Depression is an enormously important topic in the area of workplace mental health, not only in terms of the impact depression can have on the workplace, but also the role the workplace can play as an aetiological agent of the disorder.
In a 1990 study, Greenberg et al. (1993a) estimated that the economic burden of depression in the United States that year was approximately US$ 43.7 billion. Of that total, 28% was attributable to direct costs of medical care, but 55% was derived from a combination of absenteeism and decreased productivity while at work. In another paper, the same authors (1993b) note:
“two distinguishing features of depression are that it is highly treatable and not widely recognized. The NIMH has noted that between 80% and 90% of individuals suffering from a major depressive disorder can be treated successfully, but that only one in three with the illness ever seeks treatment.… Unlike some other diseases, a very large share of the total costs of depression falls on employers. This suggests that employers as a group may have a particular incentive to invest in programs that could reduce the costs associated with this illness.”
Everyone feels sad or “depressed” from time to time, but a major depressive episode, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) (American Psychiatric Association 1994), requires that several criteria be met. A full description of these criteria is beyond the scope of this article, but portions of criterion A, which describes the symptoms, can give one a sense of what a true major depression looks like:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is number 1 or 2.
- depressed mood most of the day, nearly every day
- markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive or inappropriate guilt nearly every day
- diminished ability to think or concentrate, or indecisiveness nearly every day
- recurrent thoughts of death, recurrent suicidal ideation, with or without a plan, or a suicide attempt.
Besides giving one an idea of the discomfort suffered by a person with depression, a review of these criteria also shows the many ways depression can impact negatively on the workplace. It is also important to note the wide variation of symptoms. One depressed person may present barely able to move to get out of bed, while others may be so anxious they can hardly sit still and describe themselves as crawling out of their skin or losing their mind. Sometimes multiple physical aches and pains without medical explanation may be a hint of depression.
The following passage from Mental Health in the Workplace (Kahn 1993) describes the pervasiveness (and increase) of depression in the workplace:
“Depression … is one of the most common mental health problems in the workplace. Recent research … suggests that in industrialized countries the incidence of depression has increased with each decade since 1910, and the age at which someone is likely to become depressed has dropped with every generation born after 1940. Depressive illnesses are common and serious, taking a tremendous toll on both workers and workplace. Two out of ten workers can expect a depression during their lifetime, and women are one and a half times more likely than men to become depressed. One out of ten workers will develop a clinical depression serious enough to require time off from work.”
Thus, in addition to the qualitative aspects of depression, the quantitative/epidemiological aspects of the disease make it a major concern in the workplace.
Major depressive disorder is only one of a number of closely related illnesses, all under the category of “mood disorders”. The most well known of these is bipolar (or “manic-depressive”) illness, in which the patient has alternating periods of depression and mania, which includes a feeling of euphoria, a decreased need for sleep, excessive energy and rapid speech, and can progress to irritability and paranoia.
There are several different versions of bipolar disorder, depending on the frequency and severity of the depressive and manic episodes, the presence or absence of psychotic features (delusions, hallucinations) and so on. Similarly, there are several different variations on the theme of depression, depending on severity, presence or absence of psychosis, and types of symptom most prominent. Again, it is beyond the scope of this article to delineate all of these, but the reader is again referred to DSM IV for a complete listing of all the different forms of mood disorder.
The differential diagnosis of major depression involves three major areas: other medical disorders, other psychiatric disorders and medication-induced symptoms.
Just as important as the fact that many patients with depression first present to their general practitioners with physical complaints is the fact that many patients who initially present to a mental health clinician with depressive complaints may have an undiagnosed medical illness causing the symptoms. Some of the most common illnesses causing depressive symptoms are endocrine (hormonal), such as hypothyroidism, adrenal problems or changes related to pregnancy or the menstrual cycle. Particularly in older patients, neurological diseases, such as dementia, strokes or Parkinson’s disease, become more prominent in the differential diagnosis. Other illnesses that can present with depressive symptoms are mononucleosis, AIDS, chronic fatigue syndrome and some cancers and joint diseases.
Psychiatrically, the disorders which share many common features with depression are the anxiety disorders (including generalized anxiety, panic disorder and post-traumatic stress disorder), schizophrenia and drug and alcohol abuse. The list of medications that can cause depressive symptoms is quite lengthy, and includes pain medications, some antibiotics, many anti-hypertensives and cardiac drugs, and steroids and hormonal agents.
For further detail on all three areas of the differential diagnosis of depression, the reader is referred to Kaplan and Sadock’s Synopsis of Psychiatry (1994), or the more detailed Comprehensive Textbook of Psychiatry (Kaplan and Sadock 1995).
Much can be found elsewhere in this Encyclopaedia regarding workplace stress, but what is important in this article is the manner in which certain aspects of stress can lead to depression. There are many schools of thought regarding the aetiology of depression, including biological, genetic and psychosocial. It is in the psychosocial realm that many factors relating to the workplace can be found.
Issues of loss or threatened loss can lead to depression and, in today’s climate of downsizing, mergers and shifting job descriptions, are common problems in the work environment. Another result of frequently changing job duties and the constant introduction of new technologies is to leave workers feeling incompetent or inadequate. According to psychodynamic theory, as the gap between one’s current self image and “ideal self” widens, depression ensues.
An animal experimental model known as “learned helplessness” can also be used to explain the ideological link between stressful workplace environments and depression. In these experiments, animals were exposed to electric shocks from which they could not escape. As they learned that none of the actions they took had any effect on their eventual fate, they displayed increasingly passive and depressive behaviours. It is not difficult to extrapolate this model to today’s workplace, where so many feel a sharply decreasing amount of control over both their day-to-day activities and long-range plans.
In light of the aetiological link of the workplace to depression described above, a useful way of looking at the treatment of depression in the workplace is the primary, secondary, tertiary model of prevention. Primary prevention, or trying to eliminate the root cause of the problem, entails making fundamental organizational changes to ameliorate some of the stressors described above. Secondary prevention, or trying to “immunize” the individual from contracting the illness, would include such interventions as stress management training and lifestyle changes. Tertiary prevention, or helping to return the individual to health, involves both psychotherapeutic and psychopharmacological treatment.
There is an increasing array of psychotherapeutic approaches available to the clinician today. The psychodynamic therapies look at the patient’s struggles and conflicts in a loosely structured format that allows explorations of whatever material may come up in a session, however tangential it may initially appear. Some modifications of this model, with boundaries set in terms of number of sessions or breadth of focus, have been made to create many of the newer forms of brief therapy. Interpersonal therapy focuses more exclusively on the patterns of the patient’s relationships with others. An increasingly popular form of therapy is cognitive therapy, which is driven by the precept, “What you think is how you feel”. Here, in a very structured format, the patient’s “automatic thoughts” in response to certain situations are examined, questioned and then modified to produce a less maladaptive emotional response.
As rapidly as the psychotherapies have developed, the psychopharmacological armamentarium has probably grown even faster. In the few decades before the 1990s, the most common medications used to treat depression were the tricyclics (imipramine, amitriptyline and nortriptyline are examples) and the monoamine oxidase inhibitors (Nardil, Marplan and Parnate). These medications act on neurotransmitter systems thought to be involved with depression, but also affect many other receptors, resulting in a number of side effects. In the early 1990s, several new medications (fluoxetine, sertraline, Paxil, Effexor, fluvoxamine and nefazodone) were introduced. These medications have enjoyed rapid growth because they are “cleaner” (bind more specifically to depression-related neurotransmitter sites) and can thus effectively treat depression while causing much fewer side effects.
Depression is extremely important in the world of workplace mental health, both because of depression’s impact on the workplace, and the workplace’s impact on depression. It is a highly prevalent disease, and very treatable; but unfortunately frequently goes undetected and untreated, with serious consequences for both the individual and the employer. Thus, increased detection and treatment of depression can help lessen individual suffering and organizational losses.