The Business Case for Quality Mental Health
Transcription
The Business Case for Quality Mental Health
320 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 JOEM • 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. 321 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? 322 • 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 • 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- JOEM • Volume 44, Number 4, April 2002 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.35 323 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.43 324 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- • 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 JOEM • 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- JOEM • 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. References 1. Winslow R. Health employer group creates institute to brainstorm about health costs. Wall Street J. Dec 19, 2002. 2. Hitt J. Evidence based medicine. NY Times. Dec 19, 2001. 3. Gunsauley G. Caution urged in assessing disease management. Employee Benefits News. Jan 2002. 4. Moskowitz D. Predicting Washington in 2002. Business and Health. Jan 31, 2002. 5. Treatment of choice: in an ailing economy, American employers are looking for new remedies to cope with soaring medical costs. The Economist. Jan 19, 2002. 6. Brandt-Rauf P, Burton WN, McCunney RJ. Health, productivity and occupational medicine [Guest Editors’ Preface]. J Occup Environ Med. 2001;43:1. 7. Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus, HA. National trends in the outpatient treatment of depression. JAMA. 2002;287:2. 8. Goetzel RZ, Anderson DR, Whitmer RW, et al. The relationship between modifiable health risks and health care expenditures: an analysis of the multi-employer HERO health risk and cost database. J Occup Environ Med. 1998;40:843– 854. 9. McCunney RJ. Health and productivity: a role for occupational health professionals. J Occup Environ Med. 2001;43:30 – 35. 10. Maes M, Vandoolaeghe E, Neels H, et al. Lower serum zinc in major depression is a sensitive marker of treatment resistance and of the immune/inflammatory response in that illness. Biol Psychiatry. 1997;42:349 –358. JOEM • Volume 44, Number 4, April 2002 11. Simon GE, Barber C, Birnbaum HG, et al. Depression and work productivity: the comparative costs of treatment versus nontreatment. J Occup Environ Med. 2001;43:2–9. 12. Goetzel RZ, Ozminkowski RJ. Disease management as a part of total health and productivity management. Disease Manage Health Outcomes. 2000;8:121–128. 13. Greenberg PE, Finkelstein SN, Berndt ER. Economic consequences of illness in the workplace. Sloan Manage Rev. 1995; 36:26. 14. Lynch W. Health affects work and work affects health. Business and Health. Jan 2002. 15. Kessler RC, McGonagle KA, Zhoa S, et al. Lifetime and 12-months prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:9 –19. 16. Sansone RL. Dysthemic disorder: the chronic depression. Am Fam Physician. 1996;53:2588 –2594. 17. Janicak PG, Martis B. Strategies for treatment-resistant depression. Clin Cornerstone. 1999;1:58 –71. 18. Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85–94. 19. Narrow WE. One-Year Prevalence of Depressive Disorders Among Adults 18 and Over in the US: NIMH ECA Prospective Data. Rockville, MD: National Institute of Mental Health; 1999. 20. Katon W, von Korff M, Lin E, et al. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67–76. 21. Hirschfield RM, Keller MB, Panico S, et al. The national depression and manicdepressive association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–340. 22. Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58: 55– 61. 23. Conti DJ, Burton WN. The cost of depression in the workplace. Behav Healthc Tomorrow. 1995;4:25–27. 24. Goldberg D. Epidemiology of mental disorders in primary care settings. Epidemiol Rev. 1995;7:182–190. 25. Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services: three epidemiological catchment area sites. Arch Gen Psychiatry. 1984;41:971–978. 26. Mark TL, Coffey RM, King E, et al. Mental health and substance abuse treatment expenditures, 1987–1997. Health Affairs. 2000;19:107–120. 27. Hay Group. Employer Mental Health Coverage Features and Compliance With 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. the Mental Health Parity Act. Hay Report for NIMH, June 1999. Rockville, MD: National Institute for Mental Health; 1999. Zukevas SH, Regoer DR, Rae D, Rupp A, Narrow W. The Differential Impacts of Mental Health Parity and Managed Care: Evidence From a Large Natural Experiment [Working Paper]. Rockville, MD: National Institute for Mental Health; 1999. Pratt LA, Ford DE, Crum RM, et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation. 1996;94:3123–3129. Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation. 1995;91:999 –1005. Fava M, Abraham M, Pava J, Schuster J, Rosenbaum J. Cardiovascular risk factors in depression. The role of anxiety and anger. Psychosomatics. 1996;37:31–37. Nemeroff CB, Musselman DL, Evans DL. Depression and cardiac disease. Depression and Anxiety. 1998;8(suppl 1): 71–79. Jonas BS, Mussolino ME. Symptoms of depression as a prospective risk factor for stroke. Psychosom Med. 2000;62:463– 471. National Institute of Mental Health. Cooccurrence of depression with stroke [Fact Sheet]. Available at: http//www.nimh.nih.gov/publicat/stroke.cfm. Goetzel RZ, Ozminkowski RJ, Meneades L, Stewart M, Schutt DC. Pharmaceuticals— cost or investment? An employer’s perspective. J Occup Environ Med. 2000; 42:338 –351. Wells KB. Cost containment and mental health outcomes: experience from US studies. Br J Psychiat. 1995;166:43–51. Wells KB, Stewart A, Hays RD, et al. The functioning and well being of depressed patients: results from the Medical Outcomes study. JAMA. 1989;62:914 – 919. National Institute of Mental Health. Depression. Available at: http//www.nimh.nih.gov/publicat/depression.cfm. Murray CJL, Lopez AD. The Global Burden of Disease. Cambridge, MA: Harvard University Press; 1996. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and National Institutes of Health. Mental Health: A Report of the Surgeon General. Bethesda, MD: USDHHS; 1999. Coffey RM, Mark TL, King E, et al. National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1997. Rockville, MD: Center for Substance Abuse Treatment and Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; July 2000. SAMHSA publication no. SMA-00 –3499. 329 42. Callahan CM, Kesterson JO, Tierney WM. Association of symptoms of depression with diagnostic test charges among older adults. Ann Intern Med. 1997;26:426 – 432. 43. Henks HJ, Katzelnick DJ, Kobak KA, et al. Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization. Arch Gen Psychiatry. 1996; 53:899 –904. 44. Croghan TW, Obenchain RL, Crown WH. What does depression treatment really cost? Health Affairs. 1998;17:198 – 208. 45. Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry. 1995;152: 352–357. 46. Greenberg PE, Kessler RC, Nells TL, et al. Depression in the workplace: an economic perspective. In: Feighner JP, Boyer WF, eds. Selective Serotonin Reuptake Inhibitors: Advances in Basic Research and Clinical Practice. 2nd ed. New York: Wiley and Sons; 1996. 47. Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major US corporation. Am J Psychiatry. 2000;157:1274 –1278. 48. Kessler RC, Greenberg PE, Mickelson KD, Meneades LM, Wang PS. The effects of chronic medical conditions on work loss and work cutback. J Occup Environ Med. 2001:43:218 –225. 49. Kessler RC, Barber C, Birnbaum HG, et al. Depression in the workplace: effects on short-term disability. Health Affairs. 1999;18:163–171. 50. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression. J Clin Psychiatry. 1993;54: 405– 418. 51. Ozminkowski RO, Goetzel RZ, Crown WH, Long RS, Chang SY, Fulton P. Results of the Wellness Inventory (Formerly the Work Productivity Short Instrument or WPSI) at Corp XYZ. Ann Arbor, MI: The MEDSTAT Group; May 2000. 52. Ash P, Goldstein SI. Predictors of returning to work. Bull Am Acad Psychiatry Law. 1995;23:205–210. 53. Burton WN, Conti DJ, Chen CY, Schultz AB, Edington DW. The role of health risk factors and disease on worker productivity. J Occup Environ Med. 1999; 41:863– 877. 54. US Department of Health and Human Services. Healthy People 2010. Conference ed. vol II, 18 –5. Bethesda, MD: USDHHS; Jan 2000. 55. Regier DA, Hirschfeld RM, Goodwin FK, Burke JD Jr, Lazar JB, Judd LL. The NIMH depression, awareness, recognition and treatment program: structure, aims and scientific basis. Am J Psychiatry. 1988;145:1351–1357. 56. National Institute of Mental Health. The effects of depression in the workplace. 330 57. 58. 59. 60. Available at: http//www.nimh.nih.gov/ publicat/workplace.cfm. Goldman LS, Nielson NH, Champion HC. Awareness, diagnosis and treatment of depression. J Gen Intern Med. 1999; 14:569 –580. McLean PD, Hakstian AR. Clinical depression: comparative efficacy of outpatient treatments. J Consult Clin Psychol. 1979;47:818 – 836. Rosenheck RA, Druss BG, Stolar M, Leslie D, Sledge W. Effect of declining mental health service use on employees of a large corporation. Health Affairs. 1999;18:193–203. Katzelnick DJ, Kobak KA, Greist JW, Jefferson JW, Henk HJ. Effect of primary care Business Case for Quality Mental Health 61. 62. 63. 64. treatment of depression on service use by patients with high medical expenditures. Psychiatr Serv. 1997;48:59–64. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–220. Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55– 61. Simon GE, Katzelnick DJ. Depression, use of medical services and cost-offset effects. J Psychosom Res. 1997;42:333–344. Finkelstein SN, Berndt ER, Greenberg PE, et al. Improvement in subjective • Goetzel et al work performance after treatment for chronic depression: some preliminary results. Psychopharmacol Bull. 1996;32: 33– 40. 65. McCulloch JM, Ozminkowski RJ, Cuffel B, et al. Analysis of a managed psychiatric disability program. J Occup Environ Med. 2001;43:101–109. 66. Claxton, AJ, Chawla AJ, Kennedy S. Absenteeism among employees treated for depression. J Occup Environ Med. 1999;41:605– 611. 67. Simon GE, Revicki D, Heiligenstein J, et al. Recovery from depression, work productivity, and health care costs among primary care patients. General Hosp Psychiatry. 2000;22:153–162.