When a teenage apprentice posted suicidal thoughts on social media, his employer was alerted to the need for better communication between line managers, the GP, mental health clinicians and the occupational health adviser. Susan Hill and Anne Harriss present a case study.
James (not his real name), a 19-year-old engineering apprentice, was an urgent management occupational health referral due to posting on social media his thoughts about self-harm and suicide. James had a history of low mood that had been increasing since the start of his apprenticeship 18 months previously. He expressed dark, suicidal feelings, insomnia and tearfulness; he was lonely and struggling with interpersonal relationships.
An urgent psychiatric referral was arranged and the consultant psychiatrist diagnosed reactive depression but indicated that James was not currently suicidal. James’s manager had concerns that his mental ill-health could pose a risk to himself or his peers while he used dangerous tools and decided to only allocate him administrative duties.
Although unfit to return to normal duties, it was considered that supporting him to remain in work would benefit James as it is widely considered that work is good for physical and mental health (Waddell and Burton, 2006). His manager allocated administrative duties although James would have preferred to return to his usual apprenticeship responsibilities.
At a subsequent OH follow-up appointment 11 days later James revealed he was no longer experiencing suicidal thoughts and he was declared fit to return to normal apprentice duties. Three weeks later, a further urgent OH referral was requested by his manager who had concerns regarding his mental health and his fitness to be at work.
He was aware that his GP had referred him for talking therapy by telephone. This was six weeks after his initial referral to the OH department, somewhat delayed in view of the initial severity of presenting symptoms. Telephone support is not the treatment of choice; NICE (2013, p10) recommends three to 12 sessions of psychological intervention that is “specifically structured for people who self-harm” and tailored to the clients’ own individual needs and should be psychodynamic in approach.
James returned to work on a full-time basis a week later and, although not considered a suicide risk by his GP or psychiatrist, his line manager again allocated him to administrative duties. A critical situation arose two weeks later when James stopped taking his medication due to their side-effects and again expressed suicidal intent precipitating another urgent OH referral and a psychiatric re-referral.
James admitted experiencing suicidal thoughts for half of each day but that it was no worse than previous years. The recommendation was to follow a two-fold approach using psychotherapy and long-term medication. A further OH case conference was arranged including James, his parents and a human resources manager.
The organisation’s duty of care towards James and the other apprentices was noted and his support was explored. As the side-effects of anti-depressant medication could impact on his ability to operate machinery safely it was decided that James would not operate any machinery for three weeks while medication side-effects were assessed. During this period James was to undergo a phased return to work, gradually increasing to full-time working hours.
At a follow-up review four weeks later he appeared more relaxed and confident and was no longer experiencing suicidal thoughts. Now working full-time he was deemed fit for his role and the case closed.
Relevant to James’ current presentation was being bullied at school as a teenager. Bullying can lead to self-harm, which in turn can lead to anxiety and depression in young people (Tantam and Huband, 2009). Bullying may have resulted in him suffering from depression as a teenager. James did not allude to this although it could be argued that as a teenager he may not have recognised his feelings as depression.
About 25% of young people self-harm at some point in their lives and self-harm may be indicative of serious problems such as dysfunctional family relationships, mental illness, bullying, substance misuse and sexual or physical abuse (Royal College of Psychiatrists, 2014).
Although risk factors associated with self-harm in young people are not dissimilar to those for completed suicide it is essential for OH professionals working with young people to understand factors which make suicide more likely.
For example, males are more likely to commit suicide (females are more likely to self-harm), suffer from major depression (whereas self-harm is frequently associated with anxiety disorders) and experience family dysfunction.
Mental health issues in a young person may differ from those over the age of 24, evidenced by West et al (2007) for the Royal College of Psychiatrists. They concluded that the highest incidence of self-harm and suicide was in the unemployed and that employment/unemployment was a stronger predictor of self-harm than parental social class or gender.
Furthermore, in light of the fact that young people are reluctant to access support it can be more successful to enable them to develop personal coping strategies. This should inform OH practice enabling an evidence-based approach to this increasingly common mental health issue.
NICE (2004) guidance recommends a psychosocial risk assessment for people who self-harm. This should include the persons’ skills and strengths and coping strategies and ascertain any apparent mental health issues, physical or personal problems and social circumstances. Requirements for psychological intervention or support should also be addressed.
It is relevant to note that suicide is the third leading killer of young people aged 15 to 24. A mental health or substance misuse disorder underpins 90% of suicide cases (Stanhope and Lancaster, 2008).
Tantam and Huband (2009) argue that there are two types of children who kill themselves, those who are socially isolated with mentally ill mothers or those who are aggressive, impulsive and frequently in trouble at school. This is a narrow, simplistic viewpoint to explain a complex, multi-factorial condition and seemed irrelevant to James.
It is unusual for a young person to openly threaten to self-harm; it is frequently performed in secret. Self-harm is not usually an attempt at committing suicide as young people describe it as a way of expressing deep emotional feelings such as low self-esteem (NICE, 2011).
However, McDougall et al (2010) argue that although “self-harm appears on the same spectrum as suicide, each has a different pattern, purpose and intention” and that attempting to determine suicidal intent is challenging.
Health professionals sometimes see self-harm and suicidal intent as attention-seeking, which is unhelpful. However, Tantam and Hubbard (2009) suggest that using the term “attention needing” shifts the emphasis from the young person doing wrong to someone else’s responsibility to do something right.
Although James’ presenting issue was self-harm and suicidal feelings, his subsequent diagnosis of depression is relevant. Depression is normally considered as mild, moderate or severe and can become chronic, which could be the case with James in view of his presenting history.
The National Centre for Mental Health (2017) states that depression affects everyone differently but symptoms can include feeling low for long periods, feeling hopeless, helpless, anxious, irritable, changes in appetite and losing interest in things normally enjoyed. It can also lead to thoughts of suicide and self-harm as in James’ case.
Causes of depression include childhood experiences, life events, mental and physical health problems, genetics, medication, drugs and alcohol (MIND, 2017).
The bullying James experienced at school may have impacted on his self-esteem; struggling to cope with difficult emotions at that time may have made him less able to cope with life challenges. This could be evidenced by the psychiatrist’s diagnosis of reactive depression during his recent crisis in response to being bored at work and difficult interpersonal relationships.
People with mild depression often improve without treatment, and lifestyle changes are often sufficient to improve symptoms. Psychodynamic approaches including cognitive behavioural therapy (CBT) can be helpful depending on the root cause of a person’s depression. CBT identifies unhelpful ways of thinking and ways of breaking the cycle of negative thoughts.
In moderate to severe cases of depression medication may be appropriate. Had James initially received an appropriate course of treatment his later crisis may have been avoided.
James was challenging to assess. Although he was more likely to commit suicide because he was male and suffering from depression the psychiatrist had maintained that he wasn’t suicidal and, indeed, his presentation was one of a young man who was seeking help.
Assessment of fitness to work
Popular models to provide a rigorous and fair process are the bio-psychosocial model flag system (Watson, 2010) and Fitness to Work (Murugiah et al, 2002). Assessing whether fitness to work is a key role of the OH nurse, Murugiah et al (2002) comment that “care must be taken that fitness to work does not become a mere inventory of anatomical and functional attributes without attempts to compare the individual to his or her work”. Everton et al (2014) state that understanding the client’s job role is key to a functional assessment.
James had no difficulties performing physically demanding aspects of his work but reported increasing low mood for the past 18 months. The symptoms he described were indicative of depression. This, and his posts on social media expressing suicide and self-harm ideation were serious pathology (red flag) and compounded by the initial lack of a structured return-to-work plan and medication side effects.
Using the Hospital Anxiety and Depression Scale (HADS) at the first referral could have resulted in appropriate treatment being initiated earlier. The posts on social media could be seen as unhealthy coping strategies (yellow flag) indicating the need for further investigation by a mental health professional.
James struggled with relationships and his allocation to administration resulted in dissatisfaction in his role (blue flag). His managers appeared supportive but it was evident they wished to “manage James out of his role” as they were struggling to support him.
There appeared to be an element of concern regarding potential consequences of James’s condition (suicide) and whether they would be deemed responsible. They had not considered the organisation’s position with regards to the Equality Act 2010. As the organisation paid employees six months’ sick pay therefore James was under no financial pressure to work (black flag).
James was in the second year of a three-year engineering apprenticeship and was expected to rotate to different sites to gain experience. The apprentices received support and training from a team leader and group leader but the number of apprentices make the task challenging for them.
A range of tools including circular saws, drills and welding equipment were used within the department in which he worked. The manager’s initial risk assessment resulted in James’s suspension from working with dangerous tools. A second risk assessment when James commenced medication highlighted the need to continue his suspension while ascertaining any relevant side-effects.
Because James had been experiencing mental ill-health for more than a year the Equality Act 2010 might apply. Although ultimately a legal matter for courts to decide and not an OH decision, making reasonable adjustments enabling James to continue in his role as far as practicable (Smedley et al, 2013) is good practice.
The recommended adjustment was a phased return to work on reduced hours over a period of four weeks. Relevant to this case is the legal precedent for employer culpability regarding suicide. In the case of Corr v IBC Vehicles Ltd (Kloss, 2010), following injuries sustained at work Mr Corr became depressed and committed suicide.
The court found in his widow’s favour deciding that the injury and subsequent suicide were a chain of events and the company were found responsible for his death. This raises the prospect that companies could be found responsible for the death of employees who take their own lives due to workplace-provoked depression.
Reflecting on this case prompted discussion with colleagues regarding the benefit of improved access to mental health practitioners enabling an expert approach to support employees with mental health issues.
James’s manager failed to refer him to the OH department until he reached crisis point. James was already restricted to administrative duties, causing him distress. The OH department took the appropriate course of action and made an urgent referral to a psychiatrist and although James was seen and diagnosed promptly the psychiatrist had not undertaken a full risk assessment. Furthermore, he was not referred for psychotherapy and was discharged by the OH department to full duties after only 11 days with no phased return to work or follow-up arranged.
Enhanced communication between OH, the GP and psychiatrist may have resulted in James not being prescribed antidepressants by the GP without the knowledge of the psychiatrist or OH department. A referral to a psychotherapist was only made six weeks following the first crisis.
Heron and Greenberg (2013) highlight difficulties faced by people returning to work following a period of mental health illness even though they may have made a good functional and clinical recovery. From this case it appears that although the psychiatrist and GP may communicate regarding clinical treatment the relevance of work and the role of the OH team as part of that process is largely excluded.
It was only following the second crisis point six weeks after the initial sickness absence began that a case meeting was held involving all relevant OH parties and a comprehensive return to work programme was planned, supported by the local mental health team and James’s GP.
The OH team experienced frustration with regards to James’s care due to limited access to mental health practitioners. Their own gaps in the understanding of mental health issues led to an underlying concern that he might commit suicide and therefore his management was based on a defensive rather than evidence-based practice such as that recommended by NICE (2013). This was not necessarily in James’s best interest either medically or personally.
The organisation’s return to work policy emphasises the fact there should be no difference between a return to work plan for physical or mental ill health and that the focus should be on the functional abilities of the worker. Had a comprehensive risk assessment been performed at the first referral with immediate access to psychotherapeutic support backed up by a robust return to work plan it may be that the distress caused to James, his peers and his manager would have been avoided.
As a result of the challenges faced by the OH department and the organisation in this case, the manager and her colleagues have established that early referral to the OH professionals may provide better outcomes for employees experiencing mental health issues.
The OH professionals recognise the need for increasing their knowledge surrounding mental ill health and the implementation of robust policies. The organisation has recognised the benefit of training mental health first aiders to enable early recognition and support for employees experiencing mental health issues.
Susan Hill RGN, BSc (Hons) Occupational Health Nursing (SCPHN) is an occupational health adviser. Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, NTFS, PFHEA, CMIOSH, FRCN, Hon FFOM is Professor occupational health, course director, London South Bank University.
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