Mental Health Conditions and Work
Most people with mental ill-health are affected by mild-to-moderate illness—predominantly mood and anxiety disorders, commonly referred to as “common mental illness”. According to the Global Burden of Diseases Study, mental disorders and substance abuse were the chief causes of years lived with disability (175 million years worldwide in 2010) [
69]. In the European Union, the estimated total costs of mental illness were around 3.5 % of GDP in 2010, with similar estimates for developed non-European countries [
70]. Mental ill-health affects one-fifth of the working-age population at any given moment [
70]. In the US, a survey found a total of 6.4 % of employed respondents had a major depressive disorder episode in the past 12 months, and an additional 1.1 % had major depressive episodes due to bipolar disorder or mania-hypomania [
71].
In OECD countries, mental ill-health is responsible for between one-third and one-half of all long-term sickness and disability among the working-age population [
70]. In the US, 36 % of Social Security Disability Insurance (SSDI) and 60 % of working-age Supplemental Security Income (SSI) beneficiaries have a mental illness as their primary reason for inability to work [
72]. Relative to the mentally healthy, the employment rate of people who suffer from poor mental health is 15–30 % lower and their unemployment compensation rate is twice as high [
73]. Co-morbidity of back pain and common mental disorders is associated with a higher risk of disability pension than either individual condition, when added up [
74].
In the workplace, mental ill-health has a greater financial impact due to low productivity at work than work absence. Approximately 30 % of lost work productivity due to depression in the US workforce is attributable to absenteeism, but 70 % is attributable to presenteeism [
71]. For major depressive disorders (MDD), annualized estimates are 225 million lost workdays and $36.6 billion lost productivity per year in the US [
71].
Mental Health and the Work Environment
Although work is a generally protective environment and fosters good mental health [
75], it can also cause distress for certain employees and exacerbate mental health conditions [
73]. Poor-quality jobs, problematic leadership, and psychosocial stress in the workplace can put the psychological health of the worker under strain and even trigger specific mental health conditions [
76]. In the EU, high psychological demands, discrimination, bullying, and work-life imbalance have been observed as risk factors for sickness absence onset [
77].
As with other chronic conditions, cause-and-effect relationships between the work environment and mental health are complex and multi-directional. On the one hand, poor psychosocial work environment can cause mental ill-health. On the other hand, workers with mental health problems tend to work in lower-quality jobs and environments, earn less per hour, have less secure jobs, are less satisfied with their jobs, report strain more often, and perceive their work situation more negatively [
73]. The importance of psychosocial hazards in the work environment has been acknowledged by many countries through labor legislation requiring employers to routinely assess, prevent and control psychosocial risks at work. However, employers may consider the incentives for reducing psychosocial workplace risks as less compelling than for general workplace risks. Many enterprises, especially most small enterprises, receive minimal support or incentives to address psychosocial risks.
A wide range of interventions with a focus at the individual (worker), organizational (workplace), system (healthcare) level, or in combination have been developed and evaluated. A typology of these interventions is presented in Table
2. The nature of workplace involvement is often difficult to determine in these studies (being the place of delivery, the operator-facilitator and/or the target of the intervention). Even when interventions are indicated as workplace-based or oriented, most are in fact individually targeted [
78‐
81].
Table 2
Intervention strategies from the scientific literature to improve outcomes for workers with mental health disorders
Worker level | Psychological intervention | Cognitive and/or behavioral therapy Skills training (stress inoculation training) Gradual exposure Problem solving therapy Occupational therapy Job coaching |
| Physical intervention | Relaxation training Exercise |
| Pharmacological intervention | Medication |
Workplace level | Altering material conditions | Reduce physical exposures Reduce chemical exposures |
| Altering work schedules | Working hours Working shifts Work intensity Work pace and deadlines Rest breaks |
| Altering work organization | Reduce psychological job demands Reduce problematic social factors Assess efforts and provide rewards Adjust responsibilities Alter processes and procedures Alter team organization and structure |
Healthcare provider level | Provide enhanced care | Strengthen work focus in primary care Strengthen work focus in psychiatric care Strengthen role of occupational physician |
| Improve care coordination | Integrated case management across disciplines Coordination of care |
Several systematic reviews attempted to synthetize the evidence from original studies, but the heterogeneity of interventions and outcomes precludes any single conclusion (Table
3). For example, a Cochrane systematic review [
80] identified 5 workplace-based interventions intended to promote return to work for workers will mental ill-health [
82‐
86], which demonstrated a significant improvement in time until first RTW (HR 2.64, 95 % CI 1.41–4.95), but no impact on sustained RTW (HR 0.79, 95 % CI 0.54–1.17). All studies had been conducted in the Netherlands. Two main components of these interventions are worth mentioning. Firstly, a cognitive perspective of the RTW process was adopted, with the provision of a psycho-educational component including empowerment, problem resolution skills and self-help competencies. Secondly, a collaborative / participative approach was adopted, aiming at achieving a consensus between the supervisor and the worker about work accommodations and the RTW process. Both components required professionals (occupational therapist, RTW coordinator) who were trained about addressing workplace issues and the work organization, in addition to the principles of cognitive—behavioral therapy. The authors of a recent review concluded that there was at best low quality evidence on the effectiveness of workplace interventions for workers with mental health problems [
80].
Table 3
Conclusions of systematic reviews of the scientific literature concerning mental health and work outcomes
| Review of intervention practices for depression in the workplace | Evidence was graded as “very low” for all outcomes identified; therefore, no interventions were recommended |
Nieuwenhuijsen et al. [ 80] | Review of interventions to improve return-to-work (RTW) after depression | Moderate quality evidence that adding a work-directed intervention to clinical intervention reduces number of days on sick leave; moderate quality evidence that enhancing primary or occupational care with cognitive behavioral therapy reduces days on sick leave |
| Review of interventions to facilitate RTW after adjustment disorders | No randomized controlled trials (RCTs) were found of employee assistance programs; Eight studies focused on the work environment; moderate-quality evidence that problem solving therapy significantly enhanced partial RTW at one-year follow-up |
| Review of effects of organizational-level interventions at work on employee health | Success rates were higher among more comprehensive interventions tackling material, organizational and work-time related conditions simultaneously |
| Review of ways to manage stress at work (A summary of existing reviews reporting on anxiety, depression, and absenteeism) | Individual interventions had a greater effect size for individual-level outcomes; there was mixed evidence on the effectiveness of organizational interventions on absenteeism; there was clear evidence that employer-based physical activity promotion has a small effect on total absenteeism; Some interventions paradoxically led to deterioration in mental health and absenteeism |
| Review of evidence for workplace health promotion on job well-being, work ability, and absenteeism | Sickness absence is reduced by activities promoting healthy lifestyle and ergonomics |
| Review of the evidence supporting job stress interventions | Individual-focused approaches are effective at the individual level, but these interventions have no measurable impact at the organizational level |
| Review of active workplace interventions to reduce sickness absence | One early intervention in employees with mild to severe depressive complaints and high risk of future long-term sickness absence proved to be effective in preventing/reducing both sickness absence and depressive complaints |
| Review of process evaluations in job stress management programs | Fewer than half of studies linked process evaluation to outcome evaluation; process relevant variables were recruitment, intervention dose received, participants’ attitudes toward intervention, and program reach |
Several limitations of the published workplace-related mental health studies must be emphasized. There is a lack of theoretical reasoning as the basis for the proposed interventions, especially in relation to addressing the work environment [
78,
87]. The nature of the impairments and work limitations due to MH conditions were not well described. The concept of “early intervention” that is supported in most musculoskeletal condition—related RTW research has actually led to worse results in at least one mental health-related study, perhaps suggesting that work resumption should be delayed in some instances until significant MH improvement or stabilization has occurred [
84]. As related to persistent mental health conditions there is a large discrepancy between psychosocial work factors identified as related to work disability in MH conditions, and the paucity of interventions at the organizational (workplace) level that might actually mitigate these factors.
In the few studies that reported process evaluations, implementation obstacles have included interventions being too complex, delivered too early in the course of the MH condition, or too time-consuming [
84,
86]. The risks for the worker with MH problems of discussing psychosocial work factors with workplace actors are also rarely discussed, which is concerning, given the importance of workplace collaboration emphasized in many RTW interventions [
83,
85,
88,
89].
Observations from the Grey Literature
This literature emphasizes that interventions often are delayed until it is too late to exert any lasting effect, key stakeholders are left out, and different institutions and services tend to work in isolation [
73]. Therefore, the OECD advocates for a shift toward earlier (but not too early), more integrated and front-line interventions, in order to avoid work exclusion of people with mental ill health [
73]. Line managers and general practitioners have been identified as best placed to identify work-related issues, to address impacts and implications, and to involve other professionals as necessary [
73]. However, they need improved skills to work with employees experiencing mental health challenges, operational guidelines, and better tools to assist them with both identification and triage and referral processes. Anti-stigma policies can create a better environment to address employee concerns and challenges directly [
73].
While a number of potential job accommodations are described in the grey literature related to mental health conditions, there are very few investigations of the effects of these work adjustments in the scientific literature. The roles of frontline managers and work organization are studied more often, but the results are also quite limited (Table
4).
Table 4
Sample recommendations (grey literature) for workplace approaches to reducing mental health absenteeism
American College of Occupational and Environmental Medicine [ 100] | Use comprehensive approaches that span injury prevention, health promotion, and accommodation Provide primary prevention through mental health and resilience promotion Identify and modify sources of stress and other relevant risk factors, reduce stigma Provide employee education, voluntary screening, supervisor training, and employee assistance programs Facilitate early detection and treatment before sickness absence or job loss occurs Establish referral pathways to find evidence-based practitioners experienced in workplace issues Provide workplace accommodations for disability prevention and return to work Engage on-site medical personnel to actively support treatment adherence Ensure management commitment to an integrated workplace approach for dealing with depression Evaluate programs periodically for most effective coordination of mental health problems |
American College of Occupational and Environmental Medicine [ 9] | Ensure that medical determinations of ability to work are based on accurate job information Recognize potential negative life impacts of a prolonged work absence Early disability prevention efforts are best Educate employees about the benefits of an early return to work Insure appropriate medical treatment of mental health conditions |
Job Accommodation Network [ 101] | Give practical guidance on workplace accommodations to address specific functional problems at work Suggest potential accommodations for a range of mental conditions and provide case example illustrations |
| Use evidence-based Supported Employment (SE) for people with serious mental illnesses Provide a reasonably supportive workplace with flexibility and empathy |
| Become involved in community efforts to provide accommodations for persons with mental health problems EAP programs may help to reduce mental-health related work disability Use disease and case management, disability management, and early contact and improved communication Provide routine occupational health consultations at the workplace for employees with mental health disorders |
Organization for Economic Cooperation and Development [ 104] | Address mental health stigma Manager training and support to respond to workers’ mental health issues, including toolkits Human resource professionals who provide education and support to managers about the RTW process |
Organisation for Economic Cooperation and Development [ 104] | Avoid high levels of job stress Provide early response to sick leave Adopt strategies to avoid workplace conflicts and reduce stigma Insist on being an active part of a workers’ rehabilitation plan to achieve a sustained return to work Ensure adequate manager support and positive reinforcement Modified duty or partial sick leave may be an effective strategy to prevent total work absence |
World Health Organization [ 105] | Increase general employee awareness of mental health issues Support employees at risk Provide early access to treatment for employees with mental health problems Reintegrate employees with a mental health problem into the workplace Effective accommodation should include supervisor orientation, modified work times, and co-worker support Potentially useful accommodations are flexible working hours, education, using selected co-workers as mentors Protect confidentiality Change job content |
Recommendations for Future Studies
Based on our review, input from the Special Panel and participants of the Hopkinton conference, several key research priorities emerge. There are some questions that may appear to be unique to specific chronic conditions, but upon careful consideration, many of these issues are variations of the major research needs we identified. For example, the observed variability of work disability factors across age cohorts parallels the variability within a single diagnostic category. However, there is still not sufficient evidence to conclude that all key principles of workplace-centered work disability prevention apply equally across all conditions, as a few studies suggest otherwise [
90].
1. Identifying mechanisms in the RTW process Research should identify the mechanisms of a successful RTW process in the workplace, for those with chronic illnesses, across the lifespan, and develop robust theoretical models that guide workplace interventions. There is already a start with research that has identified the characteristics of success in workers with chronic health conditions who maintain employment, as well as studies using logic modelling (such as intervention mapping), and other methods to identify the process and systems of successful RTW processes or interventions. But current investigations do not address the challenges of persons with specific chronic conditions or workers across the lifespan. Workplace stakeholders should be involved from the outset in defining the problem and developing solutions.
2. Identifying those at greatest risk of disability We need research on how to effectively and efficiently identify workers with chronic illness, who are at risk for WD, addressing workers across the whole lifecourse, applicable to multiple conditions. This should consider not only workplace and individual factors, but also the influence of socioeconomic inequality, gender issues, and other factors that are relevant. And a longitudinal view is important—not only work disability prevention, initial return to work, but also maintaining work, quality of work life, and career progression as important outcomes in both young and older workers.
3. Identifying possibilities for work accommodation and support We need research to identify the accommodations and other workplace supports that lead to optimal WDP outcomes, and whether and how the most effective interventions differ by condition. Rather than relying on standardized, diagnosis –based interventions, there is an overarching need to insure that more interventions are individually-directed, worker-centered and workplace-focused, rather than proscriptive and externally generated.
4. Determining appropriate strategies Studies should determine whether different strategies are needed for chronic health conditions that are less visible, episodic, variable in impact, or highly influenced by comorbidity. The focus should be on conditions where symptoms or work impact are less visible and apparent to others, health conditions (such as rheumatoid arthritis or bipolar disorder) or symptoms that are episodic and affect work, or conditions that have a variable and sometimes unpredictable impact on work ability. Comorbidity effects are just starting to be appreciated, yet there are not effective workplace strategies to address their impact on WD. Cancer has a potentially unique situation in that chemotherapy leads to side-effects that can last for a long time, are often under-recognized by workers and their employers,—especially if the appearance of these side-effects is delayed for several years after a ‘cure’ has been achieved. This could be a significant opportunity for condition-specific education of supervisors and employers.
5. Greater focus on work retention and sustainability For most chronic health conditions, there is a need for greater focus on work retention/sustainability and career development and progression. Most studies have focused on the individual alone, but more interventions are needed that address work conditions, integrating a proactive approach to vocational adjustment. For post-retirement workers, understanding their career status, financial status, and how this relates to WDP interventions may be particularly important.
6.
Incorporating workplace (organizational) solutions Rather than focusing on the worker alone, workplace WDP studies should also address workplace climate, attitudes, responses and readiness for change in relation to WDP chronic health conditions, even though these interventions will be more costly and time-consuming at the outset. Studies should specifically target new ways to enhance supportive environments through co-worker and supervisor training and education of organizational leadership about the challenges of work participation with chronic illness. Emerging studies are addressing workplace policies and practices, making an economic case for broader programs that improve workplace health and safety [
91]. Parallel evaluations should address employment of persons with chronic health conditions affecting their ability to work.
7. Recognition of stigma as a potential obstacle to work participation Research should address the importance of stigma as an obstacle to work participation. We should learn more about the factors that lead to both overt and covert (subtle) work discrimination, and develop primary and secondary prevention approaches for this problem in relation to chronic health conditions. Although this is primarily considered with mental health conditions, it is likely to interfere with WDP in other conditions as well, particularly with conditions that are relatively new to the workplace such as early onset dementia, autoimmune disease in young persons, chronic HIV infection.
8.
Considering the broader health care and work disability systems For chronic health conditions, workplace interventions need to be articulated within the broader healthcare and disability systems. Increased emphasis should be placed on integrated and sustainable involvement among employer, worker and health care providers. Investigation in some contexts and the Special Panel suggest the potential value of developing and testing a stepped care approach to WD in the workplace—where an initial simple workplace intervention is followed by a sequence of more intensive interventions if the initial approach is not successful [
42].
9.
Clarifying responsibilities From a public policy point of view, there is a need for greater clarification of the responsibilities of all primary actors and that financial incentives are clearly aligned to achieve desired outcomes [
73]. Research studies could be designed to incorporate multiple stakeholders in data collection of potential risk factors or in the development and testing of new intervention strategies.
Avenues for Future Studies
The overview of the scientific and the grey literature also provided an opportunity to identify important avenues for future studies. Early screening by frontline actors (managers, general practitioners, and occupational physicians) should be developed and linked with appropriate (stepped and/or integrated) care. Frontline managers in the workplace should receive training and support in this respect, both for screening and accommodating workers. The effectiveness of job accommodation / work (re)organization strategies proposed in the grey literature should be evaluated. Eventually, these efforts should be integrated with usual mental health care and medical case management services to offer a more seamless intervention for workers.