It is important for clinicians to assess work and patient factors that may contribute to workplace mental health disorders, specifically MDD. For example, in a 2013 survey of work-related mental disorders, 31–33% of claims were due to work pressure, and 18–27% to harassment or bullying at work (69). Work pressures were related to work deadlines, interpersonal conflicts with employers or colleagues, disciplinary actions, performance reviews, and promotion disappointments (69). Meta-analyzes of prospective and case–control studies have identified several workplace factors associated with depressive symptoms and absenteeism (Table 2) (70, 71).

In addition to workplace factors, certain patient characteristics may also indicate a higher likelihood of a work-related mental disorder, particularly among those who have experienced a physical or psychological work-related injury (37). These may include specific depressive symptoms of insomnia, low mood, anhedonia, and suicidal thoughts; chronic physical health problems; poor social and personal support system; history of past or current depression, anxiety, substance use, or other mental disorder. Thus, the relationship of a mental diagnosis to work should be based on the clinical assessment and assessment of the factors described in Table 2, and the timing of pressures, events, or changes in the workplace relative to symptom onset (16, 37, 70, 71).

Although screening tools to determine that a mental disorder is related to workplace factors are absent, tools to assess functioning and work impairment can be very useful in clinical assessment. Examples of some of the tools that have been validated for the assessment of functioning are shown in Table 3 (72–78). In addition, the Occupational Depression Inventory (ODI), a validated 10-item instrument, has shown utility to quantify the severity of work-attributed depressive symptoms (77, 78).

Burnout is defined in the International Classification of Diseases 11^th Revision (ICD-11) as a syndrome resulting from chronic workplace stress, and it is specific to the occupational context (79). The three dimensions of burnout are exhaustion, mental distancing from one’s job, and reduced professional efficacy (79). There are no DSM-5 diagnostic criteria for burnout (42). Burnout resembles depression, and although some evidence suggests it is a distinct condition (80), this remains controversial (81). A systematic review examining the relationships between burnout and depression or anxiety concluded that the conditions were associated but did not conclusively overlap; burnout appeared to be a different construct (80). However, person-centered longitudinal analysis of symptom clusters found burnout and depression both develop in tandem at similar levels, suggesting conceptual similarity in the work context (82). A meta-analysis of 14 studies suggests the core symptoms of burnout, exhaustion, largely overlap with depression, compared to the putative dimension of detachment and efficacy (83). Both burnout and MDD have each been shown to predict suicide risk; however, burnout was not consistently associated with other suicide risk factors when MDD was present (84). In addition, people who suffer from burnout may present with many symptoms that look like those seen in patients with MDD (Table 4) (79, 80, 85).

Burnout is commonly assessed using the Maslach Burnout Inventory (MBI) (86, 87). However, because the symptoms included in burnout scales are very similar to some but not all of the symptoms that characterize depression, it is important to determine if patients presenting with burnout have MDD according to the DSM-5 criteria (88).

There are key differences between presentations of malingering, somatoform, and factitious disorder (Table 5) (42, 89, 90). It is important to be aware of and identify individuals who may have alternative gain and do not want to return to work, and to consider these other presentations in the differential diagnosis.

Malingering is not a medical diagnosis, and it can be difficult to identify with certainty. It is generally defined as fabricating or exaggerating symptoms (mental or physical) for secondary gains, such as financial compensation, obtaining drugs, avoiding obligations or discipline at school or work, or getting attention (91). Certain factors can increase the suspicion of malingering such as presentation in a medico-legal context, a discrepancy between self-reported stress or disability and medical findings, poor cooperation during an assessment, poor compliance or poor response to prescribed treatments, an unexpected escalation of symptoms, vagueness around prior management strategies, use of multiple different healthcare providers, and a history of antisocial behavior (90, 92). Studies have shown that patients who are malingering report more symptoms than those with confirmed MDD (89, 93). They may endorse suggested symptoms indiscriminately, including those that are atypical or rare, believing this will be more convincing of severe illness (93). Conversely, genuine patients report only the symptoms that they are really experiencing.

It is very challenging to identify malingering in the absence of a patient’s confession or contradictory objective information. The reliability of patient self-reports should be well documented in the patient’s records, and requests be made for an independent medical opinion to clarify the presence of genuine illness and impairment. Malingering might be suspected after conducting a thorough medical history, identifying inconsistency in symptom presentation, and observed mental status, and perhaps employing diagnostic tools such as the Minnesota Multiphasic Personality Inventory (MMPI-3) or the Personality Assessment Inventory (PAI) (94, 95). In the absence of proof of a conscious motivation for obvious personal gain, factitious disorder or somatic symptom disorder should also be considered after a thorough evaluation (Table 5) (42, 89, 90).

Comorbid medical conditions and other mental disorders confer more disability, require more complex treatment approaches, and are associated with longer time to recovery, and a lower likelihood of achieving functional recovery. As a result, comorbid conditions can lead to greater work disability and more absenteeism than MDD alone (20, 96). Depression and anxiety are frequently comorbid, with around 50% of patients with MDD also suffering an anxiety disorder in their lifetime (97, 98). Comorbid anxiety has been associated with increased rates of suicide, poorer response to treatment, increased severity, increased risk of chronicity and recurrence, and differences in neurobiology compared to depression alone (99, 100). Substance use disorders are also common comorbidities in patients with MDD (101). Patients with depressive symptoms should be routinely assessed for anxiety, substance use, and suicide risk. Useful tools were mentioned previously.

An estimated 2.2 million Canadian adults have both physical and mental comorbidity [Canadian Community Health Survey (CCHS), 2014] (102). The presence of a comorbid mental condition in patients with chronic medical conditions were associated with lower health-related quality of life (HRQoL), increased annual healthcare costs, and an increased risk of suicidal ideation (27, 102). Common comorbid conditions included hypertension, cancer, post-stroke, arthritis, cataracts, chronic obstructive pulmonary disease, diabetes, epilepsy, heart disease, pain, migraine, and thyroid disease (27, 103). In patients with cognitive impairments, which are associated with mental health disorders, the diagnosis of early-onset Alzheimer’s disease may also be considered. Comorbid medical conditions may be particularly important to consider when patients experience a mental disorder after suffering a work-related injury (37). Patients with acute or chronic medical conditions who have high rates of absenteeism or presenteeism, or those who fail to return to work after a physical or psychological injury, should be evaluated for a mood disorder. A Canadian study found higher odds of functional limitations in patients with comorbid mental and physical health disorders, highlighting the importance of treating both mental and physical health to improve functioning and prevent future decline (104).

The Australian guidelines reviewed evidence from seven cross-sectional or cohort studies that assessed patient characteristics and work-related factors that are associated with longer-term inability to work (37). These characteristics shown in Table 6 can help a clinician determine when a person with a mental disorder has the capacity to return to work. Similarly, a prospective observational study of patients on sick leave being treated for mental disorders found that several work characteristics influenced return to work. These included control over decision making, support from colleagues, respect and recognition, and job promotion opportunities (105). Additionally, the person’s self-assessed present and future ability to work and symptom burden also predicted return to work.

From a psychiatric perspective, impairment and disability are substantially different. An individual with a psychiatric impairment does not necessarily have a related work disability. The clinical assessment of work functioning in individuals with mental health conditions is complex and assessment practices are highly variable. The occupational medicine concepts–impairment, capacity, limitations, restrictions, disability, accommodation, and worklessness–can help clinicians organize their approach to the evaluation of the patient’s functional capacity, sick-leave/disability or return to work status (106). Furthermore, understanding and assessing these concepts are critical to evaluating fitness to work, completing insurance forms, and tracking functional outcomes.

The assessment of fitness to remain at work or to consider time off can be challenging. As a clinician, it is important to understand the relationship between mental health symptoms, disorders, and impairments that interfere with carrying out work duties. Primarily, impairments (a deviation or loss of functioning due to a disorder) may or may not lead to a limitation or restriction. It is essential to determine a relationship between how a specific symptom interferes with performance of a specific job requirement. Most existing mental health screening tools, neuropsychological tests, and the mental status examination help in screening for mental health disorders but have limited value in determining performance of work demands or the entire work role. Furthermore, disentangling daily life stressors and work factors can make the fitness assessment challenging.

A fitness assessment should include collateral information about the work environment, reported work stress, conflicts, negative evaluations, and details of the type of work. Functioning assessment will involve an integrative approach using self-report, collateral information from employer and disability professionals, as well as functional and cognitive screening tools such as the SDS, WHO-DAS, or PDQ-5 (see Tables 1, 3). Urine drug screening may be helpful for those with concurrent substance use issues or relapses due to medication non-adherence.

Finally, a formal assessment of barriers to return to work should be identified. Some of the barriers to return to work include the severity of disease, motivation to return to work, work stress, and barriers to mental health services such as recognizing the need for treatment, attitudes associated with stigma, treatment, and a desire to handle the disease independently, and structural issues around finances and access to services.

As discussed in Section 3, impairments in cognition play a major role in workplace dysfunction. Cognitive impairment has been associated with decrements in social, occupational, and global functioning, and has been shown to have a greater impact on workplace dysfunction than the severity of depressive symptoms (51–55, 57).

A meta-analysis of 9 placebo-controlled RCTs, which included mainly vortioxetine, duloxetine, and SSRIs, found that antidepressants had a positive effect on psychomotor speed and delayed recall (113). Canadian guidelines include suggestions for specific pharmacological treatments based on clinical specifiers and dimensions of MDD (112). For patients with cognitive dysfunction preferred pharmacotherapies include: vortioxetine (level 1), bupropion, duloxetine, or an SSRI (level 2), or moclobemide (level 3) (112). Nonetheless, the issue of generalizability of the clinical trial data to work-related MDD is lacking.

As described in Section 3, measurement tools to assess functioning can be very useful during clinical assessment. One of the most commonly used measures of work-related functional outcomes is the Sheehan Disability Scale (SDS), and in particular the SDS-work item (i.e., the symptoms have disrupted your work/school work; rated on a scale of 0–10) (72). One limitation of the SDS is that it captures role functioning at work rather than work functioning. Although other tools such as Work Limitations Questionnaire (WLQ) (75) and Work Productivity and Activity Impairment (WPAI) (76) capture work functioning, they are not routinely used by most clinicians as they were developed for group-level usage.

Antidepressant treatment trials with work-related outcomes were identified from systematic reviews (114–117), updated with Medline searches as of February 2023. A total of 27 RCTs were identified that provided subjective measures of work-related disability and/or productivity (mainly SDS-work measures). Functional outcomes are generally secondary endpoints in RCTs and often the data are not included in the primary study publication. For this review, studies were included if they were randomized, double-blind, placebo- or active comparator-controlled study design, included a work functioning outcome measured at baseline and endpoint, and the data were available in the primary publication or one of the systematic reviews. The results of 22 studies comparing an antidepressant to placebo (118–139), and 5 studies comparing 2 different antidepressants (140–144) are shown in Supplementary material S4. Most selective serotonin reuptake inhibitors (SSRI), serotonin and noradrenaline reuptake inhibitors (SNRI), noradrenaline and dopamine reuptake inhibitors (NDRI), and multi-modal antidepressants showed positive benefits on measures of work impairment; however, results of individual studies were highly variable. This may be due in part to the fact that work outcomes were secondary endpoints, and studies may not have been powered to adequately assess these outcomes.

In summary, the body of evidence suggests that antidepressants from different classes are associated with secondary improvements in work functioning, but there is little evidence to suggest a specific medication is preferable for patients with work-related MDD.

A systematic review of interventions to improve return to work in patients with MDD identified 6 studies assessing the effects of antidepressants on the duration of sickness absence (Table 10) (41, 145–150). The results of 3 studies comparing SSRI to SNRI were inconsistent (41, 145–147), with 2 studies showing no differences between agents (145, 146), and one showing a greater benefit with the SSRI, escitalopram compared to the SNRI, duloxetine (147). Another study also showed a benefit with escitalopram compared to another SSRI, citalopram (148). No differences were found between a SSRI and a TCA in reducing sickness absence or work functioning as measured by the Social Adjustment Scale (SAS) work composite (149). Compared to placebo, one study found no benefit of a TCA or a MAO on sickness absence, but a significant positive effect on the work (150).

Two other studies looked at the number of underproductive or lost days per week as measured by the SDS subscores (118, 143). One study found decreases with both vortioxetine (from 5.3 to 2.7 days) and venlafaxine XR (from 5.2 to 3.0 days) at week 8, but between-group statistics were not reported (143). In another study, reductions were significantly greater with agomelatine compared to placebo (number of lost work days −1.13 days, and number of underproductive days −2.03) (118). In summary, antidepressants seem to reduce sick leave and earlier return to work, but no differences were identified between classes.

The benefits of antidepressant treatment on work functioning, including absenteeism and presenteeism, have also been demonstrated in observational studies conducted in real-world settings.

The Prospective Epidemiological Research on Functioning Outcomes Related to Major depressive disorder (PERFORM) study was a large 2-year European observational study (151). Initiation (79% of patients) or switch of antidepressant monotherapy (21%) (per routine clinical practice) was associated with improvements in both depressive symptoms (e.g., PDQ-5, PHQ-9 scores) and functional impairment (e.g., SDS total score, WPAI absenteeism and presenteeism scores) (151).

The Assessment in Work productivity and the Relationship with Cognitive symptoms (AtWoRC) study was a real-world open-label study in Canadian working adults with MDD. The study showed significant improvements in cognitive function and workplace productivity with vortioxetine at both week 12 (58), and 1 year (68). WPAI presenteeism was more strongly correlated with other measures of workplace productivity (i.e., SDS work/school and the overall WLQ productivity loss score) than WPAI absenteeism (152). Results of a pharmacoeconomic analysis showed that these improvements were associated with a savings of $4,550/per patient/per week (2017 CAN$) over the 1-year study (33). In the Real-Life Effectiveness of Vortioxetine in Depression (RELIEVE) study, vortioxetine significantly improved all work productivity measures (sick leave, absenteeism, and presenteeism) compared to baseline at week 24 (153).

Recently there has been interest in the use of esketamine and ketamine, with CANMAT recommending ketamine as a third-line choice for patients with treatment resistant depression (154). In terms of effects on functioning, a meta-analysis of randomized and observation studies found mixed results were reported with respect to effects on general functioning (155). Data from the Canadian Rapid Treatment Center of Excellence on the use of ketamine in 171 patients with treatment resistant depression in community practice found a significant reduction in workplace disability, and symptoms of presenteeism and absenteeism (156).

A meta-analysis of RCTs found that both psychotherapy and pharmacotherapy had significant beneficial effects on functioning (SDS or SAS) and quality of life (Q-LES-Q or SF-36) in patients with depression (163). The combination was more effective than either treatment alone.

In a meta-analysis of 28 studies of the effectiveness of workplace-delivered digital mHealth interventions (e.g., CBT, mindfulness/meditation, stress management) there was a small, but significant effect on engagement and productivity, but effects on absenteeism and presentism were not significant (164). In a pragmatic trial, a digital mindfulness app showed similar benefits; however, drop-out rates were very high with only 15% of participants completing all 5 assessments over 8 weeks (165). An analysis of studies over time found no evidence of an increase in efficacy of these interventions over the past decade, despite a tripling of the number of studies and the advances in technology (166). Of note, most of these studies were on unselected employees, and only a minority were on individuals with mental health conditions or high stress levels (164–166).

A pilot study showed a significant improvement in work productivity associated with a brief group CBT intervention that was tailored to work-related issues (167).

In terms of specific work-related outcomes, a systematic review and meta-analysis found 16 RCTs that assessed the efficacy of psychotherapies for return to work in patients on sickness absence due to mental disorders (depression, stress disorders, and mixed diagnoses) (168) Among patients with mental disorders, the psychological interventions were significantly more effective in reducing sickness absence overall, and compared to treatment as usual (effect sizes = 0.13) (Table 12). There were no significant differences between different psychological treatments (0.21) or psychological vs. non-psychological treatments (0.37). In addition, studies that included an intervention that targeted work-related processes (9 of 30 trials) were more effective than those that did not (Table 13) (168). In these studies, the types of return to work interventions varied substantially, and the key mechanisms to target in work-focused interventions remain unclear.

Similarly, a meta-analysis of 45 RCTs, found small but significant reductions in sick leave and symptoms with psychological treatments in patients with common mental disorders (e.g., diagnosis or symptoms of depression, anxiety, stress or insomnia) (169). There were no significant differences between CBT, collaborative care, work-focused interventions, or problem-solving therapy. An analysis that included 21 RCTs found that web-based psychological interventions delivered in the workplace had significant effects on both psychological well-being and work effectiveness compared with control groups (170). In this meta-analysis, no significant differences were found between CBT versus other psychological therapies, and offering guidance versus self-guidance for the work effectiveness outcome. In another meta-analysis of 6 studies internet-delivered CBT was not associated with a reduction in sickness absence compared to control groups (171).

For patients with work-related mental disorders, effective interventions include psychoeducation, pharmacotherapy, and psychotherapy (see Section 4), and work-focused interventions (e.g., addressing interpersonal conflicts, providing work accommodations) (Table 14) (16, 172). A systematic review including 36 studies found that multi-domain interventions that included at least 2 of 3 domains (e.g., healthcare provision, service coordination, and work accommodation) significantly reduced duration away from work and had a positive impact on cost outcomes among patients with mental disorders (173). For example, the addition of psychological treatment, such as online CBT, to usual care reduced sick leave by 15 days (41). Other interventions, such as improving or streamlining the organization of care, adding a structured telephone outreach and care management program to pharmacotherapy, or adding specific providers for depression care, also helped to reduce sickness absence days (41).

Clinicians alone cannot affect all the dimensions needed to ensure a patient’s functional recovery and return to fully productive work. In addition to clinical care, clinicians must be aware of possible workplace interventions as this has been shown to improve outcomes in work-related depression. A meta-analysis of nine studies in patients with MDD found that a combination of a work-focused intervention and a clinical intervention reduced sickness absences by 25 days within the first year of follow-up, in addition to reducing depressive symptoms (41). Work-focused interventions assisted employees in getting changes in work tasks or working hours, supported a gradual return to work, or helped workers adjust to work situations (41).

In addition to pharmacotherapy, psychotherapy and workplace interventions, lifestyle management approaches such as exercise should be strongly considered to manage workplace depression. While many studies have assessed the use of exercise-based interventions for mental disorders, specific evidence supporting the use of such modalities for improving work-related outcomes is scarce. A Cochrane systematic review of interventions to improve return to work in patients with MDD included two randomized controlled trials (41, 174, 175). For the outcome of reducing sickness absence, supervised strength exercise was more effective than relaxation, whereas aerobic exercise was not more effective than relaxation or stretching. Two additional randomized trials were found (176, 177). In a 12-week trial among 946 patients with depression, physical exercise was as effective as usual care by a physician in improving self-rated work capacity (176). Another study found that while both treatments lowered the rates of long-term sick leave over time, physical exercise was significantly superior to treatment as usual at 3 months, but not at 1 year (177).

In treating work-related depression clinicians are encouraged to engage with the workplace to enhance treatment outcomes. Unfortunately, multidisciplinary collaboration for the management of patients with work-related mental disorders may be under-used in clinical practice (178). In one survey, 40% of primary care physicians had never had contact with an occupational health physician, and 49% had not had contact with psychotherapists (179).

Clinicians should liaise with workplace coordinators (with the permission of the patient). Some companies (especially larger organizations) have dedicated personnel to manage disability claims and coordinate care, whereas others may offer these services through their insurance companies. A scoping review found that the lack of coordination between stakeholders involved in the process creates confusion around returning to work for patients with a mental disorder. A coordinator can help involve all relevant stakeholders (178). The coordinator should be knowledgeable about rehabilitation and mental health services, organizational procedures and management values, and the needs of workers and the organizations (178). Liaising with these coordinators (with permission of the patient) can help ensure access to comprehensive treatment including medication and psychotherapy, facilitate communication with patients on sick leave, monitor progress, and develop a plan for returning to work. These coordinators have the added benefit of helping to ensure that patients do not feel cut-off and isolated, especially if they have limited social support.

Coordination of care between the various stakeholders is vital to promote successful return to work. With the patient’s consent, clinicians are obliged to communicate with other care providers, the patient’s employer, or other individuals or entities involved to facilitate the return to work process and prevent the fragmentation of care. Often, it may be helpful to have the patient participate in these conversations. An additional benefit of constructive communication between the clinician and a patient’s employer is the identification of workplace factors, both medical and non-medical, hindering worker recovery. Such a collaborative approach provides a greater opportunity to address potential barriers (37).

Achieving successful return to work has some essential ingredients, regardless of the health condition. Physicians are just part of the recipe. The Institute for Work and Health has developed a booklet called “Seven principles for successful return to work”² which can help clinicians understand the process (180).

Even when a patient provides consent for a clinician to communicate with third-parties, an employer is not entitled to know the specifics of a worker’s mental health diagnosis. However, an employer may request that a clinician confirm that the employee’s condition limits or restricts them from performing the essential duties of their role. If they are unable to work in any capacity, then medical documentation would need to meet thresholds for “disability” as defined by an insurance provider.

When discussing a work-related mental disorder with a patient’s employer or providing information to other relevant third parties such as a private insurer, it is the clinician’s responsibility to ensure that the focus is on the workplace and the employee’s needs and functional capacities as they relate to the work role. Clinicians may find it helpful to obtain a detailed job description, or checklist describing the duties and expectations of the job. The Canadian Medical Association has published a policy statement outlining the role of clinicians in the completion of third-party forms (Table 15) (181).

The individual worker must decide whether, and to what extent, to discuss their mental disorder with their supervisor or other relevant individuals at the workplace. There are situations where such a discussion would be beneficial or even necessary to provide the required accommodation and support. The worker should be encouraged to engage their supervisor as support, as this will facilitate an understanding of changes in work behavior, and a discussion of the eventual resumption of usual productivity levels. It also should be noted that there are instances in which workers may decline to disclose their disability to their employer and continue to be productive at work. The decision to discuss their mental disorder with a supervisor should be made while considering the type of job and culture of the workplace.

Although workers are legally entitled to accommodation, a knowledge and skills gap may exist among employers regarding their awareness of the legal expectations, and effective approaches regarding how to discuss and provide needed accommodations for a worker. Similarly, workers also may not know how to articulate the difficulties they are experiencing with their job assignments, or not know how to communicate their needs. Patients should be reminded that it is their responsibility to inform their employer about specific needs as they arise and be prepared to provide supporting medical documentation if requested.

In the 4-part series, Healthy Brains at Work, conducted by the Conference Board of Canada, 93% of employers surveyed had supportive policies and practices in place to provide the flexibility needed for workers to remain on the job while receiving treatment or recovering (182).

The decision of whether to inform co-workers about a mental health issue remains entirely with the patient. There is a greater potential for a more supportive working environment (105, 183, 184). Supervisor and colleague support have been identified as important factors in predicting return to work among patients with mental disorders (105, 183, 184).

Factors that might influence a worker’s decision to disclose their mental health disorder include: receiving advice from a trusted person (e.g., a physician, a colleague, or a personal contact), managerial changes (e.g., new policy, the manager begins talking about mental health issues, or the manager is replaced), and experiences of colleagues (seeing others have positive response among others at work) (185, 186).

Clinicians must be aware of the type and quality of rehabilitation services as an important factor in promoting return to work (37). A study of two vocational approaches found that the most important factors predicting return to work were: feelings of hope and self-esteem/efficacy among patients, positive attitudes and behaviors among professionals (e.g., genuine interest, engagement, and support), and integration of both health and vocational services in return to work programs (187). Meta-analyzes and RCTs show that interventions by occupational health services (generally problem-solving treatment or CBT) can reduce the number of sick days compared to usual care among patients with work-related mental disorders (187). However, these interventions did not consistently improve symptoms of mental disorders, underscoring the need to simultaneously target both return to work and improvement of symptoms with an integrated approach.

As discussed in Section 1, stigma regarding mental health disorders continues to exist in the workplace. In this case, there are a number of things to consider in the disclosure decision (1): who to disclose to (2), timing (3), message content, and (4) communication style (188). In workplaces in which stigma exists, patients may have concerns around perceived or actual negative effects on career opportunities, or non-supportive environments (185, 186). As a clinician, be prepared to challenge and help the patient to work through possible distortions associated with mental health disorders such as feelings of persecution, personalization, and “catastrophizing.” Ultimately, self-stigmatization may be a greater barrier to accessing the needed support to achieve a successful return to work. However, after these discussions, clinicians should be accepting of the patient’s perceptions of their individual workplace and support their decision.

Clinicians should also be aware of the potential impact of stigma in the workplace on patient recovery from a work-related mental disorder, particularly MDD. Stigmatizing attitudes in employers, refusal to implement accommodations, as well as pressure toward productivity and performance, have been documented as negatively influencing the return to work of employees with depression (189, 190).

A systematic review of 16 studies found that anti-stigma interventions at the workplace can improve employee knowledge and supportive behaviors toward people with mental disorders (191). Workplace awareness and stigma reduction programs have also been shown to encourage employees to seek treatment for mental health disorders (192).

In Canada, educational workplace initiatives such as The Working Mind program developed by the Mental Health Commission of Canada are effective in reducing stigma and increasing resilience and coping abilities, across a variety of settings (193), and benefits were maintained at a 3-month follow-up (194). These workplace programs include strategies to reduce stigma, improve awareness of the symptoms of mental disorders, promote coping skills, and provide information about workplace policies and practices to help employees who experience problems (193).

In completing the medical note (sick note), clinicians should be aware that the Canadian Medical Association (CMA) policy position is that sick notes are an unnecessary burden for clinicians and that employers should be restricted from requiring an employee to provide a sick note for short leaves of absence due to personal illness, injury, or medical emergency (195). However, whether employers can require clinicians’ confirmation of the employee’s inability to go to work varies widely. Some provinces have legislation pending addressing the issue of sick notes and some individual employers have introduced policies abandoning sick notes for short-term absences. Reporting to the Workers’ Compensation Boards in Canada may be necessary.

As described in section 1, sustained unemployment has many negative consequences. For individuals in jobs with a safety-sensitive component (e.g., emergency services, heavy equipment operators, pilots, transportation workers), return to work assessments are more comprehensive and focused on limiting risk. As a guiding principle in fitness for duty assessments, public safety may trump the individual’s right to work. The policy of the CMA states: “The treating physician must be aware of the risks to the patient, his or her coworkers or the public that could arise from the patient’s condition or drug therapy. If the patient’s medical condition and the nature of the work performed are likely to endanger the safety of others significantly, the physician must put the public interest before that of the patient/employee” (109).

In order to return to safety-sensitive work after a period of illness the worker must demonstrate normal or adequate capacity to reliably perform and respond to safety-sensitive demands. For example, as described in the Canadian railway medical guides (196), “The individual’s bipolar I disorder has been in remission for a continuous period of 1 year during which the individual has been maintained on a stable dose of medication.” In essence, there must be no imminent risk of relapse of the mental health disorder.

Finally, if a medical code is requested, provide ICD-11 or DMS-5 codes, rather than non-descript terms such as “mental health” or “stress.” Consider the sick note as a medical intervention with associated clinical benefits and risks.

Clinician should facilitate setting up work accommodations to help address functional limitations in patients with mental disorders, and improve their ability to successfully complete work-related tasks (Table 16) (30). Occupational health and human resources are the first points of contact when making accommodation requests and submitting relevant medical forms. They can ensure that any restrictions and limitations are communicated to the manager, without conveying diagnosis or other sensitive medical information, so that appropriate accommodation can be implemented and monitored. Using booklets such as “Supporting Employee Success”³ can be helpful in understanding the process (180).

A systematic review of 15 studies found that work accommodations reduced limitations in the work place, improved length of job tenure, and reduced the severity of some mental disorders (30). Work accommodations have been shown to increase job tenure by between 7 to 24 months compared to individuals receiving no accommodations (197, 198). A study of 715 Canadian employees with a current mental disorder found that receiving needed work accommodations was associated with a 25% lower risk of having a mood/anxiety disorder during the 1-year follow-up (32). Programs such as job coaching are associated with minimal costs for both start-up and maintenance, and employee assistance programs have minimal direct and indirect costs (30, 199).

Failing to disclose a workplace-related mental disorder can limit access to accommodations (30, 198, 200). It is important to educate patients on the importance and benefits of workplace accommodations, and patients may need to talk to their employer about specific accommodations that could be helpful (Table 16).

Assessing accommodations is a collaborative effort between the clinician, patient, and workplace. Clinicians should obtain consent from the patient prior to communicating with other stakeholders to better understand job description and role, to help determine possible accommodations such as reduced work hours or workload, re-evaluate job responsibilities, or a possible transfer to a new role. Accommodation can be temporary or permanent in nature and should be re-evaluated periodically to monitor and evaluate treatment effects on patient outcomes.

Furthermore, the Work Accommodation and Natural Support Scale (WANSS) has been developed and validated for people with mental illness returning to work (200). Two versions are available for implementing accommodations in the workplace, which consider the needs for employees and the feasibility for managers/supervisors (201–203). The tools described in Table 3 can also be useful to monitor the effects of MDD on functioning and work productivity, and may be helpful when assessing the need for workplace accommodations.

If a patient is unable to return to work after the sick leave, the clinician must assess if the patient can return to work with or without accommodation or be eligible for disability. Short-term disability refers to a limited period of time that qualifies a person for benefits. Depending on the insurance provider the disability benefits and their definition of short-term may vary. In Canada, most short-term disability benefits are between 3 and 6 months before transitioning into long-term disability.

Charts to track recovery can also be very helpful, such as those in the booklet “Supporting Employee Success,” or those published in the “Global Business and Economic Roundtable on Mental Health”⁴ (1). These charts can help clinicians track the patient’s symptoms and functioning, and their ability to perform job duties, and can be useful when completing insurance forms. It should be noted that a decrease in symptoms may not necessarily be accompanied by an increase in work functioning.