Mental health at work

Introduction

Estimates suggest that 25% of European citizens will experience a mental health problem in their lifetime, and approximately 10% of long term health problems and disabilities can be linked to mental and emotional disorders (European Network for Workplace Health Promotion ^[1]). Results from the 6th European Working Condition Survey found that one in four European workers reported that work has a negative impact on their health^[2]. Using the workplace as a setting to promote good mental health, not only helps protect employee’s mental (and physical) health and wellbeing, but also makes good business sense. This article aims to provide the reader with an overview of the costs, the causes and consequences of mental ill health in the workplace; and provide an informed commentary on the methods and practices to develop and sustain psychologically safe and healthy workplaces.

Mental health in the workplace

Work can contribute to the development of mental ill health through poor working conditions and work organization issues. However conversely, employment can provide individuals with purpose, financial resources and a source of identify; which has been shown to promote increased positive mental wellbeing ^[3]. There is growing recognition across the European Union, and moreover globally, of the economic and social impact of mental ill health; and, in turn, of the relative importance of promoting mental wellbeing and preventing the onset of mental disorders in society-at-large ^[4].

Mental health problems, such as depression, anxiety disorders and alcohol and drug use disorders, affect more than one in six people across the European Union in any given year. Besides the impact on people’s well-being, the total costs of mental ill-health is estimated at over € 600 billion – or more than 4% of GDP – across the 28 EU countries (Health at a Glance: Europe 2018^[5]). In November 2005, the European Commission published a Green paper – Promoting the Mental Health of the Population. Towards a mental health strategy for the EU as a first response to the WHO mental health declaration for Europe^[6]. It identified the workplace as one of the most important social context in which to address mental health problems, and promote mental health and wellbeing^{[7][8][9][10]}. This article will examine these issues in more detail.

Understanding mental health and mental ill health

Mental Health

The World Health Organisation (WHO) and the Ottawa Charter for Health Promotion ^[11] define health as: “… a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity" ^[11]. This definition provides a comprehensive and holistic understanding of the concept of health, including and supported by three interconnected areas: physical, mental and social health. This holistic definition of health has two basic assumptions: (1) there is no health without mental health; and (2) health cannot – and should not – be viewed as merely the absence of illness or disease, but rather as a state of positive physical, mental and social wellbeing. The WHO ^[4] suggests mental health should be conceptualised as ‘a complete state of wellbeing’ in which the individual: realises his or her own abilities; can cope with the normal stresses of life; is able to establish and maintain social relationships; and can contribute to society by being productive.

Mental disorders and mental ill health

Mental disorders are clinically significant conditions characterised by altered thoughts, emotions or behaviours with associated distress and impaired functioning ^[12]. The ICD-11 is a book published by the WHO, and aims to provide a standardised diagnostic manual for mental disorders. The DSM-V, published by the American Psychiatric Association, is another commonly used diagnostic manual for mental disorders. These manuals provide a classification system that aims to separate mental illness into diagnostic categories based on the description of the individual’s symptoms and the course of the illness. Mental disorders are categorised as follows (based on ICD-11^[13]):

• Neurodevelopmental disorders
• Schizophrenia or other primary psychotic disorders
• Catatonia
• Mood disorders
• Anxiety or fear-related disorders
• Obsessive-compulsive or related disorders
• Disorders specifically associated with stress
• Dissociative disorders
• Feeding or eating disorders
• Elimination disorders
• Disorders of bodily distress or bodily experience
• Disorders due to substance use or addictive behaviours
• Impulse control disorders
• Disruptive behaviour or dissocial disorders
• Personality disorders and related traits
• Paraphilic disorders
• Factitious disorders
• Neurocognitive disorders
• Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium  

Estimates of severe mental disorders (such as severe depression, bipolar disorder or schizophrenia), are between 1-2% of the working population ^[14]. Severe mental disorders should be treated and assessed by a trained healthcare professional, and will often require a specialist (such as, a Psychiatrists). The British National Office of Statistics estimates that an additional 20% of the working population have been found to have symptoms that by virtue of their nature, severity, and duration do meet the diagnostic criteria ^[15] and therefore would be classified as a mental disorder; but would not be viewed as severe. These disorders are often referred to as ‘common mental health problems (CMHP)’. CMHP are those that are most frequent and prevalent. In the United Kingdom, for example, CMHP are often successfully treated in primary care settings (e.g, GPs), rather than by specialists (e.g., Psychiatrists). The most common of CMHP are depression, anxiety, or a mix of the two ^[12].

Many individuals may experience symptoms of emotional distress, which may not be of sufficient severity to warrant a diagnosis of a mental disorder, but nevertheless result in a significant degree of personal suffering, distress, and decreased productivity ^[12]. These are often referred to as ‘sub-clinical’ disorders, which are highly prevalent among the working population. The British National Office of Statistic ^[15] estimate that 20% of the working age population will experience symptoms associated with mental ill health (such as, sleep problems, fatigue, irritability and worry), but do not meet the diagnostic criteria of a mental disorder. However, these symptoms are associated with mental ill health can have a real and significant impact on the individual’s quality of life and ability to function adequately.

The impact and costs of mental health problems

The impact of mental health problems in the workplace has serious consequences not only for the individual employee, but also for the productivity of the enterprise. Employee performance, rates of illness, absenteeism, accidents and staff turnover are all affected by employee’s mental health status. EU-OSHA (2014)^[16] reports that the total cost of mental ill health in Europe is €240 billion/per year of which €136 billion/per year is the cost of reduced productivity including absenteeism and €104 billion/per year is the cost of direct costs such as medical treatment. Reduced performance due to psychosocial problems may cost twice that of absence. For the interested reader, the EU-OSHA (2014) report ^[16] provides an overview of the literature examining the costs associated with work-related stress and psychosocial risks.

Absenteeism, unemployment and long-term disability

Across the EU 16% of all work-related health problems are described as Stress, depression or anxiety (Labour Force Survey, 2013^[17]). These work-related health problems bring about increasing levels of absenteeism, unemployment and long term disability claims. For example, data from the UK show that whilst the overall absenteeism rate shows a downward trend, the proportion of days lost due to poor mental health appears to have risen (trend 2006 – 2018)^[18]. The evidence shows clearly that work-related stress and psychosocial issues lead to increased absenteeism and staff turnover rates. It has been calculated that each case of stress- related ill health leads to an average of 30.9 working days lost^[19].

Presenteeism and productivity

Mental health problems can often cause fatigue and impaired concentration, and poor memory ^[20][21][22]. A two year longitudinal study found a positive relationship between mental health and work performance. More specifically, as mental health improved so did performance; conversely, as mental health declined so did performance ^[23]. One large study found depression had a greater negative impact on time management and productivity than any otherhealth problem; and was found to be equivalent to rheumatoid arthritis in its impact on physical tasks ^[24]. Sickness presenteeism refers to being physically present at work, but mentally/ cognitively absent. An association between sickness presenteeism and mental health problems has been observed. A large Swedish study of 3801 workers found presenteeism to be related to musculoskeletal pain , fatigue and slight depression ^[25]. It remains difficult to measure presenteeism although some studies suggest that its impact may be as much as five times greater than the costs of absenteeism alone. Presenteeism is also itself a strong predictor of future poor mental and physical health^[19]. According to the 6^th EWCS, on average, employees went to work despite being ill on three days in the 12^thmonths before the date of the survey^[2]. UK studies estimate that the costs to businesses of poor mental health in the workplace are up to £45bn (total annual cost, 2020), comprising £7bn in absence costs, £27bn – £29bn in presenteeism costs and £9bn in costs of staff turnover. There are also other indirect costs to employers of poor mental health, such as the adverse impact on creativity, innovation, and other employees^[18].

Understanding the link between work and mental health

The development of mental health problems are the result of a complex interplay between biological (e.g, genetic characteristics and disturbance of neural communications), psychological (e.g., coping) and social/ environmental factors (such as, poverty, urbanisation, education level, and gender ^[26][12]). One social context that can play a significant role in mental health problems is the workplace. The current section seeks to outline some of the key risk and protective factors for mental health found in the working environment.

There is evidence to indicate that the poororganisation and management of work plays a significant role in the development of mental health problems. Across research findings, psychosocial issues (such as lack of job control, low decision latitude, low skill discretion, job strain, and effort reward imbalance) have been found to be associated with the risk of depression, poor health functioning, anxiety, distress, fatigue, job dissatisfaction, burnout and sickness absence ^{[27][28][29][30][31]}.

A systematic review and meta-analysis (2020)^[32] on the association between work-related psychosocial risk factors and stress-related mental disorders found moderate evidence that work-related psychosocial risk factors are associated with a higher risk of stress-related mental disorders. Effort-reward imbalance, low organisational justice and high job demands exhibited the largest increased risk of stress-related mental disorders. No significant or inconsistent associations were found for job insecurity, decision latitude, skill discretion and bullying^[32]. A literature review in 2003 found the following key work factors to be associated with mental ill health: long working hours; work overload and pressure, lack of control; lack of participation in decision making; poor social support; and unclear management and work role ^[33]. A longitudinal study conducted in the UK may provide some insight into causal relationship between work characteristics and the development of mental disorders ^[34]. Demands at work were found to increase the risk of mental disorders, whilst social support and high decision authority were found to decrease the relative risk. Additionally, high efforts and low rewards at work were found to be associated with the increased risk of mental disorders. A population-based longitudinal study conducted in Canada found work stress to be significantly associated with the risk of major depressive episodes. This study found that individuals who reported experiencing work stress were 2.35 times more likely to report a major depressive episode ^[35]. Work stress is understood to be a moderator/ mediator of the relationship between occupational hazards exposure and mental health. That is work stress can magnify the relative risk of exposure to psychosocial hazards and mental health problems.

The impact of risk factors in the workplace has been observed to vary across different workplaces, occupational groups and cultures. A study of 3142 managers, nurses and paramedical staff, and professionals from four organisations was conducted by WHO ^[12]. Results indicated that feeling overworked was a contributing factor across all three occupational groups. However, amongnurses and paramedical staff the pressure associated with decision-making was an identified as a key risk factor; whilst, in contrast, professionals and managers identified poor relationships with superiors. Additionally, there is growing evidence to indicate that the impact of risk factors may also vary across genders. A review conducted in 2006 found the impact of work stressors on common mental disorders to differ for women and men ^[36]. An EU-OSHA report ^[16] provides an extensive discussion on gender and health and safety. The report concludes, however, more in-depth research is required to more fully understand the contributory role of gender in mental health in workplace.

The WHO ^[12] have listed a number of protective factors for mental health: including, social skills, secure and stable family life, supportive relationship with another adult, sense of belonging, positive work climate, opportunities for success and recognition of achievement, economic security, good physical health, attachments and networks within the community, and access to social support. Two dimensions of the psychosocial working environment that have been consistently identified as key protective factors for mental health include:social support and high control/ decision authority at work. For example, a study that followed a group of British Civil servants (6895= men and 3414= women) over a period of time found that social support and control at work were found to protect mental health, whilst high job demands and effort-reward imbalance were risk factors forpsychiatric disorders ^[34].

Addressing mental health in the workplace

The workplace can provide a social context in which to develop a mentally healthy environment that is supportive to all workers. Contemporary frameworks for mental health no longer concentrate exclusively on the prevention and management of mental illness; but, instead follow aholistic approach including the promotion of wellbeing and enhancing functioning paired with the preventative measures ^[37]. Broadly, the aim of mental health promotion is not restricted to solely preventing mental health problems; but has a wider range of health, social, and economic benefits. Mental health promotion can be viewed as a process of enhancing the protective factors that contribute and support good mental health, paired with identifying and addressing key risk factors ^[38].Contemporary frameworks for mental health no longer concentrate exclusively on the prevention and management of mental illness; but, instead follow a holistic approach including the promotion of wellbeing and enhancing functioning paired with the preventative measures ^[37].

It is important to note, that effective promotion of mental health in the workplace should be only one critical component of an overall strategy to improve wellbeing at work ^[39]. Measures to promote better mentalwellbeing and addressing risk factors to prevent mental ill health and unduework-related stress should be fully integrated into an overarching framework for wellness andworkplace health promotion ^[39]. In order to cultivate a sustainable approach to worker wellness it is important to target actions and strategies at four key areas: lifestyle, mental health, physical health and engagement (see Table 1).

Organisational level measures

Actions aimed at the organisational level to promote and protect mental health, have an strong emphasis on: taking early action to prevent the development of stress and poor mental health in at risk groups; providing an environment that is supportive for employees who have experienced poor mental health; and, finally, implementing measures to help make it easier for people with enduring mental health problems, that may have experienced discrimination and exclusion from employment, to enter and/or return to work ^[39]. The following are a list of examples of some organisational measures that aim to cultivate a psychologically safe, healthy and supportive workplace ^[41][42][43]:

• job retention initiatives to maintain in employment those who develop mental health problems whilst at work;
• the full integration of mental health into workplace health and safety policies and initiatives;
• multi-level workplace improvement programmes that seek to address role clarity and expectations, workplace relationships, job design, and organisational culture;
• awareness raising and training for occupational health, human resources staff and managers on mental health in the workplace;
• the development of a workplace culture/ environment conducive to workers’ health and wellbeing;
• identification of workplace risk factors and, in turn, the modification of the physical and psychosocial work environment to eliminate and/or reduce identified risks;
• flexible working hours and support for daily life challenges (e.g., access to child care)
• job modification and career development;
• improve communication between employer and employees;
• promoting worker control and pride over end products;
• ensuring rewards and recognition for good performance; and
• ensuring career progression opportunities, to name a few.

Strategies and initiatives to promote mental health and wellbeing should be developed and implemented in a co-ordinated effort by those responsible on all levels, including: employers, managers, supervisors, and employees. In addition, the meaningful active participation of groups targeted by the intervention should be central to any approach adapted to promote positive mental health in the workplace. The role of participation of workers is a concrete enactment of job control, demonstrates organisational fairness and justice, and builds mutual support among workers and between workers and supervisors. These concepts are fundamental and at the core of the development of a psychologically healthy and supportive work environment.

Individual level measures

Actions taken at the level of the individual to promote mental wellbeing aim to: take a salutogenic perspective towards the prevention of stress and poor mental health (ie., addressing risk factors paired with promoting protective factors); provide individuals with resources and supports to help maintain their wellbeing; and cultivate a sense of coherence to affected workers make use of the supports when required^[39]. A number of examples of measures targeted at the individual to address mental health in the workplace include ^[39][43]:

• providing individuals with clear job descriptions;
• modifying workload;
• free psychological counselling and specific psychological support;
• relaxation and meditation training;
• biofeedback;
• exercise programmes;
• stress management training;
• time management training (including, conflict resolution and problem solving skills);and
• enhanced care management of individual’s with mental health issues.

Evidence for effectiveness

A systematic review of randomized controlled trials of workplace interventions aimed at universal prevention of depression show that workplace interventions directed at an entire workforce can reduce the level of depression symptoms among workers ^[44]. Kuoppala and colleagues ^[45] examined evaluations of the effectiveness of interventions delivered in the workplace to promote better mental health and well-being. They concluded that interventions aimed at workplace mental health promotion are valuable to employees' well-being and work ability; and are productive in terms of decreasing sickness absences. However, they highlight that education and psychological interventions when applied alone have limited effectiveness in the long-term, and therefore need to be paired with organisational-level measures that target both physical and psychosocial environments at work ^[45]. A meta-analysis by Sin and Lyubomirsky ^[46] showed that mental wellbeing can be enhanced and depressive symptoms reduced through positive interventions. This meta-analysis examined evidence derived from interventions across a number of social context, including the workplace. Within the context of the workplace, this can be achieved by establishing positive leadership practices, ensuring work is meaningful, and building a positive organizational climate ^[47]. Such positive interventions are becoming increasingly popular in clinical and general settings ^[48].

However, there continues to remain a paucity of good quality of intervention evaluation research examining the impact of psychosocial interventions aimed specifically mental health and wellbeing promotion ^[49], and therefore a detailed understanding of how and why such interventions work remains unclear. Measures to address mental health in the workplace are heavily related to the nature and content of interventions to prevent and manage stress and stress-related illness (such as mental ill health and burnout), see articles: Work-related stress: Nature and management, Understanding and Preventing Worker Burnout and Interventions to prevent and manage psychosocial risks and work-related stress. This literature highlights the growing evidence of effectiveness of such interventions; with a numerous studies emphasizing the importance and value of comprehensive approaches to managing and preventing work-related stress and other associated psychosocial issues. Comprehensive intervention approaches use a combination of organisational and individually-focused intervention strategies ^[50].

A review of interventions for work-related stress and mental strain was conducted by La Montagne and colleagues ^[51]. The systematic review observed interventions using a comprehensive approach to work-related stress management had a measurable impact to employee’s health and favourable impact on organisational benefits. Conceptually similar findings have been observed by numerous other studies ^{[51][52][53][54][55]}.

Measures taken by companies

• Reorganisation of work in order to reduce job demands and work pressure (measure taken by 44% of all establishments);
• Confidential counselling for employees (43%);
• Training on conflict resolution (34%);
• Intervention if an employee works excessively long or irregular hours (30%);
• Allowing employees to take more decisions on how to do their job (70%).

Policy initiatives and Supporting practices

Ensuring a psychologically safe and healthy workplace is not just a moral obligation and a good investment for employers; but it is a legal imperative set out in Framework Directive 89/391/EEC and supported by the social partners’ framework agreements on work-related stress (2004) and harassment and violence at work (2007). The European Pact for Mental Health and Well-being (2009) recognizes the changing demands and increasing pressures facing the workplace; and encourages employers to implement additional, voluntary measures to promote mental well-being ^[42].

Since then there have been a number of initiatives aimed to support and inform workplace mental health protection and promotion strategies ^[6]. The following are some examples of recent initiatives and associated guidance aimed at employers and organizations:

• A Publicly Available Specification (PAS) 1010 was published by the British Standards Institute in 2010. This document offers guidance and good practice on assessing and managing psychosocial risks at work.
• The 8th initiative, “Work in Tune with Life", by the European Network for Workplace Health Promotion (ENWHP) focused the cultivation of mental health promotion in the workplace. Based on the available literature and examples of good practices collected, the ENWHP developed a series of guides aimed at employers ^[1] and employees ^[1] to support organisational change and development initiatives aimed at promoting mental health at work. Furthermore, this initiative developed a checklist that can be used to companies to assess the quality of the mental health promotion measures in the organisation ^[1].
• The European Network for Mental Health Promotion (ENMHP) brings together information and tools relevant to promoting mental health and wellbeing in general. On the website guidance is also available for workplaces^[57].
• EU-OSHA, through its ‘Healthy Workplaces Manage Stress’ campaign, offers a practical e-guide to managing psychosocial risks, and is particularly designed to respond to the needs of employers and people working in small enterprises. Furthermore, EU-OSHA published a practical guide to wellbeing at work - Healthy workers, thriving companies (2018)^[58]. The guide suggests a straightforward five-step process for improving the work environment to tackle these work-related psychosocial risks and musculoskeletal disorders.

Conclusion

Work can play an important role in the mental health of individuals. In that it can contribute to the development of mental ill health through poor working conditions and, conversely, can provide individuals with purpose, sense of self-worth/ self-esteem, financial resources and a source of identify. In general, mental health problems have been a highly under-recognised issue among employers and managers, despite their high prevalence among the working population. Mental health problems have been shown to have a significant direct impact on the quality of life and functioning of individuals, but also have been found to have an indirect impact on the productivity and resilience of enterprises. The workplace is an important social context in which to prevent mental ill health and, moreover, promote the optimal mental and physical health and wellbeing of workers.