Presentation on why it is nescessery to screen for mental health problems in occupational health, what to screen for and an overview of a short, self-administered, screening instrument, the Patient Health Questionnaire (partially validated, i.e. the PHQ-9 in occupational health), which can be used for the most common and most disabeling mental health disorders, i.e. depression, anxiety and alcohol abuse.

1. To screen or not to screen ?
Screening for psychosocial problems in occupational health
Philippe Persoons, MD PhD
Psychiatrist
UPC KU Leuven
External HR – European Commission

2. Overview
• Screening for psychosocial problems in occupational
health
– Why should we screen ?
– What should we screen ?
– How should we screen ?

3. WHY SHOULD WE SCREEN ?

4. Popular press: More than a third of EU population suffer
mental health problems
• Europeans are plagued by mental and neurological illnesses, with almost 165 million
people or 38% of the population suffering each year from a brain disorder such as
depression, anxiety, insomnia or dementia, according to a large new study.
• "Mental disorders have become Europe's largest health challenge of the 21st century,"
• Mental illnesses are a major cause of death, disability, and economic burden
worldwide and the WHO predicts that by 2020, depression will be the second leading
contributor to the global burden of disease across all ages.
• "Those few receiving treatment do so with considerable delays of an average of several
years and rarely with the appropriate, state-of-the-art therapies."
• …in Europe, that grim future had arrived early, with diseases of the brain already
the single largest contributor to the EU's burden of ill health.
(2011)

5. Source

6. Wittchen et al. Eur Psychoneurphar 2011

7. Prevalence of mental disorders
• 38% of adult population (2011)
– 1-year prevalence one of a series of mental disorders
(EU-27 + Norway, Iceland, Switzerland)
– 27% of adult population in 2005
• n = 164.8 million affected people
– N = 83 million in 2005
• Problems
– substance use
– Psychoses
– Depression
– Anxiety
– Eating disorders
(systematic review of data and statistics
from community studies in EU countries,
Iceland, Norway and Switzerland – in
2005: 18-65 yrs)
Wittchen et al. Eur Psychoneurphar 2011 and 2005

8. Years lived with disabilities (YLDs)
• Mental disorders = largest contributor to chronic conditions in EU
• Neuropsychiatric disorders 1st cause of YLD in Europe
• 36.1% of those attributable to all causes.
– Depressive disorder 11% of all YLD  leading chronic condition in Europe.
– Alcohol-related disorders 6.4% of all YLD  rank 3rd in Europe
– Anxiety disorders 4% of all YLD  rank 6th in Europe
– Migraines 2.7% of all YLD  rank 11th in Europe
– Schizophrenia 1.8% of all YLD  ranks 15th in Europe
– Bipolar disorder 1.6% of all YLD  ranks 17th in Europe
Source: Global Health Estimates 2014 Summary Tables: YLD by cause, age and sex, by WHO Region, 2000-2012
20.4%

9. Disability-adjusted life-years (DALYs)
• DALY: measure of overall disease burden
• DALY: sum of potential life lost expressed as the number of years lost due
to ill-health, disability or early death = YLD + YLL

10. Disability-adjusted life-years (DALYs)
• DALY: measure of overall disease burden
• DALY: expressed as the number of years lost due to ill-health, disability
or early death
• Leading causes for DALYs: 1st Cardiovascular disease 26.6%
2nd Malignant neoplasms 15.4%
3rd Neuropsychiatric disorders 15.2%
• Two of the top 10 diseases responsible for DALYs are mental health
disorders:
– Unipolar depressive disorders are the 3rd cause of DALYs (3.8% of all DALYs);
– Alcohol use disorders are the 6th leading cause of DALYs (2.9% of all DALYs);
Source: Global Health Estimates 2014 Summary

11. Direct mortality of mental illness: SUICIDE
• Worldwide ± 804,000 suicide deaths in 2012
global suicide rate of 11.4 per 100,000 population
• Europe
– High-income countries: 3.5 males commit suicide for every female.
– Low & middle-income countries: 4.1 males commit suicide for every female.
• Suicide:
– 17.6% of all deaths in young adults (15-29yrs) in high-income countries
– 2nd leading cause of death in Europe (15-29yrs; road traffic accidents = 1st)
• Mental illness
– 90% of suicides can be attributed to mental illness in high-income countries
– 22% of suicides linked to alcohol use
• Needed action: integration of services  prevention through screening
(WHO report “Preventing Suicide: A Global Imperative”, 2014)

12. WHAT SHOULD WE SCREEN FOR ?

13. Deduced from prevalences & impact
• Mood disorders – Depressive disorders
– Work related: burn-out: precursor of or co-morbidity with depression
• See further
– Co-existence with pain/somatic symptoms
• Anxiety disorders
– Panic disorder
– Generalized Anxiety disorder
– Other Anxiety disorders
– High co-morbidity with depressive disorder and other disorders
• Substance abuse – more specific: alcohol related disorders

14. Depressive disorder
Depressive disorder and physical symptoms

15. Depressive disorders
NICE-richtlijnen, 2004 www.nice.org.uk
Depressive patients suffer from
Cognitive symptoms
Anxiety symtoms
Emotional Symptoms
Guilt
Depressed mood
Suicidality
Physical Symptoms
Loss of energy
Fatigue
Sleep disorder
Loss of appetite
Loss of libido
Painful physical symptoms

16. 12-4-2017 16
• Classical DSM-5 Symptoms (see further PHQ-9)
• Physical symptoms = main reason for consultation in depression
– Fatigue, sleeping disorders, (chronic) pain, GI symptoms, general malaise,
chest pain pijn
– Medically Unexplained Symptoms frequent co-morbidity in mood disorder
• Up to 33% medically unexplained symptoms (MUS) in depressive disorder
– “Masked” depressive disorder
• Up to 69% of patients report only physical symptoms
• Vital symptoms of major depressive disorder (MDD)
– Eg. Pain + MDD  general population 17%
 pain clinic 64%
Depression: pitfalls in the recognition

17. 1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335
2. Kirmayer LJ, et al. Am J Psychiatry. 1993;150:734-741
Overlap somatic syndrome & depression
Somatic symptoms are often the main issue in
depressed patients
Kirmayer et al2:
76% patients at the GP with the
diagnosis MDD or anxiety disorder:
A “somatic pattern”
Simon et al1: 69% depressive patients
only physical symptoms as the
reason for the consultation (n = 1146)andere
symptomen
31%
enkel fysieke
symptomen
69%

18. 13-4-2017 18
Correct diagnosis of Depression
• Case-finding  focus on 
– Red flags:  (multiple) unexplained symptoms
 “difficult” consultations (± 1/6)
 increased medical consumption
 chronic physical disorders
Cardiac – Cancer – CNS disorders
– Suspected case:
• 1 core question (depression): sensitivity: 85-90%
• 2 core questions (+ anhedonia): sensitivity: 95%

19. Anxiety disorders
Anxiety disorders & physical symptoms

20. • Anxiety is very
prevalent in the EU
• 61.6 million persons
are affected by these
disorders
• Very prevalent co-
morbidity
Wittchen et al. Eur Psychoneurphar 2011

21. Anxiety disorders - importance
Highly prevalent ‐ lifetime prevalence ≥ depression
– often in young people
Impact: High personal/social cost
e.g. panic disorder and OCS: more DALYs than diabetes or HIV
Co-morbidity:
• → Secondary depression / substance abuse (alcohol/other)
• ↑ suicide attempts
• ↑ Cardiovascular morbidity / mortality
• Long lag time between start disorder and first consultation
• Often unrecognized and thus untreated
– 70% no clear treatment
– 10% psychiatrist of psychologist

22. Alcohol Abuse

23. Why screen for
Alcohol abuse
• Burden of alcohol
abuse
Wittchen et al. Eur Psychoneurphar 2011

24. HOW SHOULD WE SCREEN ?
Proposed instrument: PHQ modules

25. Depressive disorder: PHQ-9
Categorical Diagnosis
Major depressive disorder
• Item 1 or 2 > ½ days
• + 4 other > ½ days
• Except item 9 (several
days)
Dimensional score
Severity score
0-4: none
5-9: mild
10-14: moderate
15-19: moderately severe
20-27: severe

26. PHQ-9 for Depression validated
in Occupational health setting
• A receiver operator characteristics (ROC) analysis was computed for PHQ-
9 score versus the MINI. Results The optimal cut-off value of the PHQ-9
was 10. This resulted in a sensitivity of 86.1 % [95 % CI (69.7-94.8)] and a
specificity of 78.4 % [95 % CI (70.2-84.8)]. Based on the ROC analysis, the
area under the curve for the PHQ-9 was 0.90 [SE = 0.02; 95 % CI (0.85-
0.94)].
• Conclusion The PHQ-9 shows good sensitivity and specificity as a
screener for MDD within a population of employees on sickness leave.

27. • RESULTS: 250 patients screened for depression
Screening: increased frequency of Dx of current depression (30 versus 4%; P < 0.05).
Screening: associated with similar rates of absenteeism but lower number of days on
restricted duties (97 versus 159 days; P < 0.001). After adjusting for age, sex, history
of and treatment for depression, screening was associated with lower odds of being
on work restrictions [odds ratio (OR) 0.55; 95% confidence interval (CI) 0.38-0.78] or
permanent restrictions (OR 0.35; 95% CI 0.23-0.52).
• CONCLUSIONS:
Depression was common in this OH practice. Screening for depression, with
appropriate recognition and referral, may reduce time for employed
patients on restricted duties and permanent restrictions.

28. PHQ-15
• Somatic Symptoms
• Very common in
psychiatric disorders
• Often main reason for
consultation
(medicalisation)
• Very prevalent
– Depressive disorder
– Anxiety Disorder
• Cutpoints
– 5 Low
– 10 Medium
– 15 High

29. GAD-7
• Anxiety Severity
• Cutpoints
• 5 mild
• 10 moderate
• 15 severe
• Designed as a screening and
severity measure for
Generalized Anxiety Disorder
Also for 3 other anxiety
disorders (moderately):
– panic disorder
– social anxiety disorder
– post-traumatic stress disorder.
recommended cutpoint for further
evaluation is a score of 10 or greater.

30. PHQ-alcohol
• Very important given the high prevalence of alcohol related problems
– If any of 10a – 10e are yes = red flag
• CAGE questionnaire (Not PHQ - 2 or more = red flag Alcohol dependence):
– Have you ever felt you needed to Cut down on your drinking?
– Have people Annoyed you by criticizing your drinking?
– Have you ever felt Guilty about drinking?
– Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady
your nerves or to get rid of a hangover?

31. Panic attacks in PHQ-SADS
• NB. In the full PHQ all symptoms of a panic attack are also mentioned
• The PHQ-SADS might be most useful to use: PHQ-9, GAD-7, PHQ-15 +
panic measure from original PHQ – the alcohol module should be added

32. Conclusion
• Mental health disorders are highly prevalent in Europe
– Depressive/Mood disorders
– Anxiety disorders
– Substance abuse (alcohol)
• MHD have a severe impact on occupational health
• Aimed screening makes sense in an occupational health setting
• Modules of the Patient Health Questionnaire might provide a solution
– Short
– Self-report
– Well-validated
– Several languages
http://www.phqscreeners.com/select-screener

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