Hello, this is Dr. Bradshaw. I'm going to be speaking today about occupational psychiatry, the objectives, understand the impact of psychiatric disease in the workplace, examine the spectrum of occupational psychiatric disease, and outline relevant management treatment strategies. As you can imagine, mental health disorders are among the most burdensome health concern in the United States. In any given year, up to 20% of individuals may report having a mental illness. Approximately 70% of adults report at least one symptom of stress. Mental illnesses such as depression are associated with higher rates of disability and unemployment. Depression can interfere with a person's ability to complete physical job tasks and reduce cognitive performance. A little over half of employees who report moderate depression and 40% of those who report severe depression actually receive treatment to control their symptoms. First we're going to cover stress. Stress is a normal part of everyday life that can be associated with daily events or major life events. It can be cumulative and result in a buildup of stress that may manifest in many different ways. Some physiological responses to workplace stress may include increased blood pressure, increased heart rate, increased respiration, and increased metabolism. Causes of stress can include family situations, relationship issues, or workplace stressors, uncertainty about the future, as well as dissatisfaction with life. Some signs of stress, some of those might be internal such as feeling out of control or directionless, inability to keep commitments or over committing oneself, or changes in energy level, feelings of well-being, and mental alertness. These stressors can have an impact on personal and work relationships and can also be seen in the form of lack of motivation, accidents, or decrease in work productivity or quality of work. Some stress-inducing workplace situations include low job satisfaction, jobs with high stress and low control, repetitive monotonous jobs with periods of inactivity, working in isolation, boredom or inactivity, long hours, or irregular shifts resulting in fatigue. Stress-related outcomes as it relates to the workplace, job dissatisfaction, decreased productivity. There can be cardiac effects, tachycardia, hypertension, increased cholesterol, and coronary artery disease. Mental health effects may include depressive symptoms or maladaptive coping to include increased use of alcohol. Gastrointestinal effects may include peptic ulcer disease. Psychosocial stressors in the workplace have been known to have interactions with cardiovascular disease as well as modifying or exacerbating morbidity and mortality. There have been two models studied with regards to looking at these interactions. One of those models is the demand-control or job-strain model and the effort-reward and balance model. We're going to take a closer look at the demand-control or job-strain model. The measures as far as job control is control over work conditions and the job demand, such as workload. Different categories of job strain can include active jobs in which there's a high demand and high control, passive jobs in which there's low demand and low control, or high-strain jobs in which there's a high demand on the worker in which the individual perceives a low control, or low-strain jobs in which there's a low demand and the individual has high control of their work situation. Some of the assumptions in this model are that the high job demand and low job control results in a hazard to worker's health. Low job demand and high job control may be beneficial and not a hazard to a worker's health. And then job control can influence level of job satisfaction experienced by the worker. Some findings include stress at work is correlated with cardiovascular disease to include morbidity and mortality. High job demand and low job control with the highest risk for disease, and high work stress and low support from supervisors and fellow workers, also a higher risk for cardiovascular morbidity and mortality. Here's a look at the demand-control or job-strain model. I'm going to shift gears and talk about workplace violence. And the definition for workplace violence is physical assault, threatening behavior, or verbal abuse against a worker occurring in the workplace or in other venues when performing work-related activities. Some examples would include beatings, harassment, intimidation, psychological trauma, rape, shootings, stalking, and threats, whether that's verbal or written. Workplace violence is a leading cause of work-related deaths, approximately 2 million workers each year in the US. Some of the settings with increased risk include delivery and passenger services, particularly in high-crime areas, late night or early morning hours, where money is being exchanged or working alone. Workers at increased risk include health care workers, probation officers, service providers, social workers, and taxi drivers. It's more common to occur with males than females, meaning males are at a higher likelihood of performing workplace violence. Four principal types of workplace violence include coworker, which is lateral or horizontal violence in the workplace, customer or client, most common type in health care systems, personal relations, when personal relationships materialize in the workplace, and obviously there's friction, or a stranger, usually with some sort of criminal intent, such as a robbery. Early warning signs and actions observed in a worker, behavior usually builds up over time and is not an impulse. Increase in behavior is associated with an increased risk. Some of the warning signs include leakage, which is sharing of thoughts and actions to cause some sort of harm, listing motivation to act, planning action, whether that's a physical or threatening behavior, and then selecting a targeted coworker. Some OSHA guidelines for prevention include management commitment and employee involvement, work site analysis, hazard prevention and control, training, education, as well as record keeping and evaluation. Take a look at fatigue, shift work, and travel. I'm just going to be focusing on the shift work element. Fatigue is defined as the study of the relationship between components of the body's circadian regulatory rhythm and their impact on many of the body's functions throughout a 24-hour day, and certainly many systems within our body operate on these circadian rhythms to include our sleeping behavior. Circadian rhythms sync with cycles of light and darkness affecting the daily rhythms of many of the body's internal physiological processes. Workplace factors impacting a worker's well-being include fatigue, shift work, and travel. One phenomenon we can see is acute time shift syndrome, which is easier to adjust to schedule delays than advances, so meaning that scheduling shifts, moving in a forward direction, are much easier than in reverse, so switching from day shift to night shift. Or with regards to travel, traveling from east to west, and I think most of you know the mnemonic of east to west is best and west to east is least, or something along those lines that I don't quite recall, but certainly you want to take advantage of the lengthening of the day since our internal clock naturally lengthens. Symptoms that are common include GI distress, which is the most common, insomnia, and fatigue, and some prevention measures include hydration, avoiding alcohol, tobacco, or caffeine, eating light while traveling, and then certainly adhering to a good sleep regimen or sleep hygiene. Chronic time shift syndrome includes sleep disturbances, chronic fatigue, medical complaints, typically in the form of somatic complaints. Alcohol and drug abuse can exacerbate this, accidents and near misses can be demonstrated, an individual can demonstrate mood disturbances, which actually appears typically first before you see any sort of psychomotor disturbances, particularly in routines that are well rehearsed, personality changes, and relationship problems. On this slide, you can see that there are multiple systems involved or can potentially be affected by chronic time shift syndrome. Prevention strategies include rotating shifts in the direction of time delay, so that would be rotating from first shift to second shift and subsequently third shift, educating individuals to maintain sleep hygiene, maintain mealtime schedules, maintain light exposure during waking hours, and I would also emphasize maximizing light exposure during the early morning hours if you're a day shift worker, and certainly you would want to minimize light exposure during the early morning hours if you're third shift and about to go into a sleep phase. You want to avoid caffeine, alcohol, sedatives, sleep aids, NSAIDs, which suppress melatonin. With regards to sleep aids, ensuring the timing of those have been discussed with your doctor, you want to certainly provide for optimal anchoring for your sleep and the timing of these sleep aids are important, particularly the half-life if you're using any sort of sedative hypnotics. Next thing we're going to talk about are mental disorders, and so with regards to mental disorders, we're going to be talking about various psychiatric conditions that can certainly have an effect on work capacity. I think it's important that we identify these early, provide selected management for these conditions and refer appropriately if the individual is impaired, identifying what aspects are exacerbated by workplace stress, and certainly underlying psychiatric issues can be exacerbated by workplace stress, and then the appropriate assessment for these psychiatric disorders. Mental health disorders are often identified in the workplace, and workplace stressors may contribute to mental health issues. Some chemicals other than workplace substances may be associated with neuropsychiatric symptoms, so it's important to ask about outside activities to identify any potential exposures. Mental health disorders may be associated with poor job performance, poor quality of work, absenteeism or presenteeism, strained relationships, whether they're personal or work relationships. Work impairment may be secondary to their mental health condition or potentially by side effects from medication that are intended to treat their underlying condition. Identifying, managing, and referring impaired employees is important, and these individuals may be identified because of demonstrating the following, erratic behavior, risky behavior, interpersonal conflicts, unexplained changes in their work performance. Different ways for evaluating these issues are fitness for duty examinations, and oftentimes these are requested by the employer. You're assessing physical and psychological ability to perform their job, so it's important to understand the specific job requirements, and then it's also important to be able to assess and look at one's ability to perform their job following time off for medical reasons. We talked about understanding job requirements as well as the physical and psychological demands of one's job and providing evaluations and recommendations based on functional abilities and not the diagnosis, so it's important to understand what's the individual's functioning as opposed to just considering the diagnosis alone, and in some of these situations, employees may require modified duties or work restrictions based on their functional abilities, or they may require a referral to an employee assistance program, their treating physician, or a mental health professional. One aspect that's important to ensure that is assessed is cognitive function, and so this can be done by looking at the various aspects of the mental status evaluation, but more particularly the cognitive aspects to include orientation, sensorium, attention and concentration, memory, verbal and mathematic abilities, judgment, reasoning, and a lot of these things are encapsulated or captured by the mini mental status examination, but certainly bedside cognitive assessments are not the definitive evaluation if there are any aberrations or abnormalities, certainly you'd want to do more in-depth neuropsychological testing if it's required, documentation of common non-specific mental health symptoms, fatigue, particularly if it's causing problems in the workplace, anxiety symptoms, disruption of life activities, whether it's neurovegetative signs such as disturbances in sleep, appetite, libido, apathy and lack of interest in their regular activities or any sort of anhedonia, mood changes, particularly if they're abrupt changes to include persistent irritability. You'll also want to ask about perceptual disturbances or hallucinations, any sort of disturbing dreams or sleep disturbances in general, intrusive or recurrent thoughts, and that could be asked within the context of obsessions or perhaps the intrusive thoughts of an individual with trauma-related conditions such as PTSD, preoccupations and phobias, somatic delusions, suicidal ideation, homicidal ideation, or any sort of overvalued ideas. Physical examination lab testing oftentimes will need to be completed as well as part of this workup. The first psychiatric condition we're going to talk about is what used to be referred to as organic brain syndrome or encephalopathy. This really kind of covers two different areas broadly. One, the more acute and concerning would be delirium, and those are individuals that are experiencing some sort of acute stuporous state, which may be secondary to an acute toxic exposure, or perhaps it might be from a devolving or decompensation of some sort of serious underlying medical condition in which the individual is demonstrating confusion, stupor, hallucinations, or changes in sleep cycle. Chronic exposures, more commonly what we used to refer to as some sort of dementia, secondary to some sort of general medical condition, or perhaps in some subpopulations could be the result of some sort of early onset Alzheimer's, dementia, or potentially Parkinson's, can result in a change of cognitive function, changes in affect, depression, anxiety, and somatization. And it's important to understand that a lot of times neurocognitive disorders, what we used to refer to as dementia, oftentimes can present initially with changes in affective states, or anxiety, or personality changes before you start seeing any sort of cognitive decline. With regards to depression, most oftentimes a lot of us remember the acronym SIGECAPS, but the most important aspect to understand with regards to depression is that the individual has to experience one of two things, and that's a persistent low mood state or anhedonia, the inability to enjoy their usual activities. And then we look for the concurrent neurovegetative signs of disturbances in sleep or concentration, and remembering that those are specifically secondary to depressive symptoms, and that these are also occurring over a period of time. And so in order to meet criteria for a major depressive episode, the individual would need to demonstrate this nearly all day long, most days for at least two weeks. demonstrate this nearly all day long, most days for at least two weeks. But certainly an individual may demonstrate some time-limited depressive symptoms in the context of acute stressors, or perhaps they may even demonstrate depressive symptoms in the context of other psychiatric conditions to include trauma-related mood or anxiety symptoms. Oftentimes you'll see disruption of like activities. We talked about the neurovegetative signs of sleep disturbances, appetite disturbances, or even disturbances in libido. Types of depression, and these are a little bit arbitrary here, and I would say that really what's being outlined here is does the individual have actual unipolar depression versus some sort of secondary cause for the condition. So it's important in all of these psychiatric conditions to rule out one, exposure to any exogenous substances, whether that's illicit or illicit. So prescribed medications that may have side effects that cause depressive symptoms, or illicit substances, whether that's some sort of illegal drug or some other sort of substance that might also cause some depressive symptoms. And as I just talked about, you'll want rule out medication use. You'll certainly want to rule out general medical conditions to include hypothyroidism, hyperadrenocorticism, and hypoadrenocorticism, as well as low vitamin D and low testosterone. But you'll also want to make sure that the individual is not suffering from any other medical conditions. It can also demonstrate some neuropsychiatric symptoms that appear to have the outward appearance of depression to include substance intoxication withdrawal. Next, we have mania. Signs and symptoms of mania include elevated or expansive mood states, grandiosity, and with regards to grandiose delusions, perhaps maybe thinking they have some sort of superhuman or special powers, individuals demonstrating significant distractibility, inability to complete tasks in a purposeful way despite ongoing goal-directed behavior, impulsivity, being reckless, particularly putting themselves or others in danger. And oftentimes, this is typified by either promiscuous sexual behaviors that are uncharacteristic for the individual or uncharacteristic spending patterns that put themselves in some sort of financial difficulty. Once again, it's important to rule out a couple of things to include general medical conditions in which the individual may demonstrate some manic-like behavior, as well as illicit and illicit substances to include prescribed medications. And certainly, the most common cause of medication-induced or substance-induced would be amphetamine abuse. You'll also want to look at some work-related causes to include manganese and carbon disulfide. Anxiety disorders. When we talk about anxiety disorders, certainly an individual can experience anxiety as it relates to acute stressors, as we would see in adjustment disorders. But you can also see phobic anxiety when there's particular irrational fears of various types of situations or substances, if that's a fear of heights, perhaps maybe a fear of being in an open or public places, or it could be related to trauma, as we'll discuss in a second with post-traumatic stress disorder. Most problematic would be individuals that have severe generalized anxiety disorder or they're experiencing some sort of general cloud of excessive worry, difficulty controlling their worrying, difficulty initiating sleep, and particularly with racing thoughts or some sort of problem with irritability or muscle tension as it relates to anxiety symptoms. And here, we outline some of the panic symptoms that most people are classically aware of with regards to autonomic arousal in which the individual may be experiencing some sort of chest tightness, palpitations in which they feel like the heart is going to beat out of their chest, dry mouth, sweating, some sort of smothering sensation, or dizziness, feeling lightheaded, or perhaps paresthesias in which they feel tingling in their hands and fingers, or perhaps maybe in their feet, as well as hyperventilation. You would also want to rule out any sort of substance-induced anxiety symptoms, as well as general medical conditions. And look at work-related causes, including solvents. Perhaps there would be work demands in the situation in which there may be some sort of acute stressor-related anxiety, or job insecurity, or any problems with interpersonal difficulties. Post-traumatic stress disorder, and this would be an individual that has experienced in the past or recently some sort of life-threatening trauma. And of course, with DSM-5, it seems like this is broadened quite a bit to where oftentimes now, not to minimize or discount one's traumatic exposure, certainly there can be some sort of traumatic stress disorder, but it can be certainly there can be some abuse or some sort of other perceived to be traumatic exposure that may be causing some of the signs and symptoms we would classically think of with PTSD in which the individual is experiencing some sort of flashbacks or re-experiencing phenomena to include nightmares, or perhaps maybe some hyperarousal symptoms to include sleep disturbances or avoidance behavior in which the individual is actively modifying their behavior to avoid any sort of triggers that remind them of the past experience that caused trauma. And it's also important to assess for any sort of mood-related changes, or perhaps maybe negative type mood states related to the trauma in which the individual may be experiencing some sort of dissociation or perhaps some sort of sense of foreshortened future. Treatment for PTSD includes first-line trauma-based therapies to include cognitive behavioral therapies, such as prolonged exposure therapy or cognitive processing therapy. First-line medications, of course, the FDA approved medications of sertraline and paroxetine, and then there's some evidence-based for parazepine for reducing nightmares for individuals that have more severe forms of PTSD. Contraindicated, particularly by the VA treatment guidelines, is benzodiazepine use for individuals that have post-traumatic stress disorders. Oftentimes, I see individuals that have been placed on benzodiazepines, and my suspicion is that this was intended to either be some sort of acute phase treatment or to serve as some sort of transition while they're becoming therapeutic on their primary or first-line treatment agents for PTSD. And then certainly supportive counseling, which would also include family counseling, because oftentimes there's a significant impact or some family dynamics in individuals that are suffering from severe PTSD. Somatoform disorders, these are individuals in which the symptoms are not consistent with the objective findings, and they're oftentimes referred to as psychogenic pain, hypochondriasis, conversion disorder, or somatization disorders. These are individuals that, in this spectrum of conditions or disorders, include individuals that may be complaining of neurological weaknesses or various types of neurological complaints that are inconsistent with your physical exam findings. So for instance, if the individual is complaining of blindness, but yet there's nothing on your physical findings that are consistent for any reason, for they have any sort of blindness or an individual complaining of some sort of weakness in their upper extremities or musculoskeletal system, but yet there's nothing that would suggest that the individual should have any sort of issues with this. Oftentimes individuals can have what would be called primary gain, or they're not necessarily malingering. This individual is subconsciously just wanting to assume the sick role. And then, of course, individuals that are malingering would be looking for some sort of secondary gain, whether that's some sort of modification of their job duties, or even perhaps looking for some sort of disability. Malingering, from the source that I was using, it says that it refers to an sociopathic behavior. I don't know that necessarily you would assume that the individual has some sort of antisocial personality traits or even disordered behavior just based off of their malingering alone, because certainly we see this all the time in various institutions, whether it's in prisons or in the military, in which the individual may be feigning illness in order to embellish some sort of disability findings. And malingering is often found in patients with somatoform disorder, in which these subjective symptoms are not consistent with objective clinical findings. We're going to shift to management and treatment. And so we had been talking about stress at the beginning of this presentation, and that it's very normal for individuals to experience stress in their daily lives. And this may exacerbate symptoms that can cause some difficulty in the workplace that can be cumulative and not necessarily lead to any sort of psychiatric condition. So it's important to address these issues first, even in individuals that do have psychiatric conditions, to lessen their morbidity. So this would include encouraging exercise, evocational endeavors, and so doing things to unwind or relax in their off-duty hours, relaxation training, as well as looking at family support. Maximizing non-pharmacological treatment to include psychosocial therapies, to include psychotherapy. So a lot of times what we're seeing today are a lot of the therapists are using cognitive behavioral therapy, mostly because of the now growing evidence base for the use of these more pragmatic approaches, which include trying to reduce cognitive distortions through cognitive restructuring, in which they're altering patterns of thinking, identifying and refuting dysfunctional thought patterns, or what they call cognitive distortions, and then developing new thought patterns, as well as behavioral therapies, including social skills training, biofeedback, systematic desensitization, as well as relaxation techniques. Medication management, the approach on this should not be taken lightly. Oftentimes what I'll see is individuals that don't really suffer from any primary psychiatric disorder, but yet they're presenting with significant acute stress-related anxiety and depressive symptoms that appear to be consistent with an adjustment disorder, and they get started on some sort of antidepressant by their primary care. I think it'd be important to first make sure that you've ruled out any sort of general medical conditions, as well as any sort of substance induced anxiety and depressive symptoms. And for individuals that have more persistent depressive or anxiety symptoms that would benefit from use of antidepressants, certainly starting those medications at low doses and titrating up slowly, and ensuring that you optimize the use of that medication before either switching or augmenting with other types of medications. I make mention here of anxiolytics, and certainly while antidepressants have anxiolytics, I'm speaking specifically about benzodiazepines or any sort of medication used solely for the sedating purposes, to include hypnotics, which are generally used to sleep aids. I think that these should be used judiciously and should be done in a time-limited manner in which there's extensive counseling with the patient to get a good understanding of how the medication will be used, that it'll be done on a time-limited basis with the purpose of either one, providing it in conjunction with some sort of psychosocial therapy, addressing the underlying stress-related issue, or while you're becoming therapeutic, while one's becoming therapeutic on their primary agent, which is typically going to be an antidepressant. Employee assistant programs play an important role in the overall treatment strategies. They help out with providing detection early intervention, whether that's family, marital, social, or legal problems, as well as providing a means for cost-effective referrals. And then certainly individuals that are self-referring can be assured some sort of confidentiality, and this can either be provided on-site or off-site, or we're in some sort of consortium. Health promotion programs also play an important role. They can incorporate EAP, encourage health and fitness, as well as encouraging stress management. And the benefits of employing these programs is reducing absenteeism, reducing healthcare costs, as well as the ability to reflect the employer's attitudes where you can reinforce some of the organizational mission and vision. Organizational redesign, and some of the basic elements of this would include individuals acting as some sort of change agent, client-centered or employee-centered type of interventions, and looking at various types of diagnostic activities, whether that's use of screeners, providing some sort of health education, coaching or counseling, whether that's on the work side or off-site, as well as some sort of career planning. Job redesign is also an effective means to address individual and organizational mental health issues, and this can be done through shift work modifications, whether at the individual or workplace level, ergonomic considerations, engineering controls, as well as administrative controls, which may include some sort of policy changes, as well as proper employment of personal protective equipment. In summary, there are a wide range of stressors and psychiatric issues present in the occupational environment. Stress-related and psychiatric conditions pose a significant burden financially, and there are a number of ways in which stress-related and psychiatric conditions pose a significant burden financially, as well as to the individual in the workplace. Organizational and individual management and treatment strategies are available. Thank you for your time.

occupational psychiatry

mental health disorders

workplace stress

psychotherapy

employee assistance programs

workplace productivity

cognitive functions