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.
- 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 lives5,6. 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
Depression in health professionals
Health professionals, particularly doctors, are known for higher rates of suicide9,10. 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
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.
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.
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
- 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
- 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
- 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 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
- Thornicroft G, Rose D, Kassam A, Sartorius N. 'Stigma: ignorance, prejudice or discrimination?'. Br J Psychiatry. 2007; 190: 192-3.
- Department of Health. Mental health and employment in the NHS. London: Department of Health; 2002.
- Lilja L, Hellzen M, Lind I, Hellzen O. The meaning of depression: Swedish nurses' perceptions of depressed inpatients. J Psychiatr Ment Health Nurs. 2006; 13(3): 269-78.
- Cox RAFD, Brown ID, Palmer KD. Fitness for work : the medical aspects. 4th ed. / edited by Robin Cox with I. Brown and K. Palmer. ed. Oxford: Oxford University Press; 2007.
- Sainsbury Centre for Mental Health. Policy paper 8 Mental Health at Work: developing the business case. London: Sainsbury Centre for Mental Health,; 2007. p. 23.
- National Centre for Social Research, Department of Health Sciences. Adult psychiatric morbidity in England, 2007: Results of a household survey. In: NHS Information Centre for health and social care, editor. Leeds: NHS Information Centre for health and social care,; 2009.
- Deverill C, King M. Chapter 2: Common Mental Disorders. In: McManus S, Meltzer H, Brugha TS, Bebbington PE, Jenkins R, editors. Adult psychiatric morbidity in England, 2007: Results of a household survey. Leeds: NHS Information Centre for health and social care; 2009. p. 25-52.
- Norman IJ, Ryrie I. The art and science of mental health nursing : a textbook of principles and practice. 2nd ed. Maidenhead: Open University Press; 2009.
- Iliceto P, Pompili M, Spencer-Thomas S, Ferracuti S, Erbuto D, Lester D, et al. Occupational stress and psychopathology in health professionals: An explorative study with the Multiple Indicators Multiple Causes (MIMIC) model approach. Stress. 2012; [epub ahead of print http://informahealthcare.com/doi/abs/10.3109/10253890.2012.689896 ].
- Wolfersdorf M. Suicide and suicide prevention for female and male physicians [translated from german]. MMW Fortschr Med. 2007; 149(27-28): 34-6.
- Myers M, Fine C. Suicide in physicians: toward prevention. MedGenMed. 2003; 5(4): 11.
- Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health. 2001; 55(5): 296-300.
- Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. 2004; 57(1): 1-4.
- Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Freischlag J Physicians married or partnered to physicians: a comparative study in the American College of Surgeons. J Am Coll Surg. 2010 Nov;211(5):663-71. doi: 10.1016/j.jamcollsurg.2010.03.032.
- Michie S, Williams S. Reducing work related psychological ill health and sickness absence: a systematic literature review. Occup Environ Med. 2003; 60(1): 3-9.
- National Institute for Clinical Excellence. Clinical Guideline 90 Depression: the treatment and management of depression in adults (update). London: National Institute for Clinical Excellence; 2009.