OH has a key role in supporting people with depression in the workplace, collaborating with HR, line managers and primary care. Jodie Aldridge and Anne Harriss explore this area of OH’s public health role.
According to the Health and Safety Executive (HSE, 2015), depression stress and anxiety are very common illnesses encountered in the OH setting, with more than 9.9 million working days lost per year.
Depression affects the sufferer, their friends and family and has workplace implications. It is a common mental health illness that can present itself with low mood and anhedonia. Disturbed sleep, low self-worth, feelings of guilt, low energy, loss of appetite and poor concentration are further features (WHO, 1984).
Hasler (2010) states that stress sensitivity in depression is somewhat gender specific.
Although both men and women are, in the main, equally sensitive to the causes of the depressive effects of stressful life events, depending on the stressor the responses of both can differ.
Men are likely to have a depressive episode following a divorce or workplace issue, while women are more likely to be sensitive to events in their social network, such as serious illness, death or difficulty with interpersonal relationships (Kendler, Thornton and Prescott, 2001, cited in Hasler, 2010).
Selective serotonin re-uptake inhibitors (SSRIs), such as Citalopram, are widely used in the treatment of depression, and Citalopram enhances mood stability.
They are often the first choice medication treatment as they have fewer side effects than most other types of anti-depressant (NHS Choices, 2015).
The Royal College of Psychiatrists (RCP) (2015) states that following three months of taking anti-depressants, depression will be improved by 50-65% compared to 25-30% of those on placebo.
They work on the principle that two neurotransmitters are affected by depression: serotonin and noradrenaline. This medication increases the concentration of these chemicals. How definitely this improves the mood of an individual is uncertain, but it is often prescribed as a mood stabiliser (RSP, 2015).
As can be encountered with any medication there can be side effects associated with their use. Those associated with Citalopram include increased anxiety and nausea (Royal College of Psychiatrists, 2015) and are usually experienced in the first few weeks of treatment.
Effective treatment is not limited to medication, and talking therapies are also helpful. Integrating these elements into vocational rehabilitation can allow clients experiencing depression to overcome barriers to returning to work (Thornbory, 2014).
Assessing suspected depression
Several tools are available to assess patients with suspected depressive illness, including the (Beck and others, 1996) BD1-11 multiple-choice questionnaire. The Patient Health Questionnaire (PHQ-9) was developed as an adaptation of the BDI-II and consists of 10 questions and a scoring card. The client completes both these questionnaires.
According to the MacArthur Initiative (2011), these are not screening tools specifically for depression but can monitor the severity of depression and response to treatment.
Wittkampf et al (2009), however, suggests that the PHQ-9 works well as a screening but not as a diagnostic instrument for depressive disorder. Diagnostic tools do not always capture all of the important factors impacting on the course of depression and treatment response, therefore it is necessary to consider both personal past medical history and family history of depression (NICE 2009).
Therapies for depression in the workplace
Completion of an assessment form starts an effective dialogue and discussion on current mental state and previous medical history in order to establish physical risk and mental state in a respectful and understanding way and would assess risk of self-harm and suicidal intent as suggested in the NICE guidelines (NICE, 2004).
Several “talking therapies”, including counselling, are available to treat mild-moderate depression. Problem-solving techniques can help where the depression has been caused by complications and worries in life.
Cognitive behavioural therapy (CBT) is a NICE-recommended therapy for the treatment of depression (NICE, 2009).
It helps individuals to consider how they automatically think about themselves, the world and others, challenging their “autopilot” thinking patterns, aiming to change that cycle and behaviours.
Informing the client’s GP regarding vocational rehabilitation programmes available within the organisation and any referral to other agencies ensures a multi-professional collaboration between primary care and OH departments.
The Faculty of Occupational Medicine (FOM, 2005) publication Health and Work Handbook highlights the respective roles and responsibilities of OH and GP services in supporting clients back to better health and work. These specialities have access to different resources that can play a key role in client recovery.
Local health and social services can be accessed by the GP, while OH may be able to refer their clients to employee assistance programmes (EAPs), private healthcare schemes and facilitate communication with line managers and HR. These all play a part in supporting the client in their recovery. Beaumont (2003) suggests a better way to achieve a sustainable and supportive return to work is through collaborative working and effective communication.
Assessing fitness
The Murugiah et al framework (2002) cited in Hammond and Harriss (2013) is useful when assessing physical and/or mental health in the light of fitness to return to work.
This framework incorporates factors to consider when assessing the fitness for a return to work, including personal attributes, psychological and or physical attributes, work characteristics and work environment. It is used to meet the needs of the employee and employer, and supports the OH assessment (Hammond and Harriss 2013).
Following an OH assessment, with the client’s consent, a report should be sent to the referring manager responding to questions incorporated within the referral form advising the business on the management of the case.
Templeman (2006), cited in Thornbory (2014), states that assisting the management of any organisation in managing sickness absence is fundamental to the success of an OH service.
Dealing with absence is the responsibility of management, HR and the employee. The advice requested from OH supports management in helping to reduce absence rates and promote a healthy workplace (Lewis and Thornbory, 2010).
OH role in return to work
Prior to any contact with OH, the employee must be aware from management that an OH referral has been made, why it has been made and they must agree to the assessment (Kloss 2010).
When undertaking an assessment, it is the responsibility of the OH nurse (OHN) to ensure that the employee is aware of all applicable information about the reason for the referral, the process, their legal rights for undergoing an OH assessment and that a report about the consultation will be released to the referrer (Lewis and Thornbory, 2010). It should also be made clear that consent can be withheld at any point (Kloss, 2010).
For consent to be valid, it must be informed and given freely from the client to provide this information from both a legal and ethical perspective (Nursing and Midwifery Council, 2015; Lewis and Thornbory, 2010).
The client should be made aware that any consultation with an OH professional, whether physician or a nurse, is bound by confidentiality.
Palmer et al (2013) propose three components fundamental to an OH assessment, including the:
- employee’s strengths and weaknesses in relation to their job;
- job and workplace demands; and
- expectations of the outcome by both employee and employer.
The OHN has a vital role in assessing the client’s fitness for work and advising on an effective return-to-work strategy incorporating reasonable adjustments for the employer to consider (cited in Ghiasse and Harriss, 2015).
Working collaboratively with the employer and employee on a return plan is likely to benefit a sustainable return to work.
The use of psychosocial flags (Kendall et al, 2009, cited in Watson, 2010) within the assessment allows the OHN to recognise aspects of the client, their social background and their illness and symptoms to assess how these factors affect the return to work and recovery process.
For example, a black flag would relate to unhelpful beliefs and advice from family and social isolation from work colleagues and the workplace. A yellow flag links to catastrophising and thinking that returning to work will make the situation worse, and uncertainty of what the future holds.
It is important to recognise that rehabilitation “…is not about forcing people back to work. Work, in fact, is often a crucial step in helping people return to health. And businesses have much to gain in terms of reduced sickness absence, and improved staff engagement and retention” (McKenzie 2007, cited in Thornbory 2010).
Waddell and Burton (2006) emphasise that work is often the vital step in returning to full health and can be an effective part of the treatment phase of the process.
Maintaining positive, regular contact with the workplace is recommended in the NICE (2009) guidelines of good practice in sickness absence. This responsibility is a fundamental part of the manager’s role, but often they feel uncomfortable doing this as some do not know what to say and do not want to cause further distress.
The organisation’s attendance management policy and the manager’s responsibility in the sickness absence process should be highlighted. The OHN plays an important part in signposting relevant resources and providing training in manager capabilities.
It is helpful for the client to meet with their line manager prior to the return to work. It is also advantageous for them to meet with colleagues briefly. Although this may precipitate feelings of anxiety, it does provide an opportunity to discuss with the manager what was to be shared with her team.
It is important to remain aware that returning to work following a period of absence can be daunting and is an indication as to why keeping in contact with employees when they are off work is effective and supportive. It can be less difficult and help ease anxieties when they do return (Everton et al, 2014).
The longer an employee is away from the workplace, the harder it becomes for them to return. The longer the absence, the less likely that they will ever return (Waddell and Burton, 2006).
An employee absent from work for six months or longer has an 80% chance of being off work for five years, and this underlines the importance of early OH interventions (Waddell and Burton, 2006).
Reducing long-term sickness helps to maintain a healthy workforce and productive organisation, which mutually benefits employees, employers and society (Health and Safety Executive, 2005). Work is an essential part of an individual’s wellbeing, self-esteem and health. Waddell and Burton (2006) assert that “good work is good for you” and the OHN’s role is to carry out an assessment of the employee’s fitness for returning and make recommendations to management with the aim to facilitate a sustainable and supportive return to work.
Recommendations for management regarding a return to work should be based on the health assessment carried out and adjustments advised for employees returning following a mental illness diagnosis (Department of Health, 2012, cited in Harrington, 2014). These included:
- adjusted hours/shifts if a phased return is deemed necessary;
- adjusted duties;
- working with a “buddy” during any phased return;
- additional breaks of 5-10 minutes as required if feeling stressed or anxious; and
- workplace stress risk assessment.
Other adjustments may include regular weekly catch-up meetings with the manager allowing both parties to discuss the progress and effectiveness of the return-to-work strategy. The vocational rehabilitation plan (VRP) should be designed to be time limited. Initially, this time-frame could be as short as four to six weeks, but may need to be extended due to client need and subject to the support of the manager. The VRP should be formulated in conjunction with the client and agreed by their line manager as he/she makes the decisions as to whether or not the plan is reasonable and can be supported.
It is advantageous to arrange an OH review part way into the rehabilitation programme to ensure the plan is endorsed by the manager and is effective in helping client recovery. Supporting managers with a clear and timely plan and advice is important as better outcomes are achieved if the employee is supported by the business (Wright cited in Flemming, 2015).
A stress risk assessment is advisable in many cases as this assists in highlighting any workplace issues, allowing the manager to act on these findings. This is in compliance with the duty of care encompassed within the Health and Safety at Work etc Act (1974) and the requirements of the Management of Health and Safety at Work Regulations (1999), which require employers to carry out appropriate assessments of any workplace health and safety risks that their staff are exposed to in order to take measures to control the identified risk.
Collaborate with managers and third parties
Successful collaboration with multi-disciplinary professionals is fundamental to fitness-to-work assessments and the development of effective return strategies. Working with a GP, psychologist, line manager, HR and the employee is mutually beneficial and is likely to result in a well-managed return to work.
New learning from such experiences will facilitate OH involvement in advising organisations. For example, the training of managers in long-term sickness absence and raising the awareness of mental health and associated illnesses in the organisation could be helpful.
Promoting both national and local strategies will help to create a culture where employees can discuss health issues and managers feel comfortable and equipped to engage in these conversations.
This could be through working with charities such as Mind and incorporating mental health awareness workshops in the organisation’s wellness calendar initially and to look into mental health first-aid training for all line managers.
OHNs have a unique and integral role in working with businesses to promote public health. This benefits organisations, individuals and the wider society.
Jodie Aldridge BSc, RN, SCPHN is an OH manager, and Anne Harriss MSc, BEd, RGN, RSCPHN, OHNC, NTF (HEA), PFHEA, CMIOSH, FRCN is professor of occupational health at London South Bank University.
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