Mental health at work: societal, economic and health imperatives align; it's time to act

Summary

The enormous impact of mental illness on work and productivity is a global challenge, with immense costs to wider society. Now is the time for action, with new international guidelines and an emergent consensus on occupational mental healthcare. Alongside governments, organisations and employers, psychiatrists have a leading role to play.

Concern about the health of our working population has never been greater. Almost 60% of the global population work, yet the lost productivity from depression and anxiety costs the world economy US$1 trillion.¹ The Office for National Statistics highlights that self-reported long-term ill health continues to rise within the UK working-age population, and in 2023 the most prevalent health condition, reported by 12%, was ‘depression, bad nerves or anxiety’.² These are 5 million people whose well-being and productivity are subject to impairment. This includes 53% – 1.35 million – of those on long-term sickness and therefore economically inactive.² For many, mental illness is a secondary condition, suggesting complex and interlinked health issues. The human suffering, loss and cost to society is considerable.

In the UK, the Chancellor of the Exchequer's 2023 Autumn Statement and Back to Work Plan aim to support the long-term sick and disabled, both into employment and to remain in work. This includes an expansion of the Individual Placement and Support programme embedded within mental health services, with a funding commitment to increase access to NHS Talking Therapies and provide Cognitive Behavioural Therapy (CBT) for common mental disorders.³ With a clear political imperative there is a call to action for employers, healthcare providers and society. There is an opportunity for psychiatrists to lead the drive on which evidence-based interventions and services should be implemented in future.

How to optimise mental health in the workplace

We know that good work can have a positive impact on mental health.⁴ It gives structure to daily life, rewards effort and achievement, provides social contact and instils self-agency. Conversely, poor working conditions or practices risk causing stress and can lead to mental disorders, while unemployment is a risk for suicide. This is amplified during a cost of living crisis when limited incomes are stretched, which disproportionately affects those in the lowest paid work. No profession is immune and even the National Health Service (NHS) is still reeling and recovering from the pandemic, with unprecedented industrial action and burnout. The case to improve mental health at work everywhere is therefore inarguable, both in the UK and globally.

The World Health Organization (WHO) published mental health at work guidelines in 2022⁵ and with the International Labour Organization produced a policy framework of strategies: to prevent exposure to psychological risks; protect and promote mental health and well-being; and support those with mental disorders.¹ The brief highlights that 50% of the societal cost associated with mental illness is indirect, with 12 billion lost days at work. With the impact of reduced productivity far exceeding the costs of action, the economic case, and political one, is clear and the need for clinicians to engage and help sculpt effective service delivery is paramount.

Primary prevention is the first step to improve workplace mental health, as ‘prevention is better than cure’, and this includes the management of psychosocial risks. At a government level, legislation such as the UK's Equalities Act 2010 will prevent discrimination-related harm, while the Health and Safety Executive's six-domain management standards approach provides a framework for employers to think about stress and the risks to workers’ mental health.⁴ Organisations should train managers to be alert for the signs of distress and to feel confident speaking with their teams about mental health. This should not aim to turn managers into care providers, rather to create a supportive culture that proactively supports their teams and hopefully prevent the need to access medical intervention. Secondary prevention includes establishing a peer support network allowing distressed team members to speak in confidence to someone at their own level who can help problem solve, enhance coping skills and facilitate access to professional assessment and treatment if needed. Tertiary prevention, of particular importance in our current context, is the provision of evidence-based interventions for those with mental health conditions. For example, employee assistance programmes, placement schemes and wider occupational health provision have a key role to play.⁴

Evidence-based interventions and Mental Health
First Aid

To achieve the WHO strategic goals, we need to know what will work and what does not. For instance, Mental Health First Aid (MHFA) is a training approach that has proliferated in recent years, with the general aim to teach people to recognise mental disorders and deal with immediate crisis, and in turn support workplace mental health. However, despite its wide reach, a recent Cochrane review of 21 studies (and 22 604 participants) highlighted the lack of good-quality evidence. The review could not draw conclusions about the effect of MHFA interventions, noting studies of insufficient size to detect difference and high risk of bias.⁶ Furthermore, there are risks with non-evidence-based interventions; they can provide false reassurance, divert attention from developing issues and have an opportunity cost. Ensuring that all those in supervisory positions are ‘psychologically savvy’ and facilitating periodic team-based reflection is more likely to protect workers’ mental health. Establishing peer support systems, such as Trauma Risk Management (TRiM), particularly in trauma-exposed occupations, is also evidence based.⁴

The psychiatrist's role

The crucial impact – both good and bad – of work on mental health is now recognised by the Royal College of Psychiatrists’ 2022 Position Statement on occupational mental health.⁷ This states that all mental healthcare professionals should view remaining at, or returning to, appropriate work as an important treatment outcome, and that an understanding of the bi-directional impact of work and health is paramount. The World Psychiatric Association's consensus on workplace mental health has also been approved,⁸ reflecting the emergent position and international significance of occupationally focused practice.

An employment history must be a routine part of clinical assessment to achieve this; the holistic formulation of patient need will include their occupational situation, alongside biopsychosocial precipitating and perpetuating factors.⁷ Voluntary or unpaid work can also provide significant benefit and must not be neglected: for some these roles are essential and they deliver immense value to communities and society. Yet stigma can still be a barrier to overcome, especially in severe and enduring mental illness, and is a worldwide problem. A multidisciplinary approach, co-designing future goals with patients, in partnership with occupational health services, is often crucial. Psychiatrists should feel confident to liaise with such colleagues and identify reasonable adjustments in overcoming barriers to safe and effective work. By advocating for patients, especially those marginalised and unfamiliar with workplace processes, healthcare teams can exert a valuable impact.⁷

Some psychiatrists have particular experience working alongside occupational health services and with employers to maximise fitness for work. Knowledge of specialist environments can facilitate a return to work, particularly in roles governed by specific legislation or in safety critical employment,⁷ such as pilots, divers, police, doctors and the armed forces. However, we argue strongly that although occupational psychiatry might be an area of specialist expertise for some, it is of relevance for all as part of core psychiatric competencies and understanding both what is important for our patients and what may be a precipitating or perpetuating factor in their mental illness.

Work and mental health – the call to action

The need to act and reverse the rising trend in mental ill health in the working-age population is clear and paramount. The challenge is global. Healthcare providers and psychiatrists aim to alleviate human suffering. Organisations need a healthy workforce to be productive and deliver their goods and services to society. Tackling unemployment and workforce shortages will support an economically prosperous nation and society. Individuals, clinicians, employers and the government all seek the same – healthy people thriving at work.

With disappointing data on the mental health of the working-age population, and concern about how current financial pressures will impact this, we also have an explicit moment of opportunity now, and the winds of political backing. The WHO has published international guidelines for mental health at work.⁵ We can frame workplace interventions as primary, secondary and tertiary prevention, based on evidence. An international position on occupational mental healthcare is emerging. We all have an essential role to play, and psychiatrists can and must champion these approaches at every level.