WHO Guideline Mental Health at Work
WHO Guideline Mental Health at Work
WHO Guideline Mental Health at Work
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Contents
Foreword .................................................................................................................. v
Acknowledgements ............................................................................................... vi
Abbreviations ............................................................................................................. vii
Introduction ............................................................................................................. 1
Background ........................................................................................................................ 2
Recommendations ................................................................................................... 9
Recommendations for organizational interventions ...................................... 11
iii
Dissemination and update of the guidelines ............................................................ 79
References ......................................................................................................................................... 82
Glossary ................................................................................................................................................ 91
https://apps.who.int/iris/handle/10665/363102
iv
Foreword
Working people, like all people, deserve an inherent right to the highest attainable standard of mental health at work, regardless
of their type of employment. And people living with mental health conditions have a right to access, participate and thrive in
work. Governments and employers have a responsibility to uphold that right by providing work that simultaneously prevents
workers from experiencing excessive stress and mental health risks; protects and promotes workers’ mental health and well-
being; and supports people to fully and effectively participate in the workforce, free from stigma, discrimination or abuse.
Yet the world of work is changing. Across the globe, technology, globalization, demographic shifts, emergencies and climate
change are reshaping how and where we work. The COVID-19 pandemic has disrupted labour markets and accelerated the pace
of change – especially in remote work, e-commerce and automation. Some jobs are being lost; some are being created; almost
all are changing. For many, these changes are creating new pressures or exacerbating existing stresses around work that have the
potential to undermine workers’ mental health.
Addressing mental health at work effectively will help prepare for the future of work and a changing world.
Managing mental health at work can appear challenging. But it should not be seen as onerous. Rather, it offers an opportunity
for growth and sustainable development. Safe, healthy and inclusive workplaces not only enhance mental and physical health
but likely also reduce absenteeism, improve work performance and productivity, boost staff morale and motivation, and
minimize conflict between colleagues. When people have good mental health, they are better able to cope with the stresses of
life, realize their own abilities, learn and work well and contribute actively to their communities. And when people have good
working conditions, their mental health is protected.
These guidelines provide evidence-based recommendations on interventions that can be implemented to better prevent,
protect and promote, and support the mental health of workers. It highlights the importance of organizational interventions,
manager and worker training and interventions for individuals. Particular attention is given to workers living with mental health
conditions and the interventions that can be used to support them to gain employment, return to work following an absence or
to be supported by reasonable accommodations at work.
The World Health Organization (WHO) is committed to supporting Member States to promote and protect the mental health
of workers. Indeed, the Comprehensive mental health action plan 2013–2030 emphasizes the need for countries to promote
safe, supportive and decent working conditions for all. The WHO Global Strategy on Health, Environment and Climate Change
identifies workplaces as an essential setting for the prevention of a range of modifiable risks, particularly for non-communicable
diseases. These guidelines mark a milestone in leveraging workplaces as a platform for action, providing a framework for the
evidence-based action required to ensure effective prevention, promotion and support for mental health at work.
In all countries and across sectors, the wealth of enterprises and societies depends on the mental health of workers.
We encourage governments, enterprises and all stakeholders in the world of work to use and implement these guidelines as an
effective tool for securing safe, healthy and inclusive workplaces that promote and protect mental health.
Soumya Swaminathan
WHO Chief Scientist
v
Acknowledgements
The WHO guidelines on mental health at work was prepared WHO acknowledges the technical contribution from colleagues
by the World Health Organization (WHO) Department of of the International Labour Organization (ILO) and particularly
Mental Health and Substance Use and the Department Manal Azzi of ILO headquarters, Geneva, Switzerland.
of Health, Environment and Climate Change under the
leadership of Dévora Kestel and Maria Neira, respectively. Guideline Development Group (GDG): WHO would like
to thank the members of the GDG for their commitment,
Responsible Technical Officer: Aiysha Malik, Mental Health enthusiasm and expertise. The GDG members were: Jose Luis
Unit, Department of Mental Health and Substance Use, WHO. Ayuso-Mateos (Autonomous University of Madrid, Spain),
Mirai Chatterjee (Self-Employed Women’s Association,
WHO Steering Group members: Faten Ben Abdelaziz India), Capucine de Fouchier (Specialist in mental health
(Department of Health Promotion), Alex Butchart (Department and psychosocial support, Switzerland), Samuel Harvey
of Social Determinants of Health), Alarcos Cieza (Department of (Black Dog institute, Australia), Hiroto Ito (Tohoku Medical
Noncommunicable Diseases), Ivan Ivanov (Department of Health, and Pharmaceutical University, Japan), Norito Kawakami
Environment and Climate Change), Catherine Kane (Health (The University of Tokyo, Japan), Nour Kik (National Mental
Workforce Department), Hyo-Jeong Kim (Department of Health Health Programme, Ministry of Public Health, Lebanon), Spo
Emergency Interventions), Aiysha Malik (Department of Mental Kgalamono (National Institute for Occupational Health, South
Health and Substance Use) and Juana Willumsen (Department of Africa), Margaret Kitt (National Institute for Occupational
Health Promotion). The Steering Group was chaired by Mark van Safety and Health, USA), Anthony D. LaMontagne (Deakin
Ommeren (Department of Mental Health and Substance Use). University, Australia), Sapna Mahajan (Genomics Canada,
Canada), Kazem Malakouti (Iran University of Medical
The authors would like to express our gratitude to: Rebekah Sciences, Iran), Karina Nielsen (The University of Sheffield,
Thomas-Boscoe from the WHO Guideline Review Committee United Kingdom), Pratap Sharan (All India Institute of Medical
Secretariat for her technical support throughout the guidelines Sciences, India), Katherine Sorsdahl (University of Cape Town,
development process; and Evelyn Finger and Anne Sikanda, South Africa) and Graham Thornicroft (Kings College London,
from the Department of Mental Health Substance Use who United Kingdom).
provided crucial administrative support. WHO colleagues who
provided inputs at various stages of development were: Florence Guideline methodologist: WHO extends tremendous
Baingana (WHO Regional Office for Africa); Renato Oliveira e gratitude to: Corrado Barbui, University of Verona, Italy.
Souza, Claudina Cayetano (Pan American Health Organization);
Nazneen Anwar (WHO Country Office, Maldives); Khalid Saeed External Review Group (ERG): WHO is grateful for the
(WHO Regional Office for the Eastern Mediterranean); Natalie contributions of the following individuals who provided
Drew Bold, Kenneth Carswell, Alexandra Fleischmann (WHO peer-review of the draft guidelines: Atalay Alem (Addis
Department of Mental Health and Substance Use); and Martin Ababa University, Ethiopia), Fabrice Althaus (International
Vandendyck (WHO Regional Office for the Western Pacific). Committee of the Red Cross, Switzerland), Lamia Bouzgarrou
Sincere appreciation is extended to the following consultants (University of Monastir, Tunisia), Marc Corbière (University
who supported various technical aspects throughout the of Quebec in Montreal, Canada), Premilla D’Cruz (Indian
development: Aemal Akhtar (Denmark), Gergö Baranyi (United Institute of Management Ahmedabad, India), Carolyn
Kingdom of Great Britain and Northern Ireland), Chiara Gastaldon Dewa (University of California, Davis, USA), Frida Marina
(Italy), Sherianne Kramer (South Africa), Georgia Michlig (United Fischer (University of São Paulo, Brazil), Roshan Galvaan
States of America), Susan Norris (USA), Davide Papola (Italy). (University of Cape Town, South Africa), Nick Glozier
vi
(University of Sydney, Australia), Neil Greenberg (King’s its thanks to the World Health Professions Alliance for
College London, United Kingdom), Birgit Greiner (University supporting the identification of its members, in particular
College Cork, Ireland), Nadine Harker (South African Medical Helen von Dadelszen and Howard Catton.
Research Council, South Africa), Nina Hedegaard Nielsen
(Independent psychosocial risks expert, Denmark), Ehimare Evidence review, synthesis and supporting evidence
Iden (Occupational Health and Safety Managers, Nigeria), teams: Thanks are extended for the large efforts of the
Inah Kim (Hanyang University College of Medicine, Republic evidence review and synthesis teams: Hideaki Arima, Yumi
of Korea), George Leveridge (Jamaica Constabulary Force, Asai, Yui Hidaka, Mako Iida, Kotaro Imamura, Mai Iwanaga,
Jamaica), Shuang Li (National Institute for Occupational Yuka Kobayashi, Yu Komase, Natsu Sasaki (The University
Health and Poison Control, China), Elizabeth Linos of Tokyo, Japan), Reiko Inoue, Akizumi Tsutsumi (Kitasato
(University of California, Berkeley, USA), Ed Mantler (Mental University School of Medicine, Japan), Hisashi Eguchi,
Health Commission of Canada), Angela Martin (University Ayako Hino, Akiomi Inoue (University of Occupational and
of Tasmania, Australia), Christina Maslach (University of Environmental Health, Japan), Yasumasa Otsuka (University
California- Berkeley, USA), Álvaro Roberto Crespo Merlo of Tsukuba, Japan), Asuka Sakuraya (Tokyo Women’s Medical
(Federal University of Rio Grande do Sul, Brazil), María Elisa University, Japan), Akihito Shimazu (Keio University, Japan),
Ansoleaga Moreno (Universidad Diego Portales, Chile), Kanami Tsuno (Kanagawa University of Human Services,
Reiner Rugulies (National Research Centre for the Working Japan); Taylor Braund, Richard Bryant, Jasmine Choi-
Environment, Denmark), Godfrey Zari Rukundo (Mbara Christou, Mark Deady, Nadine Garland, Aimee Gayed, Sam
University of Science and Technology, Uganda), Kamalesh Haffar, Sophia Mobbs, Katherine Petrie, Jessica Strudwick
Sarkar (National Institute of Occupational Health, India), (University of New South Wales, Australia); Arpana Amarnath,
Vandad Sharifi (Tehran University of Medical Sciences, Pim Cuijpers, Eirini Karyotaki, Clara Miguel (Vrije University,
Iran), João Silvestre da Silva-Junior (São Camilo University WHO Collaborating Centre for Research and Dissemination
Center, Brazil), JianLi Wang (Dalhousie University, Canada), of Psychological Interventions, Netherlands); Liam O’Mara,
Mohammad Taghi Yasamy (Shahid Beheshti University of Kathleen Pike, Adam Rosenfeld, Hikari Shumsky (Columbia
Medical Sciences, Iran) and Dieter Zapf (Goethe University University, WHO Collaborating Centre for Capacity Building
Frankfurt, Germany). Representatives of their respective and Training in Global Mental Health, USA). Members of the
organizations and key stakeholders were: Melissa Pitotti supporting evidence teams were: Rachel Lewis, Fehmidah
(Core Humanitarian Standard [CHS] Alliance); Sarah Copsey, Munir, Alice Sinclair, Jo Yarker (Affinity Health at Work, United
Julia Flintrop (European Agency for Safety and Health at Kingdom); Promit Ananyo Chakraborty, Vanessa Evans,
Work [EU-OSHA]); Olga Kalina, Guadalupe Morales Cano Raymond Lam, Jill Murphy (University of British Columbia,
(European Network of (Ex)Users and Survivors of Psychiatry Canada) and Andrew Greenshaw, Jasmin Noble (University of
[ENUSP]); Claudia Sartor (Global Mental Health Peer Network Alberta, Canada). Thanks are also extended to Christy Braham
[GMHPN]); Madeline A. Naegle (International Council of (Women in Informal Employment: Globalizing and Organizing,
Nurses [ICN]); Pierre Vincensini (International Organisation [WIEGO]) for support during the development of supporting
of Employers [IOE]); Rory O’Neill (International Trade Union evidence for the informal economy.
Confederation [ITUC]); Victor Ugo (Mentally Aware Nigeria
Initiative [MANI]); Miguel R. Jorge (World Medical Association Financial support: WHO gratefully acknowledges the
[WMA]); and Rose Boucaut, Salam Alexis Gomez, Jepkemoi financial support provided by the Wellcome Trust for the
Joanne Kibet, Norma Elisa Gálvez Olvera, Claudia Patricia development of the guidelines.
Rojas Silva (World Physiotherapy [WP]). WHO also extends
vii
Abbreviations
CBT cognitive behavioural therapy
UN United Nations
viii
Executive summary
ix
Guidelines on mental health at work
For a large proportion of the global population, mental health health conditions (selective), or to workers experiencing
and work are integrally intertwined. Mental health is more emotional distress (indicated) – or to workers experiencing
than the absence of mental health conditions. Rather, mental mental health conditions. Through the provision of these
health is a state of mental well-being that enables people new WHO recommendations, it is anticipated that the
to cope with the stresses of life, to realize their abilities, guidelines will facilitate national and workplace-level actions
to learn well and work well, and to contribute to their in the areas of policy development, service planning and
communities. Mental health conditions occur irrespective delivery in the domains of mental and occupational health.
of whether work has causally contributed to them. Poor The guidelines seek to improve the implementation of
mental health has a negative effect on a person’s cognitive, evidence-based interventions for mental health at work.
behavioural, emotional, social and relational well-being and
functioning, their physical health, and their personal identity The guidelines were developed in accordance with the
and well-being as related to work. A person’s capacity to WHO handbook for guideline development and meet
participate in work can be consequently impaired through international standards for evidence-based guidelines. In
a reduction in productivity and performance, reduction in collaboration with the Guideline Development Group (GDG),
the ability to work safely, or difficulty in retaining or gaining the WHO Steering Group developed key questions and rated
work. Presenteeism (or lost productivity, which is where the outcomes in order to identify those which were critical
largest financial costs lie), absenteeism and staff turnover for the development of the guideline. Conflicts of interest
affect both workers and employers and, in turn, the society’s from all individual guideline contributors were declared,
economy. An estimated 15% of working-age adults have a assessed and managed in line with WHO’s Compliance, Risk
mental disorder at any point in time. The size of the public Management and Ethics (CRE) policy.
health problem of mental health conditions is greater than
the volume of investment to address it. This is the case Systematic evidence reviews were used to develop the
despite international conventions calling for the protection of summary of findings tables, according to the Grading
workers’ physical and mental health through national policies of Recommendations, Assessment, Development and
in occupational safety and health. Evaluations (GRADE) approach. The GDG developed
recommendations that considered a range of elements,
In these guidelines, the World Health Organization (WHO) namely: the certainty of the evidence; the balance between
provides evidence-based global public health guidance on desirable and undesirable effects; values and preferences of
organizational interventions, manager and worker training, beneficiaries; resource requirements and cost-effectiveness;
and individual interventions for the promotion of positive health equity, equality and discrimination; feasibility; human
mental health and prevention of mental health conditions, rights; and sociocultural acceptability.
as well as recommendations on returning to work following
absence associated with mental health conditions and
gaining employment for people living with mental health
conditions. The guidelines indicate whether and what
interventions can be delivered to whole workforces – e.g.
within a workplace (universal), to workers at-risk of mental
x
Executive Summary
4 5
Manager training for health,
Manager training for mental health humanitarian and emergency workers
Training managers to support their workers’ mental health Training managers to support the mental health of health,
should be delivered to improve managers’ knowledge, humanitarian and emergency workers should be delivered
attitudes and behaviours for mental health and to improve to improve managers’ knowledge, attitudes and behaviours
workers’ help-seeking behaviours. for mental health.
Training workers in mental health literacy and awareness may be Training health, humanitarian and emergency workers in
delivered to improve trainees’ mental health-related knowledge mental health literacy and awareness may be delivered to
and attitudes at work, including stigmatizing attitudes. improve trainees’ mental health-related knowledge and
attitudes at work, including stigmatizing attitudes.
Conditional recommendation, very low-certainty of evidence
xi
Guidelines on mental health at work
For people on absence associated with mental health conditions, (a) work-directed care plus evidence-based mental health clinical
care or (b) evidence-based mental health clinical care alone should be considered for the reduction of mental health symptoms and
reduction in days of absence.
xii
Executive Summary
Recovery-oriented strategies enhancing vocational and economic inclusion – such as (augmented) supported employment – should be
made available for people with severe mental health conditions, including psychosocial disabilities, to obtain and maintain employment.
Screening programmes
As it is unclear whether the potential benefits of screening programmes outweigh potential harms, the GDG did not make a
recommendation for or against screening programmes during employment.
xiii
Guidelines on mental health at work
xiv
Introduction
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Introduction
1
Guidelines on mental health at work
Background
For a large proportion of the global population, mental Work is a social determinant of mental health. Meaningful
health and work are integrally intertwined. Mental health work is protective for mental health; it contributes to a
is more than the absence of mental health conditions. person’s sense of accomplishment, confidence and their
Rather, mental health is a state of mental well-being that earnings, and contributes to recovery and inclusion for people
enables people to cope with the stresses of life, to realize living with psychosocial disabilities. However, harmful or poor
their abilities, to learn well and work well, and to contribute working conditions, hazardous work environments and work
to their communities. Mental health conditions occur organization, poor working relationships or unemployment –
irrespective of whether work has causally contributed and the prolonged exposure to these, rather than to positive
to them. Poor mental health has a negative effect on a working conditions – can significantly contribute to worsening
person’s cognitive, behavioural, emotional, social and mental health or exacerbate existing mental health conditions.
relational well-being and functioning, their physical health, There is reasonable consensus on the influence of certain risk
and their personal identity and well-being as related to factors, also called psychosocial risks (3), on mental health at
work. A person’s capacity to participate in work can be work. Box 1 lists some of these risk factors, but there are many
consequently impaired through a reduction in productivity additional risks which may be specific to certain countries
and performance, reduction in the ability to work safely, or occupations, and emerging risks are seen as the culture
or difficulty in retaining or gaining work. Presenteeism (or of work changes over time or as the result of major societal
lost productivity, which is where the largest financial costs events (such a global pandemic or conflict).
lie), absenteeism and staff turnover affect both workers and
employers and, in turn, the society’s economy. Society-level events influence mental health and work.
Economic recessions or emergencies elicit risks such as
An estimated 15% of working-age adults have a mental job loss, financial instability, organizational restructuring,
disorder at any point in time . Globally, as of 2019, 301
1
reduced employment opportunities, increased
million people were living with anxiety, 280 million people1
unemployment, and increased work without full-time or
were living with depression, 64 million people were
1
formal contracts (4). Work can be a microcosm for amplifying
living with schizophrenia or bipolar disorder, and 703 1
wider issues which negatively affect mental health, including
000 people died by suicide each year (1). Many of these discrimination and inequality based on sociodemographic
individuals were of working-age. The most prevalent mental factors and their intersectionality, such as age, caste, class,
health conditions (i.e. common mental disorders such as disability, gender identity, migrant status, race/ethnicity,
depression and anxiety), are estimated to cost the global religious beliefs and sexual orientation. While addressing
economy US$ 1 trillion each year, with the cost driven bullying in school-aged persons draws attention, the same
predominantly by lost productivity (2). People living with cannot be said for the volume of abusive conduct (whether
severe mental health conditions – including psychosocial by third parties or between colleagues) experienced by adults
disabilities (such as schizophrenia and bipolar disorder) –
2
at work (5, 6). Most critically, the stigma surrounding mental
are, for reasons such as stigma and discrimination, largely health conditions remains a dominant barrier to disclosure at
excluded from work despite the fact that participation in work (7), to the implementation of support at work for people
economic activities is important for recovery. living with mental health conditions or, indeed, to the uptake
of available support for workers.
1
Global Burden of Disease (GBD) Results Tool. In: Global Health Data Exchange [website]. Seattle: Institute for Health Metrics and Evaluation; 2019 (http://ghdx.healthdata.org,
accessed 1 November 2021). Note: these are IHME GBD 2019 data and do not necessarily represent ICD-11 categorization.
2
WHO recognizes that many people with lived experience of mental health conditions prefer the term ‘psychosocial disabilities.’ For consistent reading, “mental health
conditions” will primarily be used, as will “mental health conditions including psychosocial disabilities” when required. Psychosocial disabilities are included within the
umbrella definition of “mental health conditions”.
2
Introduction
An estimated two billion workers (over 60% of the global may include some family businesses, or the gig economy3.
worker population) are in the informal economy (8). Changes in the way people work, while benefiting
Compared to the formal sector, informal workers, who are economic development, can also exacerbate work-related
often women or members of marginalized groups, are not stress as workers are increasingly working longer hours.
offered social protections that provide access to health Globally, one third of the workforce is estimated to
care and coupled with low incomes and poor working work more than 48 hours per week, especially in lower-
conditions, risk the likelihood of poor mental health resourced contexts (12). Evolving knowledge on the
(9–11). In turn, workers who may face greater exposure impacts of changes to flexible working and teleworking,
to psychosocial risks, and who may, but not always, be while proving invaluable for some sectors in the context
within the informal economy include agricultural workers, of the COVID-19 pandemic, shows a mixed array of
street vendors, domestic workers, casual labourers and advantages and disadvantages (13).
A gig economy is a free market system in which temporary positions are common and organizations hire independent workers for short-term commitments.
3
3
Guidelines on mental health at work
The size of the public health problem of mental health Well-being is a billion-dollar industry, where interventions
conditions is greater than the volume of investment to related to mental health may go unregulated for their
address it. This is the case despite international conventions quality or evidence base. Although several countries and
calling for the protection of workers’ physical and mental professional societies have guidelines on the topic of
health through national policies in occupational safety and work and mental health, these are specific to the country
health (16). Programmes for work-related mental health population. International standards on workplace mental
promotion and prevention of mental health conditions health have been developed, with a specialist focus on the
are among the least frequently reported promotion and management of psychosocial risks (20).
preventions programmes, by countries (35%) (17).
Persons of working age spend a significant proportion
The promotion of mental well-being and the prevention of of their time working. An estimated 62% of the global
mental health conditions have been recognized as means to population aged 15 years and above are economically
achieving the global priority for the reduction of premature active (21). Work presents an opportunity to promote good
mortality from noncommunicable diseases (NCDs) by mental health and to prevent and support people living with
one third (United Nations Sustainable Development Goal, mental health conditions (22). To date, global evidence-
target 3.4). The WHO Comprehensive Mental Health Action based guidelines for the promotion, prevention and support
Plan, 2013–2030 (18)sets a global objective for promotion of mental health related to work are lacking; the above
and prevention and for the provision of comprehensive, rationale highlights the need for guidelines now.
integrated and responsive services in community-based
settings (including workplaces). The WHO global strategy
on health, environment and climate change (19) identifies
workplaces as essential settings for the prevention of a
range of modifiable risks, particularly for NCDs. Mental
disorders are recognized in the ILO list of occupational
diseases which was revised in 2010, under ‘mental and
behavioural disorders’.4 Some countries have extended
their list to cover work-related stress, burnout, depression
and sleep disorders. Some countries also recognize work-
related suicide and include it in their systems of reporting,
notification and compensation.
4
ILO Recommendation No. 194 concerning the List of Occupational Diseases and the Recording and Notification of Occupational Accident and Diseases specifically covers
mental health and behavioural disorders, including “(2.4.1) Post-traumatic stress disorders” and “(2.4.2) Other mental and behavioural disorders not mentioned in the preceding
item where a direct link is established scientifically, or determined by methods appropriate to national conditions and practice, between the exposure to risk factors arising from
work activities and the mental and behavioural disorder(s) contracted by the worker.”
4
Introduction
These guidelines provide recommendations on The guidelines focus on civilian adults, aged 18 years5 and
interventions – defined in further detail below – in the above, who are engaged in paid formal or informal work.
following areas: organizational interventions, manager The guidelines do not address interventions for military
and worker training and individual interventions for the personnel or persons exposed to forced labour, trafficking
promotion of positive mental health and prevention of and modern slavery, or child labour. The populations
mental health conditions. It also includes recommendations considered in this guideline include all workers with or
on returning to work following absence associated with without known mental health conditions, or persons with
mental health conditions and gaining employment for mental health conditions or psychosocial disability seeking
people living with mental health conditions. The guidelines to gain work or return to work.
indicate whether and what interventions can be delivered to
whole workforces (universal) – e.g. within a workplace – to Workers in at-risk occupations are included, that is,
workers at risk of mental health conditions (selective), for occupations with an increased likelihood of exposure to
workers experiencing emotional distress (indicated), or for adverse events (e.g. potentially traumatic events or a series
workers already experiencing mental health conditions. of events which are extremely threatening or horrific) that
increase the likelihood of mental health conditions. These
Through the provision of these recommendations, it is include emergency workers (such as national police or fire
anticipated that these guidelines will facilitate national services), humanitarian workers (international or national),
and workplace-level actions in the areas of policy and health workers (23-25)6. While many occupations
development, service planning and delivery in the domains face adversities that place them at elevated risk for poor
of mental health and occupational health. The guidelines mental health (e.g. due to harmful working conditions),
seek to improve the implementation of evidence-based these specific occupations were selected because of
interventions for mental health at work. frequent requests to WHO for guidelines for these groups.
The recommendations for these selective groups of at-risk
workers may, however, be applicable to other occupations
that are likely to experience disproportionate risks to mental
health at work.
5
According to the Minimum Age Convention, 1973 (No. 138), the general minimum age for work is set at 15 years of age (13 years for light work) and for hazardous work is 18
years (16 years under strict conditions), with the possibility of initially setting the general minimum age at 14 years (12 years for light work) where the economy and educational
facilities are insufficiently developed. The age of 18 years was set as the minimum for this guideline, as younger workers are at a different cognitive, emotional, biological and
social developmental stage and may need additional considerations for their mental health in relation to work.
9
Health workers are “all people primarily engaged in actions with the primary intent of enhancing health” – i.e. health, nursing and care occupations in the International standard
classification of occupations 2008 (ILO ICSO-08). Humanitarian workers are international or national workers who deliver humanitarian assistance. Emergency workers
provide public emergency services e.g. police, fire, emergency medical response, search and rescue (See: Guidelines on decent work in public emergency services. Geneva:
International Labour Organization, 2018 (https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_626551.pdf, accessed
25 May 2022).
5
Guidelines on mental health at work
All interventions in these guidelines are delivered in, or are related to, work. Workers may access some interventions outside
of a work context, but the intervention has been designed to specifically support workers. The interventions within the
scope of the guidelines are as follows:
Organizational interventions
These seek to assess, modify, mitigate or remove work-related psychosocial risks to mental health conditions. They are planned
actions that directly target working conditions with the aim of preventing deterioration in mental health, physical health,
quality of life and work-related outcomes of workers. The interventions can include activities directed at teams. Organizational
interventions are often focused on primary and secondary prevention but may also include tertiary prevention (e.g.
interventions to support the return to work of workers with mental health problems). Organizational interventions focused on
an individual include reasonable accommodations at work (i.e. changes to work to accommodate the person’s needs).
Individual interventions
These include interventions delivered directly to a worker (completed by the worker, with or without guidance). They
include psychosocial interventions (i.e. interventions that use a psychological, behavioural or social approach, or a
combination of these) and leisure-based physical activities such as exercise (not physical labour as a part of work).
Return-to-work programmes
This is designed to support workers in a meaningful return to work and in reducing the symptoms of mental ill-health
following periods of absence. These can be multi-component interventions combining any mix of individual, manager and
organizational interventions.
These guidelines also explored screening programmes delivered during employment (reported under key question 13 [Q13]).
The aim of the screening is to identify symptoms of mental health, followed by referral to an appropriate level of care.
Fig. 1 shows the interventions addressed in these guidelines at different population levels.
6
Introduction
GAINING EMPLOYMENT:
can be delivered to workers
with (severe) mental health
conditions (Q12)
Supporting
RETURN-TO-WORK:
workers with
can be delivered to workers who
emotional
are on absence associated with
distress or
mental health conditions (Q11)
mental health
conditions
INDICATED: can be delivered to
Mental health workers with emotional distress
promotion
Organizational (Q3); Individual (Q10)
Target audiences of these guidelines are primarily individuals or entities responsible for the planning, programming
or implementation of measures for the health, safety and well-being of workers. These can include occupational health
& safety and mental health providers as well as service-delivery managers, employers and workers and their unions,
organizations or cooperatives, human resource services, professional bodies, and employee education, well-being or
training services. The guidelines and its derivative products will also have implications for international and national policy-
makers, planners, programme managers and researchers in mental health, occupational health and labour.
7
Guidelines on mental health at work
Method
How the guidelines were developed
The guidelines were developed in accordance with the WHO handbook for guideline development (26) and meet international
standards for evidence-based guidelines. The steps for the development of WHO guidelines include the following, with
further detail provided in the relevant annexes.
Guideline contributors
Identifying who will be the contributors to the guideline process (Annex 1), and how conflicts of interest will be
managed (Annex 2)
Evidence reviews
Searching for the best available evidence to answer the key questions [and supporting evidence] (Annex 4)
Certainty of evidence
Deciding how confident we are about the certainty of that evidence in answering our key questions (Annex 4)
Formulating recommendations
Developing the recommendation statements based on the above work (Annex 5)
Drafting
Drafting this guideline document, and obtaining more inputs through wide peer review (Annex 6)
Quality check
Review for approval to publish by WHO’s quality assurance body (GRC)
Publication
Publishing the guideline, and actively supporting its dissemination
8
Recommendations
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Recommendations
This section includes the recommendations and key remarks, a summary of the main highlights of the evidence,
the rationale for the recommendations and the evidence-to-decision considerations. For full evidence profiles and
supplementary evidence, see the web Annex. To interpret the certainty of the evidence (i.e. the differences between very
low, low, moderate and high certainty of evidence), see Annex 4. To interpret the strength of the recommendation (i.e. the
meaning of conditional and strong recommendations), see Annex 5.
9
Guidelines on mental health at work
▶ Each recommendation represents one category » access to safe, supportive and decent working
of intervention options. These interventions are conditions for all people who work (including
preferably delivered comprehensively – i.e. by informal workers), with attention to organizational
embedding delivery of organizational interventions, improvements in the workplace; implementation
manager training and training for workers, individual of evidence-based programmes to promote
interventions, return-to-work programmes and gaining mental well-being and prevent mental health
employment programmes in existing or newly- conditions (WHO Comprehensive Mental Health
developed work health policies, rather than delivering Action Plan 2013-2030);
interventions independently of each other without » the cross-cutting principles of the WHO
comprehensive integration. Comprehensive Mental Health Action Plan
2013-2030, namely: universal health coverage
▶ The recommendations for these guidelines rely on (all persons should be able to access, without
preconditions and principles which would facilitate the risk of impoverishing themselves, essential
the uptake, implementation, benefit, and reduction of health and social services); human rights (mental
harm towards addressing the mental health of people health strategies, actions and interventions
who work. These include, but are not limited to: must be compliant with the UNCRPD and
other international and regional human rights
» the protection of people with mental health instruments); evidence-based practice (mental
conditions from discrimination and otherwise health strategies, actions and interventions
unfair treatment in the world of work and the need to be based on scientific evidence and/
promotion of their rights to access decent work or best practice, taking cultural considerations
on an equal basis with others and to be supported into account); a life-course approach (policies,
when there is a need to return to work or a desire plans and services for mental health need to
to participate in work (United Nations Convention take account all stages of the life course); a
on the Rights of Persons with Disabilities multisectoral approach (a coordinated response
[UNCRPD]; ILO Conventions 111, 159 and 190 and which partners health with relevant sectors
their recommendations; WHO Comprehensive such as employment and labour); and the
Mental Health Action Plan 2013-2030); empowerment of persons with mental disorders
» the protection of mental health at work (ILO and psychosocial disabilities (people with lived
Conventions 155, 161, 187 and 190 and their experience should be involved and should
recommendations; WHO Comprehensive Mental participate in all aspects of mental health policy,
Health Action Plan 2013-2030); planning and implementation).
» the fundamental right of everyone to work within
decent working conditions, to be protected
from unemployment, to be fairly and equally
compensated (Universal Declaration of Human
Rights, Article 23); including support to the
informal sector to transition to the formal
economy (ILO Recommendation 204);
10
Recommendations
for organizational
interventions
Guidelines on mental health at work
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Universal organizational interventions
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Key remarks:
▶ Universal organizational interventions are organizational interventions which can be delivered or
applied universally, that is, to a whole of a given workforce or work-setting.
Subgroup remarks:
▶ Culturally and contextually sensitive planning and delivery of interventions is required. Some
sociodemographic groups may be adversely and differentially affected by psychosocial risk
factors more than others are; assessment and planning which takes account of the diversity of
a workforce would identify such differences. Changes applied universally to psychosocial risk
factors may benefit work settings with workers from diverse sociodemographic backgrounds.
However, persons responsible for implementing organizational interventions should monitor
the impact of the changes on workers to identify whether there are disproportionate impacts
on some workers (such as, whether some workers who have flexible working arrangements
experience negative job consequences such as lack of networking opportunities).
Additional remarks:
▶ No direct evidence was obtained on preventing suicidal behaviours. Some occupations or work
environments may have ready access to lethal means of suicide. Restriction of access to the means
of suicide is one of the key suicide prevention measures (Mental Health Gap Action Programme
(mhGAP) guideline for mental, neurological and substance use disorders, 2015. Geneva: World
Health Organization; 2015). This can include not only regulations at national level but also the
implementation of organizational policies at the work level – e.g. banning highly hazardous
pesticides, restricting or regulating firearms, and restricting access to high-toxicity medicines.
12
Recommendations for organizational interventions
Key question 1 investigated whether universally delivered For participatory organizational interventions targeting
organizational interventions (e.g. interventions or job design, narrative findings from individual trials were
approaches targeting the mitigation, reduction or removal available. One cluster-randomized controlled trial (cRCT)
of psychosocial risk factors at work) have a beneficial impact reported that work unit-level12 interventions with worker
on worker outcomes (Annex 3). Evidence was extracted participation and dialogue, job redesign, and organizational
from five systematic reviews comparing usual practice learning found a significant decrease in mental health
(care as usual/other intervention/no intervention) to: symptoms (depersonalization and somatic symptoms)
flexible working arrangements (flexitime) (27), flexible but no significant findings on other critical or important
working arrangements (teleworking)7 (27); participatory outcomes (Annex 3). It should be noted that participatory
targeting the physical work environment (30); providing differing designs (28, 29, 33).
extracted evidence was of very low certainty, except where For changes to workload or breaks, (e.g. through task
otherwise indicated. rotation such as changing job tasks from high to low
For flexible working arrangements (flexitime) there the informal sector (e.g. refuse collection sector) reported
were small effects in favour of flexitime on mental health low certainty of evidence for no effect of a job rotation
symptoms (e.g. psychological health) and correspondingly intervention on mental health symptoms (i.e. the need for
low-certainty evidence for the small positive effects on recovery) at 3- , 6- and 12-month follow-up. For nudging
the work-related outcome of job satisfaction. Additional strategies targeting the physical work environment
working arrangements (such as self-scheduling) may have environment (walking strategies) for work performance. For
favourable impacts on health (32). For flexible working performance feedback/reward, one study reported that
arrangements (teleworking) there were small positive a multicomponent intervention containing performance
effects in favour of teleworking on mental health symptoms. bonus, job promotion opportunities and mentoring support
Teleworking was inversely related to absenteeism in one had higher retention rates compared to a matched wait list
study reported in Kröll (27) using a cross-sectional study control group (i.e. given the intervention after 12 months) at
7
Flexible working arrangements facilitate workers’ control over when (flexitime) and/or where (teleworking) they work.
8
Participatory approaches involve including workers alongside employers and other key stakeholders in the planning, design, implementation and evaluation of organizational
interventions. Job design refers to the content, tasks, activities or duties of a worker.
9
Changes to workloads or breaks include examples such as setting limits on working hours, introducing planned breaks, including weekend breaks, or fewer days on shift/
rotations within a week.
10
Nudging strategies include prompting a person to engage in an activity such as verbal or technology-based reminders.
11
Additional evidence is evidence identified by the review teams within web Annex evidence profiles, which were not subject to GRADE. These were high quality reviews which
met inclusion criteria for the key questions, however were not selected for GRADE, in the circumstance that other reviews may have better or more comprehensively addressed
the critical and important outcomes for the key questions.
12
Unit-level: such as within a team, department or organization.
13
Guidelines on mental health at work
Overall, no outcomes were reported for positive mental emotional exhaustion burnout (35). Low job control has
health, quality of life and functioning, suicidal behaviours, been associated with increased odds of suicide (41) and with
substance use and adverse effects. No direct evidence increased odds of absence related to mental health diagnosis
was available on the harms of implementing universally (43). Job strain (combining low decision latitude and high
delivered organizational interventions, which may be due to demands) is associated with depressive symptoms (42) and
publication bias or may reflect minimal harms (28). diagnostic-status depression (44). For organizational culture
Critically, the GDG took into account the wider body of subthreshold mental health symptoms (35, 36, 42). As for
evidence which indicates that psychosocial risks at work interpersonal relationships at work, workplace bullying
are negatively associated with mental health and related (which was defined by the review as a person perceiving they
outcomes. For example, for job content/task design, job/ are experiencing bullying) is associated with symptoms of
task rotation demonstrated positive effects on mental depression, anxiety and stress (45); workplace violence is
health symptoms (stress/burnout) (34). For workload and associated with depressive disorder (46); and low co-worker
work pace, high workload increases the risk of symptoms support and low supervisor support increase the risk of
of mental health conditions (35, 36). For work schedule, subthreshold symptoms (36), suicidal behaviours (ideation),
the evidence for an association between overtime/long and suicide mortality (41). With regard to a person’s role
working hours and depression which meets diagnostic in an organization, role ambiguity and role conflict are
status is not conclusive (37). However, long working hours associated with depression outcomes (47) and, as for career
are associated with symptoms of depression (38) and an development, job insecurity is related to higher risk of
increased likelihood for the onset of new risky alcohol use depressive symptoms (42, 48) and risk of suicidal behaviours
in people working 49–54 hours per week, and over 55 hours (ideation) (41). With regard to the home–work interface
a week (39). Shift work has been associated with binge (e.g. prioritization of time between work and private life),
drinking disorders (40), and the odds of suicidal behaviours increased work–family conflict was associated with greater
(ideation) increase with long working hours/shift work use of psychotropic medications (49). Additionally, the
(41). Factors associated with job control (i.e. low authority effort–reward imbalance (combining high efforts at work
in decision-making in own’s work) are associated with and low rewards in terms of wages, promotion prospects,
symptoms of mental health conditions (36); whereas higher job security, appreciation and respect) is associated with
decision latitude is protective for depressive symptoms increased risk of depressive disorders (50).
13
i.e. perceived fairness at work.
14
Recommendations for organizational interventions
Evidence-to-decision considerations
People who work value the changes to their working to reduce health inequalities for all workers, and for those
conditions through the means of organizational most likely to experience disproportionate psychosocial
interventions which address psychosocial risks for benefits risks at work in formal and informal sectors (web Annex).
preferences survey). A particularly high value is placed on Regarding feasibility, evidence was obtained from
participatory approaches such that workers, leadership studies conducted in high-income countries in Asia-
and other key stakeholders make decisions together for the Pacific, Europe and North America. Good practices of
betterment of their health. organizational interventions have been reported in low- and
There is variability in the resources required to implement participatory approaches (53). Small and medium-sized
organizational interventions. Participatory organizational enterprises (SMEs) or the informal sector may benefit
interventions were identified as ranging from 6 to 12 months from guidance from primary health-care services or the
(33). Variation in the composition and costs of the delivery vocational sector, who may be able to provide advice on
agents, or whether equipment is required, will have an addressing risk factors at work, where there is capacity to
impact on human resource costs. Resources (such as financial do so (54). Nevertheless, interventions such as teleworking,
expenses) may be incurred by workers themselves, such when conducted with limited organizational support or
as during teleworking. No reviews directly examined cost- resources, may conversely produce negative effects (13). The
effectiveness. Yet, during the implementation of a participatory necessity to continue to understand emerging risks (as work
organizational intervention in Japan, the cost of implementation organization and conditions evolve) and their impact on
was estimated to be ¥ 7660 per employee (approximately US$ mental health is underscored by this point.
209 per employee in the following 12 months (51). The interventions are in accordance with universal human
For health equity, equality and discrimination, no Declaration of Human Rights (55)). Interventions would need to
moderating differences were identified on the basis of be socioculturally adapted for the level of the work setting or
sociodemographic characteristics (such as gender and race) the sector itself and for the intended recipients. Organizational
regarding the impact of organizational interventions on the interventions via the primary prevention of psychosocial risks
outcomes (27). There are geographical, occupational, class to protect workers’ mental health are included in international
and gender differences in the likelihood of experiencing labour standards (56). The necessity to develop good working
risk factors related to poor working conditions (52). conditions is included in the WHO global strategy on health,
Organizational interventions for the prevention of these risk environment, and climate change (57).
15
Guidelines on mental health at work
16
Recommendations for organizational interventions
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Key remarks:
▶ Organizational interventions for health, humanitarian and emergency workers are selective as
they target a specific at-risk group (health, humanitarian or emergency workers).
▶ Health, humanitarian and emergency work is subject to risks that can disproportionately affect
the prevalence of mental health conditions in these occupations. Risks include exposure to
potentially traumatic events (such as violence and harassment), long working hours and high
work and emotional demands. Various subgroups may be further disproportionately affected
by risk factors at work (e.g. health workers in direct support roles, national humanitarian staff,
women, members of marginalized groups, younger workers). However, further expansion on
what the considerations would be for these subgroups in relation to organizational approaches is
urgently needed.
▶ The majority of direct evidence was obtained in health worker populations.
Implementation remarks:
▶ All common implementation remarks as indicated under Recommendation 1 apply. As
with Recommendation 1, these can be organizational interventions which may include
participatory processes.
17
Guidelines on mental health at work
for performance).
14
Need for recovery is the self-perceived extent to which recovery is required for mental and physical energy to return to sufficient levels to engage in work (29).
18
Recommendations for organizational interventions
Evidence-to-decision considerations
Work-related risks in the health, humanitarian and With regard to feasibility, only one study was conducted
emergency sectors place this group of workers at risk of in the African Region (64), while the majority of studies
mental health conditions. Organizational interventions were conducted in high-income countries in Europe and
to address such risks are considered a priority (62, 63). North America. The majority of direct evidence considered
Organizational interventions that address working was obtained in health workers. No studies were
conditions are valued among workers in these sectors who conducted in the humanitarian sector, yet national and
express concern that the delivery of individual interventions international humanitarian staff may prefer organizational
alone is equated with personal blame (for having a mental approaches (65). The interventions are in accordance
health condition or perceived inability to cope) (61). with universal human rights principles. Sociocultural
these vary by geographical, national, subnational and The GDG concluded that a conditional recommendation
intervention contexts. It is of note that communication and for organizational interventions was warranted for at-risk
teamwork interventions were identified as ranging from workers. Although the overall certainty of the available
4- hours to 6- months in duration so costs depend on the evidence was considered very low, the benefits on
intensity of the intervention. No reviews examined cost- emotional distress and work-related outcomes outweighed
effectiveness directly, which is a critical gap (61). the likely harms. Most promising for mental health were
For health equity, equality and discrimination, were highlighted by the GDG as especially pertinent for
organizational interventions for the prevention of risk workers in these sectors facing long hours and shift work.
factors and improvement of working conditions are While most of the evidence was obtained in health workers,
likely to reduce health inequalities for at-risk workers, this population was considered a proxy for other at-risk
including those most likely to experience disproportionate groups such as humanitarian and emergency workers, or for
psychosocial risks at work – such as young workers, workers in other at-risk sectors.
women, national humanitarian staff and health workers
different groups.
19
Guidelines on mental health at work
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Key remarks:
▶ The guidelines review process did not identify direct evidence. The indirect evidence (a
systematic review that did not include data suitable for GRADE) involved a narrative summary
of the evidence available for four categories of work accommodation interventions that can be
implemented for workers with mental health conditions, namely: accommodations regarding
communication, flexible scheduling, modification of job description, or modification to the
physical work environment.
▶ Article 27 of the United Nations Convention on the Rights of Persons with Disability (UNCRPD)
states: “Ensure that reasonable accommodation is provided to persons with disabilities in the
workplace”. For this reason, a recommendation was developed.
▶ Both the terms mental health conditions and psychosocial disabilities were explicitly used in
the recommendation to ensure that beneficiaries are likely to recognize themselves within the
recommendation.
▶ Providing reasonable accommodations promotes an inclusive work environment for workers with
mental health conditions by enhancing equitable access to opportunities and resources at work.
20
Recommendations for organizational interventions
Implementation remarks:
▶ In line with UNCRPD Article 27 on Work and Employment, workers with mental health conditions should
not be discriminated against. However, there are concerns that accessing or benefitting from such
support will identify a worker as having a mental health condition or as being perceived as unable to
cope with work, which may subject that worker to discrimination unless measures are taken proactively
within an organization to mitigate mental health stigma and protect the privacy of the person.
▶ Organizational mitigation of stigma for mental health conditions may contribute to reducing
concerns about confidentiality and stigma and can facilitate ease of access to accommodations
by promoting voluntary disclosure. Accommodations can be implemented without identifying
workers to wider colleagues or in accordance with the worker’s preference.
▶ There is insufficient evidence to identify whether one category of interventions is superior
to another. Workers living with mental health conditions should be accommodated to work
in a person-centred manner, according to their needs, requirements and preferences. Direct
supervisors play a critical role in supporting workers.
▶ Reasonable accommodations may be applied for any worker with a mental health condition(s)
including those returning from absence associated with a mental health condition. However,
they may also be utilized for workers living with mental health conditions, who have not been
on absence, and who remain in work or who newly join work.
▶ Respect for the human rights of people living with mental health conditions or psychosocial
disabilities is a necessary precondition for this recommendation; otherwise, the implementation
of reasonable accommodations may risk lacking a rehabilitative approach.
▶ Lower-resourced settings in LMICs, and globally SMEs, can be supported by the public
(health) sectors where there is capacity, to receive guidance on implementing reasonable
accommodations. Workers and employers need access to coordinated multidisciplinary
support, which could be provided feasibly through models of group occupational services (ILO
Convention 161, Article 7) (66).
▶ Managers or employers should be provided with training and resources to better support
workers who are in receipt of accommodations.
▶ All common implementation remarks, as indicated under Recommendation 1, apply.
21
Guidelines on mental health at work
Key question 3 investigated whether organizational The available evidence from observational studies
interventions delivered to workers with mental health points towards positive associations between work
conditions including psychosocial disabilities were accommodations, length of employment and improvement of
beneficial. Such interventions are referred to as (reasonable) mental health status (67). The most commonly implemented
workplace or work accommodations (Annex 3). These accommodations were related to communication and
are designed to foster sustainable participation in work scheduling. For workers receiving work accommodations,
activities by providing favourable and adapted working job tenures were reported to be 7–24 months longer than
conditions, matching the needs and requirements of the tenures of workers who did not receive accommodations
workers living with disabilities. Only indirect evidence was (67). In one trial, workers who received sufficient work
available via a systematic review that provided a narrative accommodations, compared to those who did not, were less
summary of the available evidence (67) (web Annex). likely to have a mental health condition after one year (68). In
Within the review, 15 mixed-method observational studies reporting feeling overprotected, patronised and under-
were identified. The primary outcomes were mental challenged at work (69).
22
Recommendations for organizational interventions
Evidence-to-decision considerations
Workers with mental health conditions and psychosocial Accommodations were not frequently implemented to the
disabilities experience significant barriers to sustaining their level required by workers with mental health conditions.
participation in work despite their interest, willingness, In one study, only 30.5% of workers received all required
and capacity to participate in work. Work accommodations accommodations, while 16.8% received no accommodations
seek to ensure that the outcomes that stakeholders value (74). Potential feasibility concerns include lack of support to
are improved: sustaining time on the job (i.e. tenure) and employers to implement legislation for accommodations, what
improved mental health. However, stigma and fear of options/actions are available to support their workers, and
repercussions remain critical barriers to workers’ confidence attitudinal concerns that such actions are expensive (67). All
in feeling safe to disclose their mental health status, and studies in the included review were conducted in high-income
consequently to access accommodations (71). countries, chiefly in the USA. The majority of studies included
provided. In a dated national survey conducted in the USA, Provision of work accommodations is in line with human
over half of workplaces reported no initial direct costs or rights conventions (70) and reasonable accommodations
maintenance costs of the accommodations they applied. need to be in line with the UNCRPD and national disability,
One third reported initial and maintenance costs of less equality or discrimination law. Consequently, workers
than US$ 100, with a minority reporting these costs larger with mental health conditions including psychosocial
than US$ 500 (72). No specific study on cost-benefit or cost- disabilities are, in most countries, legally entitled to
effectiveness analysis was identified. One study reported reasonable work accommodations. Relevant international
on cost savings of implementing accommodations, resulting labour standards are: the Vocational Rehabilitation and
in US$ 11.73 saved per person via financial assistance Employment (Disabled Persons) Convention, 1983 (No. 159)
programmes in the USA – reportedly a 68% greater saving (75) and the Vocational Rehabilitation and Employment
than people who did not receive accommodations (73). (Disabled Persons) Recommendation, 1983 (No. 168), where
For health equity, equality and discrimination, providing adaptations (76). While sociocultural acceptability is high
reasonable work accommodations promotes an inclusive for workers who wish to be supported by accommodations,
work environment by enhancing equitable access there remains a barrier for workers who fear disclosure
to opportunities and resources at work and, when of their mental health status at work. Workers who are
implemented successfully and without prejudice, can unable to disclose their status consequently do not
mitigate stigma. Work accommodations are therefore likely benefit from access to accommodations and, in turn, job
to reduce inequalities between workers with and without tenure is shortened (71). Efforts to reduce mental health
mental health conditions – i.e. by providing optimal stigma at work and actively promote relevant equality or
circumstances for workers in need of accommodations to discrimination legislation may help to make persons who
participate in their work. would benefit from disclosure feel supported to do so.
23
Guidelines on mental health at work
24
Recommendations
for training
managers
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Key remarks:
▶ Manager training for mental health is designed to enable managers to identify and respond
to workers who require support related to mental health, to give managers the confidence to
recognize, engage with and support team members with mental health problems and to adjust
job stressors in working conditions. Such training, however, is not designed for managers to
become mental health-care providers. Managers cannot – and should not – be in a position to
diagnose or treat mental disorders after such training.
26
Recommendations for training managers
Key question 4 investigated whether training managers effect on managers’ stigmatizing attitudes towards mental
has a beneficial impact on outcomes for managers and health. High-certainty evidence also showed a very small
workers (Annex 3). Two broad categories of manager significant effect on supervisee-reported mental health
training were identified during the review: 1) manager outcomes favouring the intervention. Low-certainty
training for mental health, which comprises components evidence from one study suggested substantial benefits
such as mental health and psychosocial risks (e.g. job of manager training for mental health on workers’
stressors) knowledge, early identification and response subsequent help-seeking behaviour (79). For work-
to emotional distress, taking appropriate actions to related outcomes, low-certainty evidence from one study
respond to distress (including referral to other sources of indicated a marginally significant reduction in perceptions
support), and communication and active listening skills; of job insecurity in workers, and there was no effect on
and 2) leadership-oriented training, which is a form of workers’ job performance in two other trials.
manager-worker interactions, and managers’ capacity For leadership-oriented training, only results for work-
to design a work environment and work organization in related outcomes were identified. Very low-certainty
favour of health and well-being. evidence from individual trials showed that there
The evidence for manager training for mental health commitment, work-related motivation and engagement;
compared to no training/wait list control was extracted however, most effects (from three out of five studies)
from one meta-analysis (77) which was updated for the were not statistically significant. In turn, no effects were
purpose of these guidelines. Evidence for leadership- observed on workers’ job satisfaction, turnover intention,
oriented training compared to no training/wait list control team effectiveness or work–life effectiveness (i.e. time
was extracted from a Cochrane review (78) (web Annex). spent between work and personal life).
For manager training for mental health, moderate- Overall, no outcomes were available for adverse effects,
certainty evidence suggested strong beneficial effects on change in leadership style, positive mental health, quality
managers’ knowledge for mental health. Strong effects of life, substance use or suicidal behaviours. No direct
were observed from very low- certainty evidence on evidence was available on the harms of implementing
27
Guidelines on mental health at work
Evidence-to-decision considerations
Both managers and workers value the outcomes that or race). Manager training for the benefit of workers’ health
manager training for mental health seeks to achieve and can include training on equality and diversity (80), and
have fewer concerns regarding this intervention than other human rights-based training with respect to mental health
types of interventions. Managers express a preference to conditions. However no included studies in the reviews
receive further information about mental health and how to considered these elements. All identified studies within the
support their workers through training (web Annex: Values reviews were carried out in high-income countries, usually
and preferences survey). Yet there is hesitation from some in medium-to-large organizations.
supporting a worker are within the role of their job, possibly It was noted that feasibility may be challenging in smaller
owing to lack of awareness of what the training involves and enterprises which may lack resources to participate in such
a lack of awareness of the mechanisms by which the job training without closer inspection and mitigation of the
stressors (psychosocial risks) can have an impact on workers. barriers (81). In this situation, managers across multiple
Managers vary in their preferences as to how to access such such training – such as through group occupational services.
training (e.g. individually, in groups, digitally, face-to-face Such training could be offered during pre-employment or on-
or blended approaches). A variety of training durations are the-job training, including in management curricula. Training
offered, ranging from 2.25 hours to 14 hours, with delivery which improves managers’ attitudes to, and knowledge of
in single sessions or over periods of up to 10 weeks (77) and mental health may improve the uptake of other levels of
with varying licensure/commission costs of training packages. interventions available for workers by mitigating concerns
The modality of training varies between didactic educational about stigma or retaliation (web Annex: Implementation
learning and skills-based practical learning. Such variability review). It is likely that the sustainability of training effects
has an impact on resource requirements. No reviews directly requires senior leadership to support behaviour changes
For health equity, equality and discrimination, there were effects of one-time training for managers appear to diminish
no identified analyses that investigated the differential after 6 months, suggesting that a biannual repetition of
benefits between subgroups of managers or their workers training may be needed as a minimum to sustain effects (82).
28
Recommendations for training managers
The benefit of manager training for mental health on The GDG concluded that a strong recommendation for
manager attitudes (reduced stigma) and improvement manager training for mental health was warranted. The
of skills/behaviours (non-discrimination) is aligned with overall certainty of evidence was considered moderate, and
universal human rights principles and would facilitate the the benefits on knowledge, attitudes, skills/behaviours and
implementation of the UNCRPD Article 27. Including human workers’ help-seeking behaviours outweighed the possible
rights components in the training alongside efforts to reduce harms. No recommendation was made at this time for
discrimination through improving knowledge, attitudes and leadership-oriented training owing to there being no available
skills/behaviours may strengthen managers’ knowledge of desirable effects on health outcomes and mixed desirable
human rights principles for mental health, although this was effects on work-related outcomes. The GDG concluded that
not explicitly included in the interventions examined by the leadership-oriented training is designed for developing
evidence. For sociocultural acceptability, there is indirect better leadership skills in managing and improving working
evidence that mental health interventions can be adapted conditions and by setting the tone of the organizational
to various cultures, and there are methodologies for how culture. However, substantially more research is required
cultural adaptations should take place. These methodologies which includes the impact of such training on workers’
may prove pertinent for potentially adapting manager mental health outcomes.
training in contexts where there is limited openness for
personal discussion in work settings (83).
29
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Training for
Manager training for health,
Mental Health
humanitarian and emergency workers
Key remarks:
▶ Recommendation 4 and its key remarks on manager training are relevant for managers of at-risk
workers. However, unlike in Recommendation 4, there was no available evidence for the impact
of manager training on workers’ help-seeking behaviours.
Implementation remarks:
▶ All common implementation remarks, as indicated under Recommendation 4, apply.
▶ Inflexible face-to-face delivery may be difficult for this population who are by the nature of their
work inherently shift workers, and their clients may be dispersed in different locations from their
supervisors. Flexible, brief or digital delivery may be feasible to access training.
▶ Proactive approaches are needed to minimize stigma and increase mental health knowledge in
these work settings.
▶ Funding or person-coverage for this population may need to be coordinated to allow for
participation in programmes during the working day. Training can also be delivered as part of pre-
service vocational training or study/education, on-the-job continued professional training or pre-
deployment training. Training should be adapted to reflect the context of the different sectors.
30
Recommendations for training managers
Key question 5 investigated whether manager training There was little very low-certainty evidence to suggest any
in selective at-risk sectors has a beneficial impact on superiority between mental health awareness training
outcomes for managers and workers (Annex 3). The for managers compared to peer-led manager training for
evidence for manager training for mental health15 in mental health knowledge or stigmatizing attitudes (i.e.
at-risk sectors compared to no training/wait list control both types of training were equally beneficial on these
and for two other types of manager training for mental outcomes). For leadership-oriented training, very low-
health –mental health awareness training for managers16 certainty evidence indicated mixed effects from individual
compared to peer-led manager training (e.g. increasing trials on at-risk workers’ mental health symptoms, with
awareness of the lived experience of mental health one trial suggesting small effects favouring training and
conditions, delivered by people with lived experience) another indicating no effect. For work-related outcomes,
– was extracted from one meta-analysis (77) which was low-certainty evidence pointed towards small positive
updated for the purpose of these guidelines. Evidence for effects on job satisfaction or turnover.
list control was extracted from two systematic reviews (78, Overall, no outcomes were reported for adverse effects,
For manager training for mental health, a moderate substance use or suicidal behaviours. No direct evidence
beneficial effect from low-certainty evidence was observed was available on the harms of implementing manager
15
Components of training for 1) manager training for mental health and 3) leadership-oriented training are described under Recommendation 4.
16
Mental health awareness training for managers included manualised training taught by trained facilitators focusing on awareness of the signs and symptoms of mental health
conditions and how to support an individual experiencing difficulty with their mental health.
31
Guidelines on mental health at work
Evidence-to-decision considerations
Evidence-to-decision considerations were largely similar or race. This is a notable gap for these sectors where the
to those for Recommendation 4 with the following “delivered by women, led by men” practice prevails (87). All
considerations highlighted as relevant for the at-risk sector of identified studies within the reviews were carried out in high-
health, humanitarian and emergency workers and those who income countries and included health or emergency workers
manage them. Manager training was considered especially who were primarily client-facing. There were no studies
pertinent for the selective at-risk areas that operate with including the humanitarian sector. There is wider qualitative
strong team-oriented work and where seniority is typically evidence which indicates that humanitarian workers express
based on technical speciality over management skills. a desire for improved leadership and better communication
manager training for mental health seeks to address, The feasibility of manager training for mental health
and managers express a preference for receiving further in occupations which are subject to long working hours
information about mental health and how to support their and shift work is a concern, especially in overburdened
workers through training. Minimal concerns regarding health systems or in countries facing active humanitarian
this type of intervention were expressed by at-risk emergencies. Brevity and accessibility will be relevant to
workers. Resource requirements are similar to those promote the feasibility of training. When incorporated into
for Recommendation 4 on manager training for mental other mandatory training for at-risk workers, training may
health (77) and repetition of training at least twice a year facilitate enrolment when compared with low enrolment
may be indicated by positive outcomes persisting over rates in voluntary training as observed in police personnel
time with significant effects observed between 2- and 6- (web Annex: Implementation review). However, managers
month follow-up (86). No reviews directly examined cost- who receive training can have a further positive effect by
effectiveness, yet a single trial which investigated the impact increasing the likelihood that their workers will access other
of manager training for mental health in emergency services support for mental health, particularly in sectors and work
demonstrated a return on investment of UK£ 9.98 for every environments where concerns about confidentiality and
UK£ 1 spent on training (85). stigma are high (web Annex: Implementation review). Another
For health equity, equality and discrimination, there health training into pre-service training (i.e. during vocational
were no identified analyses of the health, humanitarian and training, as part of vocational study) or before deployment or
emergency sectors that investigated differential benefits on-the-job continual training, although this was not examined
32
Recommendations for training managers
33
Guidelines on mental health at work
34
Recommendations
for training workers
Guidelines on mental health at work
NO
TI
DA
Training
Managerfor workers
Training forin mental
Mental health
Health
6
EN
M
M
Key remarks:
▶ Training of workers in mental health literacy and awareness is designed to improve knowledge
about mental health, reduce stigmatizing attitudes in recipients of the training, and enable
workers to support themselves or colleagues appropriately (e.g. through identifying the signs of
emotional distress and taking appropriate action such as seeking or facilitating help from formal
or informal sources). The training is not designed for workers to become mental health-care
providers or to diagnose or treat mental disorders. The limited evidence that is available suggests
that such training may not have an impact on the (self-reported) likelihood of providing help
to others; more quality research is needed to address this. There was no evidence available for
whether such training benefits colleagues’ outcomes.
Common implementation remarks for workers training for mental health literacy and awareness:
▶ The target audience of the guidelines should be aware that training for workers in mental health
literacy and awareness should be checked for its evidence base (i.e. quality and effectiveness) prior to
delivery to workers.
▶ Assessment of training transfer – i.e. the extent to which participants in the training have been able to
apply the knowledge and skills (i.e. the extent of competency) to their work outside of the training –
should be conducted alongside training implementation.
▶ Training should be offered preferably during normal paid working hours.
▶ Senior leadership commitment is required to encourage workers to utilize the training, and to
culturally sustain the effects of training.
▶ Such training benefits individual workers themselves and should be delivered with this aim in mind.
There is not yet substantial evidence to indicate that such training should be used to appoint workers
as informal helpers for their colleagues. If workers are to be trained to initially respond to co-workers
in distress, they should preferably be provided with mental health supervision or support to manage
boundaries with colleagues, identify needs and channels for referral, confidentiality and the impact on
their own mental health.
▶ Training can be periodically repeated or refreshed. However frequency of repetition should be
informed by improved research on the duration of effects.
▶ Training could also include administrative information alerting workers as to where they can find
relevant resources and policies in their work or local community settings.
▶ Such training may be beneficial in contexts where there is reduced incentive to address mental health
over and above physical health and safety concerns at work, such as in some informal work sectors.
However, raising awareness of mental health should be conducted only when there are options for
mental health referral support available to workers.
36
Recommendations for training workers
Key question 6 investigated whether training of workers No outcomes were reported for adverse effects, change
has a beneficial impact on outcomes for those who in help-seeking behaviours by colleagues who had been
receive training and for their colleagues (Annex 3). Such supported by a training recipient, positive mental health,
training is designed to increase workers’ mental health quality of life, substance use, suicidal behaviours or
literacy (knowledge and awareness) and attitudes (e.g. work-related outcomes. No direct evidence was available
anti-stigma), it includes early identification and response on the harms of implementing mental health literacy and
to emotional distress in the trainee and/or colleagues, awareness training for workers.
actions, including referral information. One systematic Additional evidence, not suitable for GRADE, indicated
review informed the evidence for the comparison of worker that such training – often called “gatekeeper training” – is
mental health training compared to wait list control (88) described in published and unpublished studies for the
(web Annex). prevention of suicide in workplaces (89). A few studies of
For training participants, low-certainty evidence work, indicated beneficial effects on knowledge, stigma
37
Guidelines on mental health at work
Evidence-to-decision considerations
Workers value highly the outcomes that worker training The ability of mental health literacy and awareness
for mental health seeks to address. Such interventions training to reduce stigma against people living with mental
are popular in work settings, particularly as there is great health conditions is in line with universal human rights
emphasis on reducing stigma for mental health in work principles. For sociocultural acceptability, there are
settings. Yet, there is also high value on “change in help- emerging concerns as to whether trainees understand their
seeking behaviours of colleague” which was an outcome that role following training, and whether they are provided
was not available within the included evidence. with formal or informal supervisory support (i.e. for those
Resource requirements may vary according to the mode of in workplaces). Trained workers who may overextend their
delivery (group, digital, face to face) and length of training, role may lack the necessary skills to manage the situations
with durations in the evidence review ranging from 1 hour they face without supportive (non-managerial) supervision
to 2 days. The licensure status of available programmes has to manage cases, such as from a mental health professional.
an impact on resource requirements: while some training This is in contrast to manager training, where managers
is relatively inexpensive, some can cost considerable time are in a direct position of power which places their workers
and money when delivered to whole workforces. No reviews under their responsibility.
evidence from Hanisch et al. (88) indicated that one study had The GDG provided a conditional recommendation for worker
evaluated its anti-stigma training as cost-effective. training for mental health. The overall certainty of evidence
For health equity, equality and discrimination, all attitudes outweighed the possible harms. It is to be noted
identified studies within the reviews were carried out in high- that that the effects on “providing help to others” may not
income countries, usually in medium-to-large organizations. have been captured due to the limitations of study follow-up
No identified analyses investigated differential benefits or periods. Additional evidence in Morgan et al. (90) indicates
harms between sociodemographic subgroups (e.g. gender moderate improvements in trainees’ confidence/intention to
or race). However, there is evidence that such training could support a colleague prospectively, where confidence alone
be adapted to LMICs and to non-anglophone/non-European may not translate into behaviour (although it is a proxy) (91).
cultures (92) and there are indications that such training may Currently such training is suitable for addressing stigmatizing
be welcome among the organized informal sector (web Annex). knowledge/attitudes at the workplace – a necessary barrier
For feasibility, smaller enterprises may lack resources to interventions for mental health at work. The GDG noted that
participate in such training and may benefit from group further evidence is needed to investigate the effectiveness of
occupational services between multiple enterprises to this training in relation to other outcomes such as influencing
38
Recommendations for training workers
NO
TI
DA
7
EN
M
M
CO
RE
Managerfor
Training Training forhumanitarian
health, Mental Health
and emergency
workers in mental health literacy and awareness
Key remarks:
▶ Training at-risk workers in mental health literacy and awareness is designed to reduce stigma
in workers, and to enable workers to support themselves or colleagues appropriately (through
identifying the signs of emotional distress and taking appropriate action such as seeking or
facilitating help from formal or informal sources). It is not designed for workers to become mental
health-care providers or to diagnose or treat mental disorders. The limited evidence that is
available suggests that such training benefits positive attitudes towards seeking help but may
not have an impact on the actual (self-reported) seeking of help for oneself or providing help to
others, and more quality research is needed to address this.
▶ However, training health, humanitarian and emergency workers in mental health knowledge,
attitudes and skills may benefit their daily client-facing work, as the objectives of the training
may be transferable to members of the public in distress.
Implementation remarks:
▶ All common implementation remarks, as indicated under Recommendation 6, apply.
▶ Training could be delivered as part of pre-service training, on-the-job training/study, pre-
deployment training or post-deployment follow-up.
39
Guidelines on mental health at work
Key question 7 investigated whether mental health literacy For workplace mental health awareness training versus
and awareness training for at-risk workers had a beneficial training as usual, low-certainty evidence demonstrated
impact on outcomes (Annex 3). No systematic reviews a small effect in favour of workplace mental health
were available that explored the effect of interventions awareness training on training recipients’ attitudes to seek
on civilian health, emergency and humanitarian workers’ help for themselves. This effect was no longer observed at
knowledge, attitudes and skills/behaviours that improve 3-year follow-up. No effects were observed on changing
their own or their colleagues’ mental health. Two RCTs training recipients’ actual help-seeking behaviours (very
evaluating these outcomes were identified through low certainty of evidence). In addition, very low-certainty
systematic searches to inform the evidence comparing evidence found there was no effect on reducing mental
usual (94) (web Annex). Overall, no outcomes were reported for adverse effects,
For contact-based workplace education compared to health, quality of life, substance use, suicidal behaviours or
mental health literacy and awareness training, very work-related outcomes. No direct evidence was available
low-certainty evidence indicated that the interventions on the harms of implementing mental health literacy and
were similar with regard to their small positive effects awareness training in at-risk workers.
17
Contact-based workplace education involved six face-to-face sessions and five online sessions delivered by peers living with mental health conditions, and included mental
health literacy, early identification and help-seeking resources.
18
Workplace mental health awareness training involved watching three videos – of approximately 30 minutes in total – of people in a similar profession to the end-users
discussing personal experiences of work challenges, adverse events and how seeking-help was beneficial.
40
Recommendations for training workers
Evidence-to-decision considerations
At-risk workers value the outcomes that worker training for The ability of mental health literacy and awareness training
mental health seeks to address. Such interventions – for the to reduce stigma for mental health is in line with universal
purposes of addressing stigma – are popular in work settings. human rights principles. For sociocultural acceptability,
Resource requirements may vary according to the mode mental health self-stigma is reportedly problematic among
of delivery (group, digital, face to face, blended) and length health-sector workers (98). However, a dual benefit for this
of training, whether licensure is required, and by the varying at-risk group may serve to increase willingness to participate
durations which were reported in the evidence as ranging from in training because the training of health, humanitarian and
30 minutes to brief sessions delivered over a 21-month period. emergency workers in mental health knowledge, attitudes and
No reviews directly examined cost-effectiveness, yet indirect skills may additionally benefit their daily front-facing work of
evidence from a single uncontrolled study in an at-risk sector service delivery. Peer support programmes in these sectors are
sample suggested cost savings of receiving such training (95). also popular. While evidence for the success of peer support
For health equity, equality and discrimination, all of interventions and outcomes, there appears to be some
identified studies within the reviews were carried out indication of short-term benefits (99).
on health and emergency workers. Additional evidence The GDG made a conditional recommendation for at-risk
indicated that pre-deployment training benefits humanitarian worker training for mental health. The overall certainty of
workers’ confidence in coping with disasters (96). No evidence was very low, and the benefits on knowledge and
identified analyses investigated differential benefits between attitudes outweighed the possible harms – i.e. that training
sociodemographic subgroups (such as gender or race). There would support trainees to improve their knowledge in mental
is emerging evidence that such training could be adapted to health, thus increasing the likelihood of early detection of
LMICs and in non-anglophone/non-European cultures (92). symptoms, and their knowledge (but not action) on what to
Notably, addressing knowledge and attitudes for mental do about such symptoms (e.g. the likelihood of seeking help).
health is included in training that seeks to build the capacity Since the findings match those found in Recommendation 6,
of primary care health workers in LMICs to support people, there was consideration of whether there should be a single
rather than colleagues, for their mental health – suggesting recommendation. However, the GDG felt it important to
that such training could be feasible (97). For feasibility, the highlight specifically the need to have a recommendation for
Implementation review).
41
Guidelines on mental health at work
42
Recommendations
for individual
interventions
NO
TI
DA
8
EN
M
M
CO
RE
8A U
niversally delivered psychosocial interventions that aim to build
workers’ skills in stress management – such as interventions based on
mindfulness or cognitive behavioural approaches – may be considered
for workers to promote positive mental health, reduce emotional distress
and improve work effectiveness.
8B O
pportunities for leisure-based physical activity – such as resistance
training, strength- training, aerobic training, walking or yoga – may be
considered for workers to improve mental health and work ability.
Key remarks:
▶ Universally delivered interventions may help to reach a large proportion of a workforce and may
be less likely to cause stigmatization as entry to the programmes is not predetermined by mental
health status.
▶ The target audience of the guidelines should be aware that interventions for workers in building
skills in stress management should be checked for their evidence base (quality and effectiveness)
prior to delivery to workers.
▶ WHO guidelines on physical activity and sedentary behaviour (2020) includes recommendations
for physical activity in working-age persons and notes that the relevant recommendations confer
health benefits, including reduction of symptoms of anxiety and depression. Where resources are
available, Recommendation 8B applies to activities that can be conducted within work settings or
where work facilitates external opportunities to participate in these physical activities.
44
Recommendations for individual interventions
Su-group remarks:
▶ Equity in delivery or uptake of individual interventions would need to be considered for
“low-status workers” versus “high-status workers”, for shift workers, informal workers or self-
employed persons.
▶ Informal female workers may have less access to digital resources within family units compared to
their male counterparts; face-to-face delivery may be preferable in these and similar circumstances.
▶ Informal workers may not be able to take time away from work to engage in the interventions;
consequently, community-based organizations such as cooperatives or the health system may
promote individual interventions in a proactive manner and could themselves be trained to
deliver individual interventions that are designed for delivery by non-specialist providers.
45
Guidelines on mental health at work
Key question 8 investigated whether universally- evidence for a strong improvement in subjective well-being.
delivered individual interventions (such as psychosocial For universally delivered CBT, mainly very low- to low-
interventions, leisure-based physical activity, or healthy certainty evidence showed a small effect of CBT on overall
lifestyle promotion) had a beneficial impact on outcomes mental health symptoms (i.e. depression, anxiety and stress)
(Annex 3). Evidence was extracted from eight systematic and subjective well-being (very low certainty of evidence).
treatment as usual, wait list control, other interventions, no For e-psychosocial interventions, evidence ranging
treatment control), evidence was available for universally- from very low to moderate certainty demonstrated small
delivered psychosocial interventions (such as cognitive effects on mental health (symptoms of stress, depression,
behavioural therapy, relaxation, interpersonal soft skills, burnout). There was low-certainty evidence for small-to-
stress management, role-related skills, and expressive moderate benefits to positive mental health (well-being
writing) (100, 101), for mindfulness and contemplative and mindfulness) and high certainty of small effects on
interventions (60, 102, 103) and cognitive behavioural work-related effectiveness. Additional evidence within the
therapy (CBT) (60, 103); e- psychosocial interventions (such included reviews indicated no difference between CBT-
as Internet-based or other digital-based cognitive therapy based approaches and other psychological approaches
or CBT, stress and coping, mindfulness, psychoeducation, on psychological health and work effectiveness outcomes
problem-solving training, positive psychology interventions, (104). Likewise, CBT showed a very small, significant positive
and acceptance and commitment therapy) (104, 105); effect, and mindfulness-based interventions showed
e-health stress management (103); physical activity and a moderate-to-large positive effect (103). No desirable
lifestyle interventions (such as general physical exercise, outcomes were identified for e-health stress management.
interventions (such as walking, yoga, resistance training, For combined psychosocial and/or physical activity and/
aerobic and weight-training exercise) (60) and combined or lifestyle interventions, very low-certainty evidence
psychosocial and/or physical activity and/or lifestyle demonstrated a moderate effect on improving positive
interventions (60) (web Annex). mental health and a strong effect on improving quality of
For universally-delivered psychosocial interventions, very moderate-certainty evidence indicated a small effect on
low-certainty evidence showed that there were small effects work ability.
of insomnia. For universally-delivered mindfulness Overall, no outcomes were reported for adverse effects,
and other contemplative interventions, there was low- substance use or suicidal behaviours. No direct evidence
certainty evidence for moderate improvements in symptoms was identified on the harms for implementation of
of general distress, overall mental health symptoms (i.e. universally-delivered psychosocial, physical activity or
46
Recommendations for individual interventions
Evidence-to-decision considerations
Workers value access to universally-delivered individual that 40% of providers were specialists (100), wider
interventions. However, they are less likely to value literature indicates that brief psychosocial interventions
these interventions if they are not provided alongside can be feasibly implemented in lower-resource settings
organizational or managerial interventions (web Annex: through non-specialist providers (110). Digitally-provided
Values and preferences survey). This is due to concerns interventions may extend reach to workers based in rural
that receiving individual interventions only is indicative settings or home-offices. Equity in delivery or uptake of
that workers may be to blame for their own mental health individual interventions would need to be considered for
status. These interventions form one part of self-care or self- “low-status workers” versus “high-status workers”, and for
management options, but alone they would not constitute shift workers, informal workers or the self-employed. For
comprehensive delivery. example, face-to-face delivery for shift workers may result
Resources vary according to delivery method (face-to-face, whereas the former it may be preferable for workers with
self-administered, digital, provider expertise), whether lower digital literacy. Informal female workers may have less
equipment is required (e.g. for physical activity) and by access to digital resources within family units, compared to
duration – one review indicated a mean duration of 10 male counterparts; therefore face-to-face delivery – such
weeks for e-psychosocial interventions (104) and 4–6 as through workers cooperatives or community-based
months for physical activity programmes (60). Follow- organizations – may be preferable in these and related
up periods were short and the duration of effects was circumstances (web Annex). Self-access or referral to such
heterogeneous and unclear, suggesting that interventions interventions may in general reduce stigma-based barriers
should be available as and when people need them. No for accessing support for mental health. For employers
direct evidence was available for cost-effectiveness. Wider or workers with limited resources, provision of guidance
sources suggested for workplace stress management (single or interventions could be supported by the public health
or multicomponent which covers but is not exclusive to sector, where there is capacity. Finally on feasibility, one
universal delivery), an estimated return on investment of included review indicated 45% completion of e-psychosocial
UK£ 2 for every UK£ 1 invested in England (108) and a 138% interventions, which was in line with engagement rates
return on investment in a review of over 250 000 workers seen in digital health interventions (104). Emerging
across 12 countries (109). evidence indicates that brief individual interventions (self-
included review conducted a subgroup analysis solely Access to evidence-based interventions to prevent distress
for gender (105), showing that gender had no significant is in line with universal human rights principles, and
moderating effects on outcomes for e-health psychosocial universal delivery removes barriers of stigma for mental
interventions. Although the majority of the work was health or for help-seeking. For sociocultural acceptability,
obtained in high-income settings, and one review indicated the content and delivery of brief psychosocial interventions
47
Guidelines on mental health at work
48
Recommendations for individual interventions
NO
TI
DA
9
EN
M
M
CO
RE
9A U
niversally delivered psychosocial interventions that aim to build
workers’ skills in stress management – such as interventions based on
mindfulness or cognitive behavioural approaches – may be considered
for health, humanitarian and emergency workers to promote positive
mental health and reduce emotional distress.
Key remarks:
▶ There is evidence for the sustainability of improvements in outcomes at short-term and medium-
term follow-up time points (≤ 6 months) but there is limited evidence for long-term lasting effects.
▶ Recommendation 10 for indicated interventions would also apply to Recommendation 9B. In
addition, WHO guidelines on conditions specifically related to stress (113) recommends against the
use of psychological debriefing following potentially traumatic events: Psychological debriefing
should not be used as an intervention to reduce the risk of post-traumatic stress, anxiety or depressive
symptoms in people recently exposed to a traumatic event (strong recommendation, very low certainty
of evidence).
49
Guidelines on mental health at work
Implementation remarks:
▶ All common implementation remarks, as indicated under Recommendation 8, apply.
▶ There is considerable stigma in these sectors for seeking support for mental health conditions or
disclosing to employers. Universal delivery of psychosocial interventions may benefit workers in
such high-stigma working environments. Likewise, self-referral options or digital interventions may
ameliorate perceived stigma and barriers to accessing face-to-face support (e.g. where there may
be concerns about confidentiality and privacy).
▶ Inflexible face-to-face delivery may be difficult for this population who are largely shift workers and
client-facing. Flexible, brief or digital delivery may improve uptake.
▶ Proactive approaches are also needed to minimize stigma and increase mental health knowledge
in these work settings.
▶ Funding or coverage for this population may need to be coordinated to allow for participation in
programmes during the working day.
▶ Universal interventions could be integrated within pre-service or on-the-job training in order to
improve stress management skill-building in preparation for work.
▶ It is unclear whether psychosocial interventions for at-risk workers with emotional distress should
be provided within or outside of work settings (e.g. providers internal to or external to the work
setting). Where feasible, options should be made available for both.
Subgroup considerations:
▶ For employers with limited resources – such as local or national humanitarian organizations –
access to interventions may be provided by the public health sector or through shared resourcing
in group occupational services.
50
Recommendations for individual interventions
Key question 9 investigated whether individual interventions For psychosocial interventions, the effects varied for mental
(such as psychosocial interventions, leisure-based physical health outcomes where there was a very low certainty of
activity, or healthy lifestyle promotion) had a beneficial effect on a small reduction in depression symptoms, and a
impact on outcomes for at-risk workers (Annex 3). Evidence moderate-sized effect on reducing stress. Low-to-moderate
was available for 1) universal delivery of individual certainty evidence indicated greater reductions on symptoms
interventions for at-risk workers (selective–universal) and 2) of burnout (exhaustion). Very low-quality evidence suggested
individual interventions for at-risk workers with emotional that psychosocial interventions exhibited a small effect on
distress (selective–indicated) (web Annex). positive mental health (e.g. resilience, optimism, self-efficacy,
Evidence was extracted from eight systematic reviews. effect on reducing suicidal ideation. There was low certainty
or no treatment control), evidence was available for: For mindfulness and other contemplative interventions,
1) universal-delivery of combined psychosocial and/or there was moderate-certainty evidence indicating moderate
physical activity and/or lifestyle promotion interventions effects on reducing mental health outcomes (depression,
(such as cognitive behavioural therapy approaches, stress stress) and small effects on general distress and burnout.
reduction and resilience programmes) (114); 2) psychosocial While there was a moderate effect on anxiety, this evidence
interventions (such as CBT approaches, mindfulness was considered very low-certainty. There was low certainty
interventions, stress management and self-care, attention in the moderate improvements in positive mental health
interventions (102, 118–120); and 4) for indicated at-risk For psychosocial interventions for indicated at-risk
workers, psychosocial interventions (such as facilitated workers, there was moderate certainty of effects on high
small group curricula, stress management and self-care reductions in levels of burnout (exhaustion).
For combined psychosocial and/or physical activity and/ did not demonstrate the desired effect on burnout
or lifestyle promotion interventions, low-certainty data depersonalization, whereas there was a moderate effect on
indicated small effects on mental health outcomes (anxiety burnout exhaustion. No other direct harms were identified.
51
Guidelines on mental health at work
Evidence-to-decision considerations
The evidence-to-decision considerations were largely evidence for a duration of effects of up to 6 months for
identical across all individual intervention recommendations individual psychosocial interventions in at-risk workers
(8, 9 and 10). The additional unique considerations for (115). Group-based delivery of psychosocial interventions
indicated individual interventions (workers with emotional may be less feasible in these sectors owing to scheduling
distress) are outlined in Recommendation 10. difficulties for typical shift work (and if conducted can
In these at-risk sectors there can be a particular stigmatization stigmatized settings (web Annex: Implementation review).
its impact on career progression (121). For this reason, there The GDG concluded that a conditional recommendation was
is a preference among workers to self-refer to psychosocial warranted for individual interventions for at-risk workers,
interventions (web Annex: Implementation review). Workers both when universally delivered and when delivered to
also reported affordability and convenience as benefits of an indicated population (i.e. at-risk workers in distress).
these interventions although most data were from workers The overall certainty of evidence was considered to be
in higher-resourced settings. There may be particular low and the benefits on mental health outcomes – and
barriers (to access individual interventions) faced by smaller positive mental health outcomes in the case of universally-
organizations or those with fewer resources, where “group delivered interventions – were considered to outweigh
occupational health services” could be contracted through the harms. The GDG did not consider there to be sufficient
pooling resources from multiple organizations or through substantial evidence to warrant a recommendation on
delivery from the public-health sector. The duration of such leisure-based physical activity interventions since, despite
interventions – which range from less than 5 hours to over 12 the combination of psychosocial physical activity and
hours – is relevant for these organizations where time during lifestyle promotion interventions, the vast majority were
work may be limited due to client-facing roles (115). psychosocial. The available literature also did not permit
For health equity, equality and discrimination, although psychosocial versus physical). However, it was noted that
health workers represent a diverse group of professions, Recommendation 8 for universally delivered interventions
most included research is based on those in direct clinical would also be applicable to this population.
52
Recommendations for individual interventions
NO
TI
DA
10
EN
M
M
CO
RE
Key remarks:
▶ It is unclear whether indicated psychosocial interventions for workers with emotional distress
should be provided within or outside of work settings (i.e. by internal or external providers).
However, where feasible, both should be available to suit the preferences of workers.
▶ WHO mhGAP guideline (123) provides recommendations on effective interventions for
depression, self-harm/suicide and substance use relevant to the general population (in low-
resourced settings).
▶ WHO guidelines on physical activity and sedentary behaviour (2020) includes recommendations
for physical activity in working-age persons and notes that the relevant recommendations confer
health benefits – including the reduction of symptoms of anxiety and depression.
53
Guidelines on mental health at work
Key question 10 investigated whether indicated individual- For e-psychosocial interventions, there was very low-
level interventions (such as psychosocial interventions, certainty evidence for small effects on mental health
leisure-based physical activity, or lifestyle promotion) outcomes (symptoms of depression and anxiety); moderate
had a beneficial impact on outcomes for workers with effects on burnout and a composite measure which
emotional distress (Annex 3). Evidence was extracted combined stress, depression and psychological stress;
from five systematic reviews. Compared to control and strong effects on outcomes of stress and insomnia
conditions (varying between treatment as usual, wait list, symptoms. Low-certainty evidence demonstrated a small
other control interventions), evidence was available for improvement in work effectiveness (defined as: work
psychosocial interventions (e.g. mixed CBT interventions, engagement, productivity, job effectiveness). For e-stress
relaxation, interpersonal soft skills, role-related skills, aerobic management interventions, there was very low-certainty
exercise and behaviour modification, and acceptance and evidence to indicate a moderate effect on a combined
commitment therapy) (100, 124); for CBT (103, 124); measure of depression, anxiety and stress symptoms.
stress and coping, mindfulness, psychoeducation, problem- Overall, no outcomes were reported for positive mental
solving training, positive psychology, and acceptance and health, quality of life, adverse effects, substance use or
commitment therapy) (104, 105); and e-stress management suicidal behaviours. No direct harms of indicated individual
For psychosocial interventions, there was low-certainty improving “lack of personal accomplishment”, a sub-
54
Recommendations for individual interventions
Evidence-to-decision considerations
The evidence-to-decision considerations were The GDG concluded that a conditional recommendation
largely identical across all individual intervention for indicated psychosocial interventions – i.e. individual
recommendations (8, 9 and 10). Additional considerations psychosocial interventions delivered to workers with
for indicated individual interventions are outlined here. emotional distress – was warranted. The overall certainty
Consideration is given to the fact that entry into such mental health outcomes and work-related outcomes were
programmes is by meeting criteria for emotional distress considered to outweigh the harms. On the basis of indirect
which may be stigmatizing if care is delivered in the work additional evidence, the GDG also concluded conditionally
setting. Therefore, in terms of sociocultural acceptability, to recommend leisure-based physical activity for the benefit
it is unclear whether such interventions are considered of reducing symptoms of emotional distress. Evidence was
acceptable at work – despite well-designed RCTs for workers available from Nigatu et al. (124) of two included trials that
with emotional distress being conducted in workplaces with investigated the treatment effects of supervised workplace
no known reports of harms (such as perceptions or fears of physical exercise – high-intensity aerobic exercise of at
No direct evidence was available on cost-effectiveness. – where small and large effects were found on symptoms
However, additional sources indicate that workplace of depression. The findings are in accordance with wider
psychosocial interventions which include CBT are cost- literature on physical activity and reducing the severity
saving, and in some cases are cost-effective for depression of mental health symptoms in adults with mental health
(126). For health equity, equality and discrimination, conditions (112, 125).
55
Guidelines on mental health at work
56
© WHO / Lindsay Mackenzie
Recommendations for
returning to work after
absence associated with
mental health conditions
Guidelines on mental health at work
NO
TI
DA
11
EN
M
M
CO
RE
Returning to workfor
Manager Training after absence
Mental associated with
Health
mental health conditions
For people on absence associated with mental health conditions, (a) work-
directed care plus evidence-based mental health clinical care or (b) evidence-
based mental health clinical care alone should be considered for the reduction of
mental health symptoms and reduction in days of absence.
Key remarks:
▶ The evidence for this recommendation comes primarily from reviews on depression and
adjustment disorders. The WHO mhGAP guideline (2015) provides recommendations for
evidence-based clinical care in the general population in low-resourced settings.
Implementation remarks:
▶ Multi-stakeholder coordination between the health provider, employer and worker, and worker
representatives or employment/vocational specialists, where feasible, may facilitate effective
implementation of return-to-work measures. The decision as to which stakeholders to include
and which interventions to participate in should be based on the worker’s preference.
▶ Such coordination may present a feasibility challenge for many lower-resourced settings in LMICs
and globally for SMEs.
▶ Work-directed care, clinical care and psychological interventions can be delivered face to face,
by telephone or online. Evidence-based clinical care, such as psychological interventions, can be
guided by a provider or can be unguided self-help, where resources are available.
▶ Interventions may be delivered during the period of absence and/or as part of early re-entry to work.
▶ Interventions should not be mandated for completion as a prerequisite for re-entering work.
58
Recommendations for returning to work after absence associated with mental health conditions
Key question 11 investigated whether supporting people to For work-directed care plus clinical care, compared with
return to work, following absence associated with mental care as usual for workers with depression, there was a low
health conditions, has a beneficial impact on outcomes certainty in small (medium-term follow-up) to moderate
(Annex 3). Evidence was extracted from two systematic (long-term follow-up) reductions in depressive symptoms.
reviews comparing return-to-work interventions for There was a small effect in reducing the days on absence
workers with depression (127) or adjustment disorders at medium-term (moderate-certainty) and long-term
(128) (web Annex). Identified interventions could be broadly (low-certainty). However, there was moderate certainty
▶ work-directed care (such as improving working not being absent. There was very low to low certainty of
conditions, reducing working hours, changing of tasks evidence for small effects on improving work functioning (at
or a lighter load of tasks, graded reintroduction to work medium term (not significant) and long term, respectively).
etc., delivered or coordinated by various methods such There was very low certainty that work-directed care plus
as multiple meetings with care providers, employer clinical intervention was no more superior (i.e. equally
and the worker- together or separately, depending on comparable or beneficial) than work-directed care alone
▶ evidence-based clinical care (such as evidence-based work-related outcomes. This anomaly (given the lack of
▶ improved health care (such as the introduction of care accounted for by the heterogeneity of the interventions that
management for depression in primary care); are included under “work-directed care”.
▶ any combination of these, with comparators being care available for workers with depression or with adjustment
as usual or any one of the intervention categories. disorders. Compared to care as usual in workers with
usual, low-to-moderate certainty results were not favourable effects in reducing days on absence (at medium-term
for workers with depression with regard to mental health follow-up). However, this was not observed at short-term
outcomes (at medium [3–12 months] and long-term follow- follow-up (up to 2 months). Multiple comparisons for
up [12 months and over]), risk of being on absence, the individual psychological interventions were available and
number of days on absence, and work functioning. are described in web Annex with several psychological
long-term follow-up.
59
Guidelines on mental health at work
For improved healthcare, compared to care as usual for specific to work. There were mixed results for leisure-
workers with depression, moderate-certainty evidence based physical activities. For CBT combined with physical
indicated small effects at medium-term follow-up on relaxation, compared to physical relaxation alone, for
depressive symptoms. However, there was moderate workers with adjustment disorders, low-certainty evidence
certainty of a moderate effect on worsening work indicated that there were effects on burnout. For supervised
functioning. No benefits in terms of absence days or the strength-training compared with relaxation for workers with
likelihood of being absent were observed for improved depression, there was low-certainty evidence of large effects
health care. Therefore, improved health care alone in the in favour of the benefit of strength-training on reduced
absence of a work-focused intervention benefitted health absence days.
outcomes only but did not benefit functioning outcomes
Evidence-to-decision considerations
Mental health conditions are considered to be a leading For cost-effectiveness, additional evidence included an
cause of absence for workers (129, 130). Workers value the economic analysis (126). Active involvement of occupational
availability of return-to-work programmes and sustainable health specialists in return to work was deemed as cost-saving
return-to-work, with the majority considering these to be and cost-effective on the basis of the benefits of reducing
extremely important (web Annex: Values and preferences absence: in the Netherlands, a return of US$ 0.87 to US$ 10.63
survey). No direct examination of resource requirements for every US$ 1 invested (132, 133), and in Finland, a cost-
was available. Providers of work-directed care or evidence- saving of US$ 17 to US$ 43 per avoided absence day (134).
in mental or occupational health, medical generalists, and For health equity, equality and discrimination, no
labour and employment specialists. Work-directed care sociodemographic subgroup analyses (such as for gender
involved multiple meetings over variable periods of time or race) were available. Feasibility of delivering return-
(e.g. nine meetings over a period of 3 months). For clinical to-work programmes for mental health may be especially
care, the number of sessions (e.g. 6–12) was dependent challenging for lower-resourced settings in LMICs and
on the structured intervention offered. Psychological globally for SMEs. All included studies (and additional
interventions can take place face to face, online or through evidence) related to high-income countries across the
telephone support. A wide variety of potential stakeholders Americas, Asia, Europe and Oceania. Coordination between
are available to support the return to work. Ultimately the health sector, social care (labour/employment),
the coordination of stakeholders is needed (by workplace employers, workers and their representatives is needed to
or national health protocols) to ensure a smooth return support return-to-work measures. However, the current lack
that respects the wishes of the worker and is in line with of coordination in many contexts impedes implementation
available resources and coordination, depending on the (web Annex: Implementation review).
60
Recommendations for returning to work after absence associated with mental health conditions
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Guidelines on mental health at work
62
Recommendations for
gaining employment
for people living
with mental health
conditions
Guidelines on mental health at work
NO
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12
EN
M
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CO
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Gaining
Manageremployment for people
Training for Mental living with
Health
mental health conditions
Key remarks:
▶ The majority of the evidence concerned people living with severe mental health conditions.
Implementation remarks:
▶ Multi-stakeholder coordination (person, family/community, workplace, representative) is
required to mobilize resources and strategies which enhance vocational and economic inclusion.
Involvement of these stakeholders and selection of the intervention should be based on the
prospective worker’s preferences.
▶ It is important to include people with lived experience of mental health conditions in the design
and delivery of these programmes in order to optimize person-centred approaches and to
empower people in making decisions for their own well-being.
▶ When people start their employment, support can continue, in order to support maintaining
employment.
▶ Such strategies should be contextualized to people’s social and cultural environment, using
formal and non-formal recovery-oriented interventions that may be available.
Additional remarks:
▶ In 2015, the WHO mhGAP guideline recommended: Recovery-oriented strategies enhancing
vocational and economic inclusion (e.g. supported employment) can be offered for people
with psychosis (including schizophrenia and bipolar disorder). Such strategies should be
contextualized to their social and cultural environment, using formal and non-formal recovery-
oriented interventions that may be available, and using a multisectoral approach (Conditional
recommendation, low certainty evidence).
64
Recommendations for gaining employment for people living with mental health conditions
Key question 12 investigated whether recovery-oriented For obtaining employment, augmented supported
strategies focusing on vocational and economic inclusion employment (moderate certainty) and supported
have a beneficial impact on outcomes (Annex 3). Evidence employment (low certainty) had higher relative effects
was extracted from four systematic reviews, including compared to psychiatric care and pre-vocational training.
one network meta-analysis (135-138). The interventions Augmented supported employment and supported
were comparisons between supported employment employment were comparable in increasing the number of
(e.g. programmes which support people to obtain paid people who obtained employment. Recipients of vocational
employment quickly, and ongoing health or vocational interventions compared to no care were more likely to
support is provided to maintain employment); augmented gain employment. There were no substantial benefits of
supported employment (e.g. supported employment with pre-vocational training or transitional employment on
to up-skill prospective employees on social, emotional and For maintaining employment, augmented supported
functioning skills before they are placed in employment); employment was more effective compared to pre-
transitional employment (e.g. stepped employment vocational training and supported employment. Supported
programmes whereby people are first placed in temporary employment was more effective than transitional
work before next moving to employment); psychiatric employment or pre-vocational training. Compared to other
care (e.g. usual psychiatric care, without any vocational vocational approaches, supported employment resulted
component); supported employment versus other in more substantial increases in any levels of employment
vocational support (a mix of interventions such as pre- obtained and in the length of job tenure.
care as usual and vocational interventions (the latter two For mental health outcomes, supported employment
were majority-supported employment programmes which had a more beneficial effect than psychiatric care but
focus on rapidly gaining paid and preferred employment, was not superior in reducing mental health symptoms
while provided with support by vocational and health- compared to transitional employment or pre-vocational
care systems) versus no care. Certainty of evidence varied training. Pre-vocational training was superior to
from very low to moderate, with the majority being of low psychiatric care only in improving mental health
certainty (web Annex). symptoms. No mental health outcomes were available for
65
Guidelines on mental health at work
For quality of life, augmented supported employment For adverse effects (operationalized as drop-out), no
resulted in better improvements in quality of life compared differences between the interventions which included
to psychiatric care, but pre-vocational training was better this outcome were observed (web Annex). Pre-vocational
than augmented supported employment for improving training resulted in lower numbers of hospital admissions
quality of life. Re-employment witnessed a small effect in compared to psychiatric care, but there were no other
improving quality of life compared to care as usual. There differences in hospitalization between interventions.
were no substantial impacts of supported employment
compared to pre-vocational training, transitional
employment or augmented supported employment;
however, supported employment had a more beneficial
effect on quality of life than psychiatric care alone.
Evidence-to-decision considerations
For values, most individuals living with severe mental settings since there is a need for available vocational and
health conditions consistently report a desire to pursue mental health services to take an active role in delivering
targeting key recovery processes, as well as enhancing For health equity, equality and discrimination, it was noted
social and economic inclusion in the community. However, that the majority of the evidence relates to severe mental
there are likely to be individual preferences for the different health conditions. For example, in one review (135), the
intervention options available. Providers of mental health majority of included diagnoses were psychotic disorders
prevention or care for workers, indicated vocational and, in van Rijn (137) the majority were schizophrenia,
support as the intervention for which they needed the followed by affective disorders and major depression. Fadyl
most information and training (web Annex: Values and (138) included studies with people living with mild-to-
preferences survey). There was no direct examination of moderate mental health conditions, the majority of which
resource requirements or cost-effectiveness. Augmented were depression and anxiety, and found positive effects of
and supported employment may be resource-intensive vocational interventions on gaining employment. However,
approaches, which may not be feasible in low-income retaining specification of the recommendation to severe
66
Recommendations for gaining employment for people living with mental health conditions
mental health conditions only, was decided because: 1) living by work freely chosen or accepted in a labour market
it is in line with the majority of the evidence; and 2) the and work environment that is open, inclusive and accessible
GDG expressed concern that lower-income countries may to persons with disabilities.” Sociocultural acceptability
not feasibly be able to provide these programmes for the may be affected by employers not being aware of the option
volume of persons meeting criteria for more commonly of – or their potential role in – recovery-oriented strategies.
occurring mental health conditions. No other subgroup It may also be influenced by prospective colleagues or
analyses (such as by gender or race) were included. supervisors who are not sensitized to the need to reduce
stigma regarding mental health at work.
Feasibility depends on the available infrastructure of
communities offering recovery-oriented strategies. For The GDG concluded that the benefits of recovery-oriented
instance, supported employment may depend on the wider strategies on enhancing vocational and economic inclusion
economic context or on the availability of a workforce on obtaining and maintaining employment outweigh the
(labour or health) to deliver support. harms (of potential drop-out). While it would have been
preferable to indicate that the recommendation applies
Most included studies were performed in high-income across the spectrum of mental health conditions, most of
countries in Europe and North America and a minority were the evidence was in support of the benefits for people living
conducted in an upper-middle-income country in Asia. An with severe mental health conditions. Both augmented
intersectoral approach is required to mobilize resources supported employment and supported employment
and strategies which enhance vocational and economic demonstrated particular promise on the key outcomes.
inclusion. Involvement of the family and the community in However, for mental health and quality-of-life-outcomes,
recovery-oriented psychosocial intervention programmes while benefits were observed, the results did not clearly
can be important to their sustainability. Feasibility may also indicate superiority for any one intervention (i.e. where
be influenced by employers’ infrastructure for participating in reported, the interventions were equally comparable),
such programmes. though it was noted that recovery-oriented strategies were
on the whole better than psychiatric care only with regard to
Supporting the right of persons living with psychosocial these outcomes.
disabilities to gain employment and stay in it is in line with
universal human rights principles (e.g. Article 23 of the
Universal Declaration of Human Rights). Article 27 on Work
and Employment of the UNCRPD recognizes “the right of
persons with disabilities to work, on an equal basis with
others; this includes the right to the opportunity to gain a
67
Guidelines on mental health at work
68
©
W
HO
/L
in
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ay
M
ac
ke
nz
ie
Screening
programmes
Guidelines on mental health at work
ON
TI
13
ES
QU
Y
KE
Screening programmes
Key remarks:
▶ This statement does not apply to screening which may be required by necessity of regulation
in some occupations, or screening when workers have been exposed to potential hazards to
(mental) health.
70
Screening programmes
Key question 13 investigated whether the use of screening false positives and false negatives when screening for mental
programmes – i.e. programmes that are designed to identify health symptoms – such that one-time-screening results,
workers with mental health problems and which are if inaccurate and if misinterpreted, could lead to harms.
then followed by providing them with, or directing them Reporting bias is also a concern in screening programmes
towards, the necessary support during employment19 – were where workers are likely to under-report their symptoms
beneficial (Annex 3). A systematic review of primary studies for fear of confidentiality breaches (139). On balance,
was conducted. Thirteen studies were identified, with the GDG concluded that it was not possible to provide a
seven eligible for GRADE, for screening programmes versus recommendation for or against screening programmes;
screening followed by care as usual, wait list control or no therefore no recommendation was made.
Low-certainty data indicated no impact of screening decision pertains to screening programmes conducted
programmes on reducing mental health symptoms or during employment, rather than pre-employment screening.
improving positive mental health. Very low-certainty The GDG noted that if screening takes place at work (e.g. by
data found small not significant improvements in work necessity of regulations), then the screening programmes
which were not sustained at 12-month follow-up, and ▶ ensured follow-up to access evidence-based
no effects on job satisfaction. There was a negligible treatment or care for people who screen positive (see
improvement in absence which was not significant, although Recommendations 3 and 10 for relevant interventions
there was evidence for a small positive effect, albeit of very for people with emotional distress);
low certainty, at longer-term 5-year follow-up. One trial ▶ involvement of qualified, professionally impartial
indicated greater likelihood of absence and lower likelihood health providers to deliver and interpret screening
of improvement in productivity for workers in receipt of results and to manage referral to follow-up care;
screening programmes. Small improvements from low- ▶ ensured privacy and confidentiality;
certainty data suggested that screening programmes were ▶ adherence to human rights principles and ethical
beneficial with regard to immediate help-seeking behaviours considerations in order to prevent discriminatory
but this was not sustained at follow-up assessments. treatment of persons screening positive.
Adherence to the supports following positive screening was
low in one trial. No other direct harms were reported. The Technical and ethical guidelines on workers
19
Evidence for pre-employment screening was not considered as it falls outside the scope of the guidelines.
71
Guidelines on mental health at work
Evidence-to-decision considerations
Improvement of mental health and work-related outcomes that screening without effective follow-up can be harmful
is valued by all stakeholders. While two included studies (142). This may render the feasibility of large-scale screening
indicated that user satisfaction was positive, additional programmes unethical in many contexts since access to
data indicate that workers are concerned about stigma quality mental health services remains limited. While
and discrimination if they screen positive, as well as the screening and identification of individuals in need of support/
confidentiality of their data to employers. Indeed, the lowest care with the goal of reducing the burden of mental ill-health
preference was given to screening programmes (web Annex: is in accordance with universal human rights principles,
Values and preferences survey). This is also reflected in wider the screening of individuals at work elicits concerns about
literature where such concerns generate under-reporting of privacy, confidentiality and informed consent. In this
mental ill-health by workers, even if their symptoms would situation, screening may appear to be involuntary and have
indicate a need for further support (139). a risk of discrimination with few observable benefits on key
72
© WHO / Blink Media - Neil Nuia
Research gaps
The GDG identified several gaps in the evidence included
within the scope of these guidelines.
73
Guidelines on mental health at work
▶ Across all intervention types, there is a critical need, where applicable, to increase the volume and quality of evidence
for effectiveness and feasibility in under-researched populations – i.e. the informal sector, SMEs and LMICs – and
for the selective at-risk workforce, such as international and national humanitarian workers, health workers not
responsible for direct clinical care (e.g. workers in health administration), community health workers and other
▶ Across all intervention types, there is a need for sociodemographic subgroup analyses to determine whether there
are differential benefits or harms associated with intervention recipients’ sociodemographic (e.g. gender, age, race) or
occupational status (e.g. occupational sector, contract status (formal, informal, self-employed, size of workplace). This
includes clear reporting of these characteristics under study or review, and clear reporting of the mental health status
of participants at baseline.
▶ Overall, there is a need for implementation research to study the acceptability, accessibility and uptake of
▶ Overall, there is a need for quality investigation to study the effectiveness and feasibility of delivering preventive
interventions which are combined at multiple levels of delivery (e.g. combinations of organizational, managers,
▶ There is a need to increase the availability of high-quality research on organizational interventions (including policies),
and their impact on mental health and work-related outcomes, regarding salient risk and protective factors at work
(which were not encountered by the evidence reviews of these guidelines) such as bullying, parental leave etc.
▶ There is also a need to increase high-quality research in the cost-effectiveness of interventions for mental health
at work.
74
Research gaps
health outcomes, psychosocial risks, and work-related outcomes – which assesses organizational interventions
that mitigate the known risk factors to workers’ mental health. This includes clear specification of the risk factors
addressed by the intervention, and designs which allow for establishing which components of the intervention
▶ Cluster-randomized designs, which include process evaluations, can be used to assess the effectiveness of
complex interventions in work settings, and the feasibility and acceptability to stakeholders.
▶ The common components for effective implementation of organizational interventions need to be identified to
▶ There is a need for an increase in better-quality investigation of emerging risk factors for the future of work and
how these can be mitigated. The evidence base should also be strengthened, taking account of ongoing changes
risk factors for the mental health of health, emergency and humanitarian workers. Studies should utilize validated
and culturally suitable measures of mental health outcomes, including disaggregation by sociodemographic
compared to other intervention levels for health, emergency and humanitarian workers.
symptoms of emotional distress or meeting criteria for mental health conditions, in order to improve positive
mental health and reduce symptoms of mental health conditions, suicidal behaviours and substance use. While
there is a relatively better body of work in the field of return-to-work interventions, there remains a gap in
evidence for workplace accommodations for workers with mental health conditions – i.e. those who are in work
either following a return to work or never having taken absence due to a mental health condition.
▶ Increased evidence on the factors for feasible, non-stigmatizing implementation of accommodations for workers
75
Guidelines on mental health at work
▶ Increase evidence of the effectiveness of manager training for mental health on priority outcomes (e.g. workers’
▶ Include a longer duration of follow-up (greater than 6 months) for key outcomes such as supervisees’ mental health.
▶ An increase in studies that identify effective components of manager training for mental health, including delivery
▶ An increase in better-quality studies and/or trials of leadership-oriented manager training and its impact on
health outcomes.
▶ An increase in better-quality studies on interventions that address help-seeking outcomes effectively (e.g. by
of help to colleagues in distress and on increasing help-seeking behaviours (including for the prevention of suicide).
▶ An increase in studies which identify effective components of workers’ training for mental health, including
humanitarian and emergency personnel in knowledge, attitudes and skills for mental health.
▶ An increase in evidence which identifies medium- to long-term follow-up duration effects to inform decisions as to
76
Research gaps
health diagnosis through use of diagnostic assessments at baseline and follow-up to determine the extent of
▶ An increase in better-quality studies which assess the comparative efficacy and cost-effectiveness of specific
individual interventions, which include medium- to long-term follow-up to assess sustainability of effects.
▶ An increase in better-quality studies which include validated work-related outcomes when assessing the effects of
▶ An increase in studies which identify effective components of (work-focused) psychosocial interventions for
mental health and work-related outcomes, such as delivery components (e.g. duration) and content components
(e.g. mode of psychosocial intervention).
▶ An increase in studies of individual interventions which include suicidal behaviours and substance use outcomes.
▶ An increase in effectiveness and implementation research which delineates additive or comparative effects
of multimodal programmes (e.g. combining individual and organizational interventions) compared to single-
▶ An increase in better-quality studies which focus on sustainable return to work (e.g. by increasing the duration of
▶ Greater inclusion of outcomes that indicate the benefit of the intervention – such as duration of time returned to
work, duration of time from partial return to work until full return to work, productivity and ability to work (rather
than only outcomes on reduction in absence days due to mental health conditions).
▶ An increase in studies that investigate cost-effectiveness of the intervention options for return to work following
▶ An increase in better-quality research to assess which combination of work-directed and clinical interventions are
77
Guidelines on mental health at work
Research gaps for gaining employment for people living with mental
health conditions
▶ An increase in studies which investigate the effectiveness of recovery-oriented strategies that enhance vocational
and economic inclusion and that consistently include outcomes on recovery for mental health conditions and
▶ An increase in better-quality studies which investigate the cost-effectiveness of options for recovery-oriented
▶ An increase in studies which investigate the effectiveness and feasibility of implementing recovery-oriented
▶ In order to be able to make a recommendation, high-quality and sufficiently powered research is needed to
evaluate the benefits and harms of screening programmes at work and their efficacy in reducing the symptoms of
78
© WHO / Blink Media - Gareth Bentley
Dissemination
and update of the
guidelines
79
Guidelines on mental health at work
Dissemination
The guidelines are available on the WHO website in English, with the executive summary available in all six United Nations
languages. National ministries responsible for mental health and occupational health will be notified of the guidelines
through WHO’s regional and country offices. Ministries for labour and employment, and representative bodies for workers
and employers, will be notified of the guidelines through the ILO. The guidelines will be shared with a broad network of
international partners, including representative organizations for persons responsible for or committed to the health,
safety and well-being of workers, as well as WHO collaborating centres, universities, nongovernmental organizations and
UN agencies.
Implementation
To facilitate implementation of the recommendations, a policy brief will accompany the guidelines, developed jointly by
WHO and ILO. The policy brief will be made available in the six United Nations languages to facilitate wide dissemination
and will present policy and implementation options which will be derived from the guidelines. WHO regional and country
offices will encourage implementation at country level. The implementation may also be supported locally through the
adoption and implementation of the WHO Comprehensive Mental Health Action Plan (2013–2030) and the WHO global
strategy for health, environment and climate change, both of which have been adopted by the World Health Assembly.
Additionally, WHO will disseminate the guidelines and the joint policy brief through a broad network of international
partners, including national ministries of health, WHO collaborating centres, key stakeholder groups (which represent the
target audience of these guidelines), universities, nongovernmental organizations and United Nations agencies. The ILO will
promote the dissemination of the policy brief among its tripartite constituents, including ministries of labour, in addition to
employer and worker organizations. This will provide policy guidance on the roles and responsibilities of actors in the world
of work in preventing, protecting and promoting, and supporting mental health at work.
80
Dissemination and update of the guidelines
WHO will seek to monitor uptake and implementation of the guidelines in national policies and programmes by reviewing
the number of countries that have adapted or endorsed the guidelines. WHO will use the WHO atlas [17] and other routine
approaches (e.g. the WHO MiNDbank database20) to assess how national policies and service delivery for workers have been
adapted to integrate the recommendations. WHO will seek to continue to collect regular feedback from implementation
activities and key stakeholders in order to evaluate the usefulness and impact of the guidelines.
The guidelines are expected to be valid for a period of five years. The WHO Secretariat, in consultation with technical experts, will
continue to follow research development in mental health promotion, prevention and interventions for workers – particularly
for questions in which the certainty of evidence was found to be of low or very low certainty. If new evidence emerges or other
important considerations arise which may have an impact on the current recommendations, WHO will coordinate an update of the
guidelines, following the procedures outlined in the WHO handbook for guideline development, second edition [26].
20
See: https://www.mindbank.info (accessed 29 May 2022).
81
Guidelines on mental health at work
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IM, Marshall M et al. Supported employment for adults 144. Code of ethics and professional conduct. Geneva: World
with severe mental illness. Cochrane Database Syst Rev. Health Organization; 2020 (https://www.who.int/about/
2013;(9):CD008297. ethics, accessed 22 May 2022).
137. van Rijn RM, Carlier BE, Schuring M, Burdorf A. Work 145. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran
as treatment? The effectiveness of re-employment J et al. AMSTAR 2: a critical appraisal tool for systematic
programmes for unemployed persons with severe reviews that include randomised or non-randomised
mental health problems on health and quality of life: a studies of healthcare interventions, or both. BMJ.
systematic review and meta-analysis. Occup Environ Med. 2017;358:j4008.
2016;73(4):275–9. 146. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y,
138. Fadyl JK, Anstiss D, Reed K, Khoronzhevych M, Levack Alonso-Coello P et al. GRADE: an emerging consensus
WM. Effectiveness of vocational interventions for on rating quality of evidence and strength of
gaining paid work for people living with mild to recommendations. BMJ. 2008;336(7650):924–6.
moderate mental health conditions: systematic review 147. Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA,
and meta-analysis. BMJ Open. 2020;10(10):e039699. Iorio A et al. The GRADE working group clarifies the
139. Marshall RE, Milligan-Saville J, Petrie K, Bryant RA, construct of certainty of evidence. J Clin Epidemiol.
Mitchell PB, Harvey SB. Mental health screening 2017;87:4–13.
amongst police officers: factors associated with under- 148. Rehfuess EA, Stratil JM, Scheel IB, Portela A, Norris SL,
reporting of symptoms. BMC Psychiatry. 2021;21(1):1–8. Baltussen R. The WHO-INTEGRATE evidence to decision
140. Technical and ethical guidelines for workers’ health framework version 1.0: integrating WHO norms and
surveillance (OSH No. 72) Geneva: International Labour values and a complexity perspective. BMJ Glob Health.
Office; 1998 (https://www.ilo.org/wcmsp5/groups/ 2019;4(Suppl 1):e000844.
public/---ed_protect/---protrav/---safework/documents/ 149. Alonso-Coello P, Schünemann HJ, Moberg J,
normativeinstrument/wcms_177384.pdf, accessed 26 Brignardello-Petersen R, Akl EA, Davoli M et al. GRADE
August 2022). Evidence to Decision (EtD) frameworks: a systematic
141. Occupational health services recommendation (No. and transparent approach to making well informed
171). Geneva: International Labour Organization; healthcare choices. 1 Introduction. BMJ. 2016:353:i2016
1985 (https://www.ilo.org/dyn/normlex/ 150. Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y,
en/f?p=NORMLEXPUB:55:0:::55:P55_TYPE,P55_ Vist GE, Liberati A et al. Going from evidence to
LANG,P55_DOCUMENT,P55_NODE:REC,en,R171,/ recommendations. BMJ. 2008;336(7652):1049–51.
Document#:~:text=Occupational%20health%20
services%20should%20participate%20in%20the%20
training%20and%20regular,to%20occupational%20
safety%20and%20health, accessed 26 August 2022).
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Glossary
91
© WHO / Malin Bring
Guidelines on mental health at work
Adverse effects For the purposes of these guidelines, adverse effects are defined as outcomes of the key
questions and could include any untoward occurrence to a study participant caused by the
intervention of interest, such as drop-out.
Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has
Burnout
not been successfully managed. It has three dimensions: feelings of energy depletion or
exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism
related to one’s job; and reduced professional efficacy.21 Burnout may be a frequently used
idiom for distress in the workplace.
Emotional distress This constitutes, for instance, sadness, anger, anxiety, irritability, or other negative emotional
states. People in emotional distress may or may not meet ICD criteria for a mental disorder.
Evidence-to- These are tabular displays of relevant considerations which are used to make a decision or to
decision formulate a recommendation.
frameworks
GRADE evidence These are tabular displays of summary measures of effect and the GRADE certainty
profiles assessments of the body of evidence for a specific question – usually defined by population,
intervention, comparator and outcome (PICO) format.
Help-seeking For the purposes of these guidelines, help-seeking behaviour is defined as an outcome of the
behaviour key questions, which includes a person taking actions to seek or access support for a given
problem such as a mental health condition.
Informal This includes employees (or persons not classified by status in employment) who are not
employment protected by national labour legislation in that job (i.e. not affiliated to a social security scheme
related to the job or not entitled to certain employment benefits); employers, members of
producers’ cooperatives and own account workers (only if what is produced is for sale) in a unit
of production that is considered informal; and contributing family workers.22
Informal sector All workers in unincorporated enterprises that produce at least partly for the market and are
not registered.
Manager For the purposes of these guidelines, a manager is a worker who is responsible for supervising,
managing or leading another worker or workers - i.e. managers are employees who plan, direct,
coordinate and evaluate the overall activities of enterprises or of organizational units within them.23
21
International Classification of Diseases 11th Revision. Geneva: World Health Organization (https://icd.who.int/en, accessed 25 May 2022).
22
Indicator description: informality. ILOSTAT. Geneva: International Labour Organization (Indicator description: Informality - ILOSTAT, accessed 25 May 2022).
23
International Standard Classification of Occupations 2008 (ISCO-08): structure, group definitions and correspondence tables. Geneva: International Labour Organization
(https://www.ilo.org/global/publications/ilo-bookstore/order-online/books/WCMS_172572/lang--en/index.htm, accessed 25 May 2022).
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Glossary
Managerial, For the purposes of these guidelines, managerial, leadership style and communication are
leadership style and outcomes of the key questions which capture the manner of communication, consideration
communication of individual employees, justice in managerial behaviours, social support, provision of clarity,
supply of information and feedback, promotion of employee participation and control, or
leadership style (e.g. abusive, laissez-faire, authoritarian, participative).
Mental disorder As defined by the ICD-11, mental disorders are syndromes characterized by clinically significant
disturbance in an individual’s cognition, emotional regulation, or behaviour that reflects a
dysfunction in the psychological, biological or developmental processes that underlie mental and
behavioural functioning. These disturbances are usually associated with distress or impairment
in personal, family, social, educational, occupational or other important areas of functioning.
Mental health A state of mental well-being that enables people to cope with the stresses of life, to realize their
abilities, to learn well and work well, and to contribute to their communities. Mental health is an
integral component of health and well-being and is more than the absence of mental disorder.
Mental health A broad term covering mental disorders and psychosocial disabilities. It also covers other
conditions mental states associated with significant distress, impairment in functioning or risk of self-
harm. It thus includes significant emotional distress.
For the purposes of these guidelines, mental health knowledge, attitudes and skills are outcomes
Mental health
of the key questions. This term captures the key target variables of interventions to reduce stigma
knowledge and
through increasing literacy (knowledge) for mental health, changing stigmatizing attitudes, and
attitudes, skills
actions or behaviours which indicate the provision of appropriate support to others
Positive mental For the purposes of these guidelines, positive mental health is an outcome of the key questions.
health It is intended to capture aspects of mental well-being, life satisfaction, positive self-concept,
self-esteem, self-control, self-efficacy resilience (in contrast to mental health conditions).
Psychosocial Aligned with the Convention on the Rights of Persons with Disabilities, it is disability that
disability arises when someone with a long-term mental impairment interacts with various barriers
that may hinder the person’s full and effective participation in society on an equal basis with
others. Examples of such barriers are discrimination, stigma and exclusion.
24
England MJ, Butler AS, Gonzalez ML, editors. Psychosocial interventions for mental and substance use disorders: a framework for establishing evidence-based standards.
Washington (DC): National Academies Press; 2015.
25
Barbui C, Purgato M, Abdulmalik J, Acarturk C, Eaton J, Gastaldon C et al. Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income
countries: an umbrella review. Lancet Psychiatry. 2020;7(2):162–72. doi:10.1016/S2215-0366(19)30511-5.
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Quality of life For the purposes of these guidelines, quality of life is an outcome of the key questions which
captures an individual’s perception of their position in life in the context of the culture and value
systems in which they live and in relation to their goals, expectations, standards and concerns.
Functioning For the purposes of these guidelines, functioning is an outcome of the key questions which
describes the ability to conduct activities and to participate in life domains other than work
(e.g. cognition, communication, mobility, self-care, relationships, domestic life, community
and civic life activities, life participation).
Satisfaction with For the purposes of these guidelines, satisfaction with care is an outcome of the key
care questions and captures users’ and families’ satisfaction with care, such as their involvement
in the decision‐making process, quality of information provided, communication about the
condition, and care providers’ skills and competencies.
Substance use For the purposes of these guidelines, substance use is an outcome of the key questions,
capturing alcohol or illicit drug use measured as alcohol use, frequency of alcohol use, alcohol-
related problems, alcohol initiation, drunkenness initiation, binge drinking and alcohol misuse.
Drug use refers to the use of cannabis, opioids and/or stimulants/misuse of prescription drugs.
Suicidal behaviours For the purposes of these guidelines, suicidal behaviours are an outcome of the key questions,
capturing self-harm (including suicide attempt), suicidal ideation and suicide mortality.
For the purposes of these guidelines, a worker is any person above 18 years of age in paid work.
Worker
Workers (persons in employment) are usually defined as all those of working age who, during a short
reference period, were engaged in any activity to produce goods or provide services for pay or profit.
Work-related For the purposes of these guidelines, work-related outcomes are an outcome of the key
outcomes questions, capturing a broad range of variables which are indicative of a person’s functioning
at work, such as absenteeism (regular absence from work), presenteeism (being at, or present
at, or attending work when not fully functioning and thereby reduced efficiency is assumed),
productivity (effectiveness in work tasks), work engagement (perception of a fulfilling
connection to work), work ability (functional capacity and competence to participate in work),
absence, turnover, resignation, return to work, job retention, job satisfaction, job tenure or
length, employment status (employed part-time, full-time, unemployed).
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Annex 1
Annex 1
Contributors to the guidelines
The following persons contributed to the development of the guidelines. Their roles are summarized in Table 1.
1. The WHO Steering Group, composed of WHO departments relevant to the guideline topic, was formed to provide
overall coordination and technical support during the guideline development process.
Name Department
Faten Ben Abdelaziz Health Promotion
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2. T
he Guideline Development Group (GDG) included technical, academic, implementation and policy
experts. Selection of GDG members took into account their relevant areas of expertise, sex and geographical representation.
Applied epidemiology,
Professor, Institute for Health workplace mental health,
Anthony D. Transformation, School of Health Western occupational health and
LaMontagne & Social Development, Deakin Pacific Region safety interventions, policy
University, Australia interventions for the
workplace evaluation
Development and
implementation of national,
Director, Genomics and Society, Region of the regional and international
Sapna Mahajand
Genome Canada, Canada Americas workplace mental health
standards, public health
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Development, implementation
Professor, Institute of Work and evaluation of
Psychology, Sheffield University European organizational interventions
Karina Nielsen
Management School, The University of Region for mental wellbeing,
Sheffield, UK organizational psychology,
return to work
a
Affiliation from start of guideline development and during recommendations meeting: International Committee of the Red
Cross, Switzerland.
b
Affiliation from start of guideline development and during recommendations meeting: Director, Research Center for
Overwork-Related Disorders, Japan Organization of Occupational Health and Safety, Japan
c
Participated in the GDG up to the recommendations meeting, at which time personal reasons prevented further
participation.
d
Affiliation from start of guideline development; prior to the recommendations meeting was with the Mental Health
Commission of Canada, Canada.
e
Participated in the GDG up to the recommendations meeting. Requested to withdraw from GDG in May 2021, due to
personal circumstances.
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3. The External Review Group (ERG), composed of technical experts, employers and workers’
organizations, and representatives of people with lived experience of mental health conducted a peer review of the
draft guidelines to provide technical feedback, identify errors of fact, comment on clarity of language and provide
considerations related to implementation, adaptation and contextual issues. Selection of ERG members took into
account members’ relevant areas of expertise, sex and geographical representation.
Fabrice Althaus International Committee of the Red Cross, Switzerland European Region
Eastern
Lamia Bouzgarrou University of Monastir, Tunisia Mediterranean
Region
Nadine Harker South African Medical Research Council, South Africa African Region
Ehimare Iden Occupational Health and Safety Managers, Nigeria African Region
João Silvestre Silva-Junior São Camilo University Center, Brazil Region of the
Americas
Inah Kim Hanyang University College of Medicine, Republic of Korea Western Pacific
Region
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Nina Hedegaard Nielsen Independent psychosocial risks expert, Denmark European Region
Godfrey Zari Rukundo Mbara University of Science and Technology, Uganda African Region
Eastern
Vandad Sharifi Tehran University of Medical Sciences, Iran Mediterranean
Region
Eastern
Mohammad Taghi Yasami Shahid Beheshti University of Medical Sciences, Iran Mediterranean
Region
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Sarah Copsey
European Agency for Safety and Health at Work [EU-OSHA]
Julia Flintrop
Olga Kalina
European Network of (Ex)Users and Survivors of Psychiatry [ENUSP]
Guadalupe Morales Cano
Rose Boucaut
Miguel R. Jorge
Rose Boucaut
*Health worker bodies who are members of the World Health Professionals Alliance (WHPA).
4. A guideline methodologist, Corrado Barbui, Professor of Psychiatry at the Department of Medicine and
Public Health, University of Verona, Italy (WHO Collaborating Centre for Research and Training in Mental Health and
Service Evaluation) was appointed. Consultants were also appointed to provide technical support to the evidence
teams in the development of their search strategy, development of evidence profiles, and in conducting the supporting
evidence work: Aemal Akhtar (Denmark), Gergö Baranyi (United Kingdom), Chiara Gastaldon (Italy), Georgia Michlig
(USA), Davide Papola (Italy).
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5. Evidence review teams and supporting evidence teams were contracted by the WHO Steering
Group to perform evidence reviews for specific key questions, develop GRADE evidence profiles, assess the certainty of the
body of evidence, draft evidence-to-decision tables; or were contracted for the supporting evidence work.
Name Affiliation
Key questions: Organizational interventions (Questions 1, 2, 3)
Hideaki Arima
Yumi Asai
Yui Hidaka
Mako Iida
Mai Iwanaga
Yuka Kobayashi
Yu Komase
Natsu Sasaki
Reiko Inoue
Kitasato University School of Medicine, Japan
Akizumi Tsutsumi **
Hisashi Eguchi
Akiomi Inoue
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Name Affiliation
Key questions: Manager and worker training interventions, screening programmes (Questions 4, 5, 6, 7, 13)
Taylor Braund
Richard Bryant*
Jasmine Choi-Christou
Mark Deady
Nadine Garland
University of New South Wales, Australia
Aimee Gayed
Sam Haffar
Sophia Mobbs
Katherine Petrie
Jessica Strudwick
Arpana Amarnath
Pim Cuijpers*
Vrije University, WHO Collaborating Centre for Research and
Dissemination of Psychological Interventions, The Netherlands
Eirini Karyotaki
Clara Miguel
Key questions: Return to work and gaining employment (Questions 11, 12)
Liam O’Mara
Kathleen Pike*
Columbia University, WHO Collaborating Centre for Capacity Building and
Training in Global Mental Health, USA
Adam Rosenfeld
Hikari Shumsky
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Annex 1
Name Affiliation
Supporting evidence: Implementation review
Rachel Lewis
Alice Sinclair
Affinity Health at Work, United Kingdom
Jo Yarker*
Fehmidah Munir
Vanessa Evans
University of British Columbia, Canada
Raymond Lam
Jill Murphy**
Andrew Greenshaw**
University of Alberta, Canada
Jasmine Noble
*Lead
** Co-Leads
6. T
echnical advisors were staff members of the International Labour Organization (ILO) led by Manal Azzi, Team
Lead on Occupational Safety and Health, ILO Headquarters, Geneva, Switzerland. The ILO is a tripartite United Nations
agency which includes governments, employers’ organizations and workers’ organizations of its 187 Member States. The
international bodies of the workers (International Trade Union Confederation) and employers (International Organisation
of Employers) organizations were key stakeholders in the guidelines and were engaged in aspects of the guideline
development, such as review of the values and preferences survey, and the review by the External Review Group.
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7. Funders: The Wellcome Trust, an independent global charitable foundation with a focus on science and health,
provided funding to the WHO Department of Mental Health and Substance Use for the development of the guidelines.
A representative of the funder attended the recommendations meeting as an observer. Observers are not permitted to
participate in the meeting to develop recommendations.
Identifying, Technical
Technical
appraising and advice on Technical support
support &
synthesizing search to evidence teams
coordination
evidence strategy
Members Selected
of the GDG members Technical
Technical Technical support
Supporting advised on of the ERG advice on
support & to integrate
evidence imp review advised design of
coordination findings
and survey on survey survey
design design
Invited to
provide
Technical Technical support Technical
Developing technical
support & to GDG and WHO support to
recommendations advice during
coordination SG GDG
selected
discussions
Drafting the
guidelines
Peer review
Approval from
NA NA NA NA NA
WHO GRC
Publishing and
NA NA NA NA NA
disseminating
Abbreviations: NA, not applicable, WHO SG, WHO Steering Group. GRC, WHO Guidelines Review Committee
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Annex 2
Annex 2
Managing declarations of
interest and conflicts of interest
The WHO Steering Group followed the current WHO Compliance, Risk Management and Ethics (CRE) policy. Prospective
members of the GDG, ERG and evidence team were asked to complete the WHO Declaration of Interests (DOI) form and
to provide their curriculum vitae. These documents, along with additional information (obtained through the Internet
and bibliographic database searches), were reviewed by the WHO Secretariat to identify conflicts of interest related to the
guideline topic.
Additionally, the names and brief biographies of potential GDG members were published on the WHO website for more
than two weeks, together with a description of the objective of the meeting, for public review and comment. No concerns
were received.
Interests were assessed as insignificant or minimal if they were considered unlikely to affect, or unlikely to reasonably be
perceived to affect, the individual’s judgement when assessing evidence or formulating recommendations. If an interest was
deemed to be potentially significant, the following management options were considered: 1) limited participation of the
individual in the guideline development process; and 2) full exclusion from the process.
At the beginning of the guideline meetings, the declaration of interests of each GDG member was presented. GDG members
and evidence teams attending the meetings were asked to provide updates if their declarations of interests had changed.
Where changes had occurred, the WHO Steering Group considered the management options as noted above. The GDG, ERG,
evidence teams and meeting observers were required to sign a confidentiality agreement.
ILO staff are subject to declarations of interest and conflict of interest management according to the policies of the ILO
(Office Directive on Ethics in the Office (143) and, in the same way as WHO staff, are subject to the Standards of Conduct for
the International Civil Service. WHO staff are also subject to WHO’s Code of Ethics and Professional Conduct (144). Meeting
observers and organization representatives were not required to complete a declaration of interests because they did not
actively participate in the guideline development discussions.
All contributors declared no interests, with the exception of those listed below. A summary of declared interests and how
they were managed is provided:
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GDG Members
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Annex 3
Annex 3
Developing the scope, key
questions and outcomes
Prior to the development of the guidelines, an initial meeting – the Landscape Forum on Workplace Mental Health was
held in Geneva, Switzerland in November 2019. One key objective was to discuss the extent of evidence for interventions
addressing mental health at work. Following this meeting, the WHO Steering Group performed preliminary scoping of the
available evidence in preparation for a draft scope for the guidelines. With the support of the Steering Group and guideline
methodologist, the scope was reviewed by the GDG at its first meeting, held virtually in April 2020, which discussed
and agreed on the final scope and PICO (population, intervention, comparison, outcome) questions of the guidelines.
Background questions were additionally devised in order to scope the best available evidence sources and to provide
relevant contextual information for the prospective main body of the guidelines and for prospective evidence-to-decision
considerations – in particular, 1) risk factors at work and their impact on mental health outcomes; and 2) the prevalence of
mental health outcomes in general working populations and specific subpopulations (such as those identified as minority
groups and humanitarian and health workers).
Members of the WHO Steering Group, in consultation with the GDG and the methodologist, developed a list of outcomes that
were most relevant to specific PICO questions. The GDG then rated each outcome on a scale from 1 to 9 and indicated whether
it considered each outcome critical (rated 7–9), important (rated 4–6) or not important (rated 1–3) for decision-making.
The final key questions are provided in the following table which includes the critical and important outcomes. Definitions
of terms can be found in the glossary. The details of the PICO format for each key question are provided in the relevant
section of the web Annex: Evidence profiles.
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OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; positive mental health; quality of life and functioning;
work-related outcomes.
Important outcomes are: adverse effects; substance use; suicidal behaviours.
OUTCOMES:
Critical outcomes are: MH symptoms and disorders; Positive MH; Quality of life and Functioning; Substance use;
Suicidal behaviours; Work-related outcomes;
Important outcomes are: Adverse effects
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; quality of life and functioning; substance use; suicidal
behaviours; work-related outcomes.
Important outcomes are: adverse effects; positive mental health.
QUESTION 4. What training for managers (a) improves knowledge, attitudes and skills/
behaviours to support the mental health and well-being of workers and/or (b) improves their
workers’ positive mental health and reduces symptoms of mental health conditions, suicidal
behaviours and substance use?
OUTCOMES:
Critical outcomes are: help-seeking behaviour (supervisees); managerial leadership style and communication
(managers); mental health knowledge, attitudes and skills (managers); mental health symptoms and disorders
(supervisees); positive mental health (supervisees); work-related outcomes (supervisees).
Important outcomes are: adverse effects (managers); substance use (supervisees); suicidal behaviours (supervisees);
quality of life and functioning (supervisees).
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Annex 3
QUESTION 5. What training for managers of civilian health, emergency and humanitarian
workers (a) improves knowledge, attitudes and skills/behaviours to support the mental health
and well-being of workers and/or (b) improves their workers’ positive mental health and reduces
symptoms of mental health conditions, suicidal behaviours and substance use?
OUTCOMES:
Critical outcomes are: help-seeking behaviour (supervisees); managerial leadership style and communication
(managers); mental health knowledge, attitudes and skills (managers); mental health symptoms and disorders
(supervisees); positive mental health (supervisees); work-related outcomes (supervisees).
Important outcomes are: adverse effects (managers); substance use (supervisees); suicidal behaviours (supervisees);
quality of life and functioning (supervisees).
QUESTION 6. What training for workers (a) improves knowledge, attitudes and skills/behaviours
to support the mental health and well-being of workers and/or (b) improves their colleagues’
positive mental health and reduces symptoms of mental health conditions, suicidal behaviours
and substance use?
OUTCOMES:
Critical outcomes are: help-seeking behaviour (colleagues); mental health knowledge, attitudes, skills (workers); mental
health symptoms and disorders (colleagues); positive mental health (colleagues); work-related outcomes (colleagues).
Important outcomes are: adverse effects (workers, colleagues); substance use (colleagues); suicidal behaviours
(colleagues); quality of life and functioning (colleagues).
QUESTION 7. What training for civilian health, emergency and humanitarian workers (a)
improves knowledge, attitudes and skills/behaviours to support the mental health and well-
being of workers and/or (b) improves colleagues’ positive mental health and reduces symptoms
of mental health conditions, suicidal behaviours and substance use?
OUTCOMES:
Critical outcomes are: help-seeking behaviour (colleagues); mental health knowledge, attitudes and skills (workers); mental
health symptoms and disorders (colleagues); positive mental health (colleagues); work-related outcomes (colleagues).
Important outcomes are: adverse effects (workers, colleagues); substance use (colleagues); suicidal behaviours (colleagues);
quality of life and functioning (colleagues).
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; positive mental health; quality of life and functioning;
work-related outcomes.
Important outcomes are: adverse effects; substance use; suicidal behaviours.
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Guidelines on mental health at work
QUESTION 9. What individual interventions (1A - psychosocial and/or 1B - physical activity and/
or 1C - health promotion [lifestyle] interventions) delivered to civilian health, emergency and
humanitarian workers improve positive mental health and reduce symptoms of mental health
conditions, suicidal behaviours and substance use?
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; positive mental health; quality of life and functioning;
substance use; suicidal behaviours; work-related outcomes.
Important outcomes are: adverse effects.
QUESTION 10. What individual interventions (1A - psychosocial and/or 1B - physical activity
and/or 1C - health promotion [lifestyle] interventions) delivered to workers with symptoms of
emotional distress or meeting criteria for mental health conditions improve positive mental
health and reduce symptoms of mental health conditions, suicidal behaviours and substance use?
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; positive mental health; quality of life and functioning;
substance use; suicidal behaviours; work-related outcomes.
Important outcomes are: adverse effects.
QUESTION 11. For people on absence due to mental health conditions, what interventions improve
(a) return to work, (b) absence and (c) positive mental health and reduce mental health symptoms?
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; quality of life and functioning; substance use; suicidal
behaviours; work-related outcomes.
Important outcomes are: adverse effects; positive mental health.
QUESTION 12. For people with a mental health condition, are recovery-oriented strategies
enhancing vocational and economic inclusion (such as supported employment) feasible and
effective?26
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; quality of life and functioning; work-related outcomes.
Important outcomes are: adverse effects; positive mental health; satisfaction with care.
QUESTION 13. Are screening programmes for mental health conditions at work acceptable and
do they reduce symptoms of mental health conditions in workers?
OUTCOMES:
Critical outcomes are: mental health symptoms and disorders; user satisfaction; work-related outcomes.
Important outcomes are: adverse effects; positive mental health; quality of life and functioning.
26
Update of the Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders, 2015. Key question. Geneva: World Health
Organization; 2015.
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Annex 4
Annex 4
Reviewing the evidence
and supporting evidence
Evidence reviews for key questions
Details of the selection process, search strategies, included reviews and primary studies for each PICO question are
presented in web Annex.
The Cochrane Database of Systematic Reviews, PubMed, EMBASE, PsycINFO and Global Index Medicus were searched to
identify existing systematic reviews that answered the key questions. On the advice of GDG members, the methodologist
and expert members of the evidence teams, where suitable reviews for specific outcomes were not available within the
past 5 years, the time frame was extended to a maximum of 10 years. The reviews that were identified were then evaluated
according to the following criteria:
▶ their methodology as appraised by the AMSTAR II (Assessing the Methodological Quality of Systematic Reviews tool
(Shea et al. (145));
▶ how directly they matched the PICO questions;
▶ whether they reported sufficient information to allow for an assessment of the certainty of the evidence (e.g. tables
with characteristics of included studies, risk-of-bias assessments at the study level, results of meta analyses in forest
plots);
▶ the date of the most recent review to ensure that the most up-to-date evidence was used.
The evidence teams prioritized the most recent and highest-quality (based on AMSTAR II ratings) reviews for each question
in relation to the population, intervention, comparison and outcomes. As many reviews as necessary were included to
address each question. A search strategy was developed in collaboration with the methodologist and evidence teams
to harmonize common search terms and strategy across the reviews. Reviews which included randomized designs were
prioritized in all key questions; however, controlled observational designs were also considered because of existing
knowledge on the common design of research in occupational settings/populations.
For two key questions (4 and 5) an update of an existing review was pursued in order to capture additional studies to better
answer the specific PICO questions. Question 13 was not addressed in an existing systematic review, and a systematic review
of primary studies was conducted. The evidence team, in consultation with the methodologist and the WHO Steering Group,
devised a new search strategy to identify relevant primary studies (web Annex). A total of 36 systematic reviews and nine
additional primary studies were included. The systematic review team also identified one network meta-analysis.
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Guidelines on mental health at work
In light of global changes in the modes of working as a result of the COVID-19 pandemic, the WHO Steering Group and
GDG considered areas of importance to supplement the evidence reviews, namely: the values and preferences of key
stakeholders and the implementation barriers and facilitators. Additionally, in light of the dearth of literature reported by
the evidence teams in relation to the informal sector, a third piece of supplementary evidence was commissioned. Full
reports of all three can be found in web Annex.
A mixed-methods survey was commissioned to capture current values and preferences of key stakeholders – workers,
employers, providers of mental health/occupational health services, including union representatives – in relation to the
outcomes and interventions in the guidelines scope. Key data from the survey were included in the evidence-to-decision
considerations.
A semi-structured interview with experts and providers of care for the informal sector was conducted in order to
identify the needs and potential avenues of work and mental health service delivery for this population.
A review of qualitative research was commissioned on the barriers to, and facilitators of, implementing interventions that
support workplace mental health. GRADE CerQual (Confidence in the Evidence from Reviews of Qualitative research)27 was
used to assess confidence in the findings of qualitative evidence.
Certainty of evidence
After identifying the best available evidence to answer each key question, another step was taken to determine the certainty
of this evidence – in other words, how confident could the GDG be that the evidence (estimate of effect) supported the
making of any recommendations on the basis of that evidence. The GRADE system was used to assess the certainty of the
body of quantitative evidence (from the evidence reviews) for each critical and important outcome (146).
27
See: https://www.cerqual.org/, accessed 29 May 2022.
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Annex 4
The evidence teams, supported by the methodologist, developed evidence profiles to summarize relative and absolute
estimates of effects and an assessment of the certainty of the evidence. The certainty of evidence for each question and each
outcome was rated as “high”, “moderate”, “low” or “very low” on the basis of established criteria, namely:
▶ study design (e.g. randomized designs increase certainty, observational designs reduce certainty);
▶ risk of bias (e.g. problems with how the studies were designed or conducted reduce certainty);
▶ inconsistency (e.g. if the studies in the review are very different in their results, this reduces certainty);
▶ indirectness (e.g. if the studies are not specific to the key PICO question (for instance, the population is slightly
different) this reduces certainty);
▶ imprecision (if there is a smaller number of participants in the studies, or the confidence intervals [CI] are wide, this
reduces certainty); and
▶ publication bias (e.g. if there are factors that would have unfairly enhanced the likelihood of these studies being
published, this reduces certainty) (147).
These assessments were presented to the GDG in GRADE evidence profiles for discussion and formulation of
recommendations. Evidence profiles for each key question are shown in web Annex.
Certainty Interpretation
We are very confident that the true effect lies close to the estimate. Further research is
High
unlikely to change confidence in the estimate of effect.
We are moderately confident in the estimate of effect. The true effect is likely to be
close to the estimate of effect, but there is a possibility that it is substantially different.
Moderate
Further research is likely to have an important impact on confidence in the estimate of
effect and may change the estimate.
Our confidence in the estimate of effect is limited. The true effect may be substantially
different from the estimate of effect. Further research is very likely to have an
Low
important impact on confidence in the estimate of effect and is very likely to change
the estimate.
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Guidelines on mental health at work
Annex 5
Developing the recommendations
The GDG met virtually for six duplicate sessions in June 2021. Graham Thornicroft and Jose Luis Ayuso-Mateos were chairs
of the meetings, which were held in duplicate sessions to accommodate the differences in time zones of GDG members.
Corrado Barbui, the methodologist, was selected as vice-chair due to anticipated absences of the two chairs.
Evidence reviews, supplementary evidence and GRADE tables were shared in advance with GDG members and were
presented throughout the meetings. Formulation of the recommendations and their strength ratings were facilitated by the
chairs and supported by the methodologist.
The GDG benefited from a structured evidence-to-decision (EtD) framework which was developed by the evidence teams,
with support from the WHO Steering Group and the methodologist, to guide the development of recommendations. The
information which contributed to the EtD framework was informed by the systematic reviews, supplementary evidence, and
the expertise of the GDG.
The EtD factors were: the priority of the problem, certainty of the evidence, balance of desirable and undesirable effects,
values, resources required, certainty in the resources required, cost-effectiveness, feasibility, health, equity, equality and
non-discrimination, human rights and sociocultural acceptability. The latter two factors were adapted from the WHO
INTEGRATE EtD (148), replacing the items of equity and acceptability in the GRADE DECIDE EtD (149).
Each recommendation could be for or against a specific intervention, and either strong or conditional (150).
▶ A strong recommendation means the GDG was confident that the desirable effects of adherence to a recommendation
outweighed the undesirable effects.
▶ A conditional recommendation means that the GDG concluded that the desirable effects of adherence to a
recommendation probably outweighed the undesirable effects.
WHO’s guideline recommendations are developed through a process that aims to achieve consensus among the GDG members.
Consensus was defined as a two-thirds majority vote. The GDG thus discussed and agreed on the recommendations, including the
wording and direction (for or against the intervention) by consensus. The strength of each recommendation (strong or conditional)
was agreed on by voting. Because meetings were held each day in duplicate, the progress of the first group of GDG members
on a given discussion was then presented to the second group for further discussion and refinement. If the second group had
major substantive disagreements with the recommendation, its revision was then presented to the first group in a final meeting.
Had there been major disagreement by the end of the final scheduled meeting, there was an agreement to reconvene the GDG if
needed. This was not the case.
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Annex 6
Annex 6
Drafting the guidelines
and external review
Following the formulation of the recommendations by the GDG, the Responsible Technical Officer drafted the guidelines for
review by the GDG and ERG. The role of the peer review was not to change the recommendations agreed by the GDG; however,
if the peer reviewers had identified major concerns, these would have been brought back to the GDG for consideration. This
situation did not occur.
The WHO Steering Group reviewed all peer review comments and, following discussion, revised the guidelines for clarity
while making sure that the recommendations remained consistent with the original meaning as formulated by the GDG.
WHO has an internal approval and quality assurance process to ensure that all WHO publications, including guidelines, meet
the highest international standards for quality, reporting and presentation. These guidelines were reviewed and approved
by the WHO Guidelines Review Committee (GRC). Finally, the guidelines were prepared for publication and dissemination.
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Contact
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Mental Health and Substance Use
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Switzerland
mailto:mentalhealthatwork@who.int
www.who.int/teams/mental-health-and-substance-use