Mental illness in the workplace

Occupational and environmental physicians are well versed in the diagnosis and treatment of physical workplace injury, and the health benefits of a return to work as early as practicable. It’s less clear cut when the issue is psychological.

Sunday night dread is probably a feeling or phrase nearly all workers could empathise with at some point in their careers: that nagging fear of work the next day, for any number of reasons. 

It was a particularly evocative phrase used by consultant psychiatrist Dr Dielle Felman FRANZCP and clinical and organisational psychologist Dr Peter Cotton FAPS in an intriguing presentation to AFOEM Fellows at RACP Congress 2017 on ‘Mental Illness and Health in the Workplace.’ 

Both talked about diagnosing and treating workplace mental health issues; specifically three common categories of presentation − depression, anxiety and post-traumatic stress disorder (PTSD). 

The Sunday night dread hypothetical case study was of a conscientious administrator of many years experience who had faced a relationship breakdown and had an ill mother, coupled with learning to use a complex new work computer system, while dealing with an overbearing manager. “The worker’s previously immaculate grooming began to suffer, as did her ability to learn the new system. She is deemed unfit for work until further notice, and three months later has increased self-medication with alcohol, and is ruminating and lacking purpose,” says Dr Felman.

“I wouldn’t have kept her at home for this long,” she says. “There seems to be this idea that you’re not going to go back to work before you recover – when in fact you’re not going to recover before you go back to work.” 

In this case, the diagnosis is depression. The right treatment is a combination of cognitive behavioural therapy, alcohol counselling, re-exposure to the work environment, and prescription of a selective serotonin reuptake inhibitor (SSRI). 

Both Drs Felman and Cotton discussed a worrying trend of some lawyers advocating that patients stay at home until a workers’ compensation claim is settled. “Some employers have even been moving to quite punitive approaches and placing employees with mental illnesses on performance management programs when they return to work,” says Dr Cotton. 

They contend a much more nuanced approach is needed when treating mental illness in the workplace. In the same way that occupational and environmental physicians know that an early return to work can aid physical recovery – counterintuitively – it can be very beneficial in recovering from mental illness. 

Both doctors believe that other referring specialties often make the mistake of diagnostically focusing on levels of mental health symptoms, rather than overall mental health functionality and what a patient currently can do. Attendance, performance, work quality and occupational health and safety risk should all be assessed in determining fitness for return to work. 

Dr Felman believes that patients who have some symptoms but are functioning in domains of life (including remaining at work in some capacity) are doing better than patients who may be symptom free through avoiding things and isolating themselves at home. “With time, there’s an exponential increase in the psychological effects of not being in work,” she says. 

Mental illness in the workplace can be perceived by employers as a minefield, with many managers avoiding addressing the issue, or using employee assistance programs (EAP) as a token measure. Even something as simple as the nature and degree of employer contact with a psychologically injured patient can have broader term ramifications. 

Both practitioners spoke of seeing regular examples of either contact so frequent it was perceived as harassment, or a sense by injured employees that they had simply been abandoned, with no contact at all. 

Mishandling dialogue with an injured worker can compound a perception by the employee of unjust treatment. Research has linked such perceptions to increased time off work, higher compensation claims, and a need for the employee to express claims of injustice to others as a means of punishing their employer. 

While wryly saying he doesn’t want to be seen as criticising his peers, PTSD presents a particular dilemma for psychologists, according to Dr Cotton. “Recent research suggests over 50 per cent of psychologists are not adequately equipped to effectively treat this condition. For example conventional counseling based therapies often prove ineffective in treating PTSD.” 

From experience working with the Victoria Police Dr Cotton mentioned the need for very specific treatments run to a strict timetable, such as exposure-based interventions and trauma-focused cognitive behaviour therapy. 

“Given the specialised treatment needed, some employers are now moving towards appointing panels of specialist psychiatrists and clinical psychologists who are specially trained in these techniques,” Dr Cotton says. 

Both Drs Felman and Cotton believe workers themselves still need increased mental health literacy, even in understanding basic concepts such as Maslow’s hierarchy of needs, or the effects of excessive alcohol or caffeine use, or poor sleep hygiene on their mental state. 

Acknowledging the stigmatisation of mental illness, nonetheless, moves such as police forces reserving roles away from the frontline for those who have suffered from mental illness is seen by both Drs Felman and Cotton as a positive move. Some health insurers are also now more receptive to conversations about cross-specialty care. 

Overall, when given the correct diagnosis, multifaceted treatment and an enlightened employer, it is possible to manage employee mental illness, effect rehabilitation and aid a return to work.