What is Mental health in the workplace?
Mental health describes a level of psychological well-being or the absence of mental ill-health. Probably the most well-known definition of mental health is that of the World Health Organization (WHO) that defines mental health as a state of well-being in which every individual realizes his or her potential, can cope with the normal stresses of life, can work productively and fruitfully, and can make a contribution to her or his community.
Poor mental health is one of the biggest issues in the workplace today, causing over 70 million working days to be lost each year (European Agency for Safety and Health at Work (EU-OSHA), 2014). This includes everything from the most commonly experienced symptoms of stress and anxiety, right through to more complex mental health conditions, such as depression, bipolar disorder and obsessive-compulsive disorder.
According to Leka et al. (2015), mental health problems can be classified according to generally acknowledged classifications like DSM (Diagnostic and Statistical Manual of Mental Diseases) or ICD (International Classification of Disease). Cultural differences, various types of assessment and competing for professional theories all affect how ‘mental health’ is defined.
This article adopts a more inclusive definition of mental health and as such will not focus solely on (the absence of) mental health problems but a positive state of psychological well-being. Well-being at work is defined as individuals’ ability to work productively and creatively, to engage in strong and positive relationships, the fulfilment of personal and social goals, contribution to the community, and a sense of purpose.
As well as having a huge impact on individual employees, poor mental health has severe repercussions for employers – including increased staff turnover, sickness absence due to debilitating depression, burnout and exhaustion, decreased motivation and lost productivity (Leka et al., 2015).
While companies of all shapes and sizes increasingly understand the importance of good mental health, many simply do not feel confident handling and communicating these issues in the workplace.
There is good evidence that certain kinds of workplace stress are associated with a higher risk of psychiatric morbidity (Bilsker, Wiseman & Gilbert, 2006). It could be expected that the incidence of such workplace stress is higher in developing countries. Thus far, social attention has focused primarily on the impact of harsh working environments on people's human rights, rather than their emotional wellbeing specifically.
Mental health in the workplace facts you need to know
People with a severe mental disorder are too often far away from the labour market and need help to find sustainable employment (Organisation for Economic Co-operation and Development (OECD), 2012). The majority of people living with a common mental disorder are employed but many are at greater risk of job loss and permanent labour market exclusion than colleagues without these problems.
This has worsened in the recent economic climate. Evans-Lacko et al. (2013) found that the gap in unemployment rates for individuals in Europe with and without mental health problems significantly increased after the onset of the economic recession. This gap was especially pronounced for males and individuals with low levels of education.
Employment rates in people with common mental disorders are 60-70%, compared with 45-55% for those with severe mental disorders but more than 70% for people with no mental disorder (Matrix, 2013).
Data suggests that 55% of people with mental health problems make unsuccessful attempts to return to work, and of those who return, 68% have less responsibility, work fewer hours and are paid less than before (Mental Health Foundation, 2007; OECD, 2012). McIntyre et al. (2011) and the OECD (2012) conclude that the annual income of individuals affected by depression is reduced by approximately 10% compared with unaffected employees.
The estimates for the proportion of the workforce in Europe that may be living with a mental health problem at any one time range from one in five (OECD, 2012) to two in five (Wittchen et al., 2011), with a lifetime risk of at least two in five (OECD, 2012). In the EU-27 it was found that 15% of citizens had sought help for a psychological or emotional problem, with 72% having taken antidepressants (European Commission, 2010).
The shares of sickness absence and early retirement for mental health problems have increased across Europe over the past few decades. The Eurobarometer (European Commission, 2010) presents EU wide statistics on positive and negative feelings more closely reflecting mental wellbeing. It shows that mental ill-health impacts on sickness absence and indicates that in 2010, EU citizens felt less positive and more negative than they were in 2005/2006.
The increase is thought to be due to reduced social stigma and discrimination against people with mental illness leading to greater recognition of previously hidden problems, rather than a true increase in prevalence (OECD, 2012; Wittchen et al., 2011). However mental health problems are still considered relatively unrecognized, underdiagnosed and untreated (OECD, 2012).
One of the key states of sub-optimal mental health that can have severe consequences is work-related stress. Work-related stress is the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope (World Health Organisation (WHO), 2003).
The ESENER survey (EU-OSHA, 2010, 2015) showed that within the EU, work-related stress is of some or major concern in nearly 80% of establishments. At the same time, less than 30% of organisations in Europe have procedures for dealing with workplace stress.
According to the 6th European Working Conditions Survey (Eurofound, 2016), the overall average well-being score for workers in the EU28 is 69 – three points higher than in 2010 (measured by the WHO-5 Well-being Index). Men score slightly higher than women (70 compared to 68). And younger workers (those aged under 35) score higher than older workers (aged 35 and over) – 70 compared to 68 (for both older age groups).
Overall, 6% of workers have a score that indicates they are at risk of mental health problems (below 28), with more women than men being at risk (7% compared to 5%). 26% of workers think that their health is negatively affected by their work. Some 27% of workers said they were absent for health reasons for five or more days in the 12 months before the survey: this was the case for 28% of women and 25% of men.
Looking more specifically at data from the UK as an example, the 2009 Psychosocial Working Conditions survey indicated that around 16.7% of all working individuals thought their job was very or extremely stressful (Packham & Webster, 2009). Estimates from the Labour Force Survey in 2013-14 suggest that the total number of cases of work-related stress, depression or anxiety accounts for 39% of all cases of work-related illnesses, where work-related illness relates to conditions which people think have been caused, or made worse, by work. While the 2009 Austrian Employee Health Monitor revealed that 42% of white-collar workers taking early retirement do so because of work-related psychosocial disorders (EU-OSHA, 2014).
Consequences of work-related stress
The large majority of results from more than a dozen prospective investigations confirm elevated risks of depression amongst employees experiencing work-related stress, and odds ratios vary between 1.2 and 4.6, depending on the type of measure, gender and occupational group under study (e.g. Bonde, 2008; Ndjaboué, Brisson, & Vézina, 2012).
The ILO has acknowledged that psychosocial hazards can cause an occupational disease, i.e. mental and behavioural disorders (International Labour Organization (ILO), 2016). However, mental health disorders like depression are not generally acknowledged as an occupational disease in lists of occupational diseases in most countries (European Commission, 2013).
Other reviews indicate that psychosocial risks that may cause mental health problems, are also systematically and causally related to other kinds of health outcomes such as physical health problems (e.g. Briggs et al., 2009; Da Costa & Viera, 2009) as well as cardiovascular morbidity and mortality (e.g. Kivimaki et al., 2012) and diabetes (De Hert et al., 2011).
The majority of at least 30 reports derived from prospective studies document elevated odds ratios of fatal or non-fatal cardiovascular (mostly coronary) events amongst those reporting job strain, effort-reward imbalance or organisational injustice (e.g. Eller et al., 2009; Kivimäki et al., 2007, 2012; Marmot, Siegrist, & Theorell, 2006; Tsutsumi & Kawakami, 2004).
A review by WHO (2010) outlined studies across world regions detailing the detrimental impact of psychosocial hazards on workers’ physical, mental and social health. This can also increase the risks of further work absenteeism, as noted in several reviews (e.g. Allebeck & Mastekaasa, 2004; Dekkers-Sanchez et al., 2008; Duijts et al., 2007). It has been calculated that each case of stress-related ill health leads to an average of 30.9 working days lost (Mental Health Foundation, 2007).
Also, a reduction in physical and psychological health through the experience of stress can cause suboptimal performance that may lead to accidents and other quality problems and reduced productivity, thereby augmenting operational risks (e.g. Nahrgang et al., 2011).
A mentally unhealthy workforce has adverse economic consequences for the business. Even very minor levels of depression are associated with productivity losses (Beck et al., 2011). Where there is a loss of highly skilled workers due to poor health, additional recruitment and training costs may be incurred by employers (McDaid, 2007). Sickness absence may also lead to an increased workload and potential risk for work-related stress in remaining team members.
In addition to absenteeism, businesses have to contend with presenteeism - poor performance due to being unwell while at work (e.g. Aronsson, Gustafsson, & Dallner, 2000; McDaid, 2007). It remains difficult to measure although some studies suggest that its impact may be as much as five times greater than the costs of absenteeism alone (Sanderson & Andrews, 2006). Presenteeism is also itself a strong predictor of future poor mental and physical health (Leineweber et al., 2012; Taloyan et al., 2012) which may imply additional costs where employers are responsible for paying the health care costs of their employees.
Cost of work-related stress and mental ill
The cost of absenteeism and premature mortality for depression in 30 European countries were estimated to be €109 billion in 2010 while costs for all anxiety disorders accounted for a further €88 billion (Olesen et al., 2012). Another study by Matrix (2013) estimated that the total costs of work-related depression alone in the EU-27 are nearly €620 billion per year. The major impact is suffered by employers due to absenteeism and presenteeism (€270 billion), followed by the economy in terms of lost output (€240 billion), the health care systems due to treatment costs (€60 billion), and the social welfare systems due to disability benefit payments (€40 billion).
In high-income countries, governments are usually responsible for paying the majority of long term sickness and disability benefits for people absent from work because of poor mental health. As the Matrix analysis indicates, there are substantial costs to welfare systems when individuals leave work because of poor mental health.
According to the latest estimates in the UK, losses due to work-related stress, depression or anxiety amounted to the equivalent of 9.9 million days, representing forty-three per cent of all working days lost due to ill-health during the period 2014/2015 (EU-OSHA, 2014). A study by the Centre for Mental Health considered health and social care costs, output loses, and human costs, estimating the total cost of mental health in the UK to be approximately £105 billion in 2009/2010 (Centre for Mental Health (CMH), 2010).
In Spain, it was estimated that between 11 % and 27 % of mental disorders can be attributed to working conditions (UGT, 2013). The direct health cost of mental and behavioural disorders attributable to work was estimated to be between €150 and €372 million in 2010. This represented 0.24 % to 0.58 % of total health expenditure in Spain for that year. Men accounted for almost two-thirds of the overall cost. In the case of substance abuse-related disorders, the total cost of which was calculated to be over €35 million, men accounted for almost four-fifths of the total.
The cost of anxiety disorders, higher for women, was nearly €15 million. According to the same report, the number of days of sick leave caused by temporary mental illness attributable to the workplace environment was 2.78 million in 2010, which is equivalent to a cost of €170.96 million. Furthermore, it has been calculated that of the 17979 deaths related to mental health problems (including suicide and self-harm) in Spain in 2010, 312 could be attributed to working conditions. Calculation of the ‘years of potential life lost’ indicated that the cost of premature mortality that could be attributed to the work ranged between €63.9 and €78.9 million.
Another study concluded that the ‘social cost’ of just one aspect of work-related stress (job strain) in France amounts to at least two to three billion euros, taking into account health care expenditure, spending related to absenteeism, people giving up work, and premature deaths (Trontin et al., 2010). While in Germany, the direct and indirect cost of job strain were estimated to be €29.2 billion annually (Bodeker & Friedrichs, 2011). This included €9.9 billion in direct costs (prevention, rehabilitation, maintenance treatment and administration) and €19.3 billion in indirect costs (lost working years through incapacity, disability and premature death).
Evidence on the effectiveness of mental health interventions
Tan et al. (2014) conducted a systematic review and meta-analysis of universal interventions in the workplace with a focus on depression. Nine workplace-based randomised controlled trials (RCTs) were identified. The majority of the included studies utilized cognitive behavioural therapy (CBT) techniques. Results indicated that a range of different depression prevention programmes produces small but overall positive effects in the workplace.
When analysed separately, universally delivered CBT-based interventions significantly reduced levels of depressive symptoms among workers. Some individual studies were able to demonstrate larger effect sizes. For example, Tsutsumi et al. (2009) found that when a team-based participatory intervention was used to improve workplace stress reduction, there was significant deterioration of general health scores in the control group while the intervention group remained the same, with an overall moderate effect size.
Interestingly, this study was also the only intervention based at the organisational level, as opposed to all other studies that were based at the individual level, suggesting the benefits of organisational level approaches deserves further attention.
Montano, Hoven and Siegrist (2014) conducted a systematic review of the effects of organisational-level interventions specifically on employees' health. Thirty-nine intervention studies published between 1993 and 2012 were included. Success rates were higher among more comprehensive interventions tackling material, organisational and work-time related conditions simultaneously. The authors recommend that to increase the number of successful organisational-level interventions in the future, commonly reported obstacles against the implementation process (for example, lack of organisational commitment, lack of training) should be addressed in developing these studies.
Enns et al. (2016) conducted a scoping review of reviews on mental health promotion in the general population. Five reviews of mental health promotion interventions in the workplace were included. Again this scoping review found that very few interventions addressed aspects of the environment that might reduce the stress load (and thus the need for coping strategies) on individuals.
The scoping review identified as an exception the review by LaMontagne et al. (2007) which included studies that modified aspects of the work environment to reduce or eliminate job stressors. The authors of the scoping review conclude that a focus on resilience, while important, should not distract from prevention efforts that involve creating environments that are more supportive of mental health by reducing risk factors in the work environment.
A meta-review by Public Health England published in 2016 found moderate evidence that individually directed approaches can reduce burnout and work-related stress. One of the most rigorous reviews of randomised control trials of workplace interventions to reduce stress showed small but positive outcomes of person-directed programmes. For example, there was reasonable evidence that staff training and workshops can be effective in preventing symptoms of burnout. These might include stress awareness courses with a focus on coping. Another individual-level intervention, cognitive-behavioural therapy, showed positive (but modest) effects and was observed to produce greater effects than other types of workplace intervention, such as relaxation and meditation techniques.
Mental health represents a priority in most developed countries compared to developing ones. As is evident there are many sources of data on mental health in the workplace from various sources. Especially at the EU level, the various sources of data must be considered critically in their totality.
It has been shown that people with severe mental disorder are too often far away from the labour market, and need help to find sustainable employment (OECD, 2012). This is shown in a study by Matrix (2013) which revealed that employment rates in people with common mental disorders are 60-70%, compared with 45-55% for those with severe mental disorders but more than 70% for people with no mental disorder.
Work-related stress has been identified as one of the key states of sub-optimal mental health that can have severe consequences. Estimates from the Labour Force Survey in 2013-14 suggest that the total number of cases of work-related stress, depression or anxiety accounts for 39% of all cases of work-related illnesses.
The large majority of results from more than a dozen prospective investigations confirm elevated risks of depression amongst employees experiencing work-related stress, and odds ratios vary between 1.2 and 4.6, depending on the type of measure, gender and occupational group under study (e.g. Bonde, 2008; Ndjaboué, Brisson, & Vézina, 2012). More so, cost of absenteeism and premature mortality for depression in 30 European countries were estimated to be €109 billion in 2010 while costs for all anxiety disorders accounted for a further €88 billion (Olesen et al., 2012).
Based on the above conclusions, there is a need for the improved interface within healthcare and social security systems to accelerate the reintegration of employees into the workforce with appropriate support. Organisations should hire psychologists to disseminate good risk management practices in enterprises, including psychosocial risk management. Promotion of systematic comprehensive multi-modal approaches and practices which combine improvements in working conditions and lifestyle factors that are evidence-based is also required.
Munodiwa Zvemhara is a consultant at Industrial Psychology Consultants (Pvt) Ltd a management and human resources consulting firm.
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