Is work good for your patients' mental health?
Unemployment appears to be harmful to health
According to the Treasury, there are some 160 million working days lost each year due to sickness absence. Of these, 28 million are caused by work-related illnesses, of which almost 13 million (or two in five) are anxiety and depression.
The expectation of people taking sick leave is that they will return to work. The evidence, however, shows that if the individual is off work for 12 months, they are unlikely to return for another seven years. If they have been off work for two years, the chances of returning to work decline even further, so that they are more likely to retire than ever return to work (Waddell and Burton 2006).
Strong evidence exists that unemployment is harmful to health. The unemployed have higher mortality, poorer general health, poorer mental health and higher medical consultation, medication consumption, and hospital admission rates.
On the other hand, there is strong evidence that re-employment leads to improved self-esteem, and improved physical and mental health. The magnitude of this improvement is more or less comparable to the effects of job loss. Thus the harmful effects of unemployment can be reversed by re-employment.
Support from GPs
The type of therapies offered to people with depression and anxiety disorders should be in line with best practice and NICE guidelines. Broadly these guidelines recommend guided self-help, psychological therapies and/or medication.
Access to psychological therapies is nationally very patchy, but with the introduction of the Improving Access to Psychological Therapies Programme by the Department of Health in 2007, effective, and easily accessible, stepped care therapies will be available over the following five years.
Optimal GP management of common mental health problems in the context of rehabilitation for work therefore involves four specific, linked interventions:
1. Cognitive behavioural therapy, including computerised options recently recommended by NICE.
2. Antidepressant medication for clinically appropriate conditions with patient co-operation.
3. Graded activity: physical, social and work-related activity.
ASSESSMENT OF FITNESS TO WORK
This should include the following considerations:
- The relationship between illness and work
- What work involves (job description)
- Is work affecting the patient's symptoms?
- Negative: problems/stress at work
- Positive: distraction/escape from problems at home
- Is the illness affecting work?
- Capability/suitability for certain types of tasks
- Risk assessment
- Is specialist referral necessary to answer these questions?
The consultation process should also include an understanding of:
- The interaction between the patient's work and their presenting problem
- The demands of the job and the possibility of suitable alternative tasks
- The availability of occupational health support in the work place
- The motivation of the patient to return to work.
BACK TO WORK PLAN
For those who have been off work through mental ill health, a return to work plan - agreed with the patient, the employer and the GP - is often very helpful. The act of constructing a plan means that the likely difficulties, including unhelpful behaviour and attitudes from managers and colleagues, are foreseen and to some extent prepared for.
The plan does not have to be made by the GP but the GP should make an input. If available, a specialist employment adviser or case manager is probably the best sort of intermediary and such people are increasingly employed by local employment service providers and some employers and trades unions.
The components of such a plan will include discussion of issues such as:
- Does the decision regarding (relative) fitness for work require a specialist opinion?
- When is the patient likely to be ready to return to work?
- Would staying at home exacerbate their problems?
- What limitations does the patient currently have?
Consider if the patient would benefit from:
- Adjustments to hours of work (reduced hours/phased return)
- Changes to job/role (unfit for specified tasks)
- Changes to the environmen
- Do these changes constitute reasonable adjustments with respect to the Disability Discrimination Act.
1. Waddell G, Burton K. Is work good for your health and wellbeing? London: The Stationery Office, 2006.
2. Department for Work and Pensions. A guide for registered medical practitioners (IB204). London: DWP, 2000 (available here).
3. Seymour L, Grove B. Workplace interventions for common mental health problems. London: British Occupational Health Research Foundation, 2005 (PDF available here).
4. Wanberg C. Antecedents and outcomes of coping behaviours among unemployed and re-employed individuals. J Applied Psychol 1997; 82: 731-44.
5. Shiels C, Gabbay M, Ford FM. Patient factors associated with duration of certified sickness absence and transition to long-term incapacity. Br J Gen Pract 2004, 54, 86-91.
6. Ford F. Coping strategies in East Lancashire Condition Management Programme. UK Public Health Association annual meeting, 2006.
7. Prochaska J, DiClemente C. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice 1982; 20: 161-73.
8. World Health Organization. What is depression? Web page accessed June 16, 2008.
9. Office for National Statistics. Psychiatric Morbidity among adults living in private households (technical report). London: The Stationery Office, 2000.
10. Department of Health. National Service Framework for Mental Health. London: DH, 1999.
11. Oxford Economics. Mental Health and the UK Economy. Oxford: Oxford Economics, March 2007.
This information has been kindly provided through Dr Alan Cohen, former senior fellow at the Sainsbury Centre for Mental Health and is drawn from its briefing paper on work and wellbeing