A Call for Quality Care

Employers are only now waking up to the bottom-line benefits of correct diagnoses and immediate and proper mental-health treatment for workers in need.

Tuesday, July 1, 2008
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Let's face it: Employee mental health affects the bottom line, and the culprits are many. Stress disability rates have been growing, mental health is the leading cause of prolonged disability in people with real physical illness and presenteeism is ever present.

Productivity, retention and medical-care utilization are all strongly affected by common anxiety and depressive disorders.

And then there are the effects on your employees of frighteningly high divorce rates, single parenthood, problematic children, workplace change and so much more. But hey, we all still have to work.

So why isn't it obvious that we should pay more attention to higher-quality mental-health care?

Despite a general slowness on the part of organizations and people to catch on, a trend reversal is emerging; this is actually starting to happen.

At a recent workplace behavioral-risk conference, for instance, session speakers told a roomful of attendees that "investing in employee mental-health assessment and treatment programs reduces absence, increases productivity and helps address overall healthcare and disability cost."

In one case, channeling mental-health claims through an in-network psychiatrist reduced short-term-disability claims by 56 percent. At New York-based AOL, investments in such programs resulted in 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 quality care at all, and even medical and healthcare experts can sometimes have trouble determining where better care can be found.

Ideally, the added outlays for quality mental-health care will be more than offset by savings in such costs as absenteeism, recruitment and training, reduced productivity, presenteeism, faster return-to-work and other expenses. And from the employees' perspective, the desired outcome of mental healthcare is accurate identification of the problem, appropriate treatment and, ideally, resolution of the problem.

Barriers to quality mental healthcare are the wrong way to reduce costs!

Many people don't realize that psychiatric medication and psychotherapy are not replacements for one another. They work very well together, but they do different things. Most antidepressant 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. For example, "depression" is often an anxiety disorder -- a panic disorder, in particular.

Treatments differ for anxiety disorders and depression, and at least some psychotherapy is an important part of the mix.

Get it Right the First Time

So, quality care begins at the beginning, and most important is the initial clinical evaluation. When people have significant emotional suffering, there are usually multiple causes ("over-determined," as we psychiatrists say), and the central factor is usually not the most obvious one.

A patient with an emotionally distant spouse might instead complain of impending financial impoverishment. So, 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, co-occurring and causal medical illnesses, and more.

Just as elsewhere in the medical community, that initial diagnosis is where highly skilled clinicians with broad and advanced training are most useful.

It is all too easy to ease the suffering of a divorce, while overlooking an underlying anxiety disorder whose treatment could allow 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 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 when emotional distress can be the presenting symptom of problems such as thyroid disease, cancer or other medical illnesses, including treatable conditions such as a sleep disorder due to obesity.

So getting it right the first time goes hand in hand with solving the problem effectively and efficiently.

Trouble is, inadequately trained evaluators only see what they know, even though they may be the nicest and most concerned people anywhere. Problems overlooked at the outset don't get recognized until much later, if they ever do.

And if effective treatment is not provided, the problem just lingers.

Untreated depression, thyroid disease, family problems, alcoholism, interpersonal skill deficiencies or unexplained chest pain is, indeed, both financially and morally expensive.

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Careful now, because over-reliance on simplified diagnostic schemes may be dangerous. Breaking down human distress into a few very simple categories is tempting and may be helpful for preliminary screening or for insurance claims.

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 you to unhappiness, but that could be 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).

We humans (including employees!) are complex beings. The best mental-health solutions require thoughtful recognition of the actual problems, and awareness that diagnostic refinement is an ongoing process during treatment. At that point, effective treatment can be provided by many well-trained mental-health professionals.

If actual benefit for employer and employee is the real goal of mental healthcare, a seasoned psychiatrist is most able to keep tabs on the many possibly contributing factors.

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 things as when to refer employees, but some starting thoughts (from the April 2008 Journal of Occupational and Environmental Medicine) can be found in Charts 1 and 2 (see following page).

New Horizon Solutions

What else can be done? We at WorkPsych have recently completed a project that allowed a large employer to address growing productivity concerns throughout the organization by quantifying the specific mental-health and workplace root causes of absenteeism, presenteeism and more.

In addition to helping the employer decipher and detect the causes of these workplace problems, the process helped employees learn about what their own issues might be.

Custom data yielded targeted and effective solutions for both employer and employee, and we have now teamed up with OptumHealth to make more employers aware of this approach.

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 per year. Solutions are there. Let's start using them!


Dr. Maurice Preter is a psychiatrist and neurologist, and Dr. Jeffrey P. Kahn is a psychiatrist; both are based in New York, where Dr. Kahn is also CEO of WorkPsych Associates.

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