Strong evidence linking job stressors to adverse mental health outcomes

A growing body of epidemiological evidence links exposure to work stressors with adverse mental health outcomes. ^{Reference Belkić and Savić1} Empirical data, including a large number of longitudinal studies supporting this relationship, are strong and consistent. A meta-analysis including nearly 75 000 employees of various occupations from several European countries and Canada, found that job strain, effort-reward imbalance, low decision latitude, low social support, high psychological demands as well as job insecurity were predictive of mental ill health at follow-up. ^{Reference Stansfeld and Candy2} With regard to specific psychiatric diagnoses, several large-scale longitudinal studies have demonstrated a significant association between exposure to job strain and depression. ^{Reference Belkić and Savić1-Reference Grynderup, Mors, Hansen, Andersen, Bonde and Kaergaard3} In a case-control study from the Danish Psychiatric Central Research Register comparing 14 166 psychiatric patients with 58 060 referents, low job control was found to be associated with an increased risk of anxiety disorders in men. ^{Reference Wieclaw, Agerbo, Mortensen, Burr, Tüchsen and Bonde4} An increased risk of suicide has been reported among several stressful occupations, most consistently among physicians ^{Reference Belkić and Savić1,Reference Schernhammer and Colditz5} and other health professionals, with harassment/degrading experiences implicated as a contributory factor. Burnout is recognised as a major problem for physicians, notably among psychiatrists, for whom violence from patients and patient suicide are cited as precipitating factors. ^{Reference Kumar, Hatcher and Huggard6}

Insights from cognitive neuroscience

The mechanisms by which work stressors have an impact upon the human nervous system can be mapped using neurophysiological methods, most notably event-related potentials (ERP), as well as quantitative electroencephalography (qEEG). ^{Reference Belkić and Savić1} In ERP paradigms designed to address these issues, a number of salient insights are obtained. ^{Reference Belkić and Savić1} Among these are that P300 subcomponents indicate the counter-productivity of time pressure; increased selective attention as reflected in the P300 amplitude occurs when material incentives are imposed upon task performance; long hours of attention-demanding work are associated with attenuated P300 amplitude and occupations such as professional driving that entail a heavy burden of threat-avoidant vigilant activity are associated with heightened contingent negative variation electronegativity in anticipation of relevant imperative signals. The toll of night-shift work is reflected in increased alpha and theta activity during work, and compromised stage 2 and rapid eye movement sleep thereafter. ^{Reference Åkerstedt, Kecklund and Gillberg7} Although there have not yet been any published studies, to our knowledge, of how ERP and qEEG patterns associated with work processes are directly relevant to specific mental health disorders there are some striking similarities. ^{Reference Belkić and Savić1} Clinical experience also suggests that work stressors that have an impact on neurophysiological function, as seen in ERP and qEEG, play a role in the mental health processes under examination. ^{Reference Belkić and Savić1}

The human and economic costs of work-related mental health disorders

Work-related mental health disorders are recognised as a major public health problem, affecting millions of people, with enormous human and economics costs. ^{Reference Ahola, Virtanen, Honkonen, Isometsä, Aromaa and Lönnqvist8} Lennart Levi, one of the founders of stress medicine, has stated that work-related mental health problems are among the leading causes of morbidity and premature death in many high-income countries. ^{Reference Levi, Rossi, Perrewé and Sauter9} Considering global trends in working life, these disorders are likely to become even more common in the years to come.

The challenge for the psychiatrist

In light of the above, it is clear that the psychiatrist encounters many patients whose clinical state has been profoundly affected by their work conditions. However, as is true for most specialty training outside occupational medicine (with some noteworthy exceptions, such as pulmonary medicine), clinical training in psychiatry has afforded little attention to the work environment. Consequently, psychiatrists generally lack the expertise needed to effectively handle work-related issues.

Our experience caring for patients with mental health disorders faced with job stressors

Over the years, in a number of contexts and in several countries, we have been called upon to provide care for patients with mental health disorders who have been exposed to a heavy load of job stressors. Because of our combined interest in mental health and the work environment, we have striven to develop effective strategies to help these patients continue or return to work under more salutogenic conditions. In our workup of patients experiencing mental health disorders, we incorporate three essential considerations: (a) is this a dangerously stressful work situation; (b) is the patient’s work situation contributing to his/her disorder, and if so, how; and (c) could workplace modifications help improve the patient’s clinical status and if so, how?

The need for a new clinical paradigm: ‘occupational psychiatry’

A recent editorial in the British Journal of Psychiatry ^{Reference Gilbody, Bower and Rick10} noting the link between the work environment and mental health disorders such as depression, has emphasised the need for integrating occupational and mental health services. We fully agree with these authors. Our suggestion is that the success of such efforts could be greatly aided by individual clinicians with the needed multifaceted expertise. For patients with mental health disorders, the establishment of trust and rapport with the clinician, based upon empathy, is a prerequisite for effective care. Being shunted from one caregiver to another, especially when disclosing often painful and sensitive topics, is anathema for such patients.

In this regard, it is vital to take into account the potential stigma surrounding psychiatric disorders. This is particularly important for the most serious manifestations, such as risk of suicide and most especially in relation to employment. Occupational medicine specialists do not usually have sufficient training in psychiatry to provide the necessary care for patients with the more serious mental health disorders. Thus, we contend that the psychiatrist would be best suited to handle work-related mental health disorders, insofar as he or she had the needed expertise in occupational medicine and stress medicine. The latter could be achieved via subspecialty training. Thereby, we envision a new clinical paradigm: ‘occupational psychiatry’. The patient together with the occupational psychiatrist would interact dynamically within the larger organisational setting. At the same time, further training in psychiatry for occupational medicine specialists would be a welcome complement, which could, in practice, promote better integration of occupational and mental health services. Overall, this approach would require developing supportive environmental conditions as part of a social ecological strategy. The practice of occupational psychiatry thus needs to be embedded in a larger framework. This new clinical paradigm can be seen as a strategy for preventing demoralisation, recognised as a critical task of modern psychiatry.