The predominant type of malignant tumour of the liver (ICD-9 155) is hepatocellular carcinoma (hepatoma; HCC), i.e., a malignant tumour of the liver cells. Cholangiocarcinomas are tumours of the intrahepatic bile ducts. They represent some 10% of liver cancers in the US but may account for up to 60% elsewhere, such as in north-eastern Thai populations (IARC 1990). Angiosarcomas of the liver are very rare and very aggressive tumours, occurring mostly in men. Hepatoblastomas, a rare embryonal cancer, occur in early life, and have little geographic or ethnic variation.

The prognosis for HCC depends on the size of the tumour and on the extent of cirrhosis, metastases, lymph node involvement, vascular invasion and presence/absence of a capsule. They tend to relapse after resection. Small HCCs are resectable, with a five-year survival of 40-70%. Liver transplantation results in about 20% survival after two years for patients with advanced HCC. For patients with less advanced HCC, the prognosis after transplantation is better. For hepatoblastomas, complete resection is possible in 50-70% of the children. Cure rates after resection range from 30-70%. Chemotherapy can be used both pre- and postoperatively. Liver transplantation may be indicated for unresectable hepatoblastomas.

Cholangiocarcinomas are multifocal in more than 40% of the patients at the time of diagnosis. Lymph node metastases occur in 30-50% of these cases. The response rates to chemotherapy vary widely, but usually are less than 20% successful. Surgical resection is possible in only a few patients. Radiation therapy has been used as the primary treatment or adjuvant therapy, and may improve survival in patients who have not undergone a complete resection. Five-year survival rates are less than 20%. Angiosarcoma patients usually present distant metastases. Resection, radiation therapy, chemotherapy and liver transplantation are, in most cases, unsuccessful. Most patients die within six months of diagnosis (Lotze, Flickinger and Carr 1993).

An estimated 315,000 new cases of liver cancer occurred globally in 1985, with a clear absolute and relative preponderance in populations of developing countries, except in Latin America (IARC 1994a; Parkin, Pisani and Ferlay 1993). The average annual incidence of liver cancer shows considerable variation across cancer registries worldwide. During the 1980s, average annual incidence ranged from 0.8 in men and 0.2 in women in Maastricht, The Netherlands, to 90.0 in men and 38.3 in women in Khon Kaen, Thailand, per 100,000 of population, standardized to the standard world population. China, Japan, East Asia, and Africa represented high rates, while Latin and North American, European, and Oceanian rates were lower, except for New Zealand Maoris (IARC 1992). The geographic distribution of liver cancer is correlated with the distribution of the prevalence of chronic carriers of hepatitis B surface antigen and also with the distribution of local levels of aflatoxin contamination of foodstuffs (IARC 1990). Male-to-female ratios in incidence are usually between 1 and 3, but may be higher in high-risk populations.

Statistics on the mortality and incidence of liver cancer by social class indicate a tendency of excess risk to concentrate in the lower socio-economic strata, but this gradient is not observed in all populations.

The established risk factors for primary liver cancer in humans include aflatoxin-contaminated food, chronic infection with hepatitis B virus (IARC 1994b), chronic infection with hepatitis C virus (IARC 1994b), and heavy consumption of alcoholic beverages (IARC 1988). HBV is responsible for an estimated 50-90% of hepatocellular carcinoma incidence in high-risk populations, and for 1-10% in low-risk populations. Oral contraceptives are a further suspected factor. The evidence implicating tobacco smoking in the aetiology of liver cancer is insufficient (Higginson, Muir and Munoz 1992).

The substantial geographical variation in the incidence of liver cancer suggests that a high proportion of liver cancers might be preventable. The preventive measures include HBV vaccination (estimated potential theoretical reduction in incidence is roughly 70% in endemic areas), reduction of contamination of food by mycotoxins (40% reduction in endemic areas), improved methods of harvesting, dry storing of crops, and reduction of consumption of alcoholic beverages (15% reduction in Western countries; IARC 1990).

Liver cancer excesses have been reported in a number of occupational and industrial groups in different countries. Some of the positive associations are readily explained by workplace exposures such as the increased risk of liver angiosarcoma in vinyl chloride workers (see below). For other high-risk jobs, such as metal work, construction painting, and animal feed processing, the connection with workplace exposures is not firmly established and is not found in all studies, but could well exist. For others, such as service workers, police officers, guards, and governmental workers, direct workplace carcinogens may not explain the excess. Cancer data for farmers do not provide many clues for occupational aetiologies in liver cancer. In a review of 13 studies involving 510 cases or deaths of liver cancer among farmers (Blair et al. 1992), a slight deficit (aggregated risk ratio 0.89; 95% confidence interval 0.81-0.97) was observed.

Some of the clues provided by industry- or job-specific epidemiological studies do suggest that occupational exposures may have a role in the induction of liver cancer. Minimization of certain occupational exposures therefore would be instrumental in the prevention of liver cancer in occupationally exposed populations. As a classical example, occupational exposure to vinyl chloride has been shown to cause angiosarcoma of the liver, a rare form of liver cancer (IARC 1987). As a result, vinyl chloride exposure has been regulated in a large number of countries. There is increasing evidence that chlorinated hydrocarbon solvents may cause liver cancer. Aflatoxins, chlorophenols, ethylene glycol, tin compounds, insecticides and some other agents have been associated with the risk of liver cancer in epidemiological studies. Numerous chemical agents occurring in occupational settings have caused liver cancer in animals and may therefore be suspected of being liver carcinogens in humans. Such agents include aflatoxins, aromatic amines, azo dyes, benzidine-based dyes, 1,2-dibromoethane, butadiene, carbon tetrachloride, chlorobenzenes, chloroform, chlorophenols, diethylhexyl phthalate, 1,2-dichloroethane, hydrazine, methylene chloride, N-nitrosoamines, a number of organochlorine pesticides, perchloroethylene, polychlorinated biphenyls and toxaphene.

Back

Pancreatic cancer (ICD-9 157; ICD-10 C25), a highly fatal malignancy, ranks amongst the 15 most common cancers globally but belongs to the ten most common cancers in the populations of developed countries, accounting for 2 to 3% of all new cases of cancer (IARC 1993). An estimated 185,000 new cases of pancreatic cancer occurred globally in 1985 (Parkin, Pisani and Ferlay 1993). The incidence rates of pancreatic cancer have been increasing in developed countries. In Europe, the increase has levelled off, except in the UK and some Nordic countries (Fernandez et al. 1994). The incidence and mortality rates rise steeply with advancing age between 30 and 70 years. The age-adjusted male/female ratio of new cases of pancreatic cancer is 1.6/1 in developed countries but only 1.1/1 in developing countries.

High annual incidence rates of pancreatic cancer (up to 30/100,000 for men; 20/100,000 for women) in the period 1960-85, have been recorded for New Zealand Maoris, Hawaiians, and in Black populations in the US. Regionally, the highest age-adjusted rates in 1985 (over 7/100,000 for men and 4/100,000 in women) were reported for both genders in Japan, North America, Australia, New Zealand, and Northern, Western and Eastern Europe. The lowest rates (up to 2/100,000 for both men and women) were reported in the regions of West and Middle Africa, South-eastern Asia, Melanesia, and in temperate South America (IARC 1992; Parkin, Pisani and Ferlay 1993).

Comparisons between populations in time and space are subject to several cautions and interpretation difficulties because of variations in diagnostic conventions and technologies (Mack 1982).

The vast majority of pancreatic cancers occur in the exocrine pancreas. The major symptoms are abdominal and back pain and weight loss. Further symptoms include anorexia, diabetes and obstructive jaundice. Symptomatic patients are subjected to procedures such as a series of blood and urine tests, ultrasound, computerized tomography, cytological examination and pancreatoscopy. Most patients have metastases at diagnosis, which makes their prognosis bleak.

Only 15% of patients with pancreatic cancer are operable. Local recurrence and distant metastases occur frequently after surgery. Irradiation therapy or chemotherapy do not bring about significant improvements in survival except when combined with surgery on localized carcinomas. Palliative procedures provide little benefit. Despite some diagnostic improvements, survival remains poor. During the period 1983-85, the five-year average survival in 11 European populations was 3% for men and 4% for women (IARC 1995). Very early detection and diagnosis or identification of high-risk individuals may improve the success of surgery. The efficacy of screening for pancreatic cancer has not been determined.

Mortality and incidence of pancreatic cancer do not reveal a consistent global pattern across socio-economic categories.

The dismal picture offered by diagnostic problems and treatment inefficacy is completed by the fact that the causes of pancreatic cancer are largely unknown, which effectively hampers the prevention of this fatal disease. The unique established cause of pancreatic cancer is tobacco smoking, which explains about 20-50% of the cases, depending on the smoking patterns of the population. It has been estimated that elimination of tobacco smoking would decrease the incidence of pancreatic cancer by about 30% worldwide (IARC 1990). Alcohol consumption and coffee drinking have been suspected as increasing the risk of pancreatic cancer. On closer scrutiny of the epidemiological data, however, coffee consumption appears unlikely to be causally connected to pancreatic cancer. For alcoholic beverages, the only causal link with pancreatic cancer is probably pancreatitis, a condition associated with heavy alcohol consumption. Pancreatitis is a rare but potent risk factor of pancreatic cancer. It is possible that some as yet unidentified dietary factors might account for a part of the aetiology of pancreatic cancer.

Workplace exposures may be causally associated with pancreatic cancer. Results of several epidemiological studies that have linked industries and jobs with an excess of pancreatic cancer are heterogeneous and inconsistent, and exposures shared by alleged high-risk jobs are hard to identify. The population aetiologic fraction for pancreatic cancer from occupational exposures in Montreal, Canada, has been estimated to lie between 0% (based on recognized carcinogens) and 26% (based on a multi-site case-control study in the Montreal area, Canada) (Siemiatycki et al. 1991).

No single occupational exposure has been confirmed to increase the risk of pancreatic cancer. Most of the occupational chemical agents that have been associated with an excess risk in epidemiological studies emerged in one study only, suggesting that many of the associations may be artefacts from confounding or chance. If no additional information, e.g., from animal bio-assays, is available, the distinction between spurious and causal associations presents formidable difficulties, given the general uncertainty about the causative agents involved in the development of pancreatic cancer. Agents associated with increased risk include aluminium, aromatic amines, asbestos, ashes and soot, brass dust, chromates, combustion products of coal, natural gas and wood, copper fumes, cotton dust, cleaning agents, grain dust, hydrogen fluoride, inorganic insulation dust, ionizing radiation, lead fumes, nickel compounds, nitrogen oxides, organic solvents and paint thinners, paints, pesticides, phenol-formaldehyde, plastic dust, polycyclic aromatic hydrocarbons, rayon fibres, stainless steel dust, sulphuric acid, synthetic adhesives, tin compounds and fumes, waxes and polishes, and zinc fumes (Kauppinen et al. 1995). Among these agents, only aluminium, ionizing radiation and unspecified pesticides have been associated with excess risk in more than one study.

Back

This chapter provides an overview of major types of mental health disorder that can be associated with work—mood and affective disorders (e.g., dissatisfaction), burnout, post-traumatic stress disorder (PTSD), psychoses, cognitive disorders and substance abuse. The clinical picture, available assessment techniques, aetiological agents and factors, and specific prevention and management measures will be provided. The relationship with work, occupation or branch of industry will be illustrated and discussed where possible.

This introductory article first will provide a general perspective on occupational mental health itself. The concept of mental health will be elaborated upon, and a model will be presented. Next, we will discuss why attention should be paid to mental (ill) health and which occupational groups are at greatest risk. Finally, we will present a general intervention framework for successfully managing work-related mental health problems.

What Is Mental Health: A Conceptual Model

There are many different views about the components and processes of mental health. The concept is heavily value laden, and one definition is unlikely to be agreed upon. Like the strongly associated concept of “stress”, mental health is conceptualized as:

• a state—for example, a state of total psychological and social well-being of an individual in a given sociocultural environment, indicative of positive moods and affects (e.g., pleasure, satisfaction and comfort) or negative ones (e.g., anxiety, depressive mood and dissatisfaction).
• a process indicative of coping behaviour—for example, striving for independence, being autonomous (which are key aspects of mental health).
• the outcome of a process—a chronic condition resulting either from an acute, intense confrontation with a stressor, such as is the case in a post-traumatic stress disorder, or from the continuing presence of a stressor which may not necessarily be intense. This is the case in burnout, as well as in psychoses, major depressive disorders, cognitive disorders and substance abuse. Cognitive disorders and substance abuse are, however, often considered as neurological problems, since pathophysiological processes (e.g., degeneration of the myelin sheath) resulting from ineffective coping or from the stressor itself (alcohol use or occupational exposition to solvents, respectively) can underlie these chronic conditions.

Mental health may also be associated with:

• Person characteristics like “coping styles”—competence (including effective coping, environmental mastery and self-efficacy) and aspiration are characteristic of a mentally healthy person, who shows interest in the environment, engages in motivational activity and seeks to extend him- or herself in ways that are personally significant.

Thus, mental health is conceptualized not only as a process or outcome variable, but also as an independent variable—that is, as a personal characteristic that influences our behaviour.

In figure 1 a mental health model is presented. Mental health is determined by environmental characteristics, both in and outside the work situation, and by characteristics of the individual. Major environmental job characteristics are elaborated upon in the chapter “Psychosocial and organizational factors”, but some points on these environmental precursors of mental (ill) health have to be made here as well.

Figure 1. A model for mental health.

There are many models, most of them stemming from the field of work and organizational psychology, that identify precursors of mental ill health. These precursors are often labelled “stressors”. Those models differ in their scope and, related to this, in the number of stressor dimensions identified. An example of a relatively simple model is that of Karasek (Karasek and Theorell 1990), describing only three dimensions: psychological demands, decision latitude (incorporating skill discretion and decision authority) and social support. A more elaborate model is that of Warr (1994), with nine dimensions: opportunity for control (decision authority), opportunity for skill use (skill discretion), externally generated goals (quantitative and qualitative demands), variety, environmental clarity (information about consequences of behaviour, availability of feedback, information about the future, information about required behaviour), availability of money, physical security (low physical risk, absence of danger), opportunity for interpersonal contact (prerequisite for social support), and valued social position (cultural and company evaluations of status, personal evaluations of significance). From the above it is clear that the precursors of mental (ill) health are generally psychosocial in nature, and are related to work content, as well as working conditions, conditions of employment and (formal and informal) relationships at work.

Environmental risk factors for mental (ill) health generally result in short-term effects such as changes in mood and affect, like feelings of pleasure, enthusiasm or a depressed mood. These changes are often accompanied by changes in behaviour. We may think of restless behaviour, palliative coping (e.g., drinking) or avoiding, as well as active problem-solving behaviour. These affects and behaviours are generally accompanied by physiological changes as well, indicative of arousal and sometimes also of a disturbed homeostasis. When one or more of these stressors remains active, the short-term, reversible responses may result in more stable, less reversible mental health outcomes like burnout, psychoses or major depressive disorder. Situations that are extremely threatening may even immediately result in chronic mental health disorders (e.g., PTSD) which are difficult to reverse.

Person characteristics may interact with psychosocial risk factors at work and exacerbate or buffer their effects. The (perceived) coping ability may not only moderate or mediate the effects of environmental risk factors, but may also determine the appraisal of the risk factors in the environment. Part of the effect of the environmental risk factors on mental health results from this appraisal process.

Person characteristics (e.g., physical fitness) may not only act as precursors in the development of mental health, but may also change as a result of the effects. Coping ability may, for example, increase as the coping process progresses successfully (“learning”). Long-term mental health problems will, on the other hand, often reduce coping ability and capacity in the long run.

In occupational mental health research, attention has been particularly directed to affective well-being—factors such as job satisfaction, depressive moods and anxiety. The more chronic mental health disorders, resulting from long-term exposure to stressors and to a greater or lesser extent also related to personality disorders, have a much lower prevalence in the working population. These chronic mental health problems have a multitude of causal factors. Occupational stressors will consequently be only partly responsible for the chronic condition. Also, people suffering from these kinds of chronic problem will have great difficulty in maintaining their position at work, and many are on sick leave or have dropped out of work for quite a long period of time (1 year), or even permanently. These chronic problems, therefore, are often studied from a clinical perspective.

Since, in particular, affective moods and affects are so frequently studied in the occupational field, we will elaborate on them a little bit more. Affective well-being has been treated both in a rather undifferentiated way (ranging from feeling good to feeling bad), as well as by considering two dimensions: “pleasure” and “arousal” (figure 2). When variations in arousal are uncorrelated with pleasure, these variations alone are generally not considered to be an indicator of well-being.

Figure 2. Three principal axes for the measurement of affective well-being.

When, however, arousal and pleasure are correlated, four quadrants can be distinguished:

1. Highly aroused and pleased indicates enthusiasm.
2. Low aroused and pleased indicates comfort.
3. Highly aroused and displeased indicates anxiety.
4. Low aroused and displeased indicates depressed mood (Warr 1994).

Well-being can be studied at two levels: a general, context-free level and a context-specific level. The work environment is such a specific context. Data analyses support the general notion that the relation between job characteristics and context-free, non-work mental health is mediated by an effect on work-related mental health. Work-related affective well-being has commonly been studied along the horizontal axis (Figure 2) in terms of job satisfaction. Affects related to comfort in particular have, however, largely been ignored. This is regrettable, since this affect might indicate resigned job satisfaction: people may not complain about their jobs, but may still be apathetic and uninvolved (Warr 1994).

Why Pay Attention to Mental Health Issues?

There are several reasons that illustrate the need for attention to mental health issues. First of all, national statistics of several countries indicate that a lot of people drop out of work because of mental health problems. In the Netherlands, for example, for one-third of those employees who are diagnosed as disabled for work each year, the problem is related to mental health. The majority of this category, 58%, is reported to be work related (Gründemann, Nijboer and Schellart 1991). Together with musculoskeletal problems, mental health problems account for about two-thirds of those who drop out for medical reasons each year.

Mental ill health is an extensive problem in other countries as well. According to the Health and Safety Executive Booklet, it has been estimated that 30 to 40% of all sickness absence from work in the UK is attributable to some form of mental illness (Ross 1989; O’Leary 1993). In the UK, it has been estimated that one in five of the working population suffers each year from some form of mental illness. It is difficult to be precise about the number of working days lost each year because of mental ill health. For the UK, a figure of 90 million certified days—or 30 times that lost as a result of industrial disputes—is widely quoted (O’Leary 1993). This compares with 8 million days lost as a result of alcoholism and drink-related diseases and 35 million days as a result of coronary heart disease and strokes.

Apart from the fact that mental ill health is costly, both in human and financial terms, there is a legal framework provided by the European Union (EU) in its framework directive on health and safety at work (89/391/EEC), enacted in 1993. Although mental health is not as such an element which is central to this directive, a certain amount of attention is given to this aspect of health in Article 6. The framework directive states, among other things, that the employer has:

“a duty to ensure the safety and health of workers in every aspect related to work, following general principles of prevention: avoiding risks, evaluating the risks which cannot be avoided, combating the risks at source, adapting the work to the individual, especially as regards the design of workplaces, the choice of work equipment and the choice of work and production methods, with a view, in particular, to alleviating monotonous work and work at a predetermined work rate and to reduce their effects on health.”

Despite this directive, not all European countries have adopted framework legislation on health and safety. In a study comparing regulations, policies and practices concerning mental health and stress at work in five European countries, those countries with such framework legislation (Sweden, the Netherlands and the UK) recognize mental health issues at work as important health and safety topics, whereas those countries which do not have such a framework (France, Germany) do not recognize mental health issues as important (Kompier et al. 1994).

Last but not least, prevention of mental ill health (at its source) pays. There are strong indications that important benefits result from preventive programmes. For example, of the employers in a national representative sample of companies from three major branches of industry, 69% state that motivation increased; 60%, that absence due to sickness decreased ; 49%, that the atmosphere improved; and 40%, that productivity increased as a result of a prevention programme (Houtman et al. 1995).

Occupational Risk Groups of Mental Health

Are specific groups of the working population at risk of mental health problems? This question cannot be answered in a straightforward manner, since hardly any national or international monitoring systems exist which identify risk factors, mental health consequences or risk groups. Only a “scattergram” can be given. In some countries national data exist for the distribution of occupational groups with respect to major risk factors (e.g., for the Netherlands, Houtman and Kompier 1995; for the United States, Karasek and Theorell 1990). The distribution of the occupational groups in the Netherlands on the dimensions of job demands and skill discretion (figure 3) agree fairly well with the US distribution shown by Karasek and Theorell, for those groups that are in both samples. In those occupations with high work pace and/or low skill discretion, the risk of mental health disorders is highest.

Figure 3. Risk for stress and mental ill health for different occupational groups, as determined by the combined effects of work pace and skill discretion.

Also, in some countries there are data for mental health outcomes as related to occupational groups. Occupational groups that are especially prone to drop out for reasons of mental ill health in the Netherlands are those in the service sector, such as health care personnel and teachers, as well as cleaning personnel, housekeepers and occupations in the transport branch (Gründemann, Nijboer and Schellart1991).

In the United States, occupations which were highly prone to major depressive disorder, as diagnosed with standardized coding systems (i.e., the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III)) (American Psychiatric Association 1980), are juridicial employees, secretaries and teachers (Eaton et al. 1990). 

Management of Mental Health Problems

The conceptual model (figure 1) suggests at least two targets of intervention in mental health issues:

1. The (work) environment.
2. The person—either his or her characteristics or the mental health consequences.

Primary prevention, the type of prevention that should prevent mental ill health from occurring, should be directed at the precursors by alleviating or managing the risks in the environment and increasing the coping ability and capacity of the individual. Secondary prevention is directed at the maintenance of people at work who already have some form of (mental) health problem. This type of prevention should embrace the primary prevention strategy, accompanied by strategies to make both employees and their supervisors sensitive to signals of early mental ill health in order to reduce the consequences or prevent them from getting worse. Tertiary prevention is directed at the rehabilitation of people who have dropped out of work due to mental health problems. This type of prevention should be directed at adapting the workplace to the possibilities of the individual (which is often found to be quite effective), along with individual counselling and treatment. Table 1 provides a schematic framework for the management of mental health disorders at the workplace. Effective preventive policy plans of organizations should, in principle, take into account all three types of strategy (primary, secondary and tertiary prevention), as well as be directed at risks, consequences and person characteristics.

Table 1. A schematic overview of management strategies on mental health problems, and some examples.

The schedule as presented provides a method for systematic analysis of all possible types of measure. One can discuss whether a certain measure belongs somewhere else in the schedule; such a discussion is, however, not very fruitful, since it is often the case that primary preventive measures can work out positively for secondary prevention as well. The proposed systematic analysis may well result in a large number of potential measures, several of which may be adopted, either as a general aspect of the (health and safety) policy or in a specific case.

In conclusion: Although mental health is not a clearly defined state, process or outcome, it covers a generally agreed upon area of (ill) health. Part of this area can be covered by generally accepted diagnostic criteria (e.g., psychosis, major depressive disorder); the diagnostic nature of other parts is neither as clear nor as generally accepted. Examples of the latter are moods and affects, and also burnout. Despite this, there are many indications that mental (ill) health, including the more vague diagnostic criteria, is a major problem. Its costs are high, both in human and financial terms. In the following articles of this chapter, several mental health disorders—moods and affects (e.g., dissatisfaction), burnout, post-traumatic stress disorder, psychoses, cognitive disorders and substance abuse—will be discussed in much more depth with respect to the clinical picture, available assessment techniques, aetiological agents and factors, and specific prevention and management measures.

Back

Psychosis is a general term often used to describe a severe impairment in mental functioning. Usually, this impairment is so substantial that the individual is unable to carry on normal activities of daily living, including most work activities. More formally, Yodofsky, Hales and Fergusen (1991) define psychosis as:

“A major mental disorder of organic or emotional origin in which a person’s ability to think, respond emotionally, remember, communicate, interpret reality and behave appropriately is sufficiently impaired so as to interfere grossly with the capacity to meet the ordinary demands of life. [Symptoms are] often characterized by regressive behaviour, inappropriate mood, diminished impulse control and such abnormal mental context as delusions and hallucinations [p. 618].”

Psychotic disorders are comparatively rare in the general population. Their incidence in the workplace is even lower, probably due to the fact that many individuals who frequently become psychotic often have problems maintaining stable employment (Jorgensen 1987). Precisely how rare it is, is difficult to estimate. However, there are some suggestions that the prevalence within the general population of psychoses (e.g., schizophrenia) is less than 1% (Bentall 1990; Eysenck 1982). While psychosis is rare, individuals who are actively experiencing a psychotic state usually exhibit profound difficulties in functioning at work and in other aspects of their lives. Sometimes acutely psychotic individuals exhibit behaviours which are engaging, inspiring or even humorous. For example, some individuals who suffer from bipolar illness and are entering a manic phase exhibit high energy and grand ideas or plans. For the most part, however, psychosis is associated with behaviours which evoke reactions such as discomfort, anxiety, anger or fear in co-workers, supervisors and others.

This article will first provide an overview of the various neurological conditions and mental states in which psychosis can occur. Then, it will review workplace factors potentially associated with the occurrence of psychosis. Finally, it will summarize treatment approaches for managing both the psychotic worker and the work environment (i.e., medical management, return-to-work clearance procedures, workplace accommodations and workplace consultations with supervisors and co-workers).

Neurological Conditions and Mental Stateswithin which Psychosis Occurs

Psychosis can occur within a number of diagnostic categories identified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (American Psychiatric Association 1994). At this point, there is no commonly agreed upon definitive diagnostic set. The following are widely accepted as medical conditions within which psychoses arise.

Neurological and general medical conditions

Delusional symtomatology can be caused by a range of neurological disorders affecting the limbic system or basal ganglia, where cerebral cortical functioning remains intact. Partial complex seizure episodes are often preceded by olfactory hallucinations of peculiar smells. To an external observer, this seizure activity may appear to be simple staring or day-dreaming. Cerebral neoplasms, especially in temporal and occipital areas, can cause hallucinations. Also, delirium-causing diseases, such as Parkinson’s, Huntington’s, Alzheimer’s, and Pick’s, can result in altered states of consciousness. Several sexually transmitted diseases such as tertiary syphilis and AIDS can also produce psychosis. Lastly, deficiencies of certain nutrients, such as B-12, niacin, folic acid and thiamine, have the potential of causing neurological problems which can result in psychosis.

Psychotic symptoms such as hallucinations and delusions also occur among patients with various general medical conditions. These include several systemic diseases, such as hepatic encephalopathy, hypercalcaemia, diabetic ketoacidosis, and malfunction of endocrine glands (i.e., adrenal, thyroid, parathyroid and pituitary). Sensory and sleep deprivation have also been shown to cause psychosis.

Mental states

Schizophrenia is probably the most widely known of the psychotic disorders. It is a progressively deteriorating condition which usually has an insidious onset. A number of specific subcategories have been identified including paranoid, disorganized, catatonic, undifferentiated and residual types. People who suffer from this disorder often have limited work histories and often do not remain in the workforce. Occupational impairment among schizophrenics is very common, and many schizophrenics lose their interest or will to work as the disease progresses. Unless a job is of very low complexity, it is usually very difficult for them to stay employed.

Schizophreniform disorder is similar to schizophrenia, but an episode of this disorder is of short duration, usually lasting less than six months. Generally, persons with this disorder have good premorbid social and occupational functioning. As the symptoms resolve, the person returns to baseline functioning. Consequently, the occupational impact of this disorder may be significantly less than in cases of schizophrenia.

Schizoaffective disorder also has a better prognosis than schizophrenia but a worse prognosis than affective disorders. Occupational impairment is quite common in this group. Psychosis is also sometimes observed in major affective disorders. With appropriate treatment, occupational functioning among workers suffering from major affective disorders is generally substantially better than for those with schizophrenia or schizoaffective disorders.

Severe stressors such as losing a loved one or losing one’s job can result in a brief reactive psychosis. This psychotic disorder is probably observed more frequently in the workplace than other types of psychotic disorder, especially with schizoid, schizotypal and borderline features.

Delusional disorders are probably relatively common in the workplace. There are several types. The erotomanic type typically believes that another person, usually of a higher social status, is in love with them. Sometimes, they harass the person who they believe is in love with them by attempting contact via telephone calls, letters or even stalking. Often, individuals with these disorders are employed in modest occupations, living isolated and withdrawn lives with limited social and sexual contact. The grandiose type usually exhibits delusions of inflated worth, power, knowledge or a special relationship with a deity or a famous person. The jealous type believes inaccurately that their sexual partner has been unfaithful. The persecutory type believes inaccurately that they (or someone to whom they are close) are being cheated, maligned, harassed or in other ways malevolently treated. These persons are often resentful and angry and may resort to violence against those they believe to be hurting them. They rarely want to seek help, as they do not think there is anything wrong with them. Somatic types develop delusions, contrary to all evidence, that they are afflicted with infections. They can also believe that a part of their body is disfigured, or worry about having a bad body odour. These workers with delusional beliefs can often create work-related difficulties.

Work-related chemical factors

Chemical factors such as mercury, carbon disulphide, toluene, arsenic and lead have been known to cause psychosis in blue-collar workers. For example, mercury has been found to be responsible for causing psychosis in workers in the hat industry, appropriately named the “Mad Hatter’s psychosis” (Kaplan and Sadock 1995). Stopford (personal communication, 6 November 1995) suggests that carbon disulphide was found to cause psychosis among workers in France in 1856. In the United States, in 1989, two brothers in Nevada purchased a carbon disulphide compound to kill gophers. Their physical contact with this chemical resulted in severe psychosis—one brother shooting a person and the other shooting himself due to severe confusion and psychotic depression. The incidence of suicide and homicide increases thirteenfold with exposure to carbon disulphide. Further, Stopford reports that exposure to toluene (used in making explosives and dyestuffs) is known to cause acute encephalopathy and psychosis. Symptoms can manifest also as memory loss, mood changes (e.g., dysphoria), deterioration in eye-hand coordination and speech impediments. Hence, some organic solvents, especially those found in the chemical industry, have a direct influence on the human central nervous system (CNS), causing biochemical changes and unpredictable behaviour (Levi, Frandenhaeuser and Gardell 1986). Special precautions, procedures and protocols have been established by the US Occupational Safety and Health Administration (OSHA), National Institute for Occupational Safety and Health (NIOSH) and the chemical industry to ensure minimum risk to employees working with toxic chemicals in their work environments.

Other factors

A number of medications can cause delirium which in turn can result in psychosis. These include antihypertensives, anticholinergics (including a number of medications used to treat the common cold), antidepressants, anti-tuberculosis medicines, anti-Parkinson’s disease medicines, and ulcer medicines (such as cimetidine). Further, substance-induced psychosis can be caused by a number of licit and illicit drugs which are sometimes abused, such as alcohol, amphetamines, cocaine, PCP, anabolic steroids and marijuana. The delusions and hallucinations which result are usually temporary. Although the content may vary, persecutory delusions are quite common. In alcohol-related hallucinations a person may believe that he or she is hearing voices which are threatening, insulting, critical or condemning. Sometimes, these insulting voices speak in the third person. As with individuals exhibiting paranoid or persecutory delusions, these individuals should be carefully evaluated for dangerousness to self or others.

Post-partum psychosis is comparatively uncommon in the workplace, but is worth noting as some women are returning to work more quickly. It tends to occur in new mothers (or more rarely fathers), usually within two to four weeks after delivery.

In a number of cultures, psychosis may result from various commonly held beliefs. A number of culturally based psychotic reactions have been described, including episodes such as “koro” in South and East Asia, “qi-gong psychotic reaction” within Chinese populations, “piblokto” in Eskimo communities and “whitigo” among several American Indian groups (Kaplan and Sadock 1995). The relationship of these psychotic phenomena to various occupational variables does not appear to have been studied.

Workplace Factors Associated with the Occurrence of Psychosis

Although information and empirical research on work-related psychosis are extremely scarce, due in part to the low prevalence in the work setting, researchers have noted a relationship between psychosocial factors in the work environment and psychological distress (Neff 1968; Lazarus 1991; Sauter, Murphy and Hurrell 1992; Quick et al. 1992). Significant psychosocial stressors on the job, such as role ambiguity, role conflicts, discrimination, supervisor-supervisee conflicts, work overload and work setting have been found to be associated with greater susceptibility to stress-related illness, tardiness, absenteeism, poor performance, depression, anxiety and other psychological distress (Levi, Frandenhaeuser and Gardell 1986; Sutherland and Cooper 1988).

Stress appears to have a prominent role in the complex manifestations of various types of physiological and psychological disorders. In the workplace, Margolis and Kroes (1974) believe that occupational stress occurs when some factor or combination of factors at work interact with the worker to disrupt his or her psychological or physiological homeostasis. These factors can be external or internal. External factors are the various pressures or demands from the external environment which stem from a person’s occupation, as well as from marriage, family or friends, whereas internal factors are the pressures and demands a worker places upon him- or herself—for example, by being “ambitious, materialistic, competitive and aggressive” (Yates 1989). It is these internal and external factors, separately or in combination, which can result in occupational distress whereby the worker experiences significant psychological and physical health problems.

Researchers have speculated on whether severe or cumulative stress, known as “stress-induced arousal”, originating from the work environment, could induce work-related psychotic disorders (Bentall, Dohrenwend and Skodol 1990; Link, Dohrenwend and Skodol 1986). For example, there is evidence linking hallucinatory and delusional experiences to specific stressful events. Hallucinations have been associated with stress-induced arousal occurring as a result of mining accidents, hostage situations, chemical-factory explosions, wartime exposure, sustained military operations and loss of a spouse (Comer, Madow and Dixon 1967; Hobfoll 1988; Wells 1983).

DeWolf (1986) believes that either the exposure to or interaction of multiple stressful conditions over an extended period of time is a complex process whereby some workers experience psychological health-related problems. Brodsky (1984) found in her examination of 2,000 workers who were her patients over 18 years that: (1) the timing, frequency, intensity and duration of unpleasant work conditions were potentially harmful, and she believed that 8 to 10% of the workforce experienced disabling psychological, emotional and physical health-related problems; and (2) workers react to work-related stress in part as “a function of perceptions, personality, age, status, life stage, unrealized expectations, prior experiences, social support systems and their capacity to respond adequately or adapt.” In addition, psychological distress can potentially be exacerbated by the worker feeling a sense of uncontrollability (e.g., inability to make decisions) and unpredictability in the work environment (e.g., corporate downsizing and reorganizing) (Labig 1995; Link and Stueve 1994).

Specific examination of the work-related “antecedents” of workers experiencing psychosis has received limited attention. The few researchers who have empirically examined the relationship between psychosocial factors in the work environment and severe psychopathology have found a relationship between “noisome” work conditions (i.e., noise, hazardous conditions, heat, humidity, fumes and cold) and psychosis (Link, Dohrenwend and Skodol 1986; Muntaner et al. 1991). Link, Dohrenwend and Skodol (1986) were interested in understanding the types of jobs schizophrenics had when they experienced their first schizophrenic episode. First full-time occupations were examined for workers who experienced: (a) schizophrenic or schizophrenic-like episodes; (b) depression; and (c) no psychopathology. These researchers found that noisome work conditions existed among more blue-collar than white-collar professions. These researchers concluded that noisome work conditions were potentially significant risk factors in the manifestation of psychotic episodes (i.e., schizophrenia).

Muntaner et al. (1991) replicated the findings of Link, Dohrenwend and Skodol (1986) and examined in greater detail whether various occupational stressors contributed to increased risk of developing or experiencing psychoses. Three types of psychotic condition were examined using the criteria of DSM III—schizophrenia; schizophrenia criterion A (hallucinations and delusions); and schizophrenia criterion A with affective episode (psychotic-affective disorder). Participants in their retrospective study were from a larger Epidemiologic Catchment Area (ECA) study examining the incidence of psychiatric disorders across five sites (Connecticut, Maryland, North Carolina, Missouri and California). These researchers found that psychosocial work characteristics (i.e., high physical demands, lack of control over work and working conditions—noisome factors) placed participants at increased risk of psychotic occurrences.

As illustrations, in the Muntaner et al. (1991) study, people in construction trade occupations (i.e., carpenters, painters, roofers, electricians, plumbers) were 2.58 times more likely to experience delusions or hallucinations than people in managerial occupations. Workers in housekeeping, laundry, cleaning and servant-type occupations were 4.13 times more likely to become schizophrenic than workers in managerial occupations. Workers who identified themselves as writers, artists, entertainers and athletes were 3.32 times more likely to experience delusions or hallucinations in comparison to workers in executive, administrative and managerial occupations. Lastly, workers in occupations such as sales, mail and message delivery, teaching, library science and counselling were more at risk of psychotic, affective disorders. It is important to note that the associations between psychotic conditions and occupational variables were examined after alcohol and drug use was controlled for in their study.

A significant difference between blue-collar and white-collar professions is the types of psychological demand and psychosocial stress placed on the worker. This is illustrated in the findings of Muntaner et al. (1993). They found an association between a work environment’s cognitive complexity and psychotic forms of mental illness. The most frequent occupations held by schizophrenic patients during their last full-time job were characterized by their low level of complexity in dealing with people, information and objects (e.g., janitors, cleaners, gardeners, guards). A few researchers have examined some of the consequences of first episodic psychosis relative to employment, job performance and capacity to work (Jorgensen 1987; Massel et al. 1990; Beiser et al. 1994). For example, Beiser and co-workers examined occupational functioning after the first episode of psychosis. These researchers found 18 months after the first episode that the “psychosis compromise[d] occupational functioning”. In other words, there was a higher post-morbid decline among schizophrenic workers than among those suffering from affective disorders. Similarly, Massel et al. (1990) found that the work capacity of psychotics (e.g., people with schizophrenia, affective disorders with psychotic features or atypical psychotic disorders) was impaired in comparison to non-psychotics (e.g., people with affective disorders without psychotic features, anxiety disorders, personality disorders and substance abuse disorders). Psychotics in their study showed marked thought disturbance, hostility and suspiciousness which correlated with poor work performance.

In summary, our knowledge about the relationship between work-related factors and psychosis is in the embryonic stage. As Brodsky (1984) states, “the physical and chemical hazards of the workplace have received considerable attention, but the psychological stresses associated with work have not been as widely discussed, other than in relation to managerial responsibilities or to the coronary-prone behaviour pattern”. This means that research on the topic of work-related psychosis is vitally needed, especially since workers spend an average of 42 to 44% of their lives working (Hines, Durham and Geoghegan 1991; Lemen 1995) and work has been associated with psychological well-being (Warr 1978). We need to have a better understanding of what types of occupational stressor under what types of condition influence which types of psychological disorder. For example, research is needed to determine whether there are stages which workers move through based upon intensity, duration and frequency of psychosocial stress in the work environment, in conjunction with personal, social, cultural and political factors occurring in their daily lives. We are dealing with complex issues which will require in-depth inquiries and ingenious solutions.

Acute Management of the Psychotic Worker

Typically, the primary role of persons in the workplace is to respond to an acutely psychotic worker in a manner which facilitates the person being transported safely to an emergency room or psychiatric treatment facility. The process may be greatly facilitated if the organization has an active employee assistance programme and a critical incident response plan. Ideally, the organization will train key employees in advance for emergency crisis responses and will have a plan in place for coordinating as needed with local emergency response resources.

Treatment approaches for the psychotic worker will vary depending upon the specific type of underlying problem. In general, all psychotic disorders should be evaluated by a professional. Often, immediate hospitalization is warranted for the safety of the worker and the workplace. Thereafter, a thorough evaluation can be completed to establish a diagnosis and develop a treatment plan. The primary goal is to treat the underlying cause(s). However, even prior to conducting a comprehensive evaluation or initiating a comprehensive treatment plan, the physician responding to the emergency may need to focus initially on providing symptomatic relief. Providing a structured, low-stress environment is desirable. Neuroloptics may be used to help the patient calm down. Benzodiazepines may help reduce acute anxiety.

After managing the acute crisis, a comprehensive evaluation may include collecting a detailed history, psychological testing, a risk assessment to establish dangerousness to self or others and careful monitoring of response to treatment (including not only response to medications, but also to psychotherapeutic interventions). One of the more difficult problems with many patients who exhibit psychotic symptomatology is treatment compliance. Often these individuals tend not to believe that they have serious difficulties, or, even if they recognize the problem, they are sometimes inclined to decide unilaterally to discontinue treatment prematurely. In these instances, family members, co-workers, treating clinicians, occupational health personnel and employers are sometimes placed in awkward or difficult situations. Sometimes, for the safety of the employee and the workplace, it becomes necessary to mandate compliance with treatment as a condition for returning to the job.

After several weeks, his treating physician felt he was able to return to his job. He underwent a formal return-to-work evaluation with an independent clinician and was judged ready to return to work. While his company doctor and the treating physician determined that it was safe for him to return, his co-workers and supervisors expressed substantial concerns. Some employees noted that they might be harmed if this episode were repeated and the chemical storage areas ignited. The company took steps to increase security in safety sensitive areas. Another concern also surfaced. A number of workers stated that they believed this individual might bring a weapon to work and start shooting. None of the professionals involved in treating this worker or in evaluating him for return to work believed that there was a risk of violent behaviour. The company then elected to bring in mental health professionals (with the worker’s consent) to assure co-workers that the risk of violent behaviour was exceedingly low, to provide education on mental illnesses, and to identify proactive steps that co-workers could take to facilitate the return to work of a colleague who had undergone treatment. However, in this situation, even after this educational intervention, co-workers were unwilling to interact with this worker, further compounding the return-to-work process. While the legal rights of individuals suffering from mental disorders, including those associated with psychotic states, have been addressed by the Americans with Disabilities Act, practically speaking the organizational challenges to effectively managing occurrences of psychosis at work are often as great or greater than the medical treatment of psychotic workers.

Return to Work

The primary question to be addressed after a psychotic episode is whether the employee can safely return to his or her current job. Sometimes organizations permit this decision to be made by the treating clinicians. However, ideally, the organization should require their occupational medical system to conduct an independent fitness-for-duty evaluation (Himmerstein and Pransky 1988). In the fitness-for-duty evaluation process a number of key pieces of information should be reviewed, including the treating clinician’s evaluation, treatment and recommendations, as well as the worker’s prior job performance and the specific features of the job, including the required job tasks and the organizational environment.

If the occupational medical physician is not trained in psychiatric or psychological fitness-for-duty evaluation, then the evaluation should be performed by an independent mental health professional who is not the treating clinician. If some aspects of the job pose safety risks, then specific work restrictions should be developed. These restrictions may range from minor alterations in work activities or work schedule to more significant modifications such as alternate job placement (e.g., a light-duty assignment or a job transfer to an alternate position). In principle, these work restrictions are not different in kind from other restrictions commonly provided by occupational health physicians, such as specifying the amount of weight which a worker may be cleared to lift following a musculoskeletal injury.

As is evident in the case example above, the return to work often raises challenges not only for the affected worker, but also for co-workers, supervisors and the broader organization. While professionals are obligated to protect the confidentiality of the affected worker to the fullest extent permitted by law, if the worker is willing and competent to sign an appropriate release of information, then the occupational medical system can provide or coordinate consultation and educational interventions to facilitate the return-to-work process. Often, coordination between the occupational medical system, the employee assistance programme, supervisors, union representatives and co-workers is critical to a successful outcome.

The occupational health system should also periodically monitor the worker’s readjustment to the workplace in collaboration with the supervisor. In some instances, it may be necessary to monitor the worker’s compliance with a medication regimen recommended by the treating physician—for example, as a precondition for being permitted to engage in certain safety-sensitive job tasks. More importantly, the occupational medical system must consider not only what is best for the worker, but also what is safe for the workplace. The occupational medical system may also play a critical role in assisting the organization in complying with legal requirements such as the Americans with Disabilities Act as well as in interfacing with treatments provided under the organization’s health care plan and/or the workers’ compensation system.

Prevention Programming

At present, there is no literature on specific prevention or early intervention programmes for reducing the incidence of psychosis in the workforce. Employee assistance programmes may play a crucial role in the early identification and treatment of psychotic workers. Since stress may contribute to the incidence of psychotic episodes within working populations, various organizational interventions which identify and modify organizationally created stress may also be helpful. These general programmatic efforts may include job redesign, flexible scheduling, self-paced work, self-directed work teams and microbreaks, as well as specific programming to reduce the stressful impact of reorganization or downsizing.

Conclusion

While psychosis is a comparatively rare and multiply determined phenomenon, its occurrence within working populations raises substantial practical challenges for co-workers, union representatives, supervisors and occupational health professionals. Psychosis may occur as a direct consequence of a work-related toxic exposure. Work-related stress may also increase the incidence of psychosis among workers who suffer from (or are at risk of developing) mental disorders which place them at risk of psychosis. Additional research is needed to: (1) better understand the relationship between workplace factors and psychosis; and (2) develop more effective approaches for managing psychosis in the workplace and reduce its incidence.

Back