Occupational psychiatry

In their editorial on work and employment for people with psychiatric illness, Boardman et al (2003) overlook an important group of patients with mental ill health who are not ‘mental health service users’, yet who experience difficulty coping in the modern workplace. Occupational physicians are seeing an increasing number of patients with mental ill health, and a national surveillance scheme recently reported that, along with musculoskeletal symptoms, mental ill health is among the commonest reasons for consultation (see http://www.coeh.man.ac.uk/thor/opra.htm). Furthermore, mental ill health is responsible for a large proportion of early retirements due to ill health (Poole, 1997) and a large proportion of incapacity benefits are currently being paid for medically unexplained illnesses (Waddell, 2002).

Much of the burden of occupational ill health is managed in primary care, but overburdened general practitioners may miss the psychological or workplace components in these patients. To make matters worse, current psychiatric practice is dominated by ‘serious’ mental illness such as schizophrenia and ‘dual diagnosis’ patients, to the exclusion of patients with ‘minor’ mental illnesses such as anxiety, depression and the functional disorders. Yet it is these latter conditions that are commonly being seen in the workplace, in primary care and in those on state benefits by doctors who have little training in mental illness. Unfortunately, some psychiatrists do not receive adequate training in the management of these disorders (Bass et al, 2001), in part because they are presenting in locations outside of psychiatric services (Henderson et al, 2001). Good evidence exists that these illnesses can be treated effectively using, for example, cognitive–behavioural therapy and interpersonal therapy (Creed et al, 2003). A key feature of these studies is that the best results are usually achieved at the site where the patient presents, which is likely to be outside the province of the community mental health team.

We believe that there is a lack of expertise in the management of occupational mental ill health at its site of presentation. Psychiatrists need to engage with occupational physicians to improve the diagnosis and management of patients with psychiatric illnesses that are preventing them from working. There is also a need for more collaborative training in occupational psychiatry for psychiatrists, occupational physicians and general practitioners. Such training should be integrated into the syllabuses of all three professional groups. A diploma in occupational psychiatry might be very popular.