Addressing mental health problems as a strategy to promote employment: an overview of interventions and approaches

Peter Butterworth^a and Helen Berry^b

a Centre for Mental Health Research, The Australian National University.

b National Centre for Epidemiology and Population Health, The Australian National University.

1. Introduction
2. Macro-level interventions
3. Interventions and approaches at the micro-level
4. Conclusions
References

1. Introduction

There is growing recognition in the Australian community of the widespread prevalence and consequences of mental illness. Poor mental health can have a devastating impact on the lives of individuals, resulting in loss of quality of life, as well as having adverse effects on family functioning, parenting effectiveness and child development. There is also growing recognition of the economic consequences of mental illness.

This paper outlines why it is particularly important to consider mental health in the current social policy context, and provides evidence of the extent to which mental health problems are a barrier to greater levels of social and economic participation. The main aim of this paper, however, is to review and examine the effectiveness of interventions that take account of, and seek to address, common mental health problems as a strategy to promote employment. That is, investigating whether interventions that address anxiety and depression are effective in promoting employment amongst income support recipients. We outline a framework to classify different types of interventions and briefly describe interventions that are relevant to the Australian social policy context.

Mental health problems

There are many types of mental health problems, each with different characteristics and effects. Our focus is on the high prevalence, common mental health problems such as anxiety and depression. Goldberg and Gournay (1997) categorised disorders on the basis of characteristics such as prevalence, associated disability, response to treatment and likelihood of spontaneous remission. They identified the common mental health problems as a discrete category with these features-they are treatable; they are likely to result in disability; and they do not usually receive specialist treatment. Given this combination of features, we consider that there may be important economic and social gains from considering common mental health problems in the design and delivery of social welfare programs.

Anxiety and depression are widespread in the Australian community. Analysis of the National Survey of Mental Health and Wellbeing found that around 10 per cent of working-age Australians had an anxiety disorder and 8 per cent a depressive disorder in the previous 12 months (Butterworth 2003a). Anxiety disorders include social phobia, agoraphobia, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder. Affective or depressive disorders include major depressive episode, dysthymia, mania, hypomania and bipolar affective disorder. The interventions and approaches we outline are also applicable to people who experience sub-clinical levels of mental health problems or psychological distress (that is, symptoms that are debilitating but do not reach the criteria for recognition as a clinical disorder).

Mental health problems and disability

The common mental health problems are sometimes considered less severe than the low prevalence 'major' mental disorders such as schizophrenia. However, the consequences of common mental health problems can be just as severe and disabling. Up to 20 per cent of adult Australians experience a mental disorder within a 12-month period (Andrews, Hall, Teesson & Henderson 1999) and mental illness is the leading cause of non-fatal disease burden in Australia (Mathers, Vos & Stevenson 1999). That is, mental illness is responsible for the greatest level of disability or impairment in the Australian community-over twice that associated with either cardiovascular or musculoskeletal disorders. The profile of mental illness in the community is distinct from that of other disabling conditions. Whereas the prevalence of most forms of disability increase with age, mental disorders are most prevalent in young adulthood, and less prevalent with increasing age (Henderson, Andrews & Hall 2000). Thus, the onset and impact of these disorders co-occurs with significant life stages such as the transition from adolescence to adulthood (with potentially long-term effects on educational attainment and early labour force experiences), family formation, child rearing, and career development.

Having a common mental disorder such as anxiety or depression can, therefore, impact on a person's participation in work. For those people currently in employment, the cost of depression through absenteeism and loss of productivity is estimated to be $3.5 billion per year (www.worcproject.com.au). Appropriate interventions and assistance can reduce this burden. Studies show that evidence-based treatment for people with depression can lead to better employment outcomes (for example, Smith, Rost, Nutting, Libby, Elliott & Pyne 2002). It may also be cost effective to provide treatment for employees with depression, with the costs of treatment considered to be less than the gains achieved through increased productivity (see Wang, Simon & Kessler 2003). The Work Outcomes Research and Cost-Benefit (WORC) Project, conducted by the University of Queensland in collaboration with Harvard University, is an Australian project examining the benefits of employers screening and treating depression in the workplace. The goal of treating previously undiagnosed depression is to improve employee wellbeing, and reduce the cost to employers of absenteeism, staff turnover, and decreased productivity. The WORC Project is seeking to recruit employers to quantify the costs and benefits of screening and treating depression.

Similar to such interventions focusing on people currently in the workforce, improving the recognition and assistance provided for income support recipients with depression or anxiety disorders could maximise employment outcomes and increase economic and social participation. We argue that addressing mental health problems is particularly critical in the current social policy context where there are growing concerns about welfare dependency, the effects of structural ageing on the population, and the policy priority to maximise participation and productivity amongst people of working-age (for example, Commonwealth of Australia 2002; Department of Family and Community Services 2002).

Income support receipt and mental health

Extensive psychological research has shown that unemployment adversely affects mental health (for example, review by Dooley, Fielding & Levi 1996; recent papers by Dooley, 2003; Fryer & Fagen, 2003; review of longitudinal studies by Murphy & Athanasou 1999). This is recognised in economic and social policy literature (for example, Flatau, Galea & Ray 2000), including in a recent review in this journal (Ganley 2003). From a practical perspective, Croft (2002) reported that the prevalence of mental health problems among people who are unemployed has significant policy and service delivery implications for the assessment processes and programs delivered by Centrelink, Job Network members and other service delivery organisations. These are, however, complex issues and it must also be recognised that, for some people, poor mental health may be the primary reason for their unemployment and that in some circumstances employment itself may have adverse effects on mental health (see Ganley 2003).

We are not only concerned with unemployment but also other categories of welfare recipients. There is considerable evidence of the poor mental health of lone parents (for example, Hope, Power & Rodgers 1999). Ganley (2003) reviewed research on the mental health of women looking after children at home. Butterworth (2003a; 2003b) reported analysis of the Australian Bureau of Statistics National Survey of Mental Health and Wellbeing to estimate the prevalence of common mental disorders among Australian welfare recipients. He found that, whereas around 19 per cent of working-age Australians not reliant on welfare payments had experienced a common mental disorder (including anxiety, affective and substance-use disorders) in the previous 12 months, the corresponding figure for income support recipients was 31 per cent. Those identified as unemployed (34 per cent) and lone mothers (45 per cent) had particularly elevated levels of disorders.

While alarming, the increased prevalence of mental health problems among welfare recipients is not unexpected. Established risk factors for poor mental health include unemployment, poverty, low socio-economic status, and sole parenthood (Dohrenwend, Levav, Shrout, Schwartz, et al. 1992; Hope et al. 1999; Kessler, House & Turner 1987; Sturm & Gresenz 2002). Clearly, many of these factors overlap with welfare receipt.

International welfare research has examined the prevalence of common mental health problems among welfare recipients, demonstrating results consistent with the Australian research. American welfare recipients demonstrate significantly poorer mental health than non-recipients, with estimates that between 35 and 60 per cent of recipients experience a clinical disorder or substantial symptoms (Coiro 2001; Danziger, Corcoran, Danziger, Heflin et al. 2000; Derr, Hill & Pavetti 2000; Kalil, Born, Kunz & Caudill 2001; Kalil, Schweingruber & Seefeldt 2001; Lennon, Blome & English 2001). The findings are not restricted to English-speaking countries, with the prevalence of mental disorders among recipients of a French income support payment more than five times the rate in the general Parisian population (Kovess, Gysens, Poinsard, Chanoit & Labarte 1999).

In summary, many welfare recipients experience poor mental health. Mental health problems are a major cause of disability and are therefore likely to make (re)employment difficult. Much research shows that mental health problems decrease the likelihood of later employment (Danziger et al. 2000; Kessler & Frank 1997; Lennon et al. 2001). Derr et al. (2000) discuss several ways in which depression can affect a person's ability to work. These include a direct adverse effect on work behaviour, the episodic or irregular nature of the disorder limiting employment options; the side-effects of medication; the likelihood of limited work history or educational achievement; and the stigma associated with mental illness (which prevents treatment seeking and also creates employer reluctance to hire). There is also evidence from intervention research demonstrating that efforts to address mental health problems amongst the unemployed can facilitate the transition into work.

Interventions to address mental health

Interventions to address mental health problems may, therefore, be an effective approach to promote employment. Australian Government agencies already deliver services with an employment or participation focus to people with mental health problems (for example, the Personal Support Programme, disability employment assistance, vocational rehabilitation, the role of specialist Centrelink officers such as psychologists and social workers, and other programs for people who are homeless or at-risk youth). However, these services are generally targeted to those with low prevalence disorders, focus more on Disability Support Pension recipients than those in receipt of other forms of welfare payment, and do not have the coverage to assist very large numbers of clients. Thus, it remains untested whether assisting those with common mental health problems in the broader welfare population would have a positive effect on wellbeing and participation outcomes.

The United States Surgeon-General's report (Department of Health and Human Services 1999) identifies two main categories of interventions-psychosocial and pharmacological. A variety of different forms of psychotherapy exist, with interventions able to be delivered individually, or to couples, families and other groups. Group interventions have the benefit of being more cost efficient. Other relevant approaches (see the World Health Report 2001) include psychosocial rehabilitation (improving individual competencies and skills, with a focus on client empowerment and reduction in stigma and discrimination) and vocational rehabilitation.

Other interventions may also have a positive impact on mental health. For example, Jorm, Christensen, Griffiths and Rodgers (2002) identify a range of lifestyle and complementary treatments for depression with proven scientific efficacy. Effective treatments include St John's wort, physical exercise, acupuncture, massage and yoga.

The World Health Organization report Mental health: new understanding, new hope (WHO 2001) notes that mental health is influenced by a combination of (and interaction between) biological, psychological and social factors. The magnitude of mental health problems and their multifactorial aetiology necessitate a public health response-that is, responding to mental health needs at the population level. This includes strategies to address lifestyle and risk factors, promote stable family environments, increase social cohesion, and support positive development across the life course. Such an approach emphasises the importance of creating intersectoral links, including considering social policy issues such as housing, income support, employment, disability services, macro- and micro-economic policies, education, and criminal justice issues.

Categorising interventions for welfare recipients

As is clear even from this brief overview, there are many different responses to mental health issues. There are equally many ways to categorise these interventions. For example, the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health (Commonwealth Department of Health and Aged Care 2000) defined a spectrum of mental health interventions reflecting prevention, treatment and continuing care.

We have adopted the typology described by Dooley and Catalano (2000), which is based on two dimensions-the timing and the level of the intervention. The timing dimension has four stages. The first, proactive primary prevention, involves steps to prevent exposure to the risk factor. The second stage, reactive primary prevention, is analogous to inoculation. It involves strategies that attempt to increase people's ability to cope with risk factors. The third stage is secondary prevention. This includes interventions that target early symptoms with the aim of preventing further progression of the disorder. Finally, the tertiary prevention stage consists of efforts to manage the disorder.

The second dimension is the level at which the intervention is targeted. Dooley and Catalano (2000) note the importance of considering the broader social structures and physical environment around the individual. There is a continuum along which interventions lie, from those that specifically target the individual through to those that target families, communities, organisations or nations. For simplicity, they dichotomise this to micro-level interventions that target the individual or family; and macro-level interventions targeting higher-order levels, though it is important to recognise that there are not strict boundaries about these levels.

Table 1, adapted from Dooley and Catalano (2000), presents the matrix of eight intervention categories created by the combination of these two dimensions. The intervention typology provides a context in which to consider interventions, encouraging a holistic approach to service delivery and policy development. We consider this table is very useful for the current analysis. It also provides a framework by which we can analyse interventions. This promotes assessment of the purpose and aims of interventions, and how they could fit within a social welfare or employment context. This helps us to evaluate and determine the appropriateness of proposed mental health interventions and approaches in the social policy context. Not all of the categories in the model are directly relevant to the social policy context, but for the sake of completeness, we will present information on the types of interventions under all headings. Further, all categories of interventions need to be considered to ensure a holistic approach to addressing the mental health needs of the Australian community, including income support recipients.

In the remainder of this paper, we will describe the activities and interventions that fit within each table cell. We start by considering the cells that describe interventions at the macro-level-that is, interventions targeted at the community or population.

Table 1: Typology of interventions and examples (adapted from Dooley & Catalano, 2000)
	Intervention level (where program is targeted)
Stage (Timing and purpose of intervention)	Micro Individual or family	Macro Broader
1. Proactive primary prevention Preventing welfare reliance/ unemployment	Avoidance Education, training Early intervention (childhood and family)	Environmental Economic and workplace policies
2. Reactive primary prevention Preventing mental health symptoms that arise from welfare receipt	Ecological coping Coping skills and abilities Job-search skills Social skills and networks	Ecological enabling Social services-social welfare, health care, employment services Social capital
3. Secondary prevention Early intervention for those demonstrating early symptoms	Early detection/treatment Crisis intervention & support Counselling	Population health promotion Mental health promotion Mental health literacy Screening
4. Tertiary prevention Managing the disease	Medical care Medical and professional assistance Workplace support	Medical enabling Arrangements to support individual care-self-help groups, community attitudes about mental health and welfare receipt

2. Macro-level interventions

Proactive primary prevention-the environmental level

The first stage of macro-level interventions, proactive primary prevention, is characterised by activities such as setting economic, health and workforce policy and related areas of social policy. These issues are relevant to any consideration of mental health because health outcomes are heavily influenced by the socio- economic environment (Hawe & Shiell 2000). For example, absolute levels of individual income and relative deprivation (Marmot 2001) play a significant role in influencing outcomes (Baum 2000; Lynch, Due, Muntaner & Smith 2000; Wilkinson 2000).

Reactive primary prevention-ecological enabling

The second stage of macro-level interventions, reactive primary prevention, includes providing social services such as social welfare, health care and employment services, and activities aimed at strengthening communities, especially communities in need. It includes mental illness prevention activities, which are designed to remove risks and barriers to wellness (Waring, Hazell, Hazell & Adams 2000). Three areas of research are particularly relevant-social exclusion, social capital (McKenzie, Whitley & Weich 2002), and mental health promotion.

Social exclusion refers to a cluster of socio-demographic factors, such as poverty and deprivation, together with the associated inability of people experiencing such factors to access the full range of community resources that would otherwise be available. Dewilde (2003) has defined it in terms of the 'political economy' of the life course and, thus, as a dynamic, life-long process. Certain ecological level factors promote the likelihood of people experiencing social exclusion, such as living in remote locations (Alston, 2002) or belonging to an ethnic minority (Boydell, van Os, McKenzie, Allardyce et al. 2001). Like those living in poverty, people with mental health problems also find themselves over-represented in all areas of social exclusion (Baum 2000; Bonner, Barr & Hoskins 2002).

In Australia, the effects of exclusion are apparent in economic terms and across all forms of social participation, including contact with family and friends (Baum 2000). This is especially challenging for income support recipients with mental health problems for two reasons-because those living in deprived areas have elevated mental health service needs (Abas, Vanderpyl, Robinson & Crampton 2003; Alston 2002), together with the least access to services (Herrman 2001); and because contact with friends can reduce the risk of developing mental health problems and assist recovery (Prince, Harwood, Thomas & Mann 1998). Thus, social exclusion, mental health and income support receipt reinforce each other; the very individuals who most need access to the benefits of participation are the least likely to achieve access.

A substantial body of research details the beneficial effects on health and employment of living in communities that are rich in social capital. While this research is fraught with theoretical and methodological difficulties, and there is vigorous debate about the concept (Hawe & Shiell 2000; Henderson & Whiteford 2003; Lynch et al. 2000; Whitehead & Diderichsen 2001), there is broad consensus that social capital includes two core concepts (Putnam 2000, p21). One has to do with participating in the community, the networks of association that participating generates, and the quality of relationships within and between those networks. The other is the social cohesion that results from participating in the community- that is, the extent to which community networks bring people together and the nature of the resulting group behaviour. Social cohesion is evident in community- level phenomena such as social trust (trust in strangers), generalised reciprocity ('the kindness of strangers'), cooperation, organisation, information sharing and other pro-social norms (for example, Portes 1998).

High levels of social capital are associated with physical health benefits and lower mortality (Kawachi, Kennedy, Lochner & Prothrow-Stith 1997; Skrabski, Kopp & Kawachi 2003) and mental health benefits (McKenzie et al. 2002; Sartorius 2003). The link between mental health and some elements of social cohesion are of particular interest because they relate to community-level wellbeing and also directly to individual outcomes. For example, in Australia, those who report higher levels of social trust also report fewer symptoms of psychological distress (Berry & Rickwood 2000). Falling levels of social trust over three generations of Australians have been linked to rising levels of psychological distress (Berry & Rodgers 2003).

Access to social capital assists in finding employment (Aguilera 2002; Caulkins & Peters 2002), including self-employment (Abell 1996). A recent Australian study of the relationship between social capital, employment status (in full-time paid work, part-time paid work, or not in paid work) and job search strategy (Stone, Matthew & Hughes 2003) conceptualised social capital using two approaches. The first was a sociological approach, in which social capital was defined as a series of key concepts, such as networks, trust and reciprocity. The second, more psychological approach, classified participants into 'social capital types', including the 'social capital poor'. Networks of association and the cohesion they produce (that is, social capital) were unevenly distributed in society, with those in most need having fewest resources.

Some concepts, such as social trust and breadth of institutional ties, were important in finding and being in paid employment, and the 'social capital poor' were the most disadvantaged both in terms of being in paid employment and also in terms of job search strategy.

Different types and levels of social capital operate in indirect and, sometimes, counter-intuitive ways. Social capital does not always deliver public benefits, or deliver benefits equally to all community members (Foley & Edwards 1998). In some circumstances, social capital promotes economic growth, while in others it discourages growth (Woolcock 1998). Equally, high levels of social capital are sometimes associated with positive outcomes in mental health, sometimes negative (Caughy, O'Campo & Muntaner 2003). In sum, social capital, like social exclusion, is not shared evenly or randomly among all members of a community, and deficits in social capital are focused on the vulnerable. Some people's lives can be marked by compounding problems (Robertson & Donnermeyer 1997) both in terms of social exclusion and access to social capital.

Ecological enabling can thus be an effective mechanism for limiting the likely impact of environmental risk factors, both for mental health problems in general and for the interaction between mental health problems and the requirement for income support in particular. However, such mechanisms are not always available or effective. When people have been exposed to mental health risk factors, it becomes necessary to take action to reduce the impact of these factors and to minimise the likelihood of further harm. At this point, secondary prevention becomes necessary, which is the third stage in the model. With respect to the macro-level of analysis, this involves population health promotion.

Secondary prevention-population health promotion

Population health promotion focuses on improving health outcomes by changing behaviour, reducing risks and enhancing protective factors. Mental health promotion is an umbrella term (Herrman 2001) that includes such activities as public education and awareness raising campaigns; preventive screening (Hickie, Davenport & Ricci 2002; Mechanic 1999; Scott, Thorne & Horn 2002); awareness raising among health professionals (Harris, Harris, Lee & Powell Davies 1999); community capacity building and other community-level interventions.

The growing recognition of the need for mental health promotion belies a historical lack of recognition, due in part to considerable confusion about what mental illness is (Herrman 2001). This confusion arises partly because mental health has been considered less important than physical health (Hickie 2002; Thornton & Tuck 2000). A further complication for mental health promotion is that, like social exclusion and social capital, mental health problems are unevenly distributed in terms of socio-demographic factors, life events and personal characteristics (Braidwood 2000; Herrman 2001).

Mental health promotion must address the factors that may influence the course of mental health (Herrman 2001). These include making sure communities themselves are health promoting (Baum & Palmer 2002; Herrman 2001) and that people experiencing special mental health needs have 'somewhere to live, something to do [and] someone to love' (Bonner et al. 2002); ensuring people have the general skills required to participate in the life of the community; and ensuring people have the specific skills of mental health-resilience and the ability to '... think and learn, ... and live with their own emotions and the reactions of others' (Herrman 2001). The most important of these categories is the first (Herrman 2001)-that is, building healthy and health-promoting communities (Hawe, King, Noort, Jordens et al. 2000; Robinson & Pennebaker 2002).

Two further issues emerge in mental health promotion (Reppucci, Woolard & Fried 1999). One is less emphasis on ad hoc, simple, one-off interventions, and more on larger, multi-dimensional, multi-level approaches based on theory. The other issue emerging in mental health promotion is greater accommodation of diversity, particularly among those who belong to multiple socially excluded groups. In attempting to take account of diversity, it is worth acknowledging that neither income support recipients (Butterworth 2003b) nor people with mental health problems (Song & Singer 2001) form one homogenous group. It is interesting to note, therefore, that there are empirical approaches to profiling that are effective with welfare (Yoshikawa & Seidman 2001) and mental health issues (Rubin & Panzano 2002). Thus, it would be possible to conduct sound statistical analyses of people in receipt of income support, or experiencing common mental health problems, or both, to come to a more sophisticated understanding of the types of people that are in these categories, and what their needs are.

With respect to addressing diversity, a range of delivery strategies is necessary (Braidwood 2000; Hawe 2000; Reppucci et al. 1999), including taking interventions into multiple settings (Licata, Gillham & Campbell 2002; Secker & Membrey 2003), particularly community health care settings (Baum, Kalucy, Lawless, Barton et al. 1998).

Interventions seem to work best when several approaches are used in concert (Taylor, Lam, Roppel & Barter 1984) and successful interventions typically employ top-down and bottom-up activities (Skutle, Iversen & Bergan 2002). A range of information (Rogers 2002) and service delivery mechanisms are also required, such as innovation and experimentation in the use of technology (Farrell & McKinnon 2003; Mechanic 1999; Starling, Rosina, Nunn & Dossetor 2003); telephone counselling and crisis interventions; and the use of entertainment and information media (Anderson 2003; Taylor et al. 1984). In addition, researchers have noted the imperative for people with special mental health needs to have a say in mental health promotion activities (Herrman 2001; Hickie 2002), including negotiating service level and provision arrangements (Crane-Ross, Roth & Lauber 2000).

Tertiary prevention-medical enabling

The final stage of macro intervention involves activities that ensure that organisational arrangements are in place to support the provision of individual care. These could include putting in place systems and mechanisms to support self-help groups, providing organisational mechanisms for changing community attitudes about mental health and welfare receipt, or ensuring appropriate programs are in place to address the mental health needs of income support recipients.

3. Interventions and approaches at the micro-level

Despite evidence of the high prevalence of mental health problems among income support recipients and the extent to which this acts as a barrier to participation, there are very few interventions that specifically target people's mental health needs as a strategy to facilitate employment (Creed, Machin & Hicks 1999; Harris, Lum, Rose, Morrow et al. 2002; Proudfoot, Gray, Carson, Guest et al. 1999). In a review of over 50 European examples of good practice in interventions focusing on mental health and employment, Ozamiz, Gumplmaier and Lehtinen (2001) noted that few had the explicit primary goal of improving mental health and wellbeing as a strategy to promote employment, although many programs reported improvements in wellbeing and psychological functioning as an unintended or secondary consequence. With few exceptions, it was only programs targeted to people with low prevalence psychiatric disorders that had the primary goal of addressing mental health problems. However, Ozamiz et al. (2001) concluded that early intervention and preventative activities with a focus on mental health were highly cost effective, and recommended more emphasis be placed on such projects in the future.

In the following sections, we review interventions that focus on the individual (micro-level interventions) that are potentially applicable to the Australian social policy context. Again, we utilise Table 1 as a framework and consider interventions within each stage of intervention (each cell of Table 1) in turn.

Proactive primary prevention-avoidance

Proactive primary prevention initiatives include early intervention, family/childhood programs, and quality education. Such approaches are often so distant from the actual experience of unemployment or welfare dependence that is it difficult to recognise or quantify their impact. However, if the health and social costs of unemployment and welfare dependence were included in cost/benefit analyses of such economic policies and options, the development of interventions to address these issues would be taken more seriously (for example, Dooley & Catalano 1999; Harris, Webster, Harris & Lee 1998; Harris and Morrow 2001). Similarly, analysis of the long-term health and social benefits of proactive primary prevention strategies need to be considered when assessing their cost effectiveness. For example, the Australian Society for Health Research (Access Economics 2003) recently produced a report discussing methodologies to quantify the impact of health interventions and demonstrated stunning returns on investment in health research and development.

Reactive primary prevention-ecological coping

The aim of stage-two micro-level interventions, reactive primary prevention, is to intervene immediately after, or in anticipation of a stressor. This may involve strategies targeting recently redundant workers, young people making the transition from study into employment, or those with caring responsibilities for children, the frail aged or people with a disability. This stage of intervention is most directly applicable to this review, encompassing programs and services that are readily situated within a social welfare or employment context. As such, we provide detailed discussion of these interventions.

The interventions grouped under this heading promote the personal and social resources or capacities that have been shown to attenuate or moderate the distressing effects associated with unemployment or welfare receipt. Research has investigated the effect of personal and psychological characteristics, coping strategies, and cognitive style on the health of people who are unemployed. Turner, Kessler and House (1991) examined how social support, self-concept, and cognitive coping processes moderate the effects of unemployment on mental health. Unemployed people who had access to a confidant, were integrated into informal social networks, had high self-esteem, and/or who avoided self- denigrating thoughts experienced less adverse psychological (and physical) outcomes than did those without these characteristics.

In addition, research in the United States has found that the association between welfare receipt and depression may be moderated by a person's sense of mastery (Danziger et al. 2001); exposure to significant life traumas (Coiro 2001; Danziger et al. 2000); sense of burden or indebtedness (Danziger, Carlson & Henley 2001); hopelessness (Petterson & Friel 2001); and lack of social support (Kalil, Born et al. 2001).

On the basis of this type of information, interventions can be designed that target the characteristics that may be the causal factors, moderators or mediators of the relationship between unemployment (or welfare receipt) and health.

Caveats

We emphasise that the types of interventions we are discussing do not provide a solution to the problems of unemployment or welfare dependence. We have sympathy with criticisms of interventions that focus on the psychological barriers of those who are unemployed, without acknowledging that unemployment is socially-determined, and requires a social solution (for example, Fryer 1999). That is, a comprehensive response to the problems associated with welfare dependence must address underlying structural and societal causes (and draw on approaches and strategies from all cells of the typology described in Table 1). From this perspective, interventions seeking to promote coping, resilience and enhance job search skills, but which fail to address the underlying issues responsible for unemployment, can be considered harmful. Indeed, they may raise expectations in a situation in which repeated failure is likely-a key risk factor for hopelessness and depression. Further, the focus of such psychological interventions on the individual potentially locates responsibility for the cause of the problem entirely with the individual and not broader society. The psychological approach alone also fails to take account of the demand side or broader economic policies. While building personal capacity and resources may promote employability at the individual level, it does not increase job availability and potentially involves churning misery (see discussion by Fryer 1999). It also does not take account of variables such as the economic cycle, different needs within different communities, or the different needs and experiences of different types of job seekers (see Dooley & Catalano 2000; Fryer 1999).

However, like researchers such as Creed (1998), Dooley and Catalano (2000) and Harris et al. (1998), we consider that psychological interventions have a role in the employment context, by promoting the health and wellbeing of welfare recipients, facilitating employment outcomes, and reducing social exclusion and isolation. Addressing mental health problems through social policy initiatives complements the health system approach (WHO 2001). It must, however, be placed within a context that recognises its limitations and advocates for broader and more wide- ranging solutions to the issue of health inequalities and more expansive discussion about the nature of work.

The sub-sections that follow provide a reasonably extensive discussion of five different interventions under the reactive primary prevention heading that have proven effectiveness and are, in our opinion, worth further consideration and evaluation in the social policy context. These include interventions based on cognitive behaviour therapy (CBT), improving self-efficacy, providing social support, adopting multiple-methods, and improving mental health literacy.

Changing explanatory style-cognitive behaviour therapy

Cognitive behaviour therapy targeted at people who are unemployed is one example of an employment-focused intervention that incorporates psychological principles and practices. Morrow, Harris and Harris (1999) provide an overview of CBT in an employment context. Cognitive behaviour therapy teaches more adaptive, less negative ways of thinking about oneself, the world and the future. It emphasises the importance of cognitive processes, by demonstrating that people's thoughts determine their perceptions of, and feelings towards life events, and this determines behaviour.

Cognitive behaviour therapy has long-term benefits as it teaches strategies and techniques that improve coping abilities, and is relevant for people who do not exhibit clinical levels of mental health problems and for children. While CBT is generally delivered one-on-one in clinical practice, it can be delivered in group settings and use alternative modes of delivery (for example, via computers and self-help books).

Creed and Machin developed a CBT program for unemployed youth to improve their mental health and psychological functioning, and to help them develop skills to better deal with future problems. Evaluation showed that, immediately after the program, participants had improved levels of wellbeing, decreased psychological distress, improved self-esteem, and improved levels of coping (Creed et al. 1999). More importantly, these benefits were maintained four months later, suggesting the program did provide participants with strategies that helped them to deal with the stressors associated with unemployment. However, participation in the program did not have any effect on employment outcomes.

Proudfoot and colleagues in the United Kingdom provide another example of the use of CBT in an employment context, this time with unemployed professionals (Proudfoot, Guest, Carson, Dunn et al. 1997; Proudfoot et al. 1999). Compared to a control group, the CBT group demonstrated greater improvements in dealing with distress, and higher self-esteem, job seeking self-efficacy, life satisfaction and motivation for work. Again, most of these differences were maintained over a three- to four-month period. This study demonstrated substantial improvement in employment outcomes, with 49 per cent of the CBT group employed compared to 28 per cent of the control group.

There have been, however, some less successful implementations of CBT (for example, Harris et al. 2002; Machin & Creed 2003), perhaps due to inadequate implementation of the CBT intervention. Interventions for very disadvantaged groups (such as those in the study by Harris) may need to be more individually tailored, conducted at a slower pace, or include more behavioural, concrete activities.

To improve cost effectiveness, CBT can be delivered using self-help approaches, such as through books and manuals or by computers (Bower 2002). Proudfoot, Goldberg, Mass, Everitt et al. (2003) demonstrated the effectiveness of a computerised CBT interactive multimedia program within a general practitioner (GP) context compared to usual treatment (see Christensen & Griffiths 2002, for an Australian example). It is possible with very disadvantaged groups that facilitated self-help (Kupshik & Fisher 1999), whereby someone (not necessarily a professional) assists by working through the self-help materials with the participant, could overcome some of the limitations of this approach with very disadvantaged groups.

Targeting self-efficacy and mastery

The JOBS Program is another preventative intervention designed to promote coping skills and address the mental health needs of people who are unemployed (Caplan, Vinokur & Price 1997). This intervention aims to improve participants' job search strategies and build job search skills. The training seeks to increase job search self-efficacy (participants' belief in their capacity to succeed in searching for a job); sense of mastery and control; and ability to resist demoralisation in the face of failure (inoculation against adversity). Large-scale evaluations of the JOBS Program have been conducted in the United States.

At one- and four-month follow-up periods, unemployed program participants had more confidence in their job search abilities, greater self-efficacy, and lower levels of depression than those in the control group (Caplan, Vinokur, Price & van Ryn 1989). Program participants also demonstrated superior employment outcomes. After four months, 54 per cent had found employment compared to 29 per cent of the control group. Further, participants had obtained superior quality jobs (for example, higher earnings, more consistent with career goals, more satisfaction). In a two-and-a-half year follow-up, participants reported less time out of work, fewer work transitions, and continued greater earnings (Vinokur, Price & Caplan 1991). The program was highly cost effective, with the individuals' increased earnings and tax returns significantly exceeding costs. The financial benefits of program participation were estimated to increase substantially across the life span (Vinokur, van Ryn, Garmlich & Price 1991).

Social support

Within the unemployment literature there is evidence that social ties, such as contact with friends and family (Bolton & Oatley 1987; Kasl & Cobb 1979), reduce the effects of unemployment on psychological wellbeing. A number of employment interventions, therefore, have been designed to improve social support as a strategy to promote positive mental health. Trials have included support group interventions, one-to-one support, and strategies to enhance natural networks. In one study, Harris, Brown and Robinson (1999) assessed the effect of 'befriending' on depressed women in a disadvantaged urban setting in the United Kingdom. Female volunteers acted as a friend for the depressed 'patients'. Results showed that women participating in the intervention demonstrated significantly greater rates of remission from depression. CRS Australia has recently considered the applicability of this type of approach to the Australian social policy context (Peart 2003).

Among Australian examples is a small-group mentoring program established for redundant BHP workers in the Newcastle area (Pond, Shevels, Sutton, Traynor, Cotter & Taggart 2002). Small groups of men met weekly. The groups were activity- focused and group members decided the activities or projects that they would undertake. The self-directed nature of the group promoted a sense of empowerment. The outcomes from the program, which has not been rigorously evaluated, seem positive and suggest that participation may have enhanced job search activities, participation in employment, voluntary work, psychological wellbeing, and levels of social interaction.

Multi-method approach

While we have outlined a number of interventions based on different approaches, it should be recognised that all of the programs employed multiple interventions. While the JOBS Program emphasised self-efficacy, it also focused on social support and problem solving skills. The CBT intervention of Creed et al. (1999) also boosted self-efficacy and self-management, while the program implemented by Harris et al. (2002) in south-western Sydney included elements of memory training, assertiveness training, and relaxation and meditation techniques.

Building understanding, managing expectations, promoting empowerment

Providing accurate information is an important component of mental health promotion. Jorm (2000) used the term 'mental health literacy' to describe the knowledge and beliefs about mental disorders that aid recognition, management or prevention. Strategies to improve mental health literacy include not only the broad community education campaigns described under the macro-level, but also individual education courses, such as the Mental Health First Aid program (Kitchener & Jorm 2002).

Improving the mental health literacy of people who are unemployed or receiving income support may help them understand their experiences and better manage their symptoms. Increased knowledge improves the individual's sense of control and empowerment. Pond et al. (2002) noted that, more than any other session, redundant BHP workers valued information sessions on the experience of retrenchment and strategies to cope with redundancy. This was likely because such information normalised participants' experiences, making them aware that their feelings and responses to redundancy were not unique.

Kieselbach (1999) notes that one initiative used in Germany to assist people who are unemployed is to provide brochures containing information on the relationship between unemployment and health for both health professionals and people facing unemployment. Similarly, one element of the Unemployment and Health Project conducted by Harris and colleagues in western Sydney involved seminars and presentations by local GPs on the health effects of unemployment.

Summary

We have outlined a number of interventions and approaches within the reactive primary prevention stage. We believe these provide an important starting point for the development of social policy interventions that seek to address common mental health problems as a way of promoting employment. All of the approaches have a sound theoretical basis and have evidence supporting their effectiveness. Work needs to be undertaken, however, to adapt the approaches to the Australian social policy context and to evaluate their effectiveness (including cost effectiveness) and applicability to different groups of income support recipients. We now move on to consider the remaining stages of micro-level interventions- secondary and tertiary prevention.

Secondary prevention-early detection and treatment

The interventions classified under secondary prevention are those that target early management of symptoms. To some extent, the interventions listed in the previous section may also be applicable here. However, our focus is on interventions for people with demonstrated mental disorders, and on methods to improve the identification of those requiring assistance.

Identification is critical for the delivery of appropriate assistance to income support recipients with mental health needs. Identification can include informal processes which rely on the insight, knowledge and awareness of customer service staff (whether in Centrelink or employment or social welfare agencies) to notice characteristics and behaviours indicative of mental health problems (Derr, Douglass & Pavetti 2001; Derr, et al. 2000), and formal screening and assessment processes. There are two aspects of formal identification. Screening involves a short set of questions used to detect individuals likely to have mental health problems. Screening tools are inexpensive and easy to administer, do not necessarily require professional expertise to deliver or score, and are often used in medical and community settings to identify 'at risk' clients. Those identified via screening are referred for more detailed professional assessment. Formal screening approaches have been introduced to welfare offices in the United States (Derr et al. 2000), with over 24 states screening all recipients for mental health problems and 26 states using formal screening tools (Department of Health and Human Services 2002).

In Australia, a number of assessment processes (such as the Job Seeker Classification Instrument) are used in Centrelink to identify at-risk job seekers for specialist follow-up, but these are not specifically designed to identify clients with mental disorders. Current processes largely rely on self-disclosure (Croft 2002; Eardley, Abello & MacDonald 2001) and, therefore, depend on self-awareness and willingness to provide such personal information. As a result, many people with mental health problems are not identified and do not receive appropriate assistance. The United States experience has been similar (Danziger & Seefeldt 2002). However, the introduction of formal screening does not necessarily overcome this limitation, as disclosure is still dependent on the environment, with trust being a critical dimension. Rosman, MaCarthy and Wollverton (2001), for example, argue that screening tests may not be effective unless they are conducted within an established relationship, in which the goals of the screening are evident and meaningful to the participant (such as identifying barriers, strengths and support needs) and the participant believes that this will result in appropriate services being provided.

There may be concern that increasing mental health literacy and improving the identification of income support recipients with mental health problems will increase demand for services. While this may be the case, increasing recognition of mental health problems is consistent with the goals of the National Mental Health Plan and increased demand for mental health services by people in receipt of income support could potentially be managed by current initiatives, such as those in primary care (see next section). It would, however, also be appropriate to consider the adequacy and the potential need to increase the capacity of existing employment focused programs.

Tertiary prevention-medical care

Tertiary prevention interventions are the responsibility of the health portfolio. An effective tertiary prevention strategy, however, could involve promoting targeted referral of welfare recipients to medical professionals. In part, such referral depends on identification (mental health literacy, screening and assessment), as discussed in the previous section. The work of Harris and colleagues included efforts to promote linkages and partnerships with GPs and other mental health professionals.

The Better Outcomes in Mental Health Care initiative introduced by the Australian Government is improving the delivery of mental health services by GPs. Harris and colleagues (for example, Morrow et al. 1999) have recognised that GPs manage most of the mental health problems associated with unemployment and have, therefore, sought to improve the quality of service GPs provide, including helping GPs to promote employment and reduce the negative health impact of unemployment.

Comino, Harris, Chey, Manicavasgar et al. (2000) found that GPs treated depression and anxiety among unemployed patients differently from their employed patients, and were less likely to refer unemployed patients to self-help groups, and twice as likely to prescribe pharmacological treatments. Unemployed patients with symptoms were less satisfied with the treatment they received from their GPs than employed patients, and wanted more opportunity for discussion and more explanation about medications. There seems to be a mismatch of expectations between the GP and patients, perhaps reflecting a negative bias by GPs towards unemployed patients. In qualitative research (Harris, Silove, Kehag, Barratt et al. 1996), GPs reported that unemployed patients expected pharmacological responses and considered many unemployed patients lacked the financial, social and personal resources to benefit from more active strategies. The project conducted by Harris included ongoing training and support for GPs, raising their knowledge and awareness of unemployment issues.

Similar options exist in European countries. For example, in Norway and Denmark, people who are unemployed are encouraged to undertake regular health check-ups to promote the early recognition, detection and prevention of disorders (for example, Ozamiz et al. 2001; Ytterdahl 1999). Further, as one response to welfare reform in the United States, several states have moved to better integrate mental health services and employment programs (Derr et al. 2001; Lennon et al. 2001). One option is for payment recipients to be linked or referred to existing community mental health services. Another is for employment programs to provide funding to expand mental health services or to actively incorporate short-term mental health counselling services (Derr et al. 2000).

4. Conclusions

In this paper we have sought to provide an overview of strategies and interventions available to improve the mental health of people receiving welfare payments (or others who are not in the labour force) and which could be implemented in, or are relevant to, the social policy context.

Initially, we provided a brief overview of why this topic is important. We noted that the consequences of common mental disorders, such as anxiety disorders and depression, are generally under-estimated despite the fact that mental illness is the leading cause of disability or impairment in Australia. We also noted that Australian and international data show that the rates of mental disorders and sub- clinical psychological distress are significantly greater among welfare recipients than the rest of the population. The experience of mental illness is likely to limit income support recipients' opportunities for social and economic participation and present a barrier to their (re)employment.

To assist in mapping the range of approaches available, we presented a framework in which to categorise interventions. This framework was based on the timing (relative to the stage of the disorder) and the level (targeted to individuals/ families or at the broader community) of the intervention. This approach emphasised the need not to exclusively focus at the level of the individual. Interventions which target the individual may improve their wellbeing and their coping skills and resilience and may assist them into a job, but do nothing about the underlying social and economic causes of unemployment or welfare dependence and may be counter-productive. Thus, in the review we stressed the importance of the broader context, such as macro-level policies and strategies that can potentially improve the environment so as to promote better mental health and reduce unemployment and welfare dependency. In particular, efforts to address the mental health barriers of income support recipients need to acknowledge and address the social exclusion that many welfare recipients may experience, and the lack of social capital within their communities. Further, we demonstrated the benefits of considering income support recipients through mental health promotion.

At the individual or micro-level, we identified a number of possible approaches that may be applicable to the Australian social policy context. Options to improve coping skills and resilience include addressing cognitive style through CBT, enhancing self-efficacy, and improving social support. We also discussed the benefits of increasing welfare recipients' awareness and knowledge about mental health problems, including the relationship with unemployment or welfare dependency. Increasing mental health literacy is equally important for customer service staff in Centrelink and welfare agencies, as it is a basis for identifying clients with mental health barriers, and knowing how best to respond (for example, referral to appropriate services). Informal identification processes can be supplemented by formal approaches based on the use of screening tools. Finally, we noted the importance of considering the pathways into, and improving the relevance of, existing services in the primary and specialist medical context, or specialised employment programs to better meet the mental health needs of people receiving income support payments.

The framework provided by the intervention typology is an important tool for social policy design. It facilitates the development of comprehensive and multi-faceted solutions to social problems. It promotes the identification of gaps in existing and proposed policy and service delivery responses. It also illustrates the importance of cross-disciplinary cooperation and the role of different professionals in developing comprehensive approaches to address such social problems (for example, social policy analysts, psychologists, psychiatrists, epidemiologists, behavioural medicine, economics, public health-see Dooley & Catalano 2000).

The challenge, however, is to design, implement and evaluate policy responses that fit with the Australian social welfare context. Clearly, we would support the adoption of a range of different and complementary interventions from across the intervention typology. In addition, collaboration and partnership (with researchers, practitioners, a range of government agencies, and the non- government organisation and private service sectors) is vital. Interventions need to be based on sound theories and a solid evidence base to ensure that the assistance provided to income support recipients will be effective and will result in long-term benefits and the achievement of positive outcomes (Creed, Machin & Nicholls 1998). Governance and planning is also critical. The design, implementation and management of pilots, trials and programs are critical to ensuring that program aims (addressing mental health barriers to promote employment outcomes) are actually assessed. Further, comprehensive and robust evaluation methodology is also essential. While it may seem overwhelming, much has already been done (as outlined in this report) and the Department of Family and Community Services has recently conducted a number of relevant trials (promoting mental health literacy, providing psychological counselling, and delivering support and information via the Internet).

This paper has presented a brief overview of possible social policy responses to address the mental health problems experienced by many income support recipients, but it has significant limitations. The scope of the project was restricted to common mental health problems. As such, it did not consider low prevalence disorders, substance misuse, or the issue of co-morbidity (of either other mental health problems or physical disabilities). It is also not an exhaustive review, and only provides examples of programs rather than a complete listing of all research. Finally, it does not provide specific details of different approaches that could be implemented or what customer groups would most benefit.

Despite these limitations, we hope that this overview captures our enthusiasm about the possibilities in this area. We consider that mental health will become an increasingly important focus of welfare, employment and broader social policy in the future. Recent progress on the WORC Project (discussed earlier) serves to confirm the importance of our efforts in the welfare domain. In the context of our project, the WORC Project-with its aim of treating depression within the workplace-represents the ultimate early intervention program, by addressing mental health problems before they lead to job loss and welfare receipt. Further, if it is cost effective to address the burden of common mental disorders in the workplace, it is surely also important to consider the effect of mental health barriers among recipients of income support for whom mental illness is more prevalent and presents a barrier to employment. We suggest that there is a need to assess the cost effectiveness of implementing the types of interventions reviewed in this paper as a strategy to improve the social and economic outcomes achieved by welfare recipients.

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