How many employees in America bring their personal troubles in through the door? More than most of us would guess, experts say. And pressure-cooker workplaces are growing those numbers based on the behavioral demographics of those entering the work force.
Depression, exhaustion, stress, substance abuse, eating disorders--combined, they are pervasive in the work force. True, behavioral problems and the workplace have been linked, often corrosively, throughout the history of modern society. Prevalence has probably not increased, nor has it declined. The problems of individuals are more in the open today. A "performance problem" of yesterday could be seen as depression today. The results are more demands on managers, more expense for health and disability programs.
FUMBLING IN THE DARK
Focusing on behavioral risk, employers have been learning how to reduce personal distress and improve productivity. But human resources, constrained by privacy rules, usually does not know the precise problem. Employers are effectively trying to complete a puzzle in the dark without a count of the pieces, coherent strategy and tools.
Two doctors, Alan Langlieb and Jeffrey Kahn, concluded in 2005 that the indirect costs of depression alone to employers is "staggering." Langlieb is at the John Hopkins School of Medicine, Kahn with WorkPsych Corp., a consulting firm. They reviewed more than 100 published research reports to document the effect of depression and anxiety on work performance.
Their article in the Journal of Occupational and Environmental Medicine looked at prevalence, lost time, medical spending and intervention tools. Both employers and researchers, they wrote, "remain largely unaware of the value of quality care" for major behavioral problems. They drew their conclusions without even touching the hot topic of substance-abusing employees.
But employers at least know the symptoms of behavioral problems: erratic work performance, high benefits utilization and staff turnover. Troubled workers can be the most creative and most highly compensated. Gifted workers have been clocked at being either absent or ineffective at work for 50 or more days a year.
The Disability Management Employer Coalition picks behavioral risk as the top concern for its members. Marcia Carruthers, the organization's CEO, says that "47 percent of employers have initiated or are considering some form of behavioral risk management."
Health plans, specialized behavioral health firms and consultants are stepping up to the plate.
But our mental model of behavioral problems is, well, plain wrong. We Americans generally underestimate the incidence of serious behavioral problems in our communities and places of work. Then we often fail to understand how intervention can be really effective.
DMEC, the National Business Group on Health and the Integrated Benefits Institute have been publishing studies and hosting conferences on the links between behavioral health and productivity.
Compared with a few years ago, now we know that the incidence of behavioral problems varies within the worker population by type of condition.
For instance, in their lifetime women are more likely to experience depression (10 percent to 25 percent) than men (5 percent to 12 percent). Bipolar disorder is more prevalent among young adult workers in low-paying positions than among workers with college experience.
Sometime in their lifetime, half of Americans will meet the clinical criteria for behavioral disorders, which factor into at least half of doctor visits by adults. Top-ranked colleges are reporting as much as 30 percent of their graduating women enter into the work force with unresolved eating disorders.
And yet the challenge is worse than these statistics imply. If they are not specialists in behavior problems, doctors underdiagnose and report the true incidence only half the time.
Data on stress, eating disorders and substance abuse are poor due to vague or overlapping definitions. Jim might be overworked, stressed out from home and deeply troubled all at once. Which was the added load that sank the boat?
Self-reported labels and clinical diagnoses can confuse by overlapping one another. The Integrated Benefits Institute's CEO Tom Parry says that sleep disorders and fatigue "lead in self-reported health problems of workers." Another leading condition is anxiety, according to Parry.
ComPsych, which delivers employee assistance programs, says it encounters depression most often, and describes many workers as distracted by personal problems. Are depression, fatigue, anxiety and distraction overlapping depictions of the same worker under siege?
DMEC's Carruthers might be right to urge care in applying labels. She says one needs to "differentiate between employee risk based on performance and those based on identified or underlying psychiatric problems."
However noted and recorded, behavioral problems link to high incidence of complications with other diseases. For instance, depression drives many heart patients back into the hospital after earlier stays.
Thomson Medstat, a health-care consultancy, reports that behavioral conditions drive more short-term disability cases than do arthritis, cancer, heart disease, hypertension, migraine and respiratory infections. Ron Ozminkowski, director of health and productivity research at Medstat, says: "Workers with depression have total medical costs 70 percent higher" than other workers.
And employees at behavioral risk take longer to return to full productivity. Drawing from a national database of some 9,000 people, a study published in the American Journal of Psychiatry reported "65.5 lost workdays per worker with bipolar disorder and 27.2 lost workdays per worker with major depressive disorder" each year. These figures combine days lost by presenteeism with absenteeism.
Depression increases the odds of the employee filing for a long-term disability claim. Depression and self-management challenges such as obesity and smoking are linked to delayed recovery from a work injury.
Carruthers says that "all three stakeholders--employer, medical provider and insurer--are more inclined today jointly to focus on return-to-work as curative for a disabled employee."
With counseling and medication, employees are likely better off. Employee assistance programs tend to boost productivity regardless of the nature of the worker's problem. The Hartford has found that, even when very few workers use an employee assistance program, unscheduled absences drop significantly.
EAPs help in coaching the worker and triaging him to the right care. Effective treatment can include psychotherapy that is focused on practice strategies for coping--cognitive behavioral therapy.
Prescribing of drugs for almost every type of personal distress has created the paradox of the employee who is at once very troubled and also very competent. Take, for instance, the accomplished mental health professional who, while an inpatient in an eating disorder hospital, used the pay phone to interview for--and get--a job to run a mental health hospital.
Some clinicians, such as Robert Drake, an M.D. at Dartmouth Medical School, point to drugs with the potential of returning to work people with severe mental illness such as major depression or schizophrenia. Before, they were warehoused in disability programs or long-term-care institutions with minimal expectations for gainful employment.
Counselors to the severely mentally ill know from hard experience that both their clients and employers need to adjust their expectations. Executives have to show more flexibility in attendance rules. Co-workers have to confront their own preconceptions about mental illness. For instance, many still think that people with a diagnosis of schizophrenia are at risk of blowing off violently.
Searching for the right intervention might lead to unexpected strategies. What about smoking cessation programs? According to David Campbell, a senior executive at ComPsych, heavy smokers are likely to become addicted to prescribed pain medication for a physical condition such as back pain, because these smokers often are intensely "seeking fixes" to problems. AIM Mutual, a Massachusetts workers' compensation insurer, pays for nicotine patches for back pain claimants who smoke.
Yoga, meditation and exercise help mobilize the worker to stay at work or return to work. And they are known to aid in medical treatment of physical injuries and diseases.
So employers and insurers need to examine barriers in their health and disability plans to the delivery of alternative--now often called complementary--care. These barriers include caps on mental health benefits and refusal to cover some types of care.
Among others, the Integrated Benefits Institute aggressively promotes an organizational strategy of putting all benefits under one roof. It says there is a "sea change in how employers view the structure and process of benefits programs." Integrating disability management within an employer lets it work the puzzle with a light on.
But IBI reports only a small portion of employers use integrated claims databases and cross-train those who deliver benefits programs.
Employers need to mitigate the toll of behavioral problems, which walk in through the door and up the elevator to the C-suite, as well as down to the mailroom. Behavioral problems are an equal opportunity hazard.
is a Vermont-based writer and columnist for
Risk & Insurance®.
April 15, 2007
Copyright 2007© LRP Publications