Lessons from the pandemic: why having a good understanding of occupational psychiatry is more important now than ever before

Abstract

The COVID-19 pandemic has once again highlighted the need for all psychiatrists to have a good understanding of the bi-directional relationship between mental health and a person's ability to function well at work. Ensuring patients are able to work should be a key treatment outcome for all psychiatrists.

The COVID-19 pandemic has re-emphasised the importance of employees’ well-being, in particular health and social care staff, and highlighted the very strong links between physical and mental health. As the world tries to recover from the pandemic, there is also a need to deal with future uncertainties, including incompletely understood phenomena such as ‘long COVID’. Economic success at the heart of any nation's recovery plan is somewhat reliant on the psychiatrists who care for working-age adults understanding the bi-directional relationship between ill health and occupational functioning. For instance, there is strong evidence that previous economic downturns, such as that in 2008, had a substantially negative mental health impact unfortunately linked to an increased rate of completed suicide. Indeed, this was exemplified by data published by Public Health England this year (https://www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-surveillance-spotlights/employment-and-income-spotlight), showing that those who were financially impoverished reported by far the highest rates of thinking they would be ‘better off dead’.

Thus, helping people to gain financial stability and remain in, or find, appropriate employment or education should be a key recovery metric. However, it is also true that poor work can both exacerbate existing mental health problems and contribute to the emergence of mental health disorders. Psychiatrists, and indeed all mental health professionals, should therefore have a good understanding of the interplay of work and mental health. Ignoring this relationship risks damaging the health of working-age adults and a nation's ability to ‘bounce back’ in the years ahead. More immediately, it does a disservice to the person in your clinic, whose well-being you are trying to support as broadly as possible. This is, we argue, the role of all mental health professionals working with this age group, and not just those with specialist occupational health roles or qualifications.

Rates of employment for those with serious mental illnesses are stubbornly low. This is unfortunate as, for the vast majority of people with mental health problems, work is not only possible, but entirely appropriate and desirable. However, despite evidence showing the gains of good work that is flexible, fair, inclusive and healthy, people with psychiatric problems are often excluded or find themselves in precarious or unsuitable work.¹ Evidence from industrialised nations shows that exclusion from the workplace, and exposure to insecure work, puts people with mental health problems at high risk of financial uncertainty, social exclusion and poor health outcomes.² Furthermore, there is strong evidence that poor mental health is associated with absenteeism and presenteeism (reduced occupational functioning), which is a particularly important consideration for those in safety-critical roles.³ Psychiatrists, along with multidisciplinary team colleagues, have a key role in supporting patients to access and remain in good work. Crucially, they may help employers to understand the interface between mental health and occupational functioning, appropriately advocating for and supporting this. ‘Instillation of hope’ is a long-established psychotherapeutic construct that we suspect is familiar to all readers. Psychiatrists’ attitudes toward work, training and education for people with mental health problems have a major influence on their patient's hopes and expectations for rehabilitation, as well as broader employer and societal attitudes toward mental health.

Psychiatrists can support their patients to access good work in a number of ways. First, a thorough assessment of employment and educational attainment is a critical element of history-taking in all instances. This information should be an easily accessible part of patient notes and be updated regularly to reflect changes. An exploration of the relationship between work and/or education on the origin and impact of mental health symptoms, alongside the effects of medication on functioning, is essential as soon as patients are showing signs of a recovery, if not before. Asking about future hopes for work, education and training is key; committing to return to work is the strongest predictor of a successful return.⁴ Psychiatrists should aim to facilitate a return to appropriate work wherever possible, taking into the account the wishes of the individual and the nature of their work.

Second, it is important that psychiatrists view gaining or remaining in appropriate work or education as key treatment outcomes for all working-age patients. Discrimination against people with mental health problems, in particular severe mental illness, continues to be a major barrier to work. Yet, there is strong evidence that employment support enables even people with severe mental illnesses to return to appropriate work. Vocational rehabilitation programmes, such as Individual Placement and Support, are associated with a 60% increased chance of people with serious mental health problems being in competitive employment, and are thankfully gaining traction in the UK.⁵

Third, psychiatrists should recognise that work may be the first place that someone's mental health symptoms become unmanageable. Commonly, mental ill health is associated with accidents, mistakes and poor performance; this is known as presenteeism, which is often associated with a breakdown of working relationships. It is also not unusual for people to feel embarrassment, humiliation and reduced confidence about their behaviour at work; such experiences may strongly impede someone's desire to return to work. However, psychiatrists can support creating the conditions for a successful return to work, including by liaising closely with managers and occupational health professionals, to ensure that employers make reasonable workplace adjustments. Occupational health professionals can also assist psychiatrists to better understand potential risks of specific workplaces, to help ensure optimal and safe care planning. Another wider discussion point of the pandemic has been the issue of how working conditions themselves can hinder well-being, with debates about moving conversations from the ‘resilience’ of the individual to resilient environments that foster safe workplaces, healthier lifestyles and supportive working relationships. The details of this are beyond the remit of this article, but although psychiatrists might feel limited in their ability to affect such factors (e.g. pay, shift patterns, safety equipment), they should feel able to point out the futility of yet another well-being app being introduced when staff cannot get time off for leave or are unable to easily park their car to come to work.

Fourth, although they do not need to be experts on employment law, since they may be advised by occupational health professionals, psychiatrists should have an awareness of the Equality Act 2010 and other relevant legislation. Such knowledge will help ensure that people with mental health problems are not marginalised and facilitate encouragement of employers to provide appropriate support in keeping with disability legislation. Research has shown that employment support is often not offered or available to mental health patients, and that this is unfortunately more pronounced for ethnic minority groups.

Although occupational psychiatry is not yet recognised as a subspeciality, it is incumbent on all psychiatrists to use their expert understanding of mental health to ensure that all working-age adults they care for have access to occupational, educational and supported welfare guidance. This may involve ensuring that the mental health teams they lead liaise with patients, employers and other clinicians to assist those with mental health problems to remain at, or return to, work even if their symptoms are only partially remitted, as long as it safe to do so. Seeing work as just another important outcome, such as a reduction in symptoms or improvement in quality of life, should become the norm. Good, occupationally focused psychiatric care is also likely to reduce the risk of presenteeism, and thus make untoward incidents less likely and help increase productivity. Mental health problems are currently a leading cause of work disability in many nations, including the UK; better occupationally focused psychiatric care should help to address this issue. The Royal College of Psychiatrists has a special interest group (of which the authors are on the executive board) that aims to enhance knowledge and training on the issue. We would encourage membership: it is not ‘just’ for those who work in the area, it is for those who work with those who work – namely, you.