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Depression's Impact on Safety
THIS writer is of the opinion that terminal cancer is the only disease worse than depression. This article will not give (nor intends to give) the exact reason why I feel that way. However, upon reading the following, I hope the reader will discover the reason for him/herself.
Approximately 20 million people in the United States suffer some form of depression,1 while about 121 million suffer worldwide, according to the World Health Organization. It is among the leading causes of disability worldwide. Depression is the leading cause of disability as measured by Years Lived with Disability (YLDs) and the fourth-leading contributor to the global burden of disease in terms of Disability Adjusted Life Years (DALYs). The acronym is measured as the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.
Despite the statistics, discussion of this issue and the unique problems it presents to employees is limited. This is largely because the illness itself is not well understood, and employers assume depression is a personal matter left to mental health professionals. We see here, also, that assuming can be dangerous. Two-thirds of those suffering from the disease do not seek treatment. Some reasons are lack of resources, lack of trained providers, and the social stigma often associated with mental disorders, including depression. If these people are employed and do come to work, they do so with an illness that impairs them physically, mentally, and emotionally. It goes without saying that safety is considerably impaired--not just their own, but also the safety of others (depending on their assigned tasks).
The cost to employers in direct services and productivity is estimated to be $24 billion per year. Including medical costs, the figure could be as high as $88 billion.
What is Depression?
Hippocrates (460-377 B.C.), the father of medicine, thought depression was caused by an excess of black bile, a humor once believed to be secreted by the kidneys or spleen and to cause sadness or melancholy. The Egyptians were first to recognize depression and treat it with the power of suggestion, known today as hypnosis. Doctors and psychologists of the 17th through 19th centuries used the word "melancholia" for depression.
Today, depression is regarded as more than a mood disorder. It is considered "a serious illness that causes memory and thinking, mood, physical, and behavioral changes." It affects how one feels, thinks, sleeps, and acts.2 According to Eric Lanier (as well as others), when such feelings persist, recur, or become severe, one might experience depression and should seek medical help. Regarding eating, one may act like a perpetual eating machine or (the opposite extreme) barely eat and may need to be force-fed. Also, one might be unable to sleep, while others might sleep continually and have trouble getting out of bed.
Depression can disrupt an entire life routine, ranging from the work world to the social world. In addition to affecting eating and sleeping, it can reduce sex drive, diminish self esteem and one's outlook on life, and can affect how one acts. According to the Mayo Clinic, depression exhibits itself in four different ways:
- Mood changes: sad, helpless, hopeless; crying spells; agitation and irritability; bored easily, nothing of interest; recurrent thoughts of suicide.
- Cognitive changes: trouble remembering details, concentrating, and making decisions; difficulty accomplishing tasks.
- Physical changes: sleeps and/or eats too much or too little; diminished sex drive; lack of energy (fatigue); general aches and pains.
- Behavior changes: neglects appearance; loses track of things; withdraws from people; conflicts with people; misses deadlines; poor self-esteem; gloomy outlook.3
One is said to have major depression if exhibiting at least four of the symptoms from any of these categories and having been depressed for at least two weeks. If exhibiting at least two symptoms with at least two weeks of depression, one then is thought to have a mild case known as "dysthymia."
Although not everyone reacts the same way to the same circumstances, potential triggers include stressful situations; death and other losses (job for example); relationship problems; major life events (children leaving home); past experiences (child abuse or war); chemical dependence; prescription medications; medical conditions (cancer, heart disease, sleep apnea, chemical imbalance); chronic pain; and psychological issues.
Depression originally was thought primarily to be a woman's disease, but many men are struck by the disease. Yet they have tended to cover it up because, according to past social myths, men are not supposed to be vulnerable. Thus, many men have chosen to place themselves at risk rather than acknowledge the symptoms simply due to passé attitudes and myths.
Stressful occupations are a factor in depression. Among them are doctors and various managers; the gravity of their decisions may cause self-doubt and self-criticism. According to the National Institute for Occupational safety and Health, farmers had the highest death rate from stress-related conditions. In another study conducted by the Institute of Rural and Environmental Health, farmers were reported to have higher depression and suicide rates than other occupations. Furthermore, a study by Teruichi Shimomitsu found that the occupations offering a low number of days off, the inability to switch off, a lack of a sense of control, and a lack of a sense of support from the supervisor caused undesirable levels of occupational stress.4
Employers Should Worry
Depression in the workplace has not been given a high priority until recently, despite studies showing the rates of depression are highest between ages 25 and 44. The cost to employers in direct services and productivity is estimated to be $24 billion per year. If medical costs are figured in, the cost could be as high as $88 billion.5 According to a spring 2003 study at the University of Oregon, the cost is $44 billion per year--20 percent of the costs for all mental diseases.
Depressed workers are more accident-prone because of depression's interference with concentration and focus. For example, a depressed worker might lose a finger on a machine due to prolonged inattention. Another depressed worker might cause his/her forklift to turn over and fall to the ground due to improper handling and failure to follow safe operating procedures from the inability to pay close attention to his/her actions. Also, a depressed worker might miss work because of sickness. People who suffer from a mild form of depression often have poor physical and social functioning and risk future, more severe depression if they remain untreated. In "Depression in the Workplace: Costs and Barriers to Treatment," R.J. Goldberg and S. Steury state that patients with depression showed impairments in functioning that were comparable to or worse than those of patients with medical disorders.6
High-hazard occupations are of particular concern. These jobs carry a high stress level directly related to depression development in workers. Some examples of such occupations include, but are not necessarily limited to, police officers, truck drivers, and miners, to name just a few. Cumulative effects can cause one to reach his/her "coping threshold."7 Exceeding the threshold puts one's ability to function at risk. Many of these employees also have secondary problems, such as drug or alcohol abuse, further impairing their abilities.
Before approaching the employee, supervisors should document the signs of depression, such as:
- marked decrease in job performance
- frequently missed deadlines
- working more slowly than usual
- making excuses for not completing work
- frequently calling in sick
- appearing listless; unable to concentrate
- frequently looking distracted or "far away"
- showing decreased involvement in work
- withdrawal from interaction with co-workers
Supervisors should be trained not to moralize. In fact, this might only aggravate the condition. Instead, they should inform workers about available resources through the employer and the need to use them. Such information usually is available in the Human Resources department. Treatment has a high success rate; but not everyone wants to seek treatment because of the possible stigma this might carry. Regarding any possible stigma, we are more fortunate today by having greater knowledge of this disease than what was available more than 100 years ago, when the general attitude was that anyone with depression (or any mental disorder) was to be committed and separated from society. Senior management should clearly support the use of health and wellness programs so supervisors and employees will use them routinely.
People react to stress differently. What is stressful for one is not so for another. However, most job stressors found to cause or enhance depression fall into one of six categories:
1) Control: low decision-making latitude;
2) Demands: night shift work, long work hours, too much to do in too little time;
3) Environment: work performed in high-hazard environments;
4) Role: roles not well defined, major procedural and policy changes not well communicated;
5) Relationship: existing conflicts between employees or employee groups working together;
6) Support: job insecurity, intensive effort with few rewards.8
Safety, health, and environmental professionals can play an integral, proactive role in alerting their organizations to stressors that, if unresolved, can adversely affect productivity and mental health. These professionals also should be familiar with what depression is, its causes, and how to recognize and address it in the workplace.
Two different experiences are quoted by the Depression and Bipolar Support Alliance:
- "Because depression is a medical condition and not something one can just 'will' himself out of, I was not 'fixed' once I escaped my turbulent home life."9
- "After the flood I couldn't concentrate. I had lost everything; my house, everything in my house, my cars. Everything I owned was gone. And the city needed me to work just two days after it happened. They had me out riding around looking for manhole covers that had floated away. I was driving the city truck thinking about the flood, and worrying about what I was going to do and suddenly I would realize that I was 10 miles from nowhere and didn't know how I had got there. I didn't find many manhole covers."10
Medications vs. Talk Therapy
According to Consumer Reports (October 2004), with or without medications, most who sought care for depression or anxiety gained relief. A survey of thousands of their subscribers who received treatment for those conditions found that:
- A combination of talk therapy and medications worked best. But "mostly talk therapy" was about as effective if it lasted for 13 or more visits. Thus, if patients stuck with their visits, their outcome was better than those relying mainly on medication.
- "Mostly drug" therapy was also effective for many people. Drugs had a quicker impact on symptoms than talk therapy, but it often took trial and error to find a medication that worked without unacceptable side effects.
- 40 percent of those who took antidepressants complained of adverse sexual side effects.
- Care from primary care doctors was effective for people with mild problems but less so for people with severe ones.11
Medications on the market approved for depression present common side effects of drowsiness or disorientation, decreased sexual interest or performance, and weight gain. According to Consumer Reports, the number of U.S. children taking antidepressants has more than doubled since the early 1990s,12 when some of these drugs began to dominate the market. The FDA says to watch for signs of increased suicidal thinking in children and adults who start taking antidepressants.
Why can't the drug companies come up with an antidepressant that energizes the patient? This writer, in addition to talk therapy, has tried Elevil (now passé), Prozac, Effexor, and Zoloft, and the side effects have been the same: no energy to follow through with necessary tasks, be they at work or at home. How safe is that when driving a car or forklift or operating heavy machinery?
High-hazard occupations hold the greatest liability for the employer because of the stress associated with these positions and the link between occupational stress and depression. The cost of this illness to business is forbidding, yet it may be avoided if the illness is recognized and treated in the early stages.
This article appeared in the October 2006 issue of Occupational Health & Safety.
- Lanier, Eric, "Depression: The Hidden Workplace Illness," Professional Safety, October 2003, p.27.
- Loc. Cit.
- Ibid., p. 28.
- Loc. Cit.
- Ibid., p. 29.
- Loc. Cit., Goldberg, R.J. and S. Steury, "Depression in the Workplace: Costs and Barriers to Treatment," Psychiatric Services, 52(2001):639-1643.
- Lanier, op. cit., p. 29.
- Ibid., p. 30.
- Loc. Cit., "Personal Stories of Depression," Depression and Bipolar Support Alliance (DBSA, www.dbsalliance.org).
- Ibid., p. 29.
- Consumer Reports, October 2004, p. 22.
- Ibid., p. 28.
This article originally appeared in the October 2006 issue of Occupational Health & Safety.