This paper puts forward important concepts related to the diagnosis and treatment of individuals with mental illness and the workplace. These include the need to take an integrated bio-psycho-social approach, an emphasis on functional outcomes, the need to improve the current fragmentation of occupational mental health services, the benefits of identifying individuals at risk of developing mental health problems, the difficulties in disseminating educational information, and the impact of the relationship between workplace and family factors.

While the paper focuses on traditional approaches to treatment (prevention is addressed in another paper), there are a number of dimensions that are missing from this analysis and that need to be included in the development and evaluation of effective occupational mental health services. The framework being proposed would be strengthened if it (1) defined target groups at whom workplace mental health services should be aimed, (2) put greater emphasis on the interaction between individual and contextual or workplace factors and (3) looked at factors that can affect the "processes" of care in order to develop effective intervention models. The inclusion of these areas reflects three important principles underlying the delivery of occupational mental health services:

• It needs to be seen as a collaborative venture between management, representatives of the workforce, mental health and occupational health services, and other community resources.
  
• Occupational mental health services need to take a systems or organizational perspective, addressing factors in the workplace - as well as individual factors - that can contribute to the development of work-related problems and affect their management.
  
• Many individuals have difficulty in accessing appropriate psychiatric services for work-related problems. The workplace is in a unique position to identify these problems and facilitate referrals.

(A) We need to be clearer about whom workplace mental health services should be directed to, rather than just stating "all individuals with jobs and mental health problems." This will help to define the responsibilities of occupational mental health services (Kahn 2002). Potential roles can include assisting (1) workers and workplaces in addressing specific sources of stress that contribute to work-related mental health problems (this is discussed in the prevention paper); (2) workers who are coping with mental health problems arising from workplace difficulties, or where rapid access to suitable treatment will increase their return to productive participation in the workplace; (3) workers who require referrals to mental health services outside the workplace; or (4) workers who are returning to the workplace after dealing with a mental health problem. The question of whether these services should just focus on work-related issues that will affect the worker's ability to participate in the workplace or whether they should address general mental health issues needs to be clarified as part of the developing national agenda.

(B) A greater emphasis is required on the need to recognize and address contextual factors in the workplace as part of the assessment and treatment of a mental health problem (Maddocks 2000). Factors such as work relationships, lack of control over the work environment, etc., can contribute to the development of mental health problems and their management. Incorporating these factors into a systemic and organizational approach will allow us to take a multi-dimensional view of the origins of a problem and open up broader options for effective management (Fingret 2000).

Most workplaces also have relational and political tensions or undercurrents that can affect the way mental health problems present or can be screened for or treated, or how services are utilized. For example, (1) it may not be clear whether the services are in place to improve the well being of the individual or the productivity of the company; (2) there may be an element of coercion in suggesting that a worker receive mental healthcare in the workplace; (3) it may be stigmatizing for workers to be identified as having a mental health problem, and they may therefore wish to have their problems treated elsewhere; and (4) the workplace may be ambivalent in its acceptance of mental health problems and services.

(C) There needs to be a greater focus on the process of care and the factors that can influence this. The paper states that many different services and organizations already provide mental health services to the workplace, often in a fragmented manner with poorly defined responsibilities, although it overlooks the role of the family physician, who will bear primary responsibility for ongoing care for many people seen by occupational mental health services (Kates et al. 1997). We need to identify the optimal roles of the three sectors - occupational health services (including EAPs), mental health services and primary care - and determine how they can work together and complement one another (Goldberg and Steury 2001). The paper touches on the important issue of the need to develop and evaluate innovative models of service delivery. To be effective, these must be relevant to and fit with the demands and expectations of the workplace and key stakeholders; acknowledge and take into account specific contextual factors that can affect the way services are used; and be well linked with primary care and community mental health services (Sederer and Clemens 2002).

We also need to investigate what the optimum models are for ensuring that workers with mental health problems receive suitable treatment, determining whom they get it from, and identifying the main factors that contribute to their success. Several specific questions need to be answered: What is the optimal role for mental health specialists when working with occupational health services? Should EAP services see anything other than problems that affect an individual's participation in the workplace? How should EAP and occupational health services be linked? How should workplace services be linked with primary care and community mental health services? What services need to be in place for individuals exposed to "critical incidents"?

New models of care need to recognize that organizational and environmental factors can influence their effectiveness (Lubit and Gordon 2002). When we are developing and analyzing these models, the decisions to be made include (1) what role employees should play in the organization of mental health services, (2) what factors in the culture of the organizations can affect the integration or acceptance of models of care in the workplace, (3) who should be paying for these services and the implications of different models of treatment, (4) what staff need to be involved in these services and (5) what the most effective models are for educational and screening programs, who should be involved in their implementation and how they should be prepared and supported.

There are three other key issues not raised in the paper that need to be addressed as part of a national agenda:
(1) What are the most effective ways of reducing the psychological impact of job loss (Kates et al. 2002)? (2) Can we develop a broader understanding of the relationship between the workplace and family activities (Morrison and Deacon 2002)? (3) How do we train psychiatrists and mental health workers to appreciate the role work plays in people's lives and the impact of work-related factors on their mental health.

Additional Priorities for the National Agenda

• Who should the target populations be for occupational mental health services?
  
• What are the optimal models for delivering services to these populations and what factors promote or retard their successful implementation?
  
• How should workplace-based services be linked with community mental health services and primary care?
  
• What are the most effective models for educating and screening workers with potential or emerging mental health problems?
  
• How can we best assist workers in smaller workplaces (those with fewer than 100 workers) that don't have EAPs and that have limited on-site health resources?

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