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Depression in the Workplace

Vol. 14 •Issue 27 • Page 17
The Learning Scope

Depression in the Workplace

Undertreated and yet seen by many medical practices, depression is often first noticed in the workplace

Despite a media campaign spearheaded by well-known people like Tipper Gore, Barbara Bush and Mike Wallace, depression is still an undertreated illness. Approximately one in 10 Americans have depression. In a general medical practice, 6-8 percent of all patients seen are diagnosed as depressed, with only about 30 percent of patients who suffer from clinical depression receiving appropriate medication or psychotherapy.1

However, significant strides have been made in awareness of the disease, as evidenced in a recent survey by the National Mental Health Association. In 1991, a group poll showed only 38 percent of survey respondents regarded depression as a legitimate disease. In 2001, 57 percent of those polled who had never been diagnosed with depression but had signs and symptoms regarded it as a condition that was devastating and disruptive to one's life.2

The Price of Depression

With the increase in public awareness, perhaps the first place that depressive symptoms are recognized is in the workplace. Often, co-workers will notice when a colleague exhibits changes in concentration, indecisiveness, fatigue, memory lapses, in.creased mistakes, apathy replacing diligence and social isolation. It can be as simple as noticing that a co-worker who was once socially interactive with others has become withdrawn, refusing to go to lunch or participate in after-work activities.

Sometimes friends and co-workers try to rationalize the behaviors. For instance, "Debbie just broke up with Brian and is having a rough time. Let's give her a little time. She'll be OK in a few weeks." Or "Celeste's husband was just diagnosed with cancer. We need to help her out because she's having trouble concentrating."

But what exactly is the impact of depression in the workplace? Business & Health reported in 2000 that the estimated cost each year from increased absenteeism and reduced productivity due to depression and substance abuse is $240 billion.3 This reflects absence from work, short-term disability costs, workers compensation claims, safety incidents, employee turnover and on-the-job impairment, sometimes referred to as presenteeism.

Harvard researchers have estimated that people with depression are absent an additional quarter day per month (a total of 3 days per year) and experience a work cutback of 1.09 days per month (almost 2 weeks per year) when compared with those without psychiatric problems. When coupled with short-term disability days averaging 1.5-2.3 days over a 30-day period, this equates to a salary equivalent productivity loss of $182-$395. This is equal or less than the costs for mental health treatment over the same time period.1

A Comorbid Condition

Perhaps the more staggering statistics come when depression is viewed as a comorbid condition rather than a primary diagnosis. A recent study conducted by the Health Enhancement Research Organization asked the question, "What is the additional medical expense generated by employees who exhibit any one of 10 common modifiable health risk factors?" They included smoking, sedentary lifestyle, high cholesterol, hypertension, poor diet, being overweight, excessive alcohol consumption, high blood glucose, high stress and depression.

The results revealed a surprising result: depression was the risk factor associated with the largest medical increase. When they controlled for demographics and other risk factors, employees who reported being depressed were 70 percent more expensive in terms of their medical costs than those who were not depressed. Those who reported being highly stressed were 46 percent more expensive, and employees who reported being both depressed and highly stressed were 147 percent more expensive.1

A Medstat analysis of claims for patients having a diagnosis of depression found that their treatment only accounted for 28 percent of total health care expenditures. The remainder of the money was spent treating physical ailments associated with depression.1

The issue of comorbidity is a complex one that has been attracting increasing attention from insurers, researchers and the medical community at large. Researchers in Baltimore found that people who were free of heart disease but had a history of depression were four times more likely to suffer a heart attack.1 Researchers in Montreal revealed that heart patients who were depressed were four times as likely to die within 6 months of having a heart attack as those who were not depressed.1

Depression is now being considered a risk factor for heart disease similar to high blood pressure or high cholesterol. Depressed workers who are angry have been shown to have higher cholesterol levels. This research has raised several concerns both about the undertreatment of depression and the correlation to heart disease, since it is the leading cause of death in the United States and also the most costly health condition for U.S. employers.1

Treatment Barriers

If depression is often recognized in the workplace, and the general public is more accepting of depression as a medical illness, why isn't more being done to treat those affected?

On an individual level, there can still be many barriers to seeking treatment including stigma, shame, lack of information, poor access to care and confidentiality worries (see Table).

Some additional barriers may apply to employers including:

• ambiguity regarding their role as employers in being proactive about addressing mental health issues, feeling they may become over-involved in the personal lives of employees and be subject to legal action or violations of the Americans with Disabilities Act;

• lack of data that new initiatives or programs are warranted from a budgetary perspective;

• gaps in data that hamper decision making about the scope and cost of the problem; and

• concerns about confidentiality.4

A Broader View

The issue of depression is not unique to the United States. The International Labor Organization launched a study titled "Behavioral Disability: Detection and Treatment in the Workplace." It established bench.marks in four countries: two industrialized nations (United States and Germany) and two developing countries (Turkey and Poland). Some of the issues being addressed include: What programs are in place? How are they put together? What involvement does the government have? What are private companies doing?3

Einar Stokkes, CEO of the World Strategic Partners, has some interesting observations based on looking at many countries and their different approaches. While he feels the stigma attached to mental illness persists in other countries, the treatment philosophy may vary.3

He states that in Japan there is a lot of physical activity and the focus is on exercise as prevention. However, in the United States, the system is activated when the problem occurs. In Europe, medication therapy is used frequently and started early. The focus on prevention is also more apparent in Europe.

In northern Europe, the depression rate is higher than in the south due to the weather and amount of daylight. Employers research the use of light and music, and offer immediate counseling at the work site, especially for employees with little autonomy or where there is a higher incidence of violence.

In 1998, the Copenhagen Institute of Future Studies in Denmark published the book, "The Dream Society," which discusses a Maslow-like approach to workplace health. It outlines the "bio-values" of employees, a strong need to belong and the need to create an attractive workplace that meets workers' physical, mental health and affiliation needs.3

This world view creates an interesting opportunity for employers in the United States.

An Employer's Role

Prevention programs in the United States focus on the identification and treatment of depression. Perhaps we can take a lesson from our Euro.pean counterparts and begin to focus on a proactive approach to preventing mental health problems rather than a reactive one.

Prompting from nurse managers, occupational health nurses and staff who participate on work committees may help to initiate new programs within the facility.

Employers might consider the following solutions when addressing the problem of depression in the workplace.

Explore expanding or upgrading existing employee assistance programs (EAPs). Many now offer a menu of programs to assist employees in balancing work and family life. In addition to traditional counseling and substance abuse programs, many EAPs now address specific populations, such as employees with childcare issues, "sandwich generation" em.ployees who are caring for both dependent children and elders, and those who have a family member with a health care crisis.

These programs are often a reasonable financial addition to the benefits package since employers often only pay for service if it is used by an employee. Insurance companies guarantee easy access to care, usually within 24-48 hours.

Evaluate Environment

Employers also need to look at all aspects that contribute to mental health, such as food served to employees, especially on shifts when there is a tendency to drink too much caffeine and ingest high carbohydrate foods. After two cups of coffee, some experts claim that coffee has little effect on alertness and just makes one edgy and less able to cope with work demands. Often sleep aids and alcohol are used to promote sleep, which can introduce a vicious cycle of substance abuse.

Training programs should alert shift workers to these dangers and offer healthy alternatives such as nap rooms, fitness centers, effective lighting and other sensory stimulation such as invigorating scents in the work area. While this may sound too "New Age" for some, it can be an effective and inexpensive alternative to the cost of treating mental health and substance abuse problems after they are discovered.

For the more conventional employer, address food options for all employees, especially if it's a 24/7 workplace. Also, ensure that employees have an opportunity during their shift to "take off their game face" and vent with each other if needed. In some hospitals, employees and visitors eat together in the cafeteria, making this impossible. All employees need a break to maintain their own health and do their jobs better.

Finally, employers can facilitate access to mental health services for em.ployees. Frequently, patients will say the hardest thing to do is pick up the phone and call for an appointment. Some employees don't have access to a telephone during their workday and may request to use an office phone that provides privacy. Often it takes several calls — one to the insurance company to find a provider and then calls to actually make an appointment.

Encouraging the employee to use the EAP can provide easier access to care and scheduling an appointment. Sometimes appointments are only available during the day, and employees may request to have a specific day off or leave early. Managers should be encouraged to facilitate these re.quests, and therapists are able to provide a note to the employer if necessary.

The Nurse's Role

Nurses can have a significant role in preventing and treating depression no matter what setting they work in.

Assessment — Be sure that depression is included in all patient histories no matter the care setting. If there are questions about family and personal history of diabetes and hypertension, then there should also be one about depression. Be sure to also ask about types of treatment, duration and outcomes.

Access to care — Often nurses are perceived as less-threatening than physicians; therefore, patients as well as friends and family will ask nurses for a referral to a therapist. Network with APRNs in your community and, if you work in a doctor's office, try to learn who can take patients who have a particular type of insurance.

Again, remember that patients frequently say making the first appoint.ment is the hardest. If you know other therapists, you may offer to make an introductory call, especially for patients who might be high risk and ambivalent about seeking therapy. A therapist appreciates a call from an ob/gyn office RN stating they are referring a patient with postpartum depression who is at high risk.

Patient education — Nurses play a critical role in ongoing education of patients, employers and the community about depression and treatment options. But perhaps the greatest role that nurses can play is using these techniques to help another nurse or colleague experiencing depression to seek treatment.


1. Goetzel, R.Z., et al. (2002). Working with depression, part I: The business case for quality mental health services. Retrieved Aug. 19, 2002 from the World Wide Web:

2. Maltin, L.J. (2001). Depression: We're starting to get it. Retrieved July 17, 2001 from the World Wide Web:

3. Service, R. (2000.). A world view of mental health in the workforce. Business & Health, 18(7), 22-23, 26.

4. Goetzel, R.Z., et al. (2002). Working with depression, part II: Finding and funding effective treatment. Retrieved Aug. 19, 2002 from the World Wide Web:

Sally Ann Corbo is president of Epicare Associates Inc., West Caldwell, NJ.

Barriers to Depression Treatment

•The stigma of being labeled and its effect on opportunities for advancement or insurability;

•Shame or lack of motivation – since fatigue and passivity are also symptoms, it can be too much for a patient to seek out treatment on their own;

•Lack of information or ignorance about treatment options;

•Lack of trust in their health care provider;

•Difficulty accessing care; and

•Concerns about confidentiality.

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