A Little Help for Mental Health

Employees who are taking antidepressants and other psychiatric drugs often don't receive the help they need.

Saturday, May 2, 2009
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Employers are all too familiar with the high cost of healthcare, and many are taking strides to keep costs down and value up. However, when it comes to handling behavioral health issues, many employers are woefully in need of improvements.

Consider these findings: In 2007, U.S. adults spent more money on antidepressants and other psychiatric drugs than any other drug category, according to Medco Health Solutions Inc., a Franklin Lakes, N.J.-based pharmacy-services company.

Another study shows that more than half (53 percent) of U.S. adults suffered from the mental or physical symptoms of at least one behavioral-health issue in 2007, averaging 32 days of disability during the year, according to a study by the Bethesda, Md.-based National Institute of Mental Health published in the October 2007 issue of the Archives of General Psychiatry.

With so many Americans facing mental illness, proper care is a must; however, many sufferers are seeking treatment from their primary-care physicians rather than behavioral-health specialists such as psychiatrists.

Antidepressants were prescribed by a specialist just 36 percent of the time, while the remaining 64 percent were prescribed by primary-care offices, hospitals, outpatient programs or surgical offices, according to an August 2006 study by the Centers for Disease Control and Prevention in Atlanta, the most recent data available.

What's particularly alarming is that most general practitioners are not qualified to properly diagnose and treat behavioral-health issues, argues John Kamilis, director of clinical services at Skokie, Ill.-based Curalinc Healthcare. The result is that patients often suffer from inadequate treatment, including being prescribed the wrong drugs and not being referred for counseling, he says.

The costs for employers can be quite stiff and go beyond simply paying for those erroneous prescriptions, says Kamilis. Employees who are improperly treated will continue to have higher rates of absenteeism and presenteeism while being less productive.

So, what actions can HR executives take to get this problem under control?

In a Q&A with staff writer Jared Shelly, Kamilis discusses pharmacy-intervention programs, in which a case manager (usually in conjunction with an employee-assistance program) works with employees and their GPs to ensure the employees are receiving proper treatment, medication and counseling.

Such an approach, says Kamilis, will help eliminate the mistakes that often occur when it comes to treating behavioral problems -- although GPs can be initially resistant to the idea, he notes.

If a patient goes to a general practitioner and is misdiagnosed, how would the company know? What would the EAP do to help?

What the company may notice are problems with them coming to work on time, absenteeism, things like that. Those are some of the indications that there may be some issues going on there.

The way we find out if they're being misdiagnosed is by taking a look at the pharmacy data we get from the [third-party administrator] or the benefits manager.

The pharmacy data just gives us a brief snapshot. It doesn't tell us everything we need to know, but it gives us an indication of which members are getting psychotropic meds and information about who's prescribing the medication. I'll have an idea if it's a general practitioner or if it's a specialist like a psychiatrist or a neurologist.

If it's a GP who's prescribing it, then we'll reach out to the member to determine if they're being prescribed medication that's actually beneficial for them.

We'll do an outreach to the patient by phone call or letter to inform them of what's available and that they should contact us to be evaluated. [During an evaluation] we take a look to see what psychotropics or neurologics are being prescribed by what doctor, and we make sure that the patient's on the right path and following the correct course of action.

The case managers [at Curalinc] are all licensed masters-level clinical counselors or clinical social workers. The counselors receive additional training in pharmacology and . . . have experience determining when [medication is] going to be necessary and when that's not going to be necessary. We're not telling doctors what to prescribe, we're looking at what other treatment options are available that can be effective in helping the client.

The research we've collected and reviewed suggests that, when it comes to depression and anxiety, a lot of those types of mental-health issues can be resolved using psychotherapy or counseling, and sometimes medication isn't always necessary. If medication's needed, we can augment it with counseling to be more effective.

What are the warning signs of a worker with behavioral-health issues that HR, management and co-workers should watch out for?

Things like an employee being irritable, having emotional outbursts, acting in strange or bizarre ways, appearing preoccupied and having problems concentrating and being able to focus.

Some of the more measurable criteria would be how productive they are at work. Factory workers [for example], as far as their productivity on the assembly line, are they completing their jobs in a timely manner?

Are things getting done in the correct way? We also look at attendance issues. Are they coming to work? Are they calling in sick a lot? Are they coming to work late all the time?

What is HR's role in the process?

The way a pharmacy-intervention program is set up, it's integrated primarily with the company's pharmacy-benefit manager or its third-party administrator. That's where we get the data. HR acts as a conduit between the employee-assistance program and the data source, so they can help [an EAP] integrate that with the TPA.

Initially, HR will get that process set up and then it's just a matter of working with HR to increase awareness of the program among employees who have mental-health-related issues or family members who have mental-health-related issues so they can be aware that, if they are receiving medications, they can contact the EAP to see if [they're on] the right course of action.

After connecting an employee with an EAP, how should HR follow up?

In most cases, there isn't going to be a whole lot of follow-up with HR just because of [the Health Insurance Portability and Accountability Act] and confidentiality limitations.

But in some cases, where work productivity becomes an issue, we'll work with HR once we get the necessary releases of information so we can address any work-related issues and make any transitions to work or accommodations at work to make it easier for the employee.

So, if there are any mental-health-related issues getting in the way of [an employee's] work, productivity or attendance, we'll work with HR to address those issues so they don't get in the way.

You say general practitioners are not adequately trained to treat behavioral health problems. What mistakes can be made?

What we tend to see a lot of is misdiagnosing the problem. A perfect example is attention deficit hyperactivity disorder. A lot of times, we've been seeing kids with ADHD being misdiagnosed as having bipolar disorder. The treatment for ADHD is a lot different than for bipolar disorder.

The type of medication for ADHD is more of a stimulant. Someone who is bipolar [will behave by] acting out, so [by mistakenly giving them a stimulant] you're going to get somebody who's already hyper and manic even more hyper and manic!

Does the EAP/PIP concept encounter resistance from physicians? Do they tend to regard it as "meddling"?

Yeah, we get that once in awhile. We'll see general practitioners who feel that we're kind of stepping [on their toes]. We try to be professional with them as much as possible and we understand that some doctors can feel intimidated, like somebody from outside is telling them how to treat their patients.

Again, we're not there to tell the doctor what to prescribe. We're there to just provide some information, education and resources. A lot of times, we find that the GPs just aren't aware of the other treatment options that are available, but they feel that they're capable because they received some training and education from the pharmacy representative who came in with the medication.

Once we do some education and let them know there's a better way of dealing with this that's clinically more effective, they tend to be more open about that and more accepting of the help.

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Can you give me a specific example of how an EAP can help an employee with behavioral-health issues?

We had one case involving an employee who was relocated and was feeling depressed, having some anxiety and some problems sleeping. We received the pharmaceutical data from the TPA, so he was identified as someone we wanted to do an outreach to.

Once we did the outreach, we were able to complete an assessment and basically [we found that] he was just experiencing some mild depression due to the job relocation. As a result, he was having some sleep and appetite disturbances and some problems concentrating. His overall functioning at work and home wasn't that impaired.

One of the things stressing him out was locating daycare providers and just being in a new city. The GP put him on [the antidepressant] Zoloft and [the sleep aid] Ambien to manage the symptoms but didn't really give any referrals for counseling.

So once we got permission from the employee to talk to the GP, we worked with the doctor and came up with a course of action that involved [the employee] coming off the medication and seeing one of our EAP counselors.

After about three or four sessions, he was doing a lot better. The symptoms were under control. He was able to sleep better. His appetite was returning. One of the other things we were able to assist him with was finding referrals for child-care providers that met his needs.

So a lot of that stress was able to be alleviated solely by counseling.

Do you think psychotropic medications today are overprescribed?

One of the things we've been noticing increasingly over the last few years is that more and more people are becoming addicted to the medication. There are some psychotropic drugs that aren't very addictive, but there are others that potentially are.

Some of the addictive ones include Ritalin, Adderall -- those are ones typically used for ADHD. Any type of medication labeled as a benzodiazepine like Xanax, Valium, Ativan -- those are pretty addictive medications and typically used for anti-anxiety sedatives.

Antidepressants such as Celexa and Lexapro tend to be less addictive or hardly addictive.

What tends to happen is that, a lot of times, there's no follow-through by the GP to make sure the patient is taking the medication as prescribed or that the medication's working effectively.

Sometimes, the patient may feel that, 'OK, I'm feeling better now, I can stop taking the medication,' and then things start getting bad again. They may start doubling up on the medication to make themselves feel better. We want to be cognizant of that. That's always an issue of concern.

You turn on the TV and you see ads for these medications all the time, which kind of [makes] the doctors feel they need to prescribe something if their patient comes in requesting a medication. That's another [area] we try to work with doctors on, so they don't feel they need to prescribe something just because the patient's requesting it.

We're hearing about the antidepressant medications resulting in some increased suicides among people who are depressed. So that's the other thing we want to be aware of. If they're on an anti-depressant, are they being monitored closely? A lot of times they can be monitored by working with a counselor who can constantly assess and make sure the patient's safe.

Given the privacy rules surrounding medical issues, how would an employer determine the effectiveness of this program?

They're going to see cost savings from the decreased pharmacy claims. The other [indications] are going to be more indirect: less absenteeism at work, increased productivity and overall improvement in their behaviors in the workplace.

When the GP is prescribing the medication, the client will take longer to go through treatment. Sometimes, clients don't follow through with the treatment, so those issues are still persistent. Once we get in there and once we're able to help the client and start addressing those issues, we see that the [treatment] time [is going] down, there's less likelihood of them relapsing or falling back into a depression or anxiety.

In that sense, we see some cost savings because it's less time they need to be away from work. With corrective action, we can get them to avoid having to be hospitalized or having to make unnecessary E.R. visits because they're experiencing side effects of that medication or may have accidentally overdosed on the medication. That's a cost saving to the company as well.

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