Mental health at work

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Juliet Hassard and Tom Cox, Birkbeck College, University of London


Introduction

Estimates suggest that 25% of European citizens will experience a mental health problem in their lifetime, and approximately 10% of long term health problems and disabilities can be linked to mental and emotional disorders (European Network for Workplace Health Promotion [1]). Results from the 5th European Working Condition Survey found one in five European workers reported poor mental well-being [2]. Using the workplace as a setting to promote good mental health, not only helps protect employee’s mental (and physical) health and wellbeing, but also makes good business sense. This article aims to provide the reader with an overview of the costs, the causes and consequences of mental ill health in the workplace; and provide an informed commentary on the methods and practices to develop and sustain psychologically safe and healthy workplaces.

Mental health in the workplace

Work can contribute to the development of mental ill health through poor working conditions and work organization issues. However conversely, employment can provide individuals with purpose, financial resources and a source of identify; which has been shown to promote increased positive mental wellbeing [3]. There is growing recognition across the European Union, and moreover globally, of the economic and social impact of mental ill health; and, in turn, of the relative importance of promoting mental wellbeing and preventing the onset of mental disorders in society-at-large [4]. The cost of depression is thought amount to an estimated €118 billion in Europe [5] and $83.1 billion in the USA [6]. A systematic review of data and statistics from community studies in European Union (EU) countries, Iceland, Norway and Switzerland show that 27% of the adult population (defined as aged 18–65) had experienced at least one of a series of mental disorders in the past year (including, problems arising from substance use, psychoses, depression, anxiety, and eating disorders [7]). In November 2005, the European Commission published a Green paper – Promoting the Mental Health of the Population. Towards a mental health strategy for the EU as a first response to the WHO mental health declaration for Europe. It stipulates that more than 27% of adult Europeans are estimated to experience at least one form of mental ill health during any one year; and that by the year 2020 depression is expected to be the highest ranking cause of disease in the developed world [8] The workplace has been identified as one of the most important social context in which to address mental health problems, and promote mental health and wellbeing [9] [10] [11] [12]. This article will examine these issues in more detail.

Understanding mental health and mental ill health

Mental Health

The World Health Organisation (WHO) and the Ottawa Charter for Health Promotion [13] define health as: “… a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [13]. This definition provides a comprehensive and holistic understanding of the concept of health, including and supported by three interconnected areas: physical, mental and social health. This holistic definition of health has two basic assumptions: (1) there is no health without mental health; and (2) health cannot – and should not – be viewed as merely the absence of illness or disease, but rather as a state of positive physical, mental and social wellbeing. The WHO [4] suggests mental health should be conceptualised as ‘a complete state of wellbeing’ in which the individual: realises his or her own abilities; can cope with the normal stresses of life; is able to establish and maintain social relationships; and can contribute to society by being productive.

Mental disorders and mental ill health

Mental disorders are clinically significant conditions characterised by altered thoughts, emotions or behaviours with associated distress and impaired functioning [14]. Mental disorders are assessed using a standardised diagnostic manual either the International Classification of Diseases 10th Revision (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders 5th revision (DSM-V). The ICD-10 is a book published by the WHO, and aims to provide a standardised diagnostic manual for mental disorders. The DSM-V, published by the American Psychiatric Association, is another commonly used diagnostic manual for mental disorders. These manuals provide a classification system that aims to separate mental illness into diagnostic categories based on the description of the individual’s symptoms and the course of the illness. Mental disorders are categorised as follows:

  • organic mental disorders (e.g., dementia);
  • psychoactive substance use (e.g., harmful use of alcohol);
  • schizophrenia and associated disorders (e.g., delusional disorders);
  • mood disorders (e.g., depression, bipolar affective disorder);
  • neurotic, stress-related and somatoform disorders (e.g., anxiety disorder);
  • behavioural syndromes;
  • disorders of adult personality;
  • mental retardation;
  • disorders of psychological development (e.g., autism);
  • and child and adolescent disorders (e.g., conduct disorders).

Estimates of severe mental disorders (such as severe depression, bipolar disorder or schizophrenia), are between 1-2% of the working population [15]. Severe mental disorders should be treated and assessed by a trained healthcare professional, and will often require a specialist (such as, a Psychiatrists). The British National Office of Statistics estimates that an additional 20% of the working population have been found to have symptoms that by virtue of their nature, severity, and duration do meet the diagnostic criteria [16] and therefore would be classified as a mental disorder; but would not be viewed as severe. These disorders are often referred to as ‘common mental health problems (CMHP)’. CMHP are those that are most frequent and prevalent. In the United Kingdom, for example, CMHP are often successfully treated in primary care settings (e.g, GPs), rather than by specialists (e.g., Psychiatrists). The most common of CMHP are depression, anxiety, or a mix of the two [14].

Many individuals may experience symptoms of emotional distress, which may not be of sufficient severity to warrant a diagnosis of a mental disorder, but nevertheless result in a significant degree of personal suffering, distress, and decreased productivity [14]. These are often referred to as ‘sub-clinical’ disorders, which are highly prevalent among the working population. The British National Office of Statistic [16] estimate that 20% of the working age population will experience symptoms associated with mental ill health (such as, sleep problems, fatigue, irritability and worry), but do not meet the diagnostic criteria of a mental disorder. However, these symptoms are associated with mental ill health can have a real and significant impact on the individual’s quality of life and ability to function adequately.

The impact and costs of mental health problems

The impact of mental health problems in the workplace has serious consequences not only for the individual employee, but also for the productivity of the enterprise. Employee performance, rates of illness, absenteeism, accidents and staff turnover are all affected by employee’s mental health status. For the interested reader, a report from 2014 by EU-OSHA [17] provides an overview of the literature examining the costs associated with work-related stress and psychosocial risks.

Absenteeism, unemployment and long-term disability

Across the EU levels of absenteeism, unemployment and long term disability claims due to work-related stress and mental health problems are increasing [18]. For example in 2007, 40% of all long term disability benefit payments in Great Britain (England, Wales and Scotland) were due to mental or behavioural disorders [19]. In Austria the total number of days of sick leave was found to be decreasing between 1993 and 2002; but there has been an overall increase of 56% in sickness absence due to mental ill health [20]. In the Netherlands, in 1998, mental disorders were the main cause of incapacity (32%) and the cost of psychological illness was estimated to be 2.26 million EUR a year [21]. According to the British Broadcasting Corporation (BBC) a number of hospital staff being off sick with anxiety, stress and depression in the UK has almost doubled to 41,112 in 2014 from 20,207 in 2010 [22].

Presenteeism and productivity

Mental health problems can often cause fatigue and impaired concentration, and poor memory [23] [24] [25]. A two year longitudinal study found a positive relationship between mental health and work performance. More specifically, as mental health improved so did performance; conversely, as mental health declined so did performance [26]. One large study found depression had a greater negative impact on time management and productivity than any other health problem ; and was found to be equivalent to rheumatoid arthritis in its impact on physical tasks [27]. Sickness presenteeism refers to being physically present at work, but mentally/ cognitively absent. An association between sickness presenteeism and mental health problems has been observed. A large Swedish study of 3801 workers found presenteeism to be related to musculoskeletal pain , fatigue and slight depression [28]. In 2007, Sainsbury Centre for Mental Health estimated that impaired work efficiency due to mental ill health, costs £15.1 billion or £605 for every employee in the UK, which is almost double the estimated annual costs of absenteeism (£8.1 million) [29]. Moreover, according to the Organisation for Economic Co-operation and Development (OECD) the cost of mental health problems to businesses is estimated to be £1,035 for every employee in the UK workforce [30]. Some US studies estimate the costs of impaired presenteeism due to mental health problems are nearly four to five times the costs of absenteeism [31] [32]. Table one provides a concise overview of the estimated costs to British employers due to mental ill health in the workplace.

Table 1: Estimated annual costs to UK employers of mental ill health[29]

Understanding the link between work and mental health

The development of mental health problems are the result of a complex interplay between biological (e.g, genetic characteristics and disturbance of neural communications), psychological (e.g., coping) and social/ environmental factors (such as, poverty, urbanisation, education level, and gender [33] [14]). One social context that can play a significant role in mental health problems is the workplace. The current section seeks to outline some of the key risk and protective factors for mental health found in the working environment. There is evidence to indicate that the poor organisation and management of work plays a significant role in the development of mental health problems. Across research findings, psychosocial issues (such as lack of job control, low decision latitude, low skill discretion, job strain, and effort reward imbalance) have been found to be associated with the risk of depression, poor health functioning, anxiety, distress, fatigue, job dissatisfaction, burnout and sickness absence [34] [35] [36] [37] [38].

A literature review in 2003 found the following key work factors to be associated with mental ill health: long working hours; work overload and pressure, lack of control; lack of participation in decision making; poor social support; and unclear management and work role [39]. A longitudinal study conducted in the UK may provide some insight into causal relationship between work characteristics and the development of mental disorders [40]. Demands at work were found to increase the risk of mental disorders, whilst social support and high decision authority were found to decrease the relative risk. Additionally, high efforts and low rewards at work were found to be associated with the increased risk of mental disorders. A population-based longitudinal study conducted in Canada found work stress to be significantly associated with the risk of major depressive episodes. This study found that individuals who reported experiencing work stress were 2.35 times more likely to report a major depressive episode [41]. Work stress is understood to be a moderator/ mediator of the relationship between occupational hazards exposure and mental health. That is work stress can magnify the relative risk of exposure to psychosocial hazards and mental health problems. The impact of risk factors in the workplace has been observed to vary across different workplaces, occupational groups and cultures. A study of 3142 managers, nurses and paramedical staff, and professionals from four organisations was conducted by WHO [14]. Results indicated that feeling overworked was a contributing factor across all three occupational groups. However, among nurses and paramedical staff the pressure associated with decision-making was an identified as a key risk factor; whilst, in contrast, professionals and managers identified poor relationships with superiors. Additionally, there is growing evidence to indicate that the impact of risk factors may also vary across genders. A review conducted in 2006 found the impact of work stressors on common mental disorders to differ for women and men [41]. An EU-OSHA report [17] provides an extensive discussion on gender and health and safety. The report concludes, however, more in-depth research is required to more fully understand the contributory role of gender in mental health in workplace. The WHO [14] have listed a number of protective factors for mental health: including, social skills, secure and stable family life, supportive relationship with another adult, sense of belonging, positive work climate, opportunities for success and recognition of achievement, economic security, good physical health, attachments and networks within the community, and access to social support. Two dimensions of the psychosocial working environment that have been consistently identified as key protective factors for mental health include: social support and high control/ decision authority at work. For example, a study that followed a group of British Civil servants (6895= men and 3414= women) over a period of time found that social support and control at work were found to protect mental health, whilst high job demands and effort-reward imbalance were risk factors for psychiatric disorders [40].

Addressing mental health in the workplace

The workplace can provide a social context in which to develop a mentally healthy environment that is supportive to all workers. Contemporary frameworks for mental health no longer concentrate exclusively on the prevention and management of mental illness; but, instead follow a holistic approach including the promotion of wellbeing and enhancing functioning paired with the preventative measures [42]. Broadly, the aim of mental health promotion is not restricted to solely preventing mental health problems; but has a wider range of health, social, and economic benefits. Mental health promotion can be viewed as a process of enhancing the protective factors that contribute and support good mental health, paired with identifying and addressing key risk factors [43].Contemporary frameworks for mental health no longer concentrate exclusively on the prevention and management of mental illness; but, instead follow a holistic approach including the promotion of wellbeing and enhancing functioning paired with the preventative measures [42]. Broadly, the aim of mental health promotion is not restricted to solely preventing mental health problems; but has a wider range of health, social, and economic benefits. Mental health promotion can be viewed as a process of enhancing the protective factors that contribute and support good mental health, paired with identifying and addressing key risk factors [43]. It is important to note, that effective promotion of mental health in the workplace should be only one critical component of an overall strategy to improve wellbeing at work [44]. Measures to promote better mental wellbeing and addressing risk factors to prevent mental ill health and undue work-related stress should be fully integrated into an overarching framework for wellness and workplace health promotion [44]. In order to cultivate a sustainable approach to worker wellness it is important to target actions and strategies at four key areas: lifestyle, mental health, physical health and engagement(see Table 2).

Table 2: Elements of a sustainable workplace health and well-being programme

Evidence for the economic argument and cost effectiveness of interventions aimed at protecting and promoting mental health continues to grow [45] [46] [10]. For example, a report published in 2013 [45] examined the cost-effectiveness of different types of interventions aimed at mental health promotion and mental disorder prevention. This report observed for every €1 of investment in workplace interventions there was an associated net economic benefit of up to €13.62 annually. It is important to note, these figures are based on selected European countries and, therefore, caution used be exercised in over generalising these findings. A report by the National Institute for Health and Clinical Excellence [10] suggested that productivity losses to employers, as a result of undue stress and poor mental health, could fall by 30% with implementation of workplace mental health promotion initiatives. For a company with 1000 employees this would be an estimated net reduction in costs by an excess of €300 000. The later sections discusses those actions that have a direct impact on mental health, however it is important to note that all four areas for action in the workplace can make a positive and real contribution to mental health.

Organisational level measures

Actions to aimed at the organisational level to promote and protect mental health, have an strong emphasis on: taking early action to prevent the development of stress and poor mental health in at risk groups; providing an environment that is supportive for employees who have experienced poor mental health; and, finally, implementing measures to help make it easier for people with enduring mental health problems, that may have experienced discrimination and exclusion from employment, to enter and/or return to work [44]. The following are a list of examples of some organisational measures that aim to cultivate a psychologically safe, healthy and supportive workplace [46] [47] [48]:

  • job retention initiatives to maintain in employment those who develop mental health problems whilst at work;
  • the full integration of mental health into workplace health and safety policies and initiatives;
  • multi-level workplace improvement programmes that seek to address role clarity and expectations, workplace relationships, job design, and organisational culture;
  • awareness raising and training for occupational health, human resources staff and managers on mental health in the workplace;
  • the development of a workplace culture/ environment conducive to workers’ health and wellbeing;
  • identification of workplace risk factors and, in turn, the modification of the physical and psychosocial work environment to eliminate and/or reduce identified risks;
  • flexible working hours and support for daily life challenges (e.g., access to child care)
  • job modification and career development;
  • improve communication between employer and employees;
  • promoting worker control and pride over end products;
  • ensuring rewards and recognition for good performance; and
  • ensuring career progression opportunities, to name a few.

Strategies and initiatives to promote mental health and wellbeing should be developed and implemented in a co-ordinated effort by those responsible on all levels, including: employers, managers, supervisors, and employees. In addition, the meaningful active participation of groups targeted by the intervention should be central to any approach adapted to promote positive mental health in the workplace. The role of participation of workers is a concrete enactment of job control, demonstrates organisational fairness and justice, and builds mutual support among workers and between workers and supervisors. These concepts are fundamental and at the core of the development of a psychologically healthy and supportive work environment.

Individual level measures

Actions taken at the level of the individual to promote mental wellbeing aim to: take a salutogenic perspective towards the prevention of stress and poor mental health (ie., addressing risk factors paired with promoting protective factors); provide individuals with resources and supports to help maintain their wellbeing; and cultivate a sense of coherence to affected workers make use of the supports when required (McDaid, 2011). A number of examples of measures targeted at the individual to address mental health in the workplace include [44] [48]:

  • providing individuals with clear job descriptions;
  • modifying workload;
  • free psychological counselling and specific psychological support;
  • relaxation and meditation training;
  • biofeedback;
  • exercise programmes;
  • stress management training;
  • time management training (including, conflict resolution and problem solving skills);and
  • enhanced care management of individual’s with mental health issues.

Evidence for effectiveness

A systematic review of randomized controlled trials of workplace interventions aimed at universal prevention of depression show that workplace interventions directed at an entire workforce can reduce the level of depression symptoms among workers [49]. Kuoppala and colleagues [50] examined evaluations of the effectiveness of interventions delivered in the workplace to promote better mental health and well-being. They concluded that interventions aimed at workplace mental health promotion are valuable to employees' well-being and work ability; and are productive in terms of decreasing sickness absences. However, they highlight that education and psychological interventions when applied alone have limited effectiveness in the long-term, and therefore need to be paired with organisational-level measures that target both physical and psychosocial environments at work [50]. A meta-analysis by Sin and Lyubomirsky [51] showed that mental wellbeing can be enhanced and depressive symptoms reduced through positive interventions. This meta-analysis examined evidence derived from interventions across a number of social context, including the workplace. Within the context of the workplace, this can be achieved by establishing positive leadership practices, ensuring work is meaningful, and building a positive organizational climate [52]. Such positive interventions are becoming increasingly popular in clinical and general settings [53]. However, there continues to remain a paucity of good quality of intervention evaluation research examining the impact of psychosocial interventions aimed specifically mental health and wellbeing promotion [54], and therefore a detailed understanding of how and why such interventions work remains unclear. Measures to address mental health in the workplace are heavily related to the nature and content of interventions to prevent and manage stress and stress-related illness (such as mental ill health and burnout), see articles: Work-related stress: Nature and management, Understanding and Preventing Worker Burnout and Interventions to prevent and manage psychosocial risks and work-related stress. This literature highlights the growing evidence of effectiveness of such interventions; with a numerous studies emphasizing the importance and value of comprehensive approaches to managing and preventing work-related stress and other associated psychosocial issues. Comprehensive intervention approaches use a combination of organisational and individually-focused intervention strategies [55].

A review of interventions for work-related stress and mental strain was conducted by La Montagne and colleagues [56]. The systematic review observed interventions using a comprehensive approach to work-related stress management had a measurable impact to employee’s health and favourable impact on organisational benefits. Conceptually similar findings have been observed by numerous other studies [56] [57] [58] [59] [60].

Policy initiatives and Supporting practices

Ensuring a psychologically safe and healthy workplace is not just a moral obligation and a good investment for employers; but it is a legal imperative set out in Framework Directive 89/391/EEC and supported by the social partners’ framework agreements on work-related stress (2004) and harassment and violence at work (2007). The European Pact for Mental Health and Well-being (2009) recognizes the changing demands and increasing pressures facing the workplace; and encourages employers to implement additional, voluntary measures to promote mental well-being [47]. In recent years there have been a number of initiatives aimed to support and inform workplace mental health protection and promotion strategies [8]. The following are some examples of recent initiatives and associated guidance aimed at employers and organizations: - A Publicly Available Specification (PAS) 1010 was published by the British Standards Institute in 2010. This document offers guidance and good practice on assessing and managing psychosocial risks at work. - The 8th initiative, “Work in Tune with Life”, by the European Network for Workplace Health Promotion (ENWHP) focused the cultivation of mental health promotion in the workplace. Based on the available literature and examples of good practices collected, the ENWHP developed a series of guides aimed at employers [1] and employees [1] to support organisational change and development initiatives aimed at promoting mental health at work. Furthermore, this initiative developed a checklist that can be used to companies to assess the quality of the mental health promotion measures in the organisation [1]. - EU-OSHA, through its ‘Healthy Workplaces Manage Stress’ campaign, offers a practical e-guide to managing psychosocial risks, and is particularly designed to respond to the needs of employers and people working in small enterprises. Furthermore, there a growing number of good practices examples from Europe and beyond to help inform and guide workplace actions aimed to support worker’s mental health and wellbeing. In 2009, a case study collection by the EU-OSHA was conducted, which identified and described good practice examples from across Europe of workplace initiatives to support mental health promotion examples. This report, and the case studies there within, may act as a useful resource to inspire and inform workplace practices and policies [61].

Conclusion

Work can play an important role in the mental health of individuals. In that it can contribute to the development of mental ill health through poor working conditions and, conversely, can provide individuals with purpose, sense of self-worth/ self-esteem, financial resources and a source of identify. In general, mental health problems have been a highly under-recognised issue among employers and managers, despite their high prevalence among the working population. Mental health problems have been shown to have a significant direct impact on the quality of life and functioning of individuals, but also have been found to have an indirect impact on the productivity and resilience of enterprises. The workplace is an important social context in which to prevent mental ill health and, moreover, promote the optimal mental and physical health and wellbeing of workers.

Links for further reading

ENWHP – European Network for Workplace Health Promotion, A guide for employers to promote mental health in the workplace, TNO, Hoofddorp, 2011. Available at: [14]

ENWHP – European Network for Workplace Health Promotion, A guide to creating mentally health workplace – Employee resource, TNO, Hoofddorp, 2011. Available at: [15]

ENWHP – European Network for Workplace Health Promotion, A guide to the business case for mental health, TNO, Hoofddorp, 2011. Available at: [16]

EU-OSHA: Stress, Available at: [17]

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