Mental Illness and the Workplace: A National Concern

No country, however rich, can afford the waste of its human resources. Demoralization caused by vast unemployment is our greatest extravagance. Morally, it is the greatest menace to our social order.

-Franklin D Roosevelt

On a recent visit to Washington, I visited the Roosevelt Memorial. Although I do not sympathize with President Roosevelt's interpretation of constitutional rights, I was struck by some of the values he championed, and I've quoted one of the most inspiring inscriptions as the epigraph to this editorial.

This quotation suggests that unemployment and work should be a national concern-that we should all attend to its effects. Roosevelt was referring to the national effects of the Great Depression; the recently released report of the Standing Senate Committee on Social Affairs, Science and Technology (the Kirby and Keon Commission) highlights, among other areas, the effects of clinical depression and other mental disorders on the Canadian workforce.1 The Commission's report supports a national strategy to address mental health and addictions in the workplace.

With this report, Canada joins many other industrialized nations searching for a strategy to tackle this issue. However, the question of protecting worker health and safety is not as straightforward as it has been in the past. During the industrial revolution, when workers moved from agricultural trades to factories, books such as The Jungle1 exposed the horrendous conditions endured by many and called for workplace reform to protect workers' physical health and safety.

Currently, we live in a technological revolution. This revolution has, in the last decade, introduced globalization, new modes of communication, and changes in workforce demographics that have created new occupational health challenges.3 5 In this age, rather than using their physical strength and risking physical injury, workers are increasingly called on to use their minds. Instead of toiling in sweatshops, workers have been increasingly exposed to stressful work environments characterized by tighter deadlines and increased production targets set with seemingly little consideration for individual workloads,6-8 at the same time as companies downsize and restructure.4,5

Further, stress associated with work is compounded by the additional stress of other life events, and reactions to all these stressors are influenced by other underlying risk factors. Herein lies the difficulty in finding an answer. According to a traditional occupational disease model, worker health is jeopardized by continuous exposure to hazardous employmentrelated conditions.9 However, the most advanced etiologic models of adult mental illness include not only factors related to work environment but also genetic vulnerability, developmental factors, neurobiological factors, childhood experiences, life events, chronic situations (such as a stressful home life), and the presence of other disorders.10 Each dimension's relative weight, and how the dimensions interact, is not yet understood. Consequently, we have a complex picture with no clear focus.

Nevertheless, we are not without hope. In her paper published in this issue's In Review section, Dr Krupa1 ' reviews the current state of the evidence for interventions. She begins by emphasizing the importance of recognizing the complexity of work activities and demands. She also stresses the importance of distinguishing between disorder-related symptoms and the ability to fulfill work responsibilities; the answers to these questions will not be found solely in medical treatment. Her discussion focuses on interventions at the individual, employer, and workplace-organization levels. She notes that interventions aimed at both workers and employers offer the most promise.

It appears that, globally, countries are seeking to implement complex strategies for a complex problem by balancing the role of public benefits (that is, financial supports), programs, health services, and legislation with the role of the workplace and the worker. This section's companion paper, by Dr Dewa, Mr McDaid, and Dr Ettner,12 discusses who should pay for interventions, services, and programs to promote mental health in the workplace; it highlights the current fragmentation among payers, who include the public sector, employers, employees, and their families. Further, it asserts that such fragmentation makes it difficult to assign responsibility, including responsibility for success, to any single group-any decrease in the impact of mental illness will potentially be divided among all the payers. As a result, we are left with the potential for what economists refer to as "free riding." That is, all might benefit, but no one wants to be the first to act. Dewa et al offer suggestions for how to increase cooperation among all the stakeholder groups to achieve improved worker mental health.

Both papers in this section underscore the need for more research in the area of workplace interventions. We still do not know which interventions are most effective within a workplace setting. It is increasingly clear, however, that we cannot advance our knowledge without collaboration among the stakeholder groups. For example, the public sector must be willing both to fund and to participate in research. Employers (including those in the health care sector) should also consider funding research as well as being study participants. Workers must be willing to share their experiences. In turn, researchers must be willing to consider a research paradigm that responds to participant needs rather than focusing solely on their own research question. It is only by collaborating that we can truly effectively address the pressing national issue of workplace mental health.

[Reference]

References

1. Standing Senate Committee on Social Affairs, Science and Technology. Out of the shadows at last-transforming mental health, mental illness and addiction services in Canada. Ottawa (ON): The Senate; 2006.

2. Sinclair U. The jungle. Mineola (NY) : Dover Publications; 2001.

3. Rantanen J. Research challenges arising from changes in worklife. Scand J Work Environ Health. 1999;25(6):473-483.

4. Ostry AS, Barroetavena M, Hershler R, et al. Effect of de-industrialisation on working conditions and self reported health in a sample of manufacturing workers. J Epidemiol Community Health. 2002;56(7):506-509.

5. Bunting M. Willing slaves. Toronto (ON): HarperCollins; 2005.

6. Vezina M, Bourbonnais R, Brisson C, et al. Workplace prevention and promotion strategies. Healthc Pap. 2004;5(2):32-44.

7. Third European Survey on Working Conditions. 2001 [cited 2003 Nov 23]. Available from http://www.eurofound.ie/working/surveys.htm.

8. Bond JT, Galinsky E, Swanberg JE. The 1997 National Study of the Changing Work Force. Scand J Work Environ Health. 1998;25(Special):616-624.

9. Goldberg RJ, Steury S. Depression in the workplace: costs and barriers to treatment. Psychiatr Serv. 2001;52(12):1639-1643.

10. Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in women. Am J Psychiatry. 2002;159(7): 1133-1145.

11. Krupa T. Interventions to improve employment outcomes for workers who experience mental illness. Can J Psychiatry. 2006;52(6):339-345.

12. Dewa CS, McDaid D, Ettner SL. An international perspective on worker mental health problems: who bears the burden and how are costs addressed? Can J Psychiatry. 2006;52(6):346-356.

[Author Affiliation]

Carolyn S Dewa, MPH, PhD1

[Author Affiliation]

1 Health Economist-Senior Scientist, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto, Ontario; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.