mental health and employment

mental health and employment
Mental health problems often cause fatigue and impaired attention, concentration and poor memory (Scheid, 2005; Lerner et al., 2004; Mancoso, 1990). These problems can be compounded by the effects of medication. However, ‘functional impairment’ at work is less common than ‘affective impairment’ such as emotional distress (Mintz et al., 1992) and there is only a weak association between the objective level of severity of a mental health problem and its impact on function at work (Dion et al., 1988; Tohen et al., 2000). Despite this, one large study found that depression has a greater negative impact on time management and productivity than any other health problem and is equivalent to rheumatoid arthritis in its impact on physical tasks (Burton et al., 2004). The problems caused by mental ill health can be a particular barrier to both high status jobs and those where there are high levels of contact with the public (Scheid, 2005).
Mental health problems are a major cause of presenteeism which is where an
employee is unwell and remains in work but is less productive. As discussed in
section 1.5, as much as 60% of the employment related costs of mental illness
are due to presenteeism (Sainsbury Centre for Mental Health, 2007). This might
be because people with mental health problems lack obvious outward signs
and are reluctant to have to ‘prove’ they are ill because of the resulting stigma.
Figure 1 is a simplified representation of the complex path from being well to being long term sick. Many factors, including individual perceptions, beliefs and decisions, contribute to mov ement up and down the path and each step is not an unavoidable consequence of the preceding one. It is far from clear why certain employees develop symptoms at work or, having developed symptoms, attribute them to work. The nature of the work environment appears to be an independent risk factor for the development of symptoms in those in work, and, to some extent in predicting which employees with symptoms will take time off. At this point however, individual factors such as coping style become important. Beliefs and expectations of recovery are more prominent risk factors in those who are already off work, and common mental disorders are strong predictors of extended sick leave.

Mental healthcare in the 21st Century

Mental healthcare in the 21st Century
In England, the first National Service Framework developed by the Department
of Health was for the mental health needs of working age adults (Department of
Health, 1999). Scotland and Wales have also produced policy frameworks (Scottish Executive, 2001; Welsh Assembly, 2002). These and subsequent implementation guidance set out a common set of principles and values that underpin modern mental healthcare. These are relevant to this report:
1. Those providing care should have a sense of therapeutic optimism. The goal of care should be to promote “recovery”6 for people whose mental health problems cause significant disability.
2. Services should promote social inclusion and work actively to counter the stigma and discrimination that people with mental health problems face from society, including in the workplace.
3. The care package should encompass the range of health, social and behavioural issues that affect people with mental health problems. To achieve this, services must work across the interfaces between agencies including healthcare, social care, housing and employment.
4. Treatment and care should be evidence-based and draw on the growing number of national clinical practice guidelines.
5. People should be active agents in their care and be encouraged to express
preferences and to exercise choice. This carries with it the assumption that
people with mental health problems have responsibilities as well as rights.
6. The healthcare system has a wider responsibility to promote mental health
as well as to treat mental illness. This includes influencing the formulation and
delivery of social and economic policies including those relating to education,
training and employment.

Factors that affect the prevalence of mental health problems

Factors that affect the prevalence of mental health problems

Compared with those who do not have a disorder, people aged 16 to 74 with
a common mental disorder are more likely to be women (59%) and to be aged
between 35 and 54 (45% compared with 38%). They are also more often
disadvantaged socially in that they are more likely to be separated or divorced
(14% compared with 7%), to live alone (20% compared with 16%) or as a one parent family (9% compared with 4%), to have no formal qualification (31% compared with 27%), to come from Social Class V (7% compared with 5%) and to be a tenant of a local authority or a housing association (26% compared with 15%) (Singleton et al, 2000). Because of these associations, there are more people with mental health problems in areas of the country that have high levels of social and economic deprivation. This is reflected in greatly increased rates of presentation and treatment of mental disorders in both primary and secondary care in socially deprived areas and, in particular, in deprived inner city areas (Moser, 2001; Harrison et al., 1995).
In keeping with this, rates of claims for Incapacity Benefits on grounds of mental
and behavioural disorders are highest in urban areas (Oxford Economics, 2007)
Many people who develop a common mental disorder do not seek help from
healthcare services or if they do their mental health problem is not detected (see
section 5.2.3). Surprisingly little is known about the course of the mental health
problem and the longer term outcome for this group of people. For those whose
mental health problems are detected, there are drug and psychotherapeutic
treatments that are effective for many people at both shortening the duration
of the disorder and in reducing the likelihood of relapse. There are also effective
treatments for the various types of severe mental illness such as schizophrenia,
bipolar disorder and severe depression. The extent of recovery varies depending
on a range of factors such as the nature of the illness, age of onset, severity of
symptoms and the presence of other problems such as personality disorder or
substance misuse. Some disorders are relapsing and ongoing drug treatment might be required that can itself cause adverse effects such as sedation. A minority of people have conditions that do not respond well to treatment and will experience continuing symptoms and sometimes a slow decline in social functioning. Mental health problems can be compounded by misuse of alcohol or illicit drugs.

The impact and Treatment

The impact and Treatment
The World Health Organisation has calculated the number of years of life lost due to early death or disability caused by a range of health problems. It estimates that for the whole world mental health problems account for 13% of all lost years of healthy life (WHO, 2004) and as much as 23% in developed countries (Harnois and Gabriel, 2000).
The economic costs arise from two main sources:
1. The direct economic impacts of the behavioural or other consequences of
mental health problems. This includes the effects of mental health symptoms
on an individual’s ability to work (impacting on their income and national
productivity), the effects on the ability of family members or other carer to
work and the other ‘opportunity costs’ of unpaid care.
2. The responses of the care system (broadly defined) to those consequences
including the healthcare treatments and services provided to alleviate symptoms
and meet needs, services provided by other systems (such as social care,
housing, employment support, criminal justice, education, leisure services,
transport, and social security), and out-of-pocket expenses by the individual
or family for treatments, services, or travel to services.
The Sainsbury Centre for Mental Health estimates that the total cost of mental
health problems was £77 billion in England in 2002/03 and £8.6 billion in Scotland in 2003/04 (Sainsbury Centre for Mental Health, 2003; SAMH, 2006). More than one-half of the total is accounted for by the imputed cost of impaired quality of life.
If this is removed, the estimated cost of mental health problems in England and
Scotland in these years was £39.5 billion. About 35% of this sum is accounted
for by the costs of health and social care and 65% by lost economic activity.
More recently, the Sainsbury Centre (2007) has estimated that impaired work
efficiency (‘presenteeism’ – see section 3.1 below) due to mental ill health costs
£15.1 billion, or £605 for every employee in the United Kingdom which is almost
twice the estimated £8.4 billion annual cost of absenteeism. Some US studies put the cost of presenteeism at four or five times the cost of absenteeism (Goetzel et al., 2004; Stewart et al., 2003).

Mental health problems and their prevalence

Mental health problems and their prevalence
People with mental health problems can be divided into three broad groups:
1. At any one time, one-sixth of the working age population of Great Britain
experience symptoms associated with mental ill health such as sleep problems,
fatigue, irritability and worry that do not meet criteria for a diagnosis of a mental
disorder but which can affect a person’s ability to function adequately (Office for
National Statistics, 2001).
2. A further one-sixth of the working age population have symptoms that by
virtue of their nature, severity and duration do meet diagnostic criteria (Office
for National Statistics, 2001). These common mental disorders would be treated
should they come to the attention of a healthcare professional. The commonest
of these disorders are depression, anxiety or a mix of the two.
3. The most recent national survey found that about 0.5% of the population
has a probable psychotic illness (Office for National Statistics, 2001) and the
generally accepted estimate is that between 1% and 2% of the population will
have a severe mental illness, such as schizophrenia, bipolar disorder or severe
depression, which requires more intensive, and often continuing, treatment and
care during their lifetime (Wing, 1994).
Although as a group those with a severe mental illness are more disabled than
those with a common mental disorder, there is no clear cut relationship between
diagnosis and disability at the individual level. A person with an anxiety disorder
can be housebound and require intensive support from a carer whereas a person
with schizophrenia can lead a normal life in all respects other than the subjective
experience of their symptoms.
There was little change between 1993 and 2000 in the proportion of the population of working age that has mental health problems (Office for National Statistics, 2001). We will not know whether it has increased since then until the results of the survey undertaken in 2007 is published.