Care managers affect worker productivity

Depression intervention with care managers can improve employee productivity and save employers money, according to a study published in the September Journal of the American Medical Association (JAMA).

The study, Telephone Screening, Outreach and Care Management for Depressed Workers and Impact on Clinical and Work Productivity Outcomes: A Randomized Controlled Trial, was conducted by Harvard Medical School, Group Health Cooperative’s Center for Health Studies, and OptumHealth Behavioral Solutions.

It was funded by the National Institute of Mental Health and, according to its authors, was the first study to examine the effect on clinical outcomes and work productivity from an employer-based depression screening, outreach, and treatment program.

The researchers reported that a systematic approach to identify and treat depression improves clinical outcomes and results in higher job retention, decreased sickness, lower work absences, and increased work productivity.

“This study shows that there’s a great benefit not only to the employees but to the employer. It suggests some kind of return on investment,” says one of the study’s authors, Francisca Azocar, PhD, assistant vice president of research and evaluation for Behavioral Health Sciences at OptumHealth Behavioral Solutions in San Francisco.

Azocar says research has shown depression has a great effect in people’s lives in general, and a workplace productivity loss estimated at $30 billion annually.

She adds employers can expect that 6% of their employees are depressed at any given time. A systematic approach to treating depression can have an effect, says Azocar.

“It’s thrilling to be involved in a study that actually is able to show the value of mental health services and depression care not only for employers but for employees as well,” says Azocar, adding that the results show managed care leadership that these kinds of programs are cost effective.

Another author of the study, Philip Wang, MD, director of The National Institute of Mental Health’s Division of Services and Intervention Research in Bethesda, MD, says the recent study shows that an intervention can reduce depression symptoms for employees, improve retention of workers, and save money in the long run.

The high points in the clinical trial’s results were:

➤ Intervention participants enjoyed a 2.6-hour overall work functioning improvement per week than the usual care group

➤ An estimated $1,800 annualized value of higher mean hours worked among intervention participants (based on the median annual salary in the U.S. civilian labor force) exceeds the $100–$400 outreach and care management costs associated with “lower-to-moderate intensity interventions used in the study”

➤ Depression self-report assessment scores were “significantly” better in the intervention group than the usual care group at both the six- and 12-month marks

➤ The percentage of participants whose symptoms improved and experienced recovery were “significantly” higher among the intervention group than the usual care group at the 12-month mark

➤ Intervention group participants were more likely than those in usual care to receive mental health specialty treatment, but less likely to obtain depression treatment in primary care

Azocar says the study found employees were more productive in the intervention group. “What that translated to is about two more weeks of work a year for those in the intervention group,” says Azocar.

Wang was surprised that many in the intervention group chose telephonic therapy rather than the in-person option. He says the intervention was designed to increase people’s use of in-person treatment, but it did not substantially affect the number of people getting in-person therapy. “The consequence of that is that the intervention will ultimately be less expensive,” says Wang. “Most of the increased contacts were with telephone care managers, so it was much less expensive.”

The revelation that the intervention group was more likely to receive mental healthcare from a specialist rather than a PCP pleased Azocar.

“What the research has shown is that treatment of depression in primary care is less than adequate. In part, it’s because [PCPs] are not adequately trained [in depression]. They tend to underdiagnose, underrecognize, and undertreat depression,” says Azocar. “In addition, PCPs have too many things to do in a short amount of time.”

Human capital investments

Wang says the actual ROI is unknown, but further research is planned to take into account duration of improvements, disability payments, overall healthcare expenditures, and hiring and training costs. Wang says the magnitude of the benefits observed suggest that a formal analysis will show the depression intervention program was cost-effective because the program primarily utilized care managers rather than office visits.

The study’s authors wrote that employers should view depression intervention programs as “an opportunity to invest in improving the productive capacity of work forces [referred to by employers as ‘human capital investments’] than as workplace costs.”

Who benefits most?

Azocar says a similar depression program can help anyone and could especially assist those working blue-collar jobs who may struggle with societal stigmas associated with depression. “The study shows that it worked with all different kinds of employees,” says Azocar.

Wang says smaller employers could potentially gain from a depression program. For example, one depressed employee in a small organization might have a greater effect than would a depressed person working in a large corporation. Depression treatment could especially help those in lofty positions, such as CEOs. Having a CEO dealing with depression can affect not only one department but a whole company. That said, Wang warns companies to not just reach out to those at the top of the pyramid.

“That is one of the dangers in this—that you only cherry-pick those who you will get the most bang for your buck,” says Wang. “This looks like it will be beneficial over a wide range of workers.”

Wang is hopeful that employers will learn from the study about how depression intervention programs can help employee health and the bottom line. “I think there’s growing recognition [of the issue of work force depression],” says Wang. “We hope that [the results] will be used by employers in their decision-making. We’ll have to see how impactful they are.”

Wang says study authors will follow the intervention group for 18 months.

The authors are also planning a formal cost-benefit analysis in which they will look within the job sectors and run the numbers regarding worker replacement and turnover rate.

Innerworkings findings

Employee Benefit News and Partnership for Workplace Mental Health’s report Innerworkings: A Look at Mental Health in Today’s Workplace surveyed more than 500 people, including HR and employee benefit managers, from companies of all sizes.

The key findings were:

➤ Respondents said mental illness has more effect on lost productivity, increased absenteeism, and other indirect costs than any other health issue. The top two effects were depression (31%) and back problems (14%).

➤ Less than one-quarter believed that managers in their companies understand the toll mental illness takes on a person and family members.

➤ Two-thirds said their companies do not provide managers with education about mental health issues.

➤ Three-quarters said that employees may not seek treatment because “they do not realize they are ill or believe they can solve the problem on their own.”

➤ Twelve percent of the companies surveyed encourage mental illness screening, whereas 70% suggest mammograms and blood pressure monitoring, nearly half recommend weight management, and one-quarter promote bone density tests.

➤ Eighty percent said that “shame and stigma” may still be associated with mental illness diagnosis.

Surveys used to measure depression

The study, Telephone Screening, Outreach and Care Management for Depressed Workers and Impact on Clinical and Work Productivity Outcomes: A Randomized Controlled Trial, included a randomized controlled trial that surveyed 113,843 employees by using the World Health Organization Health and Productivity Questionnaire (HPQ). Those surveyed included a variety of workers, such as bankers, lawyers, and truck drivers from 16 large companies.

Those who met the criteria for depression via HPQ were contacted by care managers, who conducted further screening using the Quick Inventory of Depression Symptoms Self-Report (QIDS-SR) assessment. A total of 35,169 completed at least one question, and 2,358 (7.7%) were listed as possibly being depressed. A total of 1,422 consented to baseline eligibility assessments. (Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded. They were still contacted about the depression findings and asked to call the managed care organization’s number or talk to their doctors.) A total of 604 employees were randomized into an intervention group or usual care group.

The program included a telephonic outreach and care management program. Care managers, who were master’s degree–level mental health clinicians employed by OptumHealth Behavioral Solutions, contacted those listed as depressed and encouraged them to enter in-person psychotherapy, evaluated patient medication, and provided referral information.

Those who declined the outpatient therapy and/or anti-depressant medication were offered a structured telephone cognitive behavioral psychotherapy and were contacted by care managers weekly or biweekly depending on the severity of their depression.

One of the study’s authors, Francisca Azocar, PhD, assistant vice president of research and evaluation for Behavioral Health Sciences at OptumHealth Behavioral Solutions in San Francisco, says a large part of the care managers’ work was problem solving, such as helping a patient with medication compliance. “The care advocate intervention is all about empowering the member to talk with the doctor,” says Azocar.

Those in the intervention group who declined in-person treatment and still experienced “significant depressive symptoms” after two months were offered an eight-session cognitive behavioral psychotherapy program.

“Sessions included assessment of motivation for treatment and motivational enhancement exercises; focus on increasing pleasant and rewarding activities; identifying, challenging, and distancing from negative thoughts; and creating a personal self-care plan covering medication use, self-monitoring, and self-management skills,” according to the report.

After the initial conversation, all intervention participants were mailed a psychoeducational workbook that emphasized “behavioral activation, identifying and challenging negative thoughts, and developing long-term self-care plans,” according to the study.

Azocar says many preferred the telephonic psychotherapy because of the societal stigma still associated with depression. Study author Philip Wang, MD, director of The National Institute of Mental Health’s Division of Services and Intervention Research in Bethesda, MD, says that stigma could negatively affect an employee’s workplace status—either actual or perceived. He says the in-person treatment is more time-consuming because patients have to set aside time and travel to a doctor’s office. The care managers called during after-work hours so it didn’t affect the patients’ workday.

Alan A. Axelson, MD, cochair of the Partnership for Workplace Mental Health in Arlington, VA, says a health plan does most of the work in a program such as the one developed in this study.

“It doesn’t take much from the employer once they decide to do it and get employees to do the health risk assessment surveys,” says Axelson. He adds that the study’s proactive approach of reaching out to depressed employees is the kind of out-of-the-box thinking needed.

“We need to try different things,” says Axelson. “You can generate action by the health risk assessment to encourage people to deal with their depression when it’s mild to moderate rather than wait for it to become severe.”

Promote employee assistance programs regularly

Employee assistance programs are powerful tools in the fight against depression in the workplace, but they are underutilized.

Alan A. Axelson, MD, cochair of the Partnership for Workplace Mental Health in Arlington, VA, likens the situation to someone who purchases software, loads it onto a computer, and then rarely uses it because he or she can’t understand the program.

Companies must educate their work force about employee assistance programs so that they are used regularly. That’s one way to both educate employees and remove barriers to mental health wellness, says Axelson.

Workplace depression programs allow businesses to intervene in a constructive way rather than letting the issue build into a disciplinary problem. “When that really works, it saves a lot of money, but it takes some consistent effort,” says Axelson.

William L. Bruning, president of the Mid-America Coalition on Health Care in Kansas City, MO, says employers are not routinely training management about depression. Immediate supervisors are a “frontline point of engagement for a depressed” employee. “We figured out pretty quickly that we need to help supervisors at this level to understand what they were encountering, what they needed to do going about addressing it, and give them some level of comfort to open dialogue to help the employee address these issues that had such an impact on the work unit.”

Problem understood, but programs lacking

Employee benefit managers understand the effect depression has on productivity and the bottom line. In fact, mental health illness is among the most costly health issues for employers. But many of those same managers have not created programs that target depression, according to a recent study.

“Though most employers understand depression’s impact, there is still a disconnect when it comes time to create programs,” says Francisca Azocar, PhD, assistant vice president of research and evaluation for Behavioral Health Sciences at OptumHealth Behavioral Solutions in San Francisco.

Employee Benefit News and the Partnership for Workplace Mental Health released a study in May, Innerworkings: A Look at Mental Health in Today’s Workplace, about depression’s effect on the work force and employers’ response to the issue.

The survey of more than 500 people found most employers understand the problems associated with depression but have not implemented benefits and education programs to tackle the issue.

“If employers are going to be concerned about their work force at all, they need to be concerned about the mental health of their work force as they are concerned about the physical health of their work force,” says Alan A. Axelson, MD, cochair of the Partnership for Workplace Mental Health in Arlington, VA.

One barrier in creating depression intervention programs is that employers are afraid of violating employee privacy. “Employers are very loath to get into the personal lives of their employees,” says William L. Bruning, president of the Mid-America Coalition on Health Care in Kansas City, MO. “HIPAA has exacerbated that.”

Philip Wang, MD, director of The National Institute of Mental Health’s Division of Services and Intervention Research in Bethesda, MD, says employers realize the detrimental results of workplace depression: absenteeism, presenteeism, accidents, and lost productivity, but they are not necessarily sold on the cost savings involved with depression programs.

“The question in employers’ minds is, ‘Can you do anything about it? Yes, it’s costly to me, but can you show you can actually recover those [costs] or not?’ ” says Wang.

In order to spark employers to tackle depression costs, studies will need to shed light on whether interventions can have a positive monetary benefit. “They’re businesses at the end of the day, and they invest their resources in things that are going to positively impact productivity and the bottom line,” says Wang.

One way for employers to understand the effect depression is having on productivity is through the Partnership for Workplace Mental Health’s calculator. The software program allows businesses to input their work force’s characteristics, including age, sex, and number of employees. The calculator analyzes those numbers and develops depression’s monetary impact, taking into account absenteeism, disability, presenteeism, and prescription costs.

The Partnership for Workplace Mental Health is also developing a page on its Web site ( that will collect employer depression programs into a database.

Mary Claire Leftwich, program coordinator at the Partnership for Workplace Mental Health, says the free Web-based page was slated to launch in mid-November. The Employer Innovations Online program listings will include location and size of company, depression issues, why solutions were needed, and program specifics.

“Business is necessarily driven by the bottom line, so we, right out of the gate, highlight the return on investment,” says Leftwich.

When Disease Management Advisor spoke to Leftwich at the end of October, she said the Web-based tool included 25 programs, encompassing small to large companies from many parts of the country.

Axelson is hopeful employers will utilize the new Web resource when creating depression programs and other initiatives to address mental health.

“An HR person can go to their bosses and say, ‘This is what they are doing at JPMorgan Chase or Pitney Bowes. They’ve got a problem similar to what we have, this is the cost, and this was the outcome,’ ” says Axelson.

Another organization tackling workplace depression is the Mid-America Coalition on Health Care. Its focus began in 1999, the same time period during which reports that recognized depression’s hidden costs for absenteeism, productivity, and disability were released. The depression initiation, which included 15 employers, representing more than 140,000 lives, was created to review healthcare costs in terms of productivity and employee health.

Health plans urged the coalition to tackle depression, which the managed care companies viewed as the number one healthcare cost because of prescription costs, comorbid disease, and presenteeism, says Bruning.

“We put these emerging concepts in front of [employers]. It was remarkable they got it. There is something very intuitive about depression’s impact on the workplace that the employers usually get,” says Bruning.

Bruning compares depression to obesity in terms of society’s views about the health issues. People once thought depressed and obese people only needed to “pull themselves up by their bootstraps” and turn their lives around. ow, society understands the effect of both diseases and that there is more than intestinal fortitude required to fight the ailments.

The Mid-America Coalition on Health Care is working to educate not only employers but the work force in general. After five years of work conducted by 14 employers, its Web site ( includes depression resources for medical professionals, work-site supervisors, and employees.




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