Watch for workplace depression; it's a work disability and your responsibility
OH professionals are frontline defense for workers with depression
Mention depression as a workplace disability, and the first reaction from a lot of people is likely to be a snicker and a comment about how anything can blamed on the employer. But the truth is a lot more sobering. Occupational health professionals often are the first medical professionals with a chance to spot the seriously depressed worker and offer help, and that means you must know how to make the most of that opportunity.
The issue is becoming more important as courts declare depression a valid workplace disability. Not only are you obligated as a health professional to do the best thing for the depressed worker, but you need to address the problem before it turns into a costly disability case for your client. Just like a case of carpal tunnel syndrome, you'll be doing a favor for both the employer and the employee if you spot depression early.
The value of early intervention is the key thing for occupational health professionals to keep in mind, says Deann Zens, MA, CEAP, ACADC, director of the employee assistance program and addiction services at Jennie Edmundson Hospital in Council Bluffs, IA. She treats hospital employees, but she also works with the hospital's occupational health program to provide services to employers in the community. Zens explains that occupational health professionals usually are not expected to take on all the responsibility for treating a seriously depressed worker but says their ability to detect the problem is extremely valuable.
Many workers are reluctant to step forward and admit they are battling depression. Indeed, many will not even know that they are clinically depressed. But the occupational health provider has the unique opportunity to see them in their workplace, a familiar environment where any signs of depression may stand out.
"Occupational health professionals can be instrumental in getting people help as early as possible," Zens says. "You can spot these people and get them to professionals who can provide further assessment and treatment."
Depressed workers are nothing new, but there has been a trend in recent years to hold employers responsible for workers who are so stressed by workplace conditions that they become clinically depressed.
Court ruling illustrates problem
One of the most influential court rulings came out of North Carolina in December 1997, when the state Industrial Commission ruled that psychological injury, including depression, can entitle a person to workers' compensation.1 Deputy Commissioner Morgan Chapman pronounced major depression "an occupational disease" when it is the result of working conditions.
The subject of the ruling, Teresa Williford, was a 40-year-old woman who had worked as a service representative for BellSouth Telecommunications for 11 years. Recently, according to her lawsuit against the employer, BellSouth greatly stepped up the work demands on service representatives and instituted monitoring that created extreme stress. The company also urged Williford to work a lot of overtime, and she was sometimes required to work as many as 12 days in a row. She was diagnosed with diabetes in 1985, and she alleges unsympathetic supervisors made it difficult for her to manage her blood sugar levels.
Williford's doctor became concerned about her stress level and sent a note to the employer restricting the number of consecutive days she could work; he also said she needed to get up and walk for a few minutes each hour because she has fibromyalgia. But by January 1996, Williford had become severely depressed and was contemplating suicide. She was unable to work at that point, and while BellSouth paid disability benefits to her, the company denied workers' compensation benefits with the argument that Williford's depression was not work-related.
The North Carolina Industrial Commission disagreed, ruling Williford "developed major depression which was an occupational disease due to causes and conditions characteristic of and peculiar to her employment. . . ." The commission ordered BellSouth to pay Williford $443.68 per week in workers' compensation for as long as she is disabled by depression. Williford's attorney, Sally Keith, RN, JD, in Raleigh, NC, was awarded a fee equal to 25% of Williford's net compensation.
Keith says that while the case is not the first of its kind, such cases will be seen more frequently. More courts are recognizing the legitimacy of depression as a workplace disability, she says, and trends in the American work force are likely to create more cases. She cites downsizing and the type of increased workload and increased monitoring that were factors in the Williford case.
"These are legitimate claims," Keith says. "This is not just 'my job is hard, and I'm stressed about it.' The law makes that distinction quite clear. The standards are very strict and dependent on the doctor's testimony much more than what the claimant has to say."
Anyone can fall victim to depression, but to be work-related, the clinical depression must result from a job situation that puts the person at greater risk of depression than the average person.
Cases are difficult for employees to pursue
Allegations of emotional injury are much more difficult to pursue than the more commonly understood physical injuries, Keith says. They are far more difficult to get compensated, and it is common for employers to reject the claims at first. The attorney says she isn't surprised by that reaction, and she doesn't necessarily discourage it.
"These are not popular cases. Nobody likes these," she says. "Nobody in their right mind is going to say, 'OK, we'll pay all these claims.' The health care providers need to take a close look at these cases and determine their merits."
Though she was on the winning side of the Williford case, Keith says there is a great deal of opportunity to bring inappropriate claims of depression or other emotional injury in the workplace. She advises occupational health providers to look closely at the claim, neither assuming it is valid just because you are sympathetic to the employee nor rejecting it just because everyone has a bad day at work sometimes.
Once you've assessed the situation, you may want to make a recommendation to the employer as to whether the claim seems to be a genuine case of depression caused by working conditions. (In some cases, such a recommendation must come from the mental health professional to whom you have referred the worker. Either way, your client will expect you to provide some guidance.)
Keith says it is reasonable to demand proof that the condition is job-related before agreeing to compensation, but she also says there is no reason to litigate if there is reliable proof. And if it seems that the depression truly was caused by conditions in the workplace, does that always mean that the employer was an oppressive slave driver? Not necessarily, Keith says.
"Being employed is stressful, so I'm not sure the employer is doing wrong just because the evidence shows that the employee's depression is caused by factors in the workplace," she says. "But in the Williford case, they had other workers depressed for the same reasons, and it was very common. When a company starts to see that kind of thing, they need to start re-evaluating what they're doing and find out what's making these people break down."
That sort of pattern ultimately makes the employer more responsible for the emotional injuries to workers, the attorney says. The pattern more conclusively shows that the depression is caused by the workplace conditions, rather than just one worker's personal susceptibility or outside factors.
"When they don't look at that, and they just keep driving and driving, pushing workers even harder, that's when it can reach the level of wrongdoing," Keith warns.
Occupational health professionals should get the message to their clients that emotional disorders can be work-related disabilities, Zens says. The workers' compensation cases related to depression can be just as costly as physical injuries, so the employer should be just as eager to get employees the care they need.
An occupational health nurse or physician is well-suited for screening employees for depression, anxiety, and other emotional disorders, Zens says. Some nurses and physicians may want to pursue a refresher course on emotional disorders from an employee assistance program or mental health providers in the community. But Zens says most will be comfortable in spotting the early warning signs of depression. Zens suggests keeping an eye out for these common warning signs of depression in the workplace:
· lack of concentration;
· mistakes the employee wouldn't ordinarily make;
· less attention to detail;
· accidents that occur because of poor concentration or attention to detail;
· unusual agitation;
· more absenteeism;
· overall malaise;
· losing interest in friendships, peers.
Occupational health providers sometimes can spot those symptoms just through their normal interactions with the workers, and sometimes others in the workplace will alert the health provider. A supervisor or co-worker may be the first to notice the changes in a depressed worker. Watch for the symptoms more closely if you know a worker is suffering stress from a known cause, such as the death of a co-worker or an impending layoff. Also consider what you know of the employee's outside stressors, such as a divorce or alcohol problems.
"When you notice those signs in someone, document that and move them on to the professionals who can do a further assessment," Zens says. "That may be your occupational health physician, or the employee's EAP [employee assistant program] would be an obvious choice. If you don't have those resources, you should [cultivate] a relationship with a mental health provider in the community so that you can make those referrals." (For a sample of an EAP paycheck stuffer, see p. 67.)
Zens notes some occupational health physicians will feel comfortable treating a workers' depression with the necessary medications as well as referring the worker for therapy. Others may feel that treating depression is a bit outside their normal scope of practice and prefer to refer the patient on to a mental health professional. (For advice on working with patients suffering from depression, see story, p. 68. )
Patients usually respond well to offers of help, Zens says. They often are relieved that someone has recognized their plight and offered a way out.
"You let them know that this is their choice whether to pursue the assessment," she explains. "You tell them that no one is forcing them, and they are free to follow through or not. It helps them feel that they haven't lost control, and in my experience, very few say they don't want any help at all."
Reference
1. Teresa Y. Williford v. Bellsouth Telecommunications, North Carolina Industrial Commission; I.C. No. 640303.
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