Specific work-related stress

People in high occupational levels are exposed to specific psychosocial risk factors, which differ from those affecting other employees at lower occupational levels (Tennant, Reference Tennant2001). Workers in high occupational levels are expected to take on responsibilities in the management and supervision of activities of subordinate employees, to achieve customer satisfaction, to make decisions under pressure of time, and are also exposed to high levels of psychological and emotional pressure. The workload can also be very heavy in terms of hours of work. Pressure for high performance and high levels of competition among colleagues can often add to the mix. Such demanding work conditions might well be expected to represent excessive and overwhelming demands for a person with depression since the disorder is characterized by poor concentration, loss of interest and energy among other features. These conditions can represent a source of environmental stress which may easily lead to increased feelings of failure and inadequacy if the person is unable to meet the demands of work. Staying at home may also be counterproductive because a backlog of work awaits the person returning to work and this may well engender a vicious circle of further feelings of failure, hopelessness and helplessness. The return to work may therefore be more difficult for workers in high occupational levels who need to recover on a broader range of functions before returning to work.

Social support

The heavy workload and the autonomy expected in high occupational levels may also lead to social isolation in the working environment and lack of support from peers. Peers may be more competitive than supportive. Subordinates may try to take advantage while superiors may be unhelpful. No working position is completely independent from other people and those at upper intermediate levels are frequently dealing with pressures from both above and below. High occupational positions require that the worker can be independent in taking on burdensome tasks and responsibilities dealing with others and they therefore frequently come under pressure from different sources with little or no support provided. It is well known that the absence of a supportive working environment is a significant source of stress at all levels of employment (Bonde, Reference Bonde2008; Theorell et al., Reference Theorell, Hammarstrom, Aronsson, Traskman Bendz, Grape, Hogstedt, Marteinsdottir, Skoog and Hall2015).

Overwork can also limit the time available to spend in activities after work (family, hobbies, friendships), resulting in isolation even outside of the workplace and/or discord in family and friendships. An extensive literature has documented an increased risk of psychological distress in workers who have difficulties balancing work and personal life (Hawksley, Reference Hawksley2007; Couser, Reference Couser2008). Individuals, especially those in high occupational levels, can suffer lack of social support, both in the workplace and outside, and may have higher levels of family discord. These factors may exert a critical interference in the recovery process in those in high occupational levels.

Personality traits

Individuals in high occupational levels are often characterized by traits of self-confidence, vigour, motivation, aptitude for leadership and success, commitment, persistence and high sense of responsibility (e.g. Judge et al., Reference Judge, Bono, Ilies and Gerhardt2002). They usually make efforts to prevent or deny failures and feelings of weakness; they identify with the success and the results they achieve. They need to earn appreciation from others and maintain a self-image of strength, self-sufficiency and autonomy. They may not tolerate feelings of uselessness, weakness, needing help from others and negative self-evaluation.

Depression is characterized by low mood, loss of concentration, decreased energy, and by guilt and feelings of worthlessness, lowered self-esteem and the loss of ability to function as usual (DSM5). These symptoms are possibly more destructive of ability to function in those with high occupational levels. Those with a high sense of responsibility, commitment and dedication can also develop an increased sense of guilt and shame towards colleagues and subordinates whenever they fail to meet expectations.

Self-blame

The stigma attached to mental illness is well known. Those with depression feel guilty and inclined to blame themselves. Since those in high occupational levels need to project themselves as capable and strong, it is possible that the stigma of depression in society and self-stigma are more damaging for them.

The fear of being negatively labelled, being deemed unable to perform at previous capacity due to being ‘mentally ill’, often magnified by the person's own stigmatizing conception of the depressive illness, may push the individual to make great but often unsuccessful efforts to hide his/her condition, both at work and outside the workplace. This may increase the individual's exposure to professional and interpersonal stressors. As well as hiding the illness from others, it may also be inwardly denied by the individual who may not recognize they have a mental problem ascribing his/her present condition to temporary external factors instead. They tend to believe the current distress should be solved with personal effort and dedication. Negative cognition and negative emotional reactions, as well as low self-esteem and withdrawal from social life are part of depression and tend to feed on each other. These might well contribute to the high rate of suicide, which has been reported in high occupational levels (Sudak et al., Reference Sudak, Maxim and Carpenter2008; Chan et al., Reference Chan, Chiu, Lam, Wong and Conwell2014; Wada et al., Reference Wada, Eguchi, Prieto-Merino and Smith2016). According to a systematic review of the literature, although suicidal risk is higher in low occupational levels, middle–high skilled occupations have a substantially higher risk of suicide compared with the entire working-age population (rate ratio = 0.9–1.2) (Milner et al., Reference Milner, Spittal, Pirkis and LaMontagne2013). The individual may reduce participation in social life, consider themselves incapable of doing their job, to be undeserving of love from family members and friends. There is a risk of delay or even failure to request help, leading to prolonged illness duration, chronic course and poor compliance with treatment (Rusch et al., Reference Rusch, Angermeyer and Corrigan2005).

Compliance with treatment

Occupational factors have been reported as barriers to treatment adherence in some medical conditions (Adisa et al., Reference Adisa, Alutundu and Fakeye2009; Coenen et al., Reference Coenen, Willenberg, Parry, Shi, Romero, Blackwood, Maher, Healy, Dunstan and Straker2016), but this has not hitherto been studied, to our knowledge, in psychiatric disorders. Many personal barriers exist for depressed individuals in being compliant with treatments (Frank, Reference Frank1997). A number of factors contribute to poor compliance. Especially in the early stages of the illness, the individual may feel the need to cope alone, or may have poor trust in medical treatment and consequently may come late to clinical attention, sometimes after trying alternative treatment routes. They may be reluctant to take medication, to attend regularly for treatment or accept a proposal of hospitalization. They may complain of lack of time due to work obligations or the impossibility of taking time off work. Compliance may be only partial with drugs taken erratically or at lower dosages, medical appointments may be missed. Despite the need for long-term treatment, it is not uncommon for these individuals to discontinue treatment prematurely rather than wait for the full treatment benefits. Because of personality factors, work demands and life habits, individuals, especially those in high occupational levels, are often reluctant to accept treatment advice and the need for change. Work and performance are often priorities for many individuals in high occupational positions, with social relationships, family and personal care (including medical appointments) experienced as ‘less important’ or secondary to work commitments.

Transient side effects of drugs

Side effects can impact on treatment compliance even when they are minor (Montejo, Reference Montejo2009). Minor side effects may affect medication adherence but also the objective evaluation of the benefit of medication.

Jobs that are demanding from a cognitive point of view require optimal levels of psychophysical functioning (physical and mental energy, vigilance, prolonged attention, concentration) and these functions are reduced by depression. Effective treatments for depression can restore these functions (Keefe et al., Reference Keefe, McClintock, Roth, Doraiswamy, Tiger and Madhoo2014) although some can impact negatively, especially at the start of treatment, on cognitive functions, causing, for example, drowsiness (e.g. mirtazapine, amitriptyline), agitation or irritability [e.g. bupropion, Selective serotonine reuptake inhibitors (SSRIs) and some Serotonin-norepinephrine reuptake inhibitors (SNRIs)]. Cognition, which is already impaired as part of depression, may be further impaired by some antidepressants. Because of the anticholinergic and histaminergic effects common to many tricyclic antidepressants, reduced cognitive function may be felt early in treatment, before the therapeutic effects which comes later. Serotoninergic agents, because of their anti-anxiety properties, can impair the evaluation of critical aspects of situations and reduce motivation levels (McCabe et al., Reference McCabe, Mishor, Cowen and Harmer2010; Marutani et al., Reference Marutani, Yahata, Ikeda, Ito, Yamamoto, Matsuura, Matsushima, Okubo, Suzuki and Matsuda2011; Shannonhouse et al., Reference Shannonhouse, DuBois, Fincher, Vela, Henry, Wellman, Frye and Morgan2016). It has been reported that the detachment effect induced by many medications for depression such as serotoninergic inhibitors may be troublesome for some individuals (Harmer, Reference Harmer2008; Serretti et al., Reference Serretti, Calati, Goracci, Di Simplicio, Castrogiovanni and De Ronchi2010). The adverse cognitive effects can be particularly disturbing for individuals who need high cognitive performance at work. Despite a timely recovery from affective and somatic symptoms, the persistence of negative effects on the cognitive domain or the lack of improvement in cognitive impairments related to major depression (Papakostas and Culpepper, Reference Papakostas and Culpepper2015) may interfere with compliance with treatment leading the individual to discontinue the medication. Newer medications for depression are promising (Al-Sukhni et al., Reference Al-Sukhni, Maruschak and McIntyre2015; McIntyre et al., Reference McIntyre, Xiao, Syeda, Vinberg, Carvalho, Mansur, Maruschak and Cha2015; Stahl, Reference Stahl2015). Anhedonia, decreased motivation and other core features of depression may persist despite an overall apparent response to treatment for depression (Yee et al., Reference Yee, Chin, Hashim, Harbajan Singh, Loh, Sulaiman and Ng2015) and it has been suggested that some drugs for depression offer a better choice (Shelton et al., Reference Shelton, Tollefson, Tohen, Stahl, Gannon, Jacobs, Buras, Bymaster, Zhang, Spencer, Feldman and Meltzer2001; Argyropoulos and Nutt, Reference Argyropoulos and Nutt2013). Potential side effects on body weight and sexual functioning also need to be taken into account (Serretti and Chiesa, Reference Serretti and Chiesa2009; Serretti and Mandelli, Reference Serretti and Mandelli2010).

However, many patients are often just reluctant to take medications for depression for various reasons (fear of cognitive effects, unpleasant side effects, fear of addiction, etc.). Psychotropic drugs are ascribed a moral significance and often just contemplating their use can affect how people see themselves, most commonly by suggesting personal weakness. Some patients may perceive the antidepressant medication as a barely legitimate – pharmaceutical, rather than as an established and effective treatment for a medical condition (Malpass et al., Reference Malpass, Shaw, Sharp, Walter, Feder, Ridd and Kessler2009; Ridge et al., Reference Ridge, Kokanovic, Broom, Kirkpatrick, Anderson and Tanner2015).

Residual symptoms and subjective evaluation of clinical improvement

A patient's potentially altered perception of symptomatic improvement during treatment and of residual symptoms need to be taken into account. Despite response of the major depressive symptomatology, some symptoms may persist, sometimes for a prolonged period (Fava et al., Reference Fava, Fabbri and Sonino2002). For some individuals, the improvement in some symptoms such as mood, ability to engage in pleasurable activities and feelings of hope represents a significant improvement, despite the persistence of symptoms, for example, difficulties with sleep, attention and decision making (Kennedy and Foy, Reference Kennedy and Foy2005; Fava, Reference Fava2006). For other individuals, and especially those with high psychological demands at work, the same persisting symptoms (poor sleep, difficulty in sustaining attention and concentration and decision making) represent significant limitations. These individuals may continue to feel discouraged and dejected and complain of lack of benefit from treatments. Careful evaluation is needed to manage residual symptoms.