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Employee mental health affects the bottom line and the culprits are many. Stress disability rates have been growing and mental health is also the leading cause of prolonged disability in people with a physical illness.

But what remains a mystery is why most companies don't pay more attention to higher quality mental healthcare, though that may be about to change.

In a trend reversal, more scrutiny of workplace mental health is starting to come about. For instance, at a recent workplace behavioral risk conference, speakers told attendees that investing in employee mental health assessment and treatment programs reduces absence, increases productivity and addresses healthcare and disability cost.

In one case, channeling mental health claims through an in-network psychiatrist reduced short-term disability claims by 56 percent. Using that method, AOL saw a 67 percent reduction in claims approvals, a 34 percent decrease in claims duration and a 73 percent decrease in claims cost.

But much of what passes for quality care these days is not and even experts can sometimes have trouble determining where better care can be found.

Ideally, added outlays for quality mental healthcare will be more than offset by savings in such costs as absenteeism, recruitment and training, reduced productivity, presenteeism and physical healthcare expenses. From the employees' perspective, the desired outcome of mental healthcare is accurate identification of the problem, appropriate treatment and, ideally, resolution of the problem.

Many people don't realize that psychiatric medication and psychotherapy are not replacements for each other. They work very well together, but they do different things. Most anti-depressant prescriptions are written by primary care doctors who don't offer real psychotherapy to go with them. And they don't always have a precise and complete diagnosis. Patients with commonplace psychiatric syndromes will usually present with such complaints as sleeplessness, dizziness, fatigue, appetite change, aches and pains or problems at home or work. But the typical 10-minute office visit is far too little time for even a skilled psychiatrist's briefest evaluation. And a primary care doctor is most concerned with rooting out physical illnesses. Even when a patient complains of 'depression,' it often an anxiety disorder and panic disorder in particular.

RIGHT THE FIRST TIME

Quality care begins with a well-done initial clinical evaluation. When people experience emotional suffering, there are usually multiple causes--'overdetermined' as psychiatrists say. The central factor is usually not the most obvious one. A patient with an emotionally distant spouse might instead complain of impending financial impoverishment. The initial evaluation should be broad and thorough, with careful attention to personal life, workplace factors, commonplace anxiety and depressive disorders, drug and alcohol use, and co-occurring and causal medical illnesses.

Just as elsewhere in medicine, the initial evaluation is where highly skilled clinicians with broad and advanced training are most useful. It is all too easy to focus on easing the pain of a divorce, while overlooking an underlying anxiety disorder whose treatment could have allowed the repair of the marriage.

Dissatisfaction at work is often caused by misery at home. Poor job performance attributed to work stress can be due to such things as a hidden conflict with a supervisor, an unrecognized depression or even an undiagnosed medical illness. Skilled mental health evaluators are trained to sort out these issues, and psychiatrists have the most comprehensive diagnostic training of all. The medical part of their training also comes in handy for those times when emotional distress can be the presenting symptom of problems like thyroid disease, cancer or other medical illnesses, including treatable conditions such as a sleep disorder due to obesity. Even more importantly, long experience in using psychiatric medications ensures that the evaluation includes appropriate and early focus on syndromes that medication might help. So getting it right the first time goes hand-in-hand with solving the problem effectively and efficiently.

But the trouble is, less trained evaluators only see what they know, even though they may be pleasant, concerned and thoughtful people. Problems overlooked at the outset don't get recognized until much later, if ever. So effective treatment is not provided and instead the problem lingers. Untreated depression, thyroid disease, family problems, alcoholism, interpersonal skill deficiencies or unexplained chest pain can be both financially and morally expensive.

Managers of employee benefits like mental health coverage need to be careful, because overreliance on the most simplified screening methods can be dangerous. Breaking down human distress into a few very simple categories is tempting and can be helpful for preliminary screening in some selected situations.

But, premature categorization interferes with high quality treatment and ends up costing many times the front-end savings. A screening test for depression may alert a clinician to the employee's unhappiness. However, that unhappiness could be due to anything from work stress to medical illness to anxiety or to one of several different kinds of depression and most likely some combination of factors. At that point, effective treatment can be provided by many kinds of well-trained mental health professionals.

The best mental health solutions require thoughtful recognition of the actual problem or problems and awareness that diagnostic refinement is an ongoing process during treatment. Any other approach is like leaving money on the table and suffering unrelieved.

If actual benefits for employer and employee are the real goal of mental healthcare, a seasoned psychiatrist is most able to recognize the many contributing factors at evaluation. And while that is not always possible, psychiatric consultation and diagnostic aids can have a major impact on quality. There haven't been many guidelines on such dilemmas as when to refer, but the accompanying chart lists some good starting points. The full 2008 source article (recognition, diagnosis and referral of workplace depression) can be downloaded for free (WorkPsych.com/publications.html).

There aren't enough psychiatrists in our network, some say. But especially in metro areas, there are many other psychiatrists who practice outside of networks. They can be found through medical schools, hospitals, other employers and by word of mouth.

What else can be done? Manhattan-based WorkPsych Associates has recently completed a project that allowed a large employer to address productivity concerns by quantifying the specific mental health and workplace root causes of absenteeism, presenteeism and more. The employer learned the advantages and disadvantages of workplace and management approaches. What's more, the process helped employees learn about some of their own issues and how to translate that knowledge into effective treatment. The custom data yielded targeted and effective solutions for both employer and employee, sometimes addressing unexpected issues with straightforward strategies.

WorkPsych has now teamed up with Golden Valley, Minn.-based OptumHealth to make more employers aware of this approach (a press release can be downloaded at WorkPsych.com/publications.html). A separate OptumHealth project recently reported that improved follow-up care for depression meant a 40 percent increase in depression recovery, a 40 percent reduction in employment loss and the equivalent of two more work weeks of productivity per year.

Solutions are there. Let's start using them!

MAURICE PRETER, M.D., is a psychiatrist and neurologist, and JEFFREY P. KAHN, M.D., is a psychiatrist; both are Manhattan-based, where Dr. Kahn is also CEO of WorkPsych Associates.

August 1, 2008

Copyright 2008© LRP Publications