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].

Workplace Injury: Musculoskeletal Conditions & Mental Illness

Research Paper Title

Prevalence of serious mental illness and mental health service use after a workplace injury: a longitudinal study of workers’ compensation claimants in Victoria, Australia.


Serious mental illness is common among those who have experienced a physical workplace injury, yet little is known about mental health service use in this population.

This study aims to estimate the proportion of the workplace musculoskeletal injury population experiencing a mental illness, the proportion who access mental health services through the workers’ compensation system and the factors associated with likelihood of accessing services.


A longitudinal cohort study was conducted with a random sample of 615 workers’ compensation claimants followed over three survey waves between June 2014 and July 2015.

The primary outcome was receiving any type of mental health service use during this period, as determined by linking survey responses to administrative compensation system records for the 18 months after initial interview.


Of 181 (29.4%) participants who met the case definition for a serious mental illness at one or more of the three interviews, 75 (41.4%) accessed a mental health service during the 18-month observation period.

Older age (OR=0.96, 95% CI 0.93 to 0.99) and achieving sustained return to work (OR=0.27, 95% CI 0.11 to 0.69) were associated with reduced odds of mental health service use.

Although not significant, being born in Australia was associated with an increased odds of service use (OR=2.23, 95% CI 0.97 to 5.10).


The proportion of injured workers with musculoskeletal conditions experiencing mental illness is high, yet the proportion receiving mental health services is low.

More work is needed to explore factors associated with mental health service use in this population, including the effect of returning to work.


Orchard, C., Carnide, N., Mustard, C. & Smith, P.M. (2020) Prevalence of serious mental illness and mental health service use after a workplace injury: a longitudinal study of workers’ compensation claimants in Victoria, Australia. Occupational and Environmental Medicine. pii: oemed-2019-105995. doi: 10.1136/oemed-2019-105995. [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: [Accessed: 18 November, 2019].

HSE (Health & Safety Executive). (2019) Mental Health. Available from World Wide Web: [Accessed: 18 November, 2019].

The Role of the Workplace & Employers in Mental Health

1.0 Introduction

Workplaces have habitually been seen as key settings for a range of health promotion initiatives targeted at working people.

Programmes that assist, for example, employees to reduce or give up smoking, eat more healthily or improve their fitness are common. However, the published research shows that there are few evidence-based interventions carried out in or by workplaces to address common mental health problems among employees.

The research literature on programmes that address the mental health of employees has been dominated by interventions targeted either at the whole population of employees, for example stress inoculation, or at those deemed to be at high risk of stress-related disorders, for example stress reduction or management.

These approaches mirror physical health interventions aimed at individual behaviour change and do not offer a model for organisational approaches to these issues.

2.0 The Workplace and Employers

While evidence tells us that workplaces are not the sole or principal setting for delivering interventions for people with common mental health problems, employers nevertheless remain key partners.

They do, after all, have a contractual and personal relationship with their employees, as well as statutory health, safety and disability accommodation duties.

The focus of employers’ role in the management of common mental health problems among employees should be to ensure that the working environment supports retention and rehabilitation. Recent policy recommendations have highlighted this responsibility.

For example, the National Institute for Health and Clinical Excellence (NICE) reviewed some of the literature on mental health and work, as suggested by experts in the field. In the absence of randomised control trials (RCT’s) on the topic under review, Workplace Mental Health suggests that employers take a strategic and co-ordinated approach to workplace wellbeing; that employers provide opportunities for flexible working; and that line managers promote and support wellbeing among staff (NICE, 2009).

The NHS Health and Wellbeing Review (DH, 2009) acknowledged not only that some employees are likely to have existing common mental health problems, but also that the nature of the working environment can sometimes have a negative impact on staff mental wellbeing. Among the review’s recommendations were that all NHS bodies should ensure that their management practices adhered to the Health and Safety Executive’s management standards for the control of work-related stress; that more investment was needed to attract people to take up occupational medicine; that all managers are trained in the management of people with mental health problems; and that all NHS bodies give priority to the implementation of the NICE guidance on workplace mental health in order to signal their commitment to staff health and wellbeing (NICE, 2009).

A parallel piece of work complemented the NHS Health and Wellbeing Review and described findings from the Practitioner Health Programme. The intervention is targeted at doctors and dentists with health problems who might be reluctant to seek help through usual channels. In its first year, a total of 184 practitioners within the M25 area had accessed the service: 57% with mental health problems and 23% with addiction issues (Crawford et al., 2009; Ipsos MORI, 2009; Smauel et al., 2009; DH, 2010).

The UK Government’s Foresight scientific review on Mental Capital and Wellbeing (Foresight, 2008) included a chapter devoted to work (Dewe & Kompier, 2008), recommending that employers foster work environments conducive to good mental wellbeing and the enhancement of mental capital, for example, by extending the right to flexible working. The chapter also highlighted the importance of:

  • Integrating occupational health professionals with primary care;
  • The collection of wellbeing data against Key Performance Indicators; and
  • Annual wellbeing audits.

All of these recommendations mirror the findings of a longitudinal cohort study on workplace factors that may help to reduce depressive symptoms (Brenninkmeijer et al., 2008). Work resumption, partial and full, and the employer changing the employee’s tasks, promoted a more favourable outcome. However, these findings emerged from the Netherlands, where the employer and employee have a legal obligation to sit together and discuss solutions to obstacles preventing return to work, an important factor associated with the decrease in long-term disability in that country (Reijenga et al., 2006). Perhaps a policy shift will be necessary to allow workplaces in the UK to play a central role in the management of common mental health problems.

3.0 References

Brenninkmeijer, V., Houtman, I. & Blonk, R. (2008) Depressed and absent from work: predicting prolonged depressive symptomatology among employees. Occupational Medicine. 58, pp.295-301.

Crawford, J., Shafrir, A. et al. (2009) A Systematic Review of the Health of Health Practitioners. Edinburgh: Institute of Occupational Medicine. Available from World Wide Web: [Accessed: 24 November, 2019].

Dewe, P. & Kompier, M. (2008) Foresight Mental Capital and Wellbeing Project. Wellbeing and Work: Future challenges. London: The Government Office for Science. Available from World Wide Web: [Accessed: 24 November, 2019].

DH (Department of Health). (2009) NHS Health and Wellbeing Review. Interim Report. London: Department of Health. Available from World Wide Web: [Accessed: 24 November, 2019].

DH (Department of Health). (2010) Invisible Patients: Report of the working group on the health of health professionals. London: Department of Health. Available from World Wide Web: [Accessed: 24 November, 2019].

Foresight. (2008) Mental Capital and Wellbeing Project. Final Project Report. Available from World Wide Web: [Accessed: 24 November, 2019].

Ipsos MORI (2009) Fitness to Practice: The health of healthcare professionals. London.

NICE (2009a) Workplace Mental Health. Available from World Wide Web: [Accessed: 24 November, 2019].

Reijenga , F.A., Veerman, T. & van den Berg, N. (2006) Evaluation Law Gatekeeper Improvement. Report 363. Gravenhage: Ministerie van Sociale Zaken en Werkgelegenheid NL.

Samuel, B., Harvey, S.B., Laird, B. et al. (2009) The Mental Health of Health Care Professionals: A review for the Department of Health. London: King’s College London.

The Workplace & Common Mental Health Problems

1.0 Pre-2010

Common mental health problems are widespread and debilitating. Surveys carried out in Great Britain and internationally indicate that at any one time about one adult in six in the general population has a condition such as anxiety or depression. Incidence is higher among women and in people aged 45-54 years and there appears to be an upward trend in their rates over the last 15 years (Deverill & King, 2009). About three-quarters of adults with a common mental health problem are not in receipt of medication or counselling, including two thirds of those assessed as having a level of symptoms sufficient to warrant treatment (Deverill & King, 2009).

These levels of prevalence are mirrored among working age adults. At any one time nearly one worker in six will be experiencing depression, anxiety or problems related to stress. This increases to one in five when drug or alcohol dependence are included (Sainsbury Centre, 2007).

Although most of these mental health problems are unrelated to issues at work (HSE, 2007), there may be associations with workplace conditions such as long work hours, work overload, lack of control over work, lack of participation in decision making, poor social support and unclear management and work role, with some correlation with poor management style (Michie & Williams, 2003; Stansfeld, 2002; Berkels et al., 2004; Sanderson & Andrews, 2006). High demands and low support at work have been shown to be predictive of depressive symptoms worsening, independent of individual personality traits (Paterniti et al., 2002). Women are at risk of increased depression and anxiety if the management style at their workplace is not inclusive or considerate; and male employees are more at risk if they feel excluded from decision making (Kivimaki et al., 2003a; Ylippaavalniemi et al., 2005; Kivimaki et al., 2003b).

Against the backdrop of an economic recession and a labour market under pressure, people may increasingly be underemployed – that is involuntarily working part-time or for a wage at or below the poverty level because they have lost their former employment. Underemployment is an independent risk factor for worsening mental health and such suboptimal jobs may contribute to depression (Dooly et al., 2000; Friedland & Price, 2003).

The changing nature of work itself adds another layer of risk to mental health. For example atypical work, such as seasonal or casual work or fixed-term or subsidised jobs for people moving off benefits linked to unemployment support, is associated with significantly worse mental health (Sanderson & Andrews; 2006).

In summary, common mental health problems are the dominant health problem in the working age population (HWWB, 2009). Despite high rates of mental ill health, there are indications that almost half of employers think between none and one in twenty of their employees will ever experience a mental health problem during their working lives (Shaw Trust, 2006).

Low awareness among employers about the extent mental ill health, coupled with inadequate levels of treatment for those with these conditions and pervasive stigmatising public attitudes towards mental health problems (TNS Social, 2009), result in the perpetuation of a set of circumstances that are personally and financially costly to individuals, their families and their workplaces. An effective approach to the management of common mental health problems in the workplace could minimise or avert many of the related problems and costs associated with staff turnover, absenteeism and presenteeism (Sainsbury Centre, 2007; Sanderson & Andrews, 2006; Hilton, 2007).

2.0 Post-2010

Moving past 2010, the last decade has witnessed progress from employers regarding mental health. For example, many large employers now offer mental health-related services as part of their employee assistance programmes (EAP).

There are also many more opportunities outside of the workplace – such as charities and NHS services – that both employers and employees can turn to; many just need to be aware of them and be signposted.

Although there have been improvements, there is still much to be done.

3.0 References

Berkels, H., Henderson, J., Henke, N., Kuhn, K., Lavikainen, J., Lehtinen, V., Ozamiz, A., van den Heede, P. & Zenzinger, K. (2004) Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress-Related Disorders in Europe. Final Report 2001-2003. Dortmund/Dresden/Berlin: WHO.

Deverill, C. & King, M. (2009) Common Mental Disorders. In: McManus, S., Meltzer, H., Brugha, T., Bebbington, P. & Jenkins, R. (eds) Adult Psychiatric Morbidity in England: Results of a household survey. The NHS Information Centre. (

Dooley, D., Prause, J. & Ham-Rowbottom, K.A. (2000) Underemployment and depression: longitudinal relationships. Journal of Health and Social Behaviour. 41, pp.421-436.

Friedland, D.S. & Price, R.H. (2003) Underemployment consequences for the health and wellbeing of workers. American Journal of Community Psychology. 32, pp.33-45.

Hilton, M. (2007) Getting upstream of psychological disability in the workforce – who are we not seeing and at what cost? Presentation available from:

HSE (Health and Safety Executive). (2007) Self-Reported Work-Related Illness 2005/06. Available from World Wide Web: [Accessed: 20 November, 2019].

HWWB (Health, Work and Wellbeing). (2009) Working our Way to Better Mental Health: A framework for action. Available from World Wide Web: [Accessed: 20 November, 2019].

Kivimaki , M., Vahtera, E.J., Virtanen, M. & Stansfeld, S.A. (2003b) Association between organizational inequity and incidence of psychiatric disorders in female employees. Psychological Medicine. 33, pp.319-326.

Kivimaki, M., Elovainio, M., Vahtera, J. & Ferrie, J.E. (2003a) Organisational justice and health of employees: prospective cohort study. Occupational Environmental Medicine. 60, pp.27-34.

Michie, S. & Williams, S. (2003) Reducing workrelated psychological ill health and sickness
absence: a systematic literature review. Occupational and Environmental Medicine. 60, pp.3-9.

Paterniti, S., Niedhammer, I., Lang, T., & Consoli, S.M. (2002) Psychosocial factors at work, personality traits and depressive symptoms: Longitudinal results from the GAZEL study. British Journal of Psychiatry. 181(2), pp.111-117.

Sainsbury Centre. (2007) Mental Health at Work: Developing the Business Case. London: Sainsbury Centre for Mental Health.

Sanderson, K. & Andrews, G. (2006) Common mental disorders in the workforce: Recent findings from descriptive and social epidemiology. Canadian Journal of Psychiatry. 51(2), pp.63-75.

Shaw Trust (2006) The Last Workplace Taboo. Available from World Wide Web: [Accessed: 20 November, 2019].

Stansfeld, S. (2002) Work, personality and mental health. British Journal of Psychiatry. 181, pp.96-98.

TNS Social (2009) Attitudes to Mental Illness 2009. Research Report. JN189997. Available from World Wide Web: [Accessed: 20 November, 2019].

Ylippaavalniemi, J., Kivimaki, M., Elovainio, M., Virtanen, M., Keltikangas-Jarvinen, L. & Vahtera, J. (2005) Psychosocial work characteristics and incidence of newly diagnosed depression: a prospective cohort study of three different models. Social Science Medicine. 61, pp.111-112.