A systematic review of work accommodations for people with mental disorders

1Introduction

A mental disorder may affect various aspects of an individual’s life, and may hinder the capacity to maintain self-efficacy by creating barriers to achieve goals, perform to societal expectations, and engage in adaptive coping due to functional limitations [1]. This may impede individuals with common mental disorders (e.g., major depressive disorder, anxiety disorders) and severe persistent mental disorders (e.g., schizophrenia, schizoaffective disorders) from maintaining long-term competitive employment. Individuals with psychiatric disabilities are more likely to be unemployed [2]. This is further compounded by stigmatization that individuals with a psychiatric disability experience, resulting in further social and economic marginalization [2]. Poor employment outcomes in individuals with a psychiatric disability have major economic implications and result in a loss of approximately 0.3% to 0.8% in national earnings [3].

Individuals with a mental disorder may experience a wide variety of functional barriers or limitations to meet employment expectations and tasks. Some of these limitations may include impairments in attention, executive function, and communication [4]. Work accommodations are modifications to either the physical work space or procedures and policies that enable individuals with disabilities to be successful in any working environment (e.g., office, home) [5]. In comparison to a physical disability where often a structural modification may be needed (e.g., physical work space modifications), individuals with a psychiatric disability may instead require organizational modifications (e.g., scheduling flexibility, job description modifications) [5]. Individuals with a mental disorder experience a variety of functional limitations that may be similar to those associated with physical disabilities (e.g., psychomotor slowing in depression). Therefore, it is possible that positive outcomes seen in work accommodations for individuals with physical disabilities can be translated to individuals with a psychiatric disability [6].

Many countries have legislation that protects the rights of individuals with disabilities in work places and prohibits discrimination – which includes discrimination based on physical or psychiatric disability [7]. Such legislation requires employers to provide accommodations to employees and may include a variety of adjustments such as changes in working hours or environmental modifications [8]. Despite legislation, employers may be reluctant in providing these accommodations due to limited understanding of such modifications, feasibility concerns and legal uncertainty. Additionally, the fear of further stigmatization from employers may reduce disclosure of disability and further result in a lack of support and accommodations, perpetuating lack of employment [9].

There has been limited research conducted regarding the categorization of employee and employer-level interventions, which include accommodations that can lead to positive employment outcomes [10]. A scoping review on this topic by McDowell and Fossey (2015) [11], determined the size and scope of the available literature on the matter. Further important questions have yet to be investigated as there continues to be a great deal of fragmentation in the characterization of how work accommodations for individuals with psychiatric disabilities are described and the associated outcomes of their implementation. There is little understanding surrounding the frequency with which these accommodations are implemented and utilized. Increasing knowledge and understanding of work accommodations is important as individuals with psychiatric disabilities experience poor employment outcomes.

The aim of this systematic review is to addresses the following questions:

We hypothesize that work accommodations that are made available and that are provided to address mental disorder related impairments will reduce limitations faced by these individuals. By providing accommodations, there will be an increase in the number of hours worked by the employee, longer job tenure, and ultimately benefit the employee with an increased income, as well as a decrease in overall costs to employers.

2Methods

This systematic review utilized a standard and consistent methodology to selectively screen and analyze current literature and data to arrive at a conclusion [12]. The literature was screened to identify relevant articles - as defined by the inclusion criteria outlined in Table 1- that provided current information on work accommodations and their respective outcomes. Searches were conducted via PsychINFO, MEDLINE, EMBASE, and CINAHL to find relevant articles within the span of 26 years from 1990 to 2016. The search terms and strategy used in the databases are outlined in Table 2. In addition to keywords, subject headings were also included in the database search. Subject headings included: mental disorders or psychiatric disability or mental health and job accommodation when utilizable with the relevant database.

For this review, work accommodations are defined as modifications within any working environment (e.g., office, home) that relate to employment outcomes. These may include social (e.g., communication, presentations) and organizational (e.g., work duties, scheduling) adjustments. Cost-effectiveness and cost-benefits are categorized by both direct and indirect costs, with cost-benefit being the monetary value associated with work accommodations and cost-effectiveness being the overall financial analysis of these accommodations on the employers, employees, and the society as a whole. Direct costs are defined as costs associated with the implementation of the accommodation (e.g., startup cost) and indirect costs are defined as the downstream and overhead costs associated with the accommodation (e.g., extra supervisory hours, maintenance fees) [13].

The first author conducted the search through multiple databases. The first and second authors screened the article in terms of the inclusion/exclusion criteria based on the title and abstracts. Articles that outlined the classification, frequency and cost-benefits of work accommodations for individuals with a mental disorder were included. In order to elucidate the direct and indirect costs associated with work accommodations, the keywords “cost” and “effectiveness” were included in a preliminary search; however due to lack of results, these specific terms were not used in the final search. To ensure that no relevant studies were missed within the literature both backward and forwards searches were conducted on all included studies.

3Results

Of the 1362 eligible studies, 59 studies were selected for full review. Figure 1 outlines the review process. Of the 59 studies reviewed, 14 were included. One study was included from the forward and backward search of included studies after full-text review. This resulted in a total of 15 studies included in the final review. The primary reasons for the exclusions of studies was secondary to not being an empirical study, or not discussing specific work accommodations and related outcomes.

Fig. 1

PRISMA Flow diagram.

The majority of studies included (n = 9) were conducted in the USA. Three studies were conducted in Canada, 1 was conducted in the UK, and 1 was conducted in Australia. In addition, there was 1 international collaborative study from Italy, Australia and Canada. The majority of the studies were quantitative (n = 12). There were no experimental studies. The studies mainly employed the use of surveys, self-administered questionnaires, and structured/semi-structured interviews to gather data. Eleven studies discussed various types of accommodations available and the specific accommodations that were provided, as well as effects on employment outcomes. Eleven studies included participants with a severe and persistent mental disorder, 3 with common mental disorders, and 1 with bipolar disorders. Four studies discussed both the direct and indirect costs associated with work accommodations.

4Discussion

This review systematically identified work accommodations that are available and provided to individuals with mental disorders. Furthermore, this review outlined both the outcomes and the associated costs of these accommodations. Overall, there are positive outcomes associated with work accommodations for individuals with mental disorder related impairments across diagnoses and employment contexts.

With regards to employment outcomes, our hypothesis - that work accommodations provided will address mental disorder by mitigating functional limitations - was supported, as various studies demonstrated a positive relationship between accommodations and length of job tenure, and reduced course of certain mental conditions such as anxiety and/or mood disorders [15]. Moreover, positive impacts of work accommodations on employment outcomes were demonstrated, as accommodations were shown to be associated with a longer job tenure between 7–24 months of when compared to individuals receiving no accommodations [14, 25]. Work accommodations assisted in facilitating a favorable work environment such as ensuring a manageable workload, flexibility in hours, and support from supervisors and coworkers. These accommodations contributed in reducing job-related stress which may be associated with the prevalence of some disorders such as depression and anxiety-related disorders [15]. Individuals who do not receive accommodations may experience disruptions in employment which may result in a decrease of social support, financial stress, and worsening of symptoms [15].

There is no “one size fits all” arrangement with respect to work accommodations, and not all accommodations may benefit all individuals in the same way. In this review, accommodations were categorized into the following categories: 1) Communication Facilitation 2) Flexible Scheduling 3) Job Description and 4) Physical Space and 5) Other. None of the studies included in this review provided a comprehensive list of all potential accommodations that may be provided to individuals with mental disorders, however two studies [14, 18] numerically identified 231 and 322 accommodations respectively, but did not provide a comprehensive list of what these were. Of the studies, which outlined specific accommodations, the most common accommodations were communication facilitation and scheduling flexibility related accommodations [5, 17, 22, 24], while physical modifications accommodations were the least common.

Despite their apparent benefits, findings from the studies demonstrated that work accommodations are not frequently implemented. This can be attributed to lack of exposure to and knowledge surrounding mental health issues. Employment supervisors with adequate mental health training, and previous experience working with employees with mental disorders, were more likely to offer accommodations [19]. Furthermore, there may be a lack of awareness among both employers and employees of the legislatively-mandated right to reasonable work accommodations. The perceived adverse repercussions of disclosure of a mental disorder, may reduce the likelihood of accommodation [16]. Adequate education of the importance and rights to receive work accommodations is essential to improve the understanding of the legislations among supervisors and employees. Job coaches and vocational rehabilitation specialists can assist clients by providing education surrounding rights related to the disclosure of the mental disorder and the negotiation of obtaining reasonable accommodations under relevant legislation.

A barrier to implementation of work accommodations from the perspective of employers may include the perceived costs of implementing such accommodations. However, the studies which looked at costs associated with accommodations demonstrated minimal costs and lead to potential of downstream savings [27]. Work accommodations may have the potential to provide government savings in several hundred million dollars in SSI expenditure [28]. With respect to direct costs, they were minimal or otherwise nil [17]. Indirect costs were in the form of additional supervision or frequent breaks. Extra supervisory hours can potentially have a “hidden” cost associated with them and may become a significant expenditure for smaller companies [14]. Overall, the majority of direct and indirect costs associated with work accommodations are minimal, and have the potential to provide economic benefits for both employers and employees.

The limitations of specific studies included in the review mainly centered around their generalizability to the greater population. The included study samples were heterogeneous as (and participating) individuals had diverse diagnoses across a wide variety of employment contexts. There was only a single study [19] that investigated the relationship between functional limitations and work accommodations. This limited the generalizability of overall findings. Additional limitations included the fact that many of the studies had small sample sizes and non-random samples. In addition, 8 studies relied on self-reporting which may have led to a reporting bias. There were no randomized controlled trial studies as the studies were predominantly observational studies. This limited the ability for discussion on causality. Furthermore, only English language studies, published between the years 1990–2016, were eligible for inclusion, which may have further limited the data collected for this review.

5Conclusion

Work accommodations facilitate environments where individuals with a mental disorder (or disorders) can meet employment expectations and perform required responsibilities. A wide variety of accommodations may be provided with generally positive outcomes and minimal cost across different work contexts, for individuals with a variety of diagnoses. For increased implementation of accommodations, further education surrounding relevant legislation (jurisdiction specific), the minimal costs associated with accommodation, potential economic benefits, and guidance on how to implement accommodations will be beneficial.

While studies have demonstrated positive employment outcomes for individuals with a mental disorder, further research is important to better understand challenges that may exist in accessing these interventions. Considering the heterogeneity in the sample from a diagnostic perspective, focusing on functional limitations which may occur across a wide range of diagnostic categories may be important. Further research looking at which accommodations specifically benefit individuals with certain limitations may be important for future interventions and education in the work place.

Challenges surrounding disclosure in the work environment and stigma play an important role obtaining accommodations within the work place. Future studies should examine the relation between stigma, disclosure and accommodation as this may be an important area for further education initiatives and interventions. In addition, further research is needed to formally and systematically examine the cost benefit and cost-effectiveness of work accommodations. Further high-quality evidence can assist in increasing implementation of accommodations by employers, tenure of employment and work satisfaction of people with mental disorders.

Conflict of interest

None to report.