Guest Editorial: Mental Health and the Workplace: Towards a Research Agenda in Canada
During the next decade, the World Health Organization (WHO 1996) projects that among high-income countries such as Canada, depression will surpass ischemic heart disease to emerge as the leading cause of disability. The nature and magnitude of this problem is introduced well in Dewa, Lesage, Goering and Caveen paper. Annually 12% of Canadians between the ages of 15 and 64 years suffer from a mental disorder or substance dependence (Statistics Canada 2003). Results from Ontario estimate that about 8% of the working population has a diagnosable mental disorder (Dewa and Lin 2000). Preliminary findings also indicate differences in the prevalence of mental disorders among workers with regard to occupation, age, sex, physical condition, work environment and work-related stress.
As a result of these trends, mental and emotional health problems promise to take a heavy toll on the workplace in the form of work absences and decreased productivity (e.g., Perez and Wilkerson 1998; Dewa and Lin 2000). The effect of mental illness on the workplace has been measured as presenteeism (attending work with symptoms, and therefore being less productive at work), absenteeism and disability days. For example, in 2001 mental health problems were identified as one of the principal causes of workplace absenteeism (Watson Wyatt Worldwide 2000). The presence of any of these indicators has been used to indicate decreased productivity, with the largest burden attributed to presenteeism days. It has been estimated that these work-related productivity losses cost Canada $4.5 billion annually (Stephens and Joubert 2001).
Mental illness is also associated with short-term and long-term disability, which in turn is often related to employer-sponsored insurance coverage. Mental illness accounts for 30% of disability claims, translating into $15 to $33 billion annually in Canada (Sroujian 2003). Variations in employer-sponsored insurance coverage for supplemental health benefits and fringe benefits can result in differential access to mental health services that contributes to the disparity between the need for and use of mental health services. Indeed, approximately two-thirds of Canadians with a mental disorder or substance dependence fail to contact a mental health professional (Statistics Canada 2003).
The Need for an Evidence Base
In response to the looming crisis, globally there has been a two- to three-fold increase in research in this area over the past decade with Canada leading the way. While this is encouraging news, it is also important to note that less than 1% of health-related research worldwide is devoted to this area. A bibliometric analysis of research in Canada indicates that researchers were spread across the country, with rarely more than three or four researchers in any one setting; key nodes were identified at McMaster University, Laval University and York University, and significant activities at the universities of Toronto, Montreal, British Columbia and Western Ontario and their affiliated research centres. Research has been particularly concentrated in three of the four dimensions of health research defined by the Canadian Institutes of Health Research (CIHR) - health of populations and determinants, clinical research, health services and policy. Research on the biological front has been limited.
Given the potentially staggering social and economic costs we face, it is imperative that we focus our efforts on decreasing the impact through a multi-pronged, evidence-based approach. This can only be achieved by increasing our knowledge with regard to six research streams:
- the nature and magnitude of the problem
- workplace prevention and promotion strategies
- diagnostic and treatment issues
- disability management and return to work
- stigma and work
- integrating health research and the Canadian workplace
A Canadian Response to the Looming Crisis
In answer, the Institute of Population and Public Health (IPPH) and the Institute of Neurosciences, Mental Health and Addiction (INMHA) of the Canadian Institutes of Health Research mandated a working group to develop a research agenda consistent with CIHR's goals of fostering research excellence and undertaking research that addresses major health issues and has a positive impact on Canada's economy and society.
Early on, the working group recognized that to be successful, all stakeholders, including employers, must be involved in the development and implementation of future research initiatives. This early buy-in would be essential to developing "in-workplace" strategies to reduce productivity losses and disability costs related to mental illness. In essence, to have direct application in the workplace, it is crucial that the research agenda be engaging for all stakeholders as well as stimulating and attractive for new researchers.
Inspired by the paradigm shift heralded by the Canadian Health Services Research Foundation that suggests expertise and innovation do not necessarily flow in one direction, i.e., from researchers to stakeholders, but also the other way around (Lomas et al. 2003), the working group convened an invited workshop on April 28 and 29, 2004, in Toronto. The workshop was structured to encourage participants to recommend research priorities in six streams of workplace mental health research. Throughout the priority-setting process, participants were advised that identified priorities should be stimulating to researchers and have a high probability of buy-in from all concerned stakeholders. Emphasis was also placed on identifying research priority areas in which significant progress could be easily achieved.
A broad range of stakeholder interests were represented by the over 100 people in attendance. Each attendee was specifically invited because of his or her demonstrated expertise or direct professional interest in workplace mental health issues. About 40% of the participants were researchers; the remainder were representatives of employers, unions, insurers, health providers' professional organizations, national and provincial grant agencies and planners, community organizations, consumers groups and politicians. All proved to be "good listeners" of one another's perspectives (Lomas et al. 2003) with regard to reviewing the state of knowledge, the gaps in knowledge, the research priorities and how to implement them.
This issue of HealthcarePapers contains six commissioned papers together with the responses written by Canadian researchers and experts that served as the background to the workshop. It also includes a commissioned bibliometric analysis to establish the relative position of Canada in this area of research and to delineate the strongest nodes of research activities in provinces, universities and research centres across Canada. The next part of this editorial describes briefly the background, workshop format, a preliminary statement of research priorities and the course of action envisaged to implement these strategies, taking into account the suggestions provided by researchers and stakeholders at the workshop.
Identifying Research Priorities
To facilitate a constructive dialogue at the two-day workshop and to guide the participants' deliberations, several of Canada's top researchers in the field of workplace mental health were engaged to prepare six academic papers, all of which were forwarded to the workshop participants in advance. The papers covered the six streams of research that were identified as critical to the advancement of the field. Each paper examined the state of knowledge in a particular stream of research, identified current gaps in ongoing research activities and recommended potential research priorities for the next 10 years. Several presentations by leading stakeholders set the context for a series of break-out sessions that dealt with each individual paper.
In each break-out session, the participants were given the task of debating the papers' identified priorities and determining which of these priorities should be pursued in the short term. The potential for buy-in from multiple stakeholders was a key determinant behind the selection of each priority. Participants were also charged with articulating barriers and risks to pursuing each identified priority. In each session, the context for debate was set by a brief presentation by authors and an assessment of the authors' work by pre-selected expert "respondents." On day 2 of the workshop, a validation exercise was conducted, during which a professional facilitator reviewed the priorities identified and gave all participants an opportunity to verify that those priorities reflected discussion of day 1.
There was significant overlap in the priorities identified in each session. Therefore, subsequent to the validation exercise, members of the workshop steering committee reviewed all of the identified priorities and condensed them into a smaller set of overarching and specific priorities that covered the priorities identified in all sessions. These priorities are listed below.
Preliminary Statement of Research Priorities
There is a need to enable applied research on prevention and promotion, treatment, disability management and strategies to address stigma and discrimination and foster the exchange of relevant knowledge by:
- facilitating coalition building among all stakeholder groups;
- making "the business case" for pursuing specific research initiatives, especially through economic studies;
- developing data sets, based on surveys of both the labour force and employers, that include longitudinal and cross-sectional data;
- facilitating access to, and ethical linkage of, administrative data held by employers, payers and providers;
- developing and evaluating measurement tools for prevention and promotion, treatment, disability management and interventions to address stigma and
discrimination that can be used to collect information on workers at the organizational and societal levels;
- fostering the development and evaluation of intervention models for individuals and organizations that address prevention, promotion, treatment, disability management and recovery, and stigma and discrimination initiatives;
- fostering the recognition and evaluation of current Canadian best practices with respect to promotion and prevention, treatment, disability management and recovery, and stigma and discrimination initiatives; and
- ensuring that research takes issues into account that are related to specific segments of the population, e.g., by gender, ethnicity, culture, socio-economic status, employment status and time of arrival in Canada.
Specific Research Priorities
Workplace Prevention and Promotion
- Acquire a further understanding of, and monitor the effects on mental health of, prominent trends in organizational practices.
- Emphasize target populations through studies that measure changes over time in mental health outcomes; these studies should consider broader societal contexts.
Diagnostic and Treatment Issues
- Pursue studies to clarify diagnostic entities, sub-diagnostic threshold conditions, stress and burn-out, personality disorders and associated physical and mental co-morbidities. Include in these studies an understanding of the bio-psycho-social risk and protective factors.
Disability Management and Return to Work
- Study the impact of government and corporate policies on short-term and long-term individual outcomes and workplace outcomes.
Stigma and Work
- Develop conceptual models of the causes of or results of stigmatization and discrimination, as well as what creates positive attitudes regarding individuals with mental illness in the workplace.
- Assess and monitor the scope of stigma and discrimination, their determinants and their consequences in the Canadian work setting through combinations of direct work site studies, qualitative studies and population studies.
Integrating Health Research and the Canadian Workplace
- Conduct research on how to move knowledge into action, including specific research on the knowledge exchange process with respect to mental health in the workplace.
An Implementation Strategy
The workshop included a full-plenary exercise on developing a theory of action, during which participants were directed to make recommendations on implementing the priorities identified over the course of the workshop. This exercise took place immediately after the identified priorities were validated by the full plenary.
Reflected in participants' remarks was a consensus that the workshop constituted a good start for implementing a long-term research agenda. The partnerships and dialogue begun during the workshop were considered essential to building momentum for implementation of the identified priorities. Given the broad range of stakeholders present, this consensus bodes well for future implementation.
The following list of five recommendations expresses the participants' consensus with respect to potential momentum building and implementation strategies. A full list of recommendations is available with the full report of the workshop on CIHR websites of the two sponsoring CIHR institutes of Population and Public Health and of Neurosciences, Mental Health and Addiction.
- Establish a coalition of partners to build the case for increased and sustained funding for partnership-based research in workplace mental health.
- Establish a foundation or consortium to fund research that will investigate priority areas.
- Convene a regular national conference to foster partnerships and to ensure that the identified priorities are pursued and supported by all stakeholders on an ongoing basis.
- Identify and pursue short-term objectives that have a high probability of success. Quick wins are essential. These will build momentum among stakeholders and ensure that priorities remain on the radar screen.
- Establish a permanent steering committee to foster knowledge transfer and to ensure that the identified priorities are translated into action.
- Engage more public champions.
New partnerships call for creativity; CIHR's 10-year research agenda must adopt organizational models to ensure a long-term presence in the field. In a country the size of Canada, with its wealth of research institutions and potential partners, this will require a range of funding sources. At the same time, demonstrated outcomes must be achieved quickly to build momentum and keep partners focused, while supporting early experiments with such models.
A variety of partnership models have been implemented in other research areas. For example, CIHR has demonstrated the effectiveness of supporting national centres and networks. This model could be adopted for research in workplace mental health.
At the provincial level, centres, networks and granting agencies, including Ontario's Institute for Work and Health, Quebec's Health-Research Fund sponsored networks and the independent Research Institute Robert-Sauvé, funded by the compensation board, are already involved in health and the workplace.
Another model is the CIHR's Community Alliances for Health Research. This model, which has been used successfully in suicide research, for example, is based on a partnership with community and non-profit organizations. It has a significant long-term funding commitment of $300,000 to $500,000 per year for five years. A similar model could be developed for a "Workplace Alliance for Health Research" around mental health and the workplace. The partners could be business, union, insurers, employees' assistance program firms and workers compensation boards.
Among early partnership models of note is the Business and Economic Roundtable on Addiction and Mental Health, which was founded two years ago by Bill Wilkerson. Its senior chairman is businessman and former federal finance minister Michael Wilson (see his workshop speech in the workshop report). The Roundtable has been active, first, in informing; second, in developing guidelines for businesses; and now in funding some initial research projects. This group experience could serve as a starting point by extending its partnership to include researchers and provincial or federal planning and research funding agencies like CIHR.
In the coming months, thanks to the momentum created by the workshop and to the initiative of the two sponsoring CIHR institutes, there certainly will be activity, involving the following:
- The creation of a new working group to develop new funding opportunities within CIHR but also in collaboration with other funding agencies, thereby ensuring close interactions between CIHR, researchers, workplace stakeholders and other funding organizations.
- The pursuit of the workshop newsletter informing all participants and other interested parties of the momentum building.
- The creation of a steering committee composed of researchers and workplace stakeholders to identify and link researchers and stakeholders in early opportunities and support long-term ones.
- The overseeing of the first national conference on mental health and the workplace.
- Initiatives, sponsored by the Institute of Neuroscience Mental Health and Addiction, on early life events and first episodes of mental illness in December 2004 - the calls for proposal can include pilots on prevention, early treatment interventions or positive discrimination in the workplace.
- The exploration of the potential of CIHR's ongoing initiative in commercialization as a source of funding. Here, we are not referring to biotechnologies, but rather to other products of commercial value, including tools or models of prevention, treatment and disability management interventions that are in line with identified research priorities. These can be developed by researchers or partners as employee assistance programs. The demonstration of efficacy, efficiency and feasibility, in partnership with workplace stakeholders and funding, would benefit from CIHR researchers' expertise and reputation for excellence.
- Use of the new CIHR initiatives in knowledge transfer to support the current mental health and workplace agenda.
Fortunately, we started yesterday. We started small, but we are thinking big with a view towards the long haul; this colossal public health and societal problem requires no less.
About the Author(s)
Alain Lesage, MD, Mphil, FRCP(C), DFAPA
Vice-chair, Institute Advisory Board, Institute of Neurosciences, Mental Health and Addictions, CIHR.
Professor, Department of Psychiatry, University of Montreal and Fernand-Seguin Research Centre, L-H Lafontaine Hospital, Montreal.
Carolyn S. Dewa, MPH, PhD
Health Economist, Health Systems Research & Consulting Unit, Centre for Addiction & Mental Health Associate Professor, Department of Psychiatry, University of Toronto
Jean-Yves Savoie, PhD
Chair, Institute Advisory Board, Institute of Population and Public
Rémi Quirion, PhD
Scientific Director, Institute of Neurosciences,
Mental Health and Addictions, CIHR
John Frank, MD
Scientific Director, Institute of Population and Public Health, CIHR
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Lomas, J., N. Fulop, D. Gagnon and P. Allen. 2003. "On Being a Good Listener: Setting Priorities for Applied Health Services Research." Milbank Quarterly 81(3): 363-88.
Perez, E. and B. Wilkerson. 1998. Mindsets. Ontario: Homewood Centre for Organizational Health at Riverslea.
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