For those with depression, return to work positive, but flexibility, time necessary
Some can return quickly, while others need slower re-entry
Helping an employee return to work after a diagnosis of depression is similar in some ways to planning return to work after a physical injury, but depression demands a different consideration of limitations, timing, and clinical monitoring than most physical injuries or illnesses.
"Return to work is positive [for those suffering from depression]," says Elayne Preston, RN, DOHS, COHN(C), COHN-S/CM, occupational health consultant for Employee First Health and Safety Consulting in Surrey, British Columbia. "But often it needs to be a gradual work re-entry rather than a full return right away."
The occupational health nurse's role can begin before diagnosis, helping the employee or the employee's supervisor identify whether symptoms of depression might be present, as well as encouraging and supporting the employee in seeking the care of a physician.
Spotting the signs of depression
The occupational health nurse might spot signs of depression in an employee, but Preston says the employee's supervisor likely would notice changes first.
"What supervisors pick up on is declining work performance," she says. "They pick up on cognitive loss, memory loss, and concentration loss. Supervisors will pick up on that long before anyone else."
Rather than trying to spot symptoms of depression in employees, the occupational health nurse's role is more effective in educating supervisors and employees about what depression is and what the symptoms are.
"If you can identify [depression] early, they can get help faster," she says. "Depression develops over time, not overnight, so the signs are going to show up over time."
Symptoms that meet the diagnostic criteria for Major Depressive Disorder, according to the American Psychiatric Association, are:
- depressed mood most of the day, nearly every day;
- marked loss of interest or pleasure in all or almost all activities most of the day, nearly every day;
- significant weight loss or gain;
- sleep problems — getting too little or too much nearly every day;
- psychomotor agitation or retardation — the person is either on "fast-forward or slow motion," walking or talking very slowly or very rapidly, compared to previous habits;
- fatigue or loss of energy nearly every day;
- difficulty concentrating and making decisions nearly every day;
- feelings of worthlessness or excessive or inappropriate guilt nearly every day;
- recurrent thoughts of death or suicidal ideation or attempt.
The mnemonic "SIG E CAPS + Mood" (Sleep, Interests, Guilt, Energy, Concentration, Appetite, Psychomotor, and Suicide, plus depressed Mood) often is used as a checklist in diagnosing depression. The diagnosis is indicated in a person who experiences five of the nine symptoms in a two-week period; two of the symptoms must be depressed mood and loss of interest, and they must reflect a change from the person's normal condition.
"Sometimes, the person may not realize they're depressed, so occupational health nurses can help put the pieces together for them and encourage them to see their physician," Preston says. "We try to do prevention and encourage people to be diagnosed through their physicians.
"I think depression is different than an injury or illness of a physical nature. The limitations are different and the return to work is different," says Preston. "As occupational health nurses, we see depression that has not been diagnosed or treated, and then later, we help the walking wounded return to work."
Many employees continue to work with depression. But often, time off — as much as several weeks — is required for medication to take effect in restoring function.
"Once a diagnosis is made, whether the person is off work or not, the nurse's role is to encourage the person to continue treatment," she says.
Often, that encouragement needs to include educating and reassuring the employee about prescribed antidepressant medications.
"Sometimes they have thoughts about the medications — that they are addictive or have side effects that would render them incapable of working — that really aren't the case," says Preston. "So they resist taking the medications, and they aren't able to regain enough function to do the talk therapy, and that prolongs their recovery."
People trying to recover from depression should be reassured that their prescribed medications will improve functioning and speed recovery, she says.
"Occupational health nurses can make sure the employee receives the appropriate medical treatment by connecting with medical resources in their communities and finding resources for group therapy," she says. "Connecting the employee with the company's [employee assistance program], if one is available, would, of course, be important."
With moderate to severe depression, time off from work is followed by a return to work with substantial limitations.
"With severe depression, there are serious concentration, memory, and cognitive limits," explains Preston. "In the initial stages of treatment these limitations preclude the employee from working. Antidepressant medications require four to six weeks on average to be effective."
Determining how long that absence should be often falls to the occupational health nurse in conjunction with the treating physician, along with educating supervisors that the time off is needed and that it's OK for them to be out of the workplace temporarily, she says.
Working with the employee's physician, the occupational health nurse can help ensure the re-entry program is safe and reasonable and that the physician understands the true nature of the job.
"Sometimes you have to prompt doctors, or they have trouble articulating [their patient's] limits to me — that's not the case with a broken leg, but it seems to be when you're talking about depression," she points out.
Preston says she evaluates signs employees are regaining control of their emotional health prior to developing a return-to-work plan.
"I need to see that they have some better control over their emotions, that there are few crying spells," she says. "I also need to see that they have regained some ability to concentrate — that they are able to pay bills, can read an entire newspaper article, or watch an entire movie without losing concentration."
Other limits that can be important in re-entry for employees dealing with depression include:
- The ability to tolerate distractions. This might require providing alternate work duties or placing the employee in a less distracting, busy or noisy environment.
- Stamina. Some employees have more energy in the morning, so setting their work hours to fall in the morning, rather than in the afternoon, might be more productive.
- Ability to multitask and stay focused. "Especially for a manager, who has 15 balls in the air on a normal day, there might need to be some limits on tasks that require multitasking."
- Interpersonal contact. The employee can find dealing with the public or the possibility of confrontation difficult, and "that can be a huge limitation," Preston says. Alternate duties would be recommended initially in those cases to allow for a gradual return to those types of tasks.
- Deadline pressures. Preston recommends finding alternate tasks that don't carry stressful deadline pressures.
- Medicine side effects. While following the physician's prescription for medication is important for recovery, there are some side effects that can influence a return-to-work plan. For example, if the medication makes the person groggy in the morning, having him or her come in to work later in the morning or in the early afternoon would make sense.
"Depression is seen at different severities in different people," Preston points out. "So you have to look at each case individually when considering limitations and a re-entry to work, but if someone has been off work for a while, those are the limitations I generally anticipate."
Benefits to employer in treatment
More than 70% of people diagnosed with depression are employed, with depression resulting in 400 million lost workdays a year, according to a study by CIGNA Behavioral Health.
That's why employers have a huge stake in promoting treatment for depression, says Keith Dixon, PhD, president of CIGNA Behavioral Health.
"We need to convince company CEOs that the treatment of depression is good business strategy, and that begins by documenting the value of depression treatment beyond what exists today in academic and scientific journals," Dixon said.
In the private sector, Dixon notes, depressed employees use, on average, more than $4,000 per year in medical services vs. less than $1,000 per year used by employees without depression, making depression a driving force in health care costs. At the same time, employers bear many indirect costs of depression when it isn't treated, Dixon said.
[For more information, contact:
- Elayne Preston, RN, DOHS, COHN(C), COHN-S/CM, Employee First Health and Safety Consulting, Surrey, British Columbia. Phone: (604) 531-2848. E-mail: [email protected]
- American Psychiatric Association, 750 First Street, NE, Washington, DC 20002-4242. Phone: (800) 374-2721 or (202) 336-5500. Web site: www.apa.org.
- CIGNA Behavioral Health, 11095 Viking Drive, Suite 350, Eden Prairie, MN 55344. Phone: (800) 433-5768.]
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