Managing symptoms, managing work: Depression and employment
Authors: Karen Steadman
21 May 2015
Having depression can be a significant barrier to working. Previous research has highlighted that people with depression (as with other mental health conditions) are more likely to unemployed or workless than the general population. This is despite the fact that many who experience mental health conditions are motivated and able to work. Indeed, employment is often seen as a recovery goal for individuals - demonstrative of a return to a normal. This also reflects the evidence that good quality work is in most cases good for health and wellbeing.
Identifying the barriers to employing people with depression, addressing them, and supporting people to return to and remain in work are important societal goals – not only in terms of reducing welfare spending and improving productivity, but also improving health and an individual’s quality of life.
Addressing stigmatised and discriminatory attitudes towards depression and mental heath conditions more broadly are seen as vital to improving employment outcomes. The Time to Change anti-stigma campaign has done sterling work in raising awareness of the reality of mental health conditions among employers and employees, and addressing the negative misconceptions around them.
We cannot ignore the probability that having a condition such as depression can in itself make working more difficult. Our latest research looked at how different symptoms of depression can influence employment. We argue that in order to improve employment outcomes, we must first recognise the effect that symptoms of depression can have on work, to allow us to take a more focussed approach to addressing them - identifying and utilising appropriate interventions and supports to enable people who want to work to retain their jobs, find new jobs, and to work productively.
Though low mood and poor motivation are perhaps the symptoms most obviously associated with depression, both the academic literature and the experts we spoke to agreed that a range of other symptoms needed consideration. Symptoms which effect cognition, in particular poor concentration, difficulty decision making, and negative thinking, were felt to be less well recognised by healthcare professionals and therefore might go untreated. Similarly poor awareness among employers may mean that symptoms are mistaken for poor performance – resulting in disciplinary measure, rather than health support. The effect of these symptoms is also often under-recognised among the unemployed, in particular the barrier that cyclical negative thinking can have on job-seeking, reducing self-confidence and motivation, and inducing feelings of hopelessness.
Where employment is a goal for an individual, then treatment must directly address these symptoms. Perhaps unsurprisingly, data on what interventions influence employment outcomes for people with depression is scarce. What the literature does imply though is that medication alone may not be as effective as when psychological interventions (and specifically those with a work focus) are incorporated alongside medication. Experts we spoke to discussed a range of psychological and occupational therapies which they saw as having a positive influence on employment outcomes – including CBT, but also less well-evidenced interventions such as behavioural activation. Highlighted repeatedly was the value of supported employment vocational rehabilitation, and specifically the Individual Placement and Support (IPS) model. The academic literature on IPS focusses almost exclusively on people with schizophrenia and bipolar disorder, but experts we spoke to felt that there was also value in taking this approach with people with depression. Several expert contributors were involved in the delivery of employment support (primarily in secondary mental health services), and described first-hand the positive outcomes they have witnessed. A recent pilot of IPS in primary mental health care also showed promising results, and our report furthers the call for comprehensive evaluation to enable us to make a better case to national and local commissioners for the expansion of such services.
Also fundamental to improving access to evidence-based return to work employment support is greater awareness among health care professionals, and particularly GPs, that work is an achievable goal for many people with depression. GPs need to demand greater access to services for their patients which support this outcome. Encouraging GPs to prioritise employment outcomes is key to improving employment rates.
Underlining the poor access to services is the lack of high level political acceptance that depression in the working age population is not just a health sector concern, but is also a labour market concern – effecting productivity and the welfare system. The Department of Health and the Department of Work of Pensions need to take a joint approach to such issues, and together take action to address the barriers to implementing evidence-based support across the UK. This is not only about working better with each other, but with local partners, including local government, clinical commissioners, and local jobcentres, and importantly with the voluntary sector, to develop innovative ways of providing services which meet local needs.
We must also remember that back to work support is not the full picture, but equally important is investing in effective support to help people with depression to remain in work. Local partners are again crucial here, as is the Access to Work service, and, we hope, the Fit for Work – such services require investment and appropriately skilled staff to ensure they can meet the specific needs of people with depression.
Depression is a complex and heterogeneous condition which is experienced by a substantial proportion of the UK working age population every year. It can affect anyone, at any time, from the most junior employee to the most senior. To help keep those who experience the symptoms of depression in employment, and to help those currently not working to return to work and contribute to the economy, stakeholders, led by government, need to work together to provide access to high quality, evidence based services which take a holistic approach to symptom management and vocational support needs.
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