Article: Helping employees who become severely depressed
By Bob Grove, Helen Lockett and Jan Hutchinson
Introduction
Prevention
Early intervention
Rehabilitation and return to work
Conclusion
About the authors
References
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Introduction
Mental ill health is the big problem of our age (Layard 2005) and it affects people who are in work as much as the rest of the population.
Depression, anxiety and related problems are very common indeed - in the UK about one in six workers have levels of distress that doctors would diagnose as illness (ie. more serious than having a bad day or two) and the latest mental health survey suggests this figure is no different in New Zealand (Oakley Browne et al, 2006).
On the whole employers do not recognise or they choose to ignore the signs and according to recent surveys many grossly underestimate how many of their employees may need help (Shaw Trust 2010).
The signs that workers are not well are not just absences from work. Indeed there is increasing evidence that long term absence is often preceded by a period of being at work but with severely reduced productivity - sometimes known as presenteeism (CMH /BITC 2011).
Figures produced by Centre for Mental Health using national data sets suggest that presenteeism, if ignored, may be up to twice as costly to employers as sickness absence (SCMH 2007), a finding echoed in New Zealand by Southern Cross who conducted a survey of 461 employees to understand the costs of ill-health to workplaces (Southern Cross, 2009). The total cost of mental ill health to employers in the UK is about £1000 (equivalent to $1,850 NZD) per employee per year - a significant drain on profits.
The good news is that there is quite a lot that employers can do to reduce these costs and at the same time help employees whose health and careers are at risk of spiralling downwards into long term unemployment and chronic ill health.
In fact recent studies in big companies who have taken a "whole company" approach to mental health and wellbeing suggest that with relatively simple measures about one third of these costs can be saved.
For a small/medium sized company with 100 employees this could mean £35,000 each year added to profits. For an employer the size of the UK National Health Service the savings could be an astonishing £400 million each year.
What about the distressed employee - are measures to keep them in or return them to work likely to be harmful to their health? Again there is good news - work is on the whole good for mental and physical health (Waddell and Burton 2006, AFOEM, 2010) and for many people being at work in a supportive workplace can be part of the solution rather than the problem.
And what about work stress - surely today's workplaces are contributing to mental ill health among employees? Well - toxic workplaces can indeed create the conditions which for some employees trigger mental breakdown. So it is important for employers to understand the difference between pressure which keeps us all going and makes us productive and stress which is making unmanageable demands that damage both employees and the business.
There is evidence from the UK Health and Safety Executive (HSE) that workplace stress only accounts for about 20% of sickness absence due to mental ill health (SCMH 2007). The rest is a combination of stuff that happens in people's lives and and therefore even in the best workplaces employees' mental health and the consequences of mental ill health will have to be managed.
What then can employers do to create health productive workforces and to manage the mental distress which will always be present and affecting their businesses? There are two key principles:
- Prevention is better than cure;
- Once a problem is recognised, the sooner you take action the smaller that problem is likely to be.
Prevention
Prevention - that is creating the conditions for a happy, productive workforce to function at its best - can take many forms (NICE 2009). A lot of large employers in the UK are signed up to programmes that promote employee wellbeing which have both mental and physical aspects.
Indeed there is good evidence that activity and good physical health leads to improved mental health and vice versa. In today's fast changing times the workforce needs not only to be healthy but resilient (BITC 2009)).
The common factors to all the prevention/wellbeing programmes are that they encourage employees to look after themselves, recognise unhealthy behaviours and above all are fun to participate in.
They usually include both individual and group activities and should be monitored for participation levels and impact - eg. on wellbeing, absence levels etc. Recent research (Knapp et al 2011) has shown that a simple mental health promotion programme can produce a return on investment of seven pounds (or dollars) for every one invested.
Another aspect of prevention is proactively finding out which individuals or areas of the business might be at risk of serious distress or ill health.
In smaller companies this may be as simple as training managers to spot and respond to difficulties at an early stage. For large companies there is evidence that screening for stress (Seymour et al 2010) is cost effective because it enables managers who may be quite remote from the day to day issues of the workforce to take action much sooner.
The British telecommunications company BT (formerly British Telecom) has developed a computerised screening tool called STREAM, which employees can use voluntarily if they think their stress levels are or might become unmanageable.
Too high a score will trigger an email to their line manager, or if their manager is the problem to another manager who will then try to find out what is the problem. Aggregated data across the company can also identify toxic hotspots and trigger an investigation to find out what is wrong and take action.
Finally, guidance on how to identify and deal with the causes of work stress should be basic to all Human Resources, Occupational Health and manager training. The UK Management Standards produced and tested by the HSE, involve all aspects of job design and manager behaviour and are increasingly used worldwide as the basis for reducing stress and improving productivity.
Early intervention
Even if most employees are healthy, positive and productive most of the time, there will always be individual life events or vulnerabilities that can cause severe and long lasting distress (eg. more than two weeks continuously).
These can happen to anyone - you might almost describe them as a normal part of the human condition - but actually they are very hard for most people to talk about and deal with.
For a person in distress, in addition to unshakeable low mood or crippling anxiety there is embarrassment, fear of being thought weak or a poor bet for promotion together with all the rest of the stigma still associated with mental illness.
For colleagues and managers there is the worry that a key person is not performing, hesitation or embarrassment about asking what is wrong for fear of intruding on private grief or indeed a worry that if the person does say what is wrong they will be unable to think of what to say. If the person even hints at feelings that involve self-harm or even suicide, there comes the additional worry that you might say the wrong thing and make matters worse.
All too often these factors cause the employee to try to hide their distress and clam up - maybe until things get so bad they cannot face coming in to work at all. For everyone else there is a strong impulse to keep a distance from the distressed individual and desperately hope that someone else will know what to do.
These are entirely understandable reactions but they are harder to recover from than the symptoms of the illness and can lead to career death and ruined lives. What a person in distress most needs is a supportive social environment and help with both the triggers and the manifestations of their condition. Treatment for depression and anxiety is effective, but in the UK 75% of people with these conditions get no professional help.
So what can be done? Well there is good evidence that training managers and others how to spot and respond helpfully to the signs of someone having more than a bad day is effective (Lockett and Grove, 2010a,b).
The Centre for Mental Health has, for the past three years, been working with the Australian charity beyondblue to test and deliver their line manager training to UK businesses - trading in the UK as Impact on Depression.
So far we have evidence that the three hour courses with a mix of information and workplace scenarios to discuss really hit the spot as far as managers are concerned and the information and increased confidence to act last beyond the training day itself.
In New Zealand, employers have similar workplace training programs, such as Blueprint's MH101 training and the Mental Health Foundation's Working Well.
Working Well is an initiative focusing on creating mentally healthy and productive workplaces. It was established in 2000 in response to requests from the New Zealand government and corporate organisations for workplace mental health information and training. Delivered and facilitated by expert consultants, the workshops and conference materials are based on best available evidence and good practice gleaned from a wide variety of sources. Workshop participants gain practical tools and knowledge that can be used the minute they walk out the door.
Among the most difficult areas for managers, are what to suggest about sources of help and what discretion they actually have to make temporary adjustments to workload etc.
Larger companies increasingly have Employee Assistance Programmes or counselling providers to whom they can point people and policies that support a certain amount of managerial discretion.
For smaller companies it may be that encouragement to see the family doctor or look at reputable self help resources (eg the National Depression Initiative's - The Journal fronted by All Black, John Kirwan) is the best that can be offered.
The important thing is that the message will have been given that the distressed individual is a valued member of staff and can expect concern and consideration, rather than ignoring or scapegoating. In mental health, as in other areas of life, both positive and negative expectations can easily become self-fulfilling.
Rehabilitation and return to work
For most people, professional help combined with workplace support and adjustments for a short period will be sufficient to help them to recover. For those not recovering as expected - say by the fourth week of absence or second sick note - longer and more intensive support and treatment may be required. Depression can be hard to shake off and the much rarer, more serious conditions such as schizophrenia or bipolar disorder may require specialist or even hospital treatment, with perhaps a substantial period (or lifetime) on medication.
However, the same dictum holds good for people who experience these more serious problems as for common mental health conditions - work is perfectly possible and may be part of the solution.
Keeping workplace relationships intact while treatment takes effect in many cases produces surprisingly good work outcomes - enhancing employee loyalty, reducing tribunals and preventing the ruination of life chances.
BT (formerly British Telecom) have a policy of supporting the recruitment of people with a history of severe mental ill health when they judge them to be ‘BT ready' ie. keen and willing to learn. They also get 75% of their staff, who have been off for longer than six months, back in their old jobs. Is this charity gone mad? No - actually a business decision and, importantly, reported on regularly at Board level.
For the employer the important things for someone who is long term sick are:
- To remain in touch
Continuing contact with the manager and the company should be enshrined in company policy, with managers trained in what to say to maintain hope and to give an expectation of return without verging on harassment. If redeployment or, as a last resort, severance is being contemplated, this should be done with due care and consideration, ensuring that the employee is receiving personal support from outside the management structure.
- To create a return to work plan
There is increasing evidence that case management - in which people are given joined-up support to help them back to work and manage their condition (Seymour et al 2010)) - is very helpful when an employee is too low to make important, possibly life changing, decisions unaided or feels unable to advocate for themselves. Just on a practical level the need to answer queries, keep key people informed and maintain focus on the work situation is sometimes beyond people who are very depressed or anxious. When symptomatic recovery is on the way to resolution, help coordinating the right return to work plan can make all the difference.
Although acute symptoms need to be mostly under control for people to feel able to resume work, full symptomatic recovery is not necessary. Indeed going back to work may be "just what the doctor ordered", as long as it is carefully planned and involves all the key people eg. the person themselves, their manager, Occupational Health, Human Resources, General Practitioner, trades union representative, maybe even family.
Any workplace adjustments must address the problems likely to be encountered directly and be reasonable and affordable (which the evidence suggests most are). Most important of all is agreeing what should be said to whom.
Mental illness is still heavily stigmatized by some people - even in countries like New Zealand where there have been successful anti-stigma programmes. Anticipated discrimination can be as important and damaging as actual discrimination (Thornicroft 2006) so it is important that the returning employee feels in control of what colleagues and others know about them.
Instead of worrying solely about the dilemma of "to disclose or not to disclose" it is more helpful to think of this as managing personal information - a set of thought processes and actions we all do all the time about lots of different issues (Waghorn & Spowat, 2010).
Seen in this light the discussion about what to say when planning a return to work is simply to help a person think through what they want to do and what they need to do at a time when they are less confident about their own decision making.
Conclusion
In this article we have suggested that helping people remain in, or return to, work after mental ill health is not only vital to the life chances of the individual but also good business sense.
We have proposed three elements of a whole organisation approach - prevention, early intervention and case management for those (relatively few) people who do not recover as hoped and expected. The costs of what we have suggested are not great, whereas the costs of doing nothing can be very heavy indeed for the employer and the employee.
The Centre for Mental Health and the Wise Group will continue to draw attention to, and work on how to improve, job retention - as well as how to help people get work who have dropped out of the labour market altogether.
To find out more go to the Centre - get regular updates and subscribe to our email bulletin.
Go to The Wise Group for further information.
About the authors
 |  |  |
Bob Grove is a Senior Professional Adviser at the Centre for Mental Health in London | Helen Lockett is employed in a strategic development role for the Wise Group. Prior to moving to New Zealand, Helen worked at Centre for Mental Health. | Jan Hutchinson is the Director of Programmes and Performance at the Centre for Mental Health. |
References
AFOEM 2010. Realising the health benefits of work. The Australasian Faculty of Occupational and Environmental Medicine. position statement. Sydney: AFOEM
Business in the Community (2009) Emotional Resilience Toolkit
Centre for Mental Health/BITC (2011) Managing Presenteeism: a discussion paper.
Knapp, Martin and McDaid, David and Parsonage, Michael (2011) Mental health promotion and prevention: the economic case. Personal Social Services Research Unit, London School of Economics and Political Science, London, UK.
Layard, R. (2005) Mental Health: Britain's Biggest Social Problem? Paper presented to Cabinet Strategy Unit
Lockett, H. & Grove, B. (2010a). Responding to mental distress at work, part 1. Occupational Health [at Work], 7 2 (24-27).
Lockett, H. & Grove, B. (2010b). Responding to mental distress at work, part 2. Occupational Health [at Work], 7 3 (20-23).
MA Oakley Browne, JE Wells, KM Scott (eds). 2006. Te Rau Hinengaro: The
New Zealand Mental Health Survey. Wellington: Ministry of Health.
National Institute for Clinical Excellence (NICE) 2009 Promoting mental wellbeing through productive and healthy working condition: guidance for employers
Sainsbury Centre for Mental Health (2007) Mental Health at Work: developing the business case
Seymour et al 2010 Common mental health problems at work. What we now know about successful interventions. Centre for Mental Health
Shaw Trust 2010 Mental Health: Still the Last Workplace Taboo?
Southern Cross 2009. A New Zealand study into hidden costs of unhealthy employees. Auckland: Southern Cross Health Society.
Thornicroft, G. (2006) Shunned: Discrimination against People with Mental Illness. Oxford OUP
Waghorn, G. & Spowart, C.E. (2010) Managing Personal Information in Supported Employment for People with Mental Illness, in Vocational Rehabilitation and Mental Health (ed. C. Lloyd) Wiley-Blackwell: Oxford doi: 10.1002/9781444319736.ch13
Waddell, G. & Burton, K. (2006) Is work good for your health and wellbeing? London TSO
Working Well Toolkit, Mental Health Foundation of New Zealand
Working Well newsletter, Mental Health Foundation of New Zealand
Comments
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Posted by Chris Manning 9:22 pm, 21 Feb 2012 Reply
An interesting and very helpful summary article. The NHS is the UK's largest employer and has its population level of mental illness (and beyond - because of the levels of distress addressed by and within the Service itself) and I would be interested to know:
- The specific programmes (aside from PHP in London) of which the Centre is aware that are operating schemes and interventions that address the issues raised in this report, including workforce training for HR/management and resilience training for staff (from student level onwards);
- How/whether mental health and wellbeing planning and assessment are addressed in appraisals of medical staff;
- Whether Time to Change is doing any work to address the stigmatising and discriminatory attitudes that still exist in the NHS, including those that operate against staff.
Yours in wealth (well-health) creation,
Dr Chris Manning
www.upstreamhealthcare.org
www.collegeofmedicine.org.uk
