Working With Depression, Part II:
Finding and Funding Effective Treatment

Medication and psychotherapy are significantly improved, and treatment of depression is on the rise. Still, there are major barriers for patients and forward thinking employers.

By Ron Z. Goetzel, PhD, Ronald J. Ozminkowski, PhD, Lloyd I. Sederer, MD, and Tami L. Mark, PhD

The previous article demonstrated that mental illness is an expensive, sprawling problem in the American workplace. The good news is that modern treatments are varied and highly effective. Treatment of depression, in particular, has helped a large proportion of patients because of advances in the use of medications and/or psychotherapy.

Over the last 10 years, nine new antidepressants were released in the U.S. These drugs, primarily falling into a category known as selective serotonin reuptake inhibitors (SSRIs), have worked well with more tolerable side effects, greater safety and simpler dosing than their predecessors. Consequently, their use has resulted in better patient compliance and improved physician utilization. Similar advances have occurred in the adoption of newer methods of psychotherapy, such as cognitive behavioral therapy, which are now more structured and time limited.

Still, employers have a right, even a responsibility, to question approaches to mental health.

Does effective treatment of depression save employers money?

Some choose to "ration" mental health benefits, but there is evidence that physical health costs may actually increase in the wake of such a move. In one study, researchers examined the mental health and medical care service use for about 20,000 employees. Over a three-year period, outpatient mental health service use declined by a third, presumably as a result of benefit plan changes that restricted access. On the other hand, employees who had previously used mental health services increased their non-mental health service use by 37 percent and took 22 percent more sick days.

At Bank One, Wayne Burton and Dan Conti tracked health care and productivity expenditures after their company took an opposite approach that included a redesigned EAP, providing information and education programs on depression, training managers to spot warning signs of depression and expanding coverage for mental health services. As a result, mental health as well as overall health care costs declined significantly, even though the costs of treating employees with certain antidepressant drugs increased.

Does depression treatment enhance worker productivity?

Researchers at the Massachusetts Institute of Technology (MIT) found that self-reported worker performance — an admittedly subjective measure — improved in nearly 86 percent of patients treated for depression.

Researchers at MEDSTAT evaluated a corporation's carve out managed mental health program over a four-year period. Analyses of integrated medical and short-term disability data found that significant savings were realized when disability case managers worked cooperatively, because employees returned to work much sooner. Lost workdays declined from 1.31 to 0.25 per patient in the six months following antidepressant treatment.

Using MEDSTAT integrated health and productivity data, other researchers found that work loss days increased steadily in the six months preceding the date when depression was diagnosed by a physician and pharmacological treatment was begun. In the six months following start of treatment, the employees' absence rates returned to baseline levels.

Finally, researchers at Rand Corporation examined managed care practices that implemented quality improvement (QI) programs for depression treatment. They found that clinics adopting the program improved quality of care, mental health outcomes and retention of employment for depressed patients, while medical visits did not increase. The main benefits were found in work performance. Patients in clinics that emphasized psychotherapy worked an additional 21 days over two years, compared to patients in usual care. Patients in clinics that emphasized medication worked about 18 more days.

In short, the evidence is mounting that effective depression treatment has a positive influence on worker productivity in the form of reduced absence, disability and improved retention of employment.

Barriers to effective depression management in the workplace

If depression is a prevalent condition affecting the health and productivity of workers and there is good evidence that interventions are cost effective output, why isn't more being done to increase access to appropriate depression management programs?

The answer may be found in both individual and organizational barriers to care.

• Stigma — Many people still fear that their supervisors or insurance companies will find out they have a mental health condition and that discovery will hurt their opportunities for advancement or insurability. Some fear they will be labeled a "mental patient."

• Shame/Lack of motivation — Since fatigue, hopelessness and passivity are often characteristics of depression, individuals who would benefit from treatment may postpone or completely avoid seeking help. Other people may feel unwarranted shame over having a mental illness.

• Ignorance — Some prospective patients may be unaware of treatment options or the effectiveness of care. Others may fear becoming addicted to psychotropic medications (SSRIs have no addictive qualities.) or feel that psychotherapy intrudes on their privacy. Finally, some may feel that treatment requires a "big commitment" since it is viewed as complicated, lengthy and expensive.

• Lack of confidence — Some people may not expect their primary care doctors to know how to care for mental illnesses. Conversely, some doctors may consider depression to be an appropriate clinical response, given the patient's medical condition or advanced age, and see no need to treat a "normal" reaction to events. When this occurs, lack of confidence is unfortunately substantiated.

• Deficiencies in training — Some physicians may lack the interviewing skills to accurately diagnose or the time to fully evaluate and respond to depression in their patients. They may not have access to or familiarity with good diagnostic tools. They may not feel comfortable dealing with mental health issues or be concerned that mental health care is not adequately covered by the patient's insurance plan, and consequently focus their treatment on physical conditions.

• System shortcomings — Some managed care organizations may be more concerned about restricting mental health treatment to save money (e.g., prescribing older and less expensive medication, restricting outpatient visits, limiting psychiatrists to medication management) than providing quality care. In many cases, employers may "carve out" behavioral health care services, thereby limiting coordination of care between mental and physical health providers. Finally, employers may not provide adequate insurance coverage for mental health services, restricting access to providers or reimbursing patients at lower levels than for treatment of physical disorders.

• Ambiguity regarding the role of employers — Some business leaders may feel uncomfortable or ill equipped to play a proactive role in the management of worker mental health issues. They may expect their health plans to provide these services as part of routine care. Some managers may be concerned about becoming overly involved in the personal lives of their employees. They may worry that if they get too deeply involved, they may be subject to grievances, union actions or lawsuits by disgruntled employees who view these efforts as unwanted intrusions or violations of the Americans with Disabilities Act (ADA).

• Lack of data — Some managers may argue that they cannot justify additional spending because they do not have adequate evidence that the problem is important enough for their organization, or that they would be unable to track the economic impact of any new intervention programs.

• Employer information gaps — Perhaps the greatest barrier to increased investment in mental health interventions is ignorance — ignorance about the value these programs may bring to individual workers, their families and the company itself. One can understand the frustration experienced by many employers. The field of medicine is extraordinarily complex. Knowledge of treatment effectiveness and cost effectiveness is often concentrated in a few experts. The information needed to make sound business decisions is often lacking or not well understood by the people whose job it is to develop human resource policies and implement effective programs.

How can employers better manage the mental health and well being of workers?

Employers have an important role to play in preventing and treating worker mental health issues and overall organizational health problems at three levels.

Primary prevention might include programs that teach employees how to spot mental health problems early on and respond effectively. Regular screening for depression and stress, as part of a company-sponsored health promotion initiative, is another way to identify individuals and groups who are at risk for mental health problems. Teaching employees effective coping skills is yet another form of primary prevention.

Secondary prevention programs involve detection of potential mental health issues and referral to appropriate health care professionals for treatment.

Tertiary prevention involves reducing the severity, discomfort, long-term impairment and disability associated with mental health conditions through appropriate treatment, improved compliance with medications and psychotherapy, and prevention of relapse.

Employers hold the potential to significantly impact the health, well being and productivity of their workers by conducting effective employee education programs; providing appropriate screening and early detection; regularly assessing the organization's climate; removing barriers to appropriate medical, pharmacological, psychotherapeutic care; better coordinating benefit, EAP, occupational medicine, health promotion, and other related health and productivity management services; and working toward achieving a healthy company culture.

Ron Goetzel is director of the Cornell University Institute for Health and Productivity Studies and vice president, consulting and applied research for Medstat; where Ronald Ozminkowski is director, outcomes research and econometrics; and Tami L. Mark is senior economist. Lloyd I. Sederer is Executive Deputy Commissioner for Mental Hygiene for The City of New York. The opinions expressed in this paper are the authors' and do not necessarily reflect the opinions of Cornell University, Medstat or The American Psychiatric Association, which funded preparation of this manuscript.

The authors wish to acknowledge the contributions of Alisa B. Busch, M.D., M.S. who provided scholarly material for consideration.

More Business & Health Articles on This Topic:

Working With Depression, Part I: The Business Case for Quality Mental Health Services (August 1, 2002)

A World View of Mental Health in the Workforce (July/August 2000)

The Realities of Mental Health Parity in the U.S. (July/August 2000)

Depression in the Workforce (April 1, 2000)

Resource Links:

Cornell University Institute for Health and Productivity Studies
http://www.ccpr.cornell.edu

Medstat
http://www.medstat.com

Health Enhancement Research Organization (HERO)
http://www.the-hero.org/

World Strategic Partners/The Club of Geneva
http://wspartners.com

World Health Organization
http://www.who.int/

American Psychiatric Association
http://www.psych.org/