1. The importance of mental health and disability as business issues. Given this, the research needs to consider the employee population, their challenges and needs.
   
2. Mental health disability is a multi-faceted concern that requires a research agenda that recognizes interconnections between symptom management, coping skills, individual decision making and opportunity.
   
3. The goal of disability management is to support ability and provide workers with the opportunity to function productively at work. A "real-world" focus is essential for research and the resolution of systemic barriers. The challenge is to ensure that knowledge is applicable and considers the sources of motivation and "de-motivation" for both the employees and employers.

The section entitled "Knowledge Related to Physical Health" illuminates the unquestionable role of occupational factors in return to work, and even recovery. In addition, the influence of psychological interventions in physical rehabilitation illustrates the connection between medical, psychological and occupational factors in disability management. With work, health and psychological well-being influencing each other, concerns in one area, such as demand-control and effort-reward factors at work, influence others, such as physical and psychological health. Thus, the finding that when it comes to disability management, the actions of most physicians are not consistent with clinical practice guidelines and policies is a troubling example of risk with many possible levels of impact.

Under the heading "Knowledge Related to Mental Health," the discussion paper highlights the need for specific attention to the rehabilitative needs of persons with stable work histories. The restoration of function is crucial. Here again, there is a strong indication that a one-dimensional approach is insufficient. While appropriate pharmacological treatment has a significant impact on disability duration, psychological intervention - in particular, cognitive behavioural therapy (CBT) - adds significantly to improvement in work function. CBT supports development of the skills and coping strategies that are necessary to bridge the state of being disabled and the state where one has recovered to the point where the individual is able to work as fully as they will likely be able to at work. The research also highlights the need to be attuned to mental illnesses as common co-morbid conditions, and mental health issues as predictive of outcome when there is a physical health problem.

The "Summary of Major Trends" describes a promising multi-faceted direction that considers individual perceptions and decision-making factors, job and workplace factors, supervisor training, employer-sponsored programs and the disability claims process.

From the perspective of an employer, the critical issue relating to health is productivity. Protecting productivity, managing risks to productivity, restoring lost productivity and maximizing productivity are all key business challenges.

Disability management is a critical part of productivity management. The purpose of disability management is (1) to minimize the impact and cost of disability to the employer and the employee and (2) to encourage the return to work of an employee with disabilities.

Disability management is supported by:

• treatment (to relieve symptoms or correct impairment);
  
• rehabilitation (to promote function or compensate for the loss of function);
  
• policies (that promote work re-entry);
  
• practices (to ensure a goal-focused co-ordination of interventions); and
  
• communication (to ensure clarity for sound decision making and alignment).

The key in this is the employment relationship and the roles of both employer and employee.

The "Gaps and Recommendations" sections of the discussion paper speak, in varying extents, to all of these factors. Three of the recommendations relate to treatment and care specifically for mental health issues. The recommendations express clearly the need for protocols and guidelines for the management of occupational disability related to mental health, for a focus on restoration of function and for a delivery mechanism that will improve outcomes. From a disability management perspective, the two specific areas of concern need to be addressed:

• earlier detection, early intervention and suitable care; and
  
• useful and appropriate standards of information exchange between the healthcare community and the workplace.

The remaining recommendations pertain to disability management practice. They recognize the importance of individual variables and the connection between physical and mental health. They also recognize both the risks and opportunities in applying to mental and nervous disability the best practices used for physical disability.

• In addressing these issues, the impact of the workplace and the insurance claims process require as much attention as the role of the individual and the disability management professional.
  
• We also require a clearer understanding of the psychological and social impact on mental health disability of shorter-term absences (i.e., of less than six months) and return to work.

With all of this said, the goal of research should be to answer questions in a precise enough manner to guide step-by-step improvement, yet to be broad enough in scope that the outcome is sustainable productivity - not just earlier return to work.

A final recommendation pertains to the coordination of government policies, employer practices and the health system. The economic model to be researched recognizes that "prevention" removes some of the burden on the healthcare system and that restoration of lost productivity benefits the economy. Employers have a role in lobbying for responsive healthcare. Governments can also be more active in providing incentives to employers - even temporarily or during a limited period - to pioneer leading edge practices. Such policies need to encourage improvements in the approach business takes to employee health. The results achieved will ultimately make the business case for continued investment.

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