U.S. Behavioral Health and the Workplace

According to the American Psychiatric Association Foundation, employees with depression miss on average 31.4 days per year and an additional 27.9 days of being unproductive when they report for work and are unable to focus due to the symptoms of depression.

Various studies show that 30% – 50% of all adults in the U.S. will experience mental health issues at some point in their lifetime. It’s estimated that 20 million Americans currently have a substance use disorder and that 7.9 million have mental health issues and a substance use disorder such as alcohol and drug addiction.

According to the World Health Organization, depression and anxiety alone, globally costs one trillion per year in lost productivity. This number is expected to reach six trillion by 2036. Globally, more than 300 million people (18% of which are in the U.S.) suffer from depression, many of which have some form of anxiety.

Negative work environments can lead to physical and mental health issues, substance abuse, absenteeism, and financial losses due to lost productivity.

The World Economic Forum proposed five responses to these issues:

• Implementation and enforcement of health and safety policies and practices, including identification of distress, harmful use of psychoactive substances, and physical and mental illness. These policies should include resources to manage such issues.
• The dissemination of information to employees regarding available support.
• Involve employees in decision-making to convey a feeling of control and participation, and involving them in organizational practices that support a healthy work-life balance.
• Programs for career development of employees.
• Recognizing and rewarding the contributions of employees.

Cost-benefit analysis research on strategies to address mental health, concludes net benefits. Every dollar put into enhanced treatment for common mental disorders such as anxiety, results in a return of four dollars.

The Anxiety and Depression Association of America reports that only 36.9% of those who suffer from anxiety ever seek treatment.

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a national U.S. survey that was published in 2014, revealing that anxiety, depression, and substance use disorders are the most common mental health issues.

In an August 2013 article published in the Journal of the American Medical Association by the Institute for Health Metrics and Evaluation and 125 other contributors, titled The State of U.S. Health, 1990-2010: Burden of Disease, Injuries, and Risk Factors, neuropsychiatric disorders are the leading cause of disability in the United States.

The World Health Organization has declared depression the leading single cause of disability globally, and the National Institute of Mental Health has declared this single disorder the leading cause of disability in Americans aged 15 – 44 years.

According to a study published in February 2015 in the Journal of Clinical Psychiatry, employees with major depressive disorder costs the U.S. economy more than $200 billion each year, and 50% of those costs are incurred on the employer. That exceeds the total economic costs of heart disease, stroke, cancer, and obesity.

The Depression and Anxiety Journal of the Anxiety and Depression Association of America (DAJ/ADAA) reported in 2010 that 1/3 of the costs incurred by employers from employees with these types of mental health issues are a direct result of lost productivity. In 2010, the DAJ of the ADAA published another study showing that reduced productivity of depressed employees had capital costs of $2 billion per month in the U.S.

More than 50% of those suffering from moderate depression and 40% of those suffering from severe depression, never seek treatment.

According to three separate studies, there is a direct connection between suffering from physical illness and mental illness, in that one often leads to the other, what is known as comorbidity or multi-morbidity (British Medical Journal BMJ Sept. 2012; Journal of American Medical Association – Psychiatry Oct. 2007; The King’s Fund Think Tank 2012).

This comorbidity doubles or even triples the costs of treatment according to a 2014 report by the American Psychiatric Association in conjunction with Milliman Inc.

A study published in the Dialogues in Clinical Neuroscience (2007), those suffering from depression were twice as likely to develop coronary artery disease or experience a stroke, and were four times more likely to die within six months after a heart attack.

Former U.S. Surgeon General, Vivek Murthy M.D., M.Sc., wrote in the Harvard Business Review (Sept. 2017), “Our understanding of Biology, psychology, and the workplace calls for companies to make fostering social connections a strategic priority.”

Dr. Murthy laid out the case for addressing workplace loneliness, an often overlooked but equally important factor in workplace mental health, by making these three points:

1. Lonely workers are unhealthy – greater risk of cardiovascular disease, compromised immunity, increased risk of depression, shortened lifespan.
2. Isolation in the workplace is costly – mental sluggishness from a lack of social supports leads to impaired productivity, loss of creativity, and interferes with decision-making. This impacts an organization’s revenue, spending, and performance through increased “sick leave” and health insurance claims.
3. Modern workplace contributes to the challenge – with a focus on productivity and task completion, little time is spent on building social connections (team building).

Dr. Murthy recommends the following strategies to create workplace social connections:

• Evaluate the organization’s current state of social connection by asking employees whether they feel valued and whether the corporate culture supports connectedness.
• Build understanding at all levels about high-quality relationships at work.
• Make strengthening social connections an organization-wide strategic priority.
• Encourage employees to seek help when needed and to help each other.
• Create opportunities for employees to learn more about each other, including personal experiences and interest outside of work.

For more than a decade I found myself at work witnessing, hearing about, or personally experiencing behavioral health challenges that were not effectively handled or addressed by management staff or by the employer as a whole.  Not because no one cared, but because people were woefully unprepared, untrained, and uneducated on best practices.

Behavioral health is a term that encapsulates both mental health conditions and substance use disorders. For years, I have expressed my concerns regarding how behavioral health in the workplace has been both viewed and treated, and for years I have been either ignored or not taken seriously.  In 2018, I finally found myself in a position where my voice had at least a minimal opportunity to be heard by leadership and for the next few years I pushed for change.

While the majority of my proposals were not considered (including the most important one), some of the smaller efforts were approved and we were at least able to bring some degree of educational opportunities about behavioral health to our employees.  One of these included a partnership with the a local university’s psychology department.

Leadership’s unwillingness to take my concerns regarding behavioral health in the workplace seriously and their lack of earnest desire to consider my other proposals for positive change, eventually added to the list of reasons I resigned. This mindset of not settling for a workplace that doesn’t take mental health seriously is something that I am not alone in. These past few years have shown that employees are fed-up with employers who don’t care about their mental health and don’t provide them with the time, resources, and support needed to fend off burnout and other common workplace mental health issues.

Typically the barrier preventing positive change in the workplace for behavioral health challenges is not caused by the employees, but by the employer and their leadership team, who for any number of reasons tends to avoid the topic.  This avoidance allows people to continue to suffer, generally in silence, to the point that they leave, and once word gets out that the employer is not a safe and supportive place to work, other people will not want to apply for their job openings.

From employees struggling with substance use disorders or mental health conditions, to supervisory and management staff being overwhelmed by employees struggling with these types of behavioral health challenges, there has been and continues to be a need for training and education, as well as policy and procedure change in the workplace.

Both private and public companies have the opportunity to make fundamental changes to how behavioral health challenges are addressed in their workplace and an opportunity to make a positive change in our society for those who struggle with these challenges and those who care for them.

I support any initiative taking steps to make these improvements and urge employers to do more for employees with substance use challenges and mental health conditions.  There are programs and initiatives already established for support in the workplace and more than likely employer’s already have employees qualified and willing to lead any such initiative if they’d just be given the chance to make a positive change through education, training, policy and procedure transformation!

Now is always the time to advocate for mental health changes in the workplace, not just for those currently employed but also for those who may be prospective employment candidates. There are public and private organizations offering programs to support mental health in the workplace, and also state and federal grants, tax credits, tax deductions, and other financial incentives for businesses that employ candidates with mental health conditions, mental disabilities, or who are in recovery from substance use disorders.

Here are some general recommended best practices for organizations and management staff to get started on supporting mental health in the workplace. This list is by no means all inclusive nor in any great detail, it should be considered a starting point.

• Implement health and safety policies and practices
  • Mental health is often viewed as the “ugly duckling” of the health industry. Everyone knows it exists but no one wants to acknowledge it as real or talk about it. For this reason, policies and practices that we would find appalling if implemented for physical health are deemed acceptable when enforced for mental health. People have to jump through burning hoops just in the hopes that their insurance company might help pay for the services they need for their mental health condition or substance use disorder (if they can even find effective services). This same type of “cold shoulder” and obstacle course towards treatment is forced on mental health in the workplace too, where even though scheduling regular medical doctor check-ups are encouraged and time-off permitted for even the slightest onset of the sniffles, employers do not believe that “mental health days” are a real and justifiable cause for using sick leave, or in some cases employers do not even allow their employees to use their sick leave for mental therapy sessions.
  • Too many employees are afraid to tell their employers they are struggling with their mental health and chose to suffer in secrecy and silence out of fear of punishment and other negative consequences, which leads to the employee’s self-isolation, reluctance to seek help, a risk of prolonged untreated mental illness, a decrease in work productivity from the employee, loss profits for the employer, and the list goes on. Burnout, anxiety, depression, substance use, and eating disorders are all leading mental health issues that are finally being discussed in today’s workplace, and any employer not equipped to address these issues will not fair well in an era where we as a society are finally starting to acknowledge that mental health is real.
  • When employers contract with employee assistance programs (EAP) they need to ensure that the program is comprehensive and effective. Through these programs employees often have access to a limited number of free counseling sessions and access to other resources and services, but not all programs are made equal. Sometimes there are limitations and restrictions on the free counseling sessions that make them ineffective.
• Be mental health aware and learn to recognize signs of distress
  • Anonymous workplace surveys regarding employee mental health and substance use and the effectiveness of provided resources and services can assist an employer with gauging their current workforce overall mental wellbeing. Not every employee will be honest with their answers due to fear of being discovered/identified or even retaliated against no matter how anonymous the data collection process may be, but most employees will be forthcoming with their struggles and their feedback. The results of these surveys can often be eye-opening, but more importantly they direct an employer toward what types of resources and services their employees are in need of, what’s working and what isn’t. There must be a robust regulatory system in place to review the feedback and actually implement necessary changes to improve employee resources and services.
  • Awareness of employee behavior can save lives, for example when an employee who has always had good attendance suddenly starts coming in late or missing entire days without an obvious explanation, it may be a warning sign that something is impacting the employee’s mental health. The employee doesn’t need to be contacted for reprimand or threatened with termination, they need a compassionate employer to reach out and ask what type of support may help them return to work. The old model of punishment for undesired behavior needs to be replaced with a model of compassion and support or the high turnover rates will continue.
  • There are a variety of programs that can be implemented in the workplace to teach both management and staff what signs and symptoms to look for when someone may be experiencing a mental health crisis. One of the most commonly utilized programs in the United States, United Kingdom, and Australia is Mental Health First Aid.
• Educate on topics such as substance use and mental health conditions
  • Learning how to identify someone who may be experiencing a mental health crisis is important, but it’s just as important to learn about behavioral health in general. Human resource departments should be equipped with providing educational opportunities to employees about commonly experienced mental health conditions, substance use disorders, and available treatment options. This is not about diagnosing or directly treating an employee, this is about empowerment through education, it’s about eliminating the stigma of mental health and substance use that often keeps people from seeking help, and it’s about illuminating the truth of just how prevalent and treatable these challenges really are.
  • If an employer’s HR department is not equipped to provide this type of education, most EAPs have contracts with counselors and other mental health educators who can host educational seminars about these topics both in-person and online, but this should not be a once-a-year opportunity, these educational seminars should be routine and occur regularly every quarter and cover a wide variety of mental health topics.
• Share information and resources for treatment, self-care and symptom management
  • Improving resource and service awareness should extend beyond just new employee orientation because onboarding is often a rushed process and leaves new employees overwhelmed and unable to remember everything thing they’ve been told or shown. Information regarding what mental health services are provided via their EAP should be regularly identified via emails, discussed via meetings, and posted on walls in communal spaces. It is recommended that the information be provided to them quarterly but no less than bi-annually.
  • Since life does not just happen during the day, employees should also be provided with resources and services they can contact at night after work for assistance and support with various life challenges connected to mental health. If the EAP does not provide 24/7 assistance and support, employees should be provided with the contact information for the various state and national mental crisis organizations that do.
  • Most EAPs can provide information about self-care and symptom management, but their are also many non-profit organizations that are more than willingly to provide brochures, pamphlets, booklets, and print-outs about what someone can do to better cope with a mental health condition or substance use disorder. These items can be placed in communal or centralized locations within the workplace to provide employee’s the opportunity to take them home. They also have posters that employers can hang up around the workspace.
  • For more comprehensive support or treatment services, most countries have a national organization that provides mental health services or can connect people to organizations that do. In the United States, the Substance Abuse and Mental Health Services Administration (SAMHSA) retains a registry of organizations that provide behavioral health treatment.
• Involve team members in practices that support a healthy work-life balance
  • In addition to burnout, anxiety, depression, eating disorders and substance use, another very common mental health issue faced by employees is loneliness. It is not enough to provide employees with information and access to resources and services, they also need the motivation to utilize them and this can be very difficult if they are isolated at home and in the workplace.
  • Providing employees with opportunities to partake in activities inside and outside of the workplace builds a stronger sense of community. While the “company bowling team” and the “holiday party” have been long-standing staples of the workforce experience, more attention needs to be placed on mental health related experiences such as retreats focused on mental wellness, community walks focused on mental health awareness, and volunteering programs focused on coming together to help those in need.
  • Workplace peer support groups can provide a crucial opportunity for employees to talk with their peers about what they are experiencing in their personal lives that is impacting their work life or what they are experiencing at work that is impacting all other aspects of their lives. Studies have shown that most adults meet new friends at work and this is especially true for men who find it more challenging to make friends after school compared to women. Peer support groups are a great way for people with common experiences to not only meet one another, but to also support one another.
    • The general benefits of peer support groups include:
      • Creates a confidential environment where individuals struggling with a behavioral health condition or related circumstance can openly discuss what they are experiencing or struggling with and be able to receive emotional support from those with a similar condition or circumstance.
      • Permits social validation for their struggle without the stigma or the insecure and judgmental responses from those who do not have a lived experience with, or understanding of, a behavioral health condition or related circumstance.
      • Provides an opportunity for those who often struggle alone with a behavioral health condition or related circumstance to communicate with, learn from, and recover or grow alongside those who are similarly affected by their condition or circumstance, establishing a network through which factual information, proven methods, and helpful resources can be openly exchanged.
    • It’s important to understand that there is a difference between a therapy support group and a peer support group. Peer support groups are peer-led and cannot provide therapy or any other type of treatment for a mental health condition or substance use disorder, whereas a therapy support group is led by a clinical licensed mental health practitioner. There are many other important factors when establishing peer support groups and these factors increase when considering establishing them within a specific employer. The Canada Life Assurance Company has provided a short but comprehensive outline for starting this type of program, and the Society for Human Resource Management (SHRM) published a short article on the topic in 2018. Beyond this key information, there are mental health non-profits qualified and willing to assist in the establishment of peer support groups within a workplace, but the first place to request assistance is through the employer’s EAP.
• Provide access to career development opportunities
  • As a former professional development instructor I cannot advocate enough about how important professional development opportunities are to the overall wellbeing of an employee and the overall success of a workplace. This goes beyond the core basics of any workplace education curriculum such as leadership training, conflict management, team building, and communication. Employers should be implementing a wide variety of programs, including tuition reimbursement, cross-training, mentorship, apprenticeship, and job creation/trade/exchange.
  • Part of my advocacy is to encourage workplaces to incorporate behavioral health education into the curriculum because the sooner we normalize conversations around mental health, the sooner we allow people who are struggling to feel less alienated, less stigmatized, less ashamed, and less hopeless. Employees have every right to learn about the mental health challenges they may face during their career, whether these challenges arise due to their personal life or their professional life because in both cases they will impact them in the workplace.
  • Professional development is more than just knowledge though, it is also about what employees do with that knowledge and their ability to be successful in their career. Success is not a clearly defined concept, not everyone views it in the same way nor measures it by the same standards and that’s a good thing. Regardless of how an employee perceives success, they all want to have a sense of purpose, meaning, and fulfillment in their lives, and for a lot of people their job is the primary source of these things, and it therefore falls on the employer to provide these types of opportunities for employees. The consequence of not doing so is the employee choosing to leave and look for a better employment experience elsewhere.
  • Recognizing and rewarding the contributions of employees is not new, but not all employers put effort into doing this, or when they do, it is generic and disingenuous or it’s overkill. Like all things in life, moderation is important because too much of a good thing can become monotonous and lose the power of its meaning. Kind of like cake, it’s great until someone starts baking you a cake every single day – then you get real sick of it real quick. Recognition and reward should not be treated like a participation trophy, the saturation of this type of program can quickly lead to it having the opposite effect as originally intended. Recognition, reward, and celebration of success should be reserved for those achievements that have truly gone above and beyond expectation and have honestly garnered such a degree of attention.

The bottom line is that employees are an investment, they are the single most valuable and important asset to an employer and their mental health needs to be recognized as a matter of great concern. If a policy or practice is not to the benefit of employee mental health then it needs to be seriously scrutinized and reconsidered, which means that there must always be contingency plans set in place for modifying or amending any process, procedure, or practice to reduce the negative impacts on employees. Failure to do so reflects poorly on the employer and their leadership, for any organization ill-equipped to care for its employees is ill-equipped to provide services to its customers.

You will find research and data supporting the need for these types of changes via the following private and public organizations:

• American Foundation for Suicide Prevention
• Center for Workplace Mental Health
• Centers for Disease Control and Prevention Data Portal and National Center for Health Statistics
• International Association for Suicide Prevention
• Mental Health America
• National Alliance on Mental Illness (NAMI)
• National Council for Mental Wellbeing
• National Institute of Mental Health (NIMH)
• Psych Hub
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• Workplace Suicide Prevention
• World Health Organization

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If you or someone you know is experiencing a mental health or substance use crisis, please access my immediate assistance resource page.  A comprehensive listing of online and phone resources and services is also available.