Common mental health disorders: what about work?

WONCA News has begun a regular feature on the subject of Occupational Health including useful resources for clinical practice. Peter Buijs (right) & Frank van Dijk (left) are the authors - they are Dutch occupational physicians and former family doctors, and for many years active in ICOH. In this contribution, Frank and Peter present reflections for the GP when confronted with ‘common mental disorders’ related to work. The next contribution for a future WONCA News, will be offered on more serious mental disorders.

What is the problem?

Mental health problems, often mixed with somatic complaints, are a leading cause of sick leave and work disability worldwide. They form a frequent work-related problem in general. Most patients suffer from minor mental health problems that they can cope with themselves. Some, suffer from severe complaints disrupting their private, social and working lives. Often, primary health care (PHC) is the first location where patients present with their complaints. Recognition, diagnosis, treatment or referral is crucial.

Common mental disorders include significant stress symptoms, long-lasting fatigue, and mild to moderate depressive and anxiety symptoms. Distinction is needed from more serious mental disorders such as bipolar disorder, major depression and psychotic disorders. Both work-related and private life ‘causes’ can be involved, as well as personal predisposing characteristics.

Mental health complaints such as a depression not caused by work, can have serious consequences for work functionality. Nevertheless, many GPs hesitate to ask the patient about work, regarding employment as not belonging to their domain. Similarly, many patients avoid talking about problems at work, maybe not expecting a solution in PHC. These missed chances for communication and support can have severe negative consequences for the patient. Therefore we recommend a high alert for ‘work’ during a patient’s working life.

Recognition and diagnosis in PHC

We suggest always asking the working patient with mental health complaints about problems in their job. A short list of work-related causes of stress-related disorders might be helpful (Nieuwenhuijsen et al. 2010):

Strong evidence for: • high job demands • experience of low control of the work • poor support from colleagues and/or supervisor • experience of procedural or relational injustice • a high imbalance between efforts given and rewards received Some evidence for: • emotional demands at work • job insecurity

Consider bullying and discrimination, and ask if there is work conflict. Traumatic experiences might be relevant. A risk factor for long-term sickness absence is previous sickness absence and the patient's expectation of a lengthy duration of the actual absence.

Individual predisposing factors need to be explored, such as problems in safeguarding own boundaries, limited capacities in communicating with supervisors, inadequate professional skills and predisposition for depression.

Therapy, guidance, referral

A world-wide review of occupational health guidelines on stress symptoms and mental disorders by Joosen et al. (2014) showed many similarities. Principles that can be useful are:

- Counselling has the aim to support the worker by exploring ‘causes’ of a ‘nervous breakdown’ or a (threat of) ‘burnout’; reassuring the patient when needed; and developing a shared explanation of what happened - a ‘rationale’. The aim is careful support of the patient in the recovery process.

- In case of sickness absence, supporting return to work is needed to avoid the negative effects of staying at home too long, and the risk of long-term work disability and job loss. Options to reduce stressful work conditions can be discussed. The patient can be supported in improving communication with the supervisor. An independent mediator is a possibility.

- Medication can be considered e.g. for severe depressive disorders or insomnia. Side-effects which may influence safety and work functioning have to be part of shared decision making.

- Support from or referral to an occupational physician or nurse (where available) is a good choice, with informed consent of the patient. Take in mind medical confidentiality and check the professional independence of the occupational health experts.

- Referral to a mental health specialist is an alternative; in some places an Employee Assistance Program is present. Experts often use cognitive behavioural interventions, problem solving therapy or other specialised treatments.

- Contact with the supervisor or colleagues at work, with consent and preferably in presence of the patient, may have a positive effect.

Frank van Dijk, Peter Buijs

References

Arends I, Bruinvels DJ, Rebergen DS, Nieuwenhuijsen K, Madan I, Neumeyer-Gromen A, Bültmann U, Verbeek JH. Interventions to facilitate return to work in adults with adjustment disorders. Cochrane Database Syst Rev. 2012 Dec 12;12:CD006389.

Buijs PC, van Dijk FJ, Evers M, vd Klink JJ, Anema H. Managing work-related psychological complaints by general practitioners, in coordination with occupational physicians: a pilot study. Ind Health. 2007;45:37-43.

Joosen MC, Brouwers EP, van Beurden KM, Terluin B, Ruotsalainen JH, Woo JM, Choi KS, Eguchi H, Moriguchi J, van der Klink JJ, van Weeghel J. An international comparison of occupational health guidelines for the management of mental disorders and stress-related psychological symptoms. Occup Environ Med. 2014;18 [Epub ahead of print]

Lagerveld SE, Bültmann U, Franche RL, van Dijk FJ, Vlasveld MC, van der Feltz-Cornelis CM, Bruinvels DJ, Huijs JJ, Blonk RW, van der Klink JJ, Nieuwenhuijsen K. Factors associated with work participation and work functioning in depressed workers: a systematic review. J Occup Rehabil. 2010;20:275-92.

Nieuwenhuijsen K, Bruinvels D, Frings-Dresen M. Psychosocial work environment and stress-related disorders, a systematic review. Occup Med (Lond). 2010;60:277-86.

Santibáñez Margüello M, Alonso Echabe E, Tamayo Medel G, Bolumar Montrull F, Vioque López J. [Perception of primary health care medical staff of their functions, and training and knowledge in occupational health].[Article in Spanish]. Aten Primaria. 2008;40:7-12.

Souville M, Cabut S, Viau A, Iarmarcovai G, Arnaud S, Verger P. J. General practitioners and patients with psychological stress at work. Occup Rehabil. 2009;19:256-63.

van Dijk P, Hogervorst W, ter Riet G, van Dijk F. A protocol improves GP recording of long-term sickness absence risk factors. Occup Med (Lond). 2008;58:257-62.