Mental health and well-being at the workplace

INTRODUCTION

The World Health Organization (WHO) conceptualized mental well-being as a state where the individual is able to understand his abilities, cope with normal life stressors, work productively, understand his abilities, and contribute productively to the community.[1] Mental health and well-being are a broad concept with a primary focus on the health of the workforce.[2] Certain workplace factors, such as shift work, work demands, and work stress, can put an employee at higher risk of mental problems.[3]

Impact of poor mental well-being at the workplace

Poor mental health and lower well-being of the workers can lead to lower employee satisfaction, lower work performance, burnout, and increased risk of occupational hazards. As the workers are also part of the community, the effects of poor mental health can also affect the family and society. Higher mental health and well-being can lead to greater work productivity, more prosocial behaviors, increased creativity, increased longevity, improved physical health, and more positive interpersonal relationships.[4] According to the WHO, around 60% of the total world population is in work, of which 61% work in informal jobs. It is estimated that 12 billion working days are lost every year due to depression and anxiety and 50% of the total societal cost of mental health conditions is caused due to indirect costs, including reduced productivity.[5]

Sociodemographics of workforce in India

According to the annual report of the Periodic Labour Force Survey (July 2021–June 2022), published in February 2023, the worker–population ratio (WPR) in India is around 73.8 for males and 31.7 for females. The WPR is higher among the rural population, for both males and females, compared with the urban population.[6] The proportion distribution of workers in broad industries in India is presented in Table 1. While about half of the workforce is still employed in the agricultural sector, service sector and manufacturing comprise a quarter of the employed population in India. The same survey also suggests that among those with regular wages or salaries, more than half do not have a written job contract, and about half are not eligible for paid leave or social security benefits. The average hours per week of self-employed, regular wage or salaried employees, and casual laborers ranged from 40 to 50 hours.

Table 1.

Proportion distribution of workers in different broad industries

Broad industry division	Percentage (all India, rural + urban, male + female)
Agriculture	45.5
Mining and quarrying	0.3
Manufacturing	11.6
Electricity, water, etc.	0.6
Construction	12.4
Trade, hotel, and restaurant	12.1
Transport, storage, and communications	5.6
Other services	11.9

Migration for employment purposes is also a reality in India. It has been estimated through census data that of 27.4% of individuals who had changed residence, 8.8% moved for employment reasons and 2.3% moved for business motives.[7] Economic reasons were more common for migration to urban areas, especially for men. The migrant population, especially in the unorganized sector, faces multiple difficulties, including acculturation stress, physical hazards at the workplace, and uncertainty of job security. These difficulties were starkly brought to light during the coronavirus disease 2019 (COVID-19) pandemic.[8]

Hence, we see that the workplace characteristics may be different in India as compared to some of the developed Western countries. The proportion of workers in the informal sector is quite high in India, which has a consequence on job security, insurance and other benefits, and the potential to have disability and pension benefits. The workplace characteristics also need to consider a large agrarian economy alongside a booming service economy and a gradually expanding industry. However, all of these are on the lower side of the value addition chain by global comparisons. Thus, the economic aspects of the workplace need due consideration for drawing inferences from the literature and recommendations about workplace well-being. Added to it are the cultural tenets of collectivism yet subtly creeping individualism at the social level. The young demography of the country with the dynamics of competition and espoused values of being “settled” as drivers of the employment market also has connotations for the Indian workplace well-being. Varied geographies, workplace patterns, literacy, avenues of social and economic mobility, and proclivities of migration (internal and external) are other factors that make unitary recommendations for well-being challenging in the Indian workplace. Hence, the present clinical practice guidelines take a pragmatic approach and suggest careful consideration of the mentioned factors before application.

MENTAL HEALTH AND WELL-BEING AT THE WORKPLACE

Formal sector

There is abundant literature on mental health and well-being at the workplace, especially related to the formal sector. We present some Indian studies on the epidemiology of well-being at the workplace. A study conducted by Manah Wellness among 1764 employees who were employed in white-collar jobs, residing in urban India in 2022, using the Emotional Check-In Tool, found that nearly 29% of the respondents showed moderate-to-severe signs of depression, 55% had moderate-to-severe signs of anxiety, and 78% had moderate-to-high amount of stress. However, despite this, around 99% reported moderate-to-high psychological well-being.[9]

A review of various studies that assessed the prevalence of noncommunicable diseases and mental illness in Indian workplaces found that a range of 10% to 52.9% of workers suffered from depression and a range of 7% to 57% of workers suffered from anxiety, while a range of 3.8% to 75.5% of workers suffered from workplace stress.[10]

Another study conducted by Deloitte on mental health and well-being at the workplace among 3995 respondents across 12 industries found that more than 80 percent of respondents reported being affected by at least one adverse mental health symptom with depression being the most common symptom (59%), followed by emotional exhaustion or burnout (55%), irritability or anger (51%), sleep issues (50%), and anxiety (49%). The same survey also tried to find out the sources of stress among these respondents, and they found that workplace-related stressors were the most common (47%), followed by financial stress (46%), COVID-19-related factors (42%), family relationships (39%), and social connections (37%).[11]

Another survey conducted by the White Swan Foundation for Mental Health among 800 workers found that despite more than half (56.0%) reporting mental health issues and nearly two-thirds (64.3%) reporting knowing someone at the workplace having mental health issues, only 24.6% felt that their workplace was extremely supportive for people with mental health issues and only one in four people received mental health support at the workplace. Furthermore, only one in ten people had access to Employee Assistance Program services.[12]

Informal sector

Though a large proportion of workers in India are employed in the informal sector, there is a lack of literature on the mental health concerns of the individuals employed in the informal sector. A qualitative study suggested that the structural, financial, and physical violence faced by women may have mental health consequences.[13] Another study among older individuals in the informal sector suggested that they suffer poor cognitive function more commonly than individuals in the formal sector.[14] Agrarian distress has been highlighted as a major source of mental health concerns for vulnerable farmers and is associated with farmer suicides.[15]

Armed forces

Individuals from the armed forces have also been exposed to significant stress that may result in mental health concerns. A study by Rao et al. (2008) found that about 28.8% of the Central Industrial Security Force (CISF) personnel had high stress levels.[16] It was seen that those individuals posted in high stress areas were more likely to manifest symptoms related to mental health distress. Irregular work timings and inability to take leave were the most common workload factors related to stress. A study by Basavanna and colleagues in 1996[17] among more than 2000 police personnel found that 28.6% to 48% screened positive for having a psychiatric disorder, with depressive disorders and anxiety disorders being the more common ones. Among the armed forces, stress has been commonly reported.[18] There have been several instances of suicide (with 533 suicides and 15 cases of fratricide between 2007 and 2010). However, non-service-related reasons seem to be the important causes of suicides in this population.

Medical health professionals

Medical health professions are considered one of the most stressful ones.[19] Medical students, residents, and practicing physicians have high work-related stress, stress of the responsibility of human lives, attending to patients at different times, heavy workload, and the need to constantly update knowledge to keep abreast. This results in higher rates of depression, burnout, substance use disorders, sleep disturbances, and suicide than the general population. The reader is referred to the previous Indian Psychiatric Society Clinical Practice Guidelines (IPS CPG) for a detailed discussion on mental health issues among medical health professionals.[19]

Factors affecting psychological well-being and mental health at the workplace

Poor mental health and well-being are one of the major reasons for employees' poor performance at the workplace dropping out of work. The WHO has identified ten risk factors for poor mental health in workplace[20]:

1. Work content or task design

2. Workload and work pace

3. Work schedule

4. Control

5. Environment and equipment

6. Organizational culture and function

7. Interpersonal relationships at work

8. Role in organization

9. Career development

10. Home–work interface.

A meta-analysis of seven longitudinal studies with 28431 participants found that shift work was associated with an increased risk of adverse mental health outcomes (effect size = 1.28, 95% confidence interval (CI): 1.02, 1.74), especially for depressive symptoms (effect size = 1.33, 95% CI: 1.02, 1.74). Gender was found to have a significant role in this, with female shift workers more likely to experience depressive symptoms than female non-shift workers and male counterparts.[21]

A systematic review of nine studies that tried to assess the effect of employment conditions and psychosocial workplace exposures on the mental health of young workers found that exposure to contemporaneous sexual harassment was associated with the incidence of depressive symptoms. Furthermore, poor psychosocial job quality (low job control, high job demands and complexity, job insecurity, and unfair pay) was associated with depressive symptoms.[22]

A cross-sectional study among 834 participants across 35 countries found that among patients with a diagnosis of depression in the past 12 months, 62.5% had anticipated and/or experienced discrimination in the work setting. Around 60% of the participants from high-income countries had stopped applying for jobs or training due to fear of discrimination.[23]

Apart from these, other factors that have been found to affect the workers' mental health and well-being are past mental illness and family history of mental illness. A study found that perceived mental illness-related stigma among 228 nonprofessional occupational mental health staff was significantly related to the depersonalization domain of burnout.[24]

Work from home—Benefits and disadvantages

Work from home, especially propelled by the COVID-19 pandemic, has positively and negatively impacted mental health and well-being.[25] Reduced time spent in commuting, flexibility of one's schedule, and more interaction time with friends and family were noted as major factors resulting in positive mental health outcomes. However, there is also a negative impact in the form of decreased work productivity, lack of access to a room where they could work independently, work–family conflict, increased sedentary behavior, and lack of opportunities for leisure. This has resulted in work from home being associated with depression, anxiety, and sleep difficulties. Work from home has also been associated with an increase in alcohol consumption.

ASSESSMENT

Assessment by psychiatrists

Often, individuals facing workplace stress have been referred to psychiatrists or may come on their own accord. Flowchart 1 may provide guidance for psychiatrists about addressing such individuals. In many cases, workplace stress, in conjunction with other life stressors, results in diagnosable psychiatric illnesses, such as depression. Therein, appropriate psychiatric management would be important, and suitable pharmacological, non-pharmacological, and brain stimulation techniques may be utilized. The individual may also require leave for a period of time for recuperation from his mental health condition. This should be done in accordance with the necessity in the case and would be applicable to psychiatric disorders faced. If there is a risk of harm to self and/or others, then the risk should be managed accordingly (refer to previous IPS Guidelines.[26,27] Sometimes, individuals may come with only workplace-based adjustment difficulties, which fall below the diagnostic threshold of a psychiatric disorder or may be classified as an adjustment disorder. Therein, assessing the workplace characteristics, the individual's work profile, coping methods, and other life circumstances are of value. Often, an interpersonal crisis may precipitate significant stress, resulting in the patient exhibiting symptoms of distress. Supportive therapy, counseling, exploring strategies to handle workplace stress, and symptomatic and time-limited use of medications to relieve insomnia could work. In situations of severe problems or recurring problems at work, change in the workplace, suggesting to report to management, or taking a break from work can be resorted to.

Flowchart 1.

Assessment of individuals with workplace-related issues

Assessment at the workplace

The WHO does not recommend routine screening for mental illness in the workplace due to a lack of evidence for its benefits or harms.

Yet, the assessment of well-being at the workplace has advantages for understanding the well-being status in a particular workplace location. There are several instruments to assess mental health well-being at the workplace. The utility of these instruments lies in their ability to detect those at risk of mental health issues so that they can be identified and helped reasonably. Other instruments aim to assess the positive aspects of work and functioning, to enhance the work-related factors that promote subjective well-being. Nebbs et al.[28] have reviewed 109 English-language instruments that could be potentially used to assess workplace mental health, and the reader is referred to this article for a comprehensive update. Some of the instruments and their characteristics are presented in Table 2.

Table 2.

Instruments with potential utility for workplace mental health

Instrument name	Authors or organization	Characteristics
A Shortened Stress Evaluation Tool (ASSET)	Johnson[29]	Screens employee stress. 37-item questionnaire
Brief Job Stress Questionnaire (BJSQ)	Inoue et al.[30]	Measures psychosocial factors at work. 141-item standard version and 80-item brief version
Mental Health Audit	People Diagnostix	Audits the organization’s resources and supports for promoting employee mental health. 14-item tool
ILO Stress Checkpoints	International Labor Organization	Reviews workplace conditions that may lead to employee stress. A 50-item checklist
iWorkHealth	Abdin et al.[31]	Identifies common workplace stressors. It is a 27-item tool
Measure of Psychosocial Risk Factors and Burnout	Jacobo-Galicia and Maynez-Guaderrama[32]	Evaluates burnout and psychosocial risk factors in workplace. It is an 80-item instrument
Perceived Work Characteristics Survey	Haynes et al.[33]	Assesses the psychological well-being of employees. it is a 41-item survey
New Organizational Role Stress Scale (NORS)	Srivastav[34]	Assesses role stress at work. 71-item scale. Developed in India
Employee Well-Being Scale	Pradhan and Hati[35]	31-item scale. Assesses employee well-being at work. Developed in India
Occupational Mental Health Screening Tool and Burnout Screening Tool and Workplace Assessment Screening Tool	Balachander et al., 2023[36]	Burnout screening tool looks at emotional exhaustion, depersonalization, and personal accomplishment. Has 19 items. Workplace assessment screening tool has 10 items and assesses salient aspects of workplace

ILO: International labor organization

When and how to assess?

The application of assessment and instruments would depend on their perceived utility. The screening instruments for the workplace environment can guide whether the workplace is attuned to the needs of the employees. It can also be used to track employee well-being over time and find out the responses to specific interventions. So, there may be two options for assessment: (1) on a regular basis to assess the well-being in the environment and (2) in situations where one or many employees experience significant distress that results in disruption at work.

Considerations need to be given about when to apply such scales and instruments (routine periodic assessments or triggered by certain events or interventions), who should be the employees targeted for these (all employees or selected ones), who should have access to the data from the assessment (the management or any external agency—people are less likely to give the exact picture if they are under the coercion of the employer), and what is done with the data from the evaluation (are the data consigned to archives or some actions are taken based on the findings).

Flowchart 2 presents a suggested assessment scheme for different sectors.

Flowchart 2.

Assessment according to different sectors

Issues of confidentiality and privacy

If well-being assessment is being conducted at the behest of employers, then there remains a concern about dual agency on the part of the mental health professional. This means that the mental health professional is answerable to the individual employee and the employer. Anything spoken in confidence to the mental health professional can be used by the employer to cut employee privileges or even terminate him or her. Hence, the purpose of the assessment should be explicitly stated (preferably in a written record) besides clarity on who would have access to the assessments and how the results would be used. Preferably, assessments should be conducted by third parties who are not employed directly by the institution where the employees work. Furthermore, during assessments, mental health professionals should make it clear to the employees what information they must convey to the employers and which information should not be shared.

EFFECTIVENESS OF THE INTERVENTIONS

• Many reviews, systematic reviews, and meta-analyses have focused on the various aspects of workplace interventions. Most of the studies have used multimodal interventions; hence, it is difficult to tease out the most effective component among them.

• A review of 14 systematic reviews that focused on mental health interventions in the workplace on work outcomes found that the workplace interventions had components to improve both mental and physical health and multicomponent mental health interventions had the greatest impact. Moreover, interventions that contained in vivo exposure approaches were particularly effective for anxiety disorders.[37]

• A review of 55 studies that focused on organizational interventions promoting mental health and happiness among healthcare workers found that most studies have come from high-income countries and targeted nurses. The review also found that the most common construct assessed was burnout, stress, and work satisfaction. The interventions most commonly used were developing skills and knowledge, communication and team building, managing workload and time, stress management, and leadership development.[38]

• A review of 80 reviews that focused on mental well-being interventions found the highest quality evidence for mindfulness-based therapies, education and information provision, and individual psychological therapies, with the most common positive effect reported for burnout or stress reduction and mental well-being.[2]

• A rapid systematic scoping review of 30 articles that focused on mental health interventions at the workplace in India found that there were four types of mental health interventions in India:

  1. Corporate Wellness Program (which focuses on work–life balance strategies and wellness sessions, such as yoga and meditation)

  2. Employee Assistance Program (mainly focuses on providing counseling services)

  3. Employee Well-Being Program (provides health services—both physical and mental health)

  4. Peer Support Program (providing peer support).

The review found that the majority of the available studies belonged to the first two categories. Many studies have explored preventive and promotive physical and mental health services. Some studies trained their employees on psychological first aid and established peer-support networks. Some studies focused on digital interventions provided by companies for their employee's mental health, including artificial intelligence-based ChatBot. However, the impact of these interventions and whether these interventions are effective have not been explored in this article.[39]

• A review of 66 meta-analyses that focused on universal, selective, and indicated interventions for supporting mental health at the workplace found that most meta-analyses on workplace interventions have either focused on a specific population, specific intervention, specific delivery format, or specific outcome. The review found that psychosocial interventions were the most common in all three intervention groups. Physical activity or lifestyle interventions were included in the programs that targeted either all general workers or healthcare workers, but not workers with mental illness symptoms.[40] The review found the following with respect to universal interventions:

  1. Psychosocial interventions, physical activity, and lifestyle interventions together were associated with a moderate effect on positive mental well-being (standardized mean difference (SMD) = 0.51; 95% CI: 0.31, 0.71) and a large effect on quality of life (SMD = 0.77, 95% CI: 0.28, 1.26).

  2. A meta-analysis that focused only on physical activity and lifestyle programs showed a small effect of the interventions on work ability (SMD = 0.12, 95% CI: 0.01 to 0.22).

  3. Psychosocial interventions alone had small effects on burnout (SMD = 0.17, 95% CI: 0.03 to 0.32) and insomnia (SMD = -2.21, 95% CI: 1.06 to 3.36). Mindfulness and contemplative interventions had a moderate effect on general distress (SMD = 0.49, 95% CI: 0.32 to 0.66) and a large effect on subjective well-being (SMD = 0.86, 95% CI: 0.19 to 1.53). Cognitive behavior treatment (CBT)-based interventions had a smaller effect on subjective well-being (SMD = 0.22, 95% CI: 0.04 to 0.40). Psychosocial interventions delivered through e-health formats showed a small effect on symptoms of common mental disorders (SMD = 0.25, 95% CI = 0.11 to 0.40), depression (SMD = 0.20, 95% CI: 0.03 to 0.35), burnout (SMD = 0.26, 95% CI: 0.02 to 0.5), stress (SMD = 0.27, 95% CI: 0.15 to 0.39), and work effectiveness (SMD = 0.18, 95% CI = 0.06 to 0.3) and a small-to-medium effect on well-being (SMD = 0.35, 95% CI: 0.25 to 0.46).

• All the included studies that focused on selective interventions were on healthcare workers. When psychosocial, physical, and lifestyle interventions were pooled together, there were a small effect on anxiety symptoms (SMD: 0.20p = 0.03), a moderate effect on stress (SMD = 0.060, P < 0.001), a moderate effect on resilience (SMD = 0.58, P = 0.001), and a large effect on mindfulness (SMD = 0.85, P < 0.001). Psychosocial interventions alone showed a small effect on depression symptoms (SMD = 0.29, 95% CI: 0.09 to 0.50) and a moderate effect on stress (SMD = 0.61, 95% CI: 0.15 to 1.07). These interventions also led to an absolute reduction of 2.06% in burnout symptoms. Psychosocial interventions led to a small-to-moderate effect on optimism (SMD = 0.41, 95% CI: 0.1, 0.72), self-efficacy (SMD = 0.43, 95% CI: 0.25, 0.62), and resilience (SMD = 0.45, 95% CI: 0.25, 0.65) and large effect on positive emotions (SMD = 0.85, 95% CI: 0.17, 1.53). Mindfulness-based interventions were found to have a small effect on general distress (SMD = 0.21, 95% CI: 0.04, 0.38) and burnout (SMD: 0.26, 95% CI: 0.03, 0.50), a moderate effect on depression (SMD: 0.51, 95% CI: 0.23, 0.78) and stress (SMD: 0.55, 95% CI: 0.14, 0.95), a large effect on anxiety (SMD = 0.78, 95% CI: 0.18, 1.39), and a moderate effect on self-compassion (SMD: 0.58, 95% CI: 0.19, 0.97). A Web-based CBT intervention targeting suicide-related outcomes among physicians was found to be effective, with 60% of those who followed the program being less likely to report suicidal ideation than a control group.

• The review found the following with respect to the indicated interventions. Psychosocial interventions showed small-to-moderate effects on depressive symptoms in patients with elevated depressive symptoms (SMD = 0.40, 95% CI: 0.25, 0.54). CBT-based interventions were found to have small-to-moderate effects on depressive symptoms (SMD = 0.44, 95% CI = 0.26 to 0.61). No psychosocial intervention was found to be effective for burnout symptoms. E-health interventions were found to have a small-to-moderate effect on depression (SMD: 0.40, 95% CI: 0.21, 0.53), anxiety (SMD = 0.42, 95% CI: 0.23, 0.61), and overall symptoms of common mental disorders (SMD = 0.52, 95% CI = 0.28, 0.75), a moderate effect on burnout (SMD = 0.60, 95% CI = 0.30, 0.88), large effects on stress (SMD: 0.84, 95% CI: 0.55,1.3) and insomnia (SMD: 0.80, 95% CI: 0.22, 1.39), and a small effect on improving work effectiveness (SMD = 0.32, 95% CI: 0.04, 0.61). Stress management programs showed a moderate effect on symptoms of common mental disorders (SMD = 0.64, 95% CI = 0.43, 0.85)[39]

• A systematic meta-review of 20 reviews, including 481 studies, divided the interventions into primary, secondary, and tertiary[41] [Table 3].

• A systematic review and meta-analysis of 21 randomized controlled trials (RCTs) that tried to assess the effectiveness of occupational digital mental health interventions found that these interventions had a significant effect on psychological well-being (g = 0.37, 95% CI: 0.23, 0.50) and work effectiveness (g = 0.25, 95% CI: 0.09, 0.41). No specific psychological intervention was found to be superior to others. There was no significant difference between self-guidance and offering guidance and between universal intervention vs targeted intervention. Intervention characteristics that can increase engagement include offering guidance over a shorter time frame of 6 to 7 weeks, using secondary modalities for delivering interventions and engaging users (e.g., emails and text messages), and using self-monitoring and tailoring.[42]

• A systematic review of studies that focused on the effect of yoga at the workplace on health outcomes found that the overall effect of yoga on mental health was beneficial, especially on stress.[43]

Table 3.

Interventions pertaining to workplace[41]

Primary interventions	Secondary prevention interventions	Tertiary prevention interventions
Employee control: Self-scheduling of shifts and process of gradual or partial retirement was associated with significant improvement in mental health. Flexitime, overtime, and fixed-time contracts did not have much effect Physical activity: The meta-review found that physical activity was found to be associated with a reduction in depressive and anxiety symptoms Workplace health promotion: No conclusive evidence for its positive effect on mental health	Screening: Screening for depressive symptoms followed by support and care may reduce depressive symptoms, higher job retention, and more hours of work. However, concerns are also raised about the risk of false-positive results in the screening tests, which can increase the risk of distress, increase stigma, and can make individuals to remain focused on their symptoms Counseling: Counseling has been found to have mixed results Stress management programs: CBT-based stress management programs have been effective in reducing mental illness symptoms Debriefing: Studies have found that debriefing interventions following the traumatic incident at the workplace were not effective	CBT: CBT can lead to significant improvement in anxiety or depression symptoms, but its effect on occupational outcomes was not clear Therapies that are part of a formal “Return to Work” Programme or development of problem-solving skills, which are directly related to the workplace, have been found to be effective Exposure therapy: Exposure in vivo therapy has been found to be effective in reducing PTSD symptoms and increasing the chance of return to work Medications: While medications are well known to reduce symptoms of depression and anxiety, their effect on workplace absenteeism was not clear

CBT: Cognitive behavior therapy

Thus, substantial literature has accrued on interventions to promote well-being in the workplace. However, much of the literature has come from the west. There is evidence from India as well.[38]

GUIDANCE FOR MENTAL HEALTH INTERVENTIONS

A review of 20 International Guidelines on Workplace mental health reported that the Canadian Standard had scored highest for both the quality and comprehensiveness of the content, followed by Australian Heads-Up Material, the British Health and Safety Management Standard, and the European Union Psychosocial Risk Management Excellence Framework (EU-PRIMA-EF) guidelines.[44] Based on these, the following are the steps of workplace-based interventions.

1. Community Participation: Studies have found that stakeholders' participation in the intervention's development and implementation is necessary for the intervention's successful implementation.[45,46] Furthermore, this participation itself can lead to a positive effect on the employees' mental health and work.[47]

2. Intervention Based on Needs: Interventions that are based on the actual needs at the workplace have been found to have a positive impact. This includes identifying the workplace factors that need to be targeted in the interventions, doing a pilot study, or using theoretical constructs to develop interventions focusing on the local needs and improving and expanding the interventions based on the pilot study.[45] Interventions could include universal, selective, indicated interventions, crisis interventions, medical leave, and allowing to rejoin work and rehabilitation.

3. Advocating for Realistic Expectations: Interventions that create high expectations among workers can lead to negative or short-term positive effects, as there will be a mismatch between the high expectations of the participants and what the intervention can deliver. Hence, there is a need to define what can be expected and what not to make the expectations realistic for the workers.[47]

4. Multicomponent interventions: Interventions that focus on both physical and mental health or have multicomponent mental health interventions have been found to have a greater effect on workplace outcomes.[37] Interventions should include psychosocial interventions, physical health, and lifestyle interventions.

5. Inclusive Interventions: Interventions should be as inclusive as possible, with no stigma or discrimination related to gender or minority status.

6. Interventions at Multiple Levels: Interventions are required at policy, organizational, employer, and employee levels. These are discussed further as follows.

Employee-level interventions—These aim to build resilience, augment stress management skills, mitigate emotional distress, promote positive mental health among workers, and improve their work efficiency. Employees may be offered access to interventions based on mindfulness, cognitive behavior approaches, yoga, and resistance training. Box 1 provides employee-level suggestions to improve workplace mental health.

Box 1.

Suggestions for employee-level interventions to improve workplace mental health

Physical activity, such as exercise, aerobic training, and strength training, must be encouraged to improve mental health and productivity. Organizations must create an atmosphere where employees do not feel intimidated or stigmatized to discuss their mental health issues openly, with either their manager or a designated person (counselor or mental health champion). The above are universal-level interventions that can be offered to all workers and are likely to be perceived as non-stigmatizing and, hence, more acceptable to all. For those at risk of poor mental health outcomes, regular check-ins about mental health issues must be encouraged, with the assurance of confidentiality. Such individuals may be provided organizational support in terms of flexible working hours, modifying workplace and job roles, as appropriate. To enhance uptake and sustainability, specific interventions may be incorporated into existing workplace mental health programs.

Manager-level interventions

These interventions aim to empower training managers to identify and respond to mental health issues among team members, to provide them the necessary support, and modify relevant stressors in the working environment to preempt mental health issues among workers. These interventions do not aim to empower managers to diagnose and treat team members with mental health issues. In this context, managers refer to those in a direct supervisory capacity, or involved in supervising or managing team members or holding key administrative positions where they exert managerial control over workers. Box 2 provides manager-level suggestions to improve workplace mental health.

Box 2.

Suggestions for manager-level interventions to improve workplace mental health

Managers must be systematically and periodically trained in recognizing and responding to mental health issues among team members. Training must also be imparted in communication skills, including listening, empathizing, and communication about mental health issues. Specific training for managers must focus on raising awareness in mental health issues, stress reduction measures at the workplace, measures to improve employee participation in decision-making, promoting employee mental health and well-being, and creating a culture of open communication between managers and team members. Training may include early warning signs of mental distress, starting a conversation on mental health with a distressed team member, regular check-ins with those at risk, knowing when to refer, and having knowledge of professional resources or local support groups for an appropriate referral. Encourage managers to make work environment flexible, wherever possible by permitting flexible working hours or hybrid work patterns, particularly for those at risk of poor mental health outcomes. Encourage “buddy system” where two managers working in related areas are paired, look out for each other’s well-being, and also provide necessary peer support when needed. Given the exact nature of their work, managers themselves need to be encouraged to monitor and address their mental health needs. Sufficient time needs to be provided in their schedule for this requirement. Continuous and ongoing feedback must be obtained from the managers about workplace environment and interventions to promote mental health. This feedback may be used to inform refinements in training and implementation.

Organization-level interventions

These interventions aim at resolving psychosocial risk factors and designing interventions that are participatory in nature for optimal uptake and impact in terms of mental health outcomes and work productivity. In doing so, as part of planning for organizational interventions, there must be a regular and ongoing assessment and monitoring of workplace-related factors that may impact the mental health and well-being of workers. Such occupational health hazard assessment and monitoring protocols must include changes to the work profile or organizational structure of the workplace as a trigger for reassessment. Particular attention needs to be paid to the fidelity of interventions: whether they are delivered in the manner in which they were conceptualized. Ensuring the fidelity of interventions would enhance outcomes. Box 3 provides organization-level suggestions to improve workplace mental health.

Box 3.

Suggestions for organization-level interventions to improve workplace mental health

As part of planning for organizational interventions, every organization must conduct assessment of mental health and well-being of its employees and well-being needs. This would include an assessment of key mental health indicators, gauging the extent of employee participation in decision-making, and noting employee preferences for strategies aimed at enhancing mental health and well-being. The result of this well-being and needs assessment phase should inform the strategy to enhance mental health and well-being. This strategy should have the following components: phases with timelines, objectives, strategy to deliver each objective, outcomes with appropriate measurement methods, monitoring, and evaluation. The above program must be adequately resourced and supported by the concerned organization. This involves providing adequate funding, support personnel, time, and training for employees during working hours to raise awareness about mental health issues. If the organization lacks the experience or resources to formulate and implement the strategy, then the services of professional agencies or mentors must be engaged. Organizations must create a small coordination committee comprising an appropriate representation of stakeholders. They will be responsible for developing, implementing, and evaluating mental health and well-being strategy and action plan. An evaluation plan with clear goals, objectives, and outcomes must be formulated beforehand to assess the impact of the well-being strategy, identify gaps in implementation, formulate monitoring strategies, and refine the strategy to achieve the intended outcomes. Regular surveys of occupational health among staff, providing free and unhindered access to employee well-being resources, and making contingency plans for dealing with unexpected traumatic events among employees, such as pandemic or fire hazard, would help mitigate the impact of such events and help identify those at risk. To reduce workplace-related stressors, organizations may allow some degree of self-management of workloads, encourage reasonable and appropriate breaks from work, and create a fair and transparent workplace culture where employees can voice their concerns and complaints without fear of retribution or concerns about confidentiality. Organizations must refer to global best practices and policies on organizational structure, job quality, and work design to identify and address psychosocial risk factors and workplace-related stressors.

Policy-level interventions

Globally, the cost of workdays lost due to poor mental health issues runs into billions of dollars. International conventions mandate that local and regional authorities create a safe and healthy workplace environment where workers are not discriminated against and are provided equal opportunities for vocational rehabilitation. Box 4 provides policy-level suggestions to improve workplace mental health.

Box 4.

Suggestions for policy-level interventions to improve workplace mental health

Policymakers should take a leadership role in championing the cause of workplace mental health and value promoting mental health at the workplace. They should focus on capacity-building measures to identify and respond to mental health issues at the workplace, provide uniform guidelines, and set standards for interventions aimed at improving employee mental health. They should support lower-resourced employers and organizations in evolving mental health and well-being strategies, allocate resources appropriately, and encourage the sharing of resources between organizations. Focus on awareness-building strategies among the employers, employees, and general public regarding the importance of workplace mental health by harnessing the power of mass media and social media. Engage with organizations, social arm of companies, charitable organizations, employee representative unions, and other relevant enterprises to advocate for mental health and well-being and develop, review, or revise occupational health and safety laws. Support organizations in implementing and evaluating workplace mental health and well-being policies by playing an advisory role and by recognizing, rewarding, and accrediting organizations that perform well on these parameters. Support organizations in identifying and addressing local barriers to mental health and well-being at the workplace. This can be done, for instance, by providing information about resources or services to enhance employee well-being and assisting lesser-resourced organizations in developing potentially effective and sustainable workplace mental health policies.

Interventions in the Indian setting

Several interventions have been implemented in India for workplace wellness, especially in the context of mental health. Some of these are enumerated as follows (the list may not be exhaustive):

• Employees' State Insurance Corporation (ESIC) Hospitals—ESI hospitals have been established all over India and provide therapeutic services (including mental health services) under their ambit.

• A police well-being program for police officers in Tamil Nadu was conducted with the support of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.

• Several nongovernment organizations (NGOs) (like the Self-Employed Women's Association (SEWA)) have been working to support informal workers. Their overall ambit of work also involves championing the causes of the workers and improving their well-being. Similarly, NGOs have worked to improve the condition of commercial sex workers and their children.

• Legislative actions, such as Prevention of Sexual Harassment (POSH) Act of 2013, are likely to improve the safe and secure environment at the workplace and lead to better well-being of staff members.

• The availability of child care services at the workplace (in the form of creche) enables workers to have less home–work conflict, reduce absenteeism, and hence improve occupational functioning and well-being.

• Several organizations have industrial–organizational psychologists to enhance the well-being of the employees and find avenues for improving employee productivity.

• In many organizations (including armed forces and health care), stressful job postings are alternated with relatively lighter postings.

• Systematic grievance redressal has been suggested to improve the morale at the workplace and improve the well-being of the employees.

DEALING WITH LOSS OF JOB

The loss of a job can be one of the most stressful events in a person's life. In addition to material and economic losses, it also negatively affects both physical health and mental health. The loss of a job can be due to various reasons, such as social factors (e.g., the mother leaving the job to take care of the newborn child), physical factors (physical health-related issues), mental health-related factors (mental illness and conflicts at the workplace with administrators), policy factors (e.g., lockdown secondary to COVID-19 pandemic), legal factors (e.g., suspension of the license of a company), or economic factors (loss in business, etc.).

The psychological well-being of an individual following a job loss depends on various factors, such as work role centrality, the availability of coping resources (personal, social, financial, and time structure), the cognitive appraisal of the situation by the individual, and coping strategies.[48]

Planned job loss

When a job loss is planned or expected, as in retirement, pregnant mothers planning to leave job temporarily after delivery, or an individual planning to quit a job to have a change in career, etc., proper planning can be helpful:

• Evaluate the decision to quit

  • Use decision-making or problem-solving techniques to identify the pros and cons of continuing in the same job or quitting the current job.

• Make a plan for the period after you quit the current job

  • Plan on how to manage financially after quitting the job

  • Plan on when, where, and which type of job you can apply for if needed

  • Identify your desired career path, your skills, and any professional skill or course that is needed and feasible to be completed for a better job

• Inform the employer about your decision to quit in appropriate time, express gratitude, and offer help to facilitate a smooth transition.

• Get a favorable reference or experience certificate from your employer (more useful in formal sectors)

  • Also, gather good performance appraisals that you have already received during your career, as this can help in future employment.

• Follow the protocol for resignation as per the job's rules.

Role of mental health professionals in helping the client during planned job loss

Mental health professionals can help in identifying whether the patient's current decision to leave the job is secondary to any mental illness (e.g., patient with depression planning to quit secondary to depressive cognitions, unable to focus on job secondary to attention deficit hyperactivity disorder (ADHD), and quitting job secondary to persecutory delusions or auditory hallucinations). If job loss is secondary to mental illness, depending on the mental capacity of the patient to understand the situation at the moment, the patient or the nominated representative of the patient can be informed about the mental illness, and treatment can be offered. Also, a discussion with the patient and the nominated representative to postpone the decision to quit the job till his symptoms improve should be made in such situations.

If it is not secondary to mental illness but secondary to perceived mental stress, mental health professionals can help the client deal with the mental stress using appropriate non-pharmacological techniques, such as relaxation therapies, mindfulness techniques, and psychotherapies, such as cognitive behavior therapy.

If it is neither secondary to mental illness or perceived mental stress, or if the perceived mental stress is secondary to problems not under the patient's control, the client can be guided on planning to quit the job using the strategies described above.

Unplanned job loss

When a job loss is unplanned, it can disrupt the participant's sense of purpose and direction in life and vision for the future. The individual may have a perceived sense of failure to meet societal standards or inability to meet the expectations of one's ideal self. Also, unplanned unemployment can lead to a financial crisis for an individual, which can add to the individual's mental stress. At the same time, some individuals start identifying new meanings in life.[49] How a person can manage unplanned job loss mentally depends on a number of factors, such as the presence of already available resources (financial, social, psychological, and physical), the cognitive appraisal of the situation, and the importance of work in an individual's life.

When job loss is unplanned, the following strategies can be helpful for the individual to overcome mental stress:

1. Allow oneself to grieve:

   • Grief is a normal, natural response to a loss

   • It is necessary to allow time for self to adjust to the loss

   • Accept the situation and think of the situation as a temporary setback

   • Avoid blaming yourself and have an optimistic outlook for the future

2. Seek help from others:

   • Share your feelings to your friends or family members and get emotional support from them.

   • Seek professional help from a mental health professional, if the feelings are overwhelming or significantly disrupting your day-to-day activities.

3. Structure your time

   • Loss of job often leads to a loss of time structure. Plan activities in a day to maintain the time structure

   • Include physical activity in your time structure

4. Use coping skills that can be beneficial

   • Different ways of coping have been described in the literature that can be helpful for a person to cope with unemployment, which can be broadly categorized into problem-focused coping and emotion-focused coping.[50,51]

   • Problem-focused coping skills:

     • Actively searching for new job opportunities

     • If there are health-related issues that are hindering the job,

       • Seeking help for health-related issues

       • Choosing or adapting a job that can be suitable along with the health-related issue

     • Participation in training or retraining programs

       • Improving or learning new skills that are needed for the job

     • Relocation to another region or improvement of the current financial situation

       • Relocating to a place where the job opportunity is available

• Emotion-focused coping skills:

  • These coping strategies focus on improving an individual's cognitive and emotional mastery by decreasing the threatening nature of the situation.

    • Seeking social support

    • Internal distancing

    • Avoidance and repression strategies

    • Distraction techniques

    • Optimism

    • Positive reframing

    • Community activism.

Role of mental health professionals in helping the client during unplanned job loss

Mental health professionals can help identify whether the job loss has precipitated or exacerbated any mental illness and treat the same. They can also help the client cope with the loss of the job by guiding the patient through the grief and guiding the patient to use the coping skills that are suitable and feasible for them.

Suggestions to implement a successful mental health intervention at the workplace

Sometimes, mental health professionals may be required to opine on the measures that can be taken to improve workplace well-being. Box 5 presents some suggestions for implementing a mental health intervention at the workplace.

Box 5.

Suggestions for implementing mental health intervention at the workplace

Clarify the salient features of the work environment: type of work(s), employment stability, field of work, number of personnel, complexity of hierarchy, etc. Assess the current well-being of the different workers or levels of employees and understand their concerns (using quantitative and qualitative methodologies) Ascertain gaps where more attention is required to improve workplace well-being Develop an implementation plan: This may include communication, flexibility in work timings, gender sensitization, ability to seek mental health without prejudice, group bonding exercises, vacations and time-off, grievance redressal mechanism, etc. Discuss the implementation plan with the management: cognizance of feasibility, broad cultural context, and resource requirement. Also, consideration of inadvertent adverse consequences (such as lower productivity and challenge to authority) should be there. Implementation of decided interventions: whether to implement them together or step-wise Getting feedback to analyze what went well and what did not go well (and why); tweak interventions as required.

CONCLUSION

Consideration for mental well-being at the workplace is the need of the hour, and specific approaches are required based on local realities. Various approaches at the employee, organizational, and policy levels can be leveraged to improve well-being. One has to be cognizant of the different types of workplaces, the resources that could be made available for workplace well-being, and the overall workplace culture in the broader socioeconomic situation and societal outlook before considering implementing workplace well-being measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.