Despite the high prevalence, mental illness in the workplace is commonly misunderstood and under supported (1), even though employment plays an important role in maintaining psychological health, and for men, paid work is associated with increased levels of personal growth (2).

In Australia, male dominated industries are defined as workplaces where more than 70% of the working population are males (3) and in Australia male dominated industries tend to have higher than average rates of common mental disorders with the mental disorder rates in agriculture, construction, mining, and utilities ranging between 20 and 24% (4).

When considering workplace compensation claims made in Australia between 2008 and 2011 the highest risk male occupations for metal stress are transport officers, police officers and ambulance officers/paramedics (5).

People in employment often face complexities in managing mental illness as a result of discrimination or stigma. This is particularly true when (re)entering the workforce after being acutely ill or trying to continue working despite an illness, with almost 70% of workers reporting anticipated discrimination when finding work or trying to manage their symptoms at work (6).

Discrimination, both anticipated and experienced, is the most frequently identified barrier to disclosure of mental health conditions in the workplace (7). Recent studies have shown that employers were less likely to hire someone who discloses their mental illness during recruitment, even more so than people with permanent physical disabilities (8, 9). In a workplace context, stigma and discrimination are important factors that hinder those with a mental health condition in seeking employment, staying employed, or gaining a promotion (8, 10). Discrimination and bullying can vary between industries with male dominated industries reporting experiences of discrimination associated with reduced mental health [(11), paper under submission] and female dominated industries more often reporting bullying (12).

For individuals making decisions around their disclosure important factors to consider are the organisational policies around disclosure and if these policies align with that of the individual. Organisational policies promote disclosure and managers report preferring disclosure, even though they acknowledge that it would be a significant risk to employ those with a disclosed mental illness (13). A recent European longitudinal study on attitudes towards disclosure in employers showed that 42% of employers agreed that mental illness policy was set up primarily to protect the organisation from litigation (14). However, fear of perceived public stigma has lead employees to default to a position of non-disclosure (15).

Many countries have enacted legislation to tackle such discrimination, usually framed in a disability context. The Australia Disability Discrimination Act 1992 (Cth) (16) defines “discrimination” broadly, and includes direct and indirect discrimination. The Act makes it unlawful to discriminate against, harass or victimise people with disabilities, including those with mental health conditions. It also makes it clear that an employer's reluctance to hire, or failure to make reasonable adjustments for a worker with a mental health condition are discriminationatory practices. Organisational practices and commonly accepted behaviours occur and remain unchallenged, despite falling within the legal definition of indirect discrimination.

In order to address gaps in knowledge regarding mental health in the workplace, a number of workplace manager interventions have been implemented with an emphasis on awareness training and skills development. A recent meta-analysis indicated that mental health training appears to increase managers' understanding of issues, their role and responsibilities, attitudes, and importantly, behaviours when addressing mental health concerns (17). Workplace anti-stigma interventions follow a similar process to manager training by targeting knowledge, attitudes and behaviours. A recent systematic review reports that workplace anti-stigma interventions can be particularly effective in changing employees' knowledge of mental disorders, as well as helping change behaviour of colleagues in the workplace (18).

Despite interventions aimed at managers and colleagues, employees are still reluctant to disclose. A recent Australian survey showed that 41% of those who had taken unplanned leave for their mental illness did not disclose the true reason to their employer, and only 26% disclosed their mental illness (19). Research on disclosure of mental health conditions in a workplace setting has typically focused on those with more severe mental illness (20) with interventions focusing on those that are unemployed to help facilitate return to work (21). However, little attention has been paid to helping employees make the decision to disclose mental health issues in the workplace.

For people currently in employment, deciding to disclose a mental illness is often complex, and requires thoughtful decision making to ensure personal, legal and employment risks are best managed. Decision aid tools offer a way to support people with these complexities. They can encourage thoughtful deliberation in making specific and deliberate choices amongst two or more options, and have commonly been used in decision making regarding medical treatment options (22). The recent success of the CORAL study (21), which used a paper-based decision aid tool for people with a severe mental illness in secondary care services seeking employment showed that, in this setting, the decision aid had the capacity to reduce decisional conflict. Those using the tool had an increased likelihood of obtaining employment regardless of the decision made, indicating the importance of making, and being comfortable with an informed decision.

As part of the future development of a web-based decision aid tool to support deliberations of disclosure of mental health conditions in the workplace we aim to explore factors currently influencing decision making about disclosure with two key groups, employees who have disclosed and supervisors involved in the sequelae to disclosure.

Despite only 25% of those with a mental health condition disclosing their illness at work (19), few studies have investigated the factors which influence decision-making around disclosure. This present study explores these factors among first responders and a transport organisation who either have previously disclosed or were responders to such decision processes. This study identified six key themes, all negative, of internal and external factors influencing and consequences of decision making regarding disclosure. When considering all factors together these male dominated workplaces are characterised by a culture of fear around disclosure. Managers appear underprepared to deal with the impacts of disclosure, and there is a lack of organisational systems in place to deal with mental health issues amongst employees.

The prevalence of explicit disclosure policies led to the majority of our partners declining to be involved in research that consider an option of non-disclosure. A recent qualitative study in Canada suggested that organisational policies should not focus on a stance of disclosure as the only option, the focus should be placed on creating an environment where employees feel comfortable and safe to disclose (15).

This study, similarly to Toth and Dewa (15), identified that employees start from a default position of non-disclosure, and identified that employees only move to a position of disclosure once they feel as though an event occurs such as “their cup fills up.” This dissonance between organisational policies taking a hard stance on disclosure and employees defaulting to the other option of non-disclosure has created tension and created a culture of fear around disclosure.

What was striking was that despite the researchers adopting a neutral approach and asking a specific question to prompt negative or positive experiences to whether disclosure was desirable or not, only one person considered the potential positive aspects of doing so. The single incident of a positive experience in disclosing mental illness suggests a failure of the extensive government initiatives aimed at demonstrating the possibilities of workplace accommodations, and shows dissonance between employers preferring prospective employees to disclose at the outset (26) even though they may not be willing or have the capacity to provide support or adjustments, or even be willing to hire those with a mental illness in the first place (27). Decision aids need to specifically incorporate these factors into the considerations to balance the entrenched barriers. The provision of training for managers and colleagues is not enough to address the barriers, as low rates suggest that many of those living with a mental illness are still not disclosing (19).

Self-stigma and internalisation of discrimination reduces the capacity to make decisions (28). Anticipating discrimination, worry about being a burden, being judged as weak, or being denied a promotion also influences decision making about disclosure supporting previous research that suggests those that have a mental illness often decline to seek help to avoid being stigmatised (29). Poor knowledge of potential mental illness, particularly discriminating early symptoms from daily stress (30) would be present in those not yet at a stage of decision making who may be unaware of options available to prevent deterioration, which might require disclosure. A recent study found that better knowledge, and a positive self-attitude can predict stronger intentions to disclose (31).

A number of external factors to decisions about disclosure were also identified. Some participants had experienced discrimination by others when disclosing in the past; particularly common were lack of support or preparedness of managers to provide reasonable work adjustments after disclosures. Consequences of this included a negative culture around mental illness in the workplace, which, as shown in other studies, seemingly reduces the motivation for employees to disclose (32, 33). Which we know may be detrimental in male dominated industries as men are more likely to disclose than women when there is a supportive environment (34).

Secondly, some employees anticipated discrimination or worried about being seen as weak or incompetent. This anticipated reaction is based on experience and substantiated by research, with previous studies showing that employers view people with mental illness as lacking competence to meet work demands (27, 35).

Both of these first two themes identified could have serious impacts on male dominated industries in particular, as two recent systematic reviews examining the characteristics and risk factors that are associated with common mental disorders in male dominated industries identified that an unsupportive environment, job demands and job overload are associated with psychological distress and are risk factors for depression and anxiety (36, 37).

In contrast to previous research (38), this study identified a clear dissatisfaction and distrust with current EAP services. Participants reported not knowing what was available, found it difficult to find what they needed when they were feeling unwell and overburdened. The inadequacy of the available EAP programs were also reported with complaints about session lengths, inconsistency of care and not gaining any relevant tools for recovery. Confidentiality was another factor identified that influenced decision making, participants had a general belief that EAP officers report details from the sessions to their employers. Confidentiality concerns with EAP services have been previously documented (39), however, this study shows how a lack of anticipated confidentiality can lead to decisional conflict around disclosure. Confidentiality may be limited within colleagues as some legislation and professional obligations require colleagues to report to management if someone has disclosed to them, this may be an issue specific to the Australian first responders group as they have particular safety concerns related to their professional responsibilities.

The final factors that influence decision making identified were financial implications and risk of job loss or role change. A number of participants both from the authority and disclosure groups reported either personal or second hand accounts of seeking help outside of the workplace to avoid disclosure and its consequences, often using up their holiday and sick leave and accruing personal expenses whether the illness originated or was exasperated in the workplace. Other participants also reported worry over the work that will be available to them; work via reasonable adjustments are either mundane and require relocation to have reasonable work available that has been previously shown to increase the prevalence of isolation and reduce communication and team relationships (40).

In male dominated workplaces decisions to disclose mental ill-health, even by those who had done so or who were influential for consequences, appeared driven entirely by consideration of barriers to disclosure. This suggests that anti-discrimination policy, legislation, awareness campaigns, celebrity stories, and manager training have yet to change perceptions that disclosure is negative, and have not been able to shift the culture of stigma that looms over mental health issues. There seems to be a clear disconnect between organisational policies favouring disclosure and employees favouring non-disclosure that has caused tension within the organisational culture and a fear around disclosure. Further attention is needed to encourage a more positive and productive approach in supporting employees in the workplace. Any decision aid tool needs to incorporate counterfactual and potentially positive aspects that are not yet widely considered in decisions about disclosing mental health issues in the workplace. Such content could begin to shift cultures of stigma, as well as support people to be properly informed and feel empowered and that they are making the correct decision for their situation.

ES, IC, SH, and NG contributed to the design and conduct of the study. RR and ES facilitated the focus groups. RE and ES coded the data. ES, RE, and NG had full access to all of the data and completed the analysis. All authors reviewed manuscript drafts and approved the final version.