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  • Depression in the Working Population

    BACKGROUND
    Depression in the working population is a common, chronic, and often recurrent disorder with consequences spanning a continuum from mild to barely perceptible sub-clinical effects to disabling symptoms, affecting employees at all levels of enterprise structure. In its various forms, the disorder contributes to excess absenteeism, decreased at-work productivity (presenteeism), compromise of individual employment status, disruption of work organization (i.e., the collective vocational and social fabric of work), and a surfeit of direct (medical and indemnity) and indirect health care, disability, and organizational costs.

    The American College of Occupational and Environmental Medicine (ACOEM) has a long-standing history of interest and activity in this issue. The College’s Journal of Occupational and Environmental Medicine (JOEM) has published 51 articles relating to the topic of depression and mental health issues in the workplace since 1996. In 2002, ACOEM adopted a position statement recognizing the appropriateness and value of screening for depression in the working population in clinical occupational medicine practice. ACOEM’s 2006 Guidelines for Preventing Needless Work Disability by Helping People Stay Employed, contained recommendations for addressing psychiatric conditions in workers in the context of preventing and minimizing disability (although the document did not directly address the myriad other deleterious workplace effects of depression).1 

    The April 2008 issue of JOEM addressed the definition and management of depression in the working population and included 15 scholarly articles authored by experts from the United States and Canada.2 Two overarching conclusions were reached. The first was that a more comprehensive approach, spanning a continuum from prevention and health promotion, through early identification and intervention and evidence-based disease and disability management, to relapse prevention and program evaluation, is necessary to optimize the management of depressive illness. The second was that the workplace offers unique advantages in addressing the problem in the working population which can and should be recognized and utilized by all stakeholders.

    PROBLEM DEFINITIONS
    Scope and Epidemiology.
     Six to eight percent of the U.S. population have a major depressive episode (MDE) associated with a non-bipolar major depressive disorder (MDD) annually; an additional 1 to 2% have MDE related to bipolar disorder, and another 1 to 2% have active dysthymic disorder each year.3 The incidence and prevalence of sub-threshold depression is unknown and difficult to estimate. Median age of onset is 32 years, which is significantly earlier than most other chronic diseases; the occupational significance of this is that depression affects workers earlier in and thus throughout their entire working life, markedly increasing the total burden of disease. The high prevalence and early onset of depression, its often chronic and recurrent course, and its associated functional impairment (especially in women) combine to make this disorder a leading cause of disability worldwide, as measured in disability-adjusted life years (DALYs). Major depression commonly (approximately 70% of the time) occurs with, and is complicated by, other chronic mental (anxiety, personality disorder, substance abuse) and physical (arthritis, cardiovascular disease, diabetes, obesity) disorders.3,4 

    Etiology. The etiology of depression in the working population is complex without any clearly established causative mechanism. It has been termed the “paradigmatic multifactorial disorder” with both modifiable and unmodifiable and work- and non-work-related risk factors.5 A further complicating consideration is directionality – i.e., the effects of employee depression on the workplace and the effects of the workplace on employee depression. Factors that have been associated with depression include genetic variation (as evidenced by multiple twin and adoption studies); the role of neurotransmitters (including monoamines, dopamine, gamma-aminobutyric acid, and glutamate); neuroendocrine factors; gender; past experience and cognition; life stressors; and working conditions and social support. It is likely that depression in workers results from a complex interaction of genetic influences, psychological predisposition (including past experience, personality, and temperament), and environmental adversity (including stress and other negative workplace conditions, as well as family and social influences) of which our current understanding is limited but progressing on a number of fronts.

    Diagnosis and Natural History. Voluntary screening programs can be used to promote self-identification of depressed employees, but many such workers lack insight into their condition. Workplace personnel, including supervisors, managers, human resource representatives, and co-workers play an important role in the recognition of depression in the working population. Occupational medicine professionals, including nurses, physicians and mid-level providers (nurse practitioners and physician assistants), employee assistance program personnel, psychologists, and social workers also play a prominent role in initial evaluation and management.

    Different types of depression have characteristic symptoms and natural histories, respond to different treatments, and have different treatment-response patterns and prognoses. Specialty referral for diagnosis and definitive treatment is important in many cases; the most useful diagnoses are made by well trained and experienced clinicians during interviews of adequate length and depth. The importance of appropriate diagnosis and treatment is underscored by findings that several variables, including type of depression, presence of specific symptoms, symptom severity, and comorbid conditions, as well as clinical care, work environment, and life cycle issues affect outcome of management.

    Occupational Consequences. Major depression has effects on worker behavioral, cognitive, emotional, interpersonal, and physical function. Patients with the disorder have higher rates of unemployment and job turnover and lower rates of job retention.6 Depression may also complicate pre-placement or ongoing evaluation for duty fitness. Adverse effects on work attendance (absenteeism) and association with decrements in job performance and at-work productivity (presenteeism) are well documented.7 Depressed workers may show decreased attention to safety and increased predisposition to safety violations and accidents.8 In addition, depression may contribute to work environment disruption and conflict in both the social fabric of work and job processes. Depressed employees use more health services and benefits, and the disorder may complicate stay at work, return to work, and disability prevention efforts in ill or injured workers.3,9,10 

    Epidemiologic studies have consistently demonstrated that depression is one of the most costly health problems in the labor force. MDD has been associated with a 27-times greater likelihood of work loss (including sickness absence days and decreased productivity) than among workers without a mental disorder.11 Approximately 30% of lost work productivity due to depression is attributable to absenteeism, with the remaining 70% attributable to presenteeism (either related to the symptoms of the illness or the side effects of treatment); for MDD, annualized estimates are 27.2 excess lost workdays per worker (8.7 days absenteeism + 18.2 days presenteeism), and totals of 225 million workdays and $36.6 billion lost per year.3 These losses translate into annual workplace costs of nearly $250,000 for a company with 1000 employees.9 

    Impairment and Disability Assessment. Impairment and disability, unlike depression, are not diagnoses. Impairment refers to limitation or loss of specific function(s) that is related to a diagnosed health condition, as determined by physicians or other health care professionals. Disability is a status in which a person is unable to perform some specific activity, such as work, due to one or more health impairments; it is usually a legal or benefit determination, the result of an adjudicative or administrative process. A variety of instruments, such as the Patient Health Questionnaire (PHQ-9), are available for assessment of impairment due to mental disorders. The AMA Guidelines to Evaluation of Permanent Impairment contain useful information in terms of quantification of impairment12; other useful tools include the taxonomy proposed by McDonald-Wilson et al.,13 and the triangulation approach advanced by Williams and Schouten.10 Potential accommodations include flexible work schedules; employee training and job modification or restructuring; changing work procedures; training of staff and supervisors to facilitate effective supervision, communication, and co-worker support; and policy changes.

    PROBLEM MANAGEMENT
    Business Case for Intervention.
     There is a clear link between depression and work impairment; thus, employers share the associated economic and productivity burden. Improving the quality of depression care for employees represents an opportunity for employers; achievement of this goal requires a fundamental shift in thinking and approach away from treatment cost and towards return on investment (ROI) in human capital. Improved treatment for depression may have an impact on outcomes most relevant for employers, including reduction in job-related accidents, turnover, and sickness absence along with improvements in job performance (reduction of presenteeism).14 Cost-benefit studies are beginning to demonstrate positive effects both from the employer and societal perspectives.15 

    Prevention. Primary prevention includes mental health promotion; optimization of protective factors (e.g., resilience promotion and social support); identification of and intervention in modifiable risk factors (e.g., stress), particularly in high-risk groups; and improvement of worker and management mental health literacy (including reduction of stigma). Secondary prevention includes early detection of depressive symptoms, such as through universal or focused screening programs (using validated instruments such as the PHQ-9) and early intervention to reduce the incidence of major depression (such as through evidence-based psychotherapeutic methods such as cognitive-behavioral therapy). Primary and secondary prevention efforts often overlap.

    Pharmacological and Psychotherapeutic Treatment Options. The goal of treatment is remission, not only to eliminate the suffering associated with depressive symptoms, but also to return patients to full function and prevent further depressive episodes. Although there is a limited role for initial pharmacological treatment by non-psychiatrist providers with training and experience (e.g., occupational physicians), definitive management, particularly with combination pharmacotherapy is best managed by psychiatrists experienced in workplace issues. Empirically validated, time-limited (e.g., 12 to 20 sessions) psychotherapies such as cognitive behavioral and interpersonal therapy have demonstrated effectiveness in treating depressive illness and may be appropriate either alone or combined with pharmacotherapy.16 

    Current Quality Gaps and Barriers. Current treatment patterns and outcomes suggest that quality of depression care is suboptimal at several points throughout the therapeutic process. Examples include inaccurate diagnosis, failure to prescribe treatment, inadequate medication dosage, failure to administer evidence-based psychotherapy, premature discontinuation of treatment, and lack of follow up care. Recent estimates suggest that less than half of those suffering from MDD actually seek care, and overall only 15 to 30% of those with depression receive treatment that meets minimum standards for adequacy.17 A number of factors contributing to suboptimal outcome have been identified18:

    • Patient factors include the deleterious effects of stigma, inappropriate focus (shared with providers) on physical rather than emotional or cognitive symptoms, and patient reluctance to seek and comply with treatment due to stigma and depressive symptoms.
    • Provider factors include variation in training and experience (and thus individual competency); failure to detect depression in those who seek treatment, particularly due to inappropriate focus on physical rather than emotional or cognitive symptoms, with concomitant delay in diagnosis and treatment; failure to follow clinical treatment guidelines, resulting in inadequate dosage and duration of pharmacotherapy and failure to recommend psychotherapy; lack of time, interest, and incentive for proper diagnosis and treatment; under-utilization of allied health professionals and mid-level providers; failure to appropriately refer patients to specialist providers; and lack of ongoing monitoring, maintenance care, and relapse prevention.
    • Clinical practice and organizational factors, including a pervasive fixation on acute rather than chronic conditions; failure to educate patients and their families about depression and promote self-management; failure to apply case management and stepped care approaches; and failure to integrate treatment and rehabilitation.
    • Health plan and employer factors, which include limited access (financial or geographic) to mental health professionals and psychotherapy; failure to utilize and integrate community resources; failure to incentivize investment in infrastructure appropriate to a chronic care model; and failure to coordinate and integrate care between primary care and mental health specialty providers.

    Population-based Approaches to Closing Quality Gaps. Population-based care is a public health model that encompasses both the development and implementation of an organized strategy to care for all patients in a defined population with a chronic illness, not just those who seek care in the health care system. Elements of a population-based approach to depression care include: 1) improvement in accuracy of diagnosis; 2) enhancement of acute phase management (to ameliorate symptoms and functional impairment and prevent progression to chronicity); 3) use of stepped and collaborative care model; and 4) relapse prevention. Stepped care is an integral component of the collaborative care model and refers to increasing intensity of mental health care based on severity of symptoms, with management initiated by primary care providers (including occupational physicians), coordinated by allied health providers (particularly nurses), and involving psychiatric specialists for refractory cases. Collaborative care is a multimodal approach based on an interactive, iterative process between practitioners and patient that includes: 1) patient activation and education; 2) care coordination by an allied health professional; 3) frequent follow up; 4) standardized depression measures (e.g., PHQ-9); 5) caseload registry; 6) caseload supervision by psychiatrist; 7) stepped care; and 8) planned relapse prevention. Stepped and collaborative care approaches have demonstrated increased patient adherence to antidepressant medication and enhanced depressive and functional outcomes; there is also evidence suggesting cost-effectiveness with regard to both direct (medical) and indirect (job retention, absenteeism, and productivity) costs to business.

    Integrated, Chronic Disease Approach. There is a significant gap between knowledge of best practices (efficacy) and usual care in the “real world” (effectiveness) that is responsible, in part, for the growing burden of depression worldwide. Goetzel et al. identified several characteristics of promising health management practices, including: 1) alignment with the business goals of the organization; 2) tangible senior management commitment (i.e., a supportive environment and enabling infrastructure); 3) comprehensive, integrated, coordinated, and cost effective programs; 4) needs basis, evidence informed, with focus at organizational and individual levels; 5) continuum of prevention and mental health promotion; detection; early intervention; disability management; and relapse prevention; and 6) incorporation of evaluation and continuous quality improvement.19 Designing and implementing a complex workplace depression strategy requires the cooperation of multiple stakeholders, including employees and their unions; occupational health professionals; human resources and benefits design personnel; insurers and other payors; and enterprise management at all levels.

    The recommended approach to depression care is based on Wagner’s Chronic Care Model (CCM), which incorporates changes in primary care and the healthcare system, patient education and self-management, and involvement of community resources. The result of these changes is more productive interactions between activated, informed patients and a prepared, proactive healthcare practice team. Application of the CCM has been shown to improve care quality in a cost-effective manner.20 This approach can be enhanced through an Integrated Chronic Care Model (ICCM), which adds an integrated workplace system to produce productive interactions among the prepared, proactive health care system, the corresponding prepared, proactive workplace system, the informed and activated employee/patient, and the community, in a favorable and supportive policy environment.4 These integrated subsystems are coordinated by the services of a care and case manager, who creates an effective interface to guide, interpret, and facilitate care in a stepped approach to optimize clinical, occupational, and economic outcomes for all stakeholders.

    RECOMMENDATIONS
    Corporate Medical Directors.
     The corporate medical director (CMD) is responsible for addressing this significant health issue at multiple points of impact within the enterprise and workplace and may serve in multiple roles: analyst, educator, advocate, and leader.21 Optimal response involves multiple interventions, including worker health and wellness promotion, rational health benefit design, employee and managerial education and training (particularly destigmatization), effective employee assistance programming, disability management, and employer policies and procedures. Appropriate resource allocation and programming can best be determined by determining the enterprise prevalence and cost data for depression (including the impact of the disorder on worker productivity), integrating multiple forms of health care costs to accurately depict systemic interdependencies in the total cost burden. Analysis of the resulting data allows identification of particular problem areas and prioritization of response within the context of management philosophy, strategic considerations, current and projected economic conditions, acute and long-term needs, and available resources. The CMD should also actively evaluate policies and programs based on data to improve the impact of mental health interventions.

    Clinical Practitioners. In the macrocosm proposed in the ICCM above, the occupational health practitioner plays a microcosmic role, with many opportunities for intervention.22 An integrative role based on a biopsychosocial approach is proposed, with attention to the entire constellation of factors affecting a depressed worker: sociocultural background; medical history; occupational experience and circumstances; present medical and psychological condition; current diagnostic and therapeutic modalities; interaction between work and the condition(s); non-work situational factors (e.g., family life, finances); and progress in recovery and rehabilitation. Potential roles for the occupational medicine provider include:

    • prevention (including worker health and wellness promotion);
    • clinical recognition;
    • initial clinical intervention (including pharmacotherapy and possibly psychotherapy in appropriately trained and experienced individuals);
    • appropriate specialist referral;
    • integrated approaches to patient care (chronic, stepped, and collaborative);
    • advocacy and education;
    • administration and management; and
    • research

    CONCLUSION
    Depression in the working population represents a major source of employee morbidity and a tremendous drain on enterprise productivity and financial health. Prevention, timely recognition, and appropriate management of this disorder as it occurs among working people should be a high priority among all business stakeholders. ACOEM has comprehensively examined this important issue and proposed an array of individual clinical and corporate interventions to reduce the impact of employee depression on workplace function at the individual and enterprise levels.2 The College will continue to serve as a resource for all stakeholders and a leader in efforts to manage the personal and professional effects of this chronic, recurrent, and debilitating problem.

    REFERENCES 

    1. ACOEM Stay-at-Work and Return-to-Work Process Improvement Committee. Guideline: Preventing needless work disability by helping people stay employed. J Occup Environ Med. 2006;48(9):972-87. [Accessed at www.acoem.org/guidelines.aspx?id=566 on December 24, 2008.]
    2. Caruso GM, Myette TL. Special issue: depression in the workplace. J Occup Environ Med. 2008;50(4):1-520.
    3. Kessler RC, Merikangas KR, Wang PS. The prevalence and correlates of workplace depression in the national comorbidity survey replication. J Occup Environ Med. 2008;50(4):381-90. 
    4. Myette TL. Integrated management of depression: improving system quality and creating effective interfaces. J Occup Environ Med. 2008;50(4):482-91.
    5. Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in men. Am J Psychiatry. 2006;163(1):115-24.
    6. Lerner D, Henke RM. What does research tell us about depression, job performance, and work productivity? J Occup Environ Med. 2008;50(4):401-10.
    7. Kessler RC, Akiskal HS, Ames M, Birnbaum H, Greenberg P, Hirschfeld RM, et al. Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. Am J Psychiatry. 2006;163(9):1561-8.
    8. Haslam C, Atkinson S, Brown S, Haslam RA. Perceptions of the impact of depression and anxiety and the medications for these conditions on safety in the workplace. Occup Environ Med. 2005;62(8):538-45.
    9. Greenberg PE, Kessler RC, Nells TL, Finkelstein SN, Berndt ER. Depression in the workplace: an economic perspective. In Feighner JP, Boyer WF, eds., Selective Serotonin Reuptake Inhibitors: Advances in Basic Research and Clinical Practice. 2nd ed. New York, NY: John Wiley & Sons, 1996:327-63.
    10. Williams CD, Schouten R. Assessment of occupational impairment and disability from depression. J Occup Environ Med. 2008; 50(4):441-50.
    11. Kouzis AC, Eaton WW. Emotional disability days: prevalence and predictors. Am J Public Health. 1994;84(8):1304-7.
    12. Andersson GBJ, Cocchiarella L, eds. Guidelines to the Evaluation of Permanent Impairment. 5th ed. Chicago, IL: American Medical Association, 2001.
    13. MacDonald-Wilson KL, Rogers ES, Massaro J. Identifying relationships between functional limitations, job accommodations, and demographic characteristics of persons with psychiatric disabilities. J Voc Rehab. 2003;18(1):15-24.
    14. Wang PS, Simon GE, Kessler RC. Making the business case for enhanced depression care: the National Institute of Mental Health-Harvard Work Outcomes Research and Cost-Effectiveness Study. J Occup Environ Med. 2008;50(4):468-75.
    15. Wang PS, Patrick A, Avorn J, et al. The costs and benefits of enhanced depression care to employers. Arch Gen Psychiatry. 2006;63:1345-53.
    16. Hollon SD, Thase ME, Markowitz JC. Treatment and prevention of depression. Psychol Sci Public Interest. 2002;3:39-77.
    17. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorders: results from the national co-morbidity survey replication. JAMA. 2003;289:3095-3105.
    18. Selig MD, Katon W. Gaps in depression care: why primary care physicians should hone their depression screening, diagnosis, and management skills. J Occup Environ Med. 2008;50(4):451-8.
    19. Goetzel RZ, Shecthter D, Ozminkowski RJ, et al. Promising practices in employer health and productivity management efforts: findings from a benchmarking study. J Occup Environ Med. 2007;49:111-30.
    20. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20:64-78.
    21. Burton WN, Conti DJ. Depression in the workplace: the role of the corporate medical director. J Occup Environ Med. 2008;50(4):476-81.
    22. Caruso GM. A clinical perspective on workplace depression: current and future directions. J Occup Environ Med. 2008;50(4):501-13.

    Acknowledgement
    This ACOEM statement was developed by Larry Myette, MD; Garson Garuso, MD; and Greg Stave, MD, of the Depression in the Workplace Project, a joint venture of the ACOEM Occupational Mental Health Committee and the ACOEM Health and Productivity Section. It was approved by the ACOEM Board of Directors on January 31, 2009. It updates the College’s 2002 position statement “A Screening Program for Depression.”

     

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