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Mental Health and the Workplace
Dr. Niki Fitzgerald, Ph.D., C. Psych.
October 8, 2014
1
Overview
I. Overview of Mental Health and the Workplace
II. Prevention and the Psychologically Healthy
Workplace
III. Identifying Mental Health Issues in the Workplace
IV. Managing Issues once Noticed
V. Returning to work
New disability benefit claims due to mental
disorders (in % of total claims)
3
15
20
25
30
35
40
45
50
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Australia Austria Belgium Denmark Netherlands Norway Sweden Switzerland United Kingdom
Source: OECD
calculations based
on Eurobarometer,
2010.
Economic Impact of Mental Disorders
Lim et al. A new population-based measure of economic burden of mental illness in Canada.
Canada. Chronic Dis Can. 2008;28:92-8
Dewa, Chau and Dermer. Examining the comparative incidence and costs of physical and
mental health-related disabilities in and employed population. JOEM 2010;52;758 4
In Canada, mental disorders are estimated to cost over $51 billion (CAN) in 2003, not including the cost of prescription medications
Direct Medical Costs 9.8%
Short-term Disability 16.6%
Long-term Disability 18.2%
Loss of Quality of Life 55.0%
Disability related to psychiatric disorders costs twice the average of all causes ($18000 vs. $9027)
Conference Board of Canada Survey
Conference Board of Canada. Building Mentally Healthy Workplaces: Perspectives of Canadian
Workers and Front-Line Managers. Report June 2011.port
National survey of over a 1000 employees, including
479 front-line managers, as well as 30 follow-up
interviews
12% reported currently experiencing mental health issues
32% previously experiencing mental health issues
Most mangers had little or no specific training
2009–10, claims in Canada were related to mental
health issues comprised:
78 % of short-term disability claims
67% of long-term disability claims
Guiding Principles
American Psychiatric Association, National Partnership for Workplace Mental Health,
2007 6
“ Work is central to a person’s identity and social role.
It provides income, but more than that, it is often
essential to feeling valued as a person. Loss of work
capacity for any reason is a life crisis, but especially
so when the loss is due to a mental health disability.
A person’s inability to work because of a mental
health condition requires focused and significant
professional attention and a team response.”
Onus on Employers
Whereas a few years ago the law would take note
only of egregious and intentional harms it now sees
even negligent and reckless assaults on mental
health as attracting liability.
Even the negligent imposition of excessive work
demands may attract such liability if it results in
foreseeable mental injury.
Duty to accommodate from moment the employer is
aware of the disability, regardless of whether are
formally notified by employee
Mentally injurious conduct has been censured in
several contexts including:
Treatment of employees by supervisors
Treatment of employees by fellow workers
Management of employees returning to work
Management of employees while on disability leave
Management of employees with mental disorders
Psychologically Healthy
Workplace
Healthy Workplace
Orientation
Training
Promotion
Development
ID
STD
LTD
Return to Work Care and Disability
Duty to Accommodate
Re-engage
Re-train
Counselling
Coaching
ID = Identification of problem
STD = Short Term Disability
LTD = Long Term Disability
Phases of Management
(Lam, 2008) 10
Sick leave
Psychologically Healthy Workplace
Helps to keep workers:
Safe
Engaged
Productive
Risk Factors to Mental Health Associated with
Psychologically Unsafe Workplace
Job demands and requirement of effort
Job control or influence
Reward
Fairness
Support
Workplace Factors Affecting Psychological
Health and Safety
13
From the National Standards for Psychologically Safe
Workplace:
1. Organizational Culture
2. Psychological and Social Support
3. Clear Leadership and Expectations
4. Civility and Respect
5. Psychological Demands
6. Growth and Development
7. Recognition and Reward
8. Involvement and Influence
9. Workload Management
Workplace Factors Affecting Psychological
Health and Safety cont’d
Engagement
Balance
Psychological Protection
Protection of Physical Safety
NIOSH Model of Job Stress
Building Employee Resiliency
Why? Resilient employees:
Cope better
Are more engaged and productive
Easier to work with
Adapt to change better
Resiliency programs could include
Self-regulation – able to manage emotions
Efficient problem solving – flexible in identifying solutions
Self-efficacy – feeling confident and competent
Social support – able to accept and provide support
Creating a Respectful Workplace
Improves morale and job satisfaction, teamwork,
labour relations, turnover, absenteeism
Lack of it can contribute to “toxic environment”
Means treating one another with respect,
consideration and tolerance
Can decrease bullying, harassment
Creating a workplace policy
Communicating the policy
Staff education
Increase Mental Health Knowledge
Combating Stigma is Important because:
Decreases self-stigma
May increase level of support from coworkers
Want to counter stereotypes or myths about mental health
problems including blaming the worker, or thinking they
are intractable
While majority of Canadians would discuss a family
member’s diagnosis of cancer or diabetes, only 50%
would tell a friend or coworker they have a family member
with mental illness (Canadian Medical Association, 8th Annual National Report Card
on Health Care, 29)
Combating stigma at work
American Psychiatric Association, 2007 19
Develop organizational practices that impede stigma
Education for managers to improve recognition
Workplace anti-stigma programs
Legal enforcement of discriminatory practices under
Canadian labour law
Enhancing access to confidential mental health
services in the workplace
Standardizing disability management practices so
the physical and mental disorders are treated equally
Provide Stress Management Training
Time management
Conflict Resolution
Relaxation
Structured Problem Solving
Realistic thinking
Identifying Mental Health Issues
Screening and Surveillance Goals
22
Promote continuous health surveillance by management and OH staff in a supportive manner
Create strategies for early identification which may be suited to your organization Managers/Union/Occ Health /Peer-based
Have clear and consistent process for case assessment to expedite referral to appropriate services
Be prepared to respond to risk such as suicide or violence
Supervisor Training Essentials
Importance of identifying and documenting performance issues Basis for dialogue with individual employees about how
their mental health issue was interfering with their work
Resources for employees, supervisors, and work teams
EAP/ Health and Wellness / Organizational development
OH case management and critical incident teams
Constructive ways to confront the “troubled” employee early
The business case for intervening
Guidance about roles and boundaries
Prevalence in Working Populations
Major Depressive Disorder 6.7%
Disability Claimants
Chronic pain
>10%
up to 70%
Bipolar Disorder 1.1%
Posttraumatic Stress Disorder 5%
Soldiers
Police/Fire/EMS
12-30%
7-22%
Substance Use Disorder 10%
Construction
Food/Bar
17%
16%
Attention Deficit Hyperactivity Disorder 3.5%
Substance abuse and mental health services administration, National Comorbidity Study, CC Health
Survey
1 in 5 adults will be diagnosed with depression
Globally, 350 million are affected by depression
in 12 Americans abuses alcohol or is alcoholic
(Adelson, 2006)
In 2009 there were 3,890 suicides in Canada, a rate
of 11.5 per 100,000 people
The suicide rate for males was three times higher
than the rate for females (17.9 versus 5.3 per
100,000).
Although suicide deaths affect almost all age groups,
those aged 40 to 59 had the highest rates
Prevalence of Alcohol Use Problems
American Journal of Physical Medicine & Rehabilitation February 2012 - Volume 91 - Issue 13 - p
S62–S68
Symptoms of Depression
Feelings
Sad
Tearful
Hopeless
Nothing
More angry than usual
More irritable
How you think
I’m a failure at work, at home
What’s the point
More negative then usual
Symptoms of Depression
Physical problems
New sleep problems including getting to sleep, staying asleep
Appetite changes – eating more or less than usual, craving carbs more than usual
Feeling tired more easily or more often
Feeling more fidgety or restless
Feeling more slowed down
Difficulty thinking or concentrating
What you do
Isolating
Not wanting to do the things that you normally would, having a lot more ‘ustas’
More argumentative
Depression’s Impact on Work Performance
Task Performance: Depressed mood can make it hard to manage
work responsibilities, including sustaining effort over time and
dealing with change.
Emotions: Sadness, irritability or emotional numbing make it harder
to do your job and enjoy it.
Thinking: Difficulties with concentration, decision-making or memory
make it harder to deal with job tasks and may negatively impact your
accuracy at work.
Work Relationships: There can be avoidance of co-workers or
frequent conflict, preventing successful teamwork and making the
workplace less supportive.
Physical Health: Reduced energy level and disrupted sleep make it
difficult to keep up with job demands. Physical symptoms may further
undermine workplace performance and attendance.
Causes of Depression Biological differences. People with depression appear to have
physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may be associated with depressive symptoms.
Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result from thyroid problems, menopause or a number of other conditions.
Inherited traits. Depression is more common in people whose biological (blood) relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.
Life events. Traumatic events such as the death or loss of a loved one, financial problems, high stress, or childhood trauma can trigger depression in some people.
What depression is not
A sign of innate personal weakness
Something to be ashamed of
Something that “other people get”
A life sentence
Something that is completely incapacitating
A sign of being “crazy”
Posttraumatic Stress Disorder – what it is
A set of symptoms that can develop after a traumatic
event, where trauma is defined as something that
happens when one has “experienced, witnessed, or
was confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of oneself or others.” (DSM-IV-TR)
Symptoms of PTSD
Reliving the Event
Having unwanted and recurrent thoughts, memories, or
dreams about the event
Being distressed or having physical reactions such as
sweating or having heart palpitations by reminders of the
event
Avoiding Reminders of the Event and Feeling Numb
Making an effort to avoid activities, places, people,
thoughts, or feelings related to the event
People may also have a lack of interest in daily activities,
feel cut off or detached from family or friends, or feel flat
and numb.
Symptoms of PTSD
Being Overly Alert or Wound Up
Feeling keyed up, jittery or alert
Irritability or anger
Difficulties Sleeping
Concentration Problems
Being alert or on guard for possible danger
Easily startled
What might these symptoms look like?
Being keyed up or on edge
Difficulty being at the site where the trauma occurred
Difficulty doing regular work duties
Difficulty getting along with coworkers or withdrawing from
coworkers
Not wanting to talk about the event
Tired at work
Lost time from work
Alcohol Abuse
Alcohol use interferes with responsibilities (e.g., at
work, home, or school);
Dangerous patterns of alcohol use (e.g., while
driving a car or operating machinery);
Alcohol use causes legal problems (e.g., arrests for
disorderly conduct); and
Alcohol use continues despite negative effects on
relationships (e.g., physical fights).
Alcohol Dependence
Tolerance to alcohol (need more and more alcohol to achieve desired effect);
Withdrawal when regular drinking is stopped or reduced (e.g., sweating, insomnia, nausea);
Often drink more or drink longer than intended;
Difficulty limiting or quitting drinking;
Great deal of time spent in obtaining, using, or recovering from alcohol;
Previously valued/important activities (e.g., recreational) are given up or reduced because of alcohol use; and
Alcohol use continues despite awareness that drinking is causing physical or emotional problems.
Mood Disorders (at a glance)
38
Disorder Key feature Associated
Symptoms
Behaviour
Major Depressive
Disorder
At least one
depressive episode
lasting over 2 weeks
Sad/irritable mood
Hopeless/Helpless
Inappropriate guilt
Suicidal ideation
Sleep changes
Eating changes
Cognitive changes
Poor energy
Psychosis
Neglect
Self-harm
Loss of
enjoyment
Dysthymic
Disorder
Mild depressive
symptoms for >2
years
As above As above
Seasonal
Affective Disorder
Depressive episodes
in seasonal pattern
As above Seasonal pattern
Adjustment
Disorder with
Depression
Preoccupation with
stressor
Mild and only with
exposure to stressor
Poor adaptation
to stressor
Mood Disorders (at a glance)
39
Disorder Mood Associated
Symptoms
Behaviour
Bipolar I Disorder At least one manic
episode lasting >1
week
Depressive episodes
most common
Euphoria/irritability
Grandiosity
Racing thoughts
Hypertalkativeness
Decreased sleep
Increased energy
Psychosis
Goal-directed
Risk-taking
Impulsive
Disorganized
Aggressive
Bipolar II Disorder At least one hypomanic
episode lasting 4-7
days
As above except
milder
Less impaired
Cyclothymic
Disorder
Alternating hypomanic
and depressive
episodes
Mild Less impaired
Substance-
Induced Mood
Disorder
Depressed, hypomanic
or manic
Substance
intoxication or
withdrawal
Highly
impaired
Mood Disorder due Depressed, hypomanic Present during Variable
Anxiety Disorders (at a glance)
40
Disorder Thoughts Associated
Symptoms
Behaviour
Generalized
Anxiety Disorder
Excessive worry
lasting >6
months
Tension/ fatigue
Poor concentration
Poor tolerance
unknown
Panic Disorder Fear of attacks Panic attacks
Physical complaints
Agoraphobia
OCD Obsessions Anxiety on exposure Compulsions
PTSD Fear of
recurrent
trauma
Nightmares
Flashbacks/memorie
s
Loss of enjoyment
Avoidance
Aggression
Hypervigilance
Social Phobia Fear of negative
appraisal
Situational distress Avoidance
Simple Phobia Irrational fear None Avoidance
Adjustment
Disorder with
Anxiety
Preoccupation
with stressor
Anxiety with
exposure to stressor
Poor adaptation
to stressor
What to look for
Pay attention for changes in behaviour,
personality or character, don’t ignore things or
hope for a change
Impact of Mental Disorders
on Workplace Functioning
45
Presenteeism
• Reduced work performance
• Impaired interpersonal relations
• Increased effort and longer time at work
• Frequent breaks during workday
• Poor judgment or appearing impaired
• Inappropriate conversations/comments
• Aggression/inappropriate behaviour
Absenteeism
• Lateness
• Leaving early
• Increased sick days
• Unplanned absences
• Unexplained absences
• Failure to achieve or maintain full-time employment
• Loss of overtime
Disability
• “Stress leave”
• High consumption of medical resources
• Non-adherence with treatment plan
• Failure to RTW despite physical rehabilitation
• Failure to start or complete academic retraining
• Reliance on social assistance
Absenteeism and Presenteeism both
Increase with Poorer Mental Health
46
Sickness absence incidence Average duration of sickness absence Presenteeism incidence
Percentage of persons who have been absent from
work in the past four weeks (apart from holidays)
Average number of days absent from work in the
past four weeks (of those who have been absent)
Percentage of workers not absent in the past four
weeks but who accomplished less than they would
like as a result of an emotional or physical health
problem
Note: Averages are represented by dashed lines.
Source: OECD calculations based on Eurobarometer, 2010.
42
28
19
0
5
10
15
20
25
30
35
40
45
Severe disorder Moderate disorder
No mental disorder
7.3
5.6
4.8
0
1
2
3
4
5
6
7
8
Severe disorder Moderate disorder
No mental disorder
88
69
26
0
10
20
30
40
50
60
70
80
90
Severe disorder Moderate disorder
No mental disorder
When something is noticed
Meet privately
Approach your concerns as a workplace
performance/behaviour issue
Stick to the facts
Make them feel valued and supported
Let them know that accommodations are possible and
there is confidential EAP support – be solution focused
Ask them what they think could help
Document the meeting with facts only, no opinions
Follow-up
Communication is Key
49
Some employees will need:
Verbal and written communication
Face-to-face rather than telephone contact or vice versa
Time to establish trust and rapport
Frequent clarification and focusing
Validation of their experience
Support during meetings
Let the employee’s needs and preference guide the
methods of communication but always document
Do NOT document suspected diagnoses!
Performance Appraisal Model
50
Clarify Duties
Agree on Objectives
Monitor and
Support
Review and
Evaluate
Appraisal Interview
Try to Avoid
Probing or trying to diagnose the problem
Offering a “pep”
Don’t assume that someone can just “snap out of it”
Sounding accusatory or overly critical
Arguing with them
Recovery at Work
Accommodation Prevents Disability
Canadian Human Rights Act
Employment Equity Act, Canada
53
The duty to accommodate means the employer must implement whatever measures necessary to allow its employees to work to the best of their ability.
Employee must provide sufficient information to the employer to determine appropriate accommodation options.
An employer can only deny accommodation if it does something in good faith for a purpose connected to the job, and where changing that practice to accommodate someone would cause undue hardship to the employer, considering health, safety and cost.
Physicians should consider early health accommodation with ongoing treatment rather than prolonged work leave Communication requirements
Social demands
Cognitive demands
Scheduling
Supports
Promoting Recovery from Work
1. Educate about health issues and encourage treatment
2. Arrange for timely assessment
3. Review need for accommodation or leave
4. Facilitate “active” treatment ASAP
5. Meet/talk frequently to discuss status and return to work
6. Maintain adequate written and verbal communication with involved parties
7. Consider legal and safety issues
8. Identify barriers and consult if failure to progress as expected
Types of Accommodation
Flexible scheduling
Changes in Supervision
Modifying job duties
Changes in training
Using technology
Modifying workspace and changing location
Accommodations for specific problems
Difficulty maintaining stamina
Concentration problems
Maintaining organization/meeting deadlines
Remembering things
Dealing with stress and emotions
Dealing with change
Accommodations for specific problems
Difficulty with workplace relationships
Outline clear expectations and consequences for not
meeting them
Define what is meant by good working relationships
Have regular meetings
Allow the option of not attending work-related social
functions
Responsibilities of Employees
Advise the employer of disability (not dx)
Make needs known to best of their ability
Answer questions or provide information regarding
relevant restrictions/limitations, including medical
documentation if required
Participate in discussions about possible
accommodation solutions
Work with accommodation provider on an ongoing
basis to manage the process
Meet agreed-upon performance and job standards
once accommodation is provided
Once someone is off sick…….
Chances of RTW Reduces with Time
60
0
10
20
30
40
50
60
70
80
90
100
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Weeks
After 12 weeks, an employees at a majorU.S. Manufacturer had only a 50% chanceof ever returning to work
(APA 2007)
Supporting an employee who is
off sick
Co-ordinate approaches to ensure clarity
Reassure them that you will respect personal and medical boundaries
Review needs/wishes for support ideally before they go on leave so expectations are known
Reassure them about practical issues like job security
DO NOT put pressure on them to name a return date
62
Occupational Mental Health System
Worker
Management
Family and
Community
Insurance System
Mental Health Care
Bender & Kennedy, 2003
Employee Assistance
Programs
Occ Health, HR
and Union
Work Environment
Returning to Work After a Leave
Roles and Return to Work
64
Player Role
Worker Adhere to treatment plan
Manage documentation
Cooperate with insurer and employer
Mental Health Care Providers Propose and implement rehabilitation plan
Provide timely documentation insurer and
employer as requested
Insurer Wage replacement
Funding of additional treatment if indicated
Assistance with return to work
Employee Assistance Program Short term supportive counseling
Occupational Health Department Coordinate and facilitate assessment and RTW
Human Resources Negotiate suitably accommodated work
Management Respect accommodations and monitor
Family and community Support and collateral information
Union/Lawyers/Representatives Enforce employment and labour law
Returning Someone to Work: The Employee
Experience
Common feelings of returning to work:
Guilt
Shame
Embarrassment
Concern about social interactions
Returning Someone to Work:
Manager Role
Are there factors that contributed to the
absence that could be changed or
accommodated?
Brief them on what has been
happening, changes to the work
environment
Be realistic about workloads
Have frequent informal chats and
check-ins
Make them feel welcome – but not a
special case
Address any difficulties early and adjust
Returning Someone to Work:
Occupational Health Role
Help develop RTW plan in a way
that supports recovery
Provide additional supports and
resources e.g. EAP
Provide a safe place if the employee
feels unwell
Check in with Manager and
Employee on the
success/challenges of the RTW plan
and adjust if necessary
Returning Someone to Work:
Human Resources
Collaborate on RTW plan, as
necessary
Help managers understand their role
in supporting an employee’s return to
work
Help managers understand the duty
to accommodate
Act as a resource in the
management of performance,
documentation etc
Return to Work Action Plan
Maintain contact with employee on leave
Support role of the supervisor
Understand the employee’s various tasks and
responsibilities
Understand and address coworker reactions
Understand the impact of the workplace on the
employee
Create the return to work plan
Make the first day back a positive experience (Building Mentally Healthy Workplaces, 2011)
Barriers to Return to Work
(Bender and Links, 2012)
Worker Factors Workplace Factors Clinician Factors
Avoidance and poor
engagement due to
illness or alternative
gain
Availability of temporary
and permanently
modified duties
Undertreatment and
medication side-
effects
Unresolved disputes
and outstanding
discipline
Inconsistent support and
assistance to stay at
work
Medicalization of
work issues
Repeated relapses Inflexibility following
failed RTW attempts
Broad health-related
restrictions
Maladaptive
personality traits
Preference for
termination
“Protective” care
providers
Getting Better Documentation
71
Several physician barriers may exist:
Lack of time in family practice setting
Limited knowledge impairment and required job roles
Dr. acting as a “advocate” by limiting detail of the mental
health or making broad restrictions.
Strategies to improve the quality of medical
documentation provided may include the following:
Provide the clinician with a job description highlighting
mental demands.
Use a brief standardized functional evaluation form
specific to mental health to clarify any impairments
Getting Better Documentation (cont)
72
When appropriate, provide a tentative but specific
accommodation plan in writing and ask for physician
to sign off or propose revisions
Including a prepared invoice for the physician which
provides a nominal fee for completion of all forms.
Invoices should be included with every forms
package and only require payee signature
If further information is still required, request the
Occupational Health Physician make brief telephone
to treating physician or clinician
Monitoring Progress
73
Regular meetings to check in on progress and
performance while health-related issues remain
active
Agreed upon schedule
Trusted contacts at work
Offer to collaborate with health-care providers
Planning up front for how the employee can let the
supervisor know when they are having trouble
coping, and what is needed
Planning up front for expected high risk situations
inappropriate or aggressive behaviour
Talk of suicide
Relapse Risk Factors
Changed role
Ambiguity of modified tasks
Asked to do tasks outside modified duties
Disgruntlement among coworkers
Anxiety and fears of recurrence
Strain with the employer
Distressing conversations with coworkers
Non-workplace life stressors
Non-adherence to treatment
74
Evaluation with Data
75
Job descriptions/job demands analysis
Rates of absenteeism/turnover
Return to work and accommodation data
STD/LTD rates/costs and relapse
EFAP and benefits utilization rates
Complaints/incident reports/investigations
Health risk assessment data
Workers compensation data
Organizational audits
Industry standards/best practices
Psychological health and safety in the workplace - Prevention, promotion, and
guidance to staged implementation. 2013
Treatment Resources
Centre for Addiction and Mental Health
www.camh.ca
Work, Stress and Health Program
Medication Substance Program
Homewood (http://homewood.org)
Ontario Psychological Association (www.psych.on.ca
) for list of providers in the province
Additional Resources
77
Psychologically Safe Workplace
http://www.mentalhealthcommission.ca
Mental Health Works (CMHA)
www.mentalhealthworks.ca
APA National Partnership for Workplace Mental
Health
www.workplacementalhealth.org
NIOSH Total Worker Health
http://www.cdc.gov/niosh/TWH/default.html
Working Through It
www.gwlcentreformentalhealth.com/wti
http://www.guardingmindsatwork.ca/
http://www.psychologicallysafeworkplace.ca/resource
s.html
