Safe systems of work are needed for the diagnosis of occupational mental illness

Abstract

Occupational mental illness is now the most commonly reported illness to the national surveillance scheme, Occupational Physician Reporting Activity, of work related illness [1]. Its diagnosis is problematic as it involves recognizing a pattern of subjective symptoms in a patient that can be causally attributed to work rather than to personal vulnerabilities. As with most psychiatric illness there is no objective test to confirm the diagnosis. The difficulty of verifying the existence of a stressful working environment and of associating it with a particular occupation or job have been given as reasons for not making occupational mental illness a Prescribed Industrial Injury [2]. Neither is it recognized by the Health and Safety Executive in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. This contrasts with personal injury litigation or injury awards for certain pension schemes that recognize occupational mental illness as an injury and require doctors to give an opinion about causality. Characteristics of workplaces that are hazardous for mental health have been identified from a variety of observational studies and include those where there are high demands on employees, a lack of control over the way the work is done, a lack of social support, an imbalance between effort and reward, job dissatisfaction, a hostile working environment or culture such as bullying or where there is job insecurity due to restructuring or external inspections [3–7]. Less commonly operational aspects of the job are reported as sources of stress but these tend to be in extreme circumstances where there is a risk of personal harm. The importance of obtaining information independent of the patient (known epidemiologically as triangulation) may be helpful for validation purposes. Personal factors associated with mental illness need to be assessed to include a previous personal or family history of mental illness, recent stressful life events and personality traits of neuroticism [8]. An experienced occupational physician is familiar with evaluating relevant personal and workplace factors and with diagnosing common mental illnesses such as anxiety or depression. For example, the victim of unreasonable or particularly stressful working practices with anxiety specific to work or depression, but with no other relevant trigger factor and no past medical history of mental illness or neurotic personality traits, is likely to be suffering from occupational mental illness. Such patients are usually the most vulnerable in an organization and it is one of the roles of an occupational physician to support and protect these patients while simultaneously preventing similar illnesses in other workers. Unfortunately many such patients either leave or are dismissed after a prolonged period of sickness absence on the grounds of incapability. The benefit of a correct diagnosis needs to be weighed against the harm of a false one. The occurrence of several cases of occupational mental illness from one employer reduces the likelihood of false positives, provided such diagnoses have not been made negligently or there has not been a deliberate attempt to mislead the doctor. It is regrettable that in communicating the diagnosis of occupational mental illness (with the consent of the employee) to the responsible employer it may be met with an angry response to include the threat of loss of contract, a vindictive complaint or attempts to discredit the doctor’s diagnostic skills [9]. By contrast, the communication of an occupational physical illness is unlikely to be met with such a response and in some circumstances it is a statutory requirement (e.g. the Lead, Asbestos and Ionising Radiation Regulations). The reporting of occupational mental illness to the employer’s health and safety committee, or by way of an annual report from occupational health, may be met with similar resistance thereby making the integration of certain occupational health data into management statistics and Regulatory compliance problematic [10]. Alternative strategies used by occupational physicians to handle this situation include equivocation over diagnostic aetiology or writing an additional letter to management that is not seen by the patient. However, both these methods can cause the doctor to lose credibility in the eyes of the patient and by so doing he or she will be compromising their professional independence. The Health Correspondence to: Department of Occupational Health, Dudley NHS PCT, Health Centre, Cross Street, Dudley, DY1 1RN, UK. Tel: +44 1384 366 423, fax: +44 1384 366 422; e-mail: jon.poole@dudley.nhs.uk