Depression

Depression –
A guide for human resources and management

This guide is to aid employers on a mental health condition commonly found in the workplace amongst health professionals. Many won’t seek help regardless of their understanding of the effects of the condition or their own awareness of the symptoms. Therefore, the condition may be particularly hard to identify amongst these groups.

Stigma associated with mental health conditions is one of the most significant factors in avoiding help and treatment¹. The NHS has had a clear mandate, as an employer, to reduce stigma and discrimination associated with the mental health of its employees and applicants for employment ². As well as understanding how to help the individual who may develop symptoms of depression in the workplace, NHS employers are encouraged to increase the awareness of the symptoms of common mental health problems, identify the risk factors for these conditions in the work place and reduce the barriers to getting help.

We highlight:

What is depression
How it affects people
How to identify it
How it affects health professionals
How to help those affected when at work,
How to help those affected and absent return to work
The role of Occupational Health, MedNet and the Practitioner Health Programme

What is Depression

Depression is an all-encompassing term used to describe feelings, thoughts, judgment and behaviours of a person with a low mood disorder³. As the onset of depression can start slowly, it is often the case that it is only with hindsight that work related difficulties may be linked to a depressive episode ⁴.

The condition can range from mild to severe. Some experience of depression after experiencing an adverse life event is very common and generally in the UK one in six people will experience depression or anxiety at some time in their lives^5,6. Three-quarters of people with depression will not be receiving treatment even where clinically indicated ⁷.

Although men are less likely to suffer from depression than women (1:2), the rate of suicide in men is 3 to 4 times higher ⁸. In most cases the root cause of depression is considered multi-dimensional and therefore the management of the condition and preventing relapse requires an approach that combines the biological, psychological and social factors, which includes work.

A depressive episode can occur as a result of a physical illness such as HIV or Hepatitis C infection, cancer, thyroid dysfunction, some auto-immune disorders. Whilst the functional impact on work may need to be managed the same, the implications for how long the symptoms may last and the treatments involved will be different.

How to identify depression in the workplace

The functional impact of depression is usually observed by others in the workplace i.e. the behaviours associated with the thoughts and feelings linked to depression, such as low mood, poor concentration, poor appetite, frequent crying or expressions of low self-esteem.

Depression in a health professional may present as the following:

Expression of feelings of sadness, anxiety, hopelessness, guilt, pessimism, worthlessness
Turning up late for work or disappearing half way through a clinic
Appearing distracted or tired
Alarm bells should ring if a normally sound colleague starts to make frequent clinical errors or has repeated sharps incidents or other accidents
A previously sociable individual may become withdrawn and may no longer wish to socialise with colleagues at lunch or during breaks
An individual may express suicidal thoughts to a colleague or even to a manager; if so this must be taken seriously

Functional impairments commonly linked to depression include:

Impaired cognitive functioning such as concentration and memory deficits
Reduced confidence
Decreased stamina (from a combination of fatigue, sleep disturbances, low energy, poor appetite, persistent physical symptoms such as chronic pain)
Difficulty staying organised and meeting deadlines
Difficulty handling stress and emotions
Attendance issues

Bipolar Disorder

Depression in health professionals

Health professionals, particularly doctors, are known for higher rates of suicide^9,10. They also have significant rates of anxiety, depression and other psychological disturbances such as burnout and compassion fatigue. It is suggested that the knowledge of the means to commit suicide successfully, and embarrassment at not being resilient, are contributory factors¹¹. Research has shown that:

Suicide rates are particularly increased in female doctors, anaesthetists, GPs and psychiatrists¹²
High levels of drug and alcohol problems, financial problems and problems at work are often commonly linked in these cases¹³
Surgeons married or partnered to surgeons have a higher prevalence of depressive symptoms and lower mental quality of life¹⁴

Adjustments and support to facilitate retention at work

depression II Not all individuals will need to be absent from work, though this may depend on the severity of the symptoms at the time and the impact of the cognitive factors associated with the condition or the need for time off linked to treatment. Modifications which would help the individual stay at work can contribute to the recovery of the individual, and avoid a possible risk of exacerbation of the condition which can be caused by increased negative rumination, increased feelings of alienation and stigmatisation, and undermining self-esteem and confidence. Work provides important structures and support for the individual.

Factors potentially affecting retention and return to work

Frequency of relapse
Functional capacity during periods of wellbeing
Insight and adherence to any long term treatments, particularly any mood-stabilising medication
Presence of workplace stressors such as perceived bullying, high job demand, low job support, conflict with line manager, time pressures and high academic work demands (significantly linked to depression and anxiety in health professionals¹⁶)
Shift work for those in whom sleep disturbances and sleep deprivation is a relapsing trigger
Perceptions of potential stigmatisation from colleagues, self-stigma often resulting in avoidance of help-seeking and compliance with treatment
Concerns of individual regarding confidence to perform at work - the impact of this on their colleagues and the potential loss of respect from colleagues
Concerns regarding on-going professional registration

The role of treatments in depression: Implications for Work

Depression is treatable in the majority of cases – see NICE Guidelines for further information¹⁷. As well as medication and talking therapies, diet and exercise have also been shown to be helpful – structured exercise programmes have proven to be distinctly beneficial for people with mild to moderate depression.

Most modern anti-depressants can take 3 to 4 weeks to start working effectively. Therefore, depending on whether absence or modifications are in place at this time, it should be expected that very little improvement to overall symptoms may occur during this initial phase.

Reasonable adjustments

Adjustments to tasks, hours, demands and/or environment may need to be considered by the manager. The best person to help identify what the blockages are to a return to work or what aspects of work are, or may be, difficult is the employee themselves. The manager may have concerns about the safe performance of the health professional, especially in aspects of work that are critical and normally require high levels of cognitive functioning. A referral to the organisation’s occupational health department may be useful.

Specific Mental Health Adjustments

Possible adjustments may be advised such as:

Stamina during the workday:

Provide flexible scheduling
Phased return to work
Allow longer or more frequent work breaks
Allow employee to work from home during part of the day or week
Provide part-time work schedules

Concentration:

Reduce distractions in the work area
Provide space enclosures or a private office
Plan for uninterrupted work time and allow for frequent breaks
Divide large assignments into smaller tasks and goals
Restructure job to include only essential functions

Memory deficits:

Allow the employee to tape-record meetings and provide written checklists
Provide written instructions and allow additional training time

Difficulty staying organised and meeting deadlines:

Make daily TO-DO lists and check items off as they are completed
Remind employee of important deadlines
Use electronic organisers
Divide large assignments into smaller tasks and goals

Difficulty handling stress and emotions:

Provide praise and positive reinforcement
Refer to counselling and employee assistance programs
Allow telephone calls during work hours to doctors, counsellors and others for support needed
Allow the employee to take breaks as needed

Attendance issues:

Provide flexible leave
Provide a self-paced work load and flexible hours
Reduce shift intensity, the length of shifts or the number of shifts worked consecutively without a break

Specific examples in healthcare include:

Shift and night work may not be suitable for those with sleep disturbances due to depression or those in the early stages of recovery.
Some of the medication used to treat depression can lead to daytime fatigue and loss of concentration. Advice may be required from occupational health as to what if any restrictions to the individual’s work may be required, on a temporary or permanent basis. For example, safety critical work such as surgery may need to be restricted until the medication no longer has the effect of causing fatigue and poor concentration.
In some cases the individual may wish to return to work which does not require face-to-face patient contact for the first few days.

The role of occupational health

Apart from advising on adjustments, a return to work plan and monitoring an individual, the occupational health department may also be involved in:

arranging for fast tracking for appropriate assessments
signposting to external agencies and support services
liaison with treating medical practitioners
liaison with Health Education England local offices for professional and career support
liaison with MedNet, the Practitioner Health Program or other services where the health professional may have been assessed, managed and treated

The role of organisational strategies

Hawton’s¹³ studies concluded that the “prevention of suicide in doctors requires a range of strategies, including improved management of psychiatric disorder, measures to reduce occupational stress and restriction of access to means of suicide when doctors are depressed.”

Also healthcare professionals with clear roles and tasks, supportive management and clear communication had lower rates of depression (Heyworth et al, 1993 in¹⁶).

The Role of Practitioner Health Program

The Practitioner Health Programme is a free, confidential treatment service for doctors and dentists living in London who have mental or physical health concerns and/or addiction problems.

Any medical or dental practitioner can use the service, where they have

A mental health or addiction concern (at any level of severity) and/or
A physical health concern (where that concern may impact on the practitioner’s performance).
Further information can be found at http://php.nhs.uk/

Mednet

MedNet provides doctors and dentists with confidential consultations, advice about their careers, emotional support, and when needed, access to other expert help. This may include more specialised psychotherapeutic interventions (which embrace all the mainstream modalities of psychotherapy), or specialised psychiatric advice.

To access MedNet, practitioners, of any grade or specialty, must live or work within the area covered by London Deanery and KSS Deanery.

Further information can be found at www.lpmde.ac.uk/professional-development/mednet

References

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