Absences relating to mental illness, including depression, impact on every workplace. Depression is characterised by symptoms including: sadness; loss of interest or pleasure; feelings of guilt or low self worth; disturbed sleep; and appetite changes.
Life events and/or changes in body chemistry may trigger the onset of symptoms. If inadequately treated depression may become a chronic disorder. Chronic physical health problems can precipitate or exacerbate depression and, in turn, depression can adversely affect outcomes of coexisting physical illnesses (Narasimhan and Campbell, 2010).
When compared with other aspects of life, the stigma of mental ill health has the greatest impact on people at work (Roeloffs et al, 2003). It is therefore a significant OH issue affecting the productivity of those in work by impairing their ability to function at full capacity. This article focuses on one worker and the overall impact that depression had on their work performance and details how a successful return to work (RTW) was achieved.
The client, Xena, aged 56, was living with her partner and two teenage children. She was seen by OH as a result of a management referral following a recent period of sickness absence of six weeks as a result of depression.
Xena had been employed in a full-time administrative role for 10 years. Her duties were shift based and scheduled on a six-week rolling pattern, the earliest start at 07:00 and the latest finish time at 20:00. Until this period of absence, her attendance was good and she had only taken a total of only five days of unrelated absence over the last three years. Her recent attempts to attend work on several occasions were unsuccessful. She became tearful when asked about her current state of mind and her fitness to undertake her role.
History of the problem
Xena was receiving treatment from both her GP and the community mental health team. She described disturbed sleep patterns, low mood, weepiness, irritability, poor memory and concentration and a loss of interest in social interaction. Her symptoms had gradually worsened over a number of months impacting on the workplace due to inability to concentrate on her current role, which was proving to be demanding.
Xena disclosed an 11-month history of departmental restructures including constant changes of manager, reductions in head count with limited consultation resulting in increased workload and changes to departmental processes.
She highlighted that no additional training or development had been provided to support these changes and felt there was little management support. She had completed a course of cognitive behavioural therapy (CBT) that had gone some way in helping her address her problems.
The OH adviser (OHA) asked Xena to complete the Patient Health Questionnaire (PHQ-9), to gain insight into the severity of her symptoms. This tool asks questions designed to assess the degree of depression experienced and relates this to a categorisation of mild, moderate or severe depression.
Xena’s score was 22, which suggested that she had severe depression. The OHA agreed with the opinion of the GP, who considered her unfit for work, and Xena had a certified absence for a further two weeks.
Pathological basis of the symptoms of depression
A problem-based approach was used to explore the psychological and pathological basis of her current mental health, noting the impact of Xena’s symptoms on her ability to carry out her role. There were no reported issues regarding Xena’s professional conduct or relationships with other colleagues.
Xena stated the treatment options of medication and talking therapies had been discussed during her first consultation with her doctor. It was mutually agreed that medication was inappropriate as she had not disclosed any prior history of depression. The recommendations of the National Institute for Health and Care Excellence (NICE) 2009 are that antidepressants should not be routinely used to treat persistent sub-threshold depressive symptoms or mild depression as the risk-benefit ratio is poor. CBT is a recommended therapy (NICE, 2009).
Understanding the underlying functional changes associated with depression provides an insight to Xena’s current mental health state.
Biological explanations of depression include:
- Genetic: evidence suggests that the predisposition to develop depression is inherited (Breen et al, 2011).
- Biochemistry: low levels of monoamines, predominantly noradrenaline, and serotonin levels can contribute to depression (Brigitta, 2002).
- Neuro-endocrine (hormonal) factors: the importance of stress hormones such as cortisol (McLeod, 2014).
Xena ascribed work-related issues to be the factors underpinning her psychological ill health and this was indirectly impacting on her social wellbeing. It is common for people suffering from stress to isolate themselves socially (McEwen, 2012).
What is work-related ill health?
Work-related mental ill health is a harmful response occurring from a mismatch between a worker’s job requirements and their capabilities, resources or needs. Potential causes of work-related psychological ill health include overwork, lack of clear instructions, unrealistic deadlines, lack of decision-making, job insecurity and isolated working conditions (World Health Organisation (WHO), 2004).
The elements were useful discussion points for Xena and underpinned the advice provided to her manager aimed at facilitating a successful, meaningful RTW. The assessment addressed three important outcomes:
- Xena’s mental state, including her strengths and any apparent weaknesses;
- the demands and expectations of Xena’s role; and
- the desired outcomes expected from Xena and her manager.
A series of questions were asked regarding her health history and details of her lifestyle indicating that she had close, supportive friends, had a gym membership and had slept regularly right up until the depression started. Her relationship with her family had suffered and she had developed social avoidance.
As Xena’s responses to the PHQ-9 questionnaires indicated that she had suffered depression over the last few weeks, she was asked directly about suicidal ideas or intent that could affect her own safety. Xena’s responses indicated that she had no suicidal intent.
She confirmed that CBT, a therapy that challenges thinking patterns aiming to change behaviours, had been a helpful intervention. Xena felt she could now return to work, provided measures could be put in place to review her workload and she would be provided with support until she felt confident in undertaking all elements of her role. Not being prescribed antidepressants would not impact negatively on Xena’s work performance. She was aware that she may feel increased vulnerability initially upon her RTW.
Evaluating the workplace factors and work expectations allowed an assessment on whether it was appropriate for Xena to RTW within the same role or whether or not any reasonable adjustments needed to be considered within an acceptable time frame. These discussions ensured that recommendations made to management were mutually initiated.
There are important differences between the employer-employee and healthcare professional-patient interaction. While healthcare professionals rely on their client to explain the scope of any problems, employers consider objective measures of productivity and subjective reports of social function provided by the affected employee and their colleagues.
In addition, employers have specific and well-defined reasons to discuss an employee’s performance and, where necessary, to encourage changes in attendance and/or work-associated behaviours. Such discussions between manager and staff member are important and are best undertaken sensitively.
Xena’s GP indicated on her fit note that she was well enough to RTW and was supportive of a four to six weeks graded RTW programme. Supporting a RTW at the earliest opportunity benefited Xena as the longer a person is off sick, the more difficult it becomes for them to RTW and the less likely they will return at all (Waddell and Burton, 2006).
A RTW following several weeks or months of absence is not without challenges. Many people with mental health problems fear an exacerbation of their symptoms upon returning, no matter how well their recovery has been thus far. This is especially so for those who believe that work has caused or exacerbated their health problem (Jones et al, 2005).
Xena attended CBT sessions with good effect. The OHA gave Xena an information leaflet detailing the staff psychological and welfare service in order to give further support. She was advised that this confidential service is available 24 hours a day. Section 2 of the Health and Safety at Work Act underlines an organisation’s duty of care to ensure the health and welfare of their employees.
The OHA’s advice to Xena’s manager was the requirement to undertake a formal stress risk assessment in order to discharge this duty. Integral to such a risk assessment is the importance of identifying and taking reasonable action to control workplace stressors; in this situation, instigating possible supporting strategies to control Xena’s fears and anxiety. Her manager was advised of materials produced by the Health and Safety Executive (HSE) that could be utilised in support of this stress risk assessment (HSE, 2013).
A RTW programme scheduled over a four-to-six-week period was formulated in consultation with Xena and subsequently agreed with her manager. Integral to the recommended strategy was a gradual increase of her hours, weekly workload reviews and signposting to the learning and development adviser regarding a structured package of re-training. Supportive reviews with the OHA were offered in order to assess progress during the phased RTW.
A face-to-face follow-up was scheduled at the end of the fourth week of Xena’s RTW. At this consultation it was confirmed that her RTW was proving uneventful and that the recommendations made by the OHA had been implemented.
Xena seemed to have a raised mood and was coping well with her RTW. This was coupled with an improvement in her score on the self-administered PHQ-9 questionnaire, a reduction from 22 to 11 indicating that although she was still moderately depressed, her symptoms were significantly less severe. Xena and her manager were both pleased with the effective RTW and the support available to both parties.
Role of the OH adviser
OHAs have a unique role in collaboratively working between workforce and management. They can support the improvement of worker health and workplace health strategies. The OHA is not providing a work environment that promotes mental health or one that reduces it per se. However, they can be involved in promoting and supporting both local and national strategies, creating a culture where employees can discuss difficulties faced with the knowledge that they will receive support and the assistance the organisation can provide.
Guidance from Mental Health First Aid England (2014) assists managers in dealing with employees suffering from mental ill health. It focuses on improving support and creating a healthier environment within the workplace. Mental ill health or distress is a major cause of sickness absence, reduced productivity and staff turnover. Stress may be a precipitating factor for anxiety and depression.
Work-related stress is a significant workplace issue as it is the leading cause of work-related sickness absence in the UK. The Sainsbury Centre for Mental Health (2007) estimates that it accounts for 70 million sick days annually and is associated with reduced work performance (Lerner & Henke, 2008).
The OHA’s role is to provide an assessment of the employee’s fitness for work and then make recommendations to Xena and her manager with the aim of facilitating a successful RTW. Mental ill health is stigmatising, and results in a reluctance of people to identify and accept the importance of discussing problems openly. OHAs have a part to play within organisations in supporting and promoting workplace mental health promotion strategies.
Their role benefits the organisation, the department and the individual and is integral to promoting public health within the UK. In conclusion, Xena’s RTW was well managed as a result of liaison between the OHA and Xena’s manager. The manager implemented the OHA’s recommendations regarding a phased and supported RTW. It was a management responsibility to address the other issues, including undertaking a stress risk assessment and acting on those findings.