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Mental health problems in the workplace

FEB 2010

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Low treatment rates imperil workers’ careers and companies’ productivity.

Mental health problems affect many employees — a fact that is usually overlooked because these disorders tend to be hidden at work. Researchers analyzing results from the U.S. National Comorbidity Survey, a nationally representative study of Americans ages 15 to 54, reported that 18% of those who were employed said they experienced symptoms of a mental health disorder in the previous month.

But the stigma attached to having a psychiatric disorder is such that employees may be reluctant to seek treatment — especially in the current economic climate — out of fear that they might jeopardize their jobs. At the same time, managers may want to help but aren’t sure how to do so. And clinicians may find themselves in unfamiliar territory, simultaneously trying to treat a patient while providing advice about dealing with the illness at work.

As a result, mental health disorders often go unrecognized and untreated — not only damaging an individual’s health and career, but also reducing productivity at work. Adequate treatment, on the other hand, can alleviate symptoms for the employee and improve job performance. But accomplishing these aims requires a shift in attitudes about the nature of mental disorders and the recognition that such a worthwhile achievement takes effort and time.

Here’s a quick guide to the most common mental health problems in the workplace, and how they affect both employees and employers.

Key points

  • Symptoms of mental health disorders may be different at work than in other situations.

  • Although these disorders may cause absenteeism, the biggest impact is in lost productivity.

  • Studies suggest that treatment improves work performance, but is not a quick fix.

Stealth symptoms, tangible impact

Symptoms of common problems — such as depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD), and anxiety — are all described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). But symptoms tend to manifest differently at work than they do at home or in other settings.

Although symptoms may go unnoticed, the economic consequences are tangible. Studies assessing the full work impact of mental health disorders often use the World Health Organization (WHO) Health and Work Performance Questionnaire, which not only asks employees to report how many days they called in sick, but also asks them to assess, on a graded scale, how productive they were on the days they actually were at work. The results are measured in days out of work (absenteeism) and lost productivity (“presenteeism”).

In one study examining the financial impact of 25 chronic physical and mental health problems, researchers polled 34,622 employees at 10 companies. The researchers tabulated the amount of money the companies spent on medical and pharmacy costs for employees, as well as employees’ self-reported absenteeism and lost productivity, using the WHO questionnaire.

When researchers ranked the most costly health conditions (including direct and indirect costs), depression ranked first, and anxiety ranked fifth — with obesity, arthritis, and back and neck pain in between.

Many of the studies in this field have concluded that the indirect costs of mental health disorders — particularly lost productivity — exceed companies’ spending on direct costs, such as health insurance contributions and pharmacy expenses. Given the generally low rates of treatment, the researchers suggest that companies should invest in the mental health of workers — not only for the sake of the employees but to improve their own bottom line.

Depression is the mental health disorder that has been best studied in the workplace, partly because it is so common in the general population. One survey of a nationally representative sample reported that about 6% of employees experience symptoms of depression in any given year.

Although the DSM-IV lists low mood as the defining symptom of depression, in the workplace this disorder is more likely to manifest in behaviors — such as nervousness, restlessness, or irritability — and in physical complaints, such as a preoccupation with aches and pains. In addition, employees may become passive, withdrawn, aimless, and unproductive. They also may be fatigued at work, partly as a result of the mood disorder or because they are having trouble sleeping at night. Depression may also impair judgment or cloud decision making.

Researchers who analyzed employee responses to the WHO questionnaire found that workers with depression reported the equivalent of 27 lost work days per year — nine of them because of sick days or other time taken out of work, and another 18 reflecting lost productivity. Other research has found that employees with depression are more likely than others to lose their jobs and to change jobs frequently.

Part of the problem may be lack of treatment. In one study, only 57% of employees with symptoms of major depression said they had received mental health treatment in the previous 12 months. Of those in treatment, fewer than half — about 42% — were receiving treatment considered adequate, on the basis of how consistent it was with published guidelines about minimal standards of care. The researchers estimated that over all, when lack of treatment or inadequate treatment was taken into account, only about one in four employees with major depression received adequate treatment for the disorder.

Bipolar disorder is typically characterized by cycling between elevated (manic) and depressed moods. In a manic phase, employees may appear highly energetic and creative, but actual productivity may suffer. And during full-blown mania, a person may become self-aggrandizing or disruptive, flout workplace rules, be overly aggressive, and make mistakes in judgment (such as overspending a budget). During the depressive phase, an employee may exhibit depressive symptoms as described above. Although mania may be more noticeable at work, the research suggests that the depressive phase of bipolar disorder can impair performance more than the manic phase.

One nationally representative study estimated that about 1% of American employees suffer from bipolar disorder in any year. Based on employee responses to the WHO questionnaire, the researchers estimated that employees with bipolar disorder lost the equivalent of about 28 work days per year from sick time and other absences, and another 35 in lost productivity. The authors note that although bipolar disorder may be more disabling to employees on an individual level, the cost to employers is still less than that attributed to depression, because the latter is more common in the population.

In a departure from findings about treatment rates for other mental health disorders, about two-thirds of employees with bipolar disorder said they had received treatment for it. But the likelihood of receiving adequate care depended on the type of clinician they saw. Only about 9% of those who sought care from general practitioners received care in keeping with published guidelines for bipolar disorder, compared with 45% of those who sought care from mental health professionals.

Anxiety disorders in the workplace may manifest as restlessness, fatigue, difficulty concentrating, and excess worrying. Employees may require constant reassurance about performance. Sometimes, as with depression, physical symptoms or irritability may be noticeable.

Anxiety disorders affect about 6% of the population at some point in life, but typically go undiagnosed for 5 to 10 years. And only about one in three individuals with a diagnosed disorder receives treatment for it. At the same time, the studies suggest that people with anxiety disorders are more likely than others to seek out medical care — but for problems like gastrointestinal distress, sleep disturbances, or heart trouble rather than for anxiety.

It is probably not surprising, then, that anxiety disorders cause significant work impairment. Generalized anxiety disorder, for example, results in work impairment (as measured by sick days and lost productivity) similar to that attributed to major depression.

ADHD is often considered a problem only in childhood, but it also affects adults. An international survey in 10 countries (including the United States) estimated that 3.5% of employees have ADHD. In the workplace, symptoms of ADHD may manifest as disorganization, failure to meet deadlines, inability to manage workloads, problems following instructions from supervisors, and arguments with co-workers.

Workplace performance — and the employee’s career — may suffer. Studies estimate that people with ADHD may lose 22 days per year (a combination of sick days and lost productivity), compared with people without the disorder. In addition, people with ADHD are 18 times as likely to be disciplined for behavior or other work problems, and likely to earn 20% to 40% less money than others. They are also two to four times as likely as other employees to be terminated from a job.

Treatment rates among employees with ADHD are especially low. In the United States, for example, only 13% of workers with ADHD reported being treated for this condition in the previous 12 months.

An investment in health

The literature on mental health problems in the workplace suggests that the personal toll on employees — and the financial cost to companies — could be eased if a greater proportion of workers who need treatment were able to receive it. The authors of such studies advise employees and employers to think of mental health care as an investment — one that’s worth the up-front time and cost.

Most of the research on the costs and benefits of treatment has been done on employees with depression. The studies have found that when depression is adequately treated, companies reduce job-related accidents, sick days, and employee turnover, as well as improve the number of hours worked and employee productivity.

But the research also suggests that treatment for depression is not a quick fix. Although adequate treatment alleviates symptoms and improves productivity, one study found that in the short term, employees may need to take time off to attend clinical appointments or reduce their hours in order to recover.

To overcome barriers to accessing care, and to make it more affordable to companies, the National Institute of Mental Health is sponsoring the Work Outcomes Research and Cost Effectiveness Study at Harvard Medical School. The researchers have published results from a randomized, controlled trial of telephone screening and depression care management for workers at 16 large companies, representing a variety of industries.

During the two-phase study, mental health clinicians employed by an insurance company identified workers who might need treatment, provided information about how to access it, monitored adherence to treatment, and provided telephone psychotherapy to those workers who did not want to see a therapist in person. The outcomes of 304 workers assigned to the intervention were compared with 300 controls, who were referred to clinicians for treatment but did not receive telephone support.

The researchers found that workers assigned to the telephone intervention reported significantly improved mood and were more likely to keep their jobs when compared with those in the control group. They also improved their productivity, equivalent to about 2.6 hours of extra work per week, worth about $1,800 per year (based on average wages) — while the intervention cost the employers an estimated $100 to $400 per treated employee. The researchers are conducting additional research on how to improve access to mental health care in the workplace, and to quantify costs and benefits for employers.

Studies such as these suggest that, in the long term, costs spent on mental health care may represent an investment that will pay off — not only in healthier employees, but also for the company’s financial health.

Hilton MF, et al. “The Association Between Mental Disorders and Productivity in Treated and Untreated Employees,” Journal of Occupational and Environmental Medicine (Sept. 2009): Vol. 51, No. 9, pp. 996–1003.

Kahn JP, et al., eds. Mental Health and Productivity in the Workplace: A Handbook for Organizations and Clinicians (John Wiley & Sons, 2003).

Loeppke R, et al. “Health and Productivity as a Business Strategy: A Multiemployer Study,” Journal of Occupational and Environmental Medicine (April 2009): Vol. 51, No. 4, pp. 411–28.

Wang PS, et al. “Making the Business Case for Enhanced Depression Care: The National Institute of Mental Health–Harvard Work Outcomes Research and Cost-Effectiveness Study,” Journal of Occupational and Environmental Medicine (April 2008): Vol. 50, No. 4, pp. 468–75.

For more references and a list of resources for employees and companies, please see www.health.harvard.edu/mentalextra.