware of the physical and psychological effects of long-term worklessness and had a responsibility to address these issues in the consultation, but felt limited in what they could achieve.21 There was clear agreement among participants that negotiation with patients about return to employment was not easy, and a number of participants described feeling uncomfortable about raising the subject of work. They believed that patients often did not want to discuss employment with their doctors. Patients expected GPs to be their allies and to support their claims for insurance benefits without challenging them. It was agreed that GPs lacked training about the health effects of worklessness.21 There is no reason to believe that GPs in South Africa feel any differently about these matters.



It is imperative that the medical community in general, and the occupational health fraternity in particular, shows leadership on the issue of return to work after sick leave. There is some work to be done to make other medical practitioners and those in the allied health professions, e.g. psychologists and occupational therapists, aware of the need to adopt a disability prevention model of thinking, and increase awareness of how rarely permanent disability should be the outcome.

The assumptions that absence from work is medically required, and that only correct medical diagnosis and treatment can reduce disability, are incorrect. It is clear that prolonged time away from work is harmful to the individual. Patients’ expectations need to be managed and occupational therapists should be engaged early in the process of extended sick leave certification.



1.Waddell G, Burton K. Is work good for your health and wellbeing? London: The Stationary Office; 2006. p 257. Available from: (accessed 23 Apr 2018).

2.Talmage J, Melhorn J, Hyman M, editors. AMA guides to the evaluation of work ability and return to work. Second edition. Chicago: American Medical Association; 2011.

3.Blustein DL, Kenna AC, Gill N, DeVoy JE. The psychology of working:  a new framework for counseling practice and public policy. Career Dev Q. 2008; 56: 294-309.

4.Blustein DL. The role of work in psychological health and well-being: a conceptual, historical, and public policy perspective. Am Psychol. 2008; 63(4): 228-240.

5.Sawney P. Current issues in fitness for work certification. Br J Gen Pract. 2002; 52 (476): 217-222.

6.Ewart Smith ME. Work phobia and sickness leave certificates. Afr J Psychiatry. 2009; 12(4):249-253.

7.Johnson D, Fry T. Factors affecting return to work after Injury: a study for the Victorian Work Cover Authority. 2002; (3):1-64.

8.Dunstan DA. Are sickness certificates doing our patients harm? Aust Fam Physician. 2009; 38:61-63.

9.Tellnes G, Sandvik L, Moum T. Inter-doctor variation in sickness certification. Scand J Prim Health Care. 1990; 8(1):45-52.

10. Foley M, Thorley K, Van Hout MC. Assessing fitness for work: GPs judgment making. Eur J Gen Pract. 2013; 19(4):230-236.

11.Blackwell B. Sick role susceptibility – A commentary on the contemporary data base (1989-1991) and classification system. Psychother Psychosom. 1992; 58:79-90.

12.Olney MF, Lyle C. The benefits trap: barriers to employment experienced by SSA beneficiaries. Rehabil Couns Bull. 2011; 54(4):197-209.

13.Lelliott P, Tulloch S, Boardman J, Harvey S, Henderson M, Knapp M. Mental health and work. United Kingdom: Royal College of Psychiatrists; 2008. p 64.

14.Secker J, Grove B, Seebohm P. Challenging barriers to employment, training and education for mental health service users: the service user’s perspective. J Ment Health. 2001; 10(4):395-404.

15.Rondinelli R, Genovese E, Katz R, Mayer T, Mueller K, Ranavaya M, editors. Guides to the evaluation of permanent impairment. Sixth edition. Chicago: American Medical Association; 2008.

16.Serra C, Rodriguez MC, Delclos GL, Plana M, Gómez López LI, Benavides FG. Criteria and methods used for the assessment of fitness for work: a systematic review. Occup Environ Med. 2007; 64(5):304-312.

17.South Africa. Department of Labour. The Employment Equity Act, 1998 (Act No. 55 of 1998): Pretoria: Government Gazette; 1998.

18.South Africa. Department of Labour. Employment Equity Act, 1998 (Act No. 55 of 1998): Code of Good Practice: Key aspects on the employment of people with disabilities. Pretoria: Government Gazette; 1998.

19.Gibson L, Strong J. A conceptual framework of functional capacity evaluation for occupational therapy in work rehabilitation. Aust Occup Ther J. 2003; 50(2):64-71.

20.Hussey S, Hoddinott P, Wilson P, Dowell J, Barbour R. Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland. Brit Med J. 2004; 328:88.

21.Cohen DA, Aylward M, Rollnick S. Inside the fitness for work consultation: a qualitative study. Occup Med (Lond). 2009; 59(5):347-352.

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