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Final Report
Evaluation of policy and practice to
promote mental health in the
workplace in Europe
Employment, Social Affairs & Inclusion
Evaluation of policy and practice to promote mental health in the
workplace in Europe
Final Report
November 2014 2
Partners:
Prevent
London School of Economics
TNO
University of Nottingham
Work Research Centre
Authors:
Stavroula Leka, Aditya Jain; University of Nottingham
Irene Houtman; TNO Work & Employment
David McDaid, A-La Park; London School of Economics
Veronique De Broeck; Prevent
Richard Wynne; Work Research Centre
Disclaimer
The content of this report represents the views of the contractor and is its sole
responsibility; it can in no way be taken to reflect the views of the European
Commission.
Employment, Social Affairs & Inclusion
Evaluation of policy and practice to promote mental health in the
workplace in Europe
Final Report
November 2014 3
Table of Contents
Executive Summary..........................................................................................7
Study objectives............................................................................................7
Mental health as a positive state of psychological well-being ................................ 7
Mental ill health has a profound impact on individuals, organisations and society but
awareness on the positive impact of good mental health also needs to be raised..... 7
A notable ‘policy evolution’ on mental health in the workplace in the EU but not
without challenges.........................................................................................8
A mixed picture across member states but with several good practice examples ..... 9
The status quo implies questionable progress ....................................................9
Views on the best way forward differ across countries and stakeholders ................9
The cost of inaction outweighs the cost of action .............................................. 10
SMEs, experience sharing and assessing impact............................................... 10
Further guidance ......................................................................................... 11
Key recommendations.................................................................................. 11
1. Aim and objectives ................................................................................ 12
2. Mental health in the workplace ................................................................ 12
2.1 What is mental health and psychological well-being? ............................... 12
2.2 Prevalence of mental health problems ................................................... 13
2.3 Mental health in the workplace ............................................................. 16
2.3.1 Determinants of mental health in the workplace .................................. 16
2.3.2 The impact of poor mental health in the workplace............................... 21
2.3.3 The case for promoting mental health in the workplace...................... 27
3. Methodology......................................................................................... 33
3.1 The conceptual approach..................................................................... 34
3.2 The scope of the methodology.............................................................. 35
3.3 The overall approach: Methods, instruments and analysis for each task..... 36
3.3.1 Task 1: Definition of types of legislation to be included ...................... 36
3.3.2 Task 2: Review of acts from an agreed list ....................................... 37
3.3.3 Task 3: Identification and description of gaps in legislation/ policies and
implementation ........................................................................................ 41
3.3.4 Task 4: Analysis of scenarios ......................................................... 41
3.3.5 Task 5: Preparation of a guidance document and an interpretative
document of Council Directive 89/391/EEC ................................................... 43
4. Evaluation of the policy context in the EU/EFTA countries............................ 45
4.1 Eu policy framework review ................................................................. 45
4.1.1 Regulatory instruments of relevance to mental health and psychosocial
risks in the workplace at the European level ................................................. 46
4.1.2 Non-binding/voluntary policy initiatives of relevance to mental health and
psychosocial risks in the workplace.............................................................. 58
4.1.3 The effectiveness of existing policy initiatives for promoting mental health
and psychosocial risk management in the workplace .................................... 101
4.2 Identification and description of policy gaps ......................................... 110
4.3 The national policy context in relation to mental health in the workplace: A
European review........................................................................................ 127
4.3.1 Case study analysis of national policy initiatives............................. 128
5. Establishment of baseline scenario......................................................... 129
6. Establishment of alternative scenarios .................................................... 131
6.1 Results of the Delphi study ................................................................ 133
6.1.1 The first Delphi round ................................................................. 134
6.1.2 The second Delphi round ............................................................. 136
6.2 The strengths and weaknesses for the main scenarios ........................... 145
6.2.1 Strengths and weaknesses of non-binding EU-initiatives .................. 145
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Evaluation of policy and practice to promote mental health in the
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Final Report
November 2014 4
6.2.2 Strengths and weaknesses of new EU-legislation............................. 146
6.2.3 Strengths and weaknesses of providing a technical update............... 146
6.2.4 Strengths and weaknesses of combining or consolidating EU directives
147
6.2.5 Strengths and weaknesses of maintaining the status quo ................. 147
6.3 Assessing the costs and benefits of the different policy scenarios ............ 147
6.3.1 Results .................................................................................... 148
6.3.2 Developmental costs................................................................... 151
6.3.3 Potential buy-in.......................................................................... 152
6.3.4 Assessing the costs of implementation........................................... 153
6.3.5 Conclusions on policy scenarios and economic impact...................... 157
7. Recommendations ............................................................................... 158
8. References .............................................................................................. 163
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List of tables
Table 1: Psychosocial hazards in the workplace ...................................................17
Table 2: Returns on investment from workplace mental health promotion and mental
disorder prevention programmes .......................................................................30
Table 3: Legislation type and potential gaps........................................................35
Table 4: Regulatory instruments of relevance to mental health and psychosocial risks
in the workplace at the European level ...............................................................48
Table 5: Non-binding/voluntary policy initiatives of relevance to mental health and
psychosocial risks in the workplace ....................................................................81
Table 6: Evaluation of the impact of Framework Directive 89/391 in 15 EU member
states (pre-2004).......................................................................................... 103
Table 7: Results of the implementation of the European Framework Agreement on
Work-related Stress....................................................................................... 106
Table 8: Summary of key milestones achieved in EU member states, Iceland, Norway,
and Turkey in relation to the implementation of the framework agreement on
harassment and violence at work in 2008-2010 ................................................. 108
Table 9: Policy scorecard – key facets and scoring criteria................................... 111
Table 10: Policy Scorecard – Regulatory instruments of relevance to mental health and
psychosocial risks in the workplace at the European level.................................... 112
Table 11: Policy Scorecard – Non-binding/voluntary policy initiatives of relevance to
mental health and psychosocial risks in the workplace ........................................ 120
Table 12: Delphi responses by country – Round 2 .............................................. 136
Table 13: Response by country cluster ............................................................. 137
Table 14: Response by type of relevant stakeholder ........................................... 137
Table 15: Response by relevant stakeholder by type and country cluster............... 138
Table 16: Priorities in scenario ratings (N=55)................................................... 139
Table 17: Average rating of the scenarios by country cluster (N=55) .................... 139
Table 18: Average rating of the scenarios by type of relevant stakeholder (range 5-1;
best –worst)................................................................................................. 140
Table 19: A ranking of types of non-binding EU initiatives on mental health when
selected as preferred choice (N=27-31)............................................................ 143
Table 20: Non-binding EU initiatives by country cluster (ratings from 5 (most
preferred) to 1 (5th in preference) (N=29-31)................................................... 144
Table 21: Non-binding EU initiatives by stakeholder type (ratings from 5 (most
preferred) to 1 (5th in preference) (N=29-31)................................................... 145
Table 22: Potential costs associated with different policy scenarios ....................... 151
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List of figures
Figure 1: An illustration of trends in sickness absence for poor mental health versus all
other causes of sickness absence for the DAK sickness fund in Germany .................14
Figure 2: Retirement event associated with improvement in fatigue and depressive
symptoms (GAZEL study) .................................................................................16
Figure 3: Trends in work intensification, control and learning opportunities in EU-15
(% workers) ...................................................................................................19
Figure 4: Reasons for disability benefit claims in Britain 2008 – 2012......................25
Figure 5: Duration of employment and support allowance claims in Britain 2008 –
2012 .............................................................................................................26
Figure 6: New claims for sickness compensation in Sweden 2003-2012...................27
Figure 7: Estimation of annual benefits to UK economy through workplace mental
health and wellbeing promotion......................................................................... 33
Figure 8: Potential for health and economic gains through modest improvements
towards better mental health and wellbeing at work........................................... 155
Employment, Social Affairs & Inclusion
Evaluation of policy and practice to promote mental health in the
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Executive Summary
Study objectives
Tender N° VT/2012/028 concerned a study service contract to establish the situation
in EU and EEA/EFTA countries on mental health in the workplace, evaluate the scope
and requirements of possible modifications of relevant EU Safety & Health at Work
legislation and elaborate a guidance document to accommodate corresponding
risks/concerns, with a view to ultimately ensure adequate protection of workers’
mental health from workplace related risks. On the basis of the above brief, the
current study had three objectives: The first was to provide the European Commission
with information on the situation in the EU and EFTA countries of mental health in the
workplace. This required an in depth analysis of the current EU legal framework on
workers’ health and safety protection. The second objective was to develop a range of
scenarios, and identify the pros and cons of each with the ultimate objective of
providing a sufficiently robust information base on which the Commission may rely in
order to consider policy options aiming to ensure that workers are effectively
protected from risks to their mental health arising from workplace related conditions
and/or factors. Finally, the third objective was to develop guidance to help employers
and workers alike fulfil their obligations, namely those explicitly provided for by
Framework Directive 89/391/EEC, with the overarching objective of making sure that
mental health is considered an inescapable element of any occupational safety and
health (OSH policy) and practical measures.
Mental health as a positive state of psychological well-being
Mental health describes a level of psychological well-being or the absence of a mental
disorder. Probably the most well-known definition of mental health is that of the World
Health Organization (WHO) that defines mental health as a state of well-being in
which every individual realizes his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a contribution
to her or his community. According to WHO, "health is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity". The
definition of mental health as the absence of mental health disorders is a more
conservative one. Mental health disorders can be classified according to generally
acknowledged classifications like DSM (Diagnostic and Statistical Manual of Mental
Diseases) or ICD (International Classification of Disease). Cultural differences, various
types of assessment and competing professional theories all affect how ‘mental health’
is defined. This report adopts a more inclusive definition of mental health and as such
does not focus solely on (the absence of) mental health disorders but a positive state
of psychological well-being. The focus of the report is mental health in the workplace.
Mental ill health has a profound impact on individuals, organisations
and society but awareness on the positive impact of good mental
health also needs to be raised
This study commenced with a review of the magnitude of mental health concerns in
the workplace in Europe and the impact of mental ill health on individuals,
organisations and society. The prevalence of mental ill health in the workplace,
including poor psychological well-being is widespread across all EU/EFTA countries and
there are indications that this will only increase due to exposure to risk factors such as
job insecurity, work intensification and organisational restructuring. In addition, the
impact of mental ill health is profound on individuals, organisations and society as a
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Evaluation of policy and practice to promote mental health in the
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November 2014 8
whole. At the individual level, exposure to psychosocial risks can result not only to
poor psychological health and well-being but also to physical problems such as
cardiovascular disease. These problems challenge participation in the workforce and
performance through absenteeism and presenteeism. Discrimination and social
exclusion against those affected by mental health disorders still remain a problem
exacerbating the situation. At the organisational level, evidence indicates that mental
ill health and poor psychological well-being affect business performance through
absenteeism, presenteeism, reduced job satisfaction and organisational commitment,
a poor work climate and human error. Additional costs are incurred by businesses in
terms of hiring and training costs as well as reduced productivity and innovation. At
societal level, there are associated costs to national social security and benefit
systems, national economies and challenges on healthcare systems. These trends are
projected to continue in the future. The negative impact of poor mental health in the
workplace is now undisputed. However, further awareness needs to be raised on the
positive impact of good mental health on sustainability at individual, organisational
and societal level as a means of achieving the Europe 2020 goals.
A notable ‘policy evolution’ on mental health in the workplace in the
EU but not without challenges
The second step of the study was a policy review at EU level with a focus on both
regulatory and voluntary policy instruments, detailing the ‘history’ of policy evolution
in this area in the EU. This was supplemented by a gap analysis. Employment,
including OSH, legislation as well as public health legislation address the issue by
placing emphasis on prevention through tackling risk factors and preventing
discrimination. However some challenges have been identified. Although, for example,
a common legal framework in the EU exists in relation to mental health in the
workplace through the Framework Directive 89/391/EEC which covers all types of risk
to workers’ health, there still appears to be limited awareness of this provision both by
employers and other key stakeholders. The situation seems to be negatively
exacerbated further by the fact that the Framework Directive does not include specific
terminology in relation to mental health in the workplace (for example it only refers to
broad areas from which risk factors can arise, such as work organisation, and does not
include terms such as work-related stress or psychosocial risk). From the review and
gap analysis presented on regulatory and voluntary policy initiatives it can be
observed that: a. there is lack of clarity and specificity on the terminology used; and
b. although the different instruments/initiatives are based on related paradigms, very
few of them provide specific guidance on managing risks in relation to mental health in
the workplace to enable organisations (and especially small and medium-sized
enterprises - SMEs) to implement a preventive framework of action. Several additional
policy instruments of a non-binding nature have clarified the relevance and application
of the Framework Directive in this area such as the framework agreement on work-
related stress. The EC guidance on risk assessment also includes useful detail in this
area. The gap analysis conducted in this study concerned both regulation and non-
binding policies. It showed that a number of non-binding policies have been developed
at EU level which provide specific guidance in this area while several gaps are evident
in legislation at EU level. In light of this, it would be advisable to revisit the content of
the Framework Directive in relation to psychosocial risks and mental health in the
workplace to provide further clarity and harmonise terminology across other key OSH
legislation accordingly. Two guidance documents developed through this project aim
to partly address this issue. The review also showed that there is more scope for
better co-ordination at EU institutional level in this area.
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Evaluation of policy and practice to promote mental health in the
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A mixed picture across member states but with several good practice
examples
The third step of this study was the review of policies at national level in the EU/EFTA
countries which highlighted that legislation in this area is more specific is several
member states with many cases of updated legislation in recent years. Specific
legislation refers directly to psychosocial risks, work-related stress, mental health in
the workplace, harassment and bullying. It also makes clear reference to risk
assessment for psychosocial risks as an employer responsibility. Other initiatives such
as strategies and campaigns as well as social partner agreements were also identified.
In addition, we conducted a case study analysis, including interviews with key
stakeholders, of different types of policy instruments and initiatives which showcased
several examples of good practice that have been implemented in individual, or even
across, member states. These have helped tremendously in clarifying the legal
framework and employer and employee responsibilities. An example is the
Management Standards for work-related stress in the UK that have been adapted in
Italy. Awareness raising of these initiatives and sharing of good practices across the
EU has only recently started to materialise to some extent and there is far more scope
in learning from these good practices and even exploring the feasibility of promoting a
more unified approach at EU level. To do so, existing monitoring systems in the EU
(such as the European Working Conditions Survey by Eurofound and the European
Survey of Enterprises on New & Emerging Risks by EU-OSHA) will have to be
strengthened to allow better benchmarking across members states. A more co-
ordinated action plan would be beneficial at EU level, clarifying requirements (both in
employment and public health policies) and the case for mental health promotion in
the workplace and drawing upon good practice efforts within specific countries. In
addition, monitoring across the EU and between and within Member States should be
further developed by refining existing systems. A specific issue to be considered is the
inclusion of mental health disorders in lists of occupational diseases in EU countries.
Without effective monitoring and dedicated reporting, knowledge at the Community
level about the rate of progress would be weak.
The status quo implies questionable progress
According to our analysis, if the status quo as concerns the policy context to mental
health in the workplace is maintained, it is likely that a number of activities will
continue to take place across the EU/EFTA countries in this area given the impact of
mental ill health on individuals, organisations and society. However, there is
uncertainty as to whether they will achieve the desired outcomes, especially since
preventive actions still seem to be lacking across countries. Continuation of EU
activities as currently set would not necessarily lead to an improvement of the
situation, given the progress achieved so far, nor would it necessarily lead to greater
awareness in relation to the vital importance of mental health in the workplace.
Although this option would not imply any additional administrative costs, or require re-
orientation of funds from other policies, it bears the significant and undisputed cost of
inaction.
Views on the best way forward differ across countries and
stakeholders
To explore additional scenarios at EU level, developed through our review of policies,
the next step in the study included the development and evaluation of several
scenarios on policy options in relation to mental health in the workplace in the EU on
the basis of a Delphi study including interviews and an online survey. Our analysis
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Evaluation of policy and practice to promote mental health in the
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November 2014 10
indicates that the views of key stakeholders across countries on the various policy
scenarios (maintaining the status quo; introducing non-binding EU initiatives;
combining or consolidating EU Directives; providing a technical update of existing EU
legislation; developing EU legislation in this area) differ. Overall, non-binding EU
initiatives were most often preferred, which may reflect the view from stakeholders
that additional legislation may be difficult to develop whilst well-designed non-binding
measures have been shown to help improve the focus on mental health in the
workplace in some country contexts. The scenario on ‘developing a technical update of
existing legislation’ ranked overall second, whereas ‘combining or consolidating EU
Directives’ ranked third.
Differences across countries were as follows: ‘non-binding EU initiatives’ were on
average most preferred in Southern Europe and UK & Ireland. Interestingly, in new
member states this scenario shared first place with the scenario on ‘developing new
EU legislation’. In Northern EU countries, ‘developing new EU legislation’ was the most
preferred scenario. While Continental country respondents preferred a ‘technical
update of existing legislation’. The differences in preference were more pronounced for
the different stakeholder groups as compared to country clusters. Experts and
professionals preferred ‘non-binding EU-initiatives’ the most. Employee
representatives and policy makers in some countries (particularly labour
inspectorates) most strongly preferred ‘developing new EU legislation’, whereas
employer representatives most often preferred the ‘status quo’. Regarding different
non-binding EU scenario options, the different stakeholders expressed a preference for
further awareness raising campaigns, closely followed by developing and
implementing national strategies on mental health in the workplace, and introducing
management standards.
The cost of inaction outweighs the cost of action
Furthermore, we proceeded to conduct economic analysis of the different options
which indicated the availability of very little information on the costs of implementing
different scenarios. Although qualitatively it appears that none would incur substantial
development costs, some, e.g. a new directive, would take considerably longer to
develop. The costs of implementation are likely to vary considerably; and would
depend on uptake and also on the existing infrastructure and resources in member
states. While it is difficult to determine the actual costs of implementation, it is clear
from our review of the evidence on the cost effectiveness of workplace health
promotion programmes that the economic returns overall are likely to be greater than
the costs of investment. Much of these benefits will be gained by enterprises but there
are also benefits to health and social welfare systems and to the
economy as a whole. It should also be noted that many of these economic analyses
are likely to be conservative as most only look at the benefits of a reduction in
absenteeism and/or presenteeism and do not consider other benefits to business
including better creativity and innovation, greater staff retention, and public image of
the company. There are also additional wider benefits to society if workplace actions
promote better mental health as this also helps protect against the risk of physical
health problems. In addition, these scenarios do not normally take a human rights
perspective to the promotion of mental health which would favour further action in this
area.
SMEs, experience sharing and assessing impact
It should also be noted that most of the schemes that have been evaluated have been
implemented in large enterprises; regardless of any policy scenario chosen, it would
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Evaluation of policy and practice to promote mental health in the
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Final Report
November 2014 11
be important to put further emphasis on measures to support small and medium-sized
enterprises to actively implement good practices in the workplace. There are also
potential economic benefits to governments and insurers that can be realised if they
support occupational health services and other workplace mental health promotion
actions in companies that would not otherwise be able to provide these services.
Generating further evidence base on the effectiveness of actions in the European
context and learning from various actions implemented across Europe would be a
good way forward. In addition, assessing the impact of different strategies on an
ongoing basis to help inform future implementation practice is important.
Further guidance
The final steps of this project focused on the development of two guidance documents.
The first is an interpretative document of the implementation of Council Directive
89/391/EEC in relation to mental health in the workplace. This interpretative
document aims to reiterate, in particular to employers and anyone with relevant
responsibilities in organisations, the formal requirements of Council Directive
89/391/EEC as regards mental health in the workplace. The second is a guidance
document on how to implement a comprehensive approach for the promotion of
mental health in the workplace. It is hoped that these two documents will clarify legal
requirements and good practice in this area further for employers and other key
stakeholders in Europe.
Key recommendations
Revisit the content (coverage and terminology) of Council Directive 89/391/EEC to
include clear reference to psychosocial risks and mental health in the workplace.
Promote the interpretative document of Council Directive 89/391/EEC to clarify legal
requirements for employers and other key stakeholders in Europe.
Promote the guidance document on how to implement a comprehensive approach
for the promotion of mental health in the workplace.
Harmonise coverage and terminology in relation to psychosocial risks and mental
health in the workplace across all key pieces of OSH legislation.
Consider the inclusion of mental health disorders in the list of occupational diseases
at EU level.
Continue to promote both regulatory and non-binding initiatives to raise awareness
and promote good practice.
Co-ordinate action at EU institutional level in this area to achieve maximum impact.
Raise awareness on the positive impact of good mental health and its association
with sustainability as a means of achieving the Europe 2020 goals.
Strengthen existing monitoring systems in the EU (such as the European Working
Conditions Survey by Eurofound and the European Survey of Enterprises on New &
Emerging Risks by EU-OSHA) to allow better monitoring and benchmarking across
members states.
Publicise lessons learnt from good practices implemented in member states to
motivate action across the EU.
Place further emphasis on measures to support small and medium-sized enterprises
to actively implement good practices in the workplace.
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Evaluation of policy and practice to promote mental health in the
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Final Report
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1. Aim and objectives
Tender N° VT/2012/028 concerned a “study service contract to establish the situation
in EU and EEA/EFTA countries on Mental Health in the Workplace, evaluate the scope
and requirements of possible modifications of relevant EU Safety & Health at Work
legislation and elaborate a guidance document to accommodate corresponding
risks/concerns, with a view to ultimately ensure adequate protection of workers’
mental health from workplace related risks”. On the basis of the above brief, the
current study had three objectives:
The first was to provide the European Commission with information on the situation
in the EU and EFTA countries of mental health in the workplace. This required an in
depth analysis of the current EU legal framework on workers’ health and safety
protection.
The second objective was to develop a range of scenarios, and identify the pros and
cons of each with the ultimate objective of providing a sufficiently robust
information base on which the Commission may rely in order to consider policy
options aiming to ensure that workers are effectively protected from risks to their
mental health arising from workplace related conditions and/or factors.
Finally, the third objective was to develop a guidance document to help employers
and workers alike fulfil their obligations, namely those explicitly provided for by
Framework Directive 89/391/EEC, with the overarching objective of making sure
that mental health is considered an inescapable element of any occupational safety
and health (OSH) policy and practical measures.
The study addresses the situation across the EU, in individual EU Member States and
countries which form part of the European Economic Area. This report will first present
a summary of the evidence in relation to mental health in the workplace across
European countries. It will then proceed to present an analysis of the relevant policy
framework, identifying current gaps that need to be addressed. A series of case study
analyses will then be used to identify scenarios for the future of EU mental health
policy. These scenarios will be evaluated on the basis of a cost-benefit analysis and
recommendations on the way forward will be offered. Finally, the report will detail the
development of the Guidance document foreseen by the Commission as well as an
interpretative document of Framework Directive 89/391/EEC in relation to this area. It
is hoped that these two documents will help advance good practice in promoting
mental health in the workplace and preventing associated risks in European
workplaces.
2. Mental health in the workplace
2.1 What is mental health and psychological well-being?
Mental health describes a level of psychological well-being or the absence of a mental
disorder. Probably the most well-known definition of mental health is that of the World
Health Organization (WHO) that defines mental health as a state of well-being in
which every individual realizes his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a contribution
to her or his community. According to WHO (1948), "health is a state of complete
physical, mental and social well-being and not merely the absence of disease or
infirmity". The definition of mental health as the absence of mental health disorders is
Employment, Social Affairs & Inclusion
Evaluation of policy and practice to promote mental health in the
workplace in Europe
Final Report
November 2014 13
a more conservative one. Mental health disorders can be classified according to
generally acknowledged classifications like DSM (Diagnostic and Statistical Manual of
Mental Diseases) or ICD (International Classification of Disease). Cultural differences,
various types of assessment and competing professional theories all affect how
‘mental health’ is defined. This report adopts a more inclusive definition of mental
health and as such will not focus solely on (the absence of) mental health disorders
but a positive state of psychological well-being.
This approach underlines the need to address mental health in its totality by
recognising interrelationships among risks to mental health, sub-threshold conditions
of poor psychological health and well-being (such as stress) that may not have yet
resulted in a diagnosed mental health disorder but may severely affect their
expression, and diagnosed mental health disorders. According to this perspective,
efforts to tackle mental ill health should not focus on particular problems in isolation,
such as depression for example, but should seek to put in place policies and practices
that will tackle a wider range of risk factors to mental health by appropriate
interventions. These should prioritise prevention and tackling problems at source while
also developing awareness and facilitating treatment. This report and associated
guidance documents will discuss how this comprehensive approach can be applied
with reference to mental health in the workplace.
2.2 Prevalence of mental health problems
Starting with existing evidence on mental health disorders in particular, evidence from
the WHO suggests that nearly half of the world’s population is affected by mental
illness with an impact on their self-esteem, relationships and ability to function in
everyday life. While the Mental Health Foundation (2007) states that mental health
problems directly affect about a quarter of the population in any one year.
A systematic review of studies considering prevalence of mental disorders in the EU-
27, Switzerland, Iceland and Norway was conducted by Wittchen et al. (2012). The
authors suggest that approximately 38.2% of the EU population suffer from a mental
disorder each year. The most frequent disorders are anxiety disorders (14%),
insomnia (7%), major depression (6.9%), somatoform (6.3%), alcohol and drug
dependence (>4%), ADHD (5%) in the young, and dementia (1–30%, depending on
age). Depression was found to be the most disabling condition. Only a small
percentage of people experience more severe mental illnesses such as schizophrenia.
In fact, depression and anxiety are termed by many as ‘common mental disorders’. No
substantial country variations have been identified in the prevalence of mental
disorders (Wittchen et al., 2011).
People with a severe mental disorder are too often far away from the labour market,
and need help to find sustainable employment (OECD, 2012). The majority of people
living with a common mental disorder are employed but many are at greater risk of
job loss and permanent labour market exclusion than colleagues without these
problems. This has worsened in the recent economic climate. Evans-Lacko et al.
(2013) found that the gap in unemployment rates for individuals in Europe with and
without mental health problems, significantly increased after the onset of the
economic recession. This gap was especially pronounced for males, and individuals
with low levels of education.
Employment, Social Affairs & Inclusion
Evaluation of policy and practice to promote mental health in the
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Final Report
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The estimates for the proportion of the workforce in Europe that may be living with a
mental health problem at any one time range from one in five (OECD, 2012) to two in
five (Wittchen et al., 2011), with a lifetime risk of at least two in five (OECD, 2012). In
the EU-27 it was found that 15% of citizens had sought help for a psychological or
emotional problem, with 72% having taken antidepressants (European Commission,
2010).
The shares of sickness absence and early retirement for mental health problems have
increased across Europe over the past few decades. The Eurobarometer (EC, 2010a)
presents EU wide statistics on positive and negative feelings more closely reflecting
mental well-being. It shows that mental ill-health impacts on sickness absence and
indicates that in 2010, EU citizens felt less positive and more negative than they were
in 2005/2006. Figure 1 provides one illustrative example of this in Germany where
days absent from work due to mental health problems continued to rise at a sharp
rate over the period 1997 to 2012 in contrast to largely stable rates of absence for all
other causes of sickness absence.
Figure 1: An illustration of trends in sickness absence for poor mental health versus all
other causes of sickness absence for the DAK sickness fund in Germany
The increase is thought to be due to reduced social stigma and discrimination against
people with mental illness leading to greater recognition of previously hidden
problems, rather than a true increase in prevalence (OECD, 2012; Wittchen et al.,
2011). However mental health problems are still considered relatively unrecognized,
underdiagnosed and untreated (OECD, 2012).
As previously underlined, this report takes a more holistic perspective of mental health
and considers psychological well-being and not only mental health disorders. This
means that attention has to also be paid to sub-threshold conditions of poor
psychological health and well-being that may not have yet resulted in a diagnosed
mental health disorder. For example, issues such as stress are particularly important
in these considerations since there is abundant evidence that prolonged exposure to
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unmanageable pressure can result to stress that might, in turn, result in several more
severe mental health problems (WHO, 2010). In line with this evidence, the OECD
(2012) stresses that while challenges in helping to reintegrate people with severe
mental health problems are one important focus of attention, there is a strong
argument for more policy emphasis to be placed on addressing common mental
disorders and sub-threshold conditions with more emphasis on preventive rather than
just reactive strategies. The workplace is ideal for such preventive actions to be put in
place since individuals spend at least one third of their time at work.
One of the key states of sub-optimal mental health that can have severe
consequences is work-related stress. Work-related stress is the response people may
have when presented with work demands and pressures that are not matched to their
knowledge and abilities and which challenge their ability to cope (WHO, 2003a). The
European Commission (2002) defined stress as the pattern of emotional, cognitive,
behavioural and physiological reactions to adverse and noxious aspects of work
content, work organisation and work environment. In the framework agreement on
work-related stress (2004), stress is defined as a state, which is accompanied by
physical, psychological or social complaints or dysfunctions and which results from
individuals feeling unable to bridge a gap with the requirements or expectations placed
on them. According to the Fourth European Working Conditions survey, carried out in
2005, out of those workers who report that work affects their health, 20% of workers
from the first 15 EU member states and 30% from the 12 new member states
believed that their health is at risk because of work-related stress (Eurofound, 2007).
The 2005 survey results indicated a reduction in stress levels reported for overall EU-
27 figures; however the reduction in reporting exposure to stress occurred mainly in
some of the EU-15 countries, while new member states still reported high levels of
exposure – more than 30% (EU-OSHA, 2009).
At the national level, 1.2 million workers in Austria, for example, report suffering from
work-related stress associated with time pressure. In Denmark, 8% of employees
report being ‘often’ emotionally exhausted. In Germany, 98% of works councils
claimed that stress and pressure of work had increased in recent years and 85% cited
longer working hours. In Spain, 32% of workers described their work as stressful
(Koukoulaki, 2004). In 2003, three out of five employees stated that they were
frequently confronted with urgent situations and were more often than before required
to interrupt one task to perform another leading to increased pressure and work-
related stress (Eurofound, 2007). The European Agency for Occupational Safety and
Health (2009) reports that there were significant differences in stress prevalence
across Europe. The highest levels of stress were reported in Greece (55%), and in
Slovenia (38%), Sweden (38%), and Latvia (37%), and the lowest levels were noted
in the United Kingdom (12%), Germany, Ireland, and the Netherlands (16%) as well
as in the Czech Republic (17%), France and Bulgaria (18%).
Looking more specifically at data from the UK as an example, the 2009 Psychosocial
Working Conditions survey indicated that around 16.7% of all working individuals
thought their job was very or extremely stressful (Packham & Webster, 2009).
According to the 2008/09 Labour Force Survey, an estimated 415,000 individuals
believed that they were experiencing work-related stress at a level that was making
them ill, (HSE, 2010). The latest estimates from the Labour Force Survey show that
the prevalence of stress in 2011/12 was 428,000 cases (40%) out of a total of
1,073,000 cases for all work-related illnesses. The industries that reported the highest
rates of total cases of work-related stress (three-year average) were human health
and social work, education, public administration and defence. The occupations that
reported the highest prevalence rates of work-related stress (three-year average)
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were health professionals (in particular nurses), teaching and educational
professionals and caring personal services (in particular welfare and housing associate
professionals). The main work activities attributed by respondents as causing their
work-related stress, or making it worse, were work pressure, lack of managerial
support and work related violence and bullying (HSE, 2013). In addition, in 2011/12
there was an estimated incidence of 86,000 male and 135,000 female cases of work-
related stress based on the Labour Force Survey. This compares to an estimated
prevalence of 175,000 cases of work related stress amongst males and 253 000 cases
of work related stress amongst females (HSE, 2013).
2.3 Mental health in the workplace
2.3.1 Determinants of mental health in the workplace
It is generally accepted that ‘work is good for you’, contributing to personal fulfilment
and financial and social prosperity (Cox et al., 2004; Waddell & Burton, 2006). There
are economic, social and moral arguments that, for those able to work, ‘work is the
best form of welfare’ (Deacon, 1997; King & Wickam-Jones 1999; Mead, 1997) and is
the most effective way to improve the well-being of these individuals, their families
and their communities. Moreover, for people who have experienced poor mental
health, maintaining or returning to employment can also be a vital element in the
recovery process, helping to build self-esteem, confidence and social inclusion
(Perkins, Farmer, & Litchfield 2009). A better working environment can help improve
employment rates of people who develop mental health problems. Not doing this puts
additional costs on governments who have to provide social welfare support for people
who would prefer to be in employment.
Figure 2: Retirement event associated with improvement in fatigue and depressive
symptoms (GAZEL study)
Source: Westerlund et al. (2010)
There is also growing awareness that (long-term) worklessness is harmful to physical
and mental health, so it could be assumed the opposite must be true – that work is
beneficial for health. However, that does not necessarily follow (Waddell & Burton,
2006). Work is generally good for your health and well-being, provided you have ‘a
good job’ (Langenhan, Leka & Jain, 2013; Waddell & Burton, 2006). Good jobs are
obviously better than bad jobs, but bad jobs might be either less beneficial or even
harmful. In fact, a recent study by Westerlund et al. (2010) shows an improvement in
fatigue and depressive symptoms associated with the retirement event, especially for
those exposed to the worst work environment (Figure 2).
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Evaluation of policy and practice to promote mental health in the
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