Occupational Medicine 2019;69:5–6
doi:10.1093/occmed/kqy111
EDITORIAL
Mental health in the workplace
Governments and non-government organizations world-
wide have renewed their focus on mental health, recogniz-
ing the burden that mental ill-health places on patients,
families, employers and economies. The annual costs of
mental illness to economies have been estimated at £74–
99 billion for the UK [1], more than €450 billion for the
European Union [2] and around $2.5 trillion globally
[3]. Additionally, sickness absence and early retirement
due to mental ill-health have increased in Europe [2].
Consequently, workplace mental health promotion has
become a strategic focus area. The renewed interest has
prompted recent reviews of the evidence base in relation
to common mental disorders and work [4] and of the
promotion of mental health and well-being in the work-
place [5].
Employers should promote safe and supportive work-
ing conditions and they should pay attention to work
organization improvements; however, in practice, they
may find this difficult. In part this is due to the way men-
tal ill-health is still perceived as an individual problem
and the stigma associated with it. However, it is also
due to a pervasive lack of development of appropriate
competencies in the key actors who face these issues in
the workplace (e.g. leaders, managers, human resource
professionals [6]) and lack of access to competent occu-
pational health services, especially for those working in
small and medium-sized enterprises.
Mental ill-health can be the result of exposure to
‘unhealthy’ working conditions, poor work organiza-
tion and psychosocial risks. However, mental ill-health
might also not be caused by work but be made worse
by work. Mental ill-health has many determinants and
a multi-faceted action framework is needed to address
it appropriately both within and outside the workplace.
While an appropriate health and safety legal framework
is important and sets minimum standards for employers
to adhere to, other ‘softer’ actions are equally important
and include mental health promotion guidance develop-
ment and intervention implementation in the workplace.
While in recent years more evidence is accumulating
on organizational-level interventions, aiming to develop
good working conditions and a healthy work environment,
this is still mixed and difficult to evaluate. Such interven-
tions aim at prevention but often suffer from design and
implementation issues in light of rapidly changing work
environments and organizational restructuring. On the
other hand, employee-targeted stress interventions can
be effective especially for those who have high control
over their work and there is moderate evidence for pro-
moting physical activity in the workforce [4]. Employers
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often resort to providing reactive support, e.g. employee
assistance programmes or various training programmes.
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There have been few well-designed evaluation studies of
mindfulness-based interventions and resilience training
in occupational settings [4]. There is limited evidence
that mental health first aid training improves partici-
pants’ knowledge, skills and attitudes but no evidence
regarding clinical outcomes [7]. As a result, it is not pos-
sible to develop evidence-based guidelines for any of
these training programmes.
For employees who are off work sick, early assessment
is important including enquiry about work-relatedness
and identification of other barriers and facilitators to
return to work. There are few high-quality studies of
return-to-work interventions for employees who have
mental health problems. Cognitive behavioural therapy
(CBT), for example, can improve symptoms but it is
only effective in helping employees return to work when
it focuses on work relevant solutions and particularly
when implemented as part of a multi-domain interven-
tion including making any necessary workplace modifi-
cations such as modified duties or working hours [8].
For every individual to be provided with a working
environment that is safe and does not harm their physical
or mental health is an essential part of an employer’s as
well as the state’s responsibility. However, even though
health, safety and well-being are at the core of workplace
and societal functioning and development, the current
state of the art indicates that approaches that have been
used to promote them have not had the anticipated
results. This also applies to mental health in the work-
place. A new paradigm is needed to capture the complex-
ity of the modern workplace in relation to mental health.
First, it is important to consider mega-drivers of
change: technology, demography, climate change and
globalization. For example, precarious work is on the rise
bringing with it higher job insecurity. At the same time,
the workforce is becoming older, more feminized and
diverse. Promoting mental health means understand-
ing the implications of these changes and adapting our
approaches to be more inclusive. This necessitates mov-
ing away from silos and mono-disciplinary perspectives,
strategically aligning and integrating approaches based
on risk management (prevention and protection) with
those based on mental health and well-being promotion,
whether this concerns knowledge generation, policy or
practice.
Second, and following on from the above considera-
tions, experts, researchers and practitioners are increas-
ingly ‘specialized’ in certain areas. Such specialized
6 OCCUPATIONAL MEDICINE
approaches whereby contextual factors are often ignored,
not only hinder the application of research findings in
organizations, but also lead to duplication of approaches
and antagonism between various areas. This issue can
also be found in businesses with many specialized depart-
ments that are responsible for specific processes (such
as occupational health, human resources, finance, mar-
keting, etc.), which often leads to severe organizational
inefficiencies and reduced capacities to respond fast and
adequately to new circumstances.
Third, it is important to consider various sources of
data and the available evidence critically in their totality.
In doing so, it is important to remember the realities of
work environments and the restrictions they impose on
evidence generation, especially when it comes to organ-
izational-level interventions and multi-disciplinary and
multi-level actions. Better co-ordination among various
sectors (e.g. health, labour and social security) is needed
to achieve optimal results. Depending on the specific
national social security structures, an active involvement
of the health policy sector is necessary to efficiently and
effectively shape the interfaces that exist between early
detection and primary prevention, secondary and ter-
tiary prevention as well as treatment and rehabilitation,
including occupational reintegration [2].
Fourth, competency development of key actors is cru-
cial. Training and education on mental health and well-
being are not only relevant for those on the shop floor,
but also for the development of management compe-
tencies. The development of these competencies should
be underpinned by the value case (highlighting ethical,
social and economic benefits [9]) and not merely an eco-
nomic or business case.
Finally, there is a need for mental health and well-
being to be integrated into the planning and c­ ontrol
cycle of an enterprise as well as the policy cycle
[10]. However, there are no generally accepted sets
of l­eading p ­ erformance indicators in this area, nor
are there performance indicators for measuring the
­business and policy benefits of mainstreaming mental
health and well-being. Such indicators would facilitate
the communication between experts, practitioners,
management and policy makers, and the integration
of mental health and well-being management and pro-
motion into the planning and control cycle of business
operations.
To promote mental health in the workplace holistically
and achieve real progress, there needs to be synergy and inte-
gration among various perspectives. These perspectives need
to be aligned considering current knowledge and existing
needs, developing capabilities and mainstreaming a strategic
approach in policy and practice. While there is evidence to
support the effectiveness of return-to-work programmes, we
still need more, better quality and longer-term studies to build
a robust evidence base. We also need evaluation of more hol-
istic programmes (combining various levels of prevention).
Finally, a key challenge is lack of access to occupational health
services for many organizations employing a significant part of
the workforce.
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Stavroula Leka
Centre for Organizational Health & Development, School
of Medicine, University of Nottingham, Level B,Yang Fujia
Building, Jubilee Campus, Nottingham NG8 1BB, UK
e-mail: Stavroula.Leka@nottingham.ac.uk
Paul James Nicholson
Occupational Physician, County Hall Apartments,
Chicheley Street, London SE1 7PJ, UK
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