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Business Case for Quality Mental Health
•
Goetzel et al
FAST TRACK ARTICLE
The Business Case for Quality Mental Health
Services: Why Employers Should Care About
the Mental Health and Well-Being of Their
Employees
Ron Z. Goetzel, PhD
Ronald J. Ozminkowski, PhD
Lloyd I. Sederer, MD
Tami L. Mark, PhD
A
Employers are very concerned about rising mental health care costs.
They want to know whether their health care spending is improving the
health of workers, and whether there is a productivity payback from
providing good mental health care. This article addresses the subject of
employee depression and its impact on business. The literature suggests
that depressed individuals exert a significant cost burden for employers.
Evidence is mounting that worker depression may have its greatest
impact on productivity losses, including increased absenteeism and
short-term disability, higher turnover, and suboptimal performance at
work. Although there is no conclusive evidence yet that physical health
care costs decrease when depression is effectively treated, there is growing
evidence that productivity improvements occur as a consequence of
effective treatment, and those improvements may offset the cost of the
treatment. (J Occup Environ Med. 2002;44:320 –330)
From The MEDSTAT Group, Inc, Washington, D.C. (Dr Goetzel, Dr Mark) and Ann Arbor, Mich.
(Dr Ozminkowski), and the American Psychiatric Association, Washington, D.C. (Dr Sederer).
The opinions expressed in this article are the authors’ and do not necessarily reflect the opinions of
The MEDSTAT Group, Inc, or The American Psychiatric Association, which funded preparation of
this manuscript.
Address correspondence to: Ronald J. Ozminkowski, PhD; The MEDSTAT Group, 777 East
Eisenhower Parkway, 803R, Ann Arbor, MI 48108; [email protected].
Copyright © by American College of Occupational and Environmental Health
ccording to the Washington Business
Group on Health,1 the most serious
employee benefit problem facing
employers today is the unrelenting
increase in health care costs— up
50% in the past 5 years—with no
apparent end in sight. Other concerns
expressed by human resources and
benefit managers include frustration
in assessing quality of care and demonstrating the cost-effectiveness of
medical treatments provided to their
employees.2,3 Furthermore, there is
corporate uneasiness about new or
pending legislative mandates, including those related to the patient bill of
rights, Health Insurance Portability
and Accountability Act privacy
rules, and preemption of the Employee Retirement Income Security
Act (1974).4 Some employers are
considering defined contribution
plans in which workers are handed a
“cash” amount that they can use, at
their discretion, to purchase individual health care policies.5 Others are
even considering getting completely
out of the business of providing
health care coverage for their
employees.
With the cost of benefits rising so
fast, why should employers remain
engaged in the provision of health
care benefits to their employees?
Aside from important attention to
employee morale and union pressures, for example, one answer may
be found in the following observation regarding emerging corporate
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Volume 44, Number 4, April 2002
priorities. Employers are becoming
increasingly aware that worker
health influences worker productivity, and that productivity has a positive impact on organizational performance and competitiveness. 6
Moreover, employers are recognizing the importance of their role in
better promoting the health and productivity of their workers. This may
be most evident in the area of mental
health care.
But many employers are still frustrated and confused. A recent study
by Olfson and colleagues published
in the Journal of the American Medical Association7 reported that advances in pharmacotherapy and
changes in America’s health care
environment have fostered a sharp
increase in the proportion of individuals who receive outpatient treatment for depression. During the 10year period between 1987 and 1997,
the rate of outpatient treatment for
depression in the US general population increased threefold (from
0.73% to 2.33% of the population).
In addition, the proportion of patients
treated for depression who received
antidepressant medications doubled
(increasing from 37.3% to 74.5%),
whereas the proportion receiving
psychotherapy declined slightly
(from 71.1% to 60.2%).
In response to these new and compelling data, employers might well
ask: Is this a good development? Are
we getting good value by treating
more people for depression? Are the
people who need help getting treated
in the right way? Are we realizing a
productivity benefit from this additional, and most likely costly, treatment of patients? Are we getting the
“best bang for our buck?”
This article attempts to address, at
least in part, some of these concerns.
In this document, we review and
summarize the key research on the
health and productivity consequences of appropriate and inappropriate mental health treatment, with a
particular focus on depression, the
rationale for which is described in
the section below. The information is
written in a manner principally
meant for a business audience. Corporate decision-makers must be provided objective, persuasive, scientific evidence on the value of mental
health treatment if they are to alter
their benefit policies and human resources practices.
The HERO Study
In October 1998, two of the current authors (R.Z.G. and R.J.O.)
were involved in a study published in
the Journal that attracted widespread
attention. The study, known popularly as the HERO (Health Enhancement Research Organization) research,8 reported the results of a
large-scale retrospective analysis of
medical claims and health risk data
for about 46,000 private and public
sector employees. The point of the
study was to determine the relative
importance of 10 modifiable health
risk factors in terms of their impact
on employee medical costs over a
relatively short time period (within 3
years).
The study asked the question,
What is the additional medical expense borne by employers when their
employees are at high risk for any
one of 10 common modifiable health
risk factors? These risk factors included smoking, sedentary lifestyle,
high cholesterol, hypertension, poor
diet, being overweight, excessive alcohol consumption, high blood glucose, high stress, and depression.
Econometric methods were used to
examine each of the risk factors independently, removing the “noise”
of other competing risk factors and
available demographic information
for these employees.
The results were a surprise to
many in the research community.
The risk factor predicting the largest
medical cost increase was depression. Employees who reported being
depressed were 70% more expensive
than their non-depressed counterparts. Those who reported being
highly stressed, and incapable of
managing that stress, were 46% more
costly than non-stressed employees.
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And, employees who were unfortunate enough to experience both depression and high stress were 147%
more expensive.
To the employer, the implications
of this research were enormous.
When all else was held equal, the
risk profile of that employer’s workforce imposed a significant burden
on labor costs. If a larger proportion
of employees in employer A’s workforce were depressed, when compared with a competitor’s workforce,
then employer A’s benefit and human resource expenses were likely to
be greater—all else being held equal.
If that were the case, what options
are available to employer A to level
the playing field? Firing workers at
high risk is not an option, for obvious
legal and ethical reasons. Alternatively, the employer could institute
risk reduction and disease management programs that, if successful,
would significantly impact the expense side of the employer’s accounting ledger and the company’s
bottom line. But, how could that be
done in a cost-effective way?
The HERO study got the attention
of many employers. It also left open
several questions regarding depression and stress. For one, because
workers self-reported these risks, it
was not clear when depression was a
manifestation of stress or when employees who were “stressed out”
were actually clinically depressed. In
addition, employers could not be
clear about what they could do to
better manage depression in the
workplace—in other words, what
works, what doesn’t? Employers began to ask the study authors, What
can be gained as a result of effective
management of employees with
depression?
This article aims to address these
and the following related questions
facing many employers. The questions addressed in the document are
as follows:
• What is the health and productivity cost burden of depression in the
workplace?
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• What can be done to “treat” depression—and do these treatments
work?
• Is there a financial payoff from the
successful treatment of depression?
• What are some of the barriers to
effective treatment, and how can
these be overcome?
• What is the role of prevention and
health promotion?
• What conclusions can be drawn
from this review, and what are the
knowledge gaps that employers
must fill to make better-informed
decisions?
The Context for Managing
Employee Depression
We began this article by noting
that employers are wrestling with the
issue of whether and how to provide
effective physical and mental health
insurance coverage for their employees— coverage that not only responds to their treatment needs but
also enhances workers’ productivity.
Employers are increasingly aware
that an important variable affecting
American businesses is the health
and vitality of its workers.9
A new type of employee, often
referred to as a “knowledge worker,”
now exists. This employee needs to
be creative, flexible, innovative, and
team-oriented and can respond to
business challenges such as increased global competition, reduced
cycle time for product development,
increased reliance on technology, the
need to deal effectively with information overload, and figuring out
how to do more with less. These are
all highly developed cognitive and
psychosocial skills—-very different
from the types of physical skills and
aptitudes required of workers only a
few decades ago.
How can organizations increase
the productive output of workers?
Some, very simply, require employees to put in longer hours. But intensive work output cannot be sustained
over the long-term. Faced with these
new job challenges, some workers
may feel uncomfortable about their
new job demands; this stressor may
Business Case for Quality Mental Health
leave employees at greater risk for
depression. They may worry about
their job tenure. They may have a
sense of being left “out there” with
little organizational support. Their
loyalty to their jobs may founder.
They may experience detachment,
depersonalization, and diminished
motivation to perform at peak
performance.
Although the cause of depression
is unknown, it results from a chemical imbalance in the brain related to
the presence of serotonin, other hormones, and perhaps some trace elements such as copper and zinc.10
Depression can be brought on by a
complex of inherited (biological)
vulnerability, painful developmental
experiences, and personality characteristics (such as high standards, conscientiousness, and perfectionism)
that interact with current life stressors. Preventing and controlling depression involves minimizing the impact of stress on existing vulnerabilities and trying to correct the
chemical imbalance with pharmaceutical treatment.
For workers suffering from depression, and especially for those
whose life outside of work is challenging as well, the disorder may
manifest itself as increased health
care use, higher absence rates, more
accidents, and increased disability.11
Further, low morale and poor attitudes about work can become contagious and “infect” fellow workers,
further exacerbating individual problems and bringing about increased
turnover and general organizational
malaise. Economic uncertainty adds
measurably to employees’ feelings
of unease and a lack of stability.
What can employers do in response? Some more enlightened employers have introduced health and
productivity management initiatives
designed to coordinate the many
types of programs that employees
may use when they are sick, injured,
or trying to balance work/life issues.
These programs integrate medical
benefits, disability, workers’ compensation, health promotion, disease
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Goetzel et al
management, employee assistance,
paid sick leave, and occupational
safety programs. Health and productivity management programs also
aim to enhance employee morale,
reduce turnover, and increase on-thejob productivity.12
An important component of health
and productivity management involves the management of employee
mental health and well-being. When
considering health and productivity
losses associated with employee
mental strain, health care costs represent only a fraction of what employers spend to keep workers
healthy and on the job.13 As shown
below, when employers factor in the
cost of lost productivity, such as for
unscheduled absences, dollars paid
to replacement workers, overtime
premiums, and productivity losses of
workers while on the job, the total
health and productivity cost burden
of depression is increased sharply.
For some American businesses, a
focus on health and productivity has
given rise to a new way of thinking
about workers as resources rather
than line item expenses.14 Business
leaders are increasingly concerned
about their ability to attract and retain intellectual capital—with the
health and well-being of their workers being considered a critical success factor.
A business case for increased attention being directed at employee
mental health issues can therefore be
formulated using a rationale of
health enhancement, medical cost
containment, and productivity improvement. Below, we review some
of the evidence supporting the relationship between employee mental
health and well-being, and consequent health and productivity gains
to an organization, that can accrue
from appropriate management of
employee mental health issues.
The Health and Productivity
Cost Burden of Depression
It is estimated that about one in
five Americans will be affected by a
depressive disorder (ie, major de-
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pression, dysthymia, depression not
elsewhere classified, or the depression occurrence of bipolar disorder)
in his or her lifetime.15–17 In any
given year, about 1 in 10 American
adults aged 18 years and older suffers from depression (6.6% for men
and 12.0% for women).18,19 In addition, 6% to 8% of all patients seen in
general medical practice are diagnosed as depressed.20
Many patients with depression remain undiagnosed, untreated, or under-treated.21 Despite the most recent report cited above showing a
sharp increase in depression treatment, at best, only about a third of
patients suffering from clinical depression receive appropriate treatment in the form of medication or
psychotherapy. 22,23 For patients
seeking help with their depression,
about 75% approach their primary
care doctor for such help, but only
about half of those actually receive
treatment,24 and only about 20% are
referred to a mental health
specialist.25
A report prepared by MEDSTAT
researchers for the Substance Abuse
and Mental Health Services Administration found that private insurance
expenditures for mental health and
substance abuse grew more slowly
than total national health care expenditures from 1987 to 1997.26 A separate analysis of insurance claims by
The Hay Group found that between
1988 and 1999, the value of behavioral health benefits (excluding pharmaceuticals) as a percentage of total
health benefits actually decreased
from 6.1% to 3.1%.27
Other researchers have reported
that depression treatment may appear
to be increasing, partly because depression codes are being used more
often by physicians. For example,
the percentage of patients with any
outpatient mental health care increased from 5.1% to 6.3% between
1987 and 1999. But during the same
time period, the average number of
visits per patient decreased (from
9.35 to 8.76), as did the average
expenditures per visit (from $73.31
to $69.18). Therefore, the trends
shown may not really reflect a dramatic increase in outpatient mental
health utilization, but instead better
physician coding of claims for depressed patients, while at the same
time, a reduction in the amount and
cost of care being provided to these
patients.28
What is the Health Impact of Depression? It is not always clear
whether depression causes physical
health problems or whether physical
health problems have depression as
one of their consequences. Most
likely, the associations travel in both
directions. However, comorbidities
associated with depression are considerable and are important to identify and treat.
For example, it seems now that
depression is an important risk factor
for heart disease, along with high
blood cholesterol and high blood
pressure. A study conducted in Baltimore found that of 1551 people
who were free of heart disease, those
who had a history of depression were
4 times as likely to suffer a heart
attack as those not suffering from
depression.29 In addition, researchers
in Montreal found that heart patients
who were depressed were 4 times as
likely to die within 6 months of
having a heart attack as those who
were not depressed.30 Depressed
workers who are also angry have
been shown to have higher cholesterol levels.31 Depression may cause
chronically elevated levels of stress
hormones, such as cortisol and
adrenaline, and activation of the
sympathetic nervous system (part of
the “fight or flight” response), which
can have deleterious effects on the
heart.32 A recent study of 6095 men
and women who were followed for
an average of 16 years found that
depression was predictive of stroke
across all demographic groups examined.33,34 These findings, in aggregate, raise several concerns inasmuch as heart disease is the leading
cause of death in the United States
and the most costly health condition
faced by US employers.35
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In terms of day-to-day functioning, researchers conducting the landmark Medical Outcomes Study36,37
found that patients with depression
functioned at very low levels, equivalent to patients with coronary artery
disease and lower yet than patients
with hypertension, diabetes, and arthritis. Of course, in addition to the
physical ailments associated with the
depression, there are the actual
symptoms of the disease itself, which
are debilitating.38 The symptoms of
depression, singularly and in combination with one another, can exert a
significant negative influence on personal and interpersonal activities, all
of which diminish an individual’s
quality of life.
What is the Cost Burden of Depression? Mental disorders generate
an immense cost burden. According
to the World Health Organization in
its Global Burden of Disease study,
mental illness is on a par with heart
disease and cancer as a key cause of
disability.39 The direct costs of diagnosing and treating mental disorders
in the United States totaled approximately $69 billion in 1996. Lost
productivity and disability insurance
accounted for an additional $75
billion.26,40,41
As noted above, depressed patients
are high users of medical services.
They typically come into a doctor’s
office with multiple physical ailments—3 times the number of symptoms compared with non-depressed
patients.42 When depressed patients
enter a physician’s office, they often
complain of physical symptoms such
as fatigue, chronic pain, or sleep
disorders that are not very specific
and therefore require additional testing and subsequent treatment. In
some cases, the depression may amplify an existing physical ailment
and thereby make caring for that
ailment more expensive than usual.
Very often, doctors do not recognize
the long list of presenting symptoms
as being associated with depression.
A Seattle study showed that 20% of
high-user patients were unrecognized and untreated for depression.43
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Even though depression is underdiagnosed and often poorly treated,
total medical costs for insurance
claims for which depression is the
primary diagnosis can still be substantial.35 For example, at Banc One,
Dan Conti and Wayne Burton reported that mental health claims accounted for 11% of the bank’s total
health care spending for the years
1988 to 1991.23 Today, claims for
mental health services are about half
that amount or less.35 However, even
that number may be misleading because depression is often masked by
claims for coexisting physical problems. A MEDSTAT analysis of medical claims for patients with a diagnosis of depression found that
depression treatment expenditures
accounted for only 28% of total
health care expenditures for such patients.44 The rest of the money was
spent treating physical ailments
found in patients with depression. It
is reasonable to hypothesize that a
portion of those “other” costs would
not have been incurred if depression
were non-existent.
A study by Simon and colleagues45 showed that people diagnosed with depression had nearly
twice the annual health care costs of
those without depression. Greenberg
and associates estimated the cost
burden to employers for workers
with depression to be $6000 per depressed worker per year.46 A study
by Henks and coworkers found that
depressed patients were $1500 more
expensive than their non-depressed
counterparts43—a figure that almost
exactly matched the estimate of excess medical costs for depressed patients found in the HERO study
($1509 in 1996 dollars).8
Finally, Druss and colleagues reported on data collected from 15,153
employees of a major US corporation who filed health claims in
1995.47 Employees treated for depression incurred annual per capita
health and disability costs of $5415,
significantly more than the cost for
hypertension and comparable to the
cost of three other medical condi-
Business Case for Quality Mental Health
tions examined. Employees with depressive illness plus any of the other
conditions examined cost 1.7 times
as much as those having the physical
conditions alone (a figure directly
comparable with the HERO findings). Depressive illness was also
associated with a mean of 9.86 annual sick days, significantly more
than for any of the other conditions.
What Is the Impact on Productivity? As mentioned above, health care
costs may represent just the tip of the
iceberg when examining the cost
burden of depression. Additional
economic losses associated with
worker depression include absence
from work, short-term disability
costs, workers’ compensation
claims, safety incidents, employee
turnover, and on-the-job impairment,
sometimes referred to as presenteeism. Greenberg and colleagues estimated that approximately three quarters of the $44 billion cost burden
attributed to depression (in 1990 dollars) was attributable to lost productivity and premature death due to
suicide.46
Various researchers have attempted to estimate both absence and
presenteeism costs associated with
depression. Researchers at Harvard
found that persons with depression
were absent more (1⁄4 day more per
month) and experienced significant
work cutback (1.09 days more per
month) when compared with individuals with no psychiatric problems.48
These researchers also determined
that workers with depression experienced between 1.5 and 2.3 more
short-term disability days than workers without depression over a 30-day
period.49 This translated to a salaryequivalent productivity loss of between $182 and $395 during that
same 30-day period—an amount that
was nearly equal to what would be
spent for mental health treatment
over that same time period.49
Other investigators have looked at
on-the-job productivity losses when
workers are depressed and therefore
unable to focus adequately on the
task at hand. Greenberg and col-
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Goetzel et al
leagues estimated that workers lose
as much as 20% of their productivity
when depressed because of poor concentration, memory lapses, indecisiveness, fatigue, apathy, and lack of
self-confidence.50 Ozminkowski and
associates came up with similar estimates using a newly developed presenteeism instrument. Examining the
responses of 563 employees at a
large manufacturing firm, they found
that depression accounted for approximately 25% in self-reported
losses in productivity on days when
employees were at work but suffering from depression.51 Depression
has also been associated with a decreased likelihood to return to work
while on disability. For example,
Ash & Goldstein found that the
greatest predictor of not returning to
work was the presence of depression
in the worker; 84% who did not
return to work were diagnosed with
depression (as a comorbid
condition).52
What about actual work performance? Can depression affect the
amount of output that workers produce? Very little research has been
performed in this area, although
there are some notable exceptions. In
a landmark study, Burton and colleagues examined actual reductions
in work performance for 564 Visa
credit card telephone customer service agents working at Banc One.
The researchers were able to accurately monitor the time that workers
spent being connected to customers
and the number of calls handled. One
risk factor examined in the study was
worker “distress,” which captured
the employees’ level of stress, dysphoria, or malaise. Approximately
32% of the workers were found to be
at high distress levels. For those, the
researchers calculated about 2⁄3 hours
lost per week owing to absenteeism
or short-term disability. On-the-job
productivity losses for distressed
workers were also higher than for
non-distressed workers, averaging
4.72 hours per week.53
The evidence to date indicates that
depression imposes a significant
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Volume 44, Number 4, April 2002
health and productivity cost burden
to employers. The next important
question to ask is whether employers
can do anything to better manage
depression and whether evidence exists of health care and productivity
cost savings resulting from appropriate depression management.
Does Treatment Work?
The good news is that modern
treatments for mental disorders are
highly effective, with a variety of
treatment options available for most
disorders.54 Treatment of depression
has been shown to be effective in a
large proportion of patients because
of advances in the use of medications, psychotherapy, or a combination of the two.55,56
Over the past 10 years, nine newly
marketed antidepressants were released in the United States. These
drugs, primarily falling into a broad
category of medications known as
selective serotonin reuptake inhibitors (although other classes of drugs
also exist), are highly effective and
tend to have more tolerable side effects, greater safety, and simplified
dosing. Consequently, better patient
compliance and physician utilization
results.57 Similar advances have also
occurred in the adoption of newer
methods of psychotherapy (eg, cognitive behavioral therapy) that are
now more structured and timelimited.57 It is still not always clear
when medications alone, psychotherapy alone, or a combination of the
two yield the best outcomes, especially when treating mild-to-moderate depression, but the two treatments together generally augment
one another.58
Does effective treatment of depression save employers money? Research is ongoing in this area, and
several studies can help answer that
question. There is some evidence, for
example, that when employers “ration” mental health benefits, physical
health costs may actually increase.
Rosenheck and colleagues examined
the mental health and medical care
service use for a 20,814-employee
company over a 3-year period. Over
that time, outpatient mental health
service use declined by a third, presumably as a result of benefit plan
changes that introduced new restrictions regarding access to mental
health services. The researchers
found that employees who had used
mental health services previously increased their non-mental health service use by 37%. No similar increase
was found for patients who had not
used mental health services previously. Moreover, sick-day use for
previous mental health users increased 22%, whereas sick-day use
for non-mental health users declined
11%.59 Thus, this study showed that
simply restricting access to mental
health services might have a deleterious effect on overall health care
spending and disability rates.
At Banc One, Burton and Conti
tracked health care and productivity
expenditures following the introduction of several innovative mental
health interventions at the bank.
These included a redesigned employee assistance program; providing information and education programs to employees focused on
depression; training managers on
warning signs related to depression;
and expanding benefit coverage for
mental health services. As a result,
mental health and overall health care
costs declined significantly, even
though the costs of treating employees with certain antidepressant drugs
increased.23
In another smaller-scale study
conducted by Katzelnick and colleagues, the researchers found that
medical costs for 20 patients averaged $13.28 per day during the
6-month period before they began
depression treatment and $12.55 per
day in the 6 months after treatment,
even when the costs of treating the
depression were factored in.60
Researchers at Rand Corporation
examined managed care practices
that implemented quality improvement programs aimed at improving
depression treatment. They found
that as a result of the intervention,
325
quality of care, mental health outcomes, and retention of employment
of depressed patients improved,
whereas medical visits did not increase.61 In the study, 46 clinics in
six managed care organizations were
provided intensive training programs
focused on psychotherapy treatment
or medication compliance. The treatment clinics were compared with the
usual care clinics (one third of the 46
clinics involved). A total of 1350
patients were enrolled in the study
and followed over 2 years. After the
second year, the benefits tapered off
for patients in the programs emphasizing medication treatment, whereas
the benefits persisted for patients in
programs that emphasized psychotherapy. The program with extra resources for psychotherapy proved to
be slightly more expensive than the
program emphasizing medication
management ($485 vs $419 more per
patient over 2 years, respectively).
However, the main benefits were
found in the patients’ work performance. On average, patients in clinics that emphasized psychotherapy
worked an additional 21 days over 2
years, compared with patients in
usual care. Patients in clinics that
emphasized medication worked
about 18 more days. Regardless of
employment, the patients in clinics
that emphasized psychotherapy suffered 47 fewer days of depression
over the 2-year period, and patients
in clinics that emphasized medication suffered 25 fewer such days.62
Despite these promising research
studies suggesting that mental health
treatments, and the provision of
training and support to staff providing such treatments, are effective in
improving the health and well-being
of patients, the “jury is still out” in
determining whether these interventions affect the employer’s bottom
line.
It may be true, however, that early
and effective interventions reduce
additional and often more costly interventions down the line. Just as
with heart disease, for which expensive early treatment of hypertension
326
and high cholesterol may reduce the
risk of complicated and costly heart
surgery, the same may be found for
depression treatment when appropriate and timely antidepressant medications, along with psychotherapy,
might reduce the risk of hospitalizations or other costly care later.
Large-scale retrospective claims
analyses employing rigorous economic methods are needed, as are
randomized clinical trials that determine a cause-effect relationship between effective mental health treatment and consequent health care cost
reductions.63 Perhaps more promising is the research reviewed in the
next section, which focuses on how
good depression care may boost
worker productivity, or at the very
least, stem productivity losses.
Does Depression Treatment Enhance Worker Productivity? Regarding this question, the data seem more
supportive of a “yes” answer. Researchers at the Massachusetts Institute of Technology determined that
treatment of depression results in
substantial improvements in subjective measures of work performance—self-reported worker performance improved in nearly 86% of
patients treated for depression. Predictably, the newer pharmacological
treatments (ie, selective serotonin reuptake inhibitors and other medications) achieved better outcomes than
older treatments (eg, imipramine).
The researchers also investigated
whether evidence-based depression
care affected objective measures of
productivity, in this case the volume
of medical insurance claims processed by Aetna claims processors.
They found that a substantial decline
in productivity for depressed workers was reversed as a result of effective treatment for depression.64
Researchers at MEDSTAT evaluated Pacific Bell’s Carve Out Managed Mental Health Program over a
4-year period. Analyses of integrated
medical and short-term disability
data found that when disability and
medical case managers worked cooperatively with one another, signif-
Business Case for Quality Mental Health
icant savings were realized for the
company because patients returned
to work much sooner.65
Other researchers have shown
similar effects of treatment on
worker productivity. Katzelnick and
colleagues found that the number of
lost workdays declined from 1.31 to
0.25 per patient in the 6 months after
antidepressant treatment.60 Claxton
and colleagues tracked work-loss
days for employees submitting medical claims for depression treatment.
The investigators found that workloss days increased steadily in the 6
months preceding the date when depression was diagnosed by a physician and a pharmacological treatment was begun. In the 6 months
after treatment initiation, the employees’ absence rates returned to
baseline levels.66 Finally, Simon and
colleagues studied 290 depressed patients in a Seattle Health Maintenance Organization. Even after adjusting for depression severity and
medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain
paid employment and miss fewer
days from work because of illness.67
In conclusion, it seems that effective depression treatment has a positive influence on worker productivity
in the form of reduced absence, disability, and improved retention of
employment. We focus next on the
barriers to effective treatment in the
workplace.
Barriers to Effective Depression
Management in the Workplace
The above discussion provides
mounting evidence that depression is
a prevalent condition affecting the
health and productivity of workers.
Further, there is good evidence that
various interventions, including
pharmacotherapy and psychotherapy, are effective in improving workers’ quality of life and may pay off in
terms of achieving enhanced work
output.11 So, why is not more being
done to increase access to appropri-
•
Goetzel et al
ate
depression
management
programs?
The answer may be found in both
individual and organizational barriers to care. At the individual level,
the following issues57 have been
identified as barriers to effective depression treatment:
• Stigma—Many employees still
fear that their supervisors or insurance companies will find out they
have a mental health condition and
that the discovery will influence
their opportunities for advancement or insurability. Some may
resist treatment simply because
they do not want to be labeled a
“mental” patient.
• Lack of motivation to seek care
and shame about needing care—
Because fatigue, hopelessness, and
passivity are often characteristics
of depression, individuals who
would benefit from depression
treatment may postpone or completely avoid seeking help for their
illness. In addition, some individuals may feel shame for having a
mental illness.
• Ignorance about treatment—Some
individuals may be unaware of
treatment options or the effectiveness of care. Others may fear becoming addicted to psychotropic
medications. Some may think that
psychotherapy is intrusive into
one’s private life. Finally, some
may believe that treatment requires a “big commitment” because it is viewed as complicated,
lengthy, and expensive.
• Lack of confidence in their physicians—Some persons may not expect their primary care doctors to
know how to care for mental illnesses. Conversely, some doctors
may consider the depression to be
an appropriate clinical response,
given the patient’s medical condition or advanced age. The doctor
may then assume that there is no
need to treat the patient’s depression because it is a “normal” reaction to events. When this occurs,
lack of confidence is, unfortunately, substantiated.
• Deficiencies in primary care phy-
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•
Volume 44, Number 4, April 2002
sician training—Some general
practitioners may lack the necessary interviewing skills to accurately diagnose and treat depression. Many others may lack 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 and are more comfortable
treating the medical aspects of the
patient’s complaints. Finally, they
may be concerned that mental
health care is not adequately covered by the patient’s insurance
plan; consequently, their focus for
treatment may be directed at physical conditions.
• Health care system shortcomings—Some managed care organizations may be more concerned
about restricting mental health
treatment to save money (eg, prescribing older and less expensive
medication, restricting outpatient
visits, only using psychiatrists for
medication management, etc) than
about 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,
in many cases, employers may not
provide adequate insurance coverage to their employees for mental
health services. The coverage may
restrict access to providers or reimburse patients at lower levels
than for treatment of physical
disorders.
Some additional barriers to effective depression treatment that apply
directly to employers are:
• Ambiguity regarding the role of
employers in depression management—Some business leaders may
feel uncomfortable or ill-equipped
in 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 per-
sonal 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 into their
private lives or a violation of the
Americans With Disabilities Act.
• Lack of data to support increased
investment in mental health—
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
able to track the economic impact
of any newly introduced intervention programs.
• Employer information gaps—Perhaps the greatest barrier to increased investment in mental
health interventions is 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 and difficult to understand.
Even among health care practitioners, knowledge concerning treatment effectiveness and cost-effectiveness is often concentrated in a
few experts. The information
needed to make sound business
decisions, especially concerning
mental health treatment, is often
lacking or not well understood by
the people whose job it is to develop human resource policies and
implement effective programs.
What Can Employers Do to
Better Manage the Mental
Health and Well-Being of
Workers?
By and large, employers want to
do the “the right thing” for their
employees, and at the same time be
mindful of potential benefits to their
business from doing so. Employers
have an important role to play in
preventing and treating worker mental health issues and overall organi-
327
zational health problems. These activities should be approached at both
the individual worker and organizational level. Further, interventions
should run the gamut from primary
prevention to effective disease management programs.
Primary prevention might include
education and training programs that
teach employees how to spot mental
health problems early on, and how to
respond to those problems effectively. Regular screening for depression and stress, as part of a companysponsored
health
promotion
initiative, is another way to identify
individuals and groups who are at
risk for mental health problems.
Teaching employees stress management and coping skills is yet another
form of primary prevention. Secondary prevention programs involve the
detection of potential mental health
issues and referral to appropriate
health care professionals for treatment. Finally, 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 disease relapse.
In short, 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, and psychotherapeutic
care; better coordinating benefit, employee assistance programs, occupational medicine, health promotion,
and other related health and productivity management services; and
working toward achieving a healthy
company culture.
Conclusions
Employers are very concerned
about rising health care costs. They
are worried that increased labor costs
(which include benefits) will dimin-
328
Business Case for Quality Mental Health
ish their ability to successfully compete in a global marketplace. They
are seeking ways to determine
whether their health care spending is
improving the health of workers, and
whether there is a productivity payback from providing good health
care and, in particular, good mental
health care.
This article provides a brief summary of the available information on
the subject of employee depression
and its impact on business. Among
the major findings are:
productivity improvements occur
as a consequence of effective depression treatment, and those improvements may offset the cost of
the treatment.
• Barriers still stand in the way of
effective treatment for depression.
One significant barrier is the lack
of objective information available
to employers concerning the disease, its treatment, and benefits
arising from successful treatment.
• Depression is a condition that is
quite prevalent, with about 1 in 10
Americans suffering from it in any
given year, and 1 in 5 being affected by the disease during his or
her lifetime.
• Despite increased attention being
directed at the treatment of depression, and evidence that the use of
psychotropic medication has increased sharply over the past decade, a significant segment of the
population suffering from depression remain undiagnosed, untreated, and under-treated.
• Individuals who are depressed exert a significant cost burden on
employers. Although estimates
vary, a recent analysis finds that
depressed workers cost their employers 70% more in annual health
care costs when compared with
their non-depressed colleagues.
• Evidence is mounting that worker
depression may have its greatest
impact in the area of productivity
losses, in the form of increased
absenteeism, short-term disability,
turnover, and an inability to perform at optimal levels of
performance.
• Treatment for depression is remarkably effective, with a large
proportion of patients improving
from medications, psychotherapy,
or a combination of the two.
• No conclusive evidence currently
exists that physical health care
costs decrease when depression is
effectively treated, though studies
to date may be too limited in
scope.
• There is growing evidence that
With these realities in mind, the
authors have identified certain gaps
in knowledge—subject areas representing prime opportunities for new
research in workplace-based depression care—which, if filled, would
improve employers’ ability to make
informed decisions regarding the
purchase and delivery of mental
health services for their employees.
Although a body of literature exists
that begins to address the topics
listed below (much of which is reviewed in this document), very little
research has been done in “real-life”
employer settings, using actual administrative and claims data, and
over extended periods of time.
Examining the Health and Productivity Cost Burden of Depression
Although several research studies
have examined this area in general,
no one study has considered the
health and productivity cost burden
of depression in comparison with
other common diseases facing employers. Similar to the HERO research, an analysis is needed that
compares and contrasts the cost burden of depression side-by-side with
other common health conditions in
terms of health and productivity
measures.
Examining What Employers Can
Do to Maximize the Value of Their
Mental Health Expenditures Research is needed that would examine
the health and productivity impacts
associated with adherence or nonadherence to evidence-based medicine in the treatment of depression.
Patients who are treated in compli-
Research Opportunities
•
Goetzel et al
ance with evidence-based medicine
guidelines (good-quality care) would
be compared with patients who are
treated at suboptimal levels (poorquality care). As above, the high
versus low quality of care groups
will then be compared across multiple health and productivity outcome
measures. This type of analysis will
produce an “optimal care” and “optimal cost” range for depression care
and for each of the expenditure categories analyzed. If cost savings
arise from good-quality care (as yet
unknown), such findings would provide scientific documentation that
good-quality care “pays off.”
Acknowledgment
The authors wish to acknowledge the contributions of Alisa B. Busch, MD, MS, who
provided scholarly material for consideration.
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