Abstract Background Governments and employers’ organizations have sustained focus on common mental disorders (CMD), how they impact a person’s ability to gain or continue work, the costs of sickness absence, presenteeism and job loss, and the positive impact of work on wellbeing. Sources of data Scientific literature, mainly systematic reviews and grey literature, i.e. publications not accessible through medical databases. Areas of agreement CMD are a major cause of disability, unemployment and dependency on welfare benefits. Good and healthy work is important for maintaining mental health and for promoting recovery from mental disorders. Areas of controversy Evidence is limited with respect to the effectiveness of workplace interventions to prevent CMD and especially with respect to work outcomes and work reintegration of those who have been off sick. Growing points There is growing interest in, and an increasing number of, best practice guidelines for employers, that could be improved and shared more actively. Areas timely for developing research There is need for high-quality studies of interventions that examine work outcomes in patients who have been unable to obtain or continue work because of CMD. mental health, work, management Background The global scale of the problem Mental health conditions affect hundreds of millions of people worldwide and include 2 of the top 10 global leading causes of years lived with disability (YLD). Major depression is the second commonest cause (after low back pain) and accounts for almost 52 million YLD worldwide. Anxiety disorders are ranked ninth and account for over 24 million YLD.1 Using pooled data from surveys in high, middle and low-income countries, it is estimated that the annual prevalence of common mental disorders (CMD) in the general working population is 17.6%, with a lifetime prevalence of 29.2%.2 Most commonly, surveys of CMDs included mood, anxiety and substance use disorders, conditions which are distinct from more severe mental illnesses, e.g. bipolar disorder, schizophrenia or other psychotic disorder. Subsequent surveys of adults of all ages in the United States3 and in England4 have arrived at a similar annual prevalence—17.9 and 17% respectively. Using more inclusive criteria to embrace other conditions such as attention deficit hyperactivity disorder, insomnia and major depression, it is estimated that 164.8 million people of all ages in the European Union (38.2% of the population) suffer from a form of mental disorder each year; the commonest being anxiety (14.0%), insomnia (7.0%) and major depression (6.9%).5 The global burden of non-communicable disease (NCD) is expected to increase as the global population increases, with CMDs accounting for a significant proportion of that burden. The World Economic Forum estimated that the global cost of mental illness was ~$2.5 trillion in 2010, and that it is projected to exceed $6 trillion by 2030.6 This accounts for more than half of the projected global economic burden from all NCDs over the next 2 decades and 35% of lost output.6 The Organization for Economic Co-operation and Development (OECD) estimated that the economic costs of mental illness equates to 3.5% of a nation’s gross domestic product (GDP).7 However, we should not forget that people living with CMDs also make significant contributions to GDP, between episodes of illness. The cost of work-related CMDs has been estimated in various countries and regions. In 2013 the cost to Europe was estimated to be €617 billion annually, including employers’ costs (absenteeism, presenteeism and lost productivity) and social welfare costs.8 Data has indicated that work-related stress costs Australia AU$5.3 billion annually and Canada between CA$2.9 billion and CA$11 billion annually.8 In the USA it has been estimated that the annual cost of workplace stress to the economy is around US$300 billion.8 Of course, these estimates are based on assumptions and projections making the true costs difficult to ascertain; nonetheless the evidence indicates that CMDs are a significant financial burden. With that in mind, governments have recognized that national policy has a significant role in protecting employment and employment opportunities for people with CMDs. The UK is no exception and there have been many policy initiatives, especially over the last 2 decades. The UK—a case study The most recently published UK report that considers the annual cost of poor mental health to the economy suggests the costs lie between £74 billion and £99 billion when including additional estimates for staff turnover, falls in tax revenue and lost output.9 Between £33 billion and £42 billion of this cost is borne by employers (including the cost of presenteeism—i.e. individuals at work who are less than fully productive); while the cost to the government is between £24 billion and £27 billion through benefits, healthcare and lost tax revenues.9 The authors acknowledged uncertainty about the costs of presenteeism, but that even with more conservative assumptions, the cost to employers is huge. As well as placing large demands on health services CMDs place a significant burden on employers and the economy. In 2016 all mental health issues accounted for 15.8 million lost working days or 11.5% of all UK sickness absence.10 However, work can sometimes be the cause of a CMD. Based on self-reporting, it is estimated that work-related CMDs account for ~40% of all work-related ill health and 49% of working days lost.11 It is further estimated that this accounts for 12.5 million lost working days; around 24 days per case.11 Nonetheless some areas of employment, such as the health and social care sectors, are associated with a greater risk of developing a CMD. The reasons most frequently cited as causes of work-related stress are workload, especially tight deadlines, too much pressure or responsibility, lack of managerial support, poorly managed organizational change, experiencing violence, bullying or harassment and lack of clarity about job requirements.11 UK government and non-government organizations have increased attention on CMDs, their impact on a person’s ability to gain or continue in employment and the costs to society. In 1999 the Department of Health’s ‘National Service Framework for Mental Health’ drew attention to the fact that CMDs cost the country billions in lost employment and benefits payments. In 2004 a systematic review commissioned by the UK Government reported that National Health Service psychiatric services focused on severe mental conditions and had limited involvement in the management or rehabilitation of people with CMDs.12 The review emphasized that current evidence suggested that, on balance, work is good for physical and mental health while long-term worklessness is detrimental. The concept that work helps to maintain mental health and promote recovery from CMD has since been embedded in the health and welfare reform agenda of successive governments. In 2005 a UK government strategy ‘Health, Work and Wellbeing: Caring for Our Future’ aimed to ensure that healthcare services were designed and delivered to assist working-age people to remain or become fit for work. The strategy singled out CMDs as a focus area. A systematic review followed to build the evidence base; this focused on the common health problems that accounted for two-thirds of sickness absence and long-term incapacity, i.e. CMDs and musculoskeletal and cardio-respiratory conditions.13 In 2008 ‘Working for a healthier tomorrow’ an independent review of the health of Britain’s working-age population led the government to commit to a national health and employment strategy ‘Improving health and work: changing lives’. Subsequently the Department of Health published ‘Working our way to better mental health: a framework for action’. This aimed to improve wellbeing at work for everyone and deliver better employment results for people with mental health conditions. In 2011 ‘Health at work—an independent review of sickness absence’ concluded that people with health conditions, especially those with a CMD, often did not receive appropriate early support to remain in work. Among other actions, the UK Government’s response committed to improve education on health and work for healthcare professionals and to improve understanding of the relationship between mental health and employment. At the end of 2016 the government launched a consultation paper which reinforced the desire to put mental and physical health on an equal footing [referred to as parity of esteem] and to improve support for people with mental disorders. In 2017 it published ‘Improving Lives: the Future of Work, Health and Disability’ setting out its plans to get more disabled people into work and announced measures such as providing training for work coaches to support people with CMDs. Work and mental health In the UK, according to a report based on a YouGov survey, employers are only just waking up to the scale of poor mental health at work.14 Generally, attitudes towards mental health in the workplace have improved, however, only 24% of managers have received training in mental health and there remains a pervasive culture of silence relating to mental health.14 Additionally, among those surveyed, it was reported that 15% of UK organizations did not focus on mental health and wellbeing of employees and 31% of employees felt their employer did nothing to actively promote mental wellbeing at work.14 Small businesses were almost three times as likely to admit doing nothing, compared to large businesses (44 vs 15%). To compound matters, results showed that only 38% of employees had access to an occupational health service and indeed only 13% of UK workers can access an occupational physician.15 This means that for most UK employees their only direct source of healthcare for a CMD, including conditions that either impact or is caused by their work, is their GP. This adds to GP workload considering that the vast majority of people with CMDs are treated in primary care. A wide range of mental and behavioural disorders account for about a third of GP issued sickness certificates or ‘fit notes’ that include a diagnosis.16 In many countries employers have a statutory duty to protect employees from occupational hazards and they must assess and manage risks including the risk of stress at work. The characteristics of jobs that are known to influence wellbeing at work include career outlook, clarity, fairness, interpersonal contact, job demands, opportunity for control; opportunity for skill use, pay, physical environment, significance, supervision and variety.17 The Health and Safety Executive (HSE) has produced ‘Management Standards’ to help employers conduct risk assessments for work-related stress. The HSE also provides guidance to help ensure that employers who have their own approaches can check that they are suitably equivalent.18 Large employers may address the scope of these factors in annual employee surveys, since it should come as little surprise that overlap exists between questions used to assess employee satisfaction, engagement and occupational stress. Small employers may not conduct annual employee surveys and may also benefit from the ‘Workplace Health Needs Assessment’ published in 2017 by Public Health England and which includes questions about workplace culture.19 The National Institute for Health and Care Excellence has also produced ‘Workplace health: management practices’20 and ‘Healthy workplaces: improving employee mental and physical health and wellbeing’.21 When a risk of occupational stress is identified, in keeping with standard risk management approaches, employers must take appropriate steps to manage that risk. This is best achieved by identifying and managing the causes, since interventions which focus on employees without addressing organizational causes of stress, e.g. workload, leadership style or culture, will have limited effect.22 Employee-targeted interventions can be effective, particularly for those at risk of developing a CMD and in those who have a high degree of control over their work.22,23 A Cochrane review of studies in healthcare workers reported low-quality evidence that cognitive behavioural therapy (CBT) and mental and physical relaxation reduce stress but no more than some alternative interventions (e.g. computer training, attending lessons of choice or passive attendance of psychologist at a staff meeting).24 There was also low-quality evidence that changing work schedules reduced stress.24 Other reviews find moderate evidence for enhancing employee control and promoting physical activity.25 Out of adversity comes opportunity as witnessed by the growing availability and popularity of mindfulness training and resilience programmes promoted to address stress at work. Mindfulness is the process of paying attention to the present moment in a non-judgmental manner.26 Resilience refers to employees being able to withstand or recover quickly from difficult conditions.27 Evidence is most convincing for the use of mindfulness in the management of anxiety and depression, albeit more modest outcomes are reported in more stringent meta-analyses which exclude studies that do not control for placebo effect.26 Few studies investigate the utility of mindfulness-based interventions in occupational settings and those which do suffer from low sample sizes and response rates.28 While such studies may indicate a short-term (<4 weeks) positive effect on wellbeing, long-term efficacy (>3 months) has yet to be determined.28 High-quality research is needed to ascertain long-term efficacy.29 A recent systematic review reported that resilience training can improve personal resilience, mental health, subjective wellbeing, psychosocial functioning and performance.27 As is the case with mindfulness the review identified a shortage of studies evaluating work-based resilience training; and follow-up was limited to 6 months. While most programmes utilized a cognitive-behavioural approach there is no definitive evidence for the most effective training content or format.27 Stigma and discrimination Despite attempts to destigmatize mental ill health in recent years, it often remains a taboo subject in the workplace. Only 28% of surveyed UK employees feel able to involve someone at work because many fear that it will negatively affect their job.14 Even fewer (13%) feel able to disclose a mental health condition to their manager or supervisor. Based on the survey, 15% of respondents reported that they had faced disciplinary proceedings or were dismissed after disclosing a CMD.14 Being an anonymous survey there was no follow-up to corroborate the data to establish whether CMD was the actual cause. Sometimes a CMD might follow disciplinary action for unacceptable performance. Such negative experiences reinforce the fears of patients who are reluctant to disclose a CMD to their employer.14 Black, Asian and minority ethnic employees are less likely to be comfortable talking about CMDs at work; they are also less likely to consult a GP.14 Help-seeking is also disproportionately deterred by stigma in the young, in men, in military personnel and healthcare workers.30 One initiative which seeks to address stigma and promote early help-seeking in communities, including in workplaces, is psychological or mental health first aid (MHFA) training. Training aims to enable participants to provide early and interim support to those who develop a mental health problem or crisis before being able to access professional support. Current evidence from limited numbers of studies of variable quality and design indicates that it improves participants’ knowledge, skills, attitudes and behaviour.31 There is no body of evidence relating to interventions and clinical outcomes; this hinders the development of evidence-based guidelines.32 If stigma is an issue for existing employees, it is also a dilemma for prospective employees, who may be sensitive about disclosing a gap in their employment record let alone a CMD as the cause. Researchers in Hong Kong sent four separate job applications to each of 409 job adverts over a 3-month period.33 Applications were identical except for differences in disclosed disabilities—one application did not mention disability, one mentioned hearing impairment, one mentioned walking with crutches and the last declared recovery from depression. Of the 1636 applications, 331 received offers of interview. There were statistically significant differences between the non-disability group and each of the disability groups. Comparisons between disability groups did not reach statistical significance, but there was a ranking of preference; people without a disability, followed by those with a hearing impairment, those with a mobility impairment and last, those who had suffered from depression.33 The results of this study suggest that patients should consider carefully whether to disclose a CMD to their employer or a prospective employer. This makes it very difficult for doctors to advise patients what they should do. On one hand a patient may risk being discriminated against at work if they declare a CMD, on the other employers can only discharge a legal duty to make reasonable adjustments to someone’s work when they have knowledge of a disability—or could reasonably be expected to know that an employee has a disability. This means that employers must do everything that could be reasonably expected of them to discover if someone has a disability e.g. seeking an occupational health opinion if there are concerns about someone’s behaviour at work which ought to have raised suspicions of a mental or behavioural disorder such as unexpected, or out of character, poor performance. Once it is established that the definition of a disability is fulfilled then an individual is protected against discrimination. It is important to remember that for CMDs, and for all conditions which may resolve and/or be fluctuating that in some jurisdictions a person remains protected once the condition has satisfied the definition of a disability, even if there has been no recurrence. History of the presenting complaint When a CMD is the presenting primary complaint in a working patient, in addition to understanding the symptoms and their effect on the patient, it is important to understand: the extent to which work has caused or contributed to symptoms; whether being at work will be therapeutic or aggravate the condition; what relationships are like with the manager and colleagues; whether there is special professional support available through work, e.g. occupational health service; and whether the job has safety critical aspects and performance is impaired to be a risk to the patient, co-workers or the public. These considerations can help to understand the social context and help guide the wider management of the condition, including advice to the employer, e.g. on a ‘fit note’. It is also important to consider the possibility of a patient having a CMD, whether or not it is the presenting primary condition. Many physical conditions, especially those characterized by chronic pain, are associated with increased risk for developing co-morbid depression. Among patients who suffer from chronic pain on average co-morbid major depression affects just over a half who attend pain clinics (52%) and orthopaedic or rheumatology clinics (56%) and around a quarter of those whose pain is managed in primary care (27%).34 There is reciprocal association since depression in patients with pain is associated with more pain complaints and greater impairment.34 The evidence base in patients suffering from CMDs is limited, there being no systematic evidence that better medical management alone delivers better employment outcomes. This makes it important that, in addition to considering medical factors, clinicians consider psychosocial factors which help or hinder a patient’s capacity to remain in or return to work. There is a growing body of evidence regarding the factors which help or hinder the chances of return to work in patients with common conditions, including CMDs.15 Two new systematic reviews have reported on the barriers and facilitators specific to CMDs.35,36 Anxiety, depression and higher symptom severity are regarded as barriers to return to work. Other barriers include comorbidity, previous sickness absence, older age, high psychological job demands and experiences of violence of bullying at work. Return to work facilitators include positive return to work expectations, high job control, and supervisor and co-worker support.35,36 Occupational management For patients who are absent from work because of ill health early assessment, early rehabilitation and work or workplace adjustments are effective interventions to help them return to work.15 Understanding any work-relatedness, i.e. causes or contributors along with barriers and facilitators to return to work, enables clinicians to recommend suitable workplace adjustments. In many cases these are likely to be simple and low-cost interventions involving a change in practice or workload. Such workplace adjustments are best recommended by an occupational health service which has a good understanding of the working environment, the patient’s job and the social dynamics at work and which may request independent specialist opinion for more complex cases. However, the patient may not have access to an occupational health service, in which case the treating physician might consider recommending simple workplace adjustments to the employer. Examples might include: a gradual return to work building up hours, e.g. over 2 weeks allowing time to attend medical appointments modified duties to remove or manage particular tasks that cause difficulty offering flexible working hours/patterns, e.g. performing some work at home transfer to a suitable alternative role (temporary or permanent) allocating some duties to another person to lighten the workload additional training, e.g. if stress is due to being given a task without being provided with appropriate skills training The evidence base for return to work interventions for CMD is not extensive, there are very few randomized controlled trials (RCTs) and many studies are of low quality and suffer from bias.37 This may account for lack of consensus between reviews. However, there is consensus for CMD generally23,25 and for depression specifically37,38 that CBT improves both symptoms and occupational outcomes. It also appears that interventions which combine more than one therapeutic approach might be more effective.37,39 Discussion While estimates of the economic and social costs of CMD vary considerably depending on the range of costs that are considered, there is consensus that the costs to individuals, families, employers and economies are enormous. Yet it should be remembered that many people who have a CMD have successful careers and make full contributions at work and in their communities. It is commonly promoted that people generally enjoy better mental health when they are in work, however, reciprocal causality must be acknowledged. Well-designed work will minimize the risks of causing occupational stress, while absence of illness promotes workability. However, with the right environment, work provides activity, income, social interaction and improved self-esteem. When increased attention is given to an issue, as has been the case with CMD at work in recent decades, there is a natural desire to do something or to be seen to be doing something. This may mean that employers may roll out programmes ahead of the availability of robust evidence. While many employers have introduced mindfulness and resilience programmes in the workplace the research interest regarding their effectiveness is still growing. To date research in an occupational setting has been limited and has suffered from inconsistent definitions, conceptualizations and assessed outcomes.27 While there are promising results we need larger, methodologically sound studies with longer follow-up28,29 especially comparative studies to assess the utility of different training programmes.27 This will help to ensure that available programmes are consistent with the best evidence. One particular challenge is blinding and controlling for placebo effect. The growing popularity of mindfulness is a difficult confounding variable because it is difficult to blind patients from the fact they are using mindfulness techniques.26 Evidence is also limited relating to the effectiveness of occupational management interventions especially regarding work outcomes and work reintegration.23,40 Conversely, there is an established role for supported employment vocational rehabilitation programmes, especially individual placement and support (IPS) for the management of severe mental illness,41 although there is a risk of bias in individual studies.42 IPS involves employment specialists who identify people’s job interests, assist with job finding, provide job support and engage other support services.42 A meta-analysis of RCTs reported that IPS is more than twice as likely to lead to competitive employment compared with traditional vocational rehabilitation in those with severe mental illness (schizophrenia or schizophrenia-like disorder, bipolar disorder or depression with psychotic features).41 It is not known if IPS would be effective in managing CMD, or more notably whether it would be cost-effective; this may be a potential area for research. More generally, it is suggested that there is need for more evaluations of combined organizational and individual-level interventions and for higher quality evaluation evidence, ideally RCTs.23 Nonetheless, there are empirically supported interventions that can be deployed at work to help prevent and to facilitate recovery from CMDs.22 Indeed the extent to which traditional evidence hierarchies are re-applicable to public health and occupational health interventions is debatable. RCTs are often impractical; consequently, there is little high-quality evidence for most occupational health interventions. Cohort, case-referent and cross-sectional studies may be more methodologically apt for the occupational setting. However, such studies may be excluded from systematic reviews or, if they are included, only generate recommendations of medium or limited-evidence. We need to remember that limited evidence is the highest level of evidence available where there is no evidence to the contrary. There is growing interest in the increasing number of employer best practice guidelines.43,44 Many guidelines lack a focus on prevention and instead focus on the detection and management of CMDs in the workplace43 and in particular return to work from sickness absence.42 When prevention recommendations are included they are often individually focused and lack practical tools for implementation. For instance, there is good evidence that peer support programmes can be successful in bolstering the resilience of employees working in challenging and trauma-prone roles (e.g. child social workers or emergency services).45 Those organizations which have best practice guidelines provide a range of interventions which may include well-described policies and procedures for the roles and responsibilities of stakeholders, a sickness absence or disability leave plan, manager training, a defined process to manage work and workplace accommodations and mental health literacy training for all staff.44 There is also some evidence that facilitating better disclosure decisions and management of personal information is a promising area of future research.46 Conflict of interest statement The authors have no potential conflicts of interest. References 1 Global Burden of Disease Study 2013 Collaborators . 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Managing disclosure of personal information: an opportunity to enhance supported employment . Psychiatr Rehabil J 2015 ; 38 : 306 – 13 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
British Medical Bulletin – Oxford University Press
Published: Apr 19, 2018
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