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Mental Health and the Workplace
Promoting Recovery
Ash Bender, MD, FRCPC
Work, Stress and Health
Asst. Prof., University of Toronto
February 25, 2013
1
+ Work, Stress and Health
Specialty program servicing disabled workers since 1998
Multidisciplinary Team Psychiatry
Psychology
Occupational Therapy
Administrative
Comprehensive Disability Assessment
Multidisciplinary Treatment CBT and Medications
RTW coordination
Research
Positive disability outcome in 65% of clients!
2
+ Underlying Principles
“ 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.”
(APA 2007)
3
Mental illness is common in working
adults, whether we acknowledge it or not.
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%
12%
Attention Deficit Hyperactivity Disorder 3.5%
+ Its in the Headlines... 6
“Workplace health and safety involves
body and mind” Moose jaw Times Herald
“Workplace mental health guide
sets national standard” CBC
“Santa ‘s son defies dress code policy” Polar Herald
http://letstalk.bell.ca/en/
“Follow human rights code on mental health” Financial Post
“Workplace discrimination over mental health to end” The Times
+
We talk about it every day…
“Stress”
“Work-life balance”
“Burnout”
“Mental health day”
“Stress leave”
“Unexpected departure”
Causes of Workplace Stress
8 (Health Canada 2000)
Job strain increases significantly the
chances of having a mental disorder
9
*
*
**
**
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Moderate disorder Severe disorder
***
***
**
*** ***
***
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Moderate disorder Severe disorder
***
***
***
***
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Moderate disorder Severe disorder
*** *** ** *** *** *** Active learning Job strain Passive work
Sample average without
controls
After controlling for individual
attributes
After controlling for working
conditions
Source: OECD calculations based on Eurobarometer, 2010.
+ Time to Change
U.K. anti-stigma campaign surveyed more than 2,000 employers in 2009
Asked to imagine interviewing someone for a job who admitted that they suffered from depression from time to time.
92% of people believed it would damage someone's career
Only 21% thought an admission of depression would harm the career of an MP
Most vulnerable careers were teachers (48%), the emergency services (54%) and doctors (56%)
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1
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+ Time to Change
56% said they would not employ them even if they were the best candidate
17% said they would they would be unreliable
10% said they would be blamed if the employee took time off sick
15% said that they wouldn’t work as well with others
Employers who did hire someone with mental health problems are more likely to be knowledgeable regarding laws and have policies in place, but not differ in attitude (Brohan et al. 2010)
http://www.time-to-change.org.uk/your-organisation
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Mental illness is associated with
tremendous personal, organizational and
societal cost.
+ Economic Impact of
Mental Disorders
In Canada, mental disorders are estimated to cost over
$51 billion (CAN) in 2003, not including the cost of prescription medications
$5-billion in direct medical costs
$8.5-billion a year due to long-term disability
$9.3-billion annually due to short-term sick leaves
$28-billion due to reductions in health-related quality of life (Lim et al, 2008)
In 2011, the Centers for Disease Control and Prevention found that the suicide rate from 1928 to 2007 has risen and fallen in tandem with the business cycle
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New disability benefit claims due to
mental disorders (in % of total claims)
1
6
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 BelgiumDenmark Netherlands NorwaySweden Switzerland United Kingdom
Source: OECD
calculations based
on Eurobarometer,
2010.
Impact of Mental Disorders on
Workplace Functioning
17
Presenteeism
• Reduced work performance
• Impaired interpersonal relations
• Increased effort and longer time at work
• Frequent breaks during workday
• Poor judgment
• Aggression/inappropriate behaviour
Absenteeism
• Lateness
• Leaving early
• Increased sick days
• Unplanned absences
• Failure to achieve or maintain full-time employment
• Loss of overtime
Disability
• “Stress leave”
• High consumption of medical resources
• Failure to RTW despite physical rehabilitation
• Failure to start or complete academic retraining
• Reliance on social assistance
Symptoms vs. Functioning
Irritability
Sadness
Anxiety
Anhedonia
Cognitive distortions
Suicidal ideation
Impaired concentration
Poor memory
Executive dysfunction
Agitation
Sleep changes
Intoxication
Fatigue and pain
Ego functions
Defenses
Conflict
Isolation
Avoidance
Withdrawal
Poor motivation
Erratic behaviour
Decreased task efficiency
Increased errors
Poor decision making
Reduced task vigilance
Neglect
Violence and accidents
Self-limited activities
Coping behavior
Mood
Thoughts
Cognition
Somatic
Personality
Absenteeism and presenteeism both
increase with poorer mental health
1
9
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 Moderatedisorder
No mentaldisorder
7.3
5.6
4.8
0
1
2
3
4
5
6
7
8
Severe disorder Moderatedisorder
No mentaldisorder
88
69
26
0
10
20
30
40
50
60
70
80
90
Severe disorder Moderatedisorder
No mentaldisorder
+ Depression and Productivity
Community survey of 2737 employed or recently employed adults from Alberta
8.5% experienced depression in past year
Severe depression associated with significant decreases with productivity
Individuals receiving treatment were more likely to be highly productive (2.5-7x)
Less than half of workers with moderate to severe depression received treatment
Highlights need for improving access to high quality treatment for employed Canadians
Dewa CS et al. Can J Psychiatry.
2011;56(12):743–750. 2
0
+
Conference Board
of Canada Survey
National survey of over a 1000 employees, including 479 front-line managers, as well as 30 follow-up interviews
12% reported currently experiencing a mental health issues
32% previously experiencing mental health issues
Most mangers had little or no training
2009–10 Canadian claims related to mental health
78 % of short-term disability claims
67% of long-term disability
Conference Board of Canada. Building Mentally Healthy
Workplaces: Perspectives of Canadian Workers and Front-
Line Managers. Report June 2011.port
Bring the to solution to work!
+ NIOSH Total Worker Health
“NIOSH believes that the safest and healthiest
worker only evolves in an atmosphere where
management is fully engaged in the wellbeing of its
staff, where the environment is hazard-free and
supportive, and where workplace policies and
interventions encourage healthier choices--simply
put, where the total health of the worker, in the
broadest possible sense, is optimized.”
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3
+
Key Components
I. Healthy Workplace
II. Education and Training
III. Screening and Surveillance
IV. Triage and Referral
V. Work-Focused Treatment
VI. Return to Work and Monitoring
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+
National Standard for a
Psychologically Safe
Workplace
Effective management
Psychological Safety & Protection
Communication & Engagement
Organizational Culture
Workload Management & Work-life balance
Job Environment
Awards, Recognition & Team Building
25
Mental Health
Commission of Canada http://www.psychologicallysafeworkplace.ca/
+ Combating stigma at work
Develop organizational practices that impede stigma
Education for managers to improve recognition of presenteeism
Workplace anti-stigma programs
Legal enforcement of discriminatory practices under labour law
Enhancing access to confidential mental health services in the workplace in addition to EAP
Standardizing disability management practices so the physical and mental disorders are treated equally
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(APA 2007)
+ Education and Training
Training material and programming to establish core knowledge and skills base among first-line staff
Values/Policies/Procedures
Provide educational material for employees to improve treatment-seeking
Utilize effective educational methods for delivery of relevant material and training
Face-to-face/pamphlets/web-based/wellness days
Consider cost and time investment to allow for resource allocation
27
+
Workplace Insight
High-quality computer-based training
Customizable to organization
Essential content for staff and managers
Recognition/communication skills
Responding to critical incidents
Managing return to work
Substance use and work
Workplace compliance
www.workplaceinsight.ca
+ Screening and Surveillance
29
Promote supportive health surveillance by
management and OH staff
Union and Peers-based initiatives
Develop a consistent process for qualified assessment
to expedite referral to appropriate services
Use validated screening tools for mental health-related
symptoms or impairment
DASS -21 / PHQ
Be prepared to respond to high risk issues such as
threatened suicide or violence
Screen According to Risk
Low
• Encourage voluntary self-screening
• Use web-based resources if feasible
Mod
• Routine (annual) physical/psychological
• Positive screens referred to assessment
High • Mandatory assessment for those on disability
leave or exhibiting concerning behaviour
APRAND Programme
Target more than 140,000 employees at French Power Company
For 9743 employees on sick leave
Screening for anxiety and depressive disorders
Psychoeducation about illness
Strong recommendations for treatment by occupational physician
No direct treatment provided
Improvements in symptoms severity and remission rates observed at one year with an inexpensive intervention
(Dietrich et al. 2011, Godard et al. 2006) 3
1
+ Triage and Referral
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Identify potential care pathways within organizations
using existing resources
EAP/OH Staff/Family Doctor
Introduce case management models and potential
treatment resources
Consulting Psychiatrist
Community heath partnerships
Focus on reducing time to treatment by providing
education and encouragement
Strictly manage of confidential health information
+ Occupational Mental Health System
Worker
Management
Family and
Community
Insurance System
Mental Health Care
Bender & Kennedy, 2003
Employee Assistance
Programs
HR, Occ Health
and Union
Work Environment
33
Treatment rates are extremely low
and gradually increase with age
3
4
0
5
10
15
20
25
18-24 25-34 35-44 45-54 55-64
Treatment prevalence (↗) Mental disorder prevalence
+ Treatment and Monitoring
35
Advocate for high quality mental health care
Awareness and anti-stigma campaigns
Offer a benefits which improve mental health care
Psychological treatment
Comprehensive meds formulary
Develop workplace-delivered treatment interventions
Peer-based programming
Return to work programs
More direct communication between care providers and employer health services
+ Work-focused
Psychological Care
12 month follow-up of 168 employees on full sick leave due to psychological problems including depression, anxiety and adjustment disorders
79 workers received 12 sessions of cognitive-behavioural therapy (CBT) over 6 months
89 workers received work-focused CBT (W-CBT) with sessions focused on work examples and RTW as a goal
Both experienced substantial reductions in mental health problems in both groups at similar costs ($5275)
W-CBT group achieved full RTW 65 days earlier and partial RTW 12 days earlier
36
Lagerveld and Blonk, 2012
+ Evidence for
Collaborative Care
Early psychiatric consultation, time-limited treatment
and communication with family physician results in
superior outcomes in STD claimants compared to
usual disability practices
Higher rates of return to work
(85% vs. 63%)
Lower rates of transition to LTD
(7% vs. 31%)
Shorter duration of disability
(62 vs. 76 days)
Enhanced care models are cost-effective for
employers but underutilized (Dewa et
al., 2009)
37
+ Return to Work
38
Develop strategies which promote early and
sustainable return to work
Use of RTW coordinators
Team and worker preparation
Active treatment in the workplace
Use flexible approaches to accommodation and
reintegration into the workforce
Develop supportive policies and resources for
impaired or disabled employees to prevent relapse
Recognize issues related to confidentiality often
leave others in the dark or spark rumors
+ Accommodation Prevents
Disability
The definition of light duty for a physical disability is
“less physically demanding”
Consider early mental health accommodation with
ongoing treatment rather than work leave
Communication requirements
Social demands
Cognitive demands
Scheduling
Supports 39
4
0
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
+ Global Business and Economic
Roundtable 2011 Final Report
Board of Directors and CEOSs must embrace
mental health and show leadership
Mental health must be enshrined in occupational
health and safety standards
National standards for psychologically-health
workplaces
Workplaces must become venues to prevent suicide
Joint community/workplace-based models of
treatment and support must broaden access to care
Call for cure for depression
Wilson and Wilkerson. Brain Health + Brain Skills = Brain Capital. Final Report of Global
Business and Economic Roundtable on Addiction and Mental Health. 2011.
+
42
The “take to work”
Message
Mental disorders are highly prevalent working
populations and associated with significant
individual, organizational and societal costs due to
presenteeism and absenteeism
Emerging workplace health and legal standards are
changing emphasis to support and disability
prevention by addressing stigma and job stain
Successful management and recovery requires a
systematic and collaborative approach including the
employer and health care providers
4
2
Thank you! [email protected]
