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MentalHealthandMentalIllnessInTheWorkplace:DiagnosticandTreatmentIssues

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54

MENTAL HEALTH

AND MENTAL ILLNESS IN

THE WORKPLACE: DIAGNOSTIC

AND TREATMENT ISSUES

DISCUSSION PAPER

Ash Bender, MD, FRCPC

Centre for Addiction and Mental Health, Toronto

Sidney Kennedy, MD, FRCPC

University Health Network, Toronto

ABSTRACT

Mental health, mental illness and stress-related disability are especially ill-defined,complex and controversial issues when considered in the context of the workplace. Amulti-determined disorder such as major depressive disorder (MDD) does not fit asimple cause and effect model, but is similar to other complex occupational illnessessuch as low back pain. Currently, a knowledge gap exists between mental healthprofessionals and employers regarding symptom-based models of illness and function-based models of work performance. As a result, psychiatric disorders affecting work-ers are under-identified and under-treated and likely result in unmitigatedimpairment and disability. The authors examine several conceptual models forworkplace mental illness across medical and psychological disciplines and propose aunifying construct. The utility of the existing screening methods for common work-place illnesses and their potential application are reviewed. The challenges of diag-nosis and effective treatment of workplace mental illness are highlighted within an“occupational mental health system” with suggestions for future research directions.

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Introduction In the last decade the economic impact ofmental illness in the workplace has beenthe subject of a growing number of publi-cations in the psychiatric literature(Greenberg et al. 1999; Dewa and Lin2000; Simon 2003). Mental illness hasalso captured the attention of employers,insurers and healthcare providers andremains a substantial burden (Dewa et al.2002). Results from the recentlycompleted Canadian Community HealthSurvey (Statistics Canada 2003) areexpected to provide unique Canadian datain this area. Previously, the OntarioMental Health Survey provided informa-tive data on both under-detection andunder-treatment of major mental illnessesin the community and also highlightedthe impact of these disorders in theworkplace (Dewa and Lin 2000). Withrespect to depression, there have beenseveral reports on the importance oftreatment until remission of all symptomsis achieved, both in preventing relapsesand in increasing the likelihood ofsuccessful reintegration into the workplace(Paykel et al. 1995; Druss et al. 2000;Simon et al. 2000).

Differences in professional and theo-retical backgrounds have contributed tothe gap between traditional mental healthworkers, who treat individuals withdiagnosed mental illness, and those in theemployment sector, who have tended toconsider occupational health in terms ofstress and burnout. It is our contentionthat there is much greater overlap betweenstress disorders and psychiatric disordersthan is generally recognized and that thefirst level of intervention would be toconfirm this hypothesis.

For the purpose of this paper, we havechosen to focus on entities affecting

employed and employable adults, recog-nizing that occupational difficulties arealso faced by other populations with severeand persistent mental illness. From theoccupational perspective, the emphasis haslargely been on stress and stress-relatedsyndromes, including burnout, while thoseallied to mental health and mental illnesshave focused on mood disorders andanxiety disorders, as well as substance-related and adjustment disorders. Thedegree of overlap between these twoframes of reference remains to be clarified.

These entities have been consistentlylinked to impaired work capacity in theform of decreased productivity, absen-teeism and disability, which may includeincreased frequency of accidents. Reducedoccupational attainment and increasedturnover in the workforce are also seque-lae. While robust and standardized dataare not available across work environ-ments, there is evidence to suggest thatmental illness influences the bottom line inat least five distinct ways: (1) performancelevels are sub optimal (presenteeism); (2)repeated short-term absences (< five days)that do not trigger disability claims; (3)short-term disability claims based onabsence for 5-90 days; (4) long-termdisability claims (> 90 days off work) and(5) failure of retention in the workplace.

Stress-related Syndromes andBurnout According to Cherniss (1980), psycholog-ical stress may be related to individual andorganizational factors, and it is bestdefined as “a state of being, resulting fromthe tension experienced by the imbalancebetween what is demanded and what isoffered to meet that demand.” Work-related stress appears to be unique in thatit is not easily modified and requires the

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cooperation of several systems, notablymanagement and employers in order toadapt to increased demands.

Conceptual Frameworks Health psychologists, as well as industrialand organizational psychologists, havestudied constructs of stress-relatedsyndromes and burnout for several decades.Stress-related syndromes, such as “sickbuilding syndrome,” are generally not welldelineated and researched. They are char-acterized by non-specific respiratory,gastrointestinal, dermatological, muscu-loskeletal and neurological symptomsassociated with changes of mood, memorydisturbances and difficulty concentrating(Arnetz and Wiholm 1997). Burnout is astress-related construct that is conceptual-ized in the context of specific and persis-tent workplace stressors. It has been widelyrecognized and studied, primarily inoccupational settings within the humanservice sectors, and it initially involvedmental health professionals (Freudenberger1974). Over the past three decades,burnout has become an accepted disabilityfrom an employee perspective, but it is notaccepted as a “medical disability.”

Maslach and Jackson (1981) proposedthree dimensions of burnout; emotionalexhaustion (EE), depersonalization (D)and reduced personal achievements (PA),as measured by the Maslach BurnoutInventory (MBI). Emotional exhaustion,which is generally regarded as the initialand defining feature of burnout, results inattitudinal and behavioural changes thatimpair work performance.

Symptom Severity and FunctionalImpairment There is robust evidence that burnout, asmeasured by the MBI, influences work

performance, absenteeism and disability.Situational factors, such as high effort and demand with low job satisfaction,are believed to be more important thanpersonal factors as antecedents of burnout(Iacovides et al. 2003; Karasek andTheorell 1990). In general, the moresevere and pervasive the manifestations ofburnout become, such as affecting familyand social relationships, the more likely itis to overlap with clinical disorders such as MDD and anxiety disorders.

Current understandings of stress-related syndromes and burnout haveshifted away from the typical cause-effectrelationship, which was grounded intraditional occupational medicine models.Subsequently, the interpretation hasshifted toward the biopsychosocial, recog-nizing the mediating effect of personalityand coping mechanisms in their responseto a stressor and the context in which theyinteract. Within medicine, the biopsy-chosocial model has been widely utilizedto explain disorders such as depression,anxiety and low back pain; this suggests amerging conceptual model for occupa-tional mental illness (Spurgeon 2002).

Depression, Anxiety and Substance Use That stress may trigger or exacerbatemental and physical illnesses is wellaccepted. Biological manifestations ofstress result from maladaptive responsesby the body’s internal regulating systems,including the hypothalamic-pituitary-adrenal axis. Failure to regulate stress-related hormones, includingcorticotrophin releasing factor and otherneurosteroids, may promote a chronicstate of stress in the brain, which canresult in atrophy or shrinkage of certainbrain areas – particularly the hippocampi

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– that are associated with memory andmood regulation (McEwen 1999). Asimilar model of understanding exists inresearch regarding occupational stress.

Diagnostic Frameworks Major depressive disorder (MDD),dysthymic disorder and bipolar disorderare among the most prevalent psychiatricdisorders in the workplace. Anxiety disor-ders, including panic disorder, generalizedanxiety disorder (GAD), social phobia(social anxiety disorder), post-traumaticstress disorder (PTSD) and obsessive-compulsive disorder (OCD), are alsohighly prevalent and are frequently co-morbid with mood disorders. Over timemany individuals who suffer from anxietydisorders are likely to develop co-morbiddepression (Angst et al. 1990).

Substance abuse and physical illnessare also co-morbid with both anxiety anddepressive disorders. In general, co-morbidity adversely affects outcome.One-third of mood disorder patients havea lifetime history of substance use, and20% of individuals with alcohol problemshave a lifetime history of a mood disorder(Merikangas et al. 1998). Among themedically ill, risk of death following aheart attack is significantly increased bythe presence of co-morbid depression(Frasure-Smith and Lesperance 2003).There are also many examples where co-morbid depression is associated withincreased utilization of medical services fornon-psychiatric conditions, likely due toworsening substance use, psychiatric illnessand physical illness (e.g., pain or cardiacdisease) (Osby et al. 2001). All theseinfluence the subjective experience ofhealth or “wellness,” but the effect on jobsatisfaction, organizational commitmentand retention rates is less clear.

Increasingly evident is a reduction inperformance and productivity, which islikely mediated through cognitive impair-ment, physical symptoms and interper-sonal conflict (Stewart et al. 2003).

A more unifying construct for defin-ing depressive and anxiety spectrumdisorders would include etiologic andfunctional dimensions, such as mood(irritability and emotional exhaustion),cognitive functions (concentration andmemory), interpersonal relations (conflict and sociality), behaviour (reducedoccupational achievement, absenteeism or reduced performance) and physicalsymptoms (pain, weakness, fatigue,neurological symptoms, gastrointestinalproblems). Physical symptoms are anintegral component of both depressiveand anxiety disorders and may be espe-cially relevant in justifying the “sick role”in the workplace (Stewart et al. 2003).

Symptom Severity and FunctionalImpairment Evaluating response to treatment, whethercounselling and psychotherapy or medica-tion and pharmacotherapy, is generally aninformal judgment that is reached by theindividual and the clinician together.However, both qualitative and quantitativemeasures of severity are available. TheHamilton Rating Scale for Depression(HRSD) (Hamilton 1960) and theHospital Anxiety Depression Scale (HAD)(Zigmond and Snaith 1983) are examplesof observer-rated and self-report scales.Abbreviated versions of the HRSD, such as the seven-item version (McIntyre et al.2002) take less time to administer and havebeen used in family practice and psychiatricclinics to evaluate treatment outcome.Their utility as screening instruments hasyet to be established.

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Functional outcome is a neglected butequally important measure during treat-ment of these disorders. Quality-of-lifeassessments, such as the MedicalOutcomes Short Form – 36 item scale(SF-36), have been used to evaluatefunctional impairment across numerousphysical and psychiatric disorders, but theyhave limited utility in the workplace(McHorney et al. 1992). The EndicottWork Productivity Scale (Endicott andNee 1997) and the Life FunctioningQuestionnaire (LFQ) (Altshuler et al.2002) are relatively brief validatedmeasures of workplace performance.

Screening Strategies In general, screening is indicated when acondition is highly prevalent, underde-tected and undertreated; when availableand reliable screening methods are avail-able; and when effective treatments exist(Greenfield et al. 1997). Workplacescreening has been recommended forhypertension, diabetes, cancer, TB, muscu-loskeletal disorders, chemical exposure andcountless other ailments, and more recentfindings suggest erring the same need forscreening for mental illness.

Screening for Stress-related Syndromes and Burnout The Job Content Questionnaire (JCQ),based on the Demand-Control Model(see Vézina’s paper), has been successfullyadministered in the Canadian NationalPopulation Health Survey (NPHS) andthe French GAZEL cohort, which bothinclude large samples of working individ-uals (Karasek 1985; Ibrahim et al. 2001;Niedhammer and Chea 2003). Burnouthas been measured in a large sample ofFinnish physicians with the MaslachBurnout Inventory (MBI) (Korkeila

et al. 2003). More longitudinal studies are needed to adequately evaluate these self-report instruments and the healthoutcomes which they intend to link (e.g.,self-reported health). Both may be helpfulin identifying those at increased risk fordeveloping sequelae from stress, such asdepression and anxiety disorders(Niedhammer and Chea 2003).

Screening for Depression, AnxietyDisorders and Substance Abuse General screening instruments evaluatedfor depression include the Center forEpidemiologic Study Depression (CES-D) scale (Roberts and Vernon 1983) andthe General Health Questionnaire (GHQ)(Goldberg 1972). In 2002, the USPreventative Services Task Force foundsufficient evidence to recommend routinescreening for depression in clinic popula-tions. Overall, routine screening fordepression followed by feedback to theprovider increased disease recognition by10% to 47%. It is of note that improve-ments in treatment rates and outcomeswere associated with superior outcomesonly when integrated with a depressionmanagement program (Pignone et al.2002).

Anxiety disorders are also highlyprevalent and, with the exception ofsimple phobia, are associated with impair-ment in workplace performance(Greenberg et al. 1999). To date, there isless research into screening methods foranxiety disorders than for depression. Theutility of common anxiety disorder assess-ment instruments for screening has beenevaluated in a German female populationwith the Symptom Checklist Revised(SCLR-90), the Beck Anxiety Inventory(BAI) and the Anxiety Sensitivity Index(ASI) (Hoyer et al. 2002). More research

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and development is needed in globalanxiety screening tools that would accu-rately identify workers in need of clinicalattention.

Substance abuse screening in the formof drug testing has been widely adopted,particularly in the United States. Theeffect of drug testing is substantial as adeterrent, but it is still unclear whether italone has been responsible for reducedsubstance use in populations or whether itpersuades individuals to seek treatment(Cook and Sclenger 2002). The use ofwidespread drug testing may not beapplicable to Canada, and it can be criti-cized as being insensitive to on-the-jobimpairment, adversarial and an overlyinvasive screening method (Raskin 1993).Non-invasive methods evaluated in aworkplace setting include the BriefMichigan Alcoholism Screening Test(BMAST) (Pokorny et al. 1972) and theCAGE (Ewing 1984). These instrumentswere also limited by their ability to differ-entiate present from past drinking andlack of agreement about cut-off scores(Watkins et al. 2000).

Screening for MusculoskeletalDisorders In 1986, the National Institute forOccupational Safety and Health (NIOSH)in the United States proposed a strategyto decrease cumulative trauma disorders(CTDs), such as carpal tunnel syndrome.This involved a comprehensive question-naire and physical screening over fourweeks. The effectiveness of workplacescreening programs is supported by thedecrease in incidence rates of CTDs(Melhorn 1999). One concern, however,which has been expressed by employers, isthat if an individual is evaluated, educatedor informed about CTD musculoskeletal

disorders related to the workplace, thereported rate of occurrence wouldincrease. Prospective studies have shownthis did not happen (Melhorn 1999).

Evidence from studies screening forcommon stress-related entities andpsychiatric disorders suggests that severalvalid instruments are available that can beadministered broadly on a self-reportbasis. The optimal screening instrumentsand procedures have not been explicitlydetermined for many mental illnesses andmay include novel strategies such asInternet-based methods (Houston et al.2001). To date, screening strategies haverelied primarily on self-identification andself-referral, with findings for depressionand CTD’s indicating that more struc-tured protocols yield improved outcomes.While indications for workplace mentalillness screening, particularly depressiveand anxiety disorders, do meet sufficientcriteria, there are as yet no protocols forthe workplace.

Treatment Treating Stress-related Syndromes and Burnout Strategies for limiting stress-relatedillnesses have been used and evaluated atseveral levels. The promotion and preven-tion strategies are reviewed in MichelVézina’s paper. Treatment interventionstypically involve workplace counsellingthrough employee assistance programs(EAPs). EAPs are designed to providecounselling, information and/or referrals.These were originally developed in theUnited States for alcohol-related problemsand have been extended to other stress and mental illness problems (Cooper andCartwright 1997). These confidentialservices, which employees can obtainvoluntarily, typically offer four to eight

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sessions per year per employee. Markedbenefits can occur in symptom reduction,but it is unclear if these interventions haveany impact on work performance. It is ofinterest that evidence from counsellingprograms indicates that one-quarter of all presenting problems were related toproblems outside of work (Reynolds 1997).

The impact of EAP interventions onemployees with depressive or anxietydisorders has not been established. Ascientific review of critical incident stressdebriefing (CISD) performed by theCochrane group did not support CISD asan effective intervention to prevent PTSD(Suzanna et al. 2002). This is an exampleof a widely adopted EAP practice andintervention that appears to have noclinical benefit but is considered of valueto employers and management. There is a need to evaluate the effectiveness ofexisting interventions more stringentlyand to define treatment plan thresholdsfor referral to additional psychiatricservices (McLeod and Henderson 2003).

Treating Depression, Anxiety andSubstance-related Disorders The course of mood and anxiety disordersis episodic, the peak ages of onset being inlate adolescence and early adulthood formost disorders. Despite the burgeoningmental health and socio-economic impactof depression, two large studies, theDepression Research in European Society(DEPRES) study and the Ontario HealthStudy (OHS), conclude that only abouthalf the individuals with major depressionseek help, and among those who do, onlyabout one-third receive any pharma-cotherapy (Lépine et al. 1997; Parikh et al.1997). In a longitudinal evaluation,patients with depression spent about 20%of their lives depressed and frequently

experienced residual symptoms betweenepisodes. Also in about 20% of patients,depression followed a chronic course withno remission. The recurrence rate forthose who recover from the first episode isaround 35% within two years and 60% in12 years, it is also higher in individualswho are 45 years of age or older (Kellerand Boland 1998). Given the course ofthese disorders, it seems imperative tolimit their impact on occupational attain-ment and sustainability with effectivetreatments.

Despite the availability of numerousguidelines for the treatment of mood andanxiety disorders (Kennedy et al. 2001;Segal et al. 2001a; Segal et al. 2001b;Stein 2003), recent evidence confirms thesuspicion that the actual prescription ofantidepressant medication for disabilityclaimants does not meet dose and dura-tion recommendations. In a sample ofCanadian insurance and financial sectoremployees, individuals who went on tolong-term disability were significantly lesslikely to have received first-line antide-pressants at guideline recommendeddoses. Conversely, those who were treatedin adherence with guidelines were signifi-cantly more likely to return to work after ashort-term disability claim. More thanhalf of the claimants had received antide-pressants (56%), but it was impossible toevaluate the frequency or effectiveness ofevidence-based psychotherapy (Dewa etal. 2003).

The decision to recommendpsychotherapy or pharmacotherapydepends on several issues, includingpatient preference, symptom severity,treatment availability and prior treatmentexperiences. In general, for mild tomoderate depression, evidence-basedshort-term psychotherapies (e.g., cogni-

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tive-behaviour therapy and interpersonalpsychotherapy) are as effective as medica-tion treatments (Kennedy et al. 2001).There are numerous other pharmacologi-cal techniques for promoting remission(e.g., augmentation and combinationtherapies), and in chronic depression,often lasting several years, combinedpsychotherapy and medication are supe-rior. The benefits of treating to remissioninclude reduced relapse rates, improvedpsychosocial function and reduced work-related costs (Simon et al. 2000).

Both psychological and pharmacologi-cal treatments have been employed effec-tively across the spectrum of anxietydisorders. In fact, many of the samemedications (e.g., SSRIs) and psychother-apies (e.g., CBT) are used to treat thesedisorders. The importance of early detec-tion and treatment has been emphasizedas a means of preventing future co-morbidanxiety and depression. Typically, treat-ment for co-morbid mood and anxietydisorders as well as co-morbid substance-related disorder is more complex, requiresmore than one intervention and may yieldlower rates of response and remission.Motivational interviewing techniqueshave provided successful outcomes insome substance-abuse populations.Adjustment disorders are at the interfacebetween stress-related disorder and moodand anxiety disorders. They may be wellsuited to brief focused counselling inter-ventions as offered by EAPs.

In the case of depressive disorders,there is now convincing evidence thattreatment is cost-effective, even when theemployers bear the full cost of treatment(Druss et al. 2000; Goldberg and Steury2001). In Canada, employers could furtherlimit organizational costs by effectivelyutilizing a public health care system and

reducing insurance costs through theprevention of disability. Considering thatthe great majority of Canadians areemployed, society would also benefit fromusing the workplace as a conduit for treat-ment. To date, few treatment studies haveidentified the economic impact of early andsustained evidence-based interventionsthrough improved occupational attainmentand function. Currently, identification and treatment delivery strategies appear tobe greater barriers than the effectiveness of treatment.

Healthcare Delivery We understand the system in whichemployee mental health is addressed as the “occupational mental health system”(see Figure 1). Within this fragmentedsystem, there are several barriers related to timely identification, correct diagnosis,shared treatment strategies, and preventionof relapse and disability (Goldberg andSteury 2001). The occupational mentalhealth system includes representativesfrom the healthcare providers (physicians,psychologists, EAPs and researchers), theworkplace (employers, human resources,managers and co-workers) and insuranceproviders (public and private), as well asthe home and community (family andadvocacy groups). In general, this system ispoorly integrated and is characterized bybarriers caused by lack of education, ill-defined roles, inadequate resources,delayed and unsuitable treatment andsocio-economic factors, all of whichdiscourage resource utilization and invest-ment. Ideally, interventions should beinitiated by gains-driven positive motivesrather than problem-driven negativemotives such as cost containment (Cooperand Cartwright 1997).

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Healthcare Providers Employee Assistance Programs are oftenthe first point of contact for employeeswith mental health concerns. The rates ofEAP coverage appear to be related to thesize of the organization and industrygroup. Smaller organizations (those withfewer than 100 employees) are much lesslikely to offer EAPs than large organiza-tions (those with over 1,000 employees),particularly those with educated andunionized workforces (Hartwell et al.1996). Great variability also exists in thecoverage and services provided by EAPSin different organizations and in theirutilization; and interventions often occurindependently of those provided by theprimary care physician (Reynolds 1997).

In Canada, public health physiciansstill remain the primary providers ofmental health services to working individ-uals. There is now evidence that mentaldisorders, such as depression, are associ-ated with higher utilization of generalhealth resources rather than specific

resources directed towards mental disor-ders. That is of concern in a constrainedpublic health system (Simon 2003).Interventions within physician healthpractices have achieved modestly betteroutcomes in the diagnosis and treatmentrates of depression by using organizationaland individual strategies. Effective profes-sional interventions include distributionof educational materials, educationalmeetings, clinical management consensusprocesses, educational visits and feedbackto practitioners, the use of local opinionleaders, patient feedback through self-rated screening, audit and feedback ofclinical performance, and reminders andreview of treatment barriers. Effectiveorganizational interventions includerevision of professional roles, clinicalmultidisciplinary teams, formal integra-tion of services and continuity of care(Gilbody et al. 2003). It is of interest thatthose receiving enhanced-practicemanagement of depression had lower ratesof unemployment and work conflict at

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Figure 1. Occupational Mental Health System

Patient/Worker

Work Environment

Bender and Kennedy, 2003

“Psychiatric” Care

Insurance System

Family andCommunity

Employee AssistancePrograms

Human Resources

Management

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one year than those who received usualcare (Smith et al. 2002). In the primarycare setting, novel practice strategies willcontinue to be a focus of future researchwith potential application to a workplacesetting. These may include shared-caremodels with primary care physicians,occupational medicine specialists andclinical psychologists in collaboration with psychiatrists.

The Workplace Evaluating the utility of individual andorganizational strategies for improvingtreatment outcomes in occupationalmental illness will require the collabora-tion and co-operation of several organiza-tions. Potential interventions, which havenot been adequately evaluated includedelivering confidential self-rating scales tothe work site; promotion of greater aware-ness by EAPs; recognition training forsupervisors; and more education for labourboards and the judicial system (Goldbergand Steury 2001). Because of the stigmaof mental illness and fear of discrimina-tion, targeted mental health interventions,such as health counselling for substanceabuse, may be more effective if imbeddedin socially acceptable programs for smok-ing or cardiovascular disease (Cook andSclenger 2002). Since a significantproportion of the Canadian workforce isemployed in small and medium-sizedorganizations, findings in large organiza-tions may not be generalizable and theremay therefore be a need for independentstudy of these variables (Statistics Canada2003). Despite this, most organizations dohave government-mandated occupationalhealth and safety policies and programsthat may accommodate and guide poten-tial workplace mental health strategies.

Home and Community Results from the National ComorbidityStudy highlighted the significant relation-ships between conflicts at home and in theworkplace. Those reporting increasedworkplace conflict due to family stressorswere 10 to 30 times more likely to beexperiencing psychiatric disorder thanthose who did not report such conflict.Family and community supports have thepotential for reducing work-life imbal-ances and preserving sustainable employ-ment by reducing caregiver burden,improving identification, and advocatingfor treatment seeking and better adher-ence to treatment plans. These findingsemphasize the need to examine optimalhome interventions, including workplacefamily-supportive programs (Frone 2000).

Insurance Providers The insurance industry has worked closelywith employers and labour unions, actingin good faith when handling occupationalhealth claims by (1) commissioningspecialists to examine the claimant; (2)providing vocational support services; (3)negotiating on behalf of the claimant formodified duties or modified environment;and (4) offering a financial safety netduring rehabilitation (Lloyd 1997).Unfortunately, there are frequent delays –in communication, compensation andtreatment – which lead to further morbid-ity related to psychiatric disorders.

Challenges in disseminating existing knowledge Despite the availability of evidence-basedtreatment guidelines, investment in thedissemination of this information hasbeen minimal. There is a gatheringmomentum in research as it applies tooccupational factors and a growing inter-

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est of organizations in implementingthese findings. To achieve this, Rosenheck(2001) suggested four strategies: (1)leadership coalitions to promote imple-mentation; (2) research initiatives linkedto organizational goals and values; (3)continuous monitoring of implementationprocess and program performance; and (4)development of subcultures that reinforceevaluation and learning.

Outcomes Identifying outcome measures that aremeaningful to researchers, healthcareproviders, employers and employees is animportant first step. In clinical settings,there is a gradual paradigm shift fromsymptom reduction to successful func-tional outcomes. In workplaces, maintain-ing competitiveness through enhancedproductivity and cost-control has been anemerging business driver, although thelong-term effects on employee mentalhealth have not been firmly established.Most research has relied on cross-sectional design or retrospective analysis,neither of which is able to establish acausal link between mental disorders andwork dysfunction (Simon 2003).

We propose that there is a need forlongitudinal controlled prospective studiesthat thoughtfully combine clinical andeconomic outcomes. These outcomemeasures have not been uniformlydefined, but they are taking shape. In ouropinion, the economic consequences ofmental illness are related to absenteeism,productivity (presenteeism), disabilityrates (short- and long-term), retentionrates, job satisfaction and insurance costs.The clinical outcome measures mostrelevant to the workplace are diagnosticand comorbidity rates; referral rates;response, remission and relapse rates;

quality of life and functioning; healthcareservices utilization; and program cost-effectiveness.

Conclusion We are faced with the challenge of greatlyimproving the detection and treatment ofmental illnesses in the workplace. There isa growing determination among variousstakeholders to identify occupationalfactors that contribute to mental health andmental illness and to develop appropriatetreatment interventions. The modeladopted by several countries, includingCanada, for addressing occupational lowback pain serves as a useful example.Guidelines contain recommendations fordiagnostic triage, screening for specificsymptoms, and the identification of work-place barriers and psychosocial issues. Allof these guidelines have been criticized forlack of attention to organizational barriers,implementation strategies and costs (Staalet al. 2003). There is a great opportunity inthe field of mental health to learn from thisand other occupational models.

We propose the following researchagenda:

(1) Clarify diagnostic entities and associ-ated co-morbidities with validatedresearch instruments for occupationalmental illnesses.

(2) Understand the factors that contributeto workplace stress to be risk factorsfor psychiatric disorders, and for thepopulations they affect.

(3) Develop and evaluate screening toolsfor mental illness and functionalimpairment in the workplace.

(4) Evaluate EAP interventions and theirimpact on stress and burnout andpsychiatric disorders.

(5) Develop and evaluate shared-care

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strategies that can be adapted to different sizes and types oforganizations.

(6) Develop guidelines for the manage-ment of mental illness in the contextof the “occupational mental healthsystem.”

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