Mental health initiatives in the workplace: models, methods and results from the Mental Health Commission of Canada
Authors: Keith S. Dobson, Andrew Szeto, Stephanie Knaak, Terry Krupa, Bonnie Kirsh, Dorothy Luong, Robyn McLean, Micheal Pietrus
Journal: World Psychiatry (2018)

Issues related to mental health in the workplace have become of paramount interest, in part because of the recognition that mental health of employees affects productivity, but also because some workplaces have structurally embedded stressors that may increase the risk of mental health problems. For example, police, fire and emergency services have inherent mental health challenges, which necessitate workplace health promotion. In addition to the humane argument to support the optimal mental health of workers, there is also a financial argument to address mental health in the workplace. Using an economic model simulation, it was found that a comprehensive screening program for depression had a return on investment of approximately 4:1, based on estimates of presenteeism and absenteeism alone1. When issues related to lost productivity, increased disability rates, and the indirect costs associated with hiring and training replacement employees are also considered, employers are well advised to promote optimal mental health – which means building structures and a cultural environment that are supportive of mental health in the workplace. We have addressed issues related to mental health in the workplace through the Opening Minds initiative of the Mental Health Commission of Canada. This initiative recognizes that the structure of the workplace can increase the probability of mental health problems, and that the willingness of workplace leaders to identify and speak about these issues influences mental health outcomes. For example, negative attitudes towards identifying and treating mental health problems, or direct stigma and discrimination from managers or co-workers, can create significant barriers to self-care and reduce the likelihood that an employee will seek care for mental health issues2. In concert with the Opening Minds initiative, we have produced reviews of anti-stigma activities in the workplace3, 4 and of the organizational factors that facilitate and hinder mental health and access to services5. We have modified and systematically evaluated more than twenty-four implementations of two workplace programs that aim to directly address stigma, encourage open dialogue and promote personal resilience6. We have also conducted qualitative studies of how mental ill health is experienced and managed in the workplace, and of worker perspectives on related training programs. It is our belief that these projects will enable a more sophisticated, compassionate and evidence-based approach to mental illness in the workplace, and allow workplaces to both promote mental health and recognize and address mental health challenges when they occur7. The two programs we have developed are the Road to Mental Readiness for First Responders (R2MR) and The Working Mind (TWM). The R2MR is an adaptation of a program that was created by the Department of National Defense in Canada for military personnel. A notable feature of that program is the use of the mental health continuum model, which encourages participants to conceptualize their mental health, in a non-pathologizing way, on a scale that ranges from good functioning (represented as the color green), through varying degrees of increasing distress and behavioural indicators, color-coded as yellow, orange and red, respectively. The program also encourages four coping skills, adapted from cognitive-behavioral therapy, to maintain and restore mental health, as needed. Our adaptation of the R2MR program for first responders included enhancement to the discussion about stigma and discrimination related to mental illness in the workplace. We adapted the mental health continuum model and coping skills that build personal resilience for the appropriate context. We also leveraged the research literature suggesting that contact-based education is a successful strategy to impart health-related information. Contact-based education includes the use of video materials of first responders who have experienced and overcome mental health problems, and the involvement of trained peers to deliver the program to their colleagues. This adapted R2MR program has been delivered to approximately 75,000 participants in Canada. We have consistently evaluated the program, using an open trial methodology, with pre-test, post-test, and 3-month follow-up on primary measures related to stigma and mental health resilience. Across 16 sites and multiple types of first responders (N=4,649), we observed an average effect size of 0.26 (range=0.12-0.45) for decreases in stigma, and 0.32 (range=0.20-0.49) for increases in self-reported resilience. The TWM is a further adaptation of the R2MR program, but for general workplace settings. It incorporates videos and other training materials that are consistent with those settings. The program has been delivered to approximately 25,000 Canadians. Our outcome evaluations in eight diverse settings (N=1,155) revealed an average effect size of 0.38 (range=0.15-0.51) for reduced stigma, and 0.50 (range=0.41-0.65) for increased resilience. Qualitative outcomes for both programs suggest that participants seek help earlier and support others to seek help. Versions of both TWM and R2MR exist for frontline employees and managers. The manager version includes an additional module addressing issues related to employer responsibilities (e.g., workplace accommodations) and how to develop and maintain a mentally healthy workplace. Based on the success of these programs, other variants are being developed and evaluated. For example, The Inquiring Mind is an adaptation for post-secondary students, and is currently under evaluation. Web-based booster sessions are being examined as a means to promote ongoing use of the program's knowledge and skills. A family package was created to assist family members of first responders who took the R2MR program to understand the program's insights. We have both a randomized trial of TWM underway, and an intended return on investment study of the R2MR program. Despite the work to date, there remains much to learn about these types of programs and their effects. Interested readers can learn more by contacting the Mental Health Commission of Canada at mpietrus@mentalhealthcommission.ca.