Occupational health feature: Depressive patients, work is relevant

WONCA News has begun a regular feature on the subject of Occupational Health including useful resources for clinical practice. Peter Buijs (right) & Frank van Dijk (left) are the promoters and main authors, they are Dutch occupational physicians and former family doctors, and for many years active in ICOH.

In this contribution, Frank and co-author Karen Nieuwenhuijsen present reflections for the GP when confronted with depression or depressive disorders related to work.

Depression is almost daily practice

Depressive disorders and depression are familiar mental health complaints and disorders in primary health care (PHC) practice. In the Netherlands the prevalence of depressive disorders in PHC was 15/1000 for men and 31/1000 for women per year in 2007. In the general Dutch population, 52% of the population with more severe common mental health disorders, received treatment in primary healthcare, while 39% received specialized mental healthcare treatment. In a population of US workers the 12 month prevalence of major depressive disorder was 6%. Anxiety and somatic complaints are often communicated.

Attention to work

Asking patients about the impact of their complaints on work functionality, you may notice impaired communication, impeded decision making, low concentration, lack of interest in work, sometimes making mistakes. These impacts may persist over time, even after the depression is in remission. In addition, patients often consider work as one of the main causes of depression. Depression is associated with high rates of sickness absence, more permanent work disability and unemployment. A self-reinforcing process may start: being at home for sickness absence or having no job means a lower activity level, a lower or no income, less social contacts, and a low self-esteem contributing to depressive feelings.

Primary health care may contribute to the prevention of permanent work disability and job loss and can promote recovery from depression through participation at work.

How to ask about work?

Some patients avoid talking about work, afraid of complications. Health care workers can miss hints about work, maybe feeling insecure. In this way opportunities to discuss a better future might be lost.

Every professional has her or his own style. Good timing and tact are important. You may ask if there is or are:

• a problem with functioning at work, if the patient is unable to perform work task as well as before
• a conflict, discrimination or bullying
• too much work or a lack of autonomy in the job
• a good balance between work and private life (workaholism?)
• good contact with the supervisor, colleagues, clients
• sick leave currently; more episodes of sickness absence last year; the expectation of a long duration before returning to work
• uncertainties about continuation of the job, fear for unemployment
• lack of orders, financial problems (self-employed and business owners)
• contact with an occupational or mental health service

Important goals for working with patients with a common mental disorder are sustainable work resumption or job continuation, job satisfaction, a good work-life balance and good mental functioning. In PHC various disciplines can be involved in supporting the patient: physicians, nurses, social workers, mental health professionals.

What to do?

• depressive symptom reduction by psychotherapy, physical exercise and/or appropriate medication e.g. following PHC guidelines.
• if the patient is off work; advise on maintaining a regular day structure.
• if the patient is still at work, promote a better time management strategy, (temporary) modified work hours or tasks, better social contact with supervisor and colleagues, if possible coaching on the job.
• put forward the option of online or telephone mental health programs that can be effective.
• referral to a mental health program which includes a work focus aiming at work resumption, such as work-focused cognitive behavioral therapy or adjuvant occupational therapy supporting workers in coping. An occupational psychiatry service might be a good new option for referral.
• when needed and available, contact the occupational health physician, nurse or company social worker. Informed consent is clearly needed.
• after resumption of work, monitoring can be effective to prevent a relapse. Propose a number of consultations for that purpose.

Frank van Dijk (Learning and Developing Occupational Health foundation, Netherlands),
Karen Nieuwenhuijsen (Coronel Institute, AMC Netherlands)

References

Arends I, van der Klink JJ, van Rhenen W, et al. Prevention of recurrent sickness absence in workers with common mental disorders: results of a cluster-randomised controlled trial. Occup Environ Med. 2014;71:21-9.
Beckley A, Lees B, Collington S, de Bono A. Work-related health advice in primary care. Occup Med (Lond). 2011 ;61:498-502.
Burman-roy S, Butterworth M, Madan I, et al. Which patients are seen by an occupational psychiatry service? Occup Med (Lond). 2013;63:507-9.
Hansson M, Chotai J, Bodlund O. Patients' beliefs about the cause of their depression. J Affect Disord. 2010;124:54-9.
Haslam C, Atkinson S, Brown S, Haslam RA. Perceptions of the impact of depression and anxiety and the medication for these conditions on safety in the workplace. Occup Environ Med. 2005;62:538-45.
Hees HL, Koeter MW, Schene AH. Longitudinal relationship between depressive symptoms and work outcomes in clinically treated patients with long-term sickness absence related to major depressive disorder. J Affect Disord. 2013;148:272-7.
Hees HL, de Vries G, Koeter MW, Schene AH. Adjuvant occupational therapy improves long-term depression recovery and return-to-work in good health in sick-listed employees with major depression: results of a randomised controlled trial. Occup Environ Med. 2013 ;70:252-60.
Lagerveld SE, Bültmann U, Franche RL, et al. Factors associated with work participation and work functioning in depressed workers: a systematic review. J Occup Rehabil. 2010;20:275-92.
Lagerveld SE, Blonk RW, Brenninkmeijer V, et al. Work-focused treatment of common mental disorders and return to work: a comparative outcome study. J Occup Health Psychol. 2012;17:220-34.
Nieuwenhuijsen K, Faber B, Verbeek JH, et al. Interventions to improve return to work in depressed people. Cochrane Database Syst Rev. 2014 Dec 3;12:CD006237.
Ten Have M, Nuyen J, Beekman A, de Graaf R. Common mental disorder severity and its association with treatment contact and treatment intensity for mental health problems. Psychol Med. 2013;43:2203-13.
van Dijk P, Hogervorst W, ter Riet G, van Dijk F. A protocol improves GP recording of long-term sickness absence risk factors. Occup Med 2008;58:257-62.