Mental Health and the Workplace

Dr. Niki Fitzgerald, Ph.D., C. Psych.

October 8, 2014

1

Overview

I. Overview of Mental Health and the Workplace

II. Prevention and the Psychologically Healthy

Workplace

III. Identifying Mental Health Issues in the Workplace

IV. Managing Issues once Noticed

V. Returning to work

New disability benefit claims due to mental

disorders (in % of total claims)

3

15

20

25

30

35

40

45

50

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

Australia Austria Belgium Denmark Netherlands Norway Sweden Switzerland United Kingdom

Source: OECD

calculations based

on Eurobarometer,

2010.

Economic Impact of Mental Disorders

Lim et al. A new population-based measure of economic burden of mental illness in Canada.

Canada. Chronic Dis Can. 2008;28:92-8

Dewa, Chau and Dermer. Examining the comparative incidence and costs of physical and

mental health-related disabilities in and employed population. JOEM 2010;52;758 4

In Canada, mental disorders are estimated to cost over $51 billion (CAN) in 2003, not including the cost of prescription medications

Direct Medical Costs 9.8%

Short-term Disability 16.6%

Long-term Disability 18.2%

Loss of Quality of Life 55.0%

Disability related to psychiatric disorders costs twice the average of all causes ($18000 vs. $9027)

Conference Board of Canada Survey

Conference Board of Canada. Building Mentally Healthy Workplaces: Perspectives of Canadian

Workers and Front-Line Managers. Report June 2011.port

National survey of over a 1000 employees, including

479 front-line managers, as well as 30 follow-up

interviews

12% reported currently experiencing mental health issues

32% previously experiencing mental health issues

Most mangers had little or no specific training

2009–10, claims in Canada were related to mental

health issues comprised:

78 % of short-term disability claims

67% of long-term disability claims

Guiding Principles

American Psychiatric Association, National Partnership for Workplace Mental Health,

2007 6

“ Work is central to a person’s identity and social role.

It provides income, but more than that, it is often

essential to feeling valued as a person. Loss of work

capacity for any reason is a life crisis, but especially

so when the loss is due to a mental health disability.

A person’s inability to work because of a mental

health condition requires focused and significant

professional attention and a team response.”

Onus on Employers

Whereas a few years ago the law would take note

only of egregious and intentional harms it now sees

even negligent and reckless assaults on mental

health as attracting liability.

Even the negligent imposition of excessive work

demands may attract such liability if it results in

foreseeable mental injury.

Duty to accommodate from moment the employer is

aware of the disability, regardless of whether are

formally notified by employee

Mentally injurious conduct has been censured in

several contexts including:

Treatment of employees by supervisors

Treatment of employees by fellow workers

Management of employees returning to work

Management of employees while on disability leave

Management of employees with mental disorders

Psychologically Healthy

Workplace

Healthy Workplace

Orientation

Training

Promotion

Development

ID

STD

LTD

Return to Work Care and Disability

Duty to Accommodate

Re-engage

Re-train

Counselling

Coaching

ID = Identification of problem

STD = Short Term Disability

LTD = Long Term Disability

Phases of Management

(Lam, 2008) 10

Sick leave

Psychologically Healthy Workplace

Helps to keep workers:

Safe

Engaged

Productive

Risk Factors to Mental Health Associated with

Psychologically Unsafe Workplace

Job demands and requirement of effort

Job control or influence

Reward

Fairness

Support

Workplace Factors Affecting Psychological

Health and Safety

13

From the National Standards for Psychologically Safe

Workplace:

1. Organizational Culture

2. Psychological and Social Support

3. Clear Leadership and Expectations

4. Civility and Respect

5. Psychological Demands

6. Growth and Development

7. Recognition and Reward

8. Involvement and Influence

9. Workload Management

Workplace Factors Affecting Psychological

Health and Safety cont’d

Engagement

Balance

Psychological Protection

Protection of Physical Safety

NIOSH Model of Job Stress

Building Employee Resiliency

Why? Resilient employees:

Cope better

Are more engaged and productive

Easier to work with

Adapt to change better

Resiliency programs could include

Self-regulation – able to manage emotions

Efficient problem solving – flexible in identifying solutions

Self-efficacy – feeling confident and competent

Social support – able to accept and provide support

Creating a Respectful Workplace

Improves morale and job satisfaction, teamwork,

labour relations, turnover, absenteeism

Lack of it can contribute to “toxic environment”

Means treating one another with respect,

consideration and tolerance

Can decrease bullying, harassment

Creating a workplace policy

Communicating the policy

Staff education

Increase Mental Health Knowledge

Combating Stigma is Important because:

Decreases self-stigma

May increase level of support from coworkers

Want to counter stereotypes or myths about mental health

problems including blaming the worker, or thinking they

are intractable

While majority of Canadians would discuss a family

member’s diagnosis of cancer or diabetes, only 50%

would tell a friend or coworker they have a family member

with mental illness (Canadian Medical Association, 8th Annual National Report Card

on Health Care, 29)

Combating stigma at work

American Psychiatric Association, 2007 19

Develop organizational practices that impede stigma

Education for managers to improve recognition

Workplace anti-stigma programs

Legal enforcement of discriminatory practices under

Canadian labour law

Enhancing access to confidential mental health

services in the workplace

Standardizing disability management practices so

the physical and mental disorders are treated equally

Provide Stress Management Training

Time management

Conflict Resolution

Relaxation

Structured Problem Solving

Realistic thinking

Identifying Mental Health Issues

Screening and Surveillance Goals

22

Promote continuous health surveillance by management and OH staff in a supportive manner

Create strategies for early identification which may be suited to your organization Managers/Union/Occ Health /Peer-based

Have clear and consistent process for case assessment to expedite referral to appropriate services

Be prepared to respond to risk such as suicide or violence

Supervisor Training Essentials

Importance of identifying and documenting performance issues Basis for dialogue with individual employees about how

their mental health issue was interfering with their work

Resources for employees, supervisors, and work teams

EAP/ Health and Wellness / Organizational development

OH case management and critical incident teams

Constructive ways to confront the “troubled” employee early

The business case for intervening

Guidance about roles and boundaries

Prevalence in Working Populations

Major Depressive Disorder 6.7%

Disability Claimants

Chronic pain

>10%

up to 70%

Bipolar Disorder 1.1%

Posttraumatic Stress Disorder 5%

Soldiers

Police/Fire/EMS

12-30%

7-22%

Substance Use Disorder 10%

Construction

Food/Bar

17%

16%

Attention Deficit Hyperactivity Disorder 3.5%

Substance abuse and mental health services administration, National Comorbidity Study, CC Health

Survey

1 in 5 adults will be diagnosed with depression

Globally, 350 million are affected by depression

in 12 Americans abuses alcohol or is alcoholic

(Adelson, 2006)

In 2009 there were 3,890 suicides in Canada, a rate

of 11.5 per 100,000 people

The suicide rate for males was three times higher

than the rate for females (17.9 versus 5.3 per

100,000).

Although suicide deaths affect almost all age groups,

those aged 40 to 59 had the highest rates

Prevalence of Alcohol Use Problems

American Journal of Physical Medicine & Rehabilitation February 2012 - Volume 91 - Issue 13 - p

S62–S68

Symptoms of Depression

Feelings

Sad

Tearful

Hopeless

Nothing

More angry than usual

More irritable

How you think

I’m a failure at work, at home

What’s the point

More negative then usual

Symptoms of Depression

Physical problems

New sleep problems including getting to sleep, staying asleep

Appetite changes – eating more or less than usual, craving carbs more than usual

Feeling tired more easily or more often

Feeling more fidgety or restless

Feeling more slowed down

Difficulty thinking or concentrating

What you do

Isolating

Not wanting to do the things that you normally would, having a lot more ‘ustas’

More argumentative

Depression’s Impact on Work Performance

Task Performance: Depressed mood can make it hard to manage

work responsibilities, including sustaining effort over time and

dealing with change.

Emotions: Sadness, irritability or emotional numbing make it harder

to do your job and enjoy it.

Thinking: Difficulties with concentration, decision-making or memory

make it harder to deal with job tasks and may negatively impact your

accuracy at work.

Work Relationships: There can be avoidance of co-workers or

frequent conflict, preventing successful teamwork and making the

workplace less supportive.

Physical Health: Reduced energy level and disrupted sleep make it

difficult to keep up with job demands. Physical symptoms may further

undermine workplace performance and attendance.

Causes of Depression Biological differences. People with depression appear to have

physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.

Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may be associated with depressive symptoms.

Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result from thyroid problems, menopause or a number of other conditions.

Inherited traits. Depression is more common in people whose biological (blood) relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.

Life events. Traumatic events such as the death or loss of a loved one, financial problems, high stress, or childhood trauma can trigger depression in some people.

What depression is not

A sign of innate personal weakness

Something to be ashamed of

Something that “other people get”

A life sentence

Something that is completely incapacitating

A sign of being “crazy”

Posttraumatic Stress Disorder – what it is

A set of symptoms that can develop after a traumatic

event, where trauma is defined as something that

happens when one has “experienced, witnessed, or

was confronted with an event or events that involved

actual or threatened death or serious injury, or a

threat to the physical integrity of oneself or others.” (DSM-IV-TR)

Symptoms of PTSD

Reliving the Event

Having unwanted and recurrent thoughts, memories, or

dreams about the event

Being distressed or having physical reactions such as

sweating or having heart palpitations by reminders of the

event

Avoiding Reminders of the Event and Feeling Numb

Making an effort to avoid activities, places, people,

thoughts, or feelings related to the event

People may also have a lack of interest in daily activities,

feel cut off or detached from family or friends, or feel flat

and numb.

Symptoms of PTSD

Being Overly Alert or Wound Up

Feeling keyed up, jittery or alert

Irritability or anger

Difficulties Sleeping

Concentration Problems

Being alert or on guard for possible danger

Easily startled

What might these symptoms look like?

Being keyed up or on edge

Difficulty being at the site where the trauma occurred

Difficulty doing regular work duties

Difficulty getting along with coworkers or withdrawing from

coworkers

Not wanting to talk about the event

Tired at work

Lost time from work

Alcohol Abuse

Alcohol use interferes with responsibilities (e.g., at

work, home, or school);

Dangerous patterns of alcohol use (e.g., while

driving a car or operating machinery);

Alcohol use causes legal problems (e.g., arrests for

disorderly conduct); and

Alcohol use continues despite negative effects on

relationships (e.g., physical fights).

Alcohol Dependence

Tolerance to alcohol (need more and more alcohol to achieve desired effect);

Withdrawal when regular drinking is stopped or reduced (e.g., sweating, insomnia, nausea);

Often drink more or drink longer than intended;

Difficulty limiting or quitting drinking;

Great deal of time spent in obtaining, using, or recovering from alcohol;

Previously valued/important activities (e.g., recreational) are given up or reduced because of alcohol use; and

Alcohol use continues despite awareness that drinking is causing physical or emotional problems.

Mood Disorders (at a glance)

38

Disorder Key feature Associated

Symptoms

Behaviour

Major Depressive

Disorder

At least one

depressive episode

lasting over 2 weeks

Sad/irritable mood

Hopeless/Helpless

Inappropriate guilt

Suicidal ideation

Sleep changes

Eating changes

Cognitive changes

Poor energy

Psychosis

Neglect

Self-harm

Loss of

enjoyment

Dysthymic

Disorder

Mild depressive

symptoms for >2

years

As above As above

Seasonal

Affective Disorder

Depressive episodes

in seasonal pattern

As above Seasonal pattern

Adjustment

Disorder with

Depression

Preoccupation with

stressor

Mild and only with

exposure to stressor

Poor adaptation

to stressor

Mood Disorders (at a glance)

39

Disorder Mood Associated

Symptoms

Behaviour

Bipolar I Disorder At least one manic

episode lasting >1

week

Depressive episodes

most common

Euphoria/irritability

Grandiosity

Racing thoughts

Hypertalkativeness

Decreased sleep

Increased energy

Psychosis

Goal-directed

Risk-taking

Impulsive

Disorganized

Aggressive

Bipolar II Disorder At least one hypomanic

episode lasting 4-7

days

As above except

milder

Less impaired

Cyclothymic

Disorder

Alternating hypomanic

and depressive

episodes

Mild Less impaired

Substance-

Induced Mood

Disorder

Depressed, hypomanic

or manic

Substance

intoxication or

withdrawal

Highly

impaired

Mood Disorder due Depressed, hypomanic Present during Variable

Anxiety Disorders (at a glance)

40

Disorder Thoughts Associated

Symptoms

Behaviour

Generalized

Anxiety Disorder

Excessive worry

lasting >6

months

Tension/ fatigue

Poor concentration

Poor tolerance

unknown

Panic Disorder Fear of attacks Panic attacks

Physical complaints

Agoraphobia

OCD Obsessions Anxiety on exposure Compulsions

PTSD Fear of

recurrent

trauma

Nightmares

Flashbacks/memorie

s

Loss of enjoyment

Avoidance

Aggression

Hypervigilance

Social Phobia Fear of negative

appraisal

Situational distress Avoidance

Simple Phobia Irrational fear None Avoidance

Adjustment

Disorder with

Anxiety

Preoccupation

with stressor

Anxiety with

exposure to stressor

Poor adaptation

to stressor

What to look for

Pay attention for changes in behaviour,

personality or character, don’t ignore things or

hope for a change

Impact of Mental Disorders

on Workplace Functioning

45

Presenteeism

• Reduced work performance

• Impaired interpersonal relations

• Increased effort and longer time at work

• Frequent breaks during workday

• Poor judgment or appearing impaired

• Inappropriate conversations/comments

• Aggression/inappropriate behaviour

Absenteeism

• Lateness

• Leaving early

• Increased sick days

• Unplanned absences

• Unexplained absences

• Failure to achieve or maintain full-time employment

• Loss of overtime

Disability

• “Stress leave”

• High consumption of medical resources

• Non-adherence with treatment plan

• Failure to RTW despite physical rehabilitation

• Failure to start or complete academic retraining

• Reliance on social assistance

Absenteeism and Presenteeism both

Increase with Poorer Mental Health

46

Sickness absence incidence Average duration of sickness absence Presenteeism incidence

Percentage of persons who have been absent from

work in the past four weeks (apart from holidays)

Average number of days absent from work in the

past four weeks (of those who have been absent)

Percentage of workers not absent in the past four

weeks but who accomplished less than they would

like as a result of an emotional or physical health

problem

Note: Averages are represented by dashed lines.

Source: OECD calculations based on Eurobarometer, 2010.

42

28

19

0

5

10

15

20

25

30

35

40

45

Severe disorder Moderate disorder

No mental disorder

7.3

5.6

4.8

0

1

2

3

4

5

6

7

8

Severe disorder Moderate disorder

No mental disorder

88

69

26

0

10

20

30

40

50

60

70

80

90

Severe disorder Moderate disorder

No mental disorder

When something is noticed

Meet privately

Approach your concerns as a workplace

performance/behaviour issue

Stick to the facts

Make them feel valued and supported

Let them know that accommodations are possible and

there is confidential EAP support – be solution focused

Ask them what they think could help

Document the meeting with facts only, no opinions

Follow-up

Communication is Key

49

Some employees will need:

Verbal and written communication

Face-to-face rather than telephone contact or vice versa

Time to establish trust and rapport

Frequent clarification and focusing

Validation of their experience

Support during meetings

Let the employee’s needs and preference guide the

methods of communication but always document

Do NOT document suspected diagnoses!

Performance Appraisal Model

50

Clarify Duties

Agree on Objectives

Monitor and

Support

Review and

Evaluate

Appraisal Interview

Try to Avoid

Probing or trying to diagnose the problem

Offering a “pep”

Don’t assume that someone can just “snap out of it”

Sounding accusatory or overly critical

Arguing with them

Recovery at Work

Accommodation Prevents Disability

Canadian Human Rights Act

Employment Equity Act, Canada

53

The duty to accommodate means the employer must implement whatever measures necessary to allow its employees to work to the best of their ability.

Employee must provide sufficient information to the employer to determine appropriate accommodation options.

An employer can only deny accommodation if it does something in good faith for a purpose connected to the job, and where changing that practice to accommodate someone would cause undue hardship to the employer, considering health, safety and cost.

Physicians should consider early health accommodation with ongoing treatment rather than prolonged work leave Communication requirements

Social demands

Cognitive demands

Scheduling

Supports

Promoting Recovery from Work

1. Educate about health issues and encourage treatment

2. Arrange for timely assessment

3. Review need for accommodation or leave

4. Facilitate “active” treatment ASAP

5. Meet/talk frequently to discuss status and return to work

6. Maintain adequate written and verbal communication with involved parties

7. Consider legal and safety issues

8. Identify barriers and consult if failure to progress as expected

Types of Accommodation

Flexible scheduling

Changes in Supervision

Modifying job duties

Changes in training

Using technology

Modifying workspace and changing location

Accommodations for specific problems

Difficulty maintaining stamina

Concentration problems

Maintaining organization/meeting deadlines

Remembering things

Dealing with stress and emotions

Dealing with change

Accommodations for specific problems

Difficulty with workplace relationships

Outline clear expectations and consequences for not

meeting them

Define what is meant by good working relationships

Have regular meetings

Allow the option of not attending work-related social

functions

Responsibilities of Employees

Advise the employer of disability (not dx)

Make needs known to best of their ability

Answer questions or provide information regarding

relevant restrictions/limitations, including medical

documentation if required

Participate in discussions about possible

accommodation solutions

Work with accommodation provider on an ongoing

basis to manage the process

Meet agreed-upon performance and job standards

once accommodation is provided

Once someone is off sick…….

Chances of RTW Reduces with Time

60

0

10

20

30

40

50

60

70

80

90

100

0 4 8 12 16 20 24 28 32 36 40 44 48 52

Weeks

After 12 weeks, an employees at a majorU.S. Manufacturer had only a 50% chanceof ever returning to work

(APA 2007)

Supporting an employee who is

off sick

Co-ordinate approaches to ensure clarity

Reassure them that you will respect personal and medical boundaries

Review needs/wishes for support ideally before they go on leave so expectations are known

Reassure them about practical issues like job security

DO NOT put pressure on them to name a return date

62

Occupational Mental Health System

Worker

Management

Family and

Community

Insurance System

Mental Health Care

Bender & Kennedy, 2003

Employee Assistance

Programs

Occ Health, HR

and Union

Work Environment

Returning to Work After a Leave

Roles and Return to Work

64

Player Role

Worker Adhere to treatment plan

Manage documentation

Cooperate with insurer and employer

Mental Health Care Providers Propose and implement rehabilitation plan

Provide timely documentation insurer and

employer as requested

Insurer Wage replacement

Funding of additional treatment if indicated

Assistance with return to work

Employee Assistance Program Short term supportive counseling

Occupational Health Department Coordinate and facilitate assessment and RTW

Human Resources Negotiate suitably accommodated work

Management Respect accommodations and monitor

Family and community Support and collateral information

Union/Lawyers/Representatives Enforce employment and labour law

Returning Someone to Work: The Employee

Experience

Common feelings of returning to work:

Guilt

Shame

Embarrassment

Concern about social interactions

Returning Someone to Work:

Manager Role

Are there factors that contributed to the

absence that could be changed or

accommodated?

Brief them on what has been

happening, changes to the work

environment

Be realistic about workloads

Have frequent informal chats and

check-ins

Make them feel welcome – but not a

special case

Address any difficulties early and adjust

Returning Someone to Work:

Occupational Health Role

Help develop RTW plan in a way

that supports recovery

Provide additional supports and

resources e.g. EAP

Provide a safe place if the employee

feels unwell

Check in with Manager and

Employee on the

success/challenges of the RTW plan

and adjust if necessary

Returning Someone to Work:

Human Resources

Collaborate on RTW plan, as

necessary

Help managers understand their role

in supporting an employee’s return to

work

Help managers understand the duty

to accommodate

Act as a resource in the

management of performance,

documentation etc

Return to Work Action Plan

Maintain contact with employee on leave

Support role of the supervisor

Understand the employee’s various tasks and

responsibilities

Understand and address coworker reactions

Understand the impact of the workplace on the

employee

Create the return to work plan

Make the first day back a positive experience (Building Mentally Healthy Workplaces, 2011)

Barriers to Return to Work

(Bender and Links, 2012)

Worker Factors Workplace Factors Clinician Factors

Avoidance and poor

engagement due to

illness or alternative

gain

Availability of temporary

and permanently

modified duties

Undertreatment and

medication side-

effects

Unresolved disputes

and outstanding

discipline

Inconsistent support and

assistance to stay at

work

Medicalization of

work issues

Repeated relapses Inflexibility following

failed RTW attempts

Broad health-related

restrictions

Maladaptive

personality traits

Preference for

termination

“Protective” care

providers

Getting Better Documentation

71

Several physician barriers may exist:

Lack of time in family practice setting

Limited knowledge impairment and required job roles

Dr. acting as a “advocate” by limiting detail of the mental

health or making broad restrictions.

Strategies to improve the quality of medical

documentation provided may include the following:

Provide the clinician with a job description highlighting

mental demands.

Use a brief standardized functional evaluation form

specific to mental health to clarify any impairments

Getting Better Documentation (cont)

72

When appropriate, provide a tentative but specific

accommodation plan in writing and ask for physician

to sign off or propose revisions

Including a prepared invoice for the physician which

provides a nominal fee for completion of all forms.

Invoices should be included with every forms

package and only require payee signature

If further information is still required, request the

Occupational Health Physician make brief telephone

to treating physician or clinician

Monitoring Progress

73

Regular meetings to check in on progress and

performance while health-related issues remain

active

Agreed upon schedule

Trusted contacts at work

Offer to collaborate with health-care providers

Planning up front for how the employee can let the

supervisor know when they are having trouble

coping, and what is needed

Planning up front for expected high risk situations

inappropriate or aggressive behaviour

Talk of suicide

Relapse Risk Factors

Changed role

Ambiguity of modified tasks

Asked to do tasks outside modified duties

Disgruntlement among coworkers

Anxiety and fears of recurrence

Strain with the employer

Distressing conversations with coworkers

Non-workplace life stressors

Non-adherence to treatment

74

Evaluation with Data

75

Job descriptions/job demands analysis

Rates of absenteeism/turnover

Return to work and accommodation data

STD/LTD rates/costs and relapse

EFAP and benefits utilization rates

Complaints/incident reports/investigations

Health risk assessment data

Workers compensation data

Organizational audits

Industry standards/best practices

Psychological health and safety in the workplace - Prevention, promotion, and

guidance to staged implementation. 2013

Treatment Resources

Centre for Addiction and Mental Health

www.camh.ca

Work, Stress and Health Program

Medication Substance Program

Homewood (http://homewood.org)

Ontario Psychological Association (www.psych.on.ca

) for list of providers in the province

Additional Resources

77

Psychologically Safe Workplace

http://www.mentalhealthcommission.ca

Mental Health Works (CMHA)

www.mentalhealthworks.ca

APA National Partnership for Workplace Mental

Health

www.workplacementalhealth.org

NIOSH Total Worker Health

http://www.cdc.gov/niosh/TWH/default.html

Working Through It

www.gwlcentreformentalhealth.com/wti

http://www.guardingmindsatwork.ca/

http://www.psychologicallysafeworkplace.ca/resource

s.html

Questions?

Dr. Niki Fitzgerald, Ph.D., C.Psych.

Work, Stress and Health, CAMH

Niki.Fitzgerald@camh.ca