Our attitude to mental health is hurting us all

Last month Time to Change released the results of a survey into the impact of stigma in mental health.

Stigma is the process of outcasting people from society because they do not fit with the idea of what is ‘normal.’   It has existed in all societies and all ages, taking different forms depending on the cultural norms in a time or place.

There are many examples. For example overweight or obese people are stigmatised in a culture that worships physical perfection. They are stereotyped as a group as lazy or greedy, a process which makes it easier to separate ‘them’ from ‘us.’ They lose respect and status and become easy victims of discrimination.

The important thing to notice is that the stereotyping occurs after a group is identified as not fitting in. It is not fact-based but a device to justify the stigma. Think of any persecuted group throughout history. In my own time in Bosnia, people were reduced to the status of animals as a device to harm or kill them.

A recent article in the Observer discussed the disturbing level of violence against disabled people in Britain. It described the violence and hate thrown at a man with MS.

It also pointed to a work-based survey on attitudes to disability carried out by BT in which 65 per cent of respondents said they avoided disabled people because they didn’t know how to behave around them.

A visual difference from what is perceived as ‘normal’ quite easily leads to marginalisation. However stigmatisation goes beyond that. For example, 38 per cent of those who responded to the BT survey thought disabled people were a burden on society, a negative stereotype justifying their victimisation.

Another feature of branding people with health problems is to blame them for their misfortune (see obesity, above) or secretly believe they are making up or exaggerating their condition. This is particularly so in the realm of mental health. Classifying people with depression as 'weak' is a permission to discriminate against them, even though it has no basis in reality.

An unfortunate side effect is that people who develop symptoms of say depression fear a diagnosis in part because of the stigmatising consequences. It is estimated by NICE that only about 50 per cent of people with depression see a GP. In a society that has normalised excessive drinking and drug-taking, self-medication is a less shameful response – around 5 million Britons drink every day to feel less anxious or depressed.

According to the Time to Change survey, 80 per cent of respondents had experienced stigma or discrimination in some sphere of their life because of a mental health problem, while 67 per cent would not tell their employer.

As depression and anxiety are the most common health issues of any type at work, this is a serious issue that can only be addressed by bridging the confidence gap that exists between employees and their organisations.

This begins at the top, where management culture is formed.

Recession: pushing workers to the edge

Workplace stress has been on the rise in the UK since 1992, according to a new report from the British Academy focussing on mental health and the recession.

Until the 2008/9 recession, work stressors - the triggers of stress such as high workload and loss of control - had risen between 0.5 and 1 per cent a year. This jumped to 4-6 per cent in the downturn. 

This corresponds with a series of independent reports from the DWP, CBI and CIPD which put stress at the top of workplace health issues.

The rise of the super-competitive, globalised market in the 1990s has been a major cause.  While it led to a rise in living standards as measured by GDP, it also increased job instability, work intensity, conflict and bullying and work/life imbalance, all of which have worsened in the recession.

Work intensification has been a feature of the way work has changed over the last twenty years, with nearly half of all Europeans now working at very high speed three quarters of the time. In the recession, 44 per cent of Britons said they were working under excessive pressure several days a week, with one third labouring under too great a workload. 

A record number of Britons have temporary or part-time jobs. As the new report claims, 'Workers in these types of contract are more vulnerable than permanent workers. They usually carry out the most hazardous jobs, work in poorer conditions, and often receive less occupational health and safety training. These new forms of employment contract are associated with less job security than full-time permanent contract jobs.'

In the recession, 35 per cent of employees on temporary contracts found they could not get a permanent job (as opposed to 25 per cent pre-recession), accelerating the move towards the long term 'casualisation' of the labour market.

Between 5-6 per cent of European workers have been subject to some form of bullying, violence or harassment. This has increased as the economy has moved towards the delivery of services, with 14 per cent reporting being bullied in this sector.

The restructuring, downsizing and other crises associated with the recession has accelerated this, with 20 per cent of employees reporting an increase in inter-personal conflict in the spring of 2010, and 15 per cent reporting an increase in bullying by managers.

Strangest of all in this time of increasing psychological distress, sickness absence rates have fallen since the recession. Based on all the available evidence, the obvious conclusion is that more workers are coming into work with symptoms of stress and other common mental health conditions such as anxiety and depression.

Presenteeism is a little understood but significant factor underscoring performance at work. A recent Work Foundation report indicated it could run at three times the rate of sickness absence.

In a recession it is reasonable to think that employees feel pressurised to come into work while unwell to support their colleagues or their own position in the face of redundancies. The Work Foundation report also found that many also come in to work because of the support they get from colleagues.

The mere fact that employees turn up to work, however, is not indicative of the health of an organisation. As well as under-performance, the worsening conditions at work risk exacerbating already vulnerable people, creating problems of long term absence and disability. According to the CBI mental ill health is the leading cause of long term sickness in the UK.

Employers should pay heed to this with another recession looming, as pushing the workforce to the edge has longer term consequences for them and society. Rather than accepting this as inevitable, actively managing stress can bring advantage in difficult times. 

Management Standards plus - how to collect data on mental health at work.

According to the 2009/10 absence management survey carried out by the Chartered Institute of Personnel and Development, the most common causes of stress at work were:

• Workload;
• Relationships;
• Organisational change;
• Management style.

All organisations are required to assess the risk of stress from work. The Management Standards define the characteristics, or culture, of an organisation where those risks are being effectively managed and controlled. They are the product of ten years of Health and Safety Executive research and were introduced in 2004.

The Management Standards cover six key areas of work design:

• Change – how organisational change (large or small) is managed and communicated in the organisation.
• Control – how much say the person has in the way they do their work.
• Demands - this includes issues such as workload, work patterns and the work environment.
• Relationships – this includes promoting positive working to avoid conflict and dealing with unacceptable behaviour.
• Role – whether people understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles.
• Support – this includes the encouragement, sponsorship and resources provided by the organisation, line management and colleagues.

If not properly managed any of these areas can lead to stress-related poor health and wellbeing, lower productivity and increased sickness absence.

Stress risk assessments using the same five step approach as for any other workplace hazard. This involves assessing what might cause stress in a particular workplace and collecting data on absence levels associated with mental ill health.

In carrying out a risk assessment, best practice is to follow the framework of the Management Standards. This involves obtaining feedback from employees on how work is affecting them.

In all but the smallest organisations, the most effective way of doing this is through the HSE Management Standards tool. This is a short survey in which employees score their responses to statements about the six areas of work design identified as potential causes of stress.

For example six statements relating to Control include:

• I have a say in my own work speed:
• I have a choice in deciding how I do my work.

The responses are collected and the organisation is rated between urgent and very good against a workplace where the risk of stress from control issues is being managed well. In general the more employees respond well to an area of work the higher is the rating.

A recent analysis of the survey tool found higher ratings 'are associated with increased job satisfaction, decreased job-related anxiety and depression and lower witnessed errors/nears misses. These findings lend further credibility to the use of the HSE MS Indicator Tool to help organizations manage potential sources of work-related stress.'

However, assessing what causes stress at work is only part of the story. Organisations also have to measure the level of sickness caused by mental ill health, whether at work or at home.

The traditional way of doing this is to look to the absence records. However there are a number of problems with this approach.

Research has shown that there are many more people at work with mental ill health than there are at home. If organisations measure the extent of the problem only through sickness levels they will perceive a false image of the health of their workforce.

This is compounded by what the sickness data tells us. On the one hand, mental ill health is often perceived as a weakness and not something to reveal to employers, while the view in the other direction is that  'stress' is an overused excuse for any number of reasons not to come to work.

So whether under or over reported, the absence figures are unreliable, and this is further muddied by the fact that most organisations do not maintain comprehensive sickness records in the first place.

The information is critical however, because mental ill health is a combination of factors caused by work and home environments, a fact not picked up by the Management Standards. Additionally, without reasonably reliable data on mental health it is all but impossible to understand whether the problem is getting worse or better.

One way of addressing the problem is to encourage open communication and positive signals on mental health issues. Developing a specific stress policy or signing up to the Mindful Employer Charter for Employers who are Positive about Mental Health is one example.

Organisations should also consider using the kind of mental health tools used in research and clinical settings to identify symptoms of common problems such as stress, anxiety and depression.

The advantage of these over sickness records or surveys that ask employees to self-report stress is that they more accurately reflect the underlying level of wellbeing at work, even where employees themselves are reluctant to accept they might be unwell.

While mental health surveys might seem a new and perhaps unwelcome addition to the risk assessment process, stress-related illnesses have now risen to the top of the workplace health list. Carried out in a confidential and sensitive way, most employees would welcome the interest shown in their welfare, while organisations gain another tool to help boost performance in very difficult times.

Threat or opportunity: the rising cost of stress

A third major survey of 2011 counts stress as the leading cause of absence outside of colds, headaches and other common ailments.

Earlier in the year the Department of Work and Pensions found that ‘Depression, bad nerves or anxiety’ were the most commonly reported symptoms of employees in the UK.

This was followed up by a Confederation of British Industry survey which found that 46% of short term and 61% of long term absences were caused by mental ill health.

Now the annual absence survey of the Chartered Institute of Personnel and Development has found that, across all the types and sizes of organisations it surveyed, stress accounted for 57% of short term and 68% of long term absence.

The CIPD measures absence as total days lost through illness. The other way to do it is through incidences of illness.

Research for the Centre for Mental Health has shown that someone with stress is likely to be off work for twice as long as someone without stress. An incidence of stress is more damaging to a company than any other illness.

For example, the latest data from the Health and Safety Executive shows that almost twice as many employees report back pain to their GPs than mental ill health (53% against 37%), while almost twice as many absences are caused by mental ill health than back pain (55% against 31%).

The way of measuring absence by days lost gives the impression that over half the UK workforce has symptoms of stress, a figure which seems so high that it almost questions its validity as an illness. In fact, though, one could almost halve this figure into the number of actual cases of stress, about one in four of the workforce.

Measuring the incidence of stress helps make the problem manageable.  At a really basic level, preventing one case of stress is the equivalent in days lost of two cases of back pain. Dealing with stress is a cost efficient way of bringing down absence levels.

This is more so because stress management is not inherently expensive. According to the CIPD the two top causes are workload (48%) and management style (40%), neither of which require large outlays to fix.

The HSE’s Management Standards are designed specifically to help organisations risk assess for stress, yet the CIPD survey found that only 30% of organisations used them to identify and reduce stress at work, a similar figure to the CBI survey.

The current round of reports should make organisations more alert to the problem of stress at work and the opportunity to save money at relatively little cost.

Employee wins stress case against NHS for discrimination and unfair dismissal

An Employment Appeal Tribunal has sided with a former NHS employee dismissed after becoming disabled with stress caused by his line manager.

Mr Foster worked for Leeds Teaching Hospital NHS Trust for many years, ending up as a senior security inspector in the Security Department.

In October 2006 he stopped working due to workplace stress and in February 2009 he was dismissed by the Trust on grounds of capability due to ill health under the Employment Rights Act.

Shortly after going on sick leave, Mr Foster raised a grievance alleging bullying and harassment by his line manager. He then went to see an Occupational Health doctor, who confirmed that his stress was the result of problems at work, and that his return to work would not be possible until those problems had been resolved. It was accepted by the Trust that during this whole period Mr Foster was disabled within the meaning of the Disability Discrimination Act (now the Equality Act).

After nearly a year of investigating – during which time Mr Foster was on sick leave - the Trust dismissed the grievance, refusing to consider the Occupational Health report as a part of the investigation. In fact, at no point were the reasons for Mr Foster’s absence from work considered by the Trust.

Mr Foster was then given a choice - either return to his old job, or another one in the Security Department, both of which put him under his old line manager. Redeployment elsewhere in the Trust was not an option.

Mr Foster refused. Even though the allegations against his line manager had been dismissed, that was not how he saw it. The doctor advised the Trust that he would not be able to return to work until he was redeployed outside the Security Department, but that he was ready and fit for such work elsewhere in the Trust’s 15,000 strong workforce. There was a standoff, as a result of which management recommended that Mr Foster be dismissed.

At first this recommendation was refused. The Trust put him on the redeployment register, but when a job came up he was by then too ill to take it. He had by this time been on sick leave for nearly two years.

Then, shortly after, Mr Foster’s line manager left the Trust, and a return to the Security Department became feasible. Mr Foster requested a meeting with the Trust’s management to discuss some issues relating to his health, but this was refused. He was told he would have to consent to a whole new grievance procedure if he wanted to discuss his return to work.

Mr Foster then went back to his doctor, who now advised that his prospect of returning to any work at the Trust was not foreseeable. Mr Foster had lost all faith in the Trust. As a result the Trust dismissed him.

The Tribunal found that the Trust had a duty to make reasonable adjustments to prevent Mr Foster from being at a substantial disadvantage under the Equality Act. It said:

‘people who were not disabled as a result of stress were not under the disadvantage of having to work in a department which caused them stress.’

It found that an adjustment was reasonable if it involved a prospect that Mr Foster could have been redeployed. The fact the Trust employed such a large workforce, and that later – when it was too late – a job had come up, showed there was a prospect of redeployment.

The Tribunal also found that Mr Foster had been unfairly dismissed because it had not considered any alternative arrangements for him. No reasonable employer would do that. When it did eventually consider redeployment and return to work, it was too little and too late.

The fatal flaw of the Trust was a lack of flexibility in addressing Mr Foster's concerns. When he appealed to the Trust against his dismissal, it was found there was evidence he had been harassed. However, even without this evidence, the Trust should have paid heed to the Occupational Health report and considered ways to help Mr Foster return to work. Had Mr Foster been the victim of a physical injury, perhaps the Trust might have behaved differently?

For further reading, try this resource for groundbreaking cases on mental health at work.

Two in five Europeans has a psychological condition

The results of an extraordinary survey of thirty year’s worth of mental health data carried out over 27 countries has revealed that nearly two in five Europeans has a mental or other disorder of the brain.

No doubt eyebrows will be raised and articles penned about the ‘medicalisation of normality’ – and in fact a prime example can be read in this week’s Guardian.

‘Big Pharma feeding its appetite for profits and ours for drugs, has gained an ever greater hold over our mental and emotional lives, medicalising normality.’

The argument runs that the medical establishment is continuously inventing disorders to justify its existence.

There might be some truth to that. Glaxo Smith Kline, makers of Seroxat, Paxil and other antidepressants, continues to peddle the false information that depression is caused by an ‘imbalance in brain chemicals’ which miraculously can be ‘cured’ by taking their drugs.

In fact antidepressants were discovered by accident and no one really knows how they – or depression – work.

On the other hand it is also patently absurd to state that ‘doctors could recommend group running for depression, proved to have far better effects than [antidepressants].’ Really? You’d need to do a lot of running.

Looking at the list of ‘disorders’ in the EU report, they all seem quite familiar to me – alcoholism, insomnia, anxiety, OCD, dementia and Post Traumatic Stress Disorder. I’m sure most of us know someone, maybe even ourselves, with one of these.

Take insomnia for example. This was found to be the second most common disorder in the EU, suffered by 7% of the EU population, or 29.1 million people.

So what is insomnia? Sure, people have difficulty sleeping – that doesn’t mean there’s something ‘wrong’ with them, does it?

Well, look at this study commissioned by the Mental Health Foundation. Insomnia is defined as ‘sleep disturbance for at least three nights a week to the extent that it causes a degree of day-time distress.’

The Mental Health Foundation thinks it is a ‘major public health concern’ causing 55% of insomniacs relationship difficulties (compared to 13% for non-insomniacs), 83% low mood (with the inherent risk of depression) and 94% low energy, 78% poor concentration and 68% decreased ability to get things done (with all the implications for work).

While they might not use the rather clinical term ‘disorder’ I think most insomniacs would admit that, in a very negative way, their sleep is not ‘normal.’

The same is true for depression. Sure low moods are part of life – you can’t be ‘up’ all the time. But being ‘down’ all the time, for weeks on end with no relief, is that ‘normal?’

The lead author of this ‘major milestone’ of a report predicted the negative response his findings would get:

'Lay persons, the public, and even many clinicians and researchers might be surprised and sceptical both about our 38% estimate and the large number of disorders included. This might be due to limited knowledge, negative attitudes, and potentially to misconceptions about the nature of mental disorders.’

Why can’t our brains go wrong?  I mean they are by far the most complex things we own.
The report describes mental health as the most important health issue of the 21st century, with depression by far and away the leading cause of disability and early death.

In order to tackle it public information is incredibly important. But people are not going to respond to language like ‘disorder.’ Everyone wants to be part of the ‘normal’ club, even when membership is falling.

A recent report from the Centre for Disease Control in the US has predicted that nearly one in two Americans will experience a mental health problem in their lifetime, while

‘Nearly 8.4 million Americans had suicidal thoughts in the past year and 2.2 million made plans to kill themselves. One million persons attempted suicide.’

This is not a case of ‘medicalising normality.’ By saying it is we are encouraging people to make a dangerous choice between being normal and getting well.

CBI survey: mental health is a priority at work

I’ve just stumbled across the Confederation of British Industry’s 2011 absence report.

The CBI report is interesting reading because of its scope – the respondents employ over one million people in total – and because it represents how employers see the workplace.

I was particularly interested in the results for non-manual labour. Employers were asked to list their top causes of short-term absence:

• Minor illnesses (colds etc): 98% of employers
• Migraine/chronic headaches: 47%
• Non-work related anxiety/stress/depression: 46%

An interesting point about the report is that – unlike other causes that I could see - anxiety, stress and depression were divided into work and non-work causes, with work-related mental ill health listed at 24%.

I would be curious to know how employers make this distinction. For  a variety of reasons – not least its perception as a weakness – employees are likely to underreport workplace stress. The results of the Labout Force Survey suggest that mental ill health accounts for about 35% of illnesses caused or made worse by work, a distinction which shows that work and home can aggravate as well as cause people to be made unwell.

In terms of longer-term absence (20 working days or 28 calendar days or more per year) the biggest cause of absence were:

• Non-work related anxiety/stress/depression (61%)
• Cancer (41%)
• Musculoskeletal disorders (31%)
• Work-related anxiety/stress/depression (29%). 

What to make of the results?

The employer view accords with the DWP survey of employees that ‘Depression, bad nerves or anxiety’ were the main causes of employee ill health. It also compares closely with other measures of health at work such as the annual survey of GPs, which puts mental health at 57% of all absences. Outside of common colds, mental ill health is the leading cause of absence at work.

The high rate of long term absence is also in line with the findings of the Centre for Mental Health that someone with depression or anxiety is likely to be absent on average for 19 days a year, more than double the national average. Stress is a trigger for depression and anxiety, and prevention and early intervention are therefore key strategies to keep employees in work.

The report found that 89% of employers operated some kind of stress management activity:

• Counselling: 89%
• Occupational health: 81%
• Flexible working: 69%
• Regular risk assessments: 52%
• Job redesign: 44%
• HSE management standards for stress: 36%
• Training: 35%

While this might look encouraging, the fact that only 36% of employers use the Management Standards is worrying.

A 2009 study into the Management Standards found they were ‘associated with increased job satisfaction, decreased job-related anxiety and depression and lower witnessed errors/nears misses.’ They are in fact the primary tool to prevent work-related mental ill health, while services such as counselling are more akin to an ambulance, necessary but not something you want to rely on.

The role of managers is perhaps accepted by employers, which identified day-to-day management as key planned areas for future activity. As the CBI report concludes, ‘wellbeing policies do not need to be expensive. But it is important for employers to consider what approaches are likely to yield the greatest benefits for their particular workforces.’

Rather than investing willy-nilly in wellbeing programmes, employers would be best served by carrying out a Management Standards survey first. In addition to identifying where to focus interventions, it would also provide benchmark data to monitor improvements.

The big D: overcoming fear and ignorance in work

The mental health charity SANE has launched a major new depression awareness campaign. It has commissioned life-size black dogs to place in cities throughout the UK to raise awareness of the 'invisible' condition.

Depression and anxiety were the most commonly reported illnesses in a new Department of Health and Work report on employees at work. They account for over half of all work-related absences signed off by GPs.

So it made me wonder why there is such a lack of information or help about depression at work. The Shaw Trust's follow up report, 'Mental health: Still the Last Workplace Taboo?' perhaps indicates the problem is a mix of fear and ignorance.

In the 2010 report - which sampled 300 small companies (1-50 employees) and 200 medium/large companies (over 50 employees) - these two keys statistics stand out:

• Only 22% of employers thought someone at work currently had a mental health problem.
• 40% of employers thought that someone with an illness like depression would be a 'significant risk' to their business.

Taking the rate of common mental health problems at about one in six of the working population, any organisation which has more than ten employees is practically guaranteed to have someone with or at risk of developing symptoms of depression and/or anxiety.

The fact this sounds like scare-mongering really shows the reality gap. According to the World Health Organisation, depression is the largest cause of disability in the world.

Fear, ignorance and depression are hopelessly intertwined. One of the reasons managers think their workforce is so mentally sound is because they are filtering out any feedback which says the opposite. If you were thought of as a significant risk, would you go to your line manger with a mental health problem?

Organisations need to take off their rose-tinted glasses and look at the objective evidence. Then - through confidential means - they should look at how their own workplace stacks up.

At the same time, pubic bodies such as the Health and Safety Executive and the Department of Health should be blitzing offices with a simple message. To get the ball rolling I propose a poster such as:

'Have you felt little or no joy or pleasure in life, or had a low mood you couldn't budge for at least two weeks?

Depression is one of the most common illnesses in the UK. It affects millions of Britons. There are many ways to help you feel better. 

You can quickly check if you may have symptoms of depression at www.nhs.uk/Tools/Pages/depression.aspx. 

Your GP can also help.'

Everyone - front-line staff, managers, CEOs - all are at risk of depression. By far the best tactic is prevention, and that means making people aware at the earliest point what to look out for and how to avoid it getting worse.

Such a campaign might also help to reduce stigma and help colleagues to look after each other.

Mental health at work: a measure of performance

Sickness at work is usually counted in time lost. Indeed common mental conditions – stress, anxiety and depression - account for more days of absence than any other condition, a huge tax on work and the NHS.

Now a Work Foundation report into sickness presence has provided support for the Centre for Mental Health’s findings that illness while at work is an even larger iceberg-shaped financial problem.

‘Why do employees come to work when ill? An investigation into sickness presence in the workplace’ surveyed the 1,600-odd employees of AXA, the insurance company.

By its own account, AXA prides itself on its ‘modern employment practices and for the wide range of employee benefits available to our people.’ It has a 96.5% attendance rate and low staff turnover. Overall it felt it placed a high regard on the health and wellbeing of its workforce, which in a sense makes the findings all the more troubling.

510 employees responded to the survey (about a third of employees), of which 19% self-reported depression, 25% migraines and 26% difficulty in sleeping. The other two health problems in the top five were skin problems (including hayfever and eczema - 30%) and muscular-skeletal (20%).

45% of those responding stated they had taken one or more days of sickness presence over a four week period – that is they had come in to work while ill enough to remain home.

This was the Work Foundation’s definition of sickness presence – a refinement of ‘presenteeism’, which in some definitions could include those who were perfectly well but just slacked off at work.

In the same period, 18% of the same respondents had actually taken a day off sick, indicating that sickness presence was three times the rate of absence.

It would be nice to think of the good old British worker struggling in to work for the good of the company. However what the Work Foundation found was that negative factors such as workplace stress, pressure not to take time off and money worries were the main drivers of sickness presence. Just over 40 % of employees perceived pressure from senior managers, line managers and colleagues to come to work when unwell.

This has significant repercussions for organisations. First, any data they might have on the health and wellbeing of their workforce is seriously unreflective of the actual situation. Nearly all AXA employees interviewed as a follow up to the survey stated they would go in to work with stress, anxiety or depression (although some would not if their condition was pronounced).

Second, sickness presence is directly related to performance. The Work Foundation looked at the performance data of 164 surveyed employees, and found that those reporting higher levels of sickness presence were lower performers - the 27% rated as ‘excellent’ reported half a day of sickness presence over a four-week period, whereas the 61% rated ‘successful’ had taken over a day.

Third, using pressure and stress to force employees into work just worsens the situation. Both work-related stress and pressure were significantly related to psychological wellbeing. Those reporting lower levels of psychological wellbeing (and higher levels of anxiety) were more likely to report higher levels of workplace pressure to come into work when unwell and higher levels of work-related stress.

Mental health is not just the biggest health problem at work today, it is also the measure of the corporate culture which underpins it.

Improving access to psychological therapy at work

A report on the new government programme to help people with anxiety and depression recover has claimed an overall 42% success rate in its first year.

Improved Access to Psychological Therapies is the brainchild of London School of Economics professor Richard (Lord) Layard. He is also co-author of the new report.

In the 'Depression Report' Lord Layard imagined something like a national mental health service made up of two hundred and fifty teams providing Cognitive Behavioral Therapy in GP surgeries, job centres, workplaces or premises provided by voluntary organisations.

The service would pay for itself in people lifted out of unemployment or retained in work. Research showed that 'The typical short-term success rate for CBT is about 50%. In other words, if 100 people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway.'

It is to Lord Layard's great credit that this service has come into existence, though it seems at the moment to be somewhat short of his vision. With the recovery benchmark set at 50%, this was only achieved with Generalised Anxiety Disorder (52% recovered after a course of IAPT). The recovery rate was as low as 35% for recurrent depression and 27% overall in some areas of the country. On the other hand 63% showed reliable improvement across all conditions after at least two sessions of IAPT.

Whereas Lord Layard imagined up to sixteen sessions of CBT per case, the average number for the first year was only four sessions for so-called 'Low intensity CBT '- guided self-help, structured exercise and computer-based CBT - and five sessions for 'High Intensity CBT,'  which is actual one-to-one therapy. The report found a person was more likely to recover if they received more therapy, indicating more resources are needed in this area.

A goal of IAPT was to widen access to therapy - not just in the number of therapists available (which are thin on the ground in the NHS), but also in providing ways for employees to be referred from work or for people to refer themselves without going through a GP. Bearing in mind the strain on GPs of patients with depression and anxiety and the high error rate in diagnosis, this seemed like a good idea.

Disappointingly the report found that only 7% self-referred with 85% coming through GPs and the rest through services such as A & E. There was no evidence that employers had referred employees at all.

Perhaps this is through a lack of awareness that the service exists, or because services offering IAPT are generally only accepting referrals from GPs. My small test using NHS Choices seemed to indicate that therapists were mainly only taking GP referrals. It also the case that employers tend to shy away from discussing mental health with their employees, to the detriment of both.

The recent DWP reports on mental health at work indicate that depression and anxiety are the leading causes of workplace illness, costing a minimum of £1,000 per head of the workforce per year according to the Centre for Mental Health.

Further investment in IAPT would seem to be one way the government could help.

All quiet on the depression front

The mental health establishment has collectively called on the government not to drop the indicators measuring how GPs treat depression.

The Quality Outcomes Framework is a public - if not particularly accessible - database where GPs are scored against twenty common clinical areas, from heart disease to smoking.

The National Institute for Clinical Excellence has recommended their 'retirement' as of 2012 because they were a pretty ineffective guide for patients. Unlike say heart disease, for example, the depression indicators did not cover types of treatment offered or ill-heath rates.

NICE admits in its Depression guidance that diagnosis of depression is a lottery, being based on the ability of GPs to detect emotional distress in their patients inside a ten minute consultation time. Only 39% of patients with depression are recognised as such, 'mainly because most of such patients are consulting for a somatic [i.e. physical] symptom and do not consider themselves mentally unwell, despite the presence of depression.'

According to the latest Health and Safety Executive figures, 57% of work-related absences certified by GPs were for mental ill-health. In an article for the Guardian, a GP reported that up to 50% of consultations were taken up with cases of depression and anxiety.

With depression now topping the list of all work-related illnesses, it is time for businesses and government to increase monitoring of this silent condition, and not quietly ignore it.

£400k for failing to make reasonable adjustments for stress

A 55 year old branch manager has been awarded £390,870 by an Employment Tribunal against building merchants Jewson Ltd.

Mr Jones had worked for Jewson for 22 years when he had a severe stroke and took five months sick leave to recover.

Prior to his illness he had been averaging over 60 hours working time per week, was not taking his full entitlement of holidays and was consistently carrying over a considerable proportion of untaken holiday each year.

His GP advised that on returning to work he needed to avoid stress. His employers decide there was no role in the organisation that was without stress and he was dismissed on grounds of incapacity under the Employment Rights Act.

However they had failed to consider any reasonable adjustment. Jewson were complacent in accepting that its existing working practices of long hours was necessary. The Tribunal found that some reallocation of duties and additional managerial support could have created a less stressful environment.

This note from Jackson Osborne, Mr Jones' lawyers, had the following warning:

'Jewson assumed that Mr Jones’ condition was so severe that his health was at risk if he returned to work in any role.  Jewson assumed its working practices were necessary for an efficient business.  The golden rule is: never assume.  It is nearly always worthwhile to take time to challenge your assumptions, to look at matters from a different perspective.'

The Tribunal found that the dismissal was unfair and amounted to disability discrimination by reason of failure to make reasonable adjustments.

The award is believed to be the third highest of its kind in British history.

Stressed out! Making the business case for change

An interesting post from HR Zone came my way this morning.

Quoting the DWP report 'Health and wellbeing at work: a survey of employers' (the companion to the survey of employees referred to in my earlier post), it made the point that 'only 17% of employers have any form of stress management advice and support in place despite the fact that short-term stress-related absences topped 42,000 in the three months to December last year.'

The DWP report also found that although nine in ten employers agreed there was a link between work and employees’ health and wellbeing, there was less certainty over the business case for investing, particularly in smaller companies and the private sector.

Making the business case seems to be the best way of getting through to those at the top of organisations, without which the necessary changes in organisational culture will not happen.

The new Investors in People 'Health and Wellbeing' award lists a number of business advantages for taking an active interest in heath at work:

• Improving productivity
• Reducing absence
• Increasing quality
• Better customer service
• Staff retention
• Increasing loyalty and motivation
• Attracting the best people

It also makes the point that:

'Adopting effective health and wellbeing practices doesn’t need to cost money. Some of the healthiest organisations – those that are performing well, with excellent employee engagement and motivation – don’t operate expensive wellbeing schemes. They succeed by concentrating on the fundamentals: good communication, flexible working practices, effective and fair line management, and the team support people need to meet the challenges they face at work.'

New survey of wellbeing at work

A new DWP report, 'Health and Wellbeing at work; a survey of employees' has found that 'depression, bad nerves or anxiety were reported as the most common symptoms of ill health caused by work.'

Given a list of symptoms, employees reported as follows:

• Depression, bad nerves or anxiety: 10%
• Problems/disabilities connected with your back or neck: 9%
• Chest or breathing problems, asthma, bronchitis: 8%
• Heart, blood pressure or blood circulation problems: 8%
• Problems/disabilities (including arthritis or rheumatism) connected with your legs or feet: 7%
• Other health problems or disabilities: 7%

In addition, 36% of employees reported that their depression, bad nerves or anxiety were caused by work, while 55% said work made their symptoms worse.

The same report found that only 5% of employees found life outside work very stressful.

The report contains a wealth of information and is well worth a look. It is one of four commissioned by DWP examining GP, employer and employee attitudes and behaviours towards health and well-being at work. I'll be reporting more on this soon.

The conclusions are in line with the World Health Organisation finding that depression is the largest cause of disability in the world.

You can read more in these articles: The Cost of Stress and Depression.