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By A. Onatas. Babson College. 2019.

Along with the Fit Note cheap 8mg reminyl visa medications zolpidem, the new Fit for Work was suggested to have a potential role in retention support for those with depression cheap reminyl 4 mg without prescription medicine you can give dogs, though again there were concerns that there would not be sufficient specialist knowledge and that the service would not address fundamental concerns about waiting lists for interventions where an employer does not have occupational health or private health insurance provision cheap 8mg reminyl fast delivery medications used for adhd. More evidence might be needed to ascertain what works for retention generic reminyl 8mg with mastercard medicine 4 times a day, as separate from a back to work service, so quality services can be encouraged and developed locally. Consistent themes throughout this discussion included the importance of recognising the intrinsic barriers to accessing interventions seen in the common symptoms of depression and consequently ensuring there is specialist mental health and employment support knowledge within services. The diversity of the condition and the individuals who have it requires a personalised approach based on the individual, their goals (particularly where they include employment) and their symptoms in many cases a one-to-one approach was seen as highly beneficial. The value of early intervention was consistently highlighted in terms of assessment and treatment and a collaborative approach to care (actively engaging with the individual and employers). It was also highlighted in terms of bringing together a range of experts who are equipped to provide specialist support to the different aspects of an individuals life and recovery, both in and out of the workplace. Similarly, participants placed considerable emphasis on the importance of providing treatment and employment support together, in parallel. What we have discovered is that many of the interventions which appear positive at achieving these goals are not always provided optimally or that there are barriers to accessing them. In this final section we consider the information collected from both the academic literature and interviews with experts and use this to develop six key areas around which we would like to see change. Within these categories we have made a range of recommendations for change which we feel have the potential to improve employment outcomes for those experiencing symptoms of depression. Working better together We need to improve the way that different stakeholders work together across the health and employment landscape and actively encourage them to work together to enhance support for people experiencing symptoms of depression. As we have seen, the best results are achieved when we address health and vocational needs in a co-ordinated and holistic way. Improving integration of services and support between clinicians, vocational specialists, employers, back to work support and individuals represents a positive approach to helping people remain in or return to work. Better working with and between all Symptoms of depression and their effects on employment 48 stakeholders be they government, voluntary sector or employers should be fundamental to policy in this area. The ability to provide integrated, in-parallel support for health and for employment was seen as vitally important by the experts. We need to provide individuals with well-rounded, personalised treatment and support which reflects their life goals. However, often we see government health and employment services not working together, nor even in some cases sharing information and knowledge, likely negatively affecting their understanding or knowledge of an individuals needs. Experts we spoke to highlighted specific examples including poor engagement between Jobcentre and clinicians, especially where someone is being assessed under the Work Capability Assessment, and the need to integrate employment support into health services at primary (i. This might be accomplished by: o Issuing joint commissioning guidance to encourage and support the pooling of resources to achieve shared local outcomes; or, o Revising and aligning applicable outcomes frameworks to ensure that mental health and employment is a priority for all local stakeholders. In particular, it is important to ensure that someone who is assessed as fit for work has access to appropriate health support to help them to return to work. Some experts spoke of energetic third sector providers in their local areas who are leading the way in developing evidence-based employment support services for people with mental health conditions. Enhancing employer knowledge about the needs of their employees is beneficial in terms of addressing stigma and the many implications that it has for workplace culture, as well as to improve their ability to make workplace adjustments which better support employees with depression to remain in work. Although the Fit Note provides a means for clinicians to communicate patient needs with employers, current practice is often not effective in conveying sufficient information to support a sustained return to work for people with depression. It is suggested that an employee-owned record of health and work, to complement and extend the Fit Note, could be developed for piloting. This would facilitate collection of information from all the above stakeholders; it would be possible to update it on an ongoing basis and to share it between stakeholders, with employees empowered to take a lead. It is recommended that: A template for an employee-owned health at work record is developed, to provide employees with a personalised and authoritative record on how their Symptoms of depression and their effects on employment 50 condition affects their work. This would highlight ongoing symptoms, what employers need to be aware of and what an employer can do to help them to stay in work. Promoting the concept of employment as a health outcome Recognition of employment as an outcome of clinical care has been slowly increasing but we need to keep this on the agenda and spread the message further. Getting work on the agenda during primary care consultations might be a way of improving understanding about work and developing treatment plans which reflect this. This was raised in the Chief Medical Officers report, where it was recommended that: employment status should be a routine and frequently updated part of all patients medical records. This will provide the baseline data for employment status to be an outcome of all medical specialties, including primary care (Davies, 2014). To this end, we recommend that: The Health and Social Care Information Centre, working with the Royal College of General Practitioners and other Royal Colleges, should review the existing taxonomy for the routine collection of employment data to ensure that it is usable and can be coded across all care settings. This is a change in process and the recommended activities need to be part of a comprehensive push to change the knowledge and culture of primary healthcare professionals regarding the role of employment for many people with mental health conditions. We need to continue the good work we have started and explore new ways in which we might make these changes. Further it is recommended that: An assessment is undertaken of the impact of measuring employment for those in secondary mental healthcare services in the Clinical Commissioning Group Outcome Indicator Sets. Should the outcome be positive we should consider expanding this to include people with any mental health condition, not just those in secondary care. Enhancing understanding and recognition of the symptoms of depression As highlighted in the Chief Medical Officers report, in many cases depression goes unrecognised by individuals themselves, by their clinicians or by their employers meaning many people dont receive any treatment or intervention for their condition. In order to improve employment outcomes for people with depression we need to get better at recognising symptoms of the illness so we can provide the best support. Even where depression is diagnosed, some symptoms, including cognitive symptoms such as difficulty concentrating, may be missed. Any ongoing symptoms of depression missed in treatment (particularly if access to treatment is limited) can provide an ongoing barrier to work. This need is perhaps as acute in the health environment as it is in the workplace and in employment support services. The workplace provides an important location for health and work interventions and often plays a vital role in the recognition of health conditions as well as their management. Managers need to be better equipped to support employees with mental health conditions, including in terms of preventing symptoms to escalate. It is recommended that: Mental health awareness and management training is provided to managers to enhance their understanding of employee needs. Training needs to be of a high quality, and evidence-based where possible techniques such as psycho-education may be useful. As suggested in the recent report of the Taskforce on Mental Health in Society (2015), this might be incentivised through inclusion in professional management standards and employer accreditation schemes. We would also concur with recommendations of both Mind (2014) and the Taskforce on Mental Health in Society (2015) that: Frontline staff in the Jobcentre and Work Programme providers receive training and upskilling to improve their understanding mental health conditions (including depression), helping them to better understand the needs of their clients and provide more appropriate support. It requires proactivity from the individual who may have already waited weeks or months to be contacted by the service only then to be unable to engage due to poor health, be branded as a did not attend and sent to the back of the queue. It was suggested that lessons on how to reach out to people with depression might be learnt from Assertive Outreach programmes, currently used for people with a severe and enduring mental illness, and a low-level approach might be considered. This could include health or social support staff (public or third sector) following up with people who have failed to engage with psychological therapy to identify the issues and provide support. Symptoms of depression and their effects on employment 53 It is recommended that: A form of low-level Assertive Outreach is developed and trialled to identify whether it can be used to improve engagement of patients with depression in treatment, in particular psychological therapy. For those who have had or are expected to have four weeks of sickness absence due to their depression, Fit for Work will be an option. The service will need to be monitored to see how well it is reaching people with depression and how successful it is with supporting their long-term return to work. Fit for Work assessors will also need to recognise ongoing symptoms associated with depression, which might remain a long time after remission of other symptoms and continue to cause problems at work, possibly affecting the long term sustainability of the return to work.

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Childhood mortality during and after hospitalization in western Kenya: efect of malaria treatment regimens 4 mg reminyl with mastercard treatment jerawat di palembang. Drug resistant falciparum malaria: clinical consequences and strategies for prevention 4 mg reminyl with visa symptoms of appendicitis. Surveillance of the efcacy of artesunate and mefoquine combination for the treatment of uncomplicated falciparum malaria in Cambodia order 4mg reminyl otc medicine valium. In vivo sensitivity monitoring of mefoquine monotherapy and artesunate-mefoquine combinations for the treatment of uncomplicated falciparum malaria in Thailand in 2003 reminyl 4 mg low cost medicine 19th century. Efcacy of dihydroartemisinin-piperaquine for treatment of uncomplicated Plasmodium falciparum and Plasmodium vivax in Cambodia, 2008 to 2010. Incidence of adamantane resistance among inuenza A (H3N2) viruses isolated worldwide from 1994 to 2005: a cause for concern. Laboratory methodologies for testing the antiviral susceptibility of inuenza viruses. High levels of adamantane resistance among inuenza A (H3N2) viruses and interim guidelines for use of antiviral agents United States, 200506 inuenza season. The high antibiotics, and further enhanced by transmission populations and body mass of animals as compared to through increasing international movement of people, humans must be kept in mind in these comparisons. Food-producing animals are reservoirs of consumption in food-producing animals worldwide, pathogens with the potential to transfer resistance and on the occurrence of antimicrobial resistance in to humans. The magnitude of such transmission dierent countries and dierent production systems from animal reservoirs to humans remains unknown, (4, 6), in order to make comparisons between countries and will probably vary for dierent bacterial species. The spread of resistance genes from animal bacteria to human pathogens is another potential danger which adds complexity. Herd treatment surveillance of antimicrobial resistance in humans, and antibiotic use in healthy food-producing animals food-producing animals and food is implemented in constitute the main dierences between the use only a limited number of countries. In many examples of some ongoing surveillance programmes, countries, the total amount of antibiotics used in and the bacterial species included. However, beginning with the rst report in 2011, data on food and animals are now combined in a joint report 5. The extensive and of antimicrobials that are critically important for increasing global trade in food animals and their both animal and human health. These currently derived commodities, and growing movement of include fluoroquinolones and third and fourth people, highlight the growing importance of global data generation cephalosporins. These collaborative some of these infections increases severity of disease eorts are intended to strengthen national capacities and results in poorer outcomes for patients (31, 32). Sharing existing experiences of integrated provided further guidance and recommendations, surveillance could inform further development and and called for international solidarity to fght against implementation more broadly. Although fungi are ubiquitous, there is great the Candida bloodstream infection, candidaemia. Prior antibiotic use infection caused by the yeast Candida, and is the most is one of the common risk factors for Candida common cause of fungal infection worldwide (35-37). Over 20 species of Candida can cause receiving intensive antibacterial therapy, such as those infection. Response to antifungal therapy difers by in intensive care or receiving immunosuppressive Candida species. Other examples of common fungal infections demonstrated a marked shift in causative organisms are aspergillosis, histoplasmosis and dermatophytosis of candidaemia towards species of Candida that have (commonly known as ringworm). Also, many of the existing Azoles are used most frequently to treat Candida data are limited to single-centre reports, which may infections, but some Candida species are inherently bias results towards certain patient populations. Antifungal susceptibility testing methods have Echinocandins, when available, are the empiric changed over time, making trend comparisons dicult. Formulations of amphotericin B are Antifungal susceptibility testing is not performed available in many countries, but this agent has higher in most resource-limited countries, and resistance toxicity than azoles and echinocandins. Although many azole- There are also only limited available data on how resistant Candida infections can be treated with drugs antifungal drug laboratory values correspond to of a dierent class, signicant cost, toxicity and absence how patients respond to the drug, especially among of an oral formulation can present barriers to their use. This method would not capture limitations of available antifungal drugs, the following isolates that developed resistance after exposure to resistance proles are of particular concern: antifungal drugs. For these reasons, resistance might resistance to azoles, especially fluconazole, be greater than is currently being detected or reported. Data are compiled from prior published reports of Economic impact candidaemia in hospitalized patients among state Invasive Candida infections have been reported to be or national surveillance projects, and prospective associated with high morbidity and mortality (mortality laboratory surveillance projects. In most countries of approximately 35%), as well as higher health-care where data are available, drug resistance appears to costs and prolonged length of hospitalization (46, 47). Although it is suspected that resistant infections greatly increase these costs, In some locations, candidaemia is the most common few data exist on the economic impact of resistant cause of all bloodstream infections related to vascular Candida infections. Inappropriate antifungal therapy is associated with increased mortality, increased attributable costs, and increased burden of fuconazole non-susceptible Candida species (46). Resistance to azoles is probably Resistance to the newest class of antifungal agents, increasing, and resistance to the echinocandins is the echinocandins, is emerging in some countries. It is likely that the global burden will increase with increasing populations of immunocompromized There are large gaps in information on antifungal patients as economies develop and health care resistance and the global burden of antifungal- improves. Reports of Joint Committee on the Use of Antibiotics in Animal Husbandry and Veterinary Drug (Swann Committee). Norm Norm-Vet Report: A report on usage of antimicrobial agents and occurence of antimicrobial resistance in Norway in animals and humans. Consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria in the Netherlands and Monitoring of antimicrobial resistance and antibiotic usage in animals in the Netherlands in 2012. Solna, Sweden, Swedish Institute for Communicable Disease Control and National Veterinary Institute, 2012. The European Union Summary Report on antimicrobial resistance in zoonotic and indicator bacteria from humans, animals and food in 2011. Global principles for the containment of antimicrobial resistance in animals intended for food. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. High-density livestock operations, crop eld application of manure, and risk of community-associated methicillin-resistantStaphylococcus aureus infection in Pennsylvania. High-level technical meeting to address health risks at the human-animal-ecosystems interfaces. Mexico City, Food and Agriculture Organization of the United Nations/World Organisation for Animal Health/World Health Organization, 2011. Frequency of voriconazole resistance in vitro among Spanish clinical isolates of Candida spp. According to breakpoints established by the Antifungal Subcommittee of the European Committee on Antimicrobial Susceptibility Testing. Increasing incidence of candidemia: results from a 20-year nationwide study in Iceland. Nationwide study of candidemia, antifungal use, and antifungal drug resistance in Iceland, 2000 to 2011. A 1-year prospective survey of candidemia in Italy and changing epidemiology over one decade. Excess mortality, hospital stay, and cost due to candidemia: a case-control study using data from population-based candidemia surveillance. Changes in incidence and antifungal drug resistance in candidemia: results from population-based laboratory surveillance in Atlanta and Baltimore, 2008-2011. It is essential to take appropriate measures to preserve the ecacy of the Whether plentiful or scarce, data on the resistance existing drugs so that common and life-threatening patterns for the bacteria of public health importance infections can be cured. Treatment failure due to resistance to available surveillance and collaboration exist.

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Whenever possible cheap 4mg reminyl treatment quincke edema, a sense of the population studied is provided buy reminyl 8mg free shipping medications emts can administer, to give Whenever available reminyl 4mg otc medications side effects, information on the type of some information on the variety of settings order reminyl 4 mg with amex medications in carry on. The questionnaires and technical points, was sent to a few national and were then passed on for completion by the designated international surveillance networks. Scientifc journal databases, giving a total of 6566 papers, which were articles on resistance rates in human isolates of the stored in two databases. Published reports that were excluded were those that: The retrieved abstracts were reviewed by one person. This denition does not imply that the data collected is representative for that country as a whole because information gaps are likely. Mixed samples urine or other in one hospital, and comprehensive in two hospitals. National data from dierent types of samples (blood, urinary, stool and pus bench) aggregated. National data from dierent types of samples (blood, stool, urine and pus bench) aggregated. National data from dierent types of samples (Blood, pus bench and urine) aggregated. National data from dierent types of samples (blood, urinary and wounds) aggregated. Data aggregated from more than one surveillance source (Hospitals and Clinics). Lebanon National data not available 2013 No information obtained for this Libya report Children with Libya Publication (275) 63. Antimicrobial resistance in invasive strains of Escherichia coli from southern and eastern Mediterranean laboratories. Antimicrobial resistance in pathogens causing nosocomial infections in surgery and intensive care units of two hospitals in Antananarivo, Madagascar. Bacterial isolates in blood cultures of children with suspected septicaemia in a Nigerian tertiary hospital. A fve year study on the susceptibility of isolates from various parts of the body. Resistance to 3 generation cephalosporins and other antibiotics by Enterobacteriaceae in Western Nigeria. Antibiotics susceptibility pattern of uropathogenic bacterial isolates from community- and hospital-acquired urinary tract infections in a Nigerian tertiary hospital. Nosocomial and community acquired uropathogenic isolates of Proteus mirabilis and antimicrobial susceptibility profles at a university hospital in Sub-Saharan Africa. Pattern and antibiogram of urinary tract infection at the University of Port Harcourt Teaching Hospital. Decreased susceptibility to commonly used antimicrobial agents in bacterial pathogens isolated from urinary tract infections in Rwanda: need for new antimicrobial guidelines. Hospital and community isolates of uropathogens at a tertiary hospital in South Africa. Age specic aetiological agents of diarrhoea in hospitalized children aged less than ve years in Dar es Salaam, Tanzania. Rates of antimicrobial resistance in Latin America (2004- 2007) and in vitro activity of the glycylcycline tigecycline and of other antibiotics. Patrones de resistencia antimicrobiana en uropatogenos gramnegativos aislados de pacientes ambulatorios y hospitalizados Cartagena, 2005-2008. Antimicrobial resistance of Escherichia coli in Mexico: how serious is the problem? Resistance trends in gram-negative bacteria: surveillance results from two Mexican hospitals, 2005-2010. Phenotypic detection and occurrence of extended-spectrum beta-lactamases in clinical isolates of Klebsiella pneumoniae and Escherichia coli at a tertiary hospital in Trinidad & Tobago. Community acquired urinary tract infection and susceptibility prole of Escherichia coli to the main antimicrobial agents. In vitro resistance to cephalosporins in women with bacterial urinary tract infections. Uropathogens and their susceptibility patterns in children at Princess Rhmah Hospital, Jordan. Incidence, aetiology and resistance of late-onset neonatal sepsis: a ve-year prospective study. Etiology and antibiotic susceptibility patterns of community- and hospital-acquired urinary tract infections in a general hospital in Kuwait. Escherichia coli isolated from urinary tract infections of Lebanese patients between 2000 and 2009: Epidemiology and proles of resistance. A reection on bacterial resistance to antimicrobial agents at a major tertiary care center in Lebanon over a decade. Characterization of extended- spectrum -lactamase-producing Escherichia coli and Klebsiella pneumoniae isolates from the community in Morocco. Detection of AmpC beta lactamase in clinical isolates of Escheria coli among children. An audit for microbiological surveillance and antimicrobial susceptibility in the intensive care unit. Evaluation of resistance to fuoroquinolones in clinical isolates of Escheria coli. Extended spectrum beta lactamases in urinary gram negative bacilli and their susceptibility pattern. Prevalence of antimicrobial resistance and integrons in Escherichia coli from Punjab, Pakistan. Multiple drug resistance patterns in various phylogenetic groups of uropathogenic E. Epidemiology of bacteraemia in Hamad general hospital, Qatar: a one year hospital-based study. Prevalence and antimicrobial susceptibility of extended spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in a tertiary care hospital. Clinical and laboratory profles of urinary tract infections caused by extended- spectrum beta-lactamase-producing Escherichia coli in a tertiary care center in central Saudi Arabia. Antimicrobial susceptibility pattern of bacterial pathogens causing urinary tract infections in a Saudi Arabian hospital. Prevalence of antimicrobial resistance among gram-negative isolates in an adult intensive care unit at a tertiary care center in Saudi Arabia. Antibiotic sensitivity pattern of common community-acquired uropathogens in children in a Saudi tertiary care hospital. Antimicrobial-resistant bacteria in a general intensive care unit in Saudi Arabia. Antibiotic resistance pattern and empirical therapy for urinary tract infections in children. Increased multidrug resistant Escherichia coli from hospitals in Khartoum state, Sudan. Resistance trends and risk factors of extended spectrum -lactamases in Escherichia coli infections in Aleppo, Syria. Resistance patterns of bacterial isolates to antimicrobials from 3 hospitals in the United Arab Emirates. Prevalence and antimicrobial susceptibility pattern of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the United Arab Emirates. Antibiotic resistance of coliform bacteria from community-acquired urinary tract infections in the Zenica-Doboj Canton, Bosnia and Herzegovina.

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In terms of achieving employment outcomes 4 mg reminyl medications prescribed for migraines, where the individual with depression has identified employment as a goal 4mg reminyl otc symptoms 0f a mini stroke, both psychological and occupational health support were seen as enhanced by engagement with employment specialists national provision is however very patchy 4 mg reminyl free shipping medicine merit badge. In terms of the health system cheap reminyl 4mg otc medications ending in zine, there was a call for more rigour in treatment in particular to the end of improving the recognition and treatment of ongoing symptoms and improvements in understanding about mental health in both its presentation and in terms of its relationship to employment. The main call was for greater appreciation among clinicians at all levels of the value that work often has for someones health and that work should be a prominent factor when making treatment decisions. The low (yet improving) recognition that work is a desired outcome for many people with depression was also seen as barrier to further provision of more effective types of employment support through local commissioning. An important message for clinicians and employers is that people do not have to be one hundred per cent healthy to return to work and for many people with depression a return to work before full symptoms remission can be very helpful. Along with the Fit Note, the new Fit for Work was suggested to have a potential role in retention support for those with depression, though again there were concerns that there would not be sufficient specialist knowledge and that the service would not address fundamental concerns about waiting lists for interventions where an employer does not have occupational health or private health insurance provision. More evidence might be needed to ascertain what works for retention, as separate from a back to work service, so quality services can be encouraged and developed locally. Consistent themes throughout this discussion included the importance of recognising the intrinsic barriers to accessing interventions seen in the common symptoms of depression and consequently ensuring there is specialist mental health and employment support knowledge within services. The diversity of the condition and the individuals who have it requires a personalised approach based on the individual, their goals (particularly where they include employment) and their symptoms in many cases a one-to-one approach was seen as highly beneficial. The value of early intervention was consistently highlighted in terms of assessment and treatment and a collaborative approach to care (actively engaging with the individual and employers). It was also highlighted in terms of bringing together a range of experts who are equipped to provide specialist support to the different aspects of an individuals life and recovery, both in and out of the workplace. Similarly, participants placed considerable emphasis on the importance of providing treatment and employment support together, in parallel. What we have discovered is that many of the interventions which appear positive at achieving these goals are not always provided optimally or that there are barriers to accessing them. In this final section we consider the information collected from both the academic literature and interviews with experts and use this to develop six key areas around which we would like to see change. Within these categories we have made a range of recommendations for change which we feel have the potential to improve employment outcomes for those experiencing symptoms of depression. Working better together We need to improve the way that different stakeholders work together across the health and employment landscape and actively encourage them to work together to enhance support for people experiencing symptoms of depression. As we have seen, the best results are achieved when we address health and vocational needs in a co-ordinated and holistic way. Improving integration of services and support between clinicians, vocational specialists, employers, back to work support and individuals represents a positive approach to helping people remain in or return to work. Better working with and between all Symptoms of depression and their effects on employment 48 stakeholders be they government, voluntary sector or employers should be fundamental to policy in this area. The ability to provide integrated, in-parallel support for health and for employment was seen as vitally important by the experts. We need to provide individuals with well-rounded, personalised treatment and support which reflects their life goals. However, often we see government health and employment services not working together, nor even in some cases sharing information and knowledge, likely negatively affecting their understanding or knowledge of an individuals needs. Experts we spoke to highlighted specific examples including poor engagement between Jobcentre and clinicians, especially where someone is being assessed under the Work Capability Assessment, and the need to integrate employment support into health services at primary (i. This might be accomplished by: o Issuing joint commissioning guidance to encourage and support the pooling of resources to achieve shared local outcomes; or, o Revising and aligning applicable outcomes frameworks to ensure that mental health and employment is a priority for all local stakeholders. In particular, it is important to ensure that someone who is assessed as fit for work has access to appropriate health support to help them to return to work. Some experts spoke of energetic third sector providers in their local areas who are leading the way in developing evidence-based employment support services for people with mental health conditions. Enhancing employer knowledge about the needs of their employees is beneficial in terms of addressing stigma and the many implications that it has for workplace culture, as well as to improve their ability to make workplace adjustments which better support employees with depression to remain in work. Although the Fit Note provides a means for clinicians to communicate patient needs with employers, current practice is often not effective in conveying sufficient information to support a sustained return to work for people with depression. It is suggested that an employee-owned record of health and work, to complement and extend the Fit Note, could be developed for piloting. This would facilitate collection of information from all the above stakeholders; it would be possible to update it on an ongoing basis and to share it between stakeholders, with employees empowered to take a lead. It is recommended that: A template for an employee-owned health at work record is developed, to provide employees with a personalised and authoritative record on how their Symptoms of depression and their effects on employment 50 condition affects their work. This would highlight ongoing symptoms, what employers need to be aware of and what an employer can do to help them to stay in work. Promoting the concept of employment as a health outcome Recognition of employment as an outcome of clinical care has been slowly increasing but we need to keep this on the agenda and spread the message further. Getting work on the agenda during primary care consultations might be a way of improving understanding about work and developing treatment plans which reflect this. This was raised in the Chief Medical Officers report, where it was recommended that: employment status should be a routine and frequently updated part of all patients medical records. This will provide the baseline data for employment status to be an outcome of all medical specialties, including primary care (Davies, 2014). To this end, we recommend that: The Health and Social Care Information Centre, working with the Royal College of General Practitioners and other Royal Colleges, should review the existing taxonomy for the routine collection of employment data to ensure that it is usable and can be coded across all care settings. This is a change in process and the recommended activities need to be part of a comprehensive push to change the knowledge and culture of primary healthcare professionals regarding the role of employment for many people with mental health conditions. We need to continue the good work we have started and explore new ways in which we might make these changes. Further it is recommended that: An assessment is undertaken of the impact of measuring employment for those in secondary mental healthcare services in the Clinical Commissioning Group Outcome Indicator Sets. Should the outcome be positive we should consider expanding this to include people with any mental health condition, not just those in secondary care. Enhancing understanding and recognition of the symptoms of depression As highlighted in the Chief Medical Officers report, in many cases depression goes unrecognised by individuals themselves, by their clinicians or by their employers meaning many people dont receive any treatment or intervention for their condition. In order to improve employment outcomes for people with depression we need to get better at recognising symptoms of the illness so we can provide the best support. Even where depression is diagnosed, some symptoms, including cognitive symptoms such as difficulty concentrating, may be missed. Any ongoing symptoms of depression missed in treatment (particularly if access to treatment is limited) can provide an ongoing barrier to work. This need is perhaps as acute in the health environment as it is in the workplace and in employment support services. The workplace provides an important location for health and work interventions and often plays a vital role in the recognition of health conditions as well as their management. Managers need to be better equipped to support employees with mental health conditions, including in terms of preventing symptoms to escalate. It is recommended that: Mental health awareness and management training is provided to managers to enhance their understanding of employee needs. Training needs to be of a high quality, and evidence-based where possible techniques such as psycho-education may be useful. As suggested in the recent report of the Taskforce on Mental Health in Society (2015), this might be incentivised through inclusion in professional management standards and employer accreditation schemes. We would also concur with recommendations of both Mind (2014) and the Taskforce on Mental Health in Society (2015) that: Frontline staff in the Jobcentre and Work Programme providers receive training and upskilling to improve their understanding mental health conditions (including depression), helping them to better understand the needs of their clients and provide more appropriate support. It requires proactivity from the individual who may have already waited weeks or months to be contacted by the service only then to be unable to engage due to poor health, be branded as a did not attend and sent to the back of the queue. It was suggested that lessons on how to reach out to people with depression might be learnt from Assertive Outreach programmes, currently used for people with a severe and enduring mental illness, and a low-level approach might be considered. This could include health or social support staff (public or third sector) following up with people who have failed to engage with psychological therapy to identify the issues and provide support. Symptoms of depression and their effects on employment 53 It is recommended that: A form of low-level Assertive Outreach is developed and trialled to identify whether it can be used to improve engagement of patients with depression in treatment, in particular psychological therapy.

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