Interview with Lawrence Martin M.D.
bh IN BRIEF
Dr Martin identifies changes in workplace behaviour that signal anxiety disorders and identifies which symptoms are most difficult to treat. Although most depressed patients never go off the job and many who leave, return to work, some do not. Patients with a high level of anxiety or cognitive impairment, a fundamental and disabling part of the illness, have the most difficulty. Employers can help by providing a mentally healthy workplace and ensuring that benefit programs include both comprehensive pharmacological coverage and adequate funding for effective psychotherapy. The future includes progress in the de-stigmatizing of mental illness and the development of new, more effective treatments.
(1) Dr Martin presented at Pathways to Business Health Symposia in Kitchener, December 6, 2011 and in Mississauga, May 24, 2012.
(2) Lopez, A. & Murray, D. November 1998. The global burden of disease, 1990-2020, Nature Medicine, 4 (11), 1241-1243. Available www.ufrgs.br/toc/pdfs/29.pdf
(3) For more information, see M.A.P. – Road to Recovery, businesshealth e-news (8) 4, October 2012.
Dr. Lawrence Martin is an Associate Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University. Dr. Martin has held a variety of clinical administrative roles including Assistant Chief of Psychiatry at St. Joseph’s Healthcare in Hamilton, Ontario, where he is currently Clinical Director of St Joseph’s Regional Mood and Anxiety Disorders Program.1
Findings from the Global Burden of Disease Study, carried out jointly by the World Health Organization, the World Bank and Harvard University, indicate that depression will be the #2 cause of disability by the year 20202. Understanding the role of the workplace in facilitating diagnosis and effective treatment is key to dealing with this growing cause of disability.
1. What behaviours are exhibited in the workplace with MDD/anxiety disorder?
The first change in workplace behaviour is often withdrawing from social interaction or becoming irritable, both hallmarks of depression. For example, employers should be concerned when an employee who used to have lunch with a group of colleagues starts to eat alone or consistently goes out of the office alone. Indecision, making more errors, forgetting obligations, and procrastinating are other common behaviours that result in decreased productivity and are early signals that an employee needs help.
2. Which symptoms are most difficult to treat?
The most common symptoms affecting workplace functions are low energy and impaired sleep. Each is very difficult to treat. Additional symptoms include difficulties with memory, multi-tasking and tolerating conflict/stress. Anti-depressants can improve the distressing parts of the illness like irritability, mood swings, thoughts of suicide, and self-disparagement, but it is challenging to address lack of motivation and the absence of drive. The hardest things to get back are energy and the ability to think clearly and make decisions. Cognitive impairment is a fundamental and disabling part of the illness.
3. What percentage of your patients go off work and if so, return to work?
Family practitioners treat the vast majority (95%) of depressed patients. The majority of these never go off work but remain on the job, functioning at sub-optimal levels. Of those who go off work, 70-80% return. Working in a mood disorder specialty program, I see the treatment resistant patients. Of these, 60% are on disability and many do not return to work. Patients with a high level of anxiety or who have cognitive impairment (difficulty focusing and making decisions) have a harder time returning to work.
4. What can employers do to foster a mentally healthy workplace?
Running a business that respects the employee is the first step in establishing a healthy workplace. Increasing employee awareness of mental health issues and offering anonymous screening resources are also important. Self-assessment tools such as My Action Plan (M.A.P.) and Check Up From the Neck Up, are confidential, free, online resources available to all. M.A.P. and Check Up From the Neck Up were both developed by the Mood Disorders Association of Ontario (MDAO).3 Offering workplace wellness programs and promoting regular exercise and healthy eating habits will also contribute to a mentally healthy workplace.
5. What features of a Benefits Plan can support employees with mental health issues?
One of the most important features of an optimal Benefits Plan is comprehensive pharmacological care covering new market entries. Because every drug benefits a unique population, the more variety available to physicians, the higher the treatment success rate in divergent patient populations. Most patients need to try more than one medication, or a combination, to find a balance of efficacy and tolerability. For example, pairing anti-depressants and anti-psychotics often leads to the best overall functional recovery. The second important feature of an optimal Benefits Plan is adequate funding for effective, time-limited and structured psychotherapy such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). The normal course for effective treatment is 12-15 sessions but most plans offer too few sessions to be effective.
6. What changes do you forsee in the future with respect to treating mental health issues?
Progress will continue in the de-stigmatization of mental illness, facilitating the effective treatment of patients using optimal combinations of drugs and/or therapy. I expect to see new classes of medications that are multi-modal or use new mechanisms of action. Another development will be the increasing specificity of treatments using pharmacogenomics and EEGs while the use of web-based CBT will facilitate access by remote patients.