Why health care employers should tackle depression

It causes more disability than back disorders

If you want to know the impact of depression on the workplace, just do the math.

A survey of 30,000 American workers found that 9.4% suffered from a depressive disorder. Depressive symptoms are about twice as common among women as among men — and women make up about 85% of the health care work force. Lost productivity due to depression cost employers $44 billion per year — more than three times greater than any other illness, according to a study in the Journal of the American Medical Association.1

The World Health Organization has designated depression as the leading cause of disability worldwide.

On a smaller scale, T. Larry Myette, MD, MPH, director, Strategic Workplace Health and Occupational Medicine Consultant at the Healthcare Benefit Trust in Vancouver, British Columbia, calculated the impact and realized that employers needed to address depression not only to improve productivity and cut medical costs, but to help their employees.

Depression was the single largest cause of long-term disability — larger even than back disorders.

"It really got our attention," says Myette. "Traditionally, we've been very focused on musculoskeletal disorders, such as back injuries from lifting and transferring patients."

The Healthcare Benefit Trust is a not-for-profit health and welfare trust that administers benefits for the province's health care and community social services employers. Coverage includes extended heath benefits such as prescription drugs and psychology services not insured under the provincial health care system.

Myette began looking deeper into the issue of depression among the work force served by the trust. "We found that about 18.5% of all our employees in health care and social services had at least one prescription for an antidepressant drug in a given year. When we looked at it over time, there was a steady upward progression," he says.

Myette created the Depression in the Workplace Collaborative with a team of occupational and mental health experts from British Columbia to study the problem. They summarized their findings in a report called Depression & Work Function: Bridging the Gap Between Mental Health Care and the Workplace (available at www.carmha.ca). He also authored a white paper on Managing Depression in the Workplace for hospital leaders and is co-editing a special supplement for the April 2008 issue of the Journal of Occupational and Environmental Medicine.

What is depression?

WHO offers definition

"Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities."

Getting the word out about depression is crucial, he says. Employers need to understand the cost of chronic diseases — including depression. "With the help of health and productivity measures now available, you can actually begin to calculate what the losses are for your organization, which helps create a business case for intervention," Myette says.

The business case for intervention recently was bolstered by a study published in the Journal of the American Medical Association. Researchers at the National Institute of Mental Health found that employees with clinically significant depression who received an intervention were 70% more likely to remain employed and worked an average of two hours more per week than employees who received "usual care."

The intervention group received phone calls from a trained case manager who encouraged them to receive psychotherapy and antidepressant medication and offered telephone psychotherapy to those who declined in-person psychotherapy. Those in the "usual care" group simply received feedback about the depression screening and were advised to seek help from a clinician.1

The value of the extra hours worked amounted to about $1,800 per employee per year, the researchers estimated. "Improving the treatment of depression is not just a cost. It actually is a way to get a return on investment and improve their bottom line," says Philip Wang, MD, DrPH, director of the Division of Services and Intervention Research at the National Institute of Mental Health in Rockville, MD. "Hopefully, this is evidence that interventions actually do work."

One in 10 diagnosed with depression

The first step toward addressing depression in the workplace is to review your medical benefits and disability claims. Myette discovered that 22% of long-term disability claims were for mental health and 60% of those were for depression. A similar pattern emerged for short-term disability.

Myette also initiated an employee health survey to gather additional information on personal and environmental health risks, depressive symptoms, chronic disease prevalence and associated productivity losses (absenteeism and presenteeism). The Trust also introduced a web-based screening and management tool for common mental disorders. "You have to have sufficient data to profile your organization" and understand their chronic health needs, including depression, he says.

About one in 10 (10.4%) of the employees reported that they had been diagnosed with depression and 7.1% had been diagnosed with anxiety disorders. "This is a significant issue," he says. "When we used the depression screening test at the usual cutoff for this instrument, 38% of respondents screened positive for depression."

Using a higher cutoff that indicated a greater likelihood of a current episode of depression, just over 12% of the employees who responded to the survey screened positive. "One of the major problems in the effective management of depression and other chronic disorders is detection," Myette says. "Less than half of people who actually have depression ever seek help for their depressive symptoms. Of those who seek help, many are not diagnosed or adequately treated."

Screening for depression should be incorporated into other regular health assessments of employees, he says." Screening can be as little as two questions or it can be as formal as using a tool such as the PHQ-9 [xx]. 'Have you been experiencing a depressed mood? Have you been noticing that you have decreased interest or experience less pleasure in normal activities that you used to enjoy?'"

Why it's work-related

To address the burden of depression, Myette and his colleagues created the Integrated Work-place Depression Management Program. He had discovered that the health care and social services employees did not have much access to cognitive behavioral therapy.

Employees with psychosocial needs often self- referred to their employee assistance programs (EAPs), but many EAPs did not screen for depression or were unable to offer a full course of evidence-based psychotherapy. EAPs are well positioned to support employees in distress and "one of our recommendations is that the type of services provided by EAP needs to be reassessed in light of this new evidence about depression," he says.

Need senior management buy-in

You need to get senior management buy-in to implement changes. For example, one health care employer created a steering committee to address depression. At educational sessions, they learned about the symptoms, treatments, and occupational impact of depression. "There was a transformation in the thinking of that group. By the end of the sequence they were highly motivated to take action," says Myette.

The onset of depression is usually multifactorial, including family history of depression, stress or interpersonal issues, and life events. But the workplace can contribute to depression if, for example, employees feel they have excessive demands on them but limited control or few rewards, or if their skill sets are a poor fit with the job requirements.

"On the other hand, if you have a very well-managed, very supportive, participatory workplace that makes sure people are well trained and developed in their job, then that can serve to buffer the impact of depression," Myette says.

Addressing depression is just one step toward including chronic diseases in the spectrum of employee health, he says. "We're interested in not just looking at the impact of work on health, but also in the effects of health on work and productivity," he says.


1. Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial. JAMA 2007; 298:1,401-1,411.