Marisa Huston, MA, MFT
Robert C. Larsen, MD, MPH
Occupational mental health is increasingly recognized as an important focus of an effective occupational health and safety program. Although most workers attempt to conceal their mental health illnesses and treatments out of fear of stigma and the possibility of termination, psychiatric disorders are commonly encountered in the workplace. The amount of time a person spends at work and the structured nature of work make it an ideal place to detect mental health disorders. Some mental health conditions can even be ascribed to occupational stressors. For these reasons, occupational physicians are in a pivotal position to recognize, assess, and manage mental health conditions.
Unaddressed mental health issues and occupational stress are significant occupational health problems and causes of considerable economic loss. Both diagnosed and undiagnosed psychiatric disorders can contribute to poor performance or quality of work, absenteeism, strain in work relationships, need for medication monitoring, and potential safety issues. In addition to mental health issues, violence and the threat of violence in the workplace is a growing concern that requires counsel and clinical assessment from occupational physicians.
COMMON MENTAL HEALTH CONDITIONS IN THE WORKPLACE
Though more than 200 psychiatric disorders are included in the Diagnostic and Statistical Manual of Mental Disorders, only the conditions that are most likely to present in today’s work environment will be discussed in this chapter. Substance abuse diagnoses are covered in the following chapter. Practitioners familiar with these mental health conditions will be able to facilitate the evaluation, treatment, and management of employees with psychopathology.
Many workers with mental health illnesses are taking prescription psychotropic agents. These medications, many of them quite likely to present problems of drug management, are seldom reported to employers. Although occupational physicians will almost always defer decisions on medication to mental health professionals, they nonetheless play an important role in monitoring workers for drug effects on work performance and for problematic side effects.
MAJOR DEPRESSIVE DISORDER
ESSENTIALS OF DIAGNOSIS
Feelings of worthlessness, hopelessness, and sometimes guilt.
Loss of energy or fatigue, daily.
Difficulty concentrating and making decisions.
Loss of interest or pleasure in activities; withdrawal from activities.
Disturbed sleep (insomnia, hypersomnia).
Reduced appetite and sex drive.
Thoughts of death and suicide.
General Considerations
The lifetime prevalence for major depressive disorder in US adults is 16.5%, with women being at a significant increased risk compared to men. Given the rate of occurrence, the personal pain, and the cost to employers associated with major depression, effective corporate health policy and clinical intervention should be the goals for health planning regarding this all too common mental disorder.
Clinical Findings
The hallmark of major depression is a severely depressed mood lasting at least 2 weeks. Symptoms most frequently include anhedonia, decreased energy, reduced participation in activities, and feelings of guilt or worthlessness. Other signs include impairment in concentration or cognitive functioning, sleep disturbance, changes in appetite (usually decreased), somatic complaints such as body aches and constipation, and thoughts of death.
Initial episodes of depression are more likely to be preceded by a recognizable stressor than recurrent episodes. Clinical depression regularly presents with other psychiatric and medical conditions. Anxiety, posttraumatic stress disorder, and substance abuse are often comorbid disorders accompanying major depression. Chronic pain is routinely associated with depression.
Differential Diagnosis
• Depressive disorder due to another medical condition (eg, hypothyroidism)
• Adjustment disorder with depressed mood
• Bipolar disorder
• Persistent depressive disorder (dysthymia)
• Substance- or medication-induced depressive disorder
• Nonpathological sadness
Treatment
Cognitive behavioral therapy for depression instructs patients to confront self-defeating thoughts and change negativistic behaviors. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used medical intervention for major depression. Combined treatment involving psychotherapy and antidepressant medication is more effective than either intervention alone. It should be noted that untreated clinical depression frequently remits within 3 to 12 months. Furthermore, the effectiveness of antidepressants in mild cases of depression is minimal. Cases of refractory depression are those which do not respond to at least two adequate trials of antidepressants. While controversial, electroconvulsive therapy (ECT) is used in treatment resistant cases.
BIPOLAR DISORDER
ESSENTIALS OF DIAGNOSIS
Manic episodes
Euphoric and/or irritable mood.
Increased involvement in goal-directed activities.
Racing thoughts and flight of ideas.
Decreased need for sleep.
Difficulty focusing; distractibility.
Self-inflation and grandiosity.
In some cases, delusions, hallucinations, and/or paranoia.
Depressive episodes
See Essentials of Diagnosis in Major Depressive Disorder.
General Considerations
Formerly known as manic depressive illness, bipolar disorder is a mood disorder that can cause tremendous disruption in the lives of afflicted individuals. The lifetime prevalence for bipolar disorder in US adults is approximately 4%. Employees with bipolar disorder, when not in a manic episode, can be creative and productive. In the midst of mania, those same people can be a profound source of disruption in the work setting and elsewhere.
Clinical Findings
Bipolar disorder is a cyclical mood disorder involving at least one episode of abnormally elevated energy level and mood which usually alternates with one or more episodes of depression. Manic episodes usually begin abruptly and most commonly occur during spring and summer. Less severe than overt mania is hypomania which does not cause serious impairment in occupational functioning or involve psychotic symptoms.
Mania is a period of elevated mood lasting a week or more with accompanying decreased sleep, pressured speech, racing thoughts, impulsivity, and poor judgment. Irritability, aggression, and recklessness usually create problems in relationships and work functioning. Persons in the midst of a manic episode can engage in spending sprees, take on risky business deals, and demonstrate a degree of hypersexuality. Grandiosity can reach delusional levels.
Differential Diagnosis
• Schizophrenia spectrum and other psychotic disorders
• Substance-induced manic episode
• Major depressive disorder
• Anxiety disorder
• Attention-deficit/hyperactivity disorder
Treatment
Therapeutic counseling is effective in bringing attention to situations that may trigger manic episodes and in increasing recognition of warning signs of an emerging recurrence. Mood stabilizers including lithium, carbamazepine, and lamotrigine have demonstrated efficacy in treating bipolar disorder. Atypical antipsychotics such as olanzapine are used to treat mania with agitation and psychotic symptoms.
GENERALIZED ANXIETY DISORDER
ESSENTIALS OF DIAGNOSIS
Overt anxiety or fear.
Excessive apprehension or worry.
Difficulty concentrating.
Insomnia.
Irritability and agitation.
Feelings of impending doom.
Autonomic hyperarousal symptoms such as sweating, tachycardia, tremulousness.
Somatic symptoms such as headaches, nausea, dizziness, muscle tension.
General Considerations
The lifetime prevalence for a diagnosis of generalized anxiety in US adults is 5.7%. Approximately 3% of the adult population meets the criteria for generalized anxiety each year. Benzodiazepines, which are commonly prescribed for anxiety disorders, can cause cognitive impairment, even at prescribed doses. Intoxication can result in lethargy, sedation, and impaired coordination, posing a risk for workers with safety-sensitive jobs. The occupational physician should work with management to establish a program to screen employees taking benzodiazepines, even for appropriate conditions and in therapeutic dosages.
Clinical Findings
Excessive anxiety or worry about everyday situations such as money, family, work, or social relations is the hallmark of generalized anxiety disorder. Afflicted individuals have difficulty stopping or controlling worrisome thoughts, which can lead to impairment in work performance. These worries are usually pervasive, long-standing, disproportional to the actual likelihood of feared event, and occur without precipitants. In addition to excessive worry, symptoms may include restlessness, difficulty concentrating, agitation, somatic symptoms, fatigue, and disturbed sleep.
Differential Diagnosis
• Anxiety disorder due to another medical condition (eg, hyperthyroidism or pheochromocytoma)
• Substance-induced anxiety disorder
• Posttraumatic stress disorder or adjustment disorder
• Depressive, bipolar, or psychotic disorder
• Obsessive-compulsive disorder
• Social anxiety disorder
• Nonpathological anxiety (controllable, shorter duration, precipitants, less interference with daily functioning, and usually not accompanied by physical symptoms)
Treatment
Management of acute symptoms of generalized anxiety usually includes benzodiazepines. Rather than prolonged treatment with benzodiazepines, the symptoms of restlessness, difficulty concentrating, irritability, muscle tension, fatigue, and sleep disturbance respond well to cognitive behavioral therapy. Pharmacotherapy includes the use of selective serotonin reuptake inhibitors (SSRIs). Other psychotropic drugs demonstrating efficacy are buspirone and imipramine. Non-psychotropic alternatives include the β-blocker propranolol and the calcium channel agent pregabalin.
POSTTRAUMATIC STRESS DISORDER
ESSENTIALS OF DIAGNOSIS
Exposure to an extreme traumatic event.
Intrusive recollections, disturbing dreams.
Hypervigilance, startle responses, difficulty sleeping.
Avoidance of external reminders of trauma.
Persistent and exaggerated negative beliefs and emotions.
Social withdrawal.
General Considerations
The lifetime prevalence for posttraumatic stress disorder (PTSD) in US adults is 6.8%. Employees involved in critical incidents can sometimes develop PTSD. Additionally, employment in certain industries increases the likelihood of involvement in violence, which can induce PTSD symptoms. Law enforcement officers, security guards, and bartenders experience the highest rates of workplace violence and are therefore at risk for developing PTSD.
Clinical Findings
The hallmark of posttraumatic stress disorder is exposure to an actual or threatened stressor (death, serious injury, or sexual violence) followed by indicative emotional and behavioral symptoms. Examples of stressors are armed robbery, personal assault, or a serious motor vehicle accident. The traumatic event is reexperienced through flashbacks, dreams, or exposure to stimuli that are associated with the event. Behavioral symptoms include increased states of arousal such as hypervigilance, irritability, startle reactions, difficulty concentrating, and sleep difficulties. Other diagnostic criteria include avoidance of people and activities associated with the traumatic event, negative thoughts about oneself or the world, detachment from others, and persistent negative moods such as fear, anger, or guilt.
Differential Diagnosis
• Adjustment disorder
• Acute stress disorder (less chronic form of PTSD)
• Depressive, anxiety, or psychotic disorder
• Obsessive-compulsive disorder
• Traumatic brain injury
Treatment
Early clinical intervention is effective in reducing morbidity and disability. Propranolol instituted soon after the traumatic incident can reduce autonomic arousal and improve long-term outcome. Cognitive behavioral therapy and SSRI antidepressants are effective in reducing nightmares, sleep disturbance, reexperiencing, and avoidance. Where available, group therapy involving employees from the same class of workers, such as public safety workers, can be an effective form of clinical intervention as well.
OCCUPATIONAL STRESS
Stress is an important occupational health problem and a significant cause of economic loss. While stress remains a broad and somewhat elusive concept, research efforts have led to a clearer understanding of the problem, its causes, and its consequences. When stress is deleterious, it may result in physical and/or mental disorders. It also may have more subtle manifestations that can affect personal well-being and productivity at work.
The mental health effects of stress exist on a continuum ranging from mild subjective symptoms to overt psychiatric disease with significant impairment of functioning. Subjective reports regarding personal well-being constitute some of the earliest measures of stress. Frequently noted symptoms include anxiety, tension, anger, irritability, poor concentration, apathy, and depression. These manifestations of stress interfere with a sense of well-being and may be precursors of more severe illness.
Overt psychological dysfunction frequently is attributed to stress. The most frequent psychiatric diagnosis in the working population is that of an adjustment disorder or a time-limited emotional reaction to a specific psychosocial stressor. Stress may act as a nonspecific promoter of disease. Multiple studies show statistical associations between stressors and overt psychiatric disease. Unemployment and lack of opportunity for promotion both have been related to increased psychiatric hospitalizations and suicide rates.
There is a growing body of evidence to indicate that the prevention of occupational stress may be accomplished by creating a healthy work environment based on recognized organizational principles. Organizational solutions for high-stress work units offer promise, although there is not much experimental information available to guide these interventions. It also may be possible to monitor and control stress in the workforce by recognizing problem situations as well as early clinical or behavioral signs. When individual dysfunction arises, clinical intervention may be necessary.
Injury & Accidents
There is a multifactorial relationship between occupational stress and injury in the workplace. Although there is little consistent evidence to demonstrate either the magnitude of stress-related injury or to confirm the mechanisms of the problem, this remains a promising area of stress research. A study of bus drivers demonstrated that psychological job demands, frequency of job problems, and job dissatisfaction all were related to back injuries. An increased risk of low-back pain is found in employees who report insufficient support from supervisors. In addition to high job demands, interpersonal conflict at work also may represent a separate risk factor for occupational injury. Job stress and nonwork-related stress reactions are consistently associated with upper extremity pain disorders.
The stress of high workload demands may lead to compromise of safety measures to attain higher productivity. Workers paid on a piecework basis have increased numbers of injuries. Attention span may be altered by low levels of stimulation and long periods without breaks; inattention can lead to accidents. Changes of shift are associated with higher rates of injury on the first days of new shifts. There is mounting evidence to relate shift changes and sleeplessness to airplane pilot and air traffic controller errors. There also may be a relationship between job decision latitude and frequency of injury. The contribution of stress to substance abuse also leads to accidents; a large proportion of motor vehicle accidents on the job involve alcohol.
Some authors note a relationship between stressful events in an employee’s life and subsequent occupational accidents. The possibility exists that stress from work or personal factors may contribute to the likelihood of an accident. Stressors should be assessed when evaluating injured employees; treatment of the physical impairment alone may not result in a successful return to work.
Sickness, Absence, & Productivity
A clear relationship exists between sickness, absence from work, and lost productivity. Stress may be an independent variable influencing each of these three factors. The case for stress as a contributor to sickness already has been discussed. However, absence from work is a complex phenomenon involving not just organic disease but also mental health, motivation, satisfaction with employment, and other personal and work-related factors. Some research has demonstrated a relationship between organizational stressors, such as high-demand/low-control work, and subsequent absenteeism. However, research studies on stress and absenteeism are mixed. Some studies indicate that stressors appear to predict absences associated with a physician visit but not other absences.
Presenteeism, coming to work while ill, is more prevalent than absenteeism and is a significant contributor to loss of productivity. Presenteeism is associated with high stress, life dissatisfaction, depression, and mental illness. The costs associated with presenteeism can exceed the combined costs of absenteeism and medical treatment. Efforts to control psychosocial workplace factors that enhance presenteeism, including more effective management, may result in increased productivity and decreased health care costs.
Productivity on the job is a stress-sensitive function. Reduced output, production delays, and poor performance may be manifestations of stress. Declining productivity of an organization or individual should prompt a search for occupational stressors. A stress management program may promote increases in attendance and productivity.
Shiftwork
ESSENTIALS OF DIAGNOSIS
Fatigue with work shift assignment.
Diminished work performance.
sleep alterations.
Aggravation of other diseases.
Changes in behavior.
Increased drug use.
General Considerations
Between 20% and 25% of the US workforce is assigned to some form of rotating shift work, evening, or night work. Rotating shifts usually involve regularly changing work hours. Employees’ shifts change periodically (eg, every 2–30 days), so that times spent working day, evening, and night shifts are shared by the workforce. These schedule changes have consequences for mental and physical well-being, and may influence performance and safety.
Pathogenesis
Many physiologic systems operate within a regular circadian rhythm. The circadian pacemakers, which time the approximately 24-hour rhythms in sleep and wakefulness, resynchronize only slowly after an abrupt phase shift in environmental time cues. Examples of circadian physiologies include body temperature, glucocorticoid secretion, cognitive function, gastric emptying, pulmonary function, effects and metabolism of medications, and many psychological processes. While the symptoms of jet lag are transient, the repeated shifts in the activity/sleep schedule experienced by night-shift workers on rotating or permanent schedules are often associated with chronic sleep deprivation, and over a number of years, with increased risk for various medical disorders.
Differential Diagnosis
• Chronic insomnia
• Bipolar disorder, persistent depressive disorder (dysthymia), or cyclothymic disorder
• Major depressive disorder with seasonal pattern (seasonal affective disorder)
• Substance use disorder
Prevention
A key issue with shiftwork schedules is the readjustment, or entrainment, of these physiologic rhythms. With change from a day to a night work schedule, or as a result of travel over time zones, the normal synchronization of the various circadian physiologic rhythms is disrupted. Because each physiologic rhythm readjusts at its own rate, this internal desynchrony may last for long periods. There is seldom complete re-entrainment to night-shift work. Additionally, there is significant interindividual variation in the ability to adapt, and for some, deterioration of tolerance to shiftwork with ageing.
A significant portion of the shiftwork population has some level of desynchronosis at any given time. Poor adapters may develop a constellation of characteristic pathologic manifestations of shiftwork intolerance, sometimes referred to as shiftwork-maladaptation syndrome. Clinical intolerance to shiftwork has been defined by the presence of sleep alterations, persisting fatigue (not disappearing with normal time off periods), changes in behavior, digestive disturbances, and the regular use of sleeping pills.
Clinical Findings
In addition to disrupting biological rhythms, shiftwork, particularly that including night work, disrupts social and family life, potentially negatively affecting performance efficiency, health, and social relations. Proper alignment between sleep–wakefulness and internal circadian time is crucial for cognitive performance. Individuals with shiftwork sleep disorder are at risk for significant behavioral and health-related morbidity associated with their sleep–wake symptoms. Adverse effects can manifest themselves in the short term as sleep disturbances, psychosomatic troubles, mistakes at work, and accidents. Rotating shifts and night work aggravate many preexisting chronic disorders as a result of the disruption of circadian functions. In the long term, there is an increased risk for gastrointestinal, psychoneurotic, cardiovascular, and gastrointestinal diseases. Women shift workers are vulnerable to negative reproductive outcomes.
Complications
Medical surveillance programs have been recommended for shift workers and are mandatory in some countries. Rotating shifts and night work may aggravate some preexisting chronic disorders as a result of the disruption of circadian functions. Shiftwork may complicate management of chronic diseases for which timing and adjustment of medications are important. The implications for clinical case management are relevant and, in several instances, critical. Shiftwork can interfere with mechanisms regulating drug kinetics and actions at selective brain sites, either directly or through effects on the gastrointestinal/hormonal cycles. Insulin-dependent diabetes mellitus may be more difficult to control. There is evidence for a circadian variation in the effects of insulin, circadian rhythm in gastric emptying rate, and diurnal variation has been observed in the effect of the type of meal on blood glucose control. The alteration of the sleep cycle may increase seizure frequency in epileptics due to sleep deprivation or disturbance of medication regulation. Asthmatics may also experience difficulty with medication adjustments.
The risk of cardiovascular disease in shift workers is increased by about 40%. Some studies have indicated increases in hypertension in shift workers. Some studies show an increased mortality among shift workers. Obesity, high triglycerides, and low concentrations of HDL cholesterol seem to occur together more often in shift workers than in day workers, which might indicate an association between shiftwork and the metabolic syndrome. Shiftwork may be associated with insulin-resistance syndrome in workers younger than 50.
There is a potential reproductive risk from shiftwork. Reproductive outcomes among women shift workers include increased spontaneous abortions, preterm births, and intrauterine growth retardation. Studies of night shiftwork and breast cancer risk show an increased breast cancer risk among women. Night-shift work increases the risk of cancer at several sites among men and increases the risk for breast cancer among women.
Workers assigned to shiftwork schedules, and 12-hour working days, are significantly prone to neurotic disorders. There is a common disturbance of mood in dysrhythmic workers, with a disturbing tendency toward depression as the condition becomes chronic. The majority of individuals subject to shiftwork or jet travel–related time shifts in their sleep–wake schedules commonly report some degree of depressive symptoms.
Extensive disruption in circadian function is known to occur among patients with bipolar disorder. Therefore, it is plausible that circadian dysfunction underlies pathogenesis of this common abnormality. Subtle disturbances of short-cycle rhythms such as the REM/non-REM sleep cycle could contribute to the ultrarapid cycles of mood, energy, sleep, and activity that characterize early-onset bipolar disorder. Some studies demonstrate that licit and illicit drug use increases significantly in this group of workers, with no benefit to worker health or safety, and possibly adding to the chronicity of the problem.
Treatment
There is substantial evidence that appropriately timed, bright-light treatments can successfully overcome the circadian misalignments associated with desynchronosis. The mood elevation and increased alertness that would result from this intervention might remove the influence that desynchronosis has in aggravating depression, drug abuse, and a variety of other mental health disturbances.
Stress & Workers’ Compensation
In an attempt to restrict stress claims, some workers’ compensation jurisdictions place restrictions on claims during the probationary period of employment, eliminate claims resulting from appropriate personnel actions, and increase the causation threshold to substantial or predominant cause. Some states require a co-occurring physical injury to validate a stress claim.
Stress-related workers’ compensation claims may be divided into three categories: physical-mental, mental-physical, and mental-mental. Physical-mental claims usually result from well-defined work-related injuries such as crush injuries, amputations, or other sudden, significant, well-defined occurrences, although they also may result from illnesses. The claim is made for mental health effects such as posttraumatic stress, anxiety, or depression resulting from the physical event. Such claims are recognized in all US jurisdictions, although some claim types pose a challenge to the system. For example, mental health effects that an individual claims as a result of a gradually developing occupational disease, such as asbestosis, expand the scope of the physical-mental claim and raise new issues.
The mental-physical category includes instances in which claimants contend that emotional stresses at work have caused physical ailments, including a wide variety of disorders such as myocardial infarction and neurologic, dermatologic, and gastrointestinal diseases. The epidemiologic evidence linking emotional stress to the initiation or aggravation of these disorders is variable and often weak. In the United States, most states limit these claims by requiring the presence of an unusual stressor or a close coupling of the events in time.
In recent years, mental-mental claims have drawn the most attention, and the number of claims has grown rapidly. Claimants file for compensation on the basis of mental health effects resulting from conditions at work. There are fundamentally three kinds of situations that may precipitate these claims: stress resulting from involvement in sudden, emotionally disturbing events, such as witnessing a coworker’s death; stress resulting from a continuing situation that is unusual in its demands on the worker (eg, air traffic controllers and some types of police work); and stress arising out of the conditions of everyday work. These claims, particularly the last group, often are difficult to resolve. Many of these cases involve interpersonal conflict, predominantly conflict with supervisors. Both the extent of impairment and the causal factors are difficult to assess objectively. Legal precedent has allowed the claimant’s subjective perception of events to be a factor in determining compensability in many jurisdictions.
Alternative schema for categorizing psychiatric claims include those that involve a reaction to an admitted or acknowledged physical injury, an obviously psychologically traumatic event, and cumulative stress associated with the nature of the job position. Psychiatric claims are contentious because of the subjective nature of the evidence presented. In jurisdictions that allow for cumulative stress injuries, those claims tend to be heavily litigated. Prevention and early intervention of psychiatric injuries involve employee education, employee assistance programs, reasonable mental health benefits, and appropriate personnel policies.
SITUATIONS DESERVING PSYCHIATRIC CONSULTATION
There are a number of circumstances involving mental health matters in the workplace that require specialty consultation. Common indications for obtaining a psychiatric consultation include an employee with: erratic behavior, mood instability, exposure to life-threatening trauma, the potential for violence, a recent history of closed head trauma, an established pattern of interpersonal conflict, or an unexplained change in productivity (Table 35–1). The rationale for psychiatric consultation regarding workplace mental health issues includes the need for diagnostic clarification, mental health treatment planning, fitness-for-duty psychiatric evaluation, psychiatric disability evaluation, threat assessment, psychopharmacologic medication adjustment, psychotherapy, and psychometric testing.
Table 35–1. Common indications for psychiatric consultation.
• Erratic behavior
• Mood instability
• Exposure to life-threatening trauma
• Potential for violence
• Recent history of closed head trauma
• Established pattern of interpersonal conflict
• Unexplained change in productivity
The initial clinical impression in cases involving an employee with psychopathologic symptoms should be confirmed or amended based upon input from an experienced mental health practitioner. Similarly, the treatment plan should be developed with assistance of a psychiatrist or psychologist once the diagnosis has been established. Evaluation of an employee’s fitness or impairment can require specialty consultation to identify recommended accommodations for behavior which may allow for a return to some form of work. The potentially dangerous employee warrants an assessment of the threat level posed. Employees returning to work who are taking psychotropic medication should also have the benefit of a psychiatric consult to advise whether the drug(s) used should be amended. Counseling or psychotherapy beyond basic supportive coaching is yet another intervention best left to mental health professionals. Finally, concern over mood instability, interpersonal conflict, or a history of head injury should give consideration for standardized psychometric testing directed toward assessing the specific concern.
Psychiatric Fitness-for-Duty Examinations
The psychiatric fitness-for-duty examinations should be reserved for mental health records, which are typically more highly protected than general medical records. They are governed by federal law and also state statutes in which mental health treatment and evaluation records have special provisions protecting confidentiality, as is often seen with substance abuse treatment and HIV medical records. Situations requiring the use of a psychiatric fitness-for-duty exam include: preemployment psychological screening, a disruptive employee, requests for mental-based leaves, failed attempts at return to work following psychiatric care, and threat assessment. Law enforcement agencies routinely use fitness-for-duty assessments of candidates. Such evaluations involve a clinical interview and standardized psychometric testing to screen out individuals who are overly aggressive, psychotic, impulsive, or prone toward inaction in potentially critical situations. Employees who repeatedly create disruption in a work group may do so as a result of mental illness. A fitness exam can provide valuable information for treatment referral and case management by the employer. A brief psychiatric exam may support an employee taking time away from work when that individual is in need of stress reduction and clinical intervention.
Boundaries and limits of confidentiality need to be appreciated so as not to complicate these sensitive cases. The employee who has been released to regular duties following a critical incident or a psychiatric hospitalization can be a candidate for a fitness evaluation by a mental health practitioner. Complicating factors may involve nonindustrial health problems, personal life stressors, administrative concerns, and legal considerations.
There are occasions when a treating doctor releases an employee to resume full duties prematurely following a leave of absence for treatment of a mental disorder. Safety concerns in employees treated for depression and anxiety may represent a basis for a psychiatric examination prior to workforce reentry. A bus driver may or may not be safe to resume responsibility for transporting patrons on public transit after experiencing a psychotic break. A machine operator may need to be weaned off benzodiazepines before returning to full duty after treatment for anxiety. Police officers involved in shootings routinely undergo psychiatric consultation before having access to their weapon.
The psychiatric fitness-for-duty exam must address the employee’s functionality with the examiner being aware of the essential and nonessential job functions as detailed in a written job description. Pertinent information should be communicated timely. Delays in conducting the exam and producing a report can cause disruption not only to the identified employee but also to the work group awaiting direction.
WORKPLACE VIOLENCE
Workplace violence has become a major health and safety issue over recent decades. Violence, the threat of violence, and harassment greatly impact the mental health, stress, and productivity of workers. Physicians in the workplace can play a vital role in the identification and assessment of potential violence as well as in the treatment of victims of violence. Clinicians involved in managing such problem situations must work as part of a team with human resource, legal, and insurance representatives.
Violence in the workplace can occur at any time to anyone, but some workers are more vulnerable than others. Workplace violence can be divided into four categories, distinguished by the type of perpetrator. Strangers, or those not otherwise connected to the workplace, usually commit robberies and other criminal acts. Patients or customers may act out violently with caretakers or service staff. Coworkers (current and former) commonly act out in response to a grievance or perceived injustice. Family members or nonworkplace acquaintances sometimes commit acts of violence toward an employee at work. These categories can be split further into nonfatal and fatal violence.
The highest rate of nonfatal violence in the workplace targets law enforcement officers, security guards, and bartenders. For men, 53% of nonfatal workplace violence is committed by strangers, 20% by coworkers or former coworkers, 5% by customers or clients, and 14% by relatives or other personal acquaintances. For women, 41% of nonfatal workplace violence is committed by strangers, 19% by coworkers or former coworkers, 13% by customers or clients, and 21% by relatives or other personal acquaintances.
The highest rate of fatal violence (homicide) in the workplace targets sales (and sales-related) employees and protective service employees. Approximately 70% of workplace homicides are committed by strangers (robbers and other assailants), 11% by coworkers or former coworkers, 10% by customers or clients, and 8% by relatives and other personal acquaintances (Table 35–2). Only one in five workplace homicide victims are female.
Table 35–2. Workplace homicide offenders.
• Robbers: 38%
• Other assailants: 32%
• Coworkers: 11%
• Customers/clients: 10%
• Relatives: 4%
• Nonworkplace acquaintances: 4%
Risk factors associated with violence committed by strangers, such as exchanging money with the public, working at night in a high crime area, or working where alcohol is served, can be anticipated and mitigated by security measures. Despite the small percentage of workplace violence (fatal and nonfatal) committed by coworkers, well-publicized tragic events in recent years have heightened public awareness of these types of incidents. Although the potential for violence perpetrated by coworkers can be more difficult to mitigate, these incidents are usually preceded by warning signs—behaviors that can be observed and interpreted.
Warning Behaviors
Current research on threat management has shown that targeted violence is usually the result of a progression of behaviors rather than an impulsive event. In the majority of cases of workplace violence committed by a coworker, the violent attack is the result of a build up of anger, not a sudden “snap.” Identifying, monitoring, and assessing an employee’s changing behavior is fundamental to preventing violence in the workplace.
Determining whether or not an employee may become violent has less to do with a static profile of that person than a series of dynamic variables (behaviors). Sometimes called warning behaviors, risk factors that indicate an increasing threat of violence can be identified and tracked. Whether conscious or unconscious, warning behaviors are changes in behavior that indicate an acceleration of risk. Several key warning behaviors include leakage, preparation for attack, identification with violent offenders, fixation on a person or cause, and a desire for retaliation (Table 35–3).
Table 35–3. Violence warning behaviors.
• Leakage of intentions to a third party
• Acts of preparing for an attack
• Identifying with violent offenders
• Fixation on a person or cause
• Desire for retaliation for a perceived grievance
A majority of workplace violence is preceded by a threat communicated directly to the victim. Verbal threats of violence in the workplace must be taken seriously, reported, evaluated, and managed. Leakage, defined as revealing one’s violent intentions to a third party, can be intentional or unintentional, and is not indicative of a desire to be discovered. A majority of mass murderers leak their violent intentions to someone. These revelations of violent plans can be explicit or veiled, specific or vague, a threat or a boast. A threat may be delivered in an off-hand remark, an argument, an e-mail, voice mail, or posted on the Internet for anyone to see. It is important to note, however, that not all violent attacks are preceded by threats and not all threats lead to an act of violence. Leakage alone cannot predict an act of violence; it must be assessed in the context of other warning behaviors.
Other behaviors that can indicate red flags for potential violence are preparation, identification, fixation, and desire for retaliation. Preparatory behaviors include researching or stalking targets, acquiring weapons, or suddenly acting out violently (possible “practice runs”). Identification behaviors can be identifying with someone who has perpetrated previous violent attacks or identifying oneself as an agent of violence. A fixation behavior is the preoccupation with a target or cause, with a possible growing disdain for the object of fixation. A desire for retaliation includes an original grievance or perceived “wrong” that is considered the cause of a person’s problems. The perpetrator may justify using violence to solve the problem due to feelings of being cornered or having no other options.
Other factors associated with workplace violence include certain psychopathologies and loss. Antisocial personality disorder, paranoia, and psychosis can exacerbate underlying issues and contribute to the drive toward violence. Antisocial personality disorder is associated with a lack of empathy or conscience. Paranoia and other psychotic symptoms can greatly enhance a sense of being persecuted. In addition, a significant loss or rejection, paired with poor coping skills, can contribute to the progression of violence. Loss of a relationship, loss of a job, or loss of financial stability should be taken into account when assessing warning behaviors.
Violence Prevention
Gathering information is vital in assessing and preventing violence. To do so, it is crucial to develop a culture of communication and awareness, wherein employees know what behaviors to report and to whom. Employers should have clear policies regarding harassment, intimidation, violent threats, and violence, and clearly communicate those policies to employees.
Employees should be encouraged to report any policy violation, no matter how small. Witnesses often minimize or rationalize warning behaviors and sometimes just ignore them. Some witnesses assume that others who heard the same thing will report it. The temptation to ignore or downplay threats can be mitigated by training employees to recognize warning behaviors and take them seriously. Evaluation should always include the context in which leakage or other warning behaviors occur. A successful violence prevention program is one in which employees trust that reports will not lead to unnecessary action, but will be used to assess situations in their wider context.
A threat assessment team made up of staff members, including the occupational physician, is becoming a more common component of workplaces. Threat assessment teams are usually responsible for collecting pertinent information for a threat-assessment professional to evaluate (with the team’s collaboration). Sharing knowledge of threats of violence or suspicious behaviors with a professional trained to interpret and evaluate warning behaviors is vital. Threat assessments are typically conducted by psychologists or psychiatrists who have specialty training in assessing the potential for violence. Protocols for psychiatric evaluation of threat assessment have been developed for gauging the seriousness of a threat. Information obtained through psychiatric threat assessment, which employs limited confidentiality, allows experts to help a workplace develop and implement a plan to manage potential violence. The plan may include an employer taking steps to restrict worksite access and reduce exposure to potential victims.
Prevention of violence or overt expression of aggression is always preferable to dealing with the consequences of a violent act. When violence has occurred, early intervention for victims usually requires referrals for mental health counseling.
Trauma Intervention
After a critical incident such as an armed robbery or a hostage situation, the occupational physician may be called upon to intervene on behalf of employees who have been exposed to life threatening aggression. In addition to incidents of violence, a recognizable threat to the physical integrity of an employee can take place during plant explosions, natural disasters, terrorist events, and serious motor vehicle accidents. Early intervention can mitigate the more severe elements of acute stress disorder or the more chronic condition of PTSD. Consideration should be given to using a psychological trauma expert to address psychoeducational issues with an affected work group when multiple employees are impacted by a critical incident. As discussed earlier in this chapter, psychiatric evaluation, cognitive behavioral therapy, and psychopharmacologic intervention have a potential role in trauma cases that may result in PTSD. Safety and security assessment after an episode of violence is also an important component of health planning for an entire worksite. Those other than the direct victims rely upon the employer to assure them that the chance of a future episode will be minimized.
For victims of violence, return to work may require job modification or accommodation. Some long-term bank tellers will never return to teller duties after a takeover type robbery, yet they can still be of value elsewhere within the organization. Morale and loyalty can be promoted by an organization that looks after the needs of such workers. Other forms of intervention worth considering include special skills training such as self-defense classes for employees who have been assaulted and are at risk for a further incident with a return to regular duty. Aside from attention to treatment issues, there may be an administrative need for a forensic psychiatric evaluation to address legal matters such as workers’ compensation disability benefits or other such concerns.
REFERENCES
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SELF-ASSESSMENT QUESTIONS
Select the one correct answer to each question.
Question 1: The hallmark of major depression is
a. the inability to get out of bed
b. diminished productivity
c. irritable mood
d. a severely depressed mood lasting at least 2 weeks
Question 2: Bipolar disorder is a cyclical mood disorder involving
a. at least one episode of abnormally elevated energy level and mood which usually alternate with one or more episodes of depression
b. at least one episode of depression followed by an episode of abnormally elevated energy level and mood
c. three or more episodes of mania
d. at least one episode of anxiety and one episode of major depression
Question 3: The majority of individuals subject to shiftwork or jet travel–related time shifts in their sleep–wake schedules commonly report some degree of
a. anxiety
b. manic symptoms
c. depressive symptoms
d. job dissatisfaction
Question 4: Extensive disruption in circadian function is known to occur among patients with
a. aerobic exercise regimens
b. bipolar disorder
c. high levels of productivity
d. chemical dependency withdrawal
Question 5: Determining whether or not an employee may become violent
a. has less to do with a static profile of that person than a series of dynamic variables (behaviors)
b. is impossible
c. has less to do with personality than job satisfaction
d. requires training in violence assessment