Figure 1 highlights this basic maintenance cycle.
Anxiety maintenance
Anxiety is an emotional response activated by fear-based cognition. So when an individual perceives a situation as threatening, has a view of themselves as vulnerable, the world/others as threatening and the future as unpredictable,(n25) their behavioural response will be to avoid exposure to perceived danger.(n6,n22,n24,n26,n27)
This behaviour is actively reinforced if there is a reduction in anxiety symptoms, which will occur initially as a result of the avoidance of the feared situation.(n6,n27)
However, this behaviour ultimately maintains anxiety because it prevents the disconfirmation of potentially faulty negative beliefs, which were responsible for the initial onset of anxiety.(n8,n22)
Figure 2 highlights an example of anxiety maintenance within the workplace. When the employee with anxiety is signed off sick from work, there is an initial feeling of relief, associated with not having to face difficult situations within the workplace (initial reduction of anxiety symptoms). This may develop or enhance the inaccurate perception of the linear relationship between work (environment) and anxiety (emotion).
However, where the anxiety is based on inaccurate negative cognitions (congruent with high emotional arousal), the absence of exposure to the environment at work leaves the negative cognitions unchecked and serves to give rise to further negative emotions (ultimate maintenance and/or increase in anxiety, fear, agitation, apprehension). This is further enhanced when the employee experiences distress at the thought of going back to that environment.
It is natural for an employee to want to avoid returning to work on the basis of this increased distress and to seek further sick leave. However, returning to work is what is needed to help break the maintenance of anxiety when the perception of the environment is inaccurate.
Sickness absence could serve as an avoidant behavioural response. This is further influenced by the societal perception of sickness behaviour, whereby the individual is likely to not only avoid work but many other daily activities, further exacerbating the potential for avoidant coping and the continuation of anxiety symptoms. It is therefore probable that in the absence of treatment intervention, the removal of the employee from work would serve to maintain the disorder of anxiety.
Depression
Depression is an emotional response activated by loss-based beliefs. Depressive cognition's consist of a view of the self, the world/others, and the future as negative.(n7) These negative cognitions then further interact with the individual's lowered physiological drives, emotional and behavioural responses. Specific behavioural responses include decreased levels of motivation to develop and pursue goals and the consequential reduction in activity levels, apathy, lethargy and avoidance behaviour.(n7,n28,n29)
The symptoms of depression are also believed to interfere with normal relationships because the depressed individual tends to isolate themselves from others,(n31) leading to the experience of rejection, which can further exacerbate negative self perceptions and maintain depression.(n31,n32,n33)
Figure 3 highlights an example of depression maintenance within the workplace. When signed off from work, the employee with depression experiences an instant loss of structured and goal-directed activity, which, coupled with the associated loss of social contact, can have a huge negative impact on their already negative view and, hence, the severity of the depression.
The consequential reduction of other general activity levels (sick role behaviour) and/or a low level of motivation (symptom of depression) to develop new routines to fill the void of time that was previously structured with the activity of employment, can have a reinforcing effect on depressive symptoms.
Conclusion
This review considered the potential impact of sickness absence as a maintenance factor for anxiety and depression from a CB perspective.
For anxiety, the most significant coping behaviour is avoidance, as it tends to lead to an initial decrease in symptoms but ultimately maintains the anxiety because it prevents the disconfirmation of potentially faulty negative beliefs, responsible for the initial onset of the anxiety.(n6,n22)
For depression, the most common coping behaviour is also avoidance, which leads to a reduction in general and/or social activity levels. This behaviour ultimately serves to reinforce the activating cognitions and consequently increases depressive symptoms.(n7,n28)
As a result of this review, sickness absence for individuals with anxiety and/or depression may act as a potential maintenance factor, suggesting that signing off an employee with symptoms of anxiety and/or depression without any other intervention can actually be contraindicating to their condition. Such a finding in the context of the current surge of occupational mental health and corresponding utilisation of sickness leave is extremely concerning.
However, although this review has focused on the negative implication of sickness absence on the symptoms of anxiety and depression, it does not underestimate the need for sickness absence in certain cases. It seems clear though that to use sickness absence more positively, we need to further understand some of the processes by which it can impact upon an individual.
The current Health & Safety Executive initiatives actively promoting the awareness of mental health in the workplace for both employers and employees are helpful,(n3) and may help to tackle the current problems pertaining to the societal view of mental health and the sick role. However, in light of this review, such isolated initiatives may be insufficient and further research into the efficacy of interventions for this group need to be considered. For example, the specific role of early intervention to either replace or complement sickness absence for those who are unable to continue to function at work is a priority.(n34,n35)