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IJWHM
1,2 The association of worker
productivity and mental health:
a review of the literature
78
Wayne N. Burton
University of Illinois at Chicago, Chicago, Illinois, USA, and
Alyssa B. Schultz, Chin-Yu Chen and Dee W. Edington
The University of Michigan Health Management Research Center,
Ann Arbor, Michigan, USA

Abstract
Purpose Depression and other mental health disorders have a large impact on the quality of life
and productivity of millions of individuals worldwide. For employers, mental health disorders are
associated with increased health care costs as well as productivity losses in the form of absenteeism,
short-term disability absences and reduced on-the-job productivity-known as presenteeism. The
purpose of this paper is to review the association of worker productivity and mental health.
Design/methodology/approach This review summarizes the literature on the prevalence of
mental health conditions among working adults, and the association between these disorders and
productivity. Finally, the impact of interventions or workplace policies on the productivity of those
suffering with mental health conditions is covered and recommendations for employers are suggested.
Findings Depressive disorders are relatively common in most workforces compared to other
mental health conditions. The majority of studies on mental health and productivity have been
conducted as part of nationwide surveys or in patient populations rather than worksites. The majority
of studies show associations between mental health conditions and absenteeism (particularly
short-term disability absences). When presenteeism is measured by a validated questionnaire, results
show that depression significantly impacts on-the-job productivity (presenteeism). Studies also
indicate that the treatment expenditures for employees with depression may be offset by reductions in
absenteeism, disability and on the job productivity losses.
Originality/value Workplace policies and benefits which support employees suffering with
mental health disorders and provide access to evidenced-based care adhering to best practice
guidelines may improve the quality of life of employees and lead to reduced absenteeism, disability
and lost productivity.
Keywords Mental health services, Depression, Employee productivity, Absenteeism
Paper type Literature review

Introduction
Mental health disorders are a growing major global health problem affecting the health
and productivity of millions of individuals. The most common mental health disorder,
depression, is a major health problem around the world with a lifetime prevalence
ranging from 2 percent to 15 percent (Murray and Lopez, 1996). Depression accounted
International Journal of Workplace for 4.4 percent of disability-adjusted life years (DALYs) in 2000, which was the fourth
Health Management leading cause of disease burden. In 2020 depressive disorders are projected to be the
Vol. 1 No. 2, 2008
pp. 78-94 second leading global cause of disease burden after heart disease (Murray and Lopez,
q Emerald Group Publishing Limited
1753-8351
1996). The WHO World Health Survey cross-sectional study of 245,404 adults aged 18
DOI 10.1108/17538350810893883 years and older in 60 countries reported the overall one-year prevalence for ICD-10
depressive episode alone was 3.2 percent. That compares with other medical conditions Worker
such as 4.5 percent for angina pectoris, 4.1 percent for arthritis, 3.3 percent for asthma, productivity and
and 2.0 percent for diabetes mellitus (Moussavi et al., 2007).
The reported prevalence of depressive disorders varies between countries. For mental health
example, major depression affects 6.6 percent of the adult US population in any one year,
while depressive disorders in Americans have a lifetime prevalence estimated at 16
percent (Kessler et al., 2003). In contrast, a Canadian population-based survey found that 79
4.6 percent of adults met the criteria for major depressive episodes (Blackmore et al.,
2007), while 4 percent of employed adults had a depressive episode in the previous year
(Gilmour and Patten, 2007). But depression is not just a problem affecting North
America. A study in The Netherlands found that 4.8 percent of working adults had major
depressive disorder (Laitinen-Krispijn and Bijl, 2000) while in Australia, the one-month
prevalence of depression was found to be 2.2 percent (Lim et al., 2000). A review of
prevalence studies of mental health conditions found that depression and simple phobias
were the most prevalent disorders in working populations around the world (Sanderson
and Andrews, 2006). See Table I for a list of the prevalence rates of mental health
conditions among working adults in various countries.
Depressive disorders are associated with increased morbidity and mortality. For the
employer, these conditions result in increases in disability (Murray and Lopez, 1996;
Michaud et al., 2001) as well as several workplace outcomes such as absenteeism, lost
on-the-job productivity (known as presenteeism), and increased health care costs (US
Department of Health and Human Services, 1999) The economic costs posed by
depression are estimated in the tens of billions of dollars, due largely to on-the-job
productivity losses (Greenberg et al., 1996; Kessler and Frank, 1997). Research
indicates that depressive disorders for many employers may be one of the most costly
of all health conditions (Burton et al., 1999; Druss et al., 2001; Kessler et al., 2001;
Stewart et al., 2003; Wang et al., 2003). Greenberg et al. (1993) estimated the annual cost
to employers in the USA for major depression was $43.7 billion in 1990 in terms of
work loss and reduced productivity. In The Netherlands, productivity losses
associated with mental health problems were estimated at e9.4 billion in 2004
(Rebergen et al., 2007). Depression costs in Sweden have doubled from 1997 to 2005 and
the costs of sick leave and early retirement due to depression were about e3 billion in
2005 (Sobocki et al., 2007).
But depression isnt the only mental health problem affecting working-age people.
The impact of other mental health conditions, such as bipolar disorder, may be even
more significant. While the prevalence of bipolar disorder is comparatively smaller (1.3
percent 12-month prevalence in a US community cohort; Kessler et al., 1994), employees
with bipolar disorder had 65.5 lost workdays compared to 27.2 lost workdays for
employees with major depressive disorder (Kessler et al., 1994). Another US study
found that employees with bipolar disorder had significantly greater sick leave,
short-term disability, and long-term disability absences compared to those without
bipolar disorder (Gardner et al., 2006). The cost of lost productivity associated with
schizophrenia in England was estimated to be 3.4 billion in 2004, but that estimate
includes lost wages due to unemployment in addition to absenteeism (Mangalore and
Knapp, 2007) The prevalence of absenteeism due to mental health problems in general
is reported to be between 10 and 18 percent (Wang et al., 2006). Productivity losses
associated with mental health conditions are shown in Table II.
 1,2

80

Table I.
IJWHM

employed adults
Prevalence of mental
health conditions among
Prevalence
Condition Study author(s) Country Year(s) of study Type of prevalence (percent)

Major depression Lim et al. (2000) Australia 1997 One month 2.2
Laitinen-Krispijn and Bijl (2000) The Netherlands 1996 One year 4.8
Kessler and Frank (1997) USA 1990-1992 One month 4.4
Berndt et al. (2000) USA 1993-1995 30 month 7.4
Dysthymia Lim et al. (2000) Australia 1997 One month 0.4
Laitinen-Krispijn and Bijl (2000) The Netherlands 1996 One year 1.5
Kessler and Frank (1997) USA 1990-1992 One month 0.5
Bipolar disorder Gardner et al. (2006) USA 2001-2002 One year 0.3
Anxiety Lim et al. (2000) Australia 1997 One month 1.4
Dewa and Lin (2000) Canada 1990-1991 One month 2.6
Wang et al. (2003) Canada 2003 One year 4.2
Kessler and Frank (1997) USA 1990-1992 One month 1.5
Berndt et al. (2000) USA 1993-1995 One month 4.3
Panic disorder Lim et al. (2000) Australia 1997 One month 0.2
Laitinen-Krispijn and Bijl (2000) The Netherlands 1996 One year 1.4
Kessler and Frank (1997) USA 1990-1992 One month 1.3
Study author(s) Study population Type of condition Type of productivity Results

Adler et al. (2004) Primary care patients Dysthymia Absenteeism, No difference in absences. Significantly greater
presenteeism presenteeism for employees with dysthymia compared to
controls
Adler et al. (2006) Primary care patients Depression, Presenteeism Depressed employees had significantly more presenteeism
dysthymia than controls. Changes in depression severity correlated
with presenteeism
Berndt et al. (2000) Insurance claims Depression, anxiety, Absenteeism, No difference found in presenteeism. Depression plus
processors other objectively measured another mental health condition had 37 percent more
presenteeism annual absence days than those with no disorders
Buist-Bouwman et al. Adults in The CIDI-diagnosed Self-reported work Mental disorders more often associated with work loss
(2005) Netherlands mental health loss than physical disorders
disorders
Burton et al. (1999) Telephone customer Mental health Illness absence, STD Employees with a mental health STD had significantly
service employees diagnosis for STD absence, objective greater illness absence and STD absence average hours
productivity measure per week compared to other employees with STD, but no
difference in presenteeism
Conti and Burton Financial services Depression STD absences Depression STD absence duration greater than for other
(1994) employees health conditions such as heart disease or diabetes.
12-month recidivism rates also higher for depression
compared to other conditions
Egede (2007) US National Health Depression plus other Days in bed due to Those with depression plus a chronic medical condition
Interview Survey chronic health illness, functional had significantly greater odds of days in bed (OR 1:60)
conditions disability and functional disability (OR 2:48) compared to those
with no conditions
Kessler et al. (1999) Two US national Depression STD absences Those with depression were 1.5 times as likely (95 percent
surveys CI 1.3-1.6) to incur an STD absence compared to those
without depression. The average number of disability
days was 7.6 for depressed employees compared to 4.7 for
other people
(continued)
Worker

health conditions
Productivity losses
mental health
productivity and

associated with mental

81

Table II.
 1,2

82

Table II.
IJWHM

Study author(s) Study population Type of condition Type of productivity Results

Kleinman et al. (2005) Multi-employer BPD Absenteeism, Those with BPD had 11.5 additional absence days and 20
database presenteeism percent greater presenteeism compared to those without
BPD
Laitinen-Krispijn and Employed adults in Depression, Absenteeism Significantly greater odds of absenteeism for men with
Bijl (2000) The Netherlands dysthymia, anxiety depression, dysthymia, and anxiety. Results for women
not significant
Lerner et al. (2004a) Employed adults Depression, Absenteeism, Depressed individuals had 11.4 percent presenteeism
dysthymia presenteeism compared to 6.6 percent for those with dysthymia and 2.6
percent for controls. Absence days in past two weeks:
depression 2:2 days, dysthymia 1:4 days, controls
0:6 days
Lerner et al. (2004b) Employed adults Depression, Presenteeism Four percent presenteeism for healthy controls compared
dysthymia to 6 percent for dysthymia and 10 percent for depressed
employees
Munce et al. (2007) Canadian Community Depression Absenteeism Nineteen percent of absent individuals had depression
Health survey compared to 8 percent of those who were not absent
Secnik et al. (2005) Multi-employer Adult ADHD Absenteeism, 4.33 work loss days for those with ADHD compared to
database workers 1.13 for other employees
compensation, STD
Stewart et al. (2003) Employed adults Depression Absenteeism, Depressed employees lost 5.6 hours per week compared to
presenteeism 1.5 hours for controls. 81 percent of lost time due to
presenteeism, 19 percent due to absenteeism
Stein et al. (2005) Primary care patients Anxiety disorders, Functional status, Depression, panic disorder, PTSD and phobia
depression absence days significantly associated with disability and functional
status. GAD had no impact above that of depression
The purpose of this review is to summarize the literature regarding the association Worker
between mental health conditions and worker productivity, an area which is receiving productivity and
significant attention from employers and governments around the world. Our purpose is
to provide a literature review demonstrating the global economic impact of mental health mental health
conditions on workplace productivity. Published research studies have focused on the
association of mental health conditions with incidental absenteeism and short-term
disability outcomes, while the more recent literature has investigated presenteeism. 83
Other researchers have combined several measures of productivity in an attempt to
quantify the full impact of mental health on workplace productivity. Secondly, we review
studies of workplace strategies and interventions that attempt to improve productivity
for employees suffering with mental health problems. While the bulk of research is on
depression, other mental health conditions will be covered as well.

Depression
Major depression is associated with a significant increase in both absenteeism and lost
worker productivity (presenteeism) (Sanderson and Andrews, 2006). Studies have
indicated that major depression is one of the most impairing conditions in the USA in
regards to work loss and decreased worker productivity (McCunney, 2001; Berndt et al.,
2000). For an individual employer, the financial burden of mental health disorders such
as depression is derived from medical claims data where indirect costs go largely
unmeasured. Nearly 15 years ago, Conti and Burton summarized the productivity costs
of depression at a financial services corporation (Conti and Burton, 1994). They found
that depression was associated with more disability absences and a larger disability
relapse rate compared to other medical conditions. Depressive disorders were also the
most frequent diagnosis encountered in the companys employee assistance program
(Conti and Burton, 1994). Since that time, the recognition of depression and other
mental health conditions among employees has grown.
The National Comorbidity Survey found that 59 percent of the 30 million US adults
with lifetime prevalence of major depressive disorder (MDD) were severely impaired in
their ability to perform social roles and, on average, were unable to work 35 days in the
past year (Kessler et al., 2003). Furthermore, researchers estimated that $32 billion in
lost productive work time is attributed to depression, which is time unable to go to
work and time at work unable to perform the job (Stewart et al., 2003).
Data from the 1999 National Health Interview Survey (NHIS) were analyzed by Egede
(2007). The 12-month prevalence and adjusted odds of major depression were calculated
for adults with a variety of health conditions such as hypertension or diabetes. The
randomly selected study sample of 30,801 was weighted in order to be nationally
representative of the USA. One component of the NHIS is a valid and reliable diagnostic
interview for major depressive disorder. In this study, lost productivity was defined as
days absent from work due to illness and days in bed for most of the day due to illness.
Several questions addressing functional disability were also included. Individuals with
at least one of seven medical conditions were significantly more likely to also have major
depression compared to those without a medical condition (8.8 percent versus 4.8
percent, OR 2:61). Compared to individuals with no chronic medical conditions, those
with chronic conditions plus major depression had significantly greater odds of
ambulatory visits (OR 1:50), ER visits (OR 1:94), days in bed due to illness
(OR 1:60) and functional disability (OR 2:48).
IJWHM Data from two national surveys (the National Comorbidity Survey and the Midlife
1,2 Development in the United States Survey) were analyzed in order to estimate the
association between major depression and short-term disability in the past month
among American workers (Kessler et al., 1999). After combining the results from the
two surveys, 45.9 percent of depressed employees had any short-term disability
compared to 19.9 percent of other employees. After adjusting for confounders, those
84 with depression were 1.5 times as likely (95 percent CI 1.3-1.6) to incur an STD absence
compared to those without depression. The average number of disability days was 7.6
for depressed employees compared to 4.7 for other employees.
Depression and work productivity is an issue in other countries as well. Munir et al.
(2005) studied work limitations in a UK university employee population. Respondents
with depression and anxiety reported the most significant work limitations compared
with employees with a variety of other chronic medical conditions. A Canadian study
examined the combined impact of depression and chronic pain on work absenteeism.
Over nine million individuals who reported at least one chronic pain condition were
included in the study. Of those with an illness or disability absence from work in the
previous week, 19 percent met the criteria for major depression compared to only 8
percent of those who were not absent (Munce et al., 2007).
Some studies have examined the impact of dysthymia, a lesser severity of
depression. When 69 patients diagnosed with dysthymia but not MDD were compared
to 175 depression-free controls, the patients with dysthymia had significantly less
stable work histories and a greater frequency of significant problems at work. Absence
rates were not significantly different but those with dysthymia had significantly
greater on-the-job productivity loss (6.3 percent versus 2.8 percent, p , 0:001)
compared to controls, as measured by the Work Limitations Questionnaire (WLQ)
(Adler et al., 2004).
The WLQ measures the impact of health conditions and their treatment on job
performance with 25 questions. The questionnaire assesses presenteeism in terms of
overall productivity as well as four different scales (time, output, mental/interpersonal
and physical). This questionnaire was developed by Lerner and colleagues and has
undergone validity and reliability testing (Lerner et al., 2001, 2003). To date, the
questionnaire has been used in general employee populations, as well as different
patient populations with depression (Lerner et al., 2004a). Employees with major
depressive disorder or dysthymia had significantly greater presenteeism compared to
control groups (those with rheumatoid arthritis and a second group of healthy
controls). Depressed employees had significant work impairments for
mental-interpersonal, time and output tasks while those with rheumatoid arthritis
had greater limitations in managing physical job demands (Adler et al., 2006). A
comparison study evaluated the WLQ and the Stanford Presenteeism Scale to see
which presenteeism measure was most sensitive to differences between those with and
without depression and or anxiety. The WLQ showed worse productivity as
depression severity increased and was most sensitive to changes in depression and
anxiety over six months (Sanderson et al., 2007).
As anticipated, the effects of depression on productivity increases as the severity of
depression increases (Lerner et al., 2004a). Furthermore, productivity at some types of job
can be impacted more by depression than at other jobs (Lerner et al., 2004b). Depressed
individuals in sales, service, or support jobs were impaired in their ability to handle
mental and interpersonal demands compared to controls. The WLQ scales of time and Worker
output were significantly worse when employees had jobs involving judgment and productivity and
communication skills. A high level of interaction with customers was associated with
poor mental-interpersonal and physical scale scores (Lerner et al., 2004a). mental health
Another study compared presenteeism and other work outcomes among employed
depressed patients compared to healthy patients and a group with rheumatoid
arthritis, which frequently causes work disability. The WLQ was used to assess 85
presenteeism during the previous two weeks. Patients with dysthymia or MDD
averaged presenteeism losses between 6 and 10 percent compared to 2 percent among
the arthritis patients and 4 percent among the healthy controls (Lerner et al., 2004b).
Depressed patients were significantly limited in their ability to perform mental and
interpersonal tasks compared to the other groups (p , 0:001). Time management was
also significantly affected in the depressed patients as was their total work output
(p , 0:001). Physical job aspects were significantly more limited in the arthritis
patients compared to the depressed patients (p , 0:001). Even though all subjects were
employed at baseline, since this study population was drawn from a medical clinic
rather than a worksite, it may not be representative of most worksite populations.

Other mental health conditions

Berndt et al. (2000) examined the health care resource utilization and at work
productivity for employees with and without anxiety and other mental health disorders.
The authors studied 2,222 workers at a large US insurance claims processing company
at multiple nationwide locations. Inpatient, outpatient and pharmaceutical medical
claims and objective productivity information on these workers were analyzed. The
number of medical claims processed by each worker each day measured worker
productivity. Over a 30-month time period, 14.9 percent of the workers were diagnosed
with a mental disorder, with the most prevalent disorder being depression (7.4 percent).
Although workers with mental health disorders accounted for less than 15 percent of the
population, they accounted for 31 percent of all worker medical costs. No significant
difference was noted in annualized absenteeism for workers with and without a
diagnosed mental health disorder, with the exception of workers with depression plus
another mental health disorder. On-the-job worker productivity also demonstrated no
difference for workers with and without a mental health disorder.
In a study of telephone call center workers, Burton et al. (1999) found a difference in
worker productivity for employees who had returned from a short-term disability absence
for a mental health disorder but the difference was not as great as for other medical
disorders such as diabetes mellitus. How can the finding that workers with mental health
disorders have relatively normal at-work job productivity be explained? One possible
explanation is that workers treated for mental health disorders have effective treatment
and the productivity of these workers reflects the improvement of productivity from such
therapy. In fact a recent literature review supports such an explanation (Mintz et al., 1992).
Four clinical trials in the 1980s documented a significant reduction in the prevalence of
self-reported decreased at work productivity with treatment for mental health disorders
(Brady et al., 1997). Such research is important for benefit plan design decisions in regard
to parity for mental health benefits (Goetzel et al., 2002).
Other mental health conditions such as anxiety disorders also show an association
with poor functioning and sick days from work. Four hundred eighty adults visiting an
IJWHM outpatient clinic were classified as having panic disorder, social phobia, post-traumatic
1,2 stress disorder or generalized anxiety disorder with or without major depression. In
multivariate regression analyses adjusting for confounders, panic disorder,
post-traumatic stress disorder and social phobia were significantly associated with
functioning and absence days from work. Generalized anxiety disorder had little
impact over and above the impact of major depression (Stein et al., 2005).
86 In a Dutch study of 7,076 working-age adults, the combination of physical ailments
and mental disorders were examined in terms of their impact on work loss
(Buist-Bouwman et al., 2005). All physical disorders except accidental injury were
significantly related to anxiety and mood disorders. Mental disorders were even more
significantly associated with work loss than physical disorders. The combination of
physical and mental conditions was associated with an additive increase in
absenteeism.
Bipolar disorder (BPD) is a serious mental health condition affecting about 5.7
million American adults in a given year (Kessler et al., 2005) and is more prevalent in
the working ages of 18 to 54 than in older age groups (Narrow et al., 2002). Episodic
conditions such as bipolar disorder can have a varied impact on work functioning,
including interpersonal problems, lack of continuity in work history, work loss, lack of
appropriate benefits for illness management and stigma and disclosure problems
(Michalak et al., 2007). In a manufacturing setting, the association of BPD with
presenteeism was measured in terms of the number of units processed per hour worked
using real output data (Kleinman et al., 2005). Results showed that employees with
BPD processed significantly fewer units per year compared to healthy employees. The
average number of units produced by BPD employees was 28,205 compared to 35,665
for the rest of the employees. Employees with BPD also had significantly more
absenteeism compared to other employees.
Another topic of recent interest in the mental health field is adult attention-deficit
hyperactivity disorder (ADHD). One study of a large claims database matched ADHD
cases with demographically matched controls. A subsample of the database had
absence, workers compensation and short-term disability data available for analysis.
After controlling for comorbidities including bipolar disorder and depression, adults
with ADHD had significantly higher work-loss days than those without ADHD (4.33
versus 1.13, p , 0:0001) (Secnik et al., 2005).

What can employers do?

Langleib and Kahn (2005) point out that many corporations do not yet understand the
high productivity and specifically presenteeism cost of mental health conditions
among their employees. They reason that it is crucial to provide quality mental health
care benefits to help employees and to moderate costs, particularly since it has been
shown that those who receive appropriate care for their anxiety or depression have less
disability and greater productivity.
Unfortunately, for many reasons, less than half of individuals who meet the criteria
for diagnosis for depressive disorders receive any treatment and only about one-third
of those receive minimally adequate treatment (Wells et al., 1989). There are a variety
of treatment options currently available for depressive and anxiety disorders with
response rates to medication and or psychotherapy that may approach 80-90 percent
(Wang et al., 2000). Nevertheless there remains significant treatment gaps from
evidenced based medicine guidelines for both of these medical conditions (Wang et al., Worker
2002; Young et al., 2001). productivity and
Based on the large potential economic impact of mental health conditions it is
surprising that widespread employee depression screening and treatment programs mental health
have not been embraced by organizations worldwide (Frank et al., 2003; Pincus et al.,
2003). Because few controlled trials have evaluated effects of such programs on work
outcomes in a workplace sample, corporate medical directors may still be unsure of the 87
return on investment of such programs (Wang et al., 2003). One recent
community-based study of treatment for people with anxiety and affective disorders
actually found an inverse relationship between treatment for those disorders and
employment and work performance in Australia (Waghorn and Chant, 2007). However,
the cross-sectional design of that study and the single question used to assess
treatment, Are you currently receiving treatment for a nervous or emotional
condition?, gave no indication of the quality or type of treatment received and may
actually have been an indicator of condition severity (Waghorn and Chant, 2007).
It may be difficult for employers to identify which depression treatment indicators
available in administrative medical, disability and pharmaceutical claims databases
are most useful in assessing quality of treatment. One study of 230 employees in five
health plans evaluated treatment indicators during the first six months of a new
depression treatment episode and compared them with self-reported absenteeism over
12 months. While the medication indicator was not significantly associated with
absenteeism changes, the psychotherapy indicator was associated with a 26.1 percent
improvement in absenteeism over 12 months (Rost et al., 2005). More recently Burton
et al. (2007) reported that adherence to antidepressant medications for employees in a
major US financial services corporation was associated with fewer short-term
disability events compared with non-adherent employees.
A comprehensive review of depression treatment studies was conducted by Simon
et al. (2001). After examining a wide variety of published work on the topic, the results
suggested that aggressive outreach and treatment of depressed employees could lead
to productivity savings that outweigh the costs of treatment. A community-based
study found similar results. That is, the estimated cost of depression treatment could
be offset by the savings yielded by a reduction in lost work days (Zhang et al., 1999).

Interventions
Since return-to-work programs for employees with musculoskeletal disorders have
been researched and analyzed for many years, Briand et al. (2007) drew parallels from
those types of programs and suggested applications to mental health conditions. One
program the Therapeutic Return to Work (TRW) program was determined to
include all the necessary components for application to mental health conditions.
Specifically, the program addresses psychological factors such as perception of health,
psychological distress, substance abuse and expectations about return to work; the
work environment such as task content, social relationships at work and the work
organization culture; and factors related to the various stakeholders such as the
interactions between the health care system, the compensation system and the work
environment. Application of the model to eight cases led to the identification of four
crucial steps in return-to-work for employees dealing with a mental health condition.
They are:
IJWHM (1) identify levers and obstacles to return-to-work;
1,2 (2) developing the readiness to commit to returning;
(3) support active mobilization; and
(4) maintaining work (Briand et al., 2007).

A randomized controlled trial of 604 employees covered by a behavioral health plan

88 evaluated a telephonic outreach and care management program that encouraged
workers to enter outpatient treatment for depression (Wang et al., 2007). In a two-stage
screening process, the Quick Inventory of Depressive Symptomatology (QIDS)
assessed depression severity while the World Health Organizations Health and
Productivity Questionnaire (HPQ) measured job retention, time missed from work,
work performance and critical workplace incidents. After one year, the intervention
group had significantly lower QIDS scores, significantly higher job retention and
significantly more hours worked compared to the usual care groups (Wang et al., 2007).
Unfortunately many employees with depression fail to reach full remission of their
symptoms of depression. There are many reasons for treatment failure including
non-adherence with medication, treatment resistant depression and inappropriate
medication or medication dosage. The benefits of achieving full remission of
depression in a patient population in Sweden were evaluated by Sobocki et al. (2006).
After treatment with antidepressant therapy, 52 percent of patients achieved full
remission (defined as having an improved or very much improved score on the Clinical
Global Impression-Severity score, combined with a clinical judgment by the treating
doctor of being in full remission) and incurred significantly fewer sick days (22 fewer
days, p 0:01) and significantly lower total costs compared to non-remitting patients
(Sobocki et al., 2006).
A cost-benefit model was constructed to determine the impact of enhanced
treatment for depression compared to usual care. Data from a randomized controlled
trial were applied to a model with various assumptions about employment. In the first
year after treatment the net cost savings of treatment in terms of absenteeism and
presenteeism was about $30 per employee and increased to $257 per employee in the
second year after treatment (LoSasso et al., 2006a, b).

Workplace policies and medical benefit plan design

It is important for organizations and corporate medical directors to ensure that the
workplace policies and medical benefits are appropriately designed to help employees
with mental health problems receive proper care (Burton and Conti, 2008). The impact
of a mental health benefit design that included reduced co-payments for mental health
treatment, added a selective contracting network, and included efforts to destigmatize
mental illness were assessed in a large US corporation (LoSasso et al., 2006a, b). Entry
into treatment and the number of outpatient therapy visits were measured for
intervention employees (n 214; 517) as well as a group of controls (n 96; 365).
These benefit changes were associated with a 26 percent increase in the probability of
initiating depression treatment and patients in the intervention group received on
average 1.2 additional therapy visits (p , 0:0001) once they began treatment compared
to controls (LoSasso et al., 2006a, b). A large observational database study in Canada
found that recommended first-line pharmaceutical agents and recommended doses
were significantly associated with return to work and a shortened disability episode Worker
(Dewa et al., 2003). productivity and
An intervention to improve primary care depression management was tested to
evaluate changes in absenteeism and productivity at work. Clinics were randomized to mental health
enhanced or usual care for depression and observed for two years. Employed patients
in the enhanced care practices reported 6.1 percent greater productivity and 22.8
percent less absenteeism over the study time period (Rost et al., 2004). 89
The addition of occupational therapy to a traditional outpatient treatment program
for major depression did not improve depression outcome but did show a reduction in
work-loss days and did not increase work stress and had improved cost-effectiveness
compared to the treatment program alone (Schene et al., 2007). A Dutch study found
that communication between the occupational physician and the general practitioner
was very poor for employees on sick leave for mental health problems and took place in
only 8 percent of cases. Agreement on diagnosis, main case of sickness absence and
return to work strategies between the two physicians was also poor (Anema et al.,
2006). The authors suggest that improved communication between occupational
physicians and general practitioners and a combined approach would lead to better
care for employees.
Corporations would also be wise to offer strategies to employees who are not yet
experiencing clinical levels of mental health problems. In one Canadian study, the Mini
International Neuropyschiatric Interview and the World Health Organizations
Disability Assessment Schedule were applied to 4,149 employed adults. Results found
that while 6.0 percent had at least one psychiatric diagnosis with clinically significant
interference, a much larger 33.5 percent had a psychiatric syndrome without clinical
interference criteria and showed a strong association with disability (Wang et al., 2006).
After a focus group study of workers with mental health problems in the UK, the
authors recommend the following workplace practices:
.
that mental health issues are included in health and safety training;
.
that organizations conduct risk assessments related to mental health,
maintaining workers with anxiety and depression at work or rehabilitating
workers after absence requires coordination between managers and the
occupational health staff; and
.
that communication between health care professions and employers is important
(Haslam et al., 2005).

Conclusions
Mental health conditions pose a significant opportunity for employers to improve the
health and productivity of their workforce. Depressive disorders are relatively common
in most workforces compared to other mental health conditions such as bipolar
disorder and phobias. While a large number of studies on mental health and
productivity have been published, the majority have been conducted as part of
nationwide surveys or in patient populations rather than examining the prevalence in
the workplace. With a few exceptions, the majority of studies show significant
associations between mental health conditions and absenteeism (particularly
short-term disability absences). When presenteeism is measured by a validated
questionnaire such as the WLQ or HPQ, results indicate that depression significantly
IJWHM impacts on-the-job productivity (presenteeism). Studies also indicate that the treatment
1,2 expenditures for employees with depression may be offset by reductions in
absenteeism, disability and on the job productivity losses. Workplace policies and
benefits which support employees suffering with mental health disorders and provide
access to evidenced-based care adhering to best practice guidelines may improve the
quality of life of employees and lead to reduced absenteeism, disability and lost
90 productivity.

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Dee W. Edington can be contacted at: dwe@aumich.edu

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