AS@W
AS@W Antidepressant Skills at Work: Dealing with Mood Problems in the Workplace

AS@W...for family physicians

Why should family physicians be concerned with workplace mental health?

Mental health disorders are major contributors to occupational impairment, absence, and disability.  This is particularly true for depression, the primary source of disability in many occupational sectors.  Depression raises the risk for secondary physical and psychiatric illness, as well as for injuries and accidents. The family physician plays an integral role in the clinical management of mental health disorders.  As in other areas of medicine, the role of the family physician working with an employed patient is to restore health; optimize social, psychological, physical, and functional capabilities; and, minimize the negative impact of injury/illness.  Management of workplace mental health issues can be challenging, as the family physician may feel torn between the concerns of patient/worker, the employer, and the insurer. Furthermore the family doctor is trained to focus on assessing and treating symptomatology – rather than determining and enhancing occupational functioning – and may not be informed about the particular job or job requirements held by the patient and the degree to which the individual is able to meet those requirements.  Nevertheless, this is a critical issue for the patient and all concerned parties.  Failure to provide appropriate, timely and specific information can lead to exacerbation and increased complexity of mental health conditions; increased risk of injury, accident or incident; and/or delayed financial compensation for disabled patients. Specialist mental health consultation and/or provision of non-pharmacological intervention from a psychologist, psychiatrist or occupational physician can be helpful but is often unavailable. Provision of practical self-care materials such as AS@W can be of significant benefit.

Who would find AS@W of value?

There are a number of patients who may benefit from the availability of AS@W:

  1. Working patients who present to their physician with emotional, behavioural, interpersonal and cognitive concerns that meet DSM-IV-TR criteria for a Major Depressive Disorder.
  2. Employed patients who present with emotional, behavioural or cognitive concerns that do not currently meet DSM-IV criteria for a Major Depressive Disorder but are sufficiently severe and pervasive that they are impairing workplace and personal functioning (e.g., persistent low mood, significant stressors).
  3. Patients with diagnosed depression who would benefit from cognitive-behavioural techniques to complement pharmacological treatment.
  4. Working patients with mood issues who require practical support in order help them deal with personal and workplace concerns so that may maintain functioning while at work.
  5. Depressed working patients for whom pharmacotherapy is not appropriate or recommended due to personal preference, practice guidelines, non-responsiveness or undue complications and side effects.
  6. Employed patients who present with depressive symptoms that are related to a primary physical health condition (e.g., chronic pain, diabetes, coronary heart disease).
  7. Employed patients who present with depressive symptoms that are comorbid with another psychiatric disorder (e.g., anxiety disorder, substance-use disorder).
  8. Patients who are off work or returning to work after a depression-related absence.
  9. Working patients who have recovered from depression but want to maintain good self-care in order to prevent or minimize relapse.

How can family physicians use AS@W?

  1. Information about AS@W can be made available to patients during the course of a visit. Such information can also be provided in the waiting areas of clinic and physician offices in the form of brochures, information sheets or business cards.
  2. Working patients who may be at greater risk for mood disorders (e.g. due to family history, post-partum status, acute stressors) can merit being screened for depression and receiving support. Similarly, patients with a primary health condition may also be at risk for comorbid depression, particularly if the condition is chronic and/or involves significant pain and impairment. AS@W can provide some practical strategies to aid the patient in managing mood issues and maintaining optimal functioning.
  3. Practice guidelines suggest that for patients with mild depression, health care professionals should consider recommending cognitive-behavioural therapy (CBT) rather than pharmacotherapy because the risk–benefit ratio is poor. If CBT is not available within the public health sector or is not accessible or financially feasible within the private system, AS@W represents an option, particularly for working adults. Although the patient can use AS@W on their own, it is optimal if the family physician can provide assistance or ‘coaching’ to the patient as part of guided self-management.
  4. If a patient is receiving pharmacotherapy for their depression, there is merit in complementing medication treatment with CBT. Indeed, there is evidence that the combination of medication and evidence-based psychotherapy may be most efficacious given their differential impact on particular symptoms and functional deficits. This is especially true for the employed patient, whether or not they are still at work, given the importance of maintaining or restoring functioning for the workplace. In the absence of availability of direct provision of CBT, AS@W represents a viable alternative.
  5. Family physicians are typically called on to provide determination of fitness to return to work, as well as identification of necessary accommodations to ensure successful work return. AS@W can be used to assist with planning and implementing this process by recommending that the patient be provided access to the guide and that employers and rehabilitation professionals work with the patient to address probable issues or barriers to successful job performance.
  6. Depression can be treated with reasonable success. However depression frequently recurs; thus it is increasingly being viewed within a chronic disease management model involving doctor-patient collaboration to manage symptoms, prevent relapse and maintain functioning. Incorporation of AS@W within such a process provides a practical context and set of skills that can be implemented by the patient, in collaboration with the family physician.

Key considerations for family physicians

  1. Encourage patients to be actively involved in decision-making with respect to their care, rehabilitation and work plan (e.g., decisions around modifying duties at work, taking leave from work, and returning to work).  Failure to do so may encourage hopelessness and helplessness, which can impede compliance and recovery.  It is helpful to elicit information on the patient’s expectations for recovery.
  2. Collaboratively consider the advantages and disadvantages of work absence.  If an absence from work is suggested, it should be a part of an overall treatment plan with specific recommendations and goals in mind for the time away from work. It is worth bearing in mind that recommending work absence is an intervention and, like any intervention, it is important to balance the therapeutic benefits with the potential side effects.
  3. Symptom relief and functional recovery should be evident within the first few months of treatment of depressed patients. If such improvement is not reported or observed within six to eight weeks, it is worth considering a change in treatment strategies and/or involvement of other mental health treatment providers.
  4. When describing deficits or recommending accommodations for depressed employees, it is important to use appropriate and specific language in communicating with employers, insurers or disability providers. Rather than categorical or vague statements, such as a patient “can’t concentrate” or “must avoid stress”, it is much more helpful to describe some degree of impairment, whether that involves a decrement in capacity or restriction in task requirements. This needs to be specific to a patient’s particular occupation, so it is advisable to request a current and accurate job description. In complex patients, a job analysis may be of value.
  5. AS@W is not intended as a substitute for provision of medical or specialist mental health care. Nor should it be considered to be in lieu of other organizational or provider programs and services that are relevant to employee mental health, such as Employee and Family Assistance or extended health plans and services.
  6. All working adults are at some risk of depression. This includes family physicians. Indeed, the demands on physicians’ time and expertise within the current healthcare system place them at potentially greater risk. Family physicians are encouraged to attend to their own mental health self care and to seek assistance as needed. AS@W can be of benefit.

Further Reading

Bilsker, D., Wiseman, S., & Gilbert, M. (2006). Managing depression-related occupational disability:  A pragmatic approach.  Canadian Journal of Psychiatry, 51, 76-83.

Canadian Medical Association. (2000). CMA policy: The physician's role in helping patients return to work after an illness or injury.  Canadian Medical Association Journal, 156(5), 680A-680F.

Simon, G. E., Revicki, D. A.,  Heiligenstein, J., Grothaus, L., VonKorff, M., & Katon, W. J. (2000). Recovery from depression, work productivity, and health care costs among primary care patients. GeneralHospital Psychiatry, 22(2), 153-162.


About AS@W

How was Antidepressant Skills at Work developed?

The guide was developed by British Columbia Mental Health and Addiction Services (BCMHAS), an agency of the Provincial Health Services Authority. The guide and accompanying materials have been authored by Dr. Dan Bilsker, Dr. Merv Gilbert, and Dr. Joti Samra – registered psychologists and scientist-practitioners with expertise in issues relating to workplace mental health. These psychologists are with the Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University. The guide was written on the basis of a review of the scientific literature; consultation with employers, unions, mental health providers and employee groups; and adaptation of existing self-care depression programs.

How can the manual be accessed?

The manual is available for viewing and free download at http://www.carmha.ca/selfcare or from www.bcmhas.ca/research. Individuals or organizations are free to print and make multiple copies of the guide, with permission from CARMHA. Print copies and audio CDs are available at a low cost from our ordering page at www.carmha.ca/ordering/

For further information about AS@W and associated resources and materials, please visit www.carmha.ca/selfcare . This information will be updated on a regular basis.