Common mental health disorders can have a devastating impact on individuals and their ability to remain in or return to work, as well as have a knock-on effect on employers and the economy. Occupational health can play a pivotal role in supporting those in need as well as highlighting the positive links between work and health, explain Racheal Arkle and Anne Harriss.
Common mental health disorders (CMD) are increasing in the UK. The 2014 Adult Psychiatric Morbidity Survey cited by McManus et al (2017) showed an increase since 2000 in CMD to one in five sufferers in the female adult population, and one in eight in the adult male population. The greater prevalence of CMD was found in those living alone and those who have poor physical health or are unemployed.
A total of 300,000 individuals lose their jobs each year due to CMD, costing employers £42bn per year (Stevenson and Farmer 2017). Return to work (RTW) is arguably one of the most underused yet most meaningful measure of health outcomes for CMD (Palmer et al 2007), providing the best prognostic outcomes irrespective of CMD diagnosis.
This is supported by Waddell and Burton (2006), who clarified the links between health and work, demonstrating that not only is health good for work but also that work is good for health.
About the authors
Racheal Arkle is a specialist occupational health nurse and Professor Anne Harriss is emeritus professor at London South Bank University
The results of the Chartered Institute of Personnel and Development/Simplyhealth Health and Well-being at Work Report (2019) showed that CMD have now overtaken musculoskeletal disorders across workforces as one of the main causes for sickness absence.
These links between health and work were further investigated by Coombs (2016), who found that work was beneficial for health, including for depression and anxiety, two of the most common mental health causes of sickness absence.
Links between common mental health disorders and work
Coombs’ findings showed that 20% of employees will be experiencing a CMD at any given time. Anxiety and stress are closely linked, as are anxiety and depression which are now shown to be the most common mood disorders seen in primary care (Kumar and Clark 2010). Cox et al (1997) articulate the cycle of anxiety and depression as: worry leading to poor sleep, leading to poor performance, leading to malaise, leading to depression, leading to more anxiety, worsening depression.
This article details the effects of depression and anxiety on Angela (pseudonym), a woman in her late thirties working full time as a personal assistant for an NHS consultant physician. She was also a single parent of two children for whom she was the sole financial provider.
Her role involved her minuting meetings and organising diaries for the healthcare team, a role demanding clarity of thought and excellent communication and organisational skills. She was responsible for communications, including complex subject matter requiring mental resilience.
Angela described experiencing a “triple bereavement”, following the death of her mother and two other close family members. This resulted in her absence from work for a total of five months, prompting an occupational health (OH) referral.
Palmer et al (2013) note that OH input can optimise successful outcomes for individuals absent from work for lengthy time periods. Surveys undertaken by the Confederation of British Industry (CBI) (2011) and by the Chartered Institute of Personnel and Development (CIPD) (2019) confirm the importance of OH input for a successful RTW.
Given the risks of long-term unemployment to those on long-term sickness absence, it is important to address this at the earliest possible opportunity.
Waddell and Burton (2006) noted that an absence from work of six months led to an 80% chance of being out of work for five years. In addition, the Adult Psychiatric Morbidity Survey (2014) noted that rates of CMD tend to be far higher in those who are single or divorced, because of mental health being closely linked to social context, Angela was therefore at high-risk with regards to poor long-term outcomes.
Angela had been absent from work for three months following her mother’s death. Her mother’s death had triggered a particularly traumatic response in Angela, as she had been her mother’s main carer through the later and palliative stages of her illness.
Angela had attempted to RTW but was unable to manage her first day back. She described anxiety symptoms recognised by MIND (2017) as typical of the “flight, fright or freeze” response that can occur in anxiety.
She acknowledged that her job role involved typing letters to patients regarding their oncology diagnosis/prognosis. She found this traumatic in the light of her own recent bereavement, leading Angela to experience symptoms of severe anxiety and depression and a further two months sickness absence followed.
Bereavement is a recognised precipitative event for anxiety and depression (Palmer et al 2007). They detail that common CMDs can produce impairments in concentration, motor, communication and social skills, all essential to Angela in her job role.
This impact on concentration and attention can result from the illness itself but also from medication, and can both lead to performance issues. Impaired motor-skills can be attributed to the same aetiology (Thornbory and Everton 2018).
The findings of Coombs (2016), following surveys of managers and health professionals including OH, agreed on the importance of manager input and support in the RTW process; so good communication from OH to support managers is essential.
Occupational health referral
Angela was seen in clinic by an occupational health nurse (OHN). The purpose of this sort of OH assessment is to assess the effects of ill health on work and work on health and to recommend any reasonable adjustments, which it is hoped will enable the employee to achieve the demands of their workload (Thornbory and Everton 2018).
When Angela arrived for her appointment, she was tearful and explained that even travelling to her workplace triggered anxiety symptoms that she felt unable to manage. She stated that she was no longer able to sleep at night, had lost significant amounts of weight and felt unable to mix socially, all consistent with the symptoms described by Lindsey et al (2006).
She described a process of rumination that she was engaging in similar to those described by Genet et al (2012), whereby rumination exacerbates the negative effects of depression and anxiety, two of the most commonly seen CMDs in primary care, and which are often linked illnesses (Kumar and Clark 2012).
Benefits of a biopsychosocial approach
A biopsychosocial approach was used in assessing Angela. The psychosocial flagging system is used in OH to assess severity of conditions that may need an automatic referral to other medical professionals and to identify barriers and facilitators to successful RTW.
The recent addition of orange flags relates to the mental wellbeing of patients and is a useful way of guiding health practitioners towards additional health care input if required (Watson, H 2010). Taking a biopsychosocial approach also allows for the holistic assessment of individuals, taking into consideration medical and non-medical matters. This is an important tool used throughout medicine in dealing with health and understanding health beliefs, which may have an impact on RTW (Coombs 2016).
Angela’s physical health had deteriorated during her absence from work. Her appearance was unkempt and she appeared thin and gaunt, resulting from her significant weight loss. She had a grey pallor and confessed to finding it very difficult to eat because of nausea associated with her anxiety. Combined with poor sleep, she reported extreme fatigue and back pain, symptoms consistent with anxiety and depression (Palmer et al 2007).
Angela self-identified struggling with depression and anxiety and was asked to complete a standardised assessment tool for both. Completion of standardised tools such as the Hospital Anxiety Depression score can be useful diagnostic tools for CMD (Zigmond and Snaith1983).
Some view the use of patient health questionnaire (PHQ-9) as unreliable in diagnosing CMD such as depression (Arroll et al 2010), while others refute this, asserting that they both have value in the primary care setting (Manea et al 2012).
Angela’s score on both anxiety and depression assessment tools was high; she had insight into her mental health, having sought support from her GP who had referred her for bereavement counselling, with which she was actively engaging.
Although it is less common for care givers to suffer from traumatic grief after the death of a relative with a terminal illness, care givers may not cope well mentally – with anxiety and depression (Hudson 2006) recognised responses in vulnerable patients.
Bereavement support and counselling are important in helping individuals to return to normal functioning. Angela had no previous history of mental ill health and had declined medication offered by her GP.
Angela reported having socially isolated herself, as being in the company of others caused her to experience anxiety. She was keen to RTW as her sick pay would only continue for a further two weeks. Without her regular salary she was unable to support herself and her two children.
She was therefore catastrophising, imagining she might lose her home and be unable to cope with the basic social needs of her family without a RTW. Her recent bereavements had resulted in her losing her primary support networks, and she felt unable to provide for her children financially and emotionally.
Angela confirmed her manager had been very supportive. She had attempted to attend the workplace on several occasions for RTW meetings but on her journey into work had became tearful and distressed and had been incapable of completing the journey. Her inability to enter social environments without becoming highly distressed resulting in her becoming increasingly isolated, further impacting negatively on her anxiety and depression.
Angela’s desire was to return to work the following Monday, but she was clearly not in a fit mental state to do so. Upon discussion, she agreed that a further two weeks off work would be beneficial, with the aim of building routine into her life to assist her mental and physical wellbeing. Further review appointments were made with a view to establishing a phased RTW once she had gained greater mental stability.
Use of mindfulness
A growing body of evidence supports the use of mindfulness as a means of improving mental health conditions such as anxiety (Hall, L, 2013). The National Institute for Health and Care Excellence’s (NICE) 2009 guidelines recommend mindfulness and cognitive behavioural therapy (CBT) in the management of depression.
Angela was offered self-referral information to a local CBT provider and advised to consider undertaking some mindfulness practices. She was also advised to consider increasing physical activity, as this is known to improve the symptoms of both anxiety and depression and can have a positive impact for individuals struggling with appetite loss and problems with sleeping (Crone and Guy 2008).
She was advised to consider making attempts to increase her weight by using eating strategies such as eating little and often or, in the absence of the ability to do this, to use protein drinks to boost her calorie intake.
With Angela’s consent a report was sent to her manager recommending that she should remain off work for a further two weeks and then be reassessed to ascertain her fitness to RTW and discuss a phased return. Her manager was advised to maintain contact with Angela.
A lack of interaction with colleagues is identified by Joosen et al (2017) as both a barrier to RTW and a cause of CMD. Palmer et al (2013) note that reduced hours or phased return assists in re-acclimatising CDM sufferers to the work environment, and is beneficial for a successful long-term outcome.
Hughes (2004) recommends phased RTWs involving reduced hours should take place over a maximum timeframe of six to eight weeks and should not start at any less than four hours per day, as fewer hours than this does not allow for any meaningful productivity.
A phased return mirroring these guidelines was detailed in Angela’s OH report, with the additional recommendation of regular one-to-one meetings with her manager and a further OH review should she struggle on her return.
In her role, Angela was assigned to a specific oncology consultant. Her manager was therefore asked to consider whether she could support another consultant, one specifically not working oncology, whilst recovering her mental stability and integrating herself back into the workplace.
Angela appeared much improved on review two weeks later. She was practising yoga daily with her daughter, explaining that it helped her to connect with her as she felt she had neglected her over the past year. This also provided opportunities to practice mindfulness.
Yoga has positive effects on both mental health and confidence, as it helps the practitioner to move from the sympathetic to parasympathetic nervous system, so helping to calm nerves relieving anxiety symptoms (Friedman 2018).
Returning to work following common mental health disorders
Angela remained nervous about her RTW because she was still experiencing some symptoms of anxiety and depression. But as they were under sufficient control a phased RTW now seemed like a realistic step forward.
She had already met with her manager without experiencing anxiety symptoms and she would now be working primarily for a urology rather than an oncology consultant. Repeated completion of mental health screening tools demonstrated that Angela assessed herself as improved from the first time that she had been seen in OH.
In the OH setting these standardised assessment tools are less useful as a diagnostic tool, but can be appropriate as a baseline assessment against which future assessments can be compared (Thornbory and Everton 2018).
Upon completion of four weeks of her phased return, Angela returned to OH and was much improved. She had had her hair done and was wearing make-up. She had gained two kilos by adding protein shakes to a meal plan that included six small meals a day, and she was slowly increasing her food intake.
Angela was discharged from OH at this stage as she was clearly managing and benefiting from her RTW. She admitted that returning to work had improved her confidence, general physical health and had pulled her out of the social isolation in which she had previously been trapped.
In 2017 Stevenson and Farmer (2017) were pushing for the UK to become world leaders in best practice when addressing the stigma and lack of support available for those experiencing CMD in the workforce.
Angela’s case provides a perfect example of how OH support can help to support those in need whilst boosting productivity for employers, demonstrating the premise of Waddell and Burton (2006) that work is good for health.
Given the very real risk of unemployment for those experiencing long-term sickness absence noted by the Department for Work and Pensions (DWP) (2014), Angela’ s case was a success story for both herself and her employer.
Supporting managers to manage sickness absence through health assessment and return to work is, naturally, an essential part of the OH role. The retention and rehabilitation of staff, and the economic benefit this has for employers and society has been widely recognised since Carol Black’s 2008 Working for a Healthier Tomorrow review and Marmot’s 2010 report.
It is also of course a legal responsibility for employers under the Health and Safety at Work Act (1974). Much is now being done to address mental ill health in the workplace. However, if OH is to become the proactive service it is expected to be, it is the responsibility of OH to channel good mental health maintenance through wellbeing, encouraging engagement throughout the workplace.
A supportive workplace alongside good OH provision in the case of acute exacerbation are complementary factors for care of employee mental health and staff retention.
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