Featured article from DMEC: Exploring Cognitive Demand Data to Help Prevent Mental Health Reinjury

By Kerri Wizner, MPH, CPH, Head of Epidemiology, MDGuidelines; Ted Norwood, JD, Integrated Benefits Inc.; Lucy Shannon, Head of Content and Research, MDGuidelines

Full article here: https://dmec.org/resources/work-magazine/return-to-work-durations-by-generation/

Publication date: January, 2025

When an employee returns to work after a mental health leave, how can employers help prevent reinjury, much like they would protect someone from physical reinjury? The first step is to identify the cause of the leave from a holistic perspective, a process that should include cognitive demand assessments of the work. Taking a holistic approach that includes physical as well as mental demands can help with mental health case management and lay a foundation for the evaluation of future job success.

When designing and tailoring return-to-work (RTW) plans for employees, clinicians and case managers should consider the mental (as well as physical) pressures of a job. Assessing cognitive demand — the mental capacity to focus, comprehend, and problem-solve — is an effective way to evaluate the skills needed for success at work. Cognitive demand includes idea generation, decision-making, and planning. And while physical demand remains the cornerstone of managing most injury and illness cases, cognitive demands also affect RTW and should be part of conversations about recovery with employees. It is increasingly important for the industry to find new ways to measure success in the workplace with increased incidence rates and costs related to poor mental health.^1,2

Here’s an example: A project manager is returning to work after a major depressive disorder that prompted a leave of absence. After exchanging a few emails, you feel confident the employee is ready to come back to work. You have set up a temporary accommodation for a gradual RTW schedule that allows flexibility for continued treatment and the ability to work from home occasionally, as outlined in clinical practice guidelines.³ However, you know this person is returning to a high-pressure work environment with strict deadlines. How can you protect the employee from mental reinjury?

Measuring Cognitive Demand

First, you need information about the cognitive tasks that the job requires. For example, determine how much time the employee spends generating new ideas, interacting with others, and planning. Jobs vary in terms of cognitive effort required to accomplish tasks. Research indicates that high cognitive demand is associated with higher rates of fatigue.⁴

Second, which tasks are mentally draining, which tasks require the most focused time, and which hurdles may affect the employee’s ability to do the job? This information, plus any provider restrictions, can help support a successful RTW experience.

Unfortunately, there are limited generalized measurements for occupational cognitive demand. For physical demand, employers often refer to the Department of Labor (DOL) Dictionary of Occupational Titles (DOT) definitions for sedentary, light, medium, heavy, and very heavy work, which are based on a job’s standing, lifting, and walking requirements. The DOT was last updated in 1991, though many entries date back to the 1970s. It describes nonexertional work requirements with a ranking for reasoning, language, and mathematics development. While the U.S. Social Security Administration continues to rely on it, many believe the DOT to be obsolete, which is why employers must look to research for guidance.

The DOL and other groups developed the Occupational Information Network (O*NET) to replace the DOT. It uses national data and surveys to provide job-specific variables, including cognitive demand. The O*NET divides cognitive abilities into seven categories with 21 subcategories that have a score of 0 to 100 for the level of ability required and its importance.⁵

This dataset outlines verbal abilities that include a subcategory of oral comprehension. For example, the “pediatricians, general” job category has a score of 71 for oral comprehension and 100 for importance. Job categories with lower scores for oral comprehension and its importance include dishwashers and sewing machine operators.

Knowing what is required for job success can help case managers find appropriate accommodations for an employee’s work. Classification systems such as the O*NET provide a foundation for evaluating how employers can adjust RTW plans as employees recover. But even with thoughtful, generalized assessments, positions often have specific factors that employers need to consider. For example, the O*NET’s structure does not explicitly consider emotional strengths or requirements such as motivation, adaptability, or political awareness.

Data Collection

It is possible to collect information from employees about cognitive demand. Researchers have created employee forms that can help to determine how job stress and mental demand may affect a person. Survey tools, such as cognitive task analyses, use interviews and observations to describe the thought processes needed to perform complex tasks. These tools may include scales for employees to rate their structure for work tasks, time planning, and coordination with others. However, there is no single best tool, and since these surveys should be completed before an injury or illness occurs, much of this work still exists in the research realm.^6,7

While the field of cognitive demand evolves, employers and insurers must be creative and flexible with employees returning to work after a mental or physical health-related leave by implementing an iterative and ongoing accommodation process required by the Americans with Disabilities Act.⁸

Including data about cognitive and physical demands in case management workflows can be beneficial for setting expectations for RTW and evaluating barriers to recovery if a case duration exceeds expectation. This data can also be helpful during an evaluation after a claim is closed. Other information about workflows to consider including:

• -Job description data so job demands can be viewed by anyone discussing RTW with an employee;
• -Risk scores based on data that summarizes a job’s cognitive demands to help design and prompt questions for case managers and different accommodation ideas for employers; and
• -Adjusted algorithms for RTW by cognitive demand requirements.

An example of applying this step in the real world is to create a cognitive work hardening program. A Canadian study⁹ describes a structured program in which an interview identifies barriers to going back to work after a mental health leave and an occupational therapist helps the employee reconnect to predisability work tasks. In this example, an employee who was two years into a depression disability was able to resume work after four weeks in the program.

Accommodations

There are many resources for defining mental health accommodations. For example, accommodations to support cognitive demand for an individual returning from leave with major depressive disorder might include, but should not be limited to, a graduated RTW plan, flexible scheduling, gradual reintroduction to stressful tasks with supervision, periodic breaks from tasks/workstation, tools or strategies to augment memory, task/organization lists and written instructions, physical activity, and positive feedback.¹⁰ Research has shown that returning to work after an episodic disorder like brain fog was often predicated on job accommodations and support.

Additional information about job tasks that are mentally taxing can support leave management professionals in tailoring accommodation suggestions. It could also help prioritize the list of appropriate resources.¹¹ For example, if several managers are out on mental health leaves and part of their job is to remember and manage everyone’s work tasks, an online tool that helps organize notes could support memory issues. This tool could be purchased and available for any manager interested so it helps all employees and especially those who seek accommodation for memory recall.

In addition to considering tasks that add strain, employers should reflect on the role of workplace culture when assessing cognitive demands. A survey of remote workers in France found that management had a major impact on mental health. Leaders who had excessive cognitive requests and forced the use of technology at all hours reduced workers’ independence to the point of exhaustion.¹²

An organization should be aware of its workplace culture and how it influences disability leaves.¹³ The more information employers have, the greater the potential for addressing issues and building the type of infrastructure that helps employees stay at work when they are able and encourages them to return to work as soon as they are able. This type of holistic approach benefits all employees.

References

1. World Economic Forum. Future of Jobs Report. 2023. Retrieved from https://www.weforum.org/publications/the-future-of-jobs-report-2023/digest/
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5. O*NET. 2023. Retrieved from https://www.onetcenter.org/
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10. Stelson E, Dash D, McCorkell L, et al. Return-to-Work with Long COVID: An Episodic Disability and Total Worker Health Analysis. Social Sci Med. 2023; 338.
11. Major Depressive Disorder. MDGuidelines. Retrieved from https://app.mdguidelines.com/health-advisor/mda/depression-major
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13. Dolce V, Vayre E, Molino M, et al. Far Away, So Close? The Role of Destructive Leadership in the Job Demands — Resources and Recovery Model in Emergency Telework. Social Sciences. 2020; 9(11).