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Workplace mental health: developing an integrated intervention approach

Workplace mental health: developing an integrated intervention approach Background: Mental health problems are prevalent and costly in working populations. Workplace interventions to address common mental health problems have evolved relatively independently along three main threads or disciplinary traditions: medicine, public health, and psychology. In this Debate piece, we argue that these three threads need to be integrated to optimise the prevention of mental health problems in working populations. Discussion: To realise the greatest population mental health benefits, workplace mental health intervention needs to comprehensively 1) protect mental health by reducing work–related risk factors for mental health problems; 2) promote mental health by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. We outline the evidence supporting such an integrated intervention approach and consider the research agenda and policy developments needed to move towards this goal, and propose the notion of integrated workplace mental health literacy. Summary: An integrated approach to workplace mental health combines the strengths of medicine, public health, and psychology, and has the potential to optimise both the prevention and management of mental health problems in the workplace. Background Workplace interventions to address common mental Mental health problems are common in the working health problems have evolved relatively independently population, and represent a growing concern, with po- along three main threads or disciplinary traditions: tential impacts on workers (e.g., discrimination), organi- medicine, public health, and psychology (Figure 1). In sations (e.g., lost productivity), workplace health and this Debate piece, we present two premises relating to compensation authorities (e.g., rising job stress-related 1) the high prevalence of such problems and disorders claims), and social welfare systems (e.g., rising working in the working population and 2) that working conditions age disability pensions for mental disorders) [1]. Grow- are a major modifiable risk factor, then argue that the three ing awareness of this issue has been paralleled by the intervention traditions or threads need to be integrated to rapid expansion of workplace interventions to address achieve the greatest population mental health benefits. An common mental health problems in the workplace set- integrated approach would 1) protect mental health by re- ting, particularly as a means to prevent, detect, and ef- ducing work–related risk factors; 2) promote mental health fectively manage depression and anxiety [2-4]. by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. Our aim in presenting this framework is to sup- * Correspondence: [email protected] port the achievement of best practice in workplace mental Population Health Strategic Research Centre, School of Health & Social health for the full range of relevant stakeholders: workers, Development, Deakin University, Burwood, VIC, Australia Melbourne School of Population and Global Health, University of employers, industry groups, labour organisations, policy- Melbourne, Melbourne, VIC, Australia makers, health professionals, researchers, and others. Full list of author information is available at the end of the article © 2014 LaMontagne et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 2 of 11 http://www.biomedcentral.com/1471-244X/14/131 In addition to clinical disorders, subclinical mental Positive Psychology, Management, health problems and generalised distress are also prevalent Organisational in the working population [8]. In summary, mental health Public Health, OH&S, Psychiatry, Development Occupational Health Psychology, disorders and related problems represent a large and com- Psychology,Health Occupational Promotion Medicine plex phenomenon in the workplace. Mental health problems among working people are Promote the also costly to society at large, healthcare systems, em- positive ployers, and affected individuals and their families. Con- Prevent Manage servative estimates of economic costs for European harm illness Union countries are 3-4% of gross domestic product [1,9]. Social costs include rising disability rates across Integrated the OECD due to mental disorders [1]. Healthcare costs approach for mental disorders vary widely, corresponding roughly with varying severity. For example, an Australian costing study found the greatest costs of depression amongst Figure 1 The three threads of the integrated approach to working people were borne by employers (far exceeding workplace mental health. healthcare costs), with turnover costs figuring more prominently than presenteeism and absenteeism costs [7]. Costing studies to date, however, are limited in their Premise One: mental health problems are prevalent in ability to quantify costs to affected individuals and their working populations families, particularly in regard to important social costs Mental health problems, both clinical (e.g., major depres- related to workplace stigma and discrimination [7]. sion, anxiety disorders) and sub-clinical (e.g., psychological distress), are very common in working populations. This Premise Two: working conditions are an important Debate piece focuses on the workplace setting - and thus modifiable risk factor for mental health problems the working population. However, it is important to ac- A substantial body of research has demonstrated the knowledge the complementary need for a more com- links between psychosocial working conditions—or job prehensive view of the entire working-age population, stressors—and worker health over the last three decades. which includes the unemployed, and those not in the Karasek and Theorell’s demand-control model has been labour force due to disability or other reasons [5]. Given particularly influential [10]. This model hypothesises that growing labour market flexibility and rising levels of un- high job strain, defined by a combination of low control employment and underemployment in many Organisa- over how the job is done in the face of high job de- tion for Economic Cooperation & Development (OECD) mands, will be harmful to health. This was first demon- countries [6], addressing worklessness as well as work is strated in relation to cardiovascular disease outcomes now particularly important. In a recent review, the OECD [10,11]. Subsequent studies have found that job strain estimated that similar proportions of the industrialised also predicts elevated risks of common mental disorders, working-age populations are affected by clinical mental even after accounting for other known risk factors disorders: with point-prevalence estimates of 5% for se- [12-14]. While there is a considerable body of evidence vere mental disorders and another 15% for moderate supporting a dominant 'normal causation' model regard- mental disorders [1]. Among those affected, those with ing the impact of working conditions on employee men- common mental disorders - depression, simple phobia, tal health, it should be noted that reversed causality, that and generalised anxiety disorder - have the highest work- is the impact of mental health on the assessment of force participation rates [3]. In Australia, for example, working conditions can also occur. There is some evi- the 2007 National Survey of Mental Health and Wellbeing dence that working conditions and mental health influ- estimated that 15% of the working population had a history ence each other reciprocally and longitudinally [15]. of major depressive disorder (lifetime prevalence [7]); of Systems thinking suggests bi-directional non-linear rela- these: tionships [16] and better understanding of these pro- cesses using advanced analytic techniques (e.g., marginal 21% reported depressive symptoms in the past year structural modelling) and stronger study designs will un- and were in treatment doubtedly be the subject of continuing research. 17% reported depressive symptoms in the past year Numerous other job stressors, either individually or in and were not in treatment combination, have been shown to influence mental 11% were recovered and in treatment health [14,17,18]. These include job insecurity, bullying 52% were recovered and not in treatment. or psychological harassment, low social support at work, LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 3 of 11 http://www.biomedcentral.com/1471-244X/14/131 organisational injustice, and effort-reward imbalance on sound principles or theory, and their feasibility and [12,14]. Unlike many historically prominent occupational effectiveness need to be demonstrated in implementa- exposures (e.g., asbestos), to which only a small pro- tion and effectiveness studies [25]. Below we summar- portion of the working population were exposed, all iseevidenceinthisregardfor thethree threadsofour working people can be potentially exposed to job proposed integrated intervention approach to workplace stressors. This means that even small increases in risk mental health. from such exposures can translate to substantial—and preventable—illness burdens. Given the population preva- Thread 1: protect mental health by reducing work–related lence of a given exposure and the associated increase in risk factors risk for a specific outcome, the proportion of that out- The relevant intervention principles and evidence in come attributable to the exposure of interest can be esti- this area come predominantly from the fields of pub- mated [19]. Based on job strain prevalence estimates of lic health (e.g., occupational health and safety, health 18.6% in males and 25.5% in females and an odds ratio of promotion) and psychology (particularly organisational 1.82 for job strain and depression [12], this method psychology). Like other public health interventions, job yielded estimates of job strain-attributable risk for depres- stress prevention and control interventions can be di- sion in an Australian working population sample as 13% rected at the primary, secondary, or tertiary levels [26-29]. of prevalent depression among working males and 17% Primary intervention aims to prevent the incidence among working women [20]. More recently, comparable of work-related mental health problems; it is ‘work- estimates were obtained from a study of the French work- directed’ - aiming to reduce job stressors at their source ing population for job strain-attributable risk for common by modifying the job or the work environment. Second- mental disorders: 10.2–31.1% for men, 5.3–33.6% for ary intervention is ameliorative and ‘worker-directed’;it women. Using a different approach, a New Zealand birth aims to modify how individuals respond to job stressors, cohort study estimated that, at age 32, 45% of incident usually through strategies to improve employees’ ability cases of depression and anxiety in previously healthy to cope with or withstand stressors. Secondary level young workers were attributable to job stress [21]. While intervention can also prevent the progress of sub-clinical further research is needed to firmly establish the causality mental health problems to diagnosable disorders. Ter- and magnitude of association of job strain and other stres- tiary intervention is reactive in that it responds to the sor exposures in relation to common mental health prob- occurrence of mental health problems; it involves treat- lems (which would suggest that the attributable risks just ing affected workers and supporting rehabilitation and presented are over-estimates), such single-exposure single- return-to-work. Theoretically, tertiary (and to some ex- outcome estimates may also underestimate the proportion tent secondary) intervention can reduce the burden of of mental health disorders attributable to job stressors, as mental disorders through early detection and treatment a comprehensive estimate would account for all relevant and limiting severity or chronicity. Some intervention job stressors and the full range of associated mental health strategies can be classified in different ways (e.g., in- outcomes [7]. In addition to depression, exposure to creasing worker resilience or coping capacity could be various job stressors has been associated with burnout, considered primary prevention if it is done before a anxiety disorders, alcohol dependence, suicide and other mental health problem has occurred, and secondary if mental health outcomes [14,22]. As such, preventing or it prevents the progression of an existing one)—most reducing exposure to job stressors and improving the importantly, primary, secondary, and tertiary interven- psychosocial quality of work could prevent a substantial tion are complementary, thus a comprehensive or sys- proportion of common mental health problems. Such tems approach to prevent and control the impacts of improvements would benefit other health domains as job stress entails all three [26]. In the preventive medicine well, as exposure to these same job stressors also pre- typology (as relevant to thread 3 below), this framework dicts elevated risks for poor health behaviours as well as roughly parallels universal, selected and indicated disease other high burden chronic illnesses, including cardiovas- prevention [30]. cular disease [23,24]. Systematic reviews of job stress prevention and control studies show that the most effective interventions com- Discussion bine primary prevention to reduce job stressors with What then is the potential for preventing and managing secondary intervention to strengthen workers’ abilities to this large and complex burden of mental health prob- withstand stressors [4,31-34]. While these systematic re- lems in the working population? The identification of views indicate what to do, the more challenging question modifiable risk factors implies potential preventability, in application to policy and practice is how to do it. While but this needs to be demonstrated through interven- the principles of intervention are broadly applicable, tion studies. Intervention strategies should be based solutions are unique to the work context (e.g., worker LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 4 of 11 http://www.biomedcentral.com/1471-244X/14/131 socio-demographics and occupational skill levels, type of potential and create change, future search, which in- workplace, presence or absence of a union). For example, volves working towards an aspirational view of the fu- strategies to improve job control for a sales clerk will dif- ture, and future inquiry—a hybrid of the two that fer from strategies to achieve the same for a manager, acknowledges the views of all relevant stakeholders, gen- even in the same workplace. Intervention design and im- erates respect for what has been done well, identifies a plementation capabilities and resources in small-medium shared aspirational view of the future, and plans steps to business settings also need to be considered [35]. Inter- move in that direction [42,43]. Positive outcomes in- vention strategies need to be tailored and context ap- clude subjective wellbeing, psychological capital, positive propriate [28,36], making the development of such mental health, employee engagement, and positive or- interventions more involved and labour-intensive than ganisational attributes such as authentic leadership, sup- interventions for most other occupational hazards (e.g., portive workplace culture and workplace social capital. installing a machine guard to prevent hand injuries). Wellbeing—also referred to as subjective or psycho- Whilst knowledge of solutions for various work con- logical wellbeing, happiness or life satisfaction—is more texts is growing, there is still a need to apply principles than the absence of ill-health states but the presence of and develop solutions on a case-by-case basis. This has positive feelings and functioning [44]. The concept has likely contributed to the slow uptake of effective job also been applied to the domain of work [45]. A key stress prevention and control strategies in practice. point here is that the term ‘well-being’ does not refer to Further, there is a persisting disconnect between evidence- the absence of the negative; instead, wellbeing is most based best practice and what is currently being under- correctly defined and measured as the presence of posi- taken in the workplace setting to address mental health, tive feelings and functioning. Despite this important dis- with prevalent practice directed more at secondary than tinction, some inappropriately use ‘mental health and primary intervention. For example, when Human Resources wellbeing’ as a catchall phrase for mental (ill) health or OH&S staff are asked about their organisation’sresponse constructs. to job stress concerns, the most common response is to There is a need for both organization-wide and indi- provide an Employee Assistance Program [37,38]. Other vidual level approaches to employee well-being and barriers to the uptake of evidence-based best practice mental health. This would align with the comprehensive include issues of stigma similar to those concerning mental or systems approach to job stress prevention described illness in general, such as a persisting view of job stress as above. Importantly, positive approaches aim to promote an individual weakness [38]. the positive aspects of work and worker capabilities To summarise, job stress prevention and control is (including wellbeing) as distinct from other strategies, distinguished by its emphasis on primary or universal which aim to increase understanding of, or prevent, men- prevention, and the need to intervene at the level of tal illness (e.g., mental health promotion and stress work organisation as well as the individual. Implementa- prevention). Some key approaches involve developing tion in practice, however, has proven challenging, in part positive workplaces by establishing positive leadership because solutions need to be context-specific. practices, ensuring work is meaningful, and building a positive organizational climate [46,47]. The newness of Thread 2: promote mental health by developing the positive approaches is reflected in its being the least positive aspects of work as well as worker strengths and commonly applied in organisational practice compared positive capacities to the other two threads of our proposed integrated ap- The relevant intervention principles and evidence in this proach [48]. Positive psychology interventions, how- area come predominantly from the field of psychology, ever, are becoming increasingly popular in clinical and in particular the rapidly developing field of positive general settings. psychology [39]. Positive psychology is defined as the A meta-analysis of the general literature (in all settings) study of “the conditions and processes that contribute to concluded that wellbeing can be sustainably enhanced the flourishing or optimal functioning of people, groups, and depressive symptoms reduced through positive inter- ventions [49]. Positive-focused workplace strategies are and institutions” [40]. What distinguishes positive psych- ology intervention in practice is that it applies strength- less commonplace and need further development. This is based methods to the achievement of positive outcomes. particularly critical given the lack of intervention effect- iveness in the workplace mental health space generally. Strength-based methods aim to identify and enhance strengths or what is being done well, rather than trying Nevertheless, there are some small but successful exam- to identify and fix what is ‘wrong’ in an individual, group ples in workplace settings, such as a positive psychology- based employee wellbeing program in a sample of work- or organisation [41]. It includes the application of methods such as appreciative inquiry, which involves ing adults that showed positive changes in wellbeing asking positive questions in order to strengthen positive over six months in comparison to non-participants [50]. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 5 of 11 http://www.biomedcentral.com/1471-244X/14/131 Whilst research on strength-based methods, and par- by developing knowledge and skills on how to recognise ticularly how to apply these methods at a primary common mental disorders and provide “First Aid” sup- level, is relatively new, research in this area is growing port until professional help can be obtained, increasing rapidly and may provide a valuable complement to understanding about the causes of mental disorders, im- problem-based methods. proving knowledge of the most effective treatments, and The promise of positive approaches is clearly sup- reducing stigma [55,57]. There is evidence of effective- ported by established knowledge of the substantial posi- ness of MHFA from various studies [57] including two tive influences of good quality work on mental health randomised-controlled trials conducted in workplace set- and wellbeing. In addition to the income and socio- tings [55,58]. In addition to improvements in mental economic position that paid work can provide, it can health literacy, there is also some evidence of improve- also positively impact adult socialisation, the develop- ments in mental health among MHFA trainees [55]. Fur- ment of identity, and the building of social connections ther, there is evidence for the effectiveness of secondary extending beyond family and neighbourhood groups and tertiary approaches to workplace suicide prevention [14,51]. Furthermore, work can provide purpose and in specific at-risk occupations such the U.S. air force meaning, thus enhancing both self-efficacy and self- [59]. Nevertheless, additional intervention studies as well esteem, both of which protect and promote mental as evidence synthesis is clearly warranted, and adequate health. For example, research into what motivates older numbers of specific types of intervention studies (e.g., workers to stay in the labour market has demonstrated workplace mental health literacy) may soon be available that opportunities to use their skills, to be creative, to to enable systematic review and meta-analyses. gain a sense of accomplishment, and opportunities to Other strategies for addressing mental health problems interact with co-workers, are often rated more highly in the workplace focus on organisational culture and at- than financial security in decisions about staying in the titudes in relation to mental illness stigma and norms labour market [52-54]. As well as having direct relevance around disclosure. Mental health stigma in workplaces is to developing strategies to promote the positives of a pervasive challenge, just as it is in broader society [60]. work for mental wellbeing, such findings are directly A study of 6,399 employees from 13 workplaces in the relevant to developing policy and practice responses to USA found that although 62% knew how to access com- the ageing workforce across the industrialised world. pany resources for depression care, only 29% indicated This highlights the need for positive approaches to address they would feel comfortable discussing the issue with eudaimonic (meaning and purpose) as well as hedonic their supervisor [61]. Unsupportive organisational cul- (positive emotional, or happiness) aspects of workplace ture and norms around depression disclosure are a con- wellbeing [14,44]. tributing factor. Managers’ and leaders’ attitudes play a To summarise, positive approaches provide a valuable central role in changing these norms and are a priority and but rarely utilised complement to risk-based or target for intervention [62,63]. The development and negatively framed approaches (such as OH&S). However dissemination of accommodation strategies is also needed, interventions involving positive work psychology are as managers , HR professionals, and others in workplaces limited by their emphasis to date on the individual level may be willing but unsure about how to accommodate a [40] and the need for further evidence of effectiveness. worker with a mental health condition (compared to Team/group and organisational level positive approaches knowledge about physical accommodation), or these are being developed, and may prove to yield greater ben- accommodations may be seen as too complicated to efits than individual-level approaches in the future. put in place [64-66]. Finally, some strategies focus on the role of organisational culture in improving return-to-work Thread 3: address mental health problems among from a mental illness-related absence [67]. working people regardless of cause To summarise, illness-focused approaches to address- Work in this area has expanded rapidly over the last ing mental health problems are strongest at the tertiary decade and has been largely developed from an illness or and secondary, or—in preventive medicine terminology— medical perspective, emphasising tertiary and secondary- selected and indicated levels. Initially, they tended to be level interventions. Workplace programs that aim to individual-focused, but strategies are rapidly expanding to address mental health problems or disorders in the address organisational culture and norms. There is prom- ising evidence of effectiveness, but further research in this workplace commonly use psychoeducation and aim to improve mental health literacy, or develop skills for regard is needed. Early detection and disclosure are ham- early intervention and the promotion of help-seeking pered by persisting stigma and the potential for discrimin- ation; the continuing improvement of strategies to address [55,56]. An example of a program being implemented in multiple OECD countries is Mental Health First Aid these barriers is a key priority for research, policy, and (MHFA), which seeks to improve mental health literacy practice. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 6 of 11 http://www.biomedcentral.com/1471-244X/14/131 The integrated approach: joining the threads The growing public awareness and employer receptiv- A defining feature of the integrated approach is the mu- ity to MHL intervention suggests that the integrated ap- tually reinforcing nature of the three threads. While the proach might best be described as workplace mental protective focus of the first thread aims to identify and health literacy. Based on Jorm’s earlier definition of address factors that can undermine the mental health of MHL as “knowledge and beliefs about mental disorders employees – and therefore encourages employers to ful- which aid their recognition, management or prevention” fil their responsibility to provide a safe and healthy [70], we would define workplace mental health literacy working environment, the overall goal of the second the knowledge, beliefs, and skills that aid in the preven- thread is to complement the risk reduction approach by tion of mental disorders in the workplace, and the recog- promoting those characteristics that can strengthen indi- nition, treatment, rehabilitation, and return to work of vidual and organisational health and can lead to high working people affected by mental disorders. Differing, levels of positive wellbeing. To some extent this comple- but overlapping sets of knowledge, beliefs and skills mentarity is already apparent; for example, understand- would apply to people in various roles in or in the rela- ing of the importance of job control has evolved from tion to the workplace setting, including for examples two sides of the same coin. Low job control was identi- workers, managers, and HR staff in a given workplace, fied in public health research as an important risk factor and worker and employer advocates and healthcare pro- for mental health problems (thread 1), and the promo- fessionals in relation to various workplaces. tion of autonomy (or high job control) is a common Further work will be required to articulate the links strategy in positive approaches (thread 2). Maintaining and genuinely integrate the threads of the integrated ap- this dual protection-promotion emphasis can benefit proach, which may indeed lead to efficiencies in imple- workplace mental health in many ways, not least in en- mentation as well as preventive synergies, such as has couraging organisations and their representatives to been realised through integrated approaches targeting can- examine the strengths and weaknesses of their working cer prevention other aspects of workplace health [71-73]. environments, to keep a more ‘balanced scorecard’ in re- lation to monitoring the performance of their various The integrated approach: cautionary notes systems, policies and practices, and to properly identify Although combining the three threads of the integrated and mobilise the resources available in their organisa- approach could substantially improve mental health out- tions to build workplaces that are not just safer and comes over above what might be achieved by each fairer but are also more attractive to and engaging for thread on its own, it is important to acknowledge the employees. potential risks and challenges of adopting this approach. The third thread can complement the first two in vari- To date, there is a persisting over-emphasis on individual- ous ways. Certain knowledge and awareness aspects of directed intervention in workplace health intervention pol- mental health literacy (MHL), for example, relate dir- icy and practice, which would need to be overcome in ectly to the other two threads. The workplace MHL order to realise a genuinely integrated approach. The great strategies we have piloted for example, highlight that uptake of workplace mental health literacy as well as poor working conditions and job stress are modifiable resilience-oriented positive psychology programs may be risk factors for common mental health problems, and partly explained by this. For example, past mental health (where applicable) that there are legislative OH&S man- literacy programs have been largely individual-directed dates to protect psychological as well as physical health education and training programs, thus far mainly evaluated [68,69], thus building employee awareness of and em- in terms of short-term changes in individuals’ knowledge, ployer commitment to the need to address working con- attitudes, and helping skills. In contrast, reducing job ditions (linking to thread 1). Workplace MHL can also stressors and improving job quality requires organizational highlight the protective value of resilience in relation to changes, which generally require more resources and a mental disorders, building motivation for and commit- longer period of change. In a recent feasibility study to de- ment to positive approaches (linking to thread 2). In velop and implement an integrated job stress and mental addition, starting where organisations are receptive (MHL health literacy intervention, significant improvements in training) can provide the encouragement/incentives to mental health literacy were observed over one year, but— employers (near term improvement in MHL) needed to disappointingly—no improvements in job demands, sustain employer interest and commitment to the im- job control, or workplace social support [68,69]. More provement of working conditions and job quality over the intensive or sustained work-directed intervention, longer longer term. This could help provide entrée into work- follow-up, or both are needed to achieve and demonstrate places that might not otherwise consider job stress or improvement in working conditions. other mental health interventions on their own, increasing There is also a risk with integrated approaches of em- the reach and uptake of the full integrated approach. ployers confusing mandatory and voluntary responsibilities. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 7 of 11 http://www.biomedcentral.com/1471-244X/14/131 In Australia and many other OECD countries, there is legal work (e.g., sickness absence, presenteeism) [3,7,35], as well obligation to provide psychologically as well as physically as from growing recognition of the need to fulfill OH&S safe working condition under OH&S law. Yet, employers obligations with respect to the protection of psychological seem to embrace workplace mental health literacy and re- as well as physical health. lated programs more readily than job stress prevention. Integrated approaches are also developing to some ex- Unions and other worker advocates are understandably tent in policy and practice across the OECD. In addition concerned that employer responses to mandatory require- to the example previously discussed, Canada very recently ments might be confused with or diluted by responses to published the first Standard for Psychological Health and voluntary programs. There is a need for improved articula- Safety in the Workplace in 2013 [77], the European Agency tion of all legal and ethical requirements, including em- for Safety and Health at Work published Mental Health ployment, anti-discrimination, and equal opportunity as Promotion in the Workplace in 2011 [78], the WHO has well as OH&S law, relevant to workplace mental health, as published generic guidance on integrated approaches (for a component of integrated approaches, for the benefit of workplace health in general) [79] as well as specific work- employers, workers, and other workplace stakeholders. place suicide prevention guidance [80]. The protection of confidentiality and the prevention of dis- While these policy and practice developments are very crimination are also key considerations in integrated and encouraging, there is a dearth of effectiveness evaluation other workplace mental health interventions. studies on these programs and intervention guidance re- Finally, to realise the greatest possible population men- sources. Intervention research on these and other inte- tal health benefits, governments and other policy-makers grated approaches should be a high priority. This would will need to consider how to ensure interventions are ac- include the full spectrum of intervention research: devel- cessible to those workers who are most in need of them. opment, implementation, and effectiveness [25]. Devel- Lower occupational status workers have the highest opmental research (developing what to do and how)isa prevalence of mental health problems, the greatest ex- particular priority for positive approaches, as most of posure to job stressors, and the lowest quality jobs the above examples focus little or not at all on how to [27,74]. These groups are typically the least likely to re- promote the positive aspects of work. As each interven- ceive job stress or other workplace mental health inter- tion approach has evolved relatively independently, there vention. In Australia and some other OECD countries, is a need for further improvement in the integration of exceptions include blue-collar males who have been strategy and guidance material from the three threads; this prioritised for workplace mental health literacy interven- would best be achieved through the involvement of the full tion by governments and non-governmental organisa- range of workplace stakeholders. For example, we have re- tions, such as mental health promotion foundations. cently applied the Delphi consensus method to work with This is largely on the basis of their low help-seeking three stakeholder groups (managers, workers, and work- behaviours and high prevalence of mental health prob- place health professionals) to develop [81] and web-publish lems. This praiseworthy policy action could be further (www.prevention.workplace-mentalhealth.net.au) a set strengthened by the integration of interventions that re- of integrated guidelines for the prevention of mental duce job stressors and improve work quality [74]. In the health problems in the workplace, extending similar absence of concerted efforts to reach priority groups, practice-based developmental research [67] to produce population level implementation of integrated or other guidelines for return to work from a mental illness (http:// workplace mental health intervention risks the exacerba- returntowork.workplace-mentalhealth.net.au/). The re- tion of mental health inequalities, as more advantaged cent Canadian standard for Psychological H&S in the groups would be more likely to experience and benefit Workplace is another source of guidance on integrated from intervention than disadvantaged groups, result- approaches to workplace mental health [77]. ing in widening disparities similar to those seen from Implementation research is also needed to inform both population-level tobacco control and other health promo- policy and practice (e.g., to answer research questions tion interventions [75,76]. such as: What factors facilitate or hinder implementation? What levels of support do various types and sizes of orga- Next steps for developing the integrated approach nisations need to implement integrated approaches? What There are various hopeful signs for the development of is practically achievable for organisations implementing integrated approaches in practice, policy, and research. their own programs?). Finally, effectiveness studies are There is growing receptivity among employers and other needed to demonstrate that integrated approaches work workplace stakeholders to the value of integrated ap- (e.g., When implemented as intended [82], are there sig- proaches, stemming largely from growing awareness of nificant improvements in mental health literacy, working the widespread prevalence and the impact of mental health conditions, and job quality over time? When implemented problems (work-related or otherwise) on productivity at as intended, are there improvements in mental health and LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 8 of 11 http://www.biomedcentral.com/1471-244X/14/131 wellbeing over time?). Economic studies (cost-effective- work and the supervisor) was effective in reducing the ness, cost-benefit) will also be required alongside effective- likelihood of recurrent sickness absences compared to ness studies to make the business case. While the costing care as usual [90]. While more research is needed to de- studies described under Premise 1 above show that there termine if these results are generalizable to other coun- are potential savings to be made, health economic evalu- tries or settings (or if this type of interventions is feasible ation research to date on worksite mental health interven- in other settings) this finding supports the notion that as- tions is limited. A recent meta-analysis of 10 studies in pects of the workplace play an important role in reducing this area found that they covered mainly screening and sickness absence due to mental health conditions, and return-to-work interventions in isolation, and found lim- in facilitating successful return to work mental health- ited evidence of positive cost-benefit ratios for screening related absence. and treatment interventions and no favourable cost- There is ample evidence that job loss is associated with effectiveness for return to work interventions [83]. It re- a decline in mental health [91,92]. The point of depart- mains to be seen whether integrated approaches would ure from the employer (e.g., with redundancy, downsiz- yield better results. ing, restructures—events which appear to be increasing To optimise the translation of research to practice, the in frequency [93]) represents one opportunity for inter- applied intervention research described above would be vention. While many employers offer job seeking sup- conducted in partnership with organisations and work- port or job retraining, and it can also be valuable to place stakeholders by multi-disciplinary teams of re- acknowledge potential mental health impacts and to searchers (at least covering disciplines relevant to each encourage help seeking in the event that it becomes of the three threads of the integrated approach). This needed. An Australian mental health foundation, beyond- will involve engagement and collaboration by researchers blue, has established a resource entitled “Taking Care of with relevant decision-makers and other workplace Yourself After Retrenchment or Financial Loss” for use stakeholders [1], and represents a move towards viewing in such circumstances by employers and others (available practice-based evidence as equally relevant as evidence- at www.beyondblue.org.au). Once separated from an em- based practice [84]. ployer and established as unemployed, social welfare, trade union, NGO, or other stakeholders can offer fur- Linking interventions in the workplace with other settings ther assistance towards re-employment as well as mental Whilst this paper is specifically focused on intervention health literacy and help-seeking education. Some such in the workplace setting, we acknowledge that work- programs in the US and Finland have shown evidence of places also interface with other important settings and prevention of job loss-related declines in mental health contexts for mental health intervention in the working as well as improved re-employment outcomes [94-96]. population. Most proximal to the workplace, there are Further development of such programs is warranted to those workers who have left work temporarily on sick- address mental health declines and increased suicide ness absence or workers’ compensation claims due to a risks associated with unemployment [97,98]. mental health problem, and who need to return to work with the same employer. This may involve return Conclusions to work from a mental health problem that is work- An integrated approach to workplace mental health can related, not work-related, or some combination of the expect near-term improvements in mental health literacy, two. This is an area of active research, policy, and prac- to be followed by longer-term improvements in working tice development. While research in this area is still conditions and job quality—given adequate organizational evolving, there is a growing recognition that the strat- commitment, support, and time to achieve organizational egies to return workers with mental health problems to change. These changes should, in turn, lead to improve- the workplace are likely different from those commonly ments in mental health and wellbeing. While improve- used to accommodate workers with physical conditions ments in psychosocial and other working conditions may [64-66,85,86]. In addition, workers with mental health be more difficult to achieve than improvements in mental conditions may be more susceptible to recurrent epi- health literacy, we would argue that efforts should con- sodes of absence [87,88]. A recent study of workers with tinue to be made in this regard in order to fulfil legal and a previous sickness absence due to mental health condi- ethical mandates to provide psychologically safe work and tions in the Netherlands identified that workers who had to reduce the substantial burden of work-related mental conflicts with their supervisor were more likely have a re- health problems. Increasing awareness of work-related current absence [89]. These same researchers have also influences on mental health, and the growing recognition demonstrated that a problem solving intervention, fo- of the need for ‘psychologically safe’ work may help to cused on processes to identify and address challenges in drive organisational efforts to improve psychosocial work- staying at work (including consultations between the ing conditions. LaMontagne et al. 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LaMontagne AD, Keegel T, Louie AM, Ostry A: Job stress as a preventable Acknowledgements upstream determinant of common mental disorders: a review for This work was supported by the Australian National Health and Medical practitioners and policy-makers. Adv Ment Health 2010, 9(1):17–35. Research Council (NHMRC) through both project (grant #1055333) and 15. de Lange AH, Taris TW, Kompier MA, Houtman IL, Bongers PM: Different post-doctoral research fellow support to AM, KP, TK (NHMRC Capacity-Building mechanisms to explain the reversed effects of mental health on work grant #546248), by beyondblue: the Australian National Depression Initiative characteristics. Scand J Work Environ Health 2005, 31(1):3–14. (project #6508), by project grant funding from the Institute for Safety, 16. Kalimo R: Reversed causality–a need to revisit systems modeling of work- Compensation, and Recovery Research (ISCRR), and Centre grant funding from stress-health relationships. Scand J Work Environ Health 2005, 31(1):1–2. the Victorian Health Promotion Foundation, Melbourne VIC, Australia (#15732). 17. D'Souza RM, Strazdins L, Lim LL-Y, Broom DH, Rodgers B: Work and health in a contemporary society: demands, control, and insecurity. J Epidemiol Author details Community Health 2003, 57:849–854. Population Health Strategic Research Centre, School of Health & Social 18. Broom DH, D'Souza RM, Strazdins L, Butterworth P, Parslow R, Rodgers B: Development, Deakin University, Burwood, VIC, Australia. Melbourne School Thelesserevil: bad jobs orunemployment? Asurvey of mid-aged of Population and Global Health, University of Melbourne, Melbourne, VIC, Australians. Soc Sci Med 2006, 63(3):575–586. Australia. The Tasmanian School of Business and Economics, University of 19. Coughlin S, Benichou J, Weed D: Attributable risk estimation in Tasmania, Hobart, TAS, Australia. Deakin Graduate School of Business, Deakin case-control studies. Epidemiol Rev 1994, 16:51–64. 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Workplace mental health: developing an integrated intervention approach

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Copyright © 2014 by LaMontagne et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; Psychiatry; Psychotherapy
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Abstract

Background: Mental health problems are prevalent and costly in working populations. Workplace interventions to address common mental health problems have evolved relatively independently along three main threads or disciplinary traditions: medicine, public health, and psychology. In this Debate piece, we argue that these three threads need to be integrated to optimise the prevention of mental health problems in working populations. Discussion: To realise the greatest population mental health benefits, workplace mental health intervention needs to comprehensively 1) protect mental health by reducing work–related risk factors for mental health problems; 2) promote mental health by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. We outline the evidence supporting such an integrated intervention approach and consider the research agenda and policy developments needed to move towards this goal, and propose the notion of integrated workplace mental health literacy. Summary: An integrated approach to workplace mental health combines the strengths of medicine, public health, and psychology, and has the potential to optimise both the prevention and management of mental health problems in the workplace. Background Workplace interventions to address common mental Mental health problems are common in the working health problems have evolved relatively independently population, and represent a growing concern, with po- along three main threads or disciplinary traditions: tential impacts on workers (e.g., discrimination), organi- medicine, public health, and psychology (Figure 1). In sations (e.g., lost productivity), workplace health and this Debate piece, we present two premises relating to compensation authorities (e.g., rising job stress-related 1) the high prevalence of such problems and disorders claims), and social welfare systems (e.g., rising working in the working population and 2) that working conditions age disability pensions for mental disorders) [1]. Grow- are a major modifiable risk factor, then argue that the three ing awareness of this issue has been paralleled by the intervention traditions or threads need to be integrated to rapid expansion of workplace interventions to address achieve the greatest population mental health benefits. An common mental health problems in the workplace set- integrated approach would 1) protect mental health by re- ting, particularly as a means to prevent, detect, and ef- ducing work–related risk factors; 2) promote mental health fectively manage depression and anxiety [2-4]. by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. Our aim in presenting this framework is to sup- * Correspondence: [email protected] port the achievement of best practice in workplace mental Population Health Strategic Research Centre, School of Health & Social health for the full range of relevant stakeholders: workers, Development, Deakin University, Burwood, VIC, Australia Melbourne School of Population and Global Health, University of employers, industry groups, labour organisations, policy- Melbourne, Melbourne, VIC, Australia makers, health professionals, researchers, and others. Full list of author information is available at the end of the article © 2014 LaMontagne et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 2 of 11 http://www.biomedcentral.com/1471-244X/14/131 In addition to clinical disorders, subclinical mental Positive Psychology, Management, health problems and generalised distress are also prevalent Organisational in the working population [8]. In summary, mental health Public Health, OH&S, Psychiatry, Development Occupational Health Psychology, disorders and related problems represent a large and com- Psychology,Health Occupational Promotion Medicine plex phenomenon in the workplace. Mental health problems among working people are Promote the also costly to society at large, healthcare systems, em- positive ployers, and affected individuals and their families. Con- Prevent Manage servative estimates of economic costs for European harm illness Union countries are 3-4% of gross domestic product [1,9]. Social costs include rising disability rates across Integrated the OECD due to mental disorders [1]. Healthcare costs approach for mental disorders vary widely, corresponding roughly with varying severity. For example, an Australian costing study found the greatest costs of depression amongst Figure 1 The three threads of the integrated approach to working people were borne by employers (far exceeding workplace mental health. healthcare costs), with turnover costs figuring more prominently than presenteeism and absenteeism costs [7]. Costing studies to date, however, are limited in their Premise One: mental health problems are prevalent in ability to quantify costs to affected individuals and their working populations families, particularly in regard to important social costs Mental health problems, both clinical (e.g., major depres- related to workplace stigma and discrimination [7]. sion, anxiety disorders) and sub-clinical (e.g., psychological distress), are very common in working populations. This Premise Two: working conditions are an important Debate piece focuses on the workplace setting - and thus modifiable risk factor for mental health problems the working population. However, it is important to ac- A substantial body of research has demonstrated the knowledge the complementary need for a more com- links between psychosocial working conditions—or job prehensive view of the entire working-age population, stressors—and worker health over the last three decades. which includes the unemployed, and those not in the Karasek and Theorell’s demand-control model has been labour force due to disability or other reasons [5]. Given particularly influential [10]. This model hypothesises that growing labour market flexibility and rising levels of un- high job strain, defined by a combination of low control employment and underemployment in many Organisa- over how the job is done in the face of high job de- tion for Economic Cooperation & Development (OECD) mands, will be harmful to health. This was first demon- countries [6], addressing worklessness as well as work is strated in relation to cardiovascular disease outcomes now particularly important. In a recent review, the OECD [10,11]. Subsequent studies have found that job strain estimated that similar proportions of the industrialised also predicts elevated risks of common mental disorders, working-age populations are affected by clinical mental even after accounting for other known risk factors disorders: with point-prevalence estimates of 5% for se- [12-14]. While there is a considerable body of evidence vere mental disorders and another 15% for moderate supporting a dominant 'normal causation' model regard- mental disorders [1]. Among those affected, those with ing the impact of working conditions on employee men- common mental disorders - depression, simple phobia, tal health, it should be noted that reversed causality, that and generalised anxiety disorder - have the highest work- is the impact of mental health on the assessment of force participation rates [3]. In Australia, for example, working conditions can also occur. There is some evi- the 2007 National Survey of Mental Health and Wellbeing dence that working conditions and mental health influ- estimated that 15% of the working population had a history ence each other reciprocally and longitudinally [15]. of major depressive disorder (lifetime prevalence [7]); of Systems thinking suggests bi-directional non-linear rela- these: tionships [16] and better understanding of these pro- cesses using advanced analytic techniques (e.g., marginal 21% reported depressive symptoms in the past year structural modelling) and stronger study designs will un- and were in treatment doubtedly be the subject of continuing research. 17% reported depressive symptoms in the past year Numerous other job stressors, either individually or in and were not in treatment combination, have been shown to influence mental 11% were recovered and in treatment health [14,17,18]. These include job insecurity, bullying 52% were recovered and not in treatment. or psychological harassment, low social support at work, LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 3 of 11 http://www.biomedcentral.com/1471-244X/14/131 organisational injustice, and effort-reward imbalance on sound principles or theory, and their feasibility and [12,14]. Unlike many historically prominent occupational effectiveness need to be demonstrated in implementa- exposures (e.g., asbestos), to which only a small pro- tion and effectiveness studies [25]. Below we summar- portion of the working population were exposed, all iseevidenceinthisregardfor thethree threadsofour working people can be potentially exposed to job proposed integrated intervention approach to workplace stressors. This means that even small increases in risk mental health. from such exposures can translate to substantial—and preventable—illness burdens. Given the population preva- Thread 1: protect mental health by reducing work–related lence of a given exposure and the associated increase in risk factors risk for a specific outcome, the proportion of that out- The relevant intervention principles and evidence in come attributable to the exposure of interest can be esti- this area come predominantly from the fields of pub- mated [19]. Based on job strain prevalence estimates of lic health (e.g., occupational health and safety, health 18.6% in males and 25.5% in females and an odds ratio of promotion) and psychology (particularly organisational 1.82 for job strain and depression [12], this method psychology). Like other public health interventions, job yielded estimates of job strain-attributable risk for depres- stress prevention and control interventions can be di- sion in an Australian working population sample as 13% rected at the primary, secondary, or tertiary levels [26-29]. of prevalent depression among working males and 17% Primary intervention aims to prevent the incidence among working women [20]. More recently, comparable of work-related mental health problems; it is ‘work- estimates were obtained from a study of the French work- directed’ - aiming to reduce job stressors at their source ing population for job strain-attributable risk for common by modifying the job or the work environment. Second- mental disorders: 10.2–31.1% for men, 5.3–33.6% for ary intervention is ameliorative and ‘worker-directed’;it women. Using a different approach, a New Zealand birth aims to modify how individuals respond to job stressors, cohort study estimated that, at age 32, 45% of incident usually through strategies to improve employees’ ability cases of depression and anxiety in previously healthy to cope with or withstand stressors. Secondary level young workers were attributable to job stress [21]. While intervention can also prevent the progress of sub-clinical further research is needed to firmly establish the causality mental health problems to diagnosable disorders. Ter- and magnitude of association of job strain and other stres- tiary intervention is reactive in that it responds to the sor exposures in relation to common mental health prob- occurrence of mental health problems; it involves treat- lems (which would suggest that the attributable risks just ing affected workers and supporting rehabilitation and presented are over-estimates), such single-exposure single- return-to-work. Theoretically, tertiary (and to some ex- outcome estimates may also underestimate the proportion tent secondary) intervention can reduce the burden of of mental health disorders attributable to job stressors, as mental disorders through early detection and treatment a comprehensive estimate would account for all relevant and limiting severity or chronicity. Some intervention job stressors and the full range of associated mental health strategies can be classified in different ways (e.g., in- outcomes [7]. In addition to depression, exposure to creasing worker resilience or coping capacity could be various job stressors has been associated with burnout, considered primary prevention if it is done before a anxiety disorders, alcohol dependence, suicide and other mental health problem has occurred, and secondary if mental health outcomes [14,22]. As such, preventing or it prevents the progression of an existing one)—most reducing exposure to job stressors and improving the importantly, primary, secondary, and tertiary interven- psychosocial quality of work could prevent a substantial tion are complementary, thus a comprehensive or sys- proportion of common mental health problems. Such tems approach to prevent and control the impacts of improvements would benefit other health domains as job stress entails all three [26]. In the preventive medicine well, as exposure to these same job stressors also pre- typology (as relevant to thread 3 below), this framework dicts elevated risks for poor health behaviours as well as roughly parallels universal, selected and indicated disease other high burden chronic illnesses, including cardiovas- prevention [30]. cular disease [23,24]. Systematic reviews of job stress prevention and control studies show that the most effective interventions com- Discussion bine primary prevention to reduce job stressors with What then is the potential for preventing and managing secondary intervention to strengthen workers’ abilities to this large and complex burden of mental health prob- withstand stressors [4,31-34]. While these systematic re- lems in the working population? The identification of views indicate what to do, the more challenging question modifiable risk factors implies potential preventability, in application to policy and practice is how to do it. While but this needs to be demonstrated through interven- the principles of intervention are broadly applicable, tion studies. Intervention strategies should be based solutions are unique to the work context (e.g., worker LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 4 of 11 http://www.biomedcentral.com/1471-244X/14/131 socio-demographics and occupational skill levels, type of potential and create change, future search, which in- workplace, presence or absence of a union). For example, volves working towards an aspirational view of the fu- strategies to improve job control for a sales clerk will dif- ture, and future inquiry—a hybrid of the two that fer from strategies to achieve the same for a manager, acknowledges the views of all relevant stakeholders, gen- even in the same workplace. Intervention design and im- erates respect for what has been done well, identifies a plementation capabilities and resources in small-medium shared aspirational view of the future, and plans steps to business settings also need to be considered [35]. Inter- move in that direction [42,43]. Positive outcomes in- vention strategies need to be tailored and context ap- clude subjective wellbeing, psychological capital, positive propriate [28,36], making the development of such mental health, employee engagement, and positive or- interventions more involved and labour-intensive than ganisational attributes such as authentic leadership, sup- interventions for most other occupational hazards (e.g., portive workplace culture and workplace social capital. installing a machine guard to prevent hand injuries). Wellbeing—also referred to as subjective or psycho- Whilst knowledge of solutions for various work con- logical wellbeing, happiness or life satisfaction—is more texts is growing, there is still a need to apply principles than the absence of ill-health states but the presence of and develop solutions on a case-by-case basis. This has positive feelings and functioning [44]. The concept has likely contributed to the slow uptake of effective job also been applied to the domain of work [45]. A key stress prevention and control strategies in practice. point here is that the term ‘well-being’ does not refer to Further, there is a persisting disconnect between evidence- the absence of the negative; instead, wellbeing is most based best practice and what is currently being under- correctly defined and measured as the presence of posi- taken in the workplace setting to address mental health, tive feelings and functioning. Despite this important dis- with prevalent practice directed more at secondary than tinction, some inappropriately use ‘mental health and primary intervention. For example, when Human Resources wellbeing’ as a catchall phrase for mental (ill) health or OH&S staff are asked about their organisation’sresponse constructs. to job stress concerns, the most common response is to There is a need for both organization-wide and indi- provide an Employee Assistance Program [37,38]. Other vidual level approaches to employee well-being and barriers to the uptake of evidence-based best practice mental health. This would align with the comprehensive include issues of stigma similar to those concerning mental or systems approach to job stress prevention described illness in general, such as a persisting view of job stress as above. Importantly, positive approaches aim to promote an individual weakness [38]. the positive aspects of work and worker capabilities To summarise, job stress prevention and control is (including wellbeing) as distinct from other strategies, distinguished by its emphasis on primary or universal which aim to increase understanding of, or prevent, men- prevention, and the need to intervene at the level of tal illness (e.g., mental health promotion and stress work organisation as well as the individual. Implementa- prevention). Some key approaches involve developing tion in practice, however, has proven challenging, in part positive workplaces by establishing positive leadership because solutions need to be context-specific. practices, ensuring work is meaningful, and building a positive organizational climate [46,47]. The newness of Thread 2: promote mental health by developing the positive approaches is reflected in its being the least positive aspects of work as well as worker strengths and commonly applied in organisational practice compared positive capacities to the other two threads of our proposed integrated ap- The relevant intervention principles and evidence in this proach [48]. Positive psychology interventions, how- area come predominantly from the field of psychology, ever, are becoming increasingly popular in clinical and in particular the rapidly developing field of positive general settings. psychology [39]. Positive psychology is defined as the A meta-analysis of the general literature (in all settings) study of “the conditions and processes that contribute to concluded that wellbeing can be sustainably enhanced the flourishing or optimal functioning of people, groups, and depressive symptoms reduced through positive inter- ventions [49]. Positive-focused workplace strategies are and institutions” [40]. What distinguishes positive psych- ology intervention in practice is that it applies strength- less commonplace and need further development. This is based methods to the achievement of positive outcomes. particularly critical given the lack of intervention effect- iveness in the workplace mental health space generally. Strength-based methods aim to identify and enhance strengths or what is being done well, rather than trying Nevertheless, there are some small but successful exam- to identify and fix what is ‘wrong’ in an individual, group ples in workplace settings, such as a positive psychology- based employee wellbeing program in a sample of work- or organisation [41]. It includes the application of methods such as appreciative inquiry, which involves ing adults that showed positive changes in wellbeing asking positive questions in order to strengthen positive over six months in comparison to non-participants [50]. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 5 of 11 http://www.biomedcentral.com/1471-244X/14/131 Whilst research on strength-based methods, and par- by developing knowledge and skills on how to recognise ticularly how to apply these methods at a primary common mental disorders and provide “First Aid” sup- level, is relatively new, research in this area is growing port until professional help can be obtained, increasing rapidly and may provide a valuable complement to understanding about the causes of mental disorders, im- problem-based methods. proving knowledge of the most effective treatments, and The promise of positive approaches is clearly sup- reducing stigma [55,57]. There is evidence of effective- ported by established knowledge of the substantial posi- ness of MHFA from various studies [57] including two tive influences of good quality work on mental health randomised-controlled trials conducted in workplace set- and wellbeing. In addition to the income and socio- tings [55,58]. In addition to improvements in mental economic position that paid work can provide, it can health literacy, there is also some evidence of improve- also positively impact adult socialisation, the develop- ments in mental health among MHFA trainees [55]. Fur- ment of identity, and the building of social connections ther, there is evidence for the effectiveness of secondary extending beyond family and neighbourhood groups and tertiary approaches to workplace suicide prevention [14,51]. Furthermore, work can provide purpose and in specific at-risk occupations such the U.S. air force meaning, thus enhancing both self-efficacy and self- [59]. Nevertheless, additional intervention studies as well esteem, both of which protect and promote mental as evidence synthesis is clearly warranted, and adequate health. For example, research into what motivates older numbers of specific types of intervention studies (e.g., workers to stay in the labour market has demonstrated workplace mental health literacy) may soon be available that opportunities to use their skills, to be creative, to to enable systematic review and meta-analyses. gain a sense of accomplishment, and opportunities to Other strategies for addressing mental health problems interact with co-workers, are often rated more highly in the workplace focus on organisational culture and at- than financial security in decisions about staying in the titudes in relation to mental illness stigma and norms labour market [52-54]. As well as having direct relevance around disclosure. Mental health stigma in workplaces is to developing strategies to promote the positives of a pervasive challenge, just as it is in broader society [60]. work for mental wellbeing, such findings are directly A study of 6,399 employees from 13 workplaces in the relevant to developing policy and practice responses to USA found that although 62% knew how to access com- the ageing workforce across the industrialised world. pany resources for depression care, only 29% indicated This highlights the need for positive approaches to address they would feel comfortable discussing the issue with eudaimonic (meaning and purpose) as well as hedonic their supervisor [61]. Unsupportive organisational cul- (positive emotional, or happiness) aspects of workplace ture and norms around depression disclosure are a con- wellbeing [14,44]. tributing factor. Managers’ and leaders’ attitudes play a To summarise, positive approaches provide a valuable central role in changing these norms and are a priority and but rarely utilised complement to risk-based or target for intervention [62,63]. The development and negatively framed approaches (such as OH&S). However dissemination of accommodation strategies is also needed, interventions involving positive work psychology are as managers , HR professionals, and others in workplaces limited by their emphasis to date on the individual level may be willing but unsure about how to accommodate a [40] and the need for further evidence of effectiveness. worker with a mental health condition (compared to Team/group and organisational level positive approaches knowledge about physical accommodation), or these are being developed, and may prove to yield greater ben- accommodations may be seen as too complicated to efits than individual-level approaches in the future. put in place [64-66]. Finally, some strategies focus on the role of organisational culture in improving return-to-work Thread 3: address mental health problems among from a mental illness-related absence [67]. working people regardless of cause To summarise, illness-focused approaches to address- Work in this area has expanded rapidly over the last ing mental health problems are strongest at the tertiary decade and has been largely developed from an illness or and secondary, or—in preventive medicine terminology— medical perspective, emphasising tertiary and secondary- selected and indicated levels. Initially, they tended to be level interventions. Workplace programs that aim to individual-focused, but strategies are rapidly expanding to address mental health problems or disorders in the address organisational culture and norms. There is prom- ising evidence of effectiveness, but further research in this workplace commonly use psychoeducation and aim to improve mental health literacy, or develop skills for regard is needed. Early detection and disclosure are ham- early intervention and the promotion of help-seeking pered by persisting stigma and the potential for discrimin- ation; the continuing improvement of strategies to address [55,56]. An example of a program being implemented in multiple OECD countries is Mental Health First Aid these barriers is a key priority for research, policy, and (MHFA), which seeks to improve mental health literacy practice. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 6 of 11 http://www.biomedcentral.com/1471-244X/14/131 The integrated approach: joining the threads The growing public awareness and employer receptiv- A defining feature of the integrated approach is the mu- ity to MHL intervention suggests that the integrated ap- tually reinforcing nature of the three threads. While the proach might best be described as workplace mental protective focus of the first thread aims to identify and health literacy. Based on Jorm’s earlier definition of address factors that can undermine the mental health of MHL as “knowledge and beliefs about mental disorders employees – and therefore encourages employers to ful- which aid their recognition, management or prevention” fil their responsibility to provide a safe and healthy [70], we would define workplace mental health literacy working environment, the overall goal of the second the knowledge, beliefs, and skills that aid in the preven- thread is to complement the risk reduction approach by tion of mental disorders in the workplace, and the recog- promoting those characteristics that can strengthen indi- nition, treatment, rehabilitation, and return to work of vidual and organisational health and can lead to high working people affected by mental disorders. Differing, levels of positive wellbeing. To some extent this comple- but overlapping sets of knowledge, beliefs and skills mentarity is already apparent; for example, understand- would apply to people in various roles in or in the rela- ing of the importance of job control has evolved from tion to the workplace setting, including for examples two sides of the same coin. Low job control was identi- workers, managers, and HR staff in a given workplace, fied in public health research as an important risk factor and worker and employer advocates and healthcare pro- for mental health problems (thread 1), and the promo- fessionals in relation to various workplaces. tion of autonomy (or high job control) is a common Further work will be required to articulate the links strategy in positive approaches (thread 2). Maintaining and genuinely integrate the threads of the integrated ap- this dual protection-promotion emphasis can benefit proach, which may indeed lead to efficiencies in imple- workplace mental health in many ways, not least in en- mentation as well as preventive synergies, such as has couraging organisations and their representatives to been realised through integrated approaches targeting can- examine the strengths and weaknesses of their working cer prevention other aspects of workplace health [71-73]. environments, to keep a more ‘balanced scorecard’ in re- lation to monitoring the performance of their various The integrated approach: cautionary notes systems, policies and practices, and to properly identify Although combining the three threads of the integrated and mobilise the resources available in their organisa- approach could substantially improve mental health out- tions to build workplaces that are not just safer and comes over above what might be achieved by each fairer but are also more attractive to and engaging for thread on its own, it is important to acknowledge the employees. potential risks and challenges of adopting this approach. The third thread can complement the first two in vari- To date, there is a persisting over-emphasis on individual- ous ways. Certain knowledge and awareness aspects of directed intervention in workplace health intervention pol- mental health literacy (MHL), for example, relate dir- icy and practice, which would need to be overcome in ectly to the other two threads. The workplace MHL order to realise a genuinely integrated approach. The great strategies we have piloted for example, highlight that uptake of workplace mental health literacy as well as poor working conditions and job stress are modifiable resilience-oriented positive psychology programs may be risk factors for common mental health problems, and partly explained by this. For example, past mental health (where applicable) that there are legislative OH&S man- literacy programs have been largely individual-directed dates to protect psychological as well as physical health education and training programs, thus far mainly evaluated [68,69], thus building employee awareness of and em- in terms of short-term changes in individuals’ knowledge, ployer commitment to the need to address working con- attitudes, and helping skills. In contrast, reducing job ditions (linking to thread 1). Workplace MHL can also stressors and improving job quality requires organizational highlight the protective value of resilience in relation to changes, which generally require more resources and a mental disorders, building motivation for and commit- longer period of change. In a recent feasibility study to de- ment to positive approaches (linking to thread 2). In velop and implement an integrated job stress and mental addition, starting where organisations are receptive (MHL health literacy intervention, significant improvements in training) can provide the encouragement/incentives to mental health literacy were observed over one year, but— employers (near term improvement in MHL) needed to disappointingly—no improvements in job demands, sustain employer interest and commitment to the im- job control, or workplace social support [68,69]. More provement of working conditions and job quality over the intensive or sustained work-directed intervention, longer longer term. This could help provide entrée into work- follow-up, or both are needed to achieve and demonstrate places that might not otherwise consider job stress or improvement in working conditions. other mental health interventions on their own, increasing There is also a risk with integrated approaches of em- the reach and uptake of the full integrated approach. ployers confusing mandatory and voluntary responsibilities. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 7 of 11 http://www.biomedcentral.com/1471-244X/14/131 In Australia and many other OECD countries, there is legal work (e.g., sickness absence, presenteeism) [3,7,35], as well obligation to provide psychologically as well as physically as from growing recognition of the need to fulfill OH&S safe working condition under OH&S law. Yet, employers obligations with respect to the protection of psychological seem to embrace workplace mental health literacy and re- as well as physical health. lated programs more readily than job stress prevention. Integrated approaches are also developing to some ex- Unions and other worker advocates are understandably tent in policy and practice across the OECD. In addition concerned that employer responses to mandatory require- to the example previously discussed, Canada very recently ments might be confused with or diluted by responses to published the first Standard for Psychological Health and voluntary programs. There is a need for improved articula- Safety in the Workplace in 2013 [77], the European Agency tion of all legal and ethical requirements, including em- for Safety and Health at Work published Mental Health ployment, anti-discrimination, and equal opportunity as Promotion in the Workplace in 2011 [78], the WHO has well as OH&S law, relevant to workplace mental health, as published generic guidance on integrated approaches (for a component of integrated approaches, for the benefit of workplace health in general) [79] as well as specific work- employers, workers, and other workplace stakeholders. place suicide prevention guidance [80]. The protection of confidentiality and the prevention of dis- While these policy and practice developments are very crimination are also key considerations in integrated and encouraging, there is a dearth of effectiveness evaluation other workplace mental health interventions. studies on these programs and intervention guidance re- Finally, to realise the greatest possible population men- sources. Intervention research on these and other inte- tal health benefits, governments and other policy-makers grated approaches should be a high priority. This would will need to consider how to ensure interventions are ac- include the full spectrum of intervention research: devel- cessible to those workers who are most in need of them. opment, implementation, and effectiveness [25]. Devel- Lower occupational status workers have the highest opmental research (developing what to do and how)isa prevalence of mental health problems, the greatest ex- particular priority for positive approaches, as most of posure to job stressors, and the lowest quality jobs the above examples focus little or not at all on how to [27,74]. These groups are typically the least likely to re- promote the positive aspects of work. As each interven- ceive job stress or other workplace mental health inter- tion approach has evolved relatively independently, there vention. In Australia and some other OECD countries, is a need for further improvement in the integration of exceptions include blue-collar males who have been strategy and guidance material from the three threads; this prioritised for workplace mental health literacy interven- would best be achieved through the involvement of the full tion by governments and non-governmental organisa- range of workplace stakeholders. For example, we have re- tions, such as mental health promotion foundations. cently applied the Delphi consensus method to work with This is largely on the basis of their low help-seeking three stakeholder groups (managers, workers, and work- behaviours and high prevalence of mental health prob- place health professionals) to develop [81] and web-publish lems. This praiseworthy policy action could be further (www.prevention.workplace-mentalhealth.net.au) a set strengthened by the integration of interventions that re- of integrated guidelines for the prevention of mental duce job stressors and improve work quality [74]. In the health problems in the workplace, extending similar absence of concerted efforts to reach priority groups, practice-based developmental research [67] to produce population level implementation of integrated or other guidelines for return to work from a mental illness (http:// workplace mental health intervention risks the exacerba- returntowork.workplace-mentalhealth.net.au/). The re- tion of mental health inequalities, as more advantaged cent Canadian standard for Psychological H&S in the groups would be more likely to experience and benefit Workplace is another source of guidance on integrated from intervention than disadvantaged groups, result- approaches to workplace mental health [77]. ing in widening disparities similar to those seen from Implementation research is also needed to inform both population-level tobacco control and other health promo- policy and practice (e.g., to answer research questions tion interventions [75,76]. such as: What factors facilitate or hinder implementation? What levels of support do various types and sizes of orga- Next steps for developing the integrated approach nisations need to implement integrated approaches? What There are various hopeful signs for the development of is practically achievable for organisations implementing integrated approaches in practice, policy, and research. their own programs?). Finally, effectiveness studies are There is growing receptivity among employers and other needed to demonstrate that integrated approaches work workplace stakeholders to the value of integrated ap- (e.g., When implemented as intended [82], are there sig- proaches, stemming largely from growing awareness of nificant improvements in mental health literacy, working the widespread prevalence and the impact of mental health conditions, and job quality over time? When implemented problems (work-related or otherwise) on productivity at as intended, are there improvements in mental health and LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 8 of 11 http://www.biomedcentral.com/1471-244X/14/131 wellbeing over time?). Economic studies (cost-effective- work and the supervisor) was effective in reducing the ness, cost-benefit) will also be required alongside effective- likelihood of recurrent sickness absences compared to ness studies to make the business case. While the costing care as usual [90]. While more research is needed to de- studies described under Premise 1 above show that there termine if these results are generalizable to other coun- are potential savings to be made, health economic evalu- tries or settings (or if this type of interventions is feasible ation research to date on worksite mental health interven- in other settings) this finding supports the notion that as- tions is limited. A recent meta-analysis of 10 studies in pects of the workplace play an important role in reducing this area found that they covered mainly screening and sickness absence due to mental health conditions, and return-to-work interventions in isolation, and found lim- in facilitating successful return to work mental health- ited evidence of positive cost-benefit ratios for screening related absence. and treatment interventions and no favourable cost- There is ample evidence that job loss is associated with effectiveness for return to work interventions [83]. It re- a decline in mental health [91,92]. The point of depart- mains to be seen whether integrated approaches would ure from the employer (e.g., with redundancy, downsiz- yield better results. ing, restructures—events which appear to be increasing To optimise the translation of research to practice, the in frequency [93]) represents one opportunity for inter- applied intervention research described above would be vention. While many employers offer job seeking sup- conducted in partnership with organisations and work- port or job retraining, and it can also be valuable to place stakeholders by multi-disciplinary teams of re- acknowledge potential mental health impacts and to searchers (at least covering disciplines relevant to each encourage help seeking in the event that it becomes of the three threads of the integrated approach). This needed. An Australian mental health foundation, beyond- will involve engagement and collaboration by researchers blue, has established a resource entitled “Taking Care of with relevant decision-makers and other workplace Yourself After Retrenchment or Financial Loss” for use stakeholders [1], and represents a move towards viewing in such circumstances by employers and others (available practice-based evidence as equally relevant as evidence- at www.beyondblue.org.au). Once separated from an em- based practice [84]. ployer and established as unemployed, social welfare, trade union, NGO, or other stakeholders can offer fur- Linking interventions in the workplace with other settings ther assistance towards re-employment as well as mental Whilst this paper is specifically focused on intervention health literacy and help-seeking education. Some such in the workplace setting, we acknowledge that work- programs in the US and Finland have shown evidence of places also interface with other important settings and prevention of job loss-related declines in mental health contexts for mental health intervention in the working as well as improved re-employment outcomes [94-96]. population. Most proximal to the workplace, there are Further development of such programs is warranted to those workers who have left work temporarily on sick- address mental health declines and increased suicide ness absence or workers’ compensation claims due to a risks associated with unemployment [97,98]. mental health problem, and who need to return to work with the same employer. This may involve return Conclusions to work from a mental health problem that is work- An integrated approach to workplace mental health can related, not work-related, or some combination of the expect near-term improvements in mental health literacy, two. This is an area of active research, policy, and prac- to be followed by longer-term improvements in working tice development. While research in this area is still conditions and job quality—given adequate organizational evolving, there is a growing recognition that the strat- commitment, support, and time to achieve organizational egies to return workers with mental health problems to change. These changes should, in turn, lead to improve- the workplace are likely different from those commonly ments in mental health and wellbeing. While improve- used to accommodate workers with physical conditions ments in psychosocial and other working conditions may [64-66,85,86]. In addition, workers with mental health be more difficult to achieve than improvements in mental conditions may be more susceptible to recurrent epi- health literacy, we would argue that efforts should con- sodes of absence [87,88]. A recent study of workers with tinue to be made in this regard in order to fulfil legal and a previous sickness absence due to mental health condi- ethical mandates to provide psychologically safe work and tions in the Netherlands identified that workers who had to reduce the substantial burden of work-related mental conflicts with their supervisor were more likely have a re- health problems. Increasing awareness of work-related current absence [89]. These same researchers have also influences on mental health, and the growing recognition demonstrated that a problem solving intervention, fo- of the need for ‘psychologically safe’ work may help to cused on processes to identify and address challenges in drive organisational efforts to improve psychosocial work- staying at work (including consultations between the ing conditions. LaMontagne et al. BMC Psychiatry 2014, 14:131 Page 9 of 11 http://www.biomedcentral.com/1471-244X/14/131 Developing an integrated approach could also be framed 6. OECD: OECD employment outlook 2013. In Organisation for economic cooperation & development. Paris: OECD Publishing; 2013. Access at http:// as moving towards a comprehensive notion of workplace www.oecd-ilibrary.org/employment/oecd-employment-outlook-2013_ mental health literacy as involving the knowledge, beliefs, empl_outlook-2013-en. and skills that aid in the prevention of mental illness in the 7. LaMontagne AD, Sanderson K, Cocker F: Estimating the Economic Benefits of Eliminating Job Strain as a Risk Factor for Depression. Melbourne: Victorian workplace, and the recognition, treatment, rehabilitation, Heath Promotion Foundation (VicHealth); 2010. access at http://www. and return to work of working people affected by mental vichealth.vic.gov.au/jobstrain. illness. This includes consideration of working conditions 8. 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LaMontagne AD, Keegel T, Louie AM, Ostry A: Job stress as a preventable Acknowledgements upstream determinant of common mental disorders: a review for This work was supported by the Australian National Health and Medical practitioners and policy-makers. Adv Ment Health 2010, 9(1):17–35. Research Council (NHMRC) through both project (grant #1055333) and 15. de Lange AH, Taris TW, Kompier MA, Houtman IL, Bongers PM: Different post-doctoral research fellow support to AM, KP, TK (NHMRC Capacity-Building mechanisms to explain the reversed effects of mental health on work grant #546248), by beyondblue: the Australian National Depression Initiative characteristics. Scand J Work Environ Health 2005, 31(1):3–14. (project #6508), by project grant funding from the Institute for Safety, 16. Kalimo R: Reversed causality–a need to revisit systems modeling of work- Compensation, and Recovery Research (ISCRR), and Centre grant funding from stress-health relationships. 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