On This Day … 01 September


  • 1939 – Adolf Hitler signs an order to begin the systematic euthanasia of mentally ill and disabled people.
  • 2004 – Random Acts of Kindness Day (New Zealand).

Aktion T4

Aktion T4 was a postwar name for mass murder by involuntary euthanasia in Nazi Germany. The name T4 is an abbreviation of Tiergartenstraße 4, a street address of the Chancellery department set up in early 1940, in the Berlin borough of Tiergarten, which recruited and paid personnel associated with T4. Certain German physicians were authorised to select patients “deemed incurably sick, after most critical medical examination” and then administer to them a “mercy death” (Gnadentod). In October 1939, Adolf Hitler signed a “euthanasia note”, backdated to 01 September 1939, which authorised his physician Karl Brandt and Reichsleiter Philipp Bouhler to implement the programme.

The killings took place from September 1939 until the end of the war in 1945; from 275,000 to 300,000 people were killed in psychiatric hospitals in Germany and Austria, occupied Poland and the Protectorate of Bohemia and Moravia (now the Czech Republic). The number of victims was originally recorded as 70,273 but this number has been increased by the discovery of victims listed in the archives of the former East Germany. About half of those killed were taken from church-run asylums, often with the approval of the Protestant or Catholic authorities of the institutions.

The Holy See announced on 02 December 1940 that the policy was contrary to divine law and that “the direct killing of an innocent person because of mental or physical defects is not allowed” but the declaration was not upheld by some Catholic authorities in Germany. In the summer of 1941, protests were led in Germany by the Bishop of Münster, Clemens von Galen, whose intervention led to “the strongest, most explicit and most widespread protest movement against any policy since the beginning of the Third Reich”, according to Richard J. Evans.

Several reasons have been suggested for the killings, including eugenics, racial hygiene, and saving money. Physicians in German and Austrian asylums continued many of the practices of Aktion T4 until the defeat of Germany in 1945, in spite of its official cessation in August 1941. The informal continuation of the policy led to 93,521 “beds emptied” by the end of 1941. Technology developed under Aktion T4 was taken over by the medical division of the Reich Interior Ministry, particularly the use of lethal gas to kill large numbers of people, along with the personnel of Aktion T4, who participated in Operation Reinhard. The programme was authorised by Hitler but the killings have since come to be viewed as murders in Germany. The number of people killed was about 200,000 in Germany and Austria, with about 100,000 victims in other European countries.

And now something slightly more positive.

Random Acts of Kindness Day

Random Acts of Kindness Day is a day to celebrate and encourage random acts of kindness.

“It’s just a day to celebrate kindness and the whole pay it forward mentality”, said Tracy Van Kalsbeek, executive director of the Stratford Perth Community Foundation, in 2016, where the day is celebrated on 04 November 4.

It is celebrated on 01 September in New Zealand and on 17 February in the US.


  • The Random Acts of Kindness Foundation (RAK) was founded in 1995 in the US.
  • It is a non-profit headquartered in Denver, Colorado.
  • Random Acts of Kindness (RAK) day began in 2004 in New Zealand.

What is a Random Act of Kindness

A random act of kindness is a nonpremeditated, inconsistent action designed to offer kindness towards the outside world.

Suggested Activities

  • Pay for the person behind you in the drive-thru.
  • Let someone go ahead of you in line.
  • Buy extra at the grocery store and donate it to a food pantry.
  • Buy flowers for someone (postal worker, grocery store clerk, bus driver, etc.).
  • Help someone change a flat tire.
  • Post anonymous sticky notes with validating or uplifting messages around for people to find.
  • Compliment a colleague on their work.
  • Send an encouraging text to someone.
  • Take muffins to work.
  • Let a car into the traffic ahead of you.
  • Wash someone else’s car.
  • Take a gift to new neighbors and introduce yourself.
  • Pay the bus fare for the passenger behind you.


What is the Prevalence & Associated Factors of Depression among Patients with Schizophrenia?

Research Paper Title

The prevalence and associated factors of depression among patients with schizophrenia in Addis Ababa, Ethiopia, cross-sectional study.


Depression is common among people with schizophrenia and associated with severe positive and negative symptoms, higher rates of disability, treatment resistance and mortality related to suicide, physical and drug-related causes.

However, to the researchers knowledge, no study has been conducted to report the magnitude of depression among people with schizophrenia in Ethiopia.

Therefore, this study aimed to determine the prevalence and associated factors of depression among people with schizophrenia.


A hospital-based cross-sectional study was conducted among 418 patients with schizophrenia selected by systematic sampling technique.

Patient Health Questionnaire 9 (PHQ-9) was used to measure depression among the study participants.

To identify the potential contributing factors, we performed binary and multi-variable logistic regression analysis adjusting the model for the potential confounding factors.

Odds ratios (OR) with the corresponding 95% confidence interval (95%CI)) was determined to evaluate the strength of association.


The prevalence estimate of depression among people with schizophrenia was found to be 18.0% [95% confidence interval: 14.50-22.30].

The multi-variable analysis revealed that current substance use (AOR 2.28, 95%CI (1.27, 4.09), suicide attempt (AOR 5.24, 95%CI (2.56, 10.72), duration of illness between 6 and 10 years (AOR 2.09, 95%CI (1.08, 4.04) and poor quality of life (AOR 3.13, 95%CI (1.79, 5.76) were found to be the factors associated with depression among people with schizophrenia.


The current study revealed that co-morbid depression was high among people with schizophrenia and associated with current substance use, suicide attempt, and long duration of the illness as well as poor quality of life.

Attention needs to be given to address co-morbid depression among people with schizophrenia.


Fanta, T., Bekel, D. & Ayano, G. (2020) The prevalence and associated factors of depression among patients with schizophrenia in Addis Ababa, Ethiopia, cross-sectional study. BMC Pyschiatry. 20(1):3. doi: 10.1186/s12888-019-2419-6.

Linking Risk of Suicidal Behaviour with Mental Disorders & Work Disability

Research Paper Title

Mental disorders and suicidal behavior in refugees and Swedish-born individuals: is the association affected by work disability?


Among potential pathways to suicidal behavior in individuals with mental disorders (MD), work disability (WD) may play an important role.

The Researchers examined the role of WD in the relationship between MD and suicidal behaviour in Swedish-born individuals and refugees.


The study cohort consisted of 4,195,058 individuals aged 16-64, residing in Sweden in 2004-2005, whereof 163,160 refugees were followed during 2006-2013 with respect to suicidal behaviour.

Risk estimates were calculated as hazard ratios (HR) with 95% confidence intervals (CI).

The reference groups comprised individuals with neither MD nor WD.

WD factors (sickness absence (SA) and disability pension (DP)) were explored as potential modifiers and mediators.


In both Swedish-born and refugees, SA and DP were associated with an elevated risk of suicide attempt regardless of MD. In refugees, HRs for suicide attempt in long-term SA ranged from 2.96 (95% CI: 2.14-4.09) (no MD) to 6.23 (95% CI: 3.21-12.08) (MD).

Similar associations were observed in Swedish-born. Elevated suicide attempt risks were also observed in DP.

In Swedish-born individuals, there was a synergy effect between MD, and SA and DP regarding suicidal behaviour.

Both SA and DP were found to mediate the studied associations in Swedish-born, but not in refugees.


There is an effect modification and a mediating effect between mental disorders and WD for subsequent suicidal behaviour in Swedish-born individuals.

Also for refugees without MD, WD is a risk factor for subsequent suicidal behaviour.

Particularly for Swedish-born individuals with MD, information on WD is vital in a clinical suicide risk assessment.


Björkenstam, E., Helgesson, M., Amin, R., Lange, T. & Mittendorfer-Rutz, E. (2020) Mental disorders and suicidal behavior in refugees and Swedish-born individuals: is the association affected by work disability? Social Psychiatry and Psychiatric Epidemiology. doi: 10.1007/s00127-019-01824-5. [Epub ahead of print].

Mental Health & the HSE


In their Annual Report and Accounts 2017/2018, the Health and Safety Executive (HSE) stated that there were “0.5 million work-related stress, depression or anxiety cases (new or long-standing) in 2016/17” (HSE, 2018, p.9).

What is the HSE?

“HSE is the independent regulator for work-related health and safety in Great Britain. We are committed to playing our part in the wider health and safety system to ensure that others play theirs in creating healthier, safer workplaces. We also deliver wider functions such as regulatory schemes intended to protect the health of people and the environment, balancing the economic and social benefits that chemicals offer to society.” (HSE, 2018, p.10).

HSE and Stress

HSE states that where (work-related) stress is prolonged it can lead to both physical and psychological damage, including anxiety and depression, and that work can also aggravate pre-existing conditions, and problems at work can bring on symptoms or make their effects worse.

They go on to state that whether work is causing the health issue or aggravating it, employers have a legal responsibility to help their employees. Work-related mental health issues must to be assessed to measure the levels of risk to staff. Where a risk is identified, steps must be taken to remove it or reduce it as far as reasonably practicable.
Some employees will have a pre-existing physical or mental health condition when recruited or may develop one caused by factors that are not work-related factors.

Employers may have further legal requirements, to make reasonable adjustments under equality legislation.

Information about employing people with a disability can be found on GOV.UK or from the Equality and Human Rights Commission in EnglandScotland, and Wales.

There is advice for line managers to help them support their employees with mental health conditions.

What is the Stevenson Farmer ‘Thriving at Work’ Review?

In 2017, the UK government commissioned Lord Stevenson and Paul Farmer (Chief Executive of Mind) to independently review the role employers can play to better support individuals with mental health conditions in the workplace.

The ‘Thriving at Work’ report sets out a framework of actions – called ‘Core Standards’ – that the reviewers recommend employers of all sizes can and should put in place.

The core standards were designed to help employers improve the mental health of their workplace and enable individuals with mental health conditions to thrive.

By taking action on work-related stress, either through using the HSE Management Standards or an equivalent approach, employers would be able to meet parts of the core standards framework, as they would:

  • Form part of a mental health at work plan;
  • Promote communications and open conversations, by raising awareness and reducing stigma; and
  • Provide a mechanism for monitoring actions and outcomes.

Can Mental Health and Work-related Stress be Interlinked?

Work-related stress and mental health problems often go together and the symptoms can be very similar. For example, work-related stress can aggravate an existing mental health problem, making it more difficult to control. And, if work-related stress reaches a point where it has triggered an existing mental health problem, it becomes hard to separate one from the other.

Common mental health problems and stress can exist independently. For example, an individual can experience work-related stress and physical changes such as high blood pressure, without having anxiety, depression or other mental health problems. They can also have anxiety and depression without experiencing stress.

The key differences between them are their cause(s) and the way(s) they are treated.

  • Stress is a reaction to events or experiences in someone’s home life, work life or a combination of both.
  • Common mental health problems can have a single cause outside work, for example bereavement, divorce, postnatal depression, a medical condition or a family history of the problem.

However, an individual can have these sorts of problems with no obvious causes. Employers can help manage and prevent stress by improving conditions at work. But they also have a role in making adjustments and helping the individual manage a mental health problem at work.

Linking HSE’s Management Standards, and Mental Ill Health and Stress

Although stress can lead to physical and mental health conditions, and can aggravate existing conditions, the good news is that it can be tackled.

By taking action to remove or reduce stressors, an employer can:

  • Prevent an individual becoming ill; and
  • Avoid those with an existing condition becoming less able to control their illness.

HSE’s Management Standards approach to tackling work-related stress establishes a framework to help employers tackle work-related stress and, as a result, also reduce the:

  • Incidence of mental ill health; and
  • Negative impact of mental ill health.

The Management Standards approach can help employers put processes in place for properly managing work-related stress. By covering six key areas of work design employers will be taking steps that will:

  • Minimise pressure;
  • Manage potential stressors; and
  • Limit the negative impact that the work could have on their employees.


HSE (Health & Safety Executive). (2018) Annual Report and Accounts 2017/18. Available from World Wide Web: http://www.hse.gov.uk/aboutus/reports/ara-2017-18.pdf. [Accessed: 18 November, 2019].

HSE (Health & Safety Executive). (2019) Mental Health. Available from World Wide Web: https://www.hse.gov.uk/stress/mental-health.htm. [Accessed: 18 November, 2019].

When Does a Mental Health Condition Become a Disability?

1.0 Introduction

A mental health condition is considered a disability if it has a long-term effect on your normal day to-day activity, and this is defined under the Equality Act 2010.

The condition is ‘long term’ if it lasts, or is likely to last, 12 months.

‘Normal day-to-day activity’ is defined as something the individual does regularly in a normal day. This includes things like using a computer, working set times or interacting with people.

Currently, the law considers the effects of an impairment on the individual. For example, someone with a mild form of depression with minor effects may not be covered. However, someone with severe depression with significant effects on their daily life is likely to be considered as having a disability.

2.0 Where Does the Equality Act 2010 Apply?

The Equality Act 2010 applies in England, Wales, and Scotland.

It does not apply in Northern Ireland, where individuals are protected by the Disability Discrimination Act 1995.

3.0 Definition of Disability under the Equality Act 2010

An individual is classed as disabled under the Equality Act 2010 if they have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on their ability to do normal daily activities.

In order to be protected by the Act, a person must have an impairment that meets the Act’s definition of disability, or be able to establish that any less favourable treatment or harassment is because of another person’s disability or because of a perceived disability.

4.0 Factors to Consider in Determining Disability

Factors to consider include:

  • The individual must have an impairment that is either physical or mental;
  • The impairment must have adverse effects which are substantial;
  • The substantial adverse effects must be long-term; and
  • The long-term substantial adverse effects must be effects on normal day-to-day activities.

4.1 What Does Substantial and Long-term Mean?

  • ‘Substantial’ is more than minor or trivial, for example, it takes much longer than it usually would to complete a daily task like getting dressed.
  • ‘Long-term’ means 12 months or more, for example, a breathing condition that develops as a result of a lung infection.

4.2 What is an Impairment?

With regards to disability, an impairment refers to an individual’s ability to carry out normal day-to-day activities and, importantly, the effect that an impairment has on this ability.

A disability can arise from a wide range of impairments which can be:

  • Sensory impairments, such as those affecting sight or hearing.
  • Impairments with fluctuating or recurring effects such as rheumatoid arthritis, myalgic encephalitis (ME), chronic fatigue syndrome (CFS), fibromyalgia, depression and epilepsy.
  • Progressive, such as motor neurone disease, muscular dystrophy, and forms of dementia;
  • Auto-immune conditions such as systemic lupus erythematosis (SLE).
  • Organ specific, including respiratory conditions, such as asthma, and cardiovascular diseases, including thrombosis, stroke and heart disease.
  • Developmental, such as autistic spectrum disorders (ASD), dyslexia and dyspraxia;
  • Learning disabilities.
  • Mental health conditions:
    • With symptoms such as anxiety, low mood, panic attacks, phobias, or unshared perceptions;
    • Eating disorders;
    • Bipolar affective disorders;
    • Obsessive compulsive disorders (OCD);
    • Personality disorders;
    • Post-traumatic stress disorder (PTSD); and
    • Some self-harming behaviour.
  • Mental illnesses, such as depression and schizophrenia.
  • Produced by injury to the body, including to the brain.

What it is important to consider is the effect of an impairment, not its cause – provided that it is not an excluded condition. For example, addiction to, or dependency on, alcohol, nicotine, or any other substance (other than in consequence of the substance being medically prescribed) are specifically excluded from the Equality Act 2010 – although any accompanying impairments maybe protected.

5.0 What about Recurring or Fluctuating Conditions?

There are special rules about recurring or fluctuating conditions (ODI, 2011, p.29), for example “…mental health conditions such as schizophrenia, bipolar affective disorder, and certain types of depression, though this is not an exhaustive list.”

Some impairments with recurring or fluctuating effects may be less obvious in their impact on the individual concerned than is the case with other impairments where the effects are more constant.

6.0 What about Progressive Conditions?

A progressive condition is one that gets worse over time, and individuals with progressive conditions can be classed as disabled.

Examples of progressive conditions include various types of dementia.

Medical prognosis of the likely impact of the condition is the normal route to establishing protection under this provision. Although the effect need not be continuous and need not be substantial, the individual will still need to demonstrate that the impairment meets the long-term condition of the definition.

7.0 Employers & Disability

If an individual’s mental health condition means they are disabled they can get support at work from their employer. Two things to note:

  • The individual’s employer cannot discriminate against them because of their disability – they are protected by the Equality Act 2010; and
  • The employer must also keep the individual’s job open for them, and cannot put pressure on the individual to resign just because they have become disabled.

7.1 Reasonable Adjustments

The individual’s employer must make ‘reasonable adjustments’ for them so that they are not disadvantaged compared to non-disabled people, with examples including:

  • A phased return to work, for example working flexible hours or part-time;
  • Time off for medical treatment or counselling;
  • Giving another employee tasks the individual cannot easily do; and/or
  • Providing practical aids and technical equipment for the individual.

7.2 Time off from Work

If the individual is an employee and cannot work because of their disability, they may be able to get Statutory Sick Pay (SSP), although some employers have their own sick pay scheme.

If the individual still cannot work after 28 weeks, or they cannot get SSP, they can apply for Universal Credit (UC) or Employment and Support Allowance (ESA).

It is important to note that time off from work should not be recorded as an ‘absence from work’ if the individual is waiting for their employer to put reasonable adjustments in place.

7.3 Dismissals and Redundancy

The individual’s employer cannot dismiss them just because they have become disabled.

However, the individual can be dismissed if their disability means they cannot do their job even with reasonable adjustments.

An individual cannot be selected for redundancy just because they are disabled.

8.0 Disability Benefits

As well as having rights to protection from discrimination if the individual becomes disabled, they may also be entitled to certain benefits. The main disability and sickness benefits include:

  • Disability Living Allowance (DLA) or Personal Independence Payment (PIP);
  • Attendance Allowance; and/or
  • Employment and Support Allowance (ESA).

DLA is paid on top of income support, ESA, and other benefits. DLA does not reduce an individual’s other benefits and, in some cases getting DLA, can actually increase the amount the individual receives in other benefits. An individual can receive DLA if they are in or out of work.

What the individual is entitled to will depend on their circumstances. The individual might also be able to get:

  • Certain types of equipment or have adaptations made to their home without paying VAT;
  • Council Tax discounts;
  • A TV licence discount; and/or
  • Free vehicle tax.

9.0 Useful Links

10.0 References

ODI (Office for Disability Issues). (2011) Equality Act 2010: Guidance. Available from World Wide Web: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/570382/Equality_Act_2010-disability_definition.pdf. [Accessed: 25 November, 2019].