It can be challenging for an employer to know how best to support an employee living with a mental health illness, especially a potentially severe and fluctuating one such as bipolar disorder. But there is much that occupational health can do to help, as Nyamadzawo Kanjipiti-Sibanda and Anne Harriss explain.
Mental ill health is a significant cause of sickness absence and loss of productivity in all sectors in the UK (Palmer et al. 2013).
This case study explores the occupational health (OH) care given to Samara (a pseudonym), a worker with a mental health problem. It commences at the point where she was offered employment as a healthcare assistant working in a special care unit within elder and dementia care of a mental health trust. When Samara submitted her completed pre-employment questionnaire she disclosed that she had a mental illness.
About the authors
Nyamadzawo Kanjipiti-Sibanda is an occupational health advisor at West London NHS Trust and Professor Anne Harriss is professor in occupational health and course director at London South Bank University
For an occupational health nurse (OHN) faced with this in similar circumstances, the Equality Act (2010) immediately comes to mind. This Act aims at improving the support for people with disabilities (Kloss and Ballard, 2012). Article 6(1) of the Act states that a person has a disability if they “have a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on [this person’s] ability to carry out normal day-to-day activities” (FRA – European Union Agency for Fundamental Rights; p22, 2011).
Many people with disabilities are highly motivated and have an impeccable attendance record (Palmer et al. 2013). This is the picture Samara displayed. However, others with mental health illness have both perceived and actual barriers to seeking gainful employment resulting from their high rate of sickness absence (Hanisch et al. 2017).
Importance of early support
Demoua et al. (2016) emphasise the importance of early support systems in sickness absence management. Clinicians should consider returning to work as an important health outcome and important in promoting recovery in people with mental illness (Hanisch et al. 2017).
An initial telephone assessment was undertaken, saving her the inconvenience of attending the OH department and complying with clearance targets set by the employing organisation (Darcy-Jones and Harriss, 2016). The assessment provided an opportunity to gain an understanding of the impact and management of her mental ill-health, to understand her previous roles and identify any work adjustments that may facilitate her being able to undertake the job requirements of her proposed job role.
Samara, aged 25, had been diagnosed with type 1 bipolar disorder as a teenager. In addition, she had a personality disorder and anorexia nervosa. Her penultimate post was working within customer service. She explained she had not enjoyed this role and considered that it adversely affected her mental health. Her current post was working in a special needs school whilst studying for a course in health and social care. Unfortunately, she had had to discontinue her studies on the grounds of cost.
The Ethics Guidance for Occupational Health Practice (FOM, 2012) highlights that pre-employment assessment should be fit for purpose therefore the approach to the assessment and the history taking reflected this. Throughout the telephone assessment the challenges associated with her prospective post were considered.
An important consideration was the high level of stress posed to healthcare workers and the effect of rotating shift patterns, particularly night duty, which could disturb her sleeping pattern, as sleep loss may trigger high mood in people with bipolar disorder (Lewis et al. 2017). Currid (2009) and Gibb et al. (2010) report that nurses in mental health setting experience high rates of stress-related sickness.
Samara told the OHN that she had had no problems with shift work to this point, as she was used to that from her previous employment. An overview of the independent role of the OH service was highlighted, including the opportunity for self-referral and the range of available OH services that includes counselling.
The complexity of interplay between having a significant mental illness and seeking work within a special care unit within a mental health trust resulted in the OHN seeking the advice from the OH physician. Samara consented to details of her medical history being sought from her psychiatrist and for her case to be discussed by the OH physician.
Consent is a fundamental legal and ethical requirement in how practitioners deal with and treat their clients. Without informed consent practitioners cannot proceed. Requesting such a report from Samara’s specialist team ensured an accurate picture of her current and past mental health problems.
This information was required to confirm that work of this type would not adversely impact on her own health, to ensure she was well enough to work as a healthcare assistant working within elder and dementia care and to consider whether any adjustments may be required to support her in the work setting. Keeping people living with mental health illness at work can be challenging due to recurrence of illness and frequent relapses (Nielsen et al. 2018).
The OH physician considered that Samara was fit for her proposed post. Samara agreed to the OH nurse monitoring her mental wellbeing from the point of employment with the aim of providing timely support should this be needed and making a re-referral back to the OH physician if required.
When asked whether any work adjustments would assist her, Samara said none were required. She was encouraged to talk to her manager should she feel this should change as her manager is responsible for workplace risk assessments and work-related stressors could aggravate existing mental health problems (HSE, 2017).
Samara was living with a complex interplay of mental health problems that included an emotionally unstable personality disorder, typified by difficulties with interpersonal relationships, mood and poor self-image alongside impulsive behaviour; anorexia nervosa and bipolar disorder.
The National Institute of Mental Health (NIMH, 2015) states that anyone can be affected by bipolar disorder and it is considered a significant illness. Approximately one in every 100 adults has bipolar disorder. Both genders are equally affected with symptoms generally appearing between the ages of 15-19 and rarely commencing after the age of 40 (Royal College of Psychiatrists, 2018).
People with bipolar disease experience extreme and contrasting mood changes either feeling depressed or feel elated and “up”. When feeling elated they are much more energetic and more active than usual (Royal College of Psychiatrists, 2018).
When feeling “up” they may exhibit what seems to others to be outrageous behaviours such as excessive shopping, spending money they don’t have or undertaking non-stop physical work described by Royal College of Psychiatrists (2018) as manic episodes.
This contrasts with times when they have depressive episodes when they feel sad and “down”. At these times they are much less active, have low energy levels and feel depressed. These episodes are followed by changes in sleep patterns, enhanced energy levels and the ability to think and reason clearly. In extreme cases they may self-harm or attempt suicide (NIMH, 2015). Extreme fluctuations in mood can damage relationships and cause difficulties in maintaining employment.
However, the RCPsych (2018) notes that, with appropriate treatment, many with bipolar disorder do lead successful lives.
Legislation
Some mental illnesses and their required medications impact on effective mental and cognitive functioning. Samara’s new role required her to be alert, physically fit enough to participate in the prevention and management of violence and aggression and to be able to cope in what can be a challenging environment.
There is a duty of care on the employer to their employees, patients and visitors under Sections 2 and 3 of the Health and Safety at Work Act (1974). The Equality Act (2010) is explicit in ensuring that employees are not discriminated against on the grounds of their mental health illness.
However, they must be capable of performing their job requirements, albeit with adjustments where these can be accommodated. Fundamental to this is the need for risk assessments to reduce the risk of harm (Lewis and Thornbory, 2010).
The organisation
Tamara was seeking employment within an NHS mental health trust providing services ranging from community to low, medium and highly secure forensic units. The OH service has an important role in support of staff in this environment and provides staff counselling, physiotherapy. Integral to this service are an OH psychiatrist and dietitian.
Samara is single, her relationship with her boyfriend having broken down. She had contact with her father. She smokes vapours and drinks alcohol occasionally.
In terms of the role she was applying for, namely as a healthcare assistant within elder and dementia care, her role involved assisting patients with their daily personal care. She was also required to contribute to de-escalation of acute incidences on the unit.
Two months after she commenced employment, her manager requested the advice of the OH service as he had concerns about her performance and what he had perceived as a deterioration in her mental health. Samara was under the care of a psychiatrist and the treating team had initiated a Wellness and Recovery Action Plan (WRAP) in place.
Integral to a WRAP is the support afforded to patients to help them develop awareness and understanding of the emotional triggers which impact on their condition (Olney and Emery-Flores (2017). Within three months of commencing employment Samara became aware of a decline in her mental health and following the guidance of the mental health team caring for her she took sick leave.
Post-relapse OH assessment
Samara disclosed she was enjoying her job and that she was aware of the reason why her manager had referred her for an OH opinion. She declared difficulty sleeping and a poor appetite but described her mood as generally good.
She stated that on the day of the assessment she was “feeling really happy and good” but she countered this by disclosing that on some days she experienced low mood with negative thoughts. She did not express suicidal ideations or intentions of self-harm. The OHN advised her of her eligibility to access the trust counselling services and she requested a referral for counselling.
At the time of the OH referral she had been seen by her consultant psychiatrist and was receiving care from the mental health recovery team which included appointments on alternate days with her care co-ordinator. Her original medication had been the anti-psychotic medication olanzapine 15mgs once a day but due to a “high mood” this was changed to aripiprazole 15mgs once a day. She was currently taking diazepam 5mgs when needed for sleep, pregabalin 150mg twice a day for severe anxiety and mebeverine 135mg three times a day prescribed for what she described as “tummy troubles”.
Mental health assessment
Samara was able to give a good account of her illness. However, her speech was slightly slurred, there was shaking of her knees and tremors of hands that she was unaware of until asked about it.
As these could be related to side-effects of pregabalin, the medication she was prescribed for anxiety, it was recommended she highlight this to her care co-ordinator at her next scheduled appointment. Although Samara wished to return to work she was not yet considered well enough and a review appointment was arranged for three weeks.
During this period the OHN continued to liaise with her care coordinator. The OHN’s role became a continuous case monitoring system of Samara’s mental health illness and included telephone and face to face, assessments supplemented with multidisciplinary case meetings involving the OH professionals and the home treatment team (HTT), followed by liaison with her manager and human resources.
The role of the OHN throughout this time was to collate the information from her care givers in order to monitor Samara’s progress to then make recommendations to her manager on appropriate adjustments to support her return once well enough.
These recommendations included restricting Samara’s duties to only working early shifts as night shifts could disturb her sleep pattern and she had difficulty to wake up for an early shift if she had worked a late shift on the previous day. Her medication also made her feel tired and therefore she preferred to go to bed early which was difficult if she was working late shifts.
Her manager was supportive and able to facilitate these adjustments with the aim of supporting Samara to stay well and in work. Employers have a duty under the Equality Act (2010) to make reasonable adjustments for employees with disabilities (Kloss and Ballard 2012).
A report was prepared for her manager, the contents of which were discussed with Samara. She was given the opportunity to read the letter before it was sent to her manager and she was satisfied with the content of that report. The report indicated that Samara was still off sick and receiving care from the HTT. Samara gave her consent for the OH practitioner to liaise with the care coordinator who was seeing her on alternate days. A further review was arranged for three weeks later.
Barriers to an effective return to work
Samara had always been keen on returning to work as soon as she could manage. When she was due to attend her review appointment she informed the OHN that her symptoms had recently worsened, however, and she had been admitted to hospital.
This recurrence of her symptoms was becoming an additional barrier to overcome in effecting her return to work (Hanisch, et al. 2017). Recurrences were taking longer to resolve than the first episode which Nielsen et.al. (2018) confirm is not unusual.
Samara was in and out of crisis, being treated by the HTT and crisis team. Samara lacked insight as to why she could not return to work despite her consultant having explained this to her. Lack of insight was not unexpected, as it is a common feature of bipolar disorder, especially during the elated phase.
Samara attended a subsequent OH appointment and it became apparent she had been attending work and was managing to conduct her job requirements despite having been advised by her caring physician that she should remain on sick leave.
Although Tse and Walsh (2001) report that stigmatisation can cause low confidence in people with mental health illness, Samara displayed the confidence to return to work. Her care coordinator had emphasised the importance of support from her colleagues and her line manager, and Samara indicated that she was receiving this support. Family, supervisor and organisational support play a very important part in the RTW for people living with mental illness (Nielsen et al. 2018; Hanisch et al. (2017). Samara was receiving good support from her family, manager and the OH team.
Effecting a return to work
A return to work following an absence resulting from mental health illness can be daunting, and a loss of confidence and a slow recovery after treatment may negatively impact on a successful return to work (Fit for Work, 2016; Hanisch et al. 2017).
A multidisciplinary approach to managing RTW was essential in supporting Samara. This multi-professional approach led to a well-supported RTW program and played an important part in her full recovery and mental wellbeing (Fit for Work 2016).
The OHN had concerns regarding her coming back to work because of the side-effects of her medications (tremors), but agreed with her care co-ordinator that returning to work would improve Samara’s overall mental health.
Engagement in paid work is pivotal in psychosocial rehabilitation for people living with mental health illness (Tse and Walsh; 2001). A co-ordinated approach between the OH service, her care team and her manager resulted in Samara returning to work.
Sign up to our weekly round-up of HR news and guidance
Receive the Personnel Today Direct e-newsletter every Wednesday
She received constant OH support that necessitated 40 contact appointments, telephone contact, email and multidisciplinary meetings. A phased return-to-work programme was developed and Samara settled back into work well. Sadly, despite this support shortly after her return she resigned in order to take up an alternative position. She may not receive this level of support in this new organisation.
References
Currid, T. (2009) Experiences of stress among nurses in acute mental health settings. Nursing standard 23 (44): 40-46
Darcy-Jones, C, and Harriss, A. (2016). Telephone health assessments: good practice in occupational health. Available from:
https://www.personneltoday.com/hr/telephone-health-assessments-good-practice-occupational-health/
Demou, E, Brown, J, Sanati, K, Kennedy, M, Murray, K, and Macdonald, E B (2016). A novel approach to early sickness absence management: The EASY (early access to support for you) way, Work, 53 (3), pp. 597-608. DOI: 10.3233/WOR-152137.
Available from https://content.iospress.com/articles/work/wor2137
Ethics Guidance for Occupational Health Practice. 7th Edition, Faculty Occupational Medicine (2012) London. Faculty of Occupational Medicine of the Royal College of Physicians.
Phased return to work after sickness absence, Fit for work (2016). Available from:
https://fitforwork.org/blog/phased-return-to-work-after-sickness-absence/
Equality. The legal protection of persons with mental health problems under non-discrimination law. Understanding disability as defined by law and the duty to provide reasonable accommodation in European Union Member States.
European Union Agency for Fundamental Rights (2011). Available from:
http://www.antigone.gr/files/en/library/documentation-of-EU-and-international-organizations/international-surveys-and-studies/FRA-2011-Legal-protection-persons-mental-health-problems_EN.pdf
Gibb, J, Cameron, I M, Hamilton, R, Murphy, E, and Naji, S. (2010). Mental health nurses’ and allied health professionals’ perceptions of the role of the Occupational Health Service in the management of work-related stress: How do they self-care? Journal of Psychiatric and Mental Health Nursing. Vol 17(9):838-845
Hanisch, S E, Wrynne, C and Weigl, M. (2017). Perceived and actual barriers to work for people with mental illness, Journal of Vocational Rehabilitation, 46 (1), pp. 19-30. DOI: 10.3233/JVR-160839.
Mental health at work and work-related stress. Common mental health problems (CMHPs). Health and Safety Executive (2017). Available from: http://www.hse.gov.uk/stress/mental-health.htm
Kloss, D and Ballard, J (2012). Discrimination law and occupational health practice. Barnet. The At Work Partnership Ltd.
Lewis, J, and Thornbory, G. (2010). Employment law and occupational health: A practical handbook. 2nd edition. Chichester. Wiley-Blackwell
Lewis, K S, Gordon-Smith, K, Forty, L, Di Florio, A, Craddock, N, Jones, L and Jones, I. (2017). Sleep loss as a trigger of mood episodes in bipolar disorder: Individual differences based on diagnostic subtype and gender, The British Journal of Psychiatry. Cambridge University Press, 211(3), pp. 169–174. doi: 10.1192/bjp.bp.117.202259.
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579327/
National Institute of Mental Health (2015) Bipolar disorder. Available from:
https://www.nimh.nih.gov/health/publications/bipolar-disorder/tr-15-3679_152248.pdf
Nielsen, K, Yarker, J, Munir, F, and Bὕltmann, U. (2018) IGLOO: An integrated framework for sustainable return to work in workers with common mental disorders, Work and Stress pp. 1-18.
Olney, M F, and Emery-Flores, D. (2017) “I get my therapy from work”: Wellness recovery action plan strategies that support employment success, Rehabilitation Counselling Bulletin, 60 (3), pp. 175-184. DOI: 10.1177/0034355216660059.
Available from: http://journals.sagepub.com/doi/pdf/10.1177/0034355216660059
Palmer, K T, Brown, I, and Hobson, J. (2013) Fitness for Work: The Medical Aspects. 5th Edition. Oxford: Oxford University Press USA – OSO.
Royal College of Psychiatrists (2018 a) Bipolar disorder. Available from:
http://www.rcpsych.ac.uk/healthadvice/problemsanddisorders/bipolardisorder.aspx
Tse, S S, and Walsh, A E S, (2001). How does work work for people with bipolar affective disorder? Occupational Therapy International, 8 (3), pp. 210.
Available from: http://psycnet.apa.org/record/2005-05337-005
Tse, S, and Yeats, M. (2002) What helps people with bipolar affective disorder succeed in employment: A grounded theory approach, Work, 19 (1), pp. 47-62.
