Editorial
Mental Health Care and the Workplace
Dan Bilsker, PhD1
There is increasing concern about the interaction between mental health problems and the workplace—the effect of mental disorders on functioning in the workplace and, conversely, the effect of workplace factors on the occurrence of mental disorders.
Such common mental disorders as depression and anxiety are among the most frequent causes of occupational disability. Because of its early onset and frequently chronic or recurrent nature, depression is the fastest-rising source of disability and the leading source of disabled days lived for adults (1). Substantial costs are associated with depressive disorders in the form of reduced worker productivity, absenteeism, and disability (2,3). Depression accounts for a steadily increasing proportion of short- and long-term disability claims (4). A recent, rather startling statistic is that “the average duration of an active long-term disability claim for depression among healthcare workers in British Columbia is now 46.4 months” (5).
Several studies have evaluated the role of stressful or unsupportive workplaces in the genesis or maintenance of psychiatric symptomatology. Researchers have found that certain kinds of workplace stress are associated with a higher frequency of depressive symptoms in employees (6,7).
Unfortunately, coordination and communication between the mental health care system and the workplace have traditionally been lacking, despite the obvious fact that patients being treated for common mental disorders by the health care system are the same people suffering the effects of depression in their role as workers. It has been observed that “the worlds of mental health and work have elaborated two cultural traditions, speak different languages, are philosophically distinct” (8). The time is right to make substantial change in the way that the health care and occupational domains collaborate to manage workplace depression (9). We need to establish a bridge between mental health care and the workplace.
This issue includes 2 articles concerned with workplace mental health, each contributing to bridging the worlds of mental health care and the workplace but in distinct ways.
The first article, by Dr Kristy Sanderson and Dr Gavin Andrews, systematically reviews empirical research concerning the relation between workplace factors and common mental disorders (mainly depression and anxiety) (10). The authors focus on methodologically sophisticated studies with large samples. The variables used to reflect both workplace disability and causal factors are complex and overlapping; however, Sanderson and Andrews provide clear definitions, making it easier for clinicians and researchers not working in this area to understand their findings. A notable finding of their review is that most individuals with common mental disorders are in fact at work, despite their symptomatology; many of them suffer some degree of “presenteeism,” working at a reduced level of productivity. Further, the authors show that certain kinds of workplace environments increase the risk of onset of common mental disorders. One such risky environment provides jobs with high demands, whether because of long hours or intense time pressure, but with little control permitted to employees regarding the nature or timing of tasks. A second type of risky environment is one in which employees do not perceive the job rewards to be equal to the effort required and thus find the work situation demoralizing. A third recently identified type of risky environment is one in which the workplace is experienced as fundamentally unjust, whether in terms of unfair decision making or disrespectful treatment by managers. This review also identifies increased risk associated with atypical employment, that is, with jobs that are not permanent (whether part-time, casual, or with some other transient arrangement). Having determined major sources of workplace risk, the authors suggest system-level interventions to improve workplace environments and, hopefully, reduce their contribution to mental disorder.
The second article, by Dr Dan Bilsker, Dr Stephen Wiseman, and Dr Merv Gilbert, focuses on the management of workplace and disability issues by psychiatrists and primary care physicians (11). This aspect of patient care is rarely addressed in medical training programs, which understandably focus on diagnosis and symptom alleviation, yet it may be crucial to the appropriate management of patients. After all, a large proportion of individuals being treated for common mental disorders are also employed. Rather than systematically reviewing the research on mental health and disability, this article suggests practical guidelines for effectively managing occupational disability issues. In particular, the authors highlight the interaction between clinician and insurance carrier. For many psychiatrists, dealing with the administrative requirements of their patients’ disability coverage plans seems frustrating and unproductive. Nevertheless, failing to assess or effectively communicate a patient’s impaired functional status can leave the patient in desperate straits: being without financial support during an episode of depression or anxiety is a severe stressor. By better understanding the perspective of insurers and the nature of disability coverage, psychiatrists will be in a stronger position to support the patient’s recovery.
However, dealing with patients who are absent from work because of disability is only one part of the picture—as noted previously, most individuals being treated for common mental disorders continue to attend work, although often with a lower level of effectiveness. Bilsker and colleagues address this issue by emphasizing the importance of approaching occupational function as a target of clinical intervention and by suggesting psychosocial strategies aimed at augmenting the patient’s sense of competence and goal-directedness.
Bridging the domains of mental health care and the workplace is a critical task if we want to effectively manage common mental disorders. The recent prioritization of this task is fostering considerable investment of energy and resources—the bridge is under construction.
References
1. National Electronic Library for Mental Health. Major depression. 2003. Available: http://193.164.179.95/nelmh/home_affective_depression.asp?c=3&fc=001&fid=51. Accessed 2003 Aug 19.
2. Goetzel RZ, Ozminkowski RJ, Sederer LI, Mark TL. The business case for quality mental health services: why employers should care about the mental health and well-being of their employees. J Occup Environ Med 2002;44:320–30.
3. Doherty N. Mental well-being in the workplace: building the business case. In: Miller DE, Lipsedge M, Litchfield P, editors. Work and mental health: an employer’s guide. UK: Gaskell Publications; 2002. p 28–33.
4. Conti DJ, Burton WN. The cost of depression in the workplace. Behav Healthc Tomorrow 1995;4(4):25–7.
5. Bilsker D, Gilbert M, Myette L, Stewart-Patterson C. Depression and work function: bridging the gap between mental health care and the workplace. Vancouver (BC): Mental Health Evaluation and Community Consultation Unit, University of British Columbia; 2004. p 31.
6. Fischer FM, Morata TC, Latorre Mdo R, Krieg EF, Fiorini AC, Colacioppo S, and others. Effects of environmental and organizational factors on the health of shiftworkers of a printing company. J Occup Environ Med 2001;43:882–9.
7. Wang J, Patten SB. Perceived work stress and major depression in the Canadian employed population, 20–49 years old. J Occup Health Psychol 2001;6:283–9.
8. Kahn JP, Langlieb AM, editors. Mental health and productivity in the workplace. San Francisco (CA): John Wiley & Sons; 2003.
9. Field K, Highet N, Robinson E. Beyondblue—the National Depression Initiative: preventing depression in the workplace. In: Morrow L, Verins I, Willis E, editors. Mental health and work—issues and perspectives. Adelaide (AU): Auseinet: The Australian Network for Promotion, Prevention and Early Intervention for Mental Health; 2002. p 266–78.
10. Sanderson K, Andrews G. Common mental disorders in the workforce: recent findings from descriptive and social epidemiology. Can J Psychiatry 2006;51:63–75.
11. Bilsker D, Wiseman S, Gilbert M. Managing depression-related occupational disability: a pragmatic approach. Can J Psychiatry 2006;51:76–83.
Author
1. Consulting Psychologist, Psychiatric Assessment Unit, Vancouver General Hospital, Vancouver, British Columbial; Clinical Assistant Professor, University of British Columbia, Vancouver, British Columbia.
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