Mental health disorders in workers

Introduction

In modern society, maintaining the mental health of the working population is a priority task due to the serious consequences of mental disorders for employment, productivity, and well-being of workers [1]. The world mental health system takes into account the high prevalence of mental illnesses in workers and the economic burden associated with the cost of treating patients with disability and a sufficient frequency of disability due to mental illnesses¹.

According to the World Economic Forum (2011) forecast², the cumulative global impact of mental disorders, in terms of lost economic benefits, between 2011 and 2030 will be USD 16.3 billion.

Mental disorders (depression, amentia, dementia) are widespread in developed countries, which allows regarding this phenomenon as a “systemic crisis in psychiatry” [2]. A high prevalence of mental disorders was observed at all stages of the new coronavirus infection (COVID-19) pandemic and in the post-COVID period among medical workers [3].

The significant role of psychosocial production factors in the development of mental health disorders triggers the need to improve the primary prevention of mental disorders in workers through the management of psychosocial risks in the workplace [4]. Today, the development and implementation of a comprehensive integrated approach to supporting workers with mental health problems in the workplace are relevant [5].

The state of mental health of the population in the world, general trends

According to the WHO, mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation of well-being and effective functioning for both the individual and the community”³.

The preservation and maintenance of the mental health of the population is a priority task in the activity of modern society, which is associated with the current trend toward a steady increase in the proportion of mental health disorders in people, including the workers employed in various sectors of the economy. In recent years, 20–25% of the world's population has been suffering from mental and behavioral disorders, while mental health is impaired in the course of life in every third or fourth person [6].

Mental health is recognized as an essential component of a healthy personality. The WHO Constitution states that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”⁴.

According to the Comprehensive Mental Health Action Plan 2013–2020 adopted by the World Health Assembly⁵, mental health is an integral part of health.

In Russia, the concept of health is enshrined in Federal Law No. 323: health is “a state of physical, mental and social well-being with the absence of disease disorders of the organs and systems of the body”⁶.

 “Mental disorders, in contrast, are disorders of a person's mental health, often characterized by some combination of disturbing thoughts, emotions, behaviors, and relationships with others. Examples of mental disorders are depression, anxiety disorder, behavioral disorder, bipolar disorder, and psychosis”⁷.

According to WHO, in 2016 the prevalence of mental disorders in the European region was over 110 million people, equivalent to 12% of the total population in the region. When substance use disorders are included, this number increases by 27 million people (up to 15% of the total population). The most common mental disorders in the European region are depression and anxiety disorders (5.1% and 4.3% respectively). Suicide is closely associated with mental health disorders, with about 90% of these being due to mental illnesses in high-income countries⁸.

Anxiety disorders average 12.6–17.2% within one year and 14.6–24.9% during life [7].

To date, the worldwide prevalence of mental health disorders (depressive and anxiety disorders, stress-related conditions) has increased and averages 17.6% [1].

According to the WHO, the continuing downward trend in mental health worldwide is driven by rapid social changes, stressful work environments, gender discrimination, social exclusion, unhealthy lifestyles, physical disorders, and human rights abuses⁹.

In the structure of the Global Burden of Disease, mental and behavioral disorders among the population concern the most active age group (15–49 years) [8]. According to WHO (2015), one of the important public health goals is to reduce by 2030 premature deaths from noncommunicable diseases by one-third through prevention, treatment, and promotion of mental health and well-being¹⁰.

Stress and anxiety are now recognized as major modifiable risk factors for coronary heart disease, and psychosocial stress – as a risk factor for cardiovascular disease (CVD). According to the conclusion of the expert council of cardiologists, anxiety disorders as a psychoemotional factor increase the risk of fatal myocardial infarction by 1.9 times, and the risk of sudden death – by 4.5 times [9].

According to the Strategy for the Development of Healthcare in the Russian Federation for the period up to 2025¹¹, there is an increase in anxiety and depressive disorders worldwide, the risk of which is directly related to socio-psychological factors. In this regard, the objectives of the strategy for the formation of a healthy lifestyle of the population¹² include improving the detection and prevention of depressive, anxiety, and post-stress disorders, improving regular medical checkups (using information technologies), and increasing the availability of psychological and psychotherapeutic assistance.

Numerous foreign and domestic data confirm the existence of problems associated with the assessment and control of the mental health of the working population and the prevention of its violation. Currently, about 15% of the working population in the world needs psychiatric care, and in Russia, their share is 25% [10].

The results of domestic epidemiological studies demonstrate that the most accurate data on the prevalence of mental disorders can be obtained by the method of unselected psychoprophylactic examination of a certain subpopulation, while the examination of workers in the conditions of professional activity is of great importance [11].

The state of mental health in the working population

Today, one of the priorities in the world is the preservation of the mental health of the working population. Promoting mental well-being is one of the main areas of occupational medicine since mental health largely determines the efficiency of the professional activities of workers [12].

Numerous studies by domestic and foreign authors confirm the relevance of studying, assessing, monitoring, and preventing mental health disorders in the working population [4].

The Declaration of Helsinki (2005), adopted as a result of a meeting of WHO Member States, emphasized the need to include work-related mental health issues in occupational health and safety programs¹³.

Over the past decade, the prevalence of severe mental disorders among the working population in countries with a high standard of living was 5%, and that of mild disorders constituted 15% [13]. At the same time, the complexity of the determinants of mental health disorders in workers was emphasized [14]. When analyzing health data of 1,954 workers employed at 63 jobs in Canada (2009–2012), a significant number of cases of psychological disorders (32.2%), depression (48.4%), and emotional exhaustion (48.8%) were revealed. Identified mental disorders were associated both with work factors (conflicts with colleagues, high demands, lack of safety in the workplace) and individual causes (conflicts between work and family life, tensions in the family) [14].

According to the Organization for Economic Cooperation and Development (OECD)¹⁴, people with mental disorders are 20% less likely to be employed and three times more likely to be unemployed than people without mental disorders.

Mental disorders have an impact on the working capacity of the population. In terms of YLD (expected number of years of healthy life lost due to disability), mental disorders rank first in the world (32.4%), exceeding the level of CVD, diabetes, chronic respiratory diseases, and cancer, and in terms of DALY (the sum of years of life lost due to mortality), mental disorders reach the level of CVD [15].

Depression is a widespread mental disorder, which is registered in 350 million people in the world¹⁵. Depression and anxiety are associated with losses in the global economy of USD 1.15 trillion annually, with a third of these costs accounted for by reduced productivity in the workplace [16].

Among the factors that induce mental health disorders, an important place is occupied by stress in the workplace [17]. According to WHO, about 18% of all problems in the working population are related to stress, depression, and anxiety.¹⁶

Psychosocial stress risk factors are gaining importance in the modern world. The intensification of labor, changing market needs, the introduction of digital technologies, high competition, instability, reduced employment opportunities, and often a lack of attention to the psychophysiological capabilities of the individual are accompanied by an increase in psychoemotional stress in work teams [18].

The concepts of the psychosocial factor, psychosocial risk, and work-related stress are enshrined in the National Standard of the Russian Federation (GOST R 55914-2013)¹⁷:

- “The psychosocial factor is the interaction between the content of the work and its organization and management, other external and organizational conditions, competencies and needs of employees”;

- “Psychosocial risk is the likelihood that psychosocial factors will have a dangerous impact on the health of the worker through his perception and experience and the severity of painful condition caused by them”;

- “Work-related stress is a combination of emotional, cognitive, behavioral, and psychological responses to adverse and harmful aspects of job responsibilities, organization and working conditions.”

Six key health hazards in the workplace are identified in the National Standard: Demand, Control, Support, Relationships, Role, and Change.

According to the International Handbook for Psychosocial Epidemiology¹⁸, psychosocial factors at work are seen as an interaction between the work environment, job content, organizational conditions, and worker capabilities (needs, culture, personal skills) and can influence health, work productivity, and job satisfaction.

In modern conditions, a systematic understanding of the role of psychosocial factors in the context of the concept of “psychosocial work environment” is being formed, which is due to the integration of various disciplines (psychology, occupational medicine, occupational health, etc.) and the common areas of research [19].

Currently, the relationship between the psychosocial work environment and health disorders is being considered [20]. The psychosocial work environment includes the “macro level” (economic, social, and political structures), the “meso level” (workplace structures), and the “micro level” (individual factors) [20]. According to Rugulies (2019), the study of the psychosocial work environment should be aimed at establishing the relationship between external factors and the health of workers [21]. The need for a comprehensive approach to assessing the psychosocial work environment as a determinant of mental health and well-being was confirmed in the Canadian Labor Force Survey (n=6408) [22]. The authors emphasized the close relationship of psychosocial factors in the workplace, causing the formation of occupational stress and subsequent stress-induced mental disorders.

The relationship of various psychosocial factors is reflected in the models of the development of occupational stress according to the type of imbalances: demand-control [23], effort-reward [24], demands-freedom and social support [25], and work-life [26].

A number of studies have proven the influence of psychosocial production factors on the development of work-related stress and the development of stress-related disorders of both mental and physical health [27][28].

In a study of 266 workers (aged 21 to 60 years) of an oil refinery using the “Workplace and Stress” test system (RAMIS in Russian), which allowed for a quantitative assessment of socio-psychological production factors, signs of occupational stress were noted by 33% of respondents [27]. The leading factors of work-related stress that adversely affected the health of workers were the low level of social support and insufficient autonomy of workers. At the same time, the harmful effects of occupational stress were manifested both in poor physical health and in mental disorders (in the form of depressive, anxious experiences) [27].

 In recent years, there has been an increase in the number of cases of absence from work due to illness and early retirement due to poor mental health in Europe [29]. At the same time, the lack of confidence in keeping a job negatively affects the mental health of an employee [30].

To date, there is a high prevalence of mental disorders among the working population, and therefore the prevention of occupational stress and stress-induced mental disorders is relevant [4].

Mental health disorders among workers in various fields of professional activity

The risk of mental disorders may be associated with working conditions, including both traditional and psychosocial factors. GOST R 55914-2013 states as follows¹⁹: “In a practical sense, psychosocial and general risks are related in terms of interaction: a relationship has been established between psychosocial and more traditional risks. Psychosocial hazards may increase the risk of exposure to traditional factors (for example, physical or chemical ones). At the same time, exposure to physical and chemical hazards can itself create a psychosocial risk due to workers' concerns about possible consequences.”

According to Kuzmina (2020), in chemical workers exposed to chemicals, noise, and emotional stress at the workplace, mental disorders have been detected (in the form of anxiety-asthenic, depressive, and vegetative disorders) and a decrease in mental adaptation, worsening with an increase in work experience in hazardous conditions [11].

Impairments of cognitive functions as one of the indicators of mental health were revealed in 41.3% of mechanical engineering workers (the mean age was 42 years) who had contact with chemicals (nitrogen compounds, sulfur and its compounds) and experienced physical overload at work [31].

The results of one of the studies of gas industry workers demonstrated the prevalence of mental disorders of 187 cases per 1,000 workers. Leading in their structure (75%) were anxiety and depressive disorders [12].

Chernov et al. (2017) studied the state of mental health of employees of locomotive crews (n=953) while conducting an examination of professional suitability and socio-psychological examination. The most frequently identified conditions were as follows: increased conflict at work and at home (24%), fatigue, absent-mindedness (23%), irritability, anxiety (20%), headaches, and sleep disorders (16%). The results obtained by the authors during the research testified to the need for medical and biological safety of the professional activities of employees of locomotive crews [32].

Mental health disorders in the form of post-traumatic stress disorder (PTSD) and depression have been identified in Canada among public safety officers (police officers, corrections officers, public relations officers, and firefighters) [33].

According to the research by Kristensen et al. (2019), in a follow-up (2008–2011) of service workers (n=445,651) in Norway, the overall prevalence of stress-related mental disorders, predominantly affective ones, was 8.6 per 100 (38,207 people) [17].

The risk group for the development of psychopathological symptoms includes workers in socially important professions (education, healthcare), for example, as part of the professional burnout syndrome resulting from chronic stress in the workplace [34][35].

In a study of teachers (n=391) of general education schools, professional burnout was detected in an average of 39.1% of cases (in 44% of cases – in teachers of secondary education, in 36% and 32% of cases – in teachers of additional and primary education). Burnout was characterized by high levels of emotional exhaustion (27%), depersonalization (20%), and reduction in personal achievement (20%). The obtained results highlighted the need to perform preventive measures by improving working conditions in terms of the intensity and severity of the labor process, reducing the influence of psychosocial production factors [36].

The working conditions of healthcare workers, characterized by high intellectual and emotional stress, responsibility for the health and life of patients, the complex impact of traditional (biological, physical, chemical, etc.) and psychosocial factors in the workplace, are associated with the development of professional burnout. Burnout has been revealed in doctors of various specialties, in middle and junior medical staff [37][38].

A systematic review of studies of 17,437 helping professionals (physicians, nurses, social workers, speech therapists, laboratory technicians, etc.) working in more than 29 countries has shown a high prevalence of depression, ranging from 2.5% to 91.3%, including among nurses (73.83%) and doctors (30.84%) [39].

The relevance of protecting the mental health of workers is evidenced by the Order of the Ministry of Health of Russia No. 342n issued on May 20, 2022 on the mandatory psychiatric examination of workers in certain types of work, for example, those related to driving vehicles, the production and use of explosive materials, arms trafficking, underground coal mining, pedagogical activities, work with children, contact with pathogens of infectious diseases of groups I and II of pathogenicity, etc.)²⁰.

Therefore, the development of mental disorders among workers in various sectors of the economy is mainly associated with work-related stress due to the impact of various psychosocial factors in the workplace.

Mental Health Disorders among Healthcare Workers during the COVID-19 Pandemic

The COVID-19 pandemic poses a serious threat not only to physical health, but also to mental health, as well as to the well-being of society as a whole²¹. Long-term mental health and psychological disorders in the context of the spread of a new coronavirus infection affect both patients who have experienced COVID-19 and socially significant categories of workers from risk groups [40]. COVID-19 has a long-term impact on the mental well-being of medical personnel, which is associated with significant physical and psychoemotional stress in the workplace, increased stress levels, and the formation of stress-induced syndromes (diseases), including anxiety, depression, burnout, and PTSD [40][41].

A decrease in the level of psychological resilience to the impact of a stressful situation induced by a pandemic has also been described in medical workers [42]. In China, the most pronounced disorders (symptoms of distress, anxiety, depression, and insomnia) were observed among medical personnel working at the epicenter of the COVID-19 outbreak [43]. In India, an online survey of physicians revealed that 34.9% of them had depression, 39.5% had anxiety, and 32.9% had manifestations of stress [44]. In Spain, the results of the study have shown that in healthcare workers, predominantly in women (86.4%) averaging 43.8 years of age, 58.6% had anxiety symptoms, 56.6% had PTSD, and 46% had depressive disorders; 41.1% felt emotionally exhausted [41]. According to the British Medical Association (BMA), when interviewing doctors, 43% of them indicated depression, anxiety, stress, burnout, emotional disorders, and other work-related mental disorders; of these, almost 70% reported deterioration in their condition during the pandemic²².

Increased workload, performance of professional duties in conditions of social distancing and interpersonal isolation, lack of personal protective equipment, increased risk of contracting COVID-19, caring for dying patients, and shortage of personnel contribute to mental disorders among medical staff [45]. Regarding mental disorders in healthcare workers, such strategies for dealing with the consequences of a pandemic as social support, avoiding information overload, and maintaining online communication are considered to be efficient [46].

Mental disorders that developed during the pandemic and were revealed in medical staff caused the need for their psychological support [47].

Responsible for supporting medical personnel working in a pandemic are health leaders who are obliged to ensure adequate organization of the work of employees, smooth out imbalances between work and personal life, and to promote employee initiatives to improve working conditions [48].

Russia has developed and is implementing a system of comprehensive psychological support for the activities of a medical institution²³ in the context of providing medical care to patients with COVID-19. This system includes special measures to reduce the psychological burden on the staff, special measures for the protection of personnel, maintaining a healthy climate in the team, as well as organizing professional and competent psychological assistance.

Strengthening control over an unfavorable situation, reducing stress in the workplace, and managing infection prevention measures are recognized as key factors in increasing the psychological stability of medical staff [49]. To date, psychological stability is considered a protective factor in the prevention of PTSD, anxiety, and depression in the context of the spread of a new coronavirus infection [41].

Prevention of mental disorders in workers: problems and solutions

The spread of mental disorders among the working population is accompanied by the emergence of a number of financial and production problems and the deterioration of the well-being of society as a whole [13]. Mental disorders are one of the leading causes of disability worldwide [50]. This necessitates finding ways to prevent anxiety and depressive disorders in the workplace and concerns various areas: medicine, psychology, healthcare, management, occupational safety, etc. [51].

The main tasks for preventing mental disorders in workers are considered to be minimization of the risk factors for the occurrence of mental disorders, as well as strengthening protective factors in the workplace. Measures to prevent mental disorders include the development of interpersonal and social competence of employees, assessment of the degree of emotional intelligence skill development, the use of educational online programs containing information about symptoms, risk factors for mental disorders, and ways to get help [52].

In order to prevent burnout, personality-oriented, organizational, and socio-psychological approaches are proposed [53], as well as the use of professional communities contributing to the joint solution of professional problems [54].

It is currently relevant to support workers with mental disorders when they return to work after a long-term disability induced by mental illness. The factors contributing to the active participation in the work of this contingent are as follows: the creation of a safe working climate (openness in relation to mental health), the exclusion of psychosocial hazards in the workplace, as well as high workload, support of managers and colleagues [55]. Along with this, healthcare and social assistance systems can help provide workers with mental disorders with a range of mental health services: timely psychiatric care, social services, including occupational rehabilitation and employment [56].

To date, it is also proposed to consider the following two aspects related to the possibility of supporting workers with mental disorders:

1. The need to take into account the severity of the disorder and specific working conditions. “Strategies for continuing work” depend on the duration and phase of the disorder: young workers with a long-term (since childhood) mental disorder need workload (stress) reduction [57]. In order to assess the ability of a worker with mental disorders to perform work, it is recommended to take into account health-related work functions, opportunities, and limitations at work, stability/instability of work, needs, and resources of the worker [58].
2. Studying the relationship between the most common mental disorders and performed work. Early diagnosis of, for example, depressive disorders is recommended in order to prevent severe depressive symptoms, which provides personalized worker support. It is important to obtain information about the state of mental health of an employee before entering employment [57].

Efficient support for workers with mental disorders in the workplace requires the joint work of all concerned (healthcare system, legal/administrative system, labor protection systems, participation of the employee him-/herself, consideration of his/her personal/family life) [5].

Conclusion

The preservation of the mental health of the population, including the working population, is one of the priority tasks for any developed society, which is explained by the medical, social, and economic importance of this issue.

Mental disorders are “the leading cause of disability and the third leading cause of the overall burden of disease (in terms of DALYs—the years of life lost due to disability),”²⁴ behind only CVD and cancer.

Due to the significant burden of mental disorders, the issue of protecting the mental health of workers as a socially significant category of citizens remains relevant. In modern conditions, the main directions for solving the problems of mental health of workers have been formed: assessment of working environment factors as determinants of mental disorders, prevention of exacerbation of mental disorder and support for workers when they return to work after a long-term disability due to mental illness.

According to the World Psychiatric Association, “the workplace can be a platform for promoting mental health and providing protective factors against mental illness.”²⁵

Maintaining the health and ability to work of workers with mental disorders requires a comprehensive and integrated approach based on the participation of specialists in occupational medicine, labor protection, health authorities, the employer, and the employee. Protecting the mental health of the working population is a serious problem, which is due to significant medical, social, and economic costs for the employee, the employer, and society. In this regard, it is relevant to develop mental health programs in the workplace with the mandatory participation of the employer providing the necessary investments and their financial profitability [59].

The experience accumulated during studying COVID-19 has shown that the pandemic of a new coronavirus infection is accompanied by a stressful situation dangerous for mental health followed by such long-term consequences as the development of psychological distress and mental disorders, which necessitates providing new approaches to their prevention and treatment [40][60].

At present, studies devoted to the assessment and management of occupational risks of mental disorders in the workplace, in particular those associated with the organizational climate, are gaining socio-economic significance [4]. According to the WHO definition, “the workplace is an important setting for health protection, health promotion and disease prevention.”²⁶

In modern conditions, the psychological support of an employee, including at the workplace, is one of the priority tasks in the field of mental health of the working population.

An interdisciplinary, interdepartmental approach to solving problems with the mental health of the working population should be considered promising, which goes far beyond the medical context and generally concerns the well-being and quality of life of workers with mental disorders.