Casting light on workplace depression

The year I was depressed, no one knew about it. Not the colleagues with whom I had lunch, nor the friends with whom I went drinking, nor my caring family members - nor myself. Depression varies in intensity, and not all its symptoms conform to layman assumptions. Even as more firms realise the importance of well-being, depression in the workplace might well go unrecognised, even by sufferers themselves. Masked or "high-functioning" depression has been gaining attention in recent years, though the latter is not a clinical term.

"There is no difference between depression and high-functioning depression," stresses Dr Kinjal Doshi, principal clinical psychologist in Singapore General Hospital's department of psychology. "While on the outside, a colleague may appear completely unaffected - they go to work and are able to accomplish their tasks and maintain their relationships - they may be suffering internally."

Granted, a diagnosis of depression often requires impairment in social, occupational, or other areas of functioning. The layman could thus reach the wrong conclusion: if you are coping with external demands, then by definition, you are not depressed.

That was my conclusion, at least. It was okay that each morning brought a leaden sense of dread, because I still got out of bed. It didn't matter that I constantly felt tired, unable to focus, or irritable, because I still got my work done. It didn't count that I cried frequently, because I had enough self-control to do so only in private.

I used others' perceptions as confirmation. A friend's appraisal of me as "chill" seemed fair; less dramatic than saying that I felt empty or hollow or apathetic. A well-meaning remark about my work efficiency was proof that any worries about my mental state were pure hypochondria.

The point, of course, is that ordinary functioning should not have to be that hard. Even without obvious external signs, internal struggles alone can be cause for concern.

"We often grade depression into mild, moderate and severe," says Dr Goh Kah Hong, head of psychological medicine at Khoo Teck Puat Hospital. "Mild is when you have a subjective feeling of low mood but your ability to perform daily tasks is not visibly impaired; moderate is when things are starting to fall apart, and you are starting to perform below par." In severe cases, one can start to have delusional beliefs, hallucinations, and suicidal thoughts, he adds.

Dr Lim Boon Leng, private psychiatrist of the Dr BL Lim Centre for Psychological Wellness, says: "Often in mild to moderate depression, sufferers are still able to work but have to put in more effort as their motivation and energy levels are low. They can also put up a front and appear to be cheerful but this can be extremely tiring for them at the end of the day."

Dr Christopher Chan, consultant in the Institute of Mental Health's department of mood and anxiety, notes the problems of masking it: "Firstly, the stress from work may continue to worsen the illness, secondly this person may experience isolation and loneliness and thirdly, this person is also more unlikely to seek help."

Some may hide their depression to avoid stigma. They may worry about being labelled, questioned on their ability to contribute, terminated, or blacklisted for future jobs, says Porsche Poh, executive director of mental health non-profit Silver Ribbon (Singapore).

Others, like myself, might be unable to admit it. "This is a common problem, where an individual with depression does not think he or she has a mental illness," says Dr Chan.

"However, often this individual is aware that something is not right with them - it could be that they are making more mistakes at work, finding it more difficult to concentrate, feeling tired more often. They may not attribute these symptoms to an illness."

Know thyself

One obstacle is that not all symptoms conform to the popular perception that depression is about feeling sad or hopeless. Those are indeed among its "affective" or mood-related symptoms, which also include a loss of interest in once-enjoyed activities.

But there are cognitive symptoms too, such as negative or distorted thinking, difficulty concentrating, distractibility, forgetfulness, and indecisiveness; and somatic or bodily symptoms, such as changes in appetite, changes in sleep, and a loss of energy.

My go-to response, if anyone noticed that I seemed down and asked if I was fine, was: "I'm just tired." When mistakes or inefficiency increased at work, I took this as confirmation of my self-assessed uselessness, rather than as symptoms to be addressed.

Depression may also manifest in ways that laymen do not expect. Dr Kua Ee Heok, a psychiatrist at Mind Care Clinic at Farrer Park Hospital, says that when patients are asked by their bosses to see him, this is often due to irritability or flaring tempers.

My colleagues once marvelled at how I had been brusque with a supervisor; I did not tell them that this was due less to a blithe devil-may-care attitude, and more an inability to care.

Another complicating factor is that depressive symptoms can fluctuate. Each time I managed to enjoy an event or look forward to something, I took it as evidence that I was fine.

"Patients with depression may have alleviation of their mood from time to time," notes Dr Lim. "This is a problem as patients themselves may be confused as to whether they truly are depressed as they often have the impression that they must be low all the time when suffering from depression. Their friends and loved ones may doubt the truthfulness of their complaints of depression seeing that they can still appear normal or are even cheerful at times."

As my search history attests - "depressed or lazy", "depressed but still interested in some things" - I was not ignorant of the possibility of depression. Yet I was intent on dismissing it.

Firstly, I felt that my condition was not serious enough to count. After all, I was coping. Yes, the idea of having to stay alive for years more, even decades, seemed exhausting and oppressive - it was comforting to imagine not existing - but I was quite clear that I didn't want to kill myself.

Even now, I doubt my past self. In an early interview for this article, an expert said to consider seeking help if one shows warning signs "for a prolonged period". I asked what this meant; perhaps it required years, so my experience did not count. The answer: according to the American Psychiatric Association, symptoms must last at least two weeks.

Secondly, I felt that I did not deserve to consider myself depressed. I had a job, friends, a loving family. People with harder lives stay cheerful; what right did I have to be sad?

Such a line of thought is only exacerbated by a common, well-meaning reaction to depression: telling the person how lucky they are. I knew full well that I was fortunate; that only made me feel guiltier for how I felt.

While depression can be triggered by work stress or major life events, that is not always the case, notes Dr Kua: "It can just come by itself."

As Nominated Member of Parliament and mental health advocate Anthea Ong puts it, it is important to understand that one can be depressed even if their life seems fine.

Thirdly, depression can distort one's sense of what is "normal". I say "the year I was depressed" as shorthand, but it was at least a year and a half. I don't know how long exactly, because I could not remember.

I knew, abstractly, that I had not always felt constantly tired and hopeless. But I did not recall what that was like. This inability to imagine an alternative extended into the future: What if this was simply how I was? If I was incapable of feeling otherwise?

In a workplace with low morale, it can also be easy to assume that everyone feels this way. Isn't everyone tired all the time? Doesn't everyone hate their job? Such normalisation can prevent one from realising that such a mental state is not healthy.

While working conditions are neither a necessary nor sufficient cause of depression, some factors which worsened my situation were among those that the World Health Organisation identifies as "risks to mental health". These included "poor communication and management practices"; "limited participation in decision-making or low control over one's area of work"; and "unclear tasks or organisational objectives".

A better place

The latest Benefit Trends Survey by Willis Towers Watson found that employers in Singapore are going beyond physical well-being to consider emotional, financial, and social wellbeing too. Some 62 per cent intend to incorporate "well-being" into their overall benefit strategy, and two in five are looking at adding or enhancing chronic disease management and mental health programmes.

Even if not all firms have compassion, cold hard capitalist logic supports mental health inclusivity too.

Says Dr Lim: "Organisations need to recognise that depression and anxiety disorders are likely important factors that affect productivity. This will help businesses and workplaces find the impetus to want to provide more education and awareness to employees about mental illnesses when they realise that doing so is essentially helpful to their bottom line."

A 2017 National Council of Social Service study found that every S$1 invested in workplace adjustments - such as access to counselling, flexi-work arrangements, and supervisor training - yielded an average of S$5.60 in returns. Gains included reduced absenteeism, reduced medical claims, improved morale, and higher productivity.

"If you deny employment to anyone who has a history of depression or might have depression in the future, you are going to lose 20 to 30 per cent of the workforce," says Dr Goh. "In a progressive society, rather than asking about the presence of mental conditions, one should seek evidence of the ability to perform duties," he adds, such as references or on-the-job assessments.

The practice of asking workers to declare previous mental health conditions should be abolished, agrees Ms Ong, who founded the WorkWell Leaders Workgroup of C-suite leaders for mental health inclusivity. Hiring should be done on merit, with support to meet mental health needs.

Even after being hired, workers should not feel pressured to disclose their conditions. At Hush TeaBar, which she runs, a medical certificate is not needed for sick leave - giving "a sense of safety" for those who would rather not explain why.

Jobs can be redesigned for mental health accessibility, akin to the existing movement to redesign jobs for persons with physical disabilities, she adds. "Then you start creating a culture of trust, a culture of empathy, but also a culture that is enabling in supporting peak performance."

Staff should have opportunities "to manage their workflow and be empowered to openly discuss and negotiate the type and amount of work that they value most", suggests Dr Doshi.

"Allowing the affected person some time off work or a decreased workload not only allows them time and space to recover, it is also a show of compassion," says Dr Lim.

But formal policies may not help if discrimination persists. "Often, peers at the workplace tend to have a dismissive attitude and may insinuate that the affected persons are malingering or are incapable," he adds.

With a little help

The waiting room at Mind Care Clinic is as welcoming as can be: soft lighting, gentle music, the scent of camomile tea. Yet I feel an irrational fear of being seen - though I am there merely in my capacity as a journalist.

Such stigma is what causes many people - even doctors and nurses - to delay seeking help, says Dr Kua. "Many of them come to see us late."

Yet seeking help early can prevent the condition from worsening, and aid recovery. It is common to have some symptoms of depression but not to the extent of a clinical diagnosis, says Dr Kua. Such subclinical depression is the focus of prevention.

Mental health literacy can help with this aspect, with Dr Kua and Ms Ong both advocating for mental health education in schools.

But knowledge alone may not be enough. What can supervisors, colleagues, or friends do, if sufferers themselves do not ask for aid?

Apart from talks to educate staff on mental health and encourage them to seek help, workshops can be held for HR and management, giving them the skills to spot warning signs and support team members, says Ms Poh. "Employers and co-workers may wish to invite those with poor work performance and sudden change of behaviour for a chat, express their concerns and look out for warning signs such as poor sleep, poor appetite, and low mood during their discussion."

Signs that are suggestive of depression include worsened functioning; appearing distracted, fatigued, or in a low mood; and becoming more pessimistic, says Dr Goh, adding: "I think it is probably not for an employer to diagnose someone with a medical condition but rather to take it as a possible cue to offer more support."

People may show signs of depression but not be clinically depressed, for instance if they are struggling with stressful life events, he notes. "As concerned bosses and colleagues, it is probably enough to let the person know that you are available and would be willing to listen."

It can also be helpful to give information about resources such as counselling.

Ms Ong suggests "mental health first aid" training on how to spot symptoms and offer resources. Just asking "How are you?" or "Can I support you?" can help by opening up the space for a conversation, she adds.

To which I'd add: try not to unwittingly shut the door. In that year, I heard friends - otherwise kind, generous people - say dismissive things about depression or joke about mental health leave, which reinforced my own self-disdain and guaranteed that I would not confide in them.

The ideal resolution to my story goes like this: I sought help, received it, and recovered with support. Unfortunately, I am an inconvenient example. I never sought help. Technically, I cannot talk about "the year I was depressed", as I was never diagnosed.

But I want to talk about it. For my past self, who could not; and for anyone who recognises something of their own experience in this, and might be persuaded to seek help.

For me, the turning point came when I left for a new job with greater control over my hours and tasks. In the breathing space that opened up, I found that it was possible not to feel constant inadequacy and futility.

That gave me the distance needed to realise that this state of mind was not inherent; that it was not my fault, and things could get better. From there - enabled by a fresh start and better working conditions - the fog began to lift.

At times, old thought patterns or feelings do resurface, reawakened by a bad week or a colleague's joke about my lack of motivation. The difference is that I now recognise these as separate from myself - a problem to be tackled, not an inescapable state.

Dr Kua has three key messages about depression, subclinical or otherwise: "Firstly, it is quite a common issue in workplaces. Secondly, the good news is that it is treatable. Thirdly, we can prevent all this. It is preventable."

It's that sense of possibility, that alternative to inevitability, which I once needed; and which I hope reaches anyone who needs to hear it. Despite how difficult it may be to believe: you do not have to keep feeling this way. It is possible for things to get better.

HELPLINES