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© Copyright 2000 Rogers Media. The following article first appeared in the December 2000 edition of
BENEFITS CANADA magazine.
Breaking down the barriers
Non-physical disabilities like mental illness are the fastest growing category of disabilities
today. Plan sponsors have an important role to play in eliminating the stigma and workplace practices that
foster these illnesses.
By Kathryn Dorrell
Sandy Naiman has endured 19 hospitalizations, countless shock treatments, and in her own words, "every
psychiatric indignity short of a lobotomy." Naiman suffers from mental illness. Diagnosed when she was just
12 years old, she is treated today for a severe mood disorder that makes her vulnerable to mania. Last year
was considered a good one, as she spent only six days in hospital.
What is also important to know about Naiman is that she is an accomplished and productive professional. She
has worked as a senior reporter at the Toronto Sun newspaper for 24 years and earned numerous
awards. Once when Naiman was in the hospital, her mother confessed to her editor that Sandy was worried
about losing her job. Nonsense, the supervisor replied, pointing out that when she's well--which is most of
the time--the prolific writer does the work of two people.
Naiman is an example of how effectively people suffering from non-physical disabilities can function in the
working world--particularly when their illnesses are treated and their employers are supportive.
Naiman is becoming a crusader of sorts on this largely misunderstood issue, working in co-operation with
the Toronto-based Business and Economic Roundtable on Mental Health. The forum of executives is dedicated
to making a business case for mental illness initiatives, encouraging organizations to play an active role
in managing non-physical disabilities and curbing the staggering costs associated with them in the process.
"Corporate courage to address mental illness is desperately needed and in short supply," says Naiman
bluntly. "It's bad business not to understand mental illness. In an information-driven economy, our minds
do heavy lifting and need to be serviced and insured just as equipment and machinery is. Long-term
disability is not the answer. If companies can fix computers and machines, they can bloody well help fix
the minds of their employees--restore them and bring them back to work."
Ironically, in the current knowledge-based economy, non-physical disabilities (which consist of psychiatric
illnesses as well as chronic fatigue and fibromyalgia) have soared while productivity, particularly in
areas that involve decision-making and innovative thinking, dwindles--often without being detected.
Mental health claims are the fastest growing category of disability costs in Canada today, according to
Manulife Financial Group. Psychiatric claims, primarily depression, are increasing at the greatest rate.
The roundtable reports that the cost of lost productivity, alone, for mental illness in Canada is $8
billion a year. Meanwhile, the World Health Organization estimates depression--the most prevalent of all
non-physical disabilities by far--will reach epochal levels by 2020, and become the greatest source of time
lost through disability and early death in developed economies.
The rising incidences of mental illnesses are attributed to a growing awareness of these conditions as well
as improvements in detection. "We've had 10 years of intense social pressure, economic stress and
uncertainty. These things contribute to depression," says Bill Wilkerson, president and co-founder of the
Business and Economic Roundtable on Mental Health. Wilkerson created the group with Michael Wilson,
president and chairman of Toronto-based RT Capital Management Inc., who became actively involved in mental
illness causes after his son committed suicide.
Still, of the estimated 1.4 million Canadians suffering from depression, the roundtable reports that only
6% have been properly diagnosed and are receiving proper treatment. "In part, there is a gap because of the
stigma--people don't want to talk about it. Physicians often won't diagnose it because it takes time. There
is [also] insufficient awareness of what the symptoms are and how they are distinctive from other kinds of
illnesses," says Wilkerson. Inaccurate diagnosis and a lack of clinical tests also plagues the management
of fibromyalgia. However, insurers say this non-physical illness is small in terms of case-load compared to
depression.
The sheer volume of mental illness cases in the workplace is compounded by the fact that employers are
relatively new to managing them, says Wilkerson. Several developments in the past 15 years have forced plan
sponsors to address this issue.
In the mid-1980s, a landmark decision from the Supreme Court of Canada struck down an industry-wide
insurance agreement that prevented employees from being on psychiatric disability for more than 24 months.
After that, an employee could be off on long-term disability for depression indefinitely. During the same
period, Prozac--the first in a new stream of effective but pricey drugs to treat depression and
anxiety--arrived on the scene. "The economic impact on insurance companies and the workplace has been
huge," says Dr. Erhard Busse, a psychiatrist and president of Burlington, Ont.-based Oncidium Health Group
Inc. Busse's consulting company works with plan sponsors and insurance companies to mediate and resolve
disability claims.
Wilkerson, a former president and chief executive officer of Liberty Health, spearheaded the roundtable
largely because he believes the insurance and benefits industries simply don't have the information needed
to tackle non-physical disabilities. "There is no question that we are taking models for physical
disabilities and plunking them on mental disabilities," he says. "To manage depression you have to start
looking at new and creative approaches."
The group has released a 12-step plan to help organizations transform themselves into depression busters.
"Once CEOs see the facts around this, they are usually pretty responsive," says Wilkerson. The roundtable
is also planning a series of what Wilkerson describes as "very aggressive" programs, including a forum that
will help human resources professionals define their role in managing workplace depression.
In many respects the workplace is the ideal venue for detecting and initiating treatment for mental
illnesses. Wilkerson points out that depression is seldom dealt with at home, and when it is, individuals
often don't know what resources are available for them. The workplace also reveals whether an employee can
effectively and productively interact with others and make decisions--failure to do so is a warning sign of
these illnesses.
Compassion aside, cost alone is a big enough motivator to encourage employers to implement initiatives that
address mental illnesses. According to research conducted on the issue by Yale University and promoted by
the roundtable, a North American company has about 100 cases of depression for each 1,000 people it
employs. But due to ignorance and the stigma and sensitivity surrounding this illness, only 25 out of every
100 employees will be diagnosed and only six will receive proper treatment. For those six alone, however, a
plan sponsor can potentially save an astounding $10,000 per employee a year in prescription drugs over the
long-term, absenteeism and average wage replacement costs, which are incurred if the incidence becomes a
short- or long-term disability (STD or LTD) case.
The first step plan sponsors can take to foster mental health, say Busse and Wilkerson, is to conduct an
internal communications program on non-physical disabilities to educate employees and senior management on
these illnesses and what services are available to help them, such as an employee assistance program or
coverage for visits to a licensed therapist. These efforts can be as simple as information in a company
newsletter or intranet site.
The next step involves looking inwards, at existing policies and even attitudes towards mental illness.
Ironically, while organizations incur enormous costs with non-physical disabilities, they may be
contributing to them through poor management practices that create unnecessary stress for employees. This,
in turn, can result in anxiety and even depression and aggravate diagnosed ailments that were once well
managed.
Busse says 80% of all STD and LTD claims that he reviews for mental illnesses have evidence of unresolved
workplace problems. "It's a huge driver of disability," he says. A landmark study of British public
employees (known as the Whitehall case) that was first launched in the 1960s, recently confirmed that
psychiatric illnesses increased with poor work environments. On the other hand, a better work environment
was seen as protective--reducing the probability of these conditions from occurring.
Busse says protective management practices include involving employees in decision-making processes when
possible, a conflict resolution system that ensures decisions are not made at the whim of a difficult
manager and regular review of disability management practices. "In one form or another these can usually be
improved," he says.
LOOMING LAWSUITS
With the role of the workplace in fuelling stress-related illnesses now widely acknowledged, plan sponsors
would be prudent to evaluate their practices and work environment in light of a potential lawsuit. While
holding an employer accountable for an individual's depression may sound like a stretch, there is a growing
tendency for our courts to rule that organizations have a duty to be fair to workers.
According to a new report, Best Advice on Stress Risk Management in the Workplace, produced by
Health Canada, Aon Consulting and CHC Working Well, a Canadian legal case directly involving the unfairness
or unreasonableness of stress due to high demand and low rewards is "virtually waiting to happen."
Dr. Deborah Lerner, a medical sociologist at the New England Medical Centre in Boston says that work
accommodation is a hot issue in the U.S. these days as employees with long-standing mental illnesses are
asserting their right to work. "There are lawsuits with people demanding modifications on the job for
depression."
Like Wilkerson, Anne Nicoll, a consultant with William M. Mercer Limited in Toronto, stresses the need for
organizations to develop practices that acknowledge the differences between non-physical and physical
disabilities. "It's much more complicated to accommodate a non-physical illness," says Nicoll. "Some
organizations that have excellent physical disability programs are all of a sudden trying to figure out how
to accommodate somebody who can't make decisions, has trouble interacting with other people or who needs
the employer to adjust the tasks that are assigned to them. That's much more challenging for employers."
Nicoll says plan sponsors must rely on physicians and psychiatrists to understand the ability restrictions
of employees suffering from mental illness and develop a restriction form, which includes cognitive skills.
"Confidentiality is just so important with non-physical disabilities," adds Nicoll. "You don't need to know
if someone is depressed or a paranoid schizophrenic. What you need to know is what this person can do and
what can't they do. The underlying reason is not relevant."
Nicoll offers three key tips to plan sponsors: ensure that work accommodations are available--be it
part-time or new work--stay in touch with the absent employee and offer early assistance. "It's not unusual
to hear employees say 'I didn't hear from anyone at work and I really would have loved to have heard from
someone and known that my job is still there, that they care, that I can come back.' " Nicoll says these
much-needed reassurances should come from the individual's direct supervisor. They shouldn't probe for
information, but simply let the employee know that they are being thought of and that their employer is
there to help them.
Individuals suffering from mental illnesses, even severe ones, don't have to remain on disability if their
conditions are well treated--often with a combination of therapy and medication--and their employers are
supportive. In Sandy Naiman's case, her employer hired her knowing that she had a mental illness, and over
the years, kind words and gestures have gone a long way.
"When I get tired, stressed out, hyper and antsy, my editor will say to me 'you know, I think you need some
time off,'" says Naiman. Her editor has taken her to the hospital on one occasion, and even called her
psychiatrist simply to let the doctor know the company was concerned. "There is no question that their
support has helped me to manage my illness," Naiman adds.
RETURN TO WORK
One of the crucial elements in preventing a mental illness from evolving into a long-term disability case
is an early intervention program and an effective return- to-work strategy. "You want to get to people
while they are still open to choices. In three to six months, they get locked into the lifestyle of
disabled," says Busse. "It's easy to bully people back to work only to have them crash within a month.
That's not what you want to do." He adds that once an individual has had an incident of depression, there
is a 50% chance of a repeat experience, so the plan sponsor must be sure to avoid scenarios such as
bringing the employee back to work full-time immediately to avoid a relapse.
"With [illnesses of the] mind, you may be free of symptoms but your confidence is shot," says Busse. "The
next time [the employee] has a bad day they say 'oh, no, it's happening again.' They don't have the
confidence to ride it out. The solution is gradual return to work, stay in touch with them so you can tell
them it's just a bad day."
In response to the growing number of non-physical illnesses that evolve into short- and long-term
disability cases, Liberty Health of Markham, Ont. has launched an early intervention program for
self-insured plans that encourages employees to return to work.
Currently, the company contacts workers to see how they are coping and to inform them of what support
systems are available once they have been off work for an average of 26 days. Its goal is to eventually
reach everyone within 10 days.
David Willows, director of life and disability for the insurer, says over 90% of the cases using the
program have been resolved without an LTD leave. "These are high-risk cases where the majority of
disabilities are non-physical," he adds.
Several plan sponsors have made a commitment to intervention programs that are resulting in lower STD and
LTD costs, as well as healthier employees.
The government of Alberta implemented an early intervention program for its 19,000 employees two years ago.
When an individual is away for more than 10 days, they are informed of the voluntary initiative. If they
want to participate, an occupational health nurse contacts them, maintaining confidentiality, and informs
them of the early support and recovery assistance program. The nurses work closely with the individuals'
family physicians, counsel family members of the ill employees and inform them of the support services
available. They also work with the supervisors to devise a written return-to-work plan that incorporates
what changes, if any, need to be made to the individuals' work environment or hours.
"Previously, the approach was 'we don't want you to return until you are 100% fit' and then when employees
would come back it was overwhelming," explains Chris Archibald, benefits consultant with the government of
Alberta.
The program has been successful. Sixty-five per cent of the participants returned to work earlier than they
would have if not in it, and the plan sponsor saved $7.40 for each $1 it spent on the initiative. "We have
sent out confidential questionnaires to the participants and they have very positive feedback and say it
definitely impacted their ability to return to work when they did," says Archibald. She adds that of all
the cases in the program, psychiatric illnesses such as depression represent the highest percentage.
The long-term disability trustees of the Halifax-based Nova Scotia Association of Health Organizations
(comprised of employee and employer representatives) started to think about a return-to-work program in
1998 when they faced a $10 million unfunded liability in the self-insured LTD plan accompanied by
increasing use among its 12,000 members, particularly for non-physical disabilities. "The health community
has changed its stance on managing these illnesses, realizing there is more benefit to the individual in
having them work in some capacity through treatment," says Carolyn MacDonald, director of insured benefits.
Today, the association has a new voluntary program that kicks in after an employee has been off for 21
days. Employees can refer themselves to the program as can a fellow co-worker, supervisor or union
representative. Once an individual decides to participate, an assessment is conducted with the employee,
employer as well as a physician, and a plan for return to work is determined. "Our external provider
conducts workplace assessments, whatever obstacles are in the way of them returning to work, we try to
remove," says MacDonald.
The financial objectives of the program are a three-year payback with a long-term goal of 30% decrease in
LTD claims. A recent three-month evaluation reveals there were 27 participants and only four individuals
that moved from STD onto LTD. An internal survey indicates that employees are happy with the effort. "One
response said 'it gave me peace of mind to know that my employer knew what I was going through,'" says
MacDonald. "We've put a lot of emphasis on the qualitative aspects of the program--it's not just about
numbers. It improves morale and our ability to retain and attract the best workers and it sends out a
message that employees are valued and important."
As an individual who suffered from asthma and eczema--two illness that, surprisingly, were once regarded as
so-called social diseases and signs of weakness--Wilkerson is determined to erase the stigma and lack of
understanding that still cloaks mental illnesses today. His determination comes from the realization that
shame and ignorance play a significant role in the management of mental illness, and his firm belief that
these illnesses are the biggest threat to sustainable business performance this century.
"Businesses need a mentally healthy workforce. We have to start investing in mental health at the same
levels we have in plant safety and other health and safety initiatives," says Wilkerson. "We have
disgracefully high levels of mental health disabilities and until we fix them, business will never achieve
the optimal levels of performance and productivity that are needed today."
Defeating depression
The Business and Economic Roundtable on Mental Health urges organizations to develop a business plan for
tackling depression in the workplace. Here is an abbreviated version of the group's 12-step plan.
1. CEO briefing. Brief the chief executive officer and senior management on the impact of depression
and other mental illnesses at work.
2. Financial targets. Set per-employee annual savings targets for reducing prescription drug and
wage replacement costs and making gains in productivity.
3. Policy reform. Establish written policies to support managers in early detection that acknowledge
the need for privacy and sensitivity. Rethink how to improve the effectiveness and use of health programs
such as employee assistance programs.
4. Value health. Make the health of the business and employees dual priorities.
5. Tackle technology. Encourage face-to-face communication as opposed to an overuse of e-mail and
voice-mail, which can overwhelm employees and eliminate much needed human contact.
6. Return to work. Create disability and return-to-work strategies for mental illness and introduce
formal protocols such as modified work programs.
7. Depression connection. Educate managers, human resources and health professionals on the major
health effects of depression such as heart disease.
8. Emotional hazards. Identify and develop a plan to eliminate emotional workplace hazards such as
unclear priorities and excessive office politics.
9. Work-life strategies. Create and implement policies that protect work-life balance among
employees with the goal of reducing illness and absenteeism.
10. Rule out. Differentiate between performance problems stemming from mental illness and those
attributable to an actual deterioration in work.
11. Health index. Create a health index to monitor the status of organizational health and use it
regularly.
12. Transformation. Reduce disability rates by 15% to 25% a year by targeting mental health issues,
improving EAP usage, eliminating unnecessary sources of stress in the workplace and reducing burnout
through specific job and work climate strategies.
Tell-tale signs
Depression is a loosely used term these days. "Frequently, we'll hear colleagues says they feel depressed
because they had a bad day or because they've had a fight with their boss," says Gabor Gellert, supervisor
of clinical quality at CHC Working Well in Mississauga, Ont. However, depression is much more severe than
simply feeling blue or sad, says Gellert, who adds that diagnosed major depression is often debilitating.
Depression can also manifest itself in the form of anxiety and anger. And due to the complex and personal
nature of this illness, physicians say it is significantly under-diagnosed.
The good news is that major depression is treatable. Gellert says recent studies show the best results are
achieved using a combination of psychotherapy--which addresses how people think and cope--and medication.
"Success rates with proper diagnosis and treatment are 80% to 90%," he adds.
Here are some signs that indicate an employee may be suffering from depression or anxiety. Gellert notes
that symptoms of sadness and lack of enjoyment in life must persist consistently for at least two weeks for
a formal diagnosis of depression to be made by a physician.
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Loss of pleasure in things that usually bring happiness.
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Difficulty making decisions and concentrating.
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Decreased productivity and dependability.
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Increase in work errors, accidents, lateness and absenteeism.
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Lack of enthusiasm and problems with morale or co-operation.
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Persistent low or sad mood.
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Decreased energy or fatigue.
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Irritability and/or crying.
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Frequent pessimism.
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Complaints of aches and pain that cannot be explained.
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