Depression and work
Authors: Dr Max Henderson
Senior Clinical Lecturer, King's College London
21 May 2015
Familiarity breeds contempt. And if not contempt, then the very definite possibility that nuance and complexity might not be fully grasped - “We know this now”. This report published by the Work Foundation shakes us from our certainty, and in my opinion points the way to a better way of understanding the relationship between depression and occupational function.
For 80 years after Culpin’s work on “The Nervous Temperament” the relationship between work and mental health was quietly ignored. In the last decade however we have been deluged with report after report stressing the impact of mental health on work and employment status. This burgeoning interest began in earnest with Dame Carol Black’s hugely important report on the health of the working age population. That a separate report on work and mental health was commissioned to sit alongside this is an excellent example of the foresight shown by Dame Carol, and the importance she attached to mental ill health. Only a few months ago the Chief Medical Officer reported on Public Mental Health, and chose the Employment chapter as her focus when launching the report to the media. In between we have had a number of policy initiatives from both the Department for Work and Pensions and the Department of Health and indeed a number of pilot studies specifically addressing the employment of those with mental illness are being evaluated by the DWP.
So now that it's mainstream we sort of know what to do now? Don't we? This report from the Work Foundation delivers a healthy reality check. For of course the answer is No - we don't know it all by any stretch of the imagination. The benefit of a report over an academic paper is that multiple angles of one problem can be examined at the same time. This report takes full advantage of this opportunity and in doing so reminds of how much we still have to learn.
The impact of the symptoms of depression on employment is considered from the perspective of those in work, those off sick, and those without work. One mistake often made is in believing that the risk factors for psychiatric illness, the impact of psychiatric illness, and as such the remedies for psychiatric illness are the same at each stage in the process. This is an unhelpful simplification and has been an obstacle to progress in the field.
Specific mention is made in the report of the cognitive symptoms of depression. There is a real risk that this group of disabling symptoms can be overlooked by patients, their doctors, and their employers. They are hidden problems in a hidden illness and may only emerge if specially asked about. Once recognised however, their impact is easily seen. From organising information for a job interview, to structuring and planning diaries at work, and focussing on important ‘homework’ in CBT, cognitive symptoms can present a substantial burden to functional improvement. Although mentioned briefly in the report, there is scope for similar attention to be paid to the common and disabling interaction between physical and psychiatric symptoms in depression and elsewhere.
There is a disappointing lack of specific research evidence on interventions in depression which can optimise employment outcomes. Why might this be? Sadly it may in part be due to a sense that work or employment were not ‘suitable’ outcome measures in a psychiatric disorder, and psychiatrists, some of whom have historically had low expectations of their patients may have unwittingly colluded with this. Issues such as length of follow up in research, working definitions of ‘return to work’ and few tools to assess this have also contributed. With targeted funding this could be easily addressed but research funding in occupational medicine, let alone occupational psychiatry is very limited. Perhaps the major funding bodies and large pharmaceutical companies could agree that all treatment studies in psychiatric disorders included at least employment status as one of the individual measures?
The nature, provision and limitation of CBT, especially when delivered through IAPT are examined in detail in this report. Much is made of the relative lack of employment support, making it more difficult to move from IAPT through to a return to work. The call for greater dedicated employment support, occupational therapy and occupational health should be heeded.
Nonetheless it is this area of the report which flags up the limitations of our current approach to depression best. For whilst undoubtedly many of the symptoms of depression are unpleasant and distressing it is the impact of depression on a person’s ability to lead their life the way they wish, this *functional* impairment, that is so important. It has been said that a person’s broad needs are somewhere to live, someone to love and something to do. Work happens to be one of those ‘something to do’s. All to often however the focus in the management of depression is on symptom relief, and misses the role of function as a key outcome. It is perhaps assumed that functional improvement will automatically follow symptomatic improvement. It doesn’t.
The assessment of depression must include more of a functional assessment. This will lead to a more detailed understanding of the interaction between illness and employment. Functional improvement (what the patient would like to aim for) should then guide treatment from whichever combination of professionals is needed for that patient.
This is an area ripe for exploration in the fields of psychopharmacology, psychology, occupational medicine, health services research and also at policy level. And this Work Foundation report has done us all a great service by highlighting the limitations of where we are now.
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