old adage of take two pills and call me in the morning
apparently doesnt apply to depression anymore. Increasingly,
those who suffer from depression are taking the pillsbut
forgoing follow-up visits to mental health professionals. That
treatment strategy leaves a lot to be desired and creates significant
potential legal and productivity problems for human resource professionalsespecially
since incidents of depression are on the rise.
is increasingly the reason stated by employees requesting leaves
of absence, disability benefits, job changes and reasonable accommodations.
There are nearly twice as many employees stating depression
as their primary diagnosis [by physicians] for 2001 as in 1999,
says Roslyn Stone, COO of Corporate Wellness Inc., a national
occupational health service provider headquartered in Mount Kisco,
effect on the workforce is both broad and deep.
affects an estimated 10 percent of American adults annually, according
to a 1999 study by the National Institute of Mental Health. And
eight out of 10 HR professionals responding to the 1999 SHRM Depression
in the Workplace Survey said depression had been a problem for
one or more employees during the past three years.
The survey also estimates that depression costs employers between
$30 billion and $40 billion per year. Depression is a tremendous
cost to the employer in terms of lost productivity, agrees
Robert L. Leahy, Ph.D., director of the American Institute for
Cognitive Therapy in New York. Depressed employees are more
likely to be absent from work, less creative, more argumentative,
[and] more likely to lose their jobs, he says.
youre depressed, you feel isolated. You carry on tasks at
work like a dead person, says A. B. Curtiss, a cognitive
behavioral therapist from Escondido, Calif., who has suffered
from depression. You feel like youre in a dense psychological
fog. Your body feels unresponsive.
Depressed individuals also may have trouble interacting with others.
As you draw away from people, you get frustrated and panicked.
You think people dont care and you start treating people
in an aggressive, angry manner, Curtiss says.
those with depression, only about a third are getting any type
of treatment, says Lydia Lewis, executive director of the National
Depressive and Manic-Depressive Association (National DMDA) in
Those who are getting treatment are relying increasingly on medication
alone, according to a January report in the Journal of the American
Medical Association (JAMA). Such a limited treatment strategy
is less effective than options that incorporate both medication
Most mental health experts agree that depression is best treated
by a combination of medication and therapy. In fact, a 2001 study
by Brown University professor Martin Keller, M.D., found that
when patients were treated with both medication and psychotherapy,
85 percent improved. By contrast, little more than 50 percent
of patients showed improvement when treated with medication (55
percent) or therapy (52 percent) alone.
should always be considered as an important option, says
Leahy. However, interpersonal psychotherapy and cognitive-behavioral
therapy are as effective as medications. My preference is to encourage
patients to use both, if possible.
alone, however, is now the most common treatment for depression
by far. According to the January JAMA article, between 1987 and
1997, the proportion of individuals being treated with anti-depressant
medications increased from 37.3 percent to 74.5 percent. At the
same time, the proportion receiving psychotherapy dropped from
71.1 percent to 60.2 percent.
wasnt always this way. Until the 1960s, therapy was the
primary treatment for depression, mainly because the anti-depressant
medications of the day carried unpleasant side effects and a high
risk of overdose.
the 1960s, selective serotonin reuptake inhibitors (SSRIs) were
developed. While this class of drugswhich includes Prozac,
Zoloft, Paxil and Celexastill carries serious side effects,
it has a negligible risk of overdose.
anti-depressant medications help improve mood, increase the sense
of pleasure, help with energy and make people feel more hopeful,
many patients stop taking the medications before they get better
because of the side effects: mainly sexual dysfunction and weight
loss or gain.
depressed individuals who stick with a regimen of medication may
see only partial results. More than 75 percent of patients who
have been taking anti-depressant medications for an average of
three to five years say their depression is not completely under
control and that they have experienced few specific quality of
life improvements, according to a study by the National DMDA.
clinical practice, only 60 to 70 percent of patients respond to
each of the anti-depressant drugs currently on the market,
says Tim Daley, sales and marketing manager at Decision Resources
Inc., of Waltham, Mass. The company, which conducts market research
in pharmaceutical and health care trends, conducted a study on
depression in late 2001. The study found that up to 40 percent
of patients do not respond to the first medication prescribed
and must be switched to another anti-depressantwhich also
may be ineffective.
for those patients who do have an initial response and remain
on drug therapy, up to 50 percent never achieve full remission.
These patients, who suffer from residual symptoms, are at high
risk for recurrence, the report states.
study was based on interviews with doctors as well as sales data,
who relieved her own depression through physical and psychological
exercises, noted the relative ineffectiveness of anti-depressant
drugs in her book, Depression Is a Choice: Winning the Battle
Without Drugs (Hyperion, 2001). For most people, drugs only
work for a while before the dosages need to be increased or the
patient needs to switch to another drug, she says.
potential problem is that the majority of individuals on anti-depressant
medication receive prescriptions through their primary care physicianswho
have neither the time nor the expertise to properly manage depression,
mental health experts say. Thus, employees may be receiving the
incorrect medication, an incorrect dose or inadequate follow-up
drugs like Prozac and Paxil, which have serious side effects,
are now marketed directly to consumers who are demanding them
from their doctors, Curtiss says.
is a core systemic problem that must be addressed to see decreasing
numbers of employees suffering from and seeking benefits for depression,
says Stone, a member of the SHRM Workplace Health and Safety Committee.
The problem is that HR professionals shouldnt get involved
in dictating or advising employees on how to treat depressionor
any other serious condition, for that matter.
So, how can HR get involved, in a legally responsible way? Experts
offer the following suggestions:
Refer employees to your Employee Assistance Program (EAP). When
an employee tells you that they are depressed, you must be careful
not to offer medical advice, warns Stone. Your emphasis
should be on helping that employee identify the best provider,
either within your managed care network or EAP, or elsewhere,
to properly diagnose and treat the employee. Your role is to help
direct the employee to the best treatment resourcenever
Also, you must be careful about how you broach the subject with
the employee. Making statements like It seems to me
youre depressed, and asking related questions, may
violate the ADA [Americans with Disabilities Act], says
employment attorney Rob Ghio of Arter & Hadden LLP in Dallas.
He recommends opening with a job performance-based surface-level
discussionYou dont seem to be yourself latelyand
suggesting that the worker use the EAP.
EAP is the safest avenue if you are concerned about ADA liability
and obligations, agrees employment lawyer Lawrence Lorber,
a partner in the Washington, D.C., office of Proskauer Rose LLP.
R. Collins, a member of the SHRM Workplace Health and Safety Committee
and president of Kenneth Collins and Associates in Orinda, Calif.,
recommends following up with employees after suggesting they contact
the EAP. Tell a person Here is a referral for counseling
and let me call you in a week or two to see if youre comfortable
with this. Set the expectation that youll follow up,
and the employee is far more likely to make the appointment.
professionals should not make employees feel they are being unduly
pressured to make use of the program, however.
up an on-site EAP program. While conducting a benchmarking study
of Fortune 500 companies, Collins discovered that supervisors
refer employees to EAPs five times more often when the program
is available on-site. An on-site presence could be a scheduled
time the [EAP counselor] is in the workplace or, depending on
the size of the facility, it could justify somebody on-site full-time,
EAP and work/life services. At Ernst & Young LLP, employees
call one toll-free number for help with everything from child
care and elder care to chemical dependency and depression. As
a result, use of the EAP component has increased from 7 percent
in 1998 to almost 11 percent in 2001. Why? Combining the services
reduced the stigma of asking for help, explains Sandra Turner,
director of the EY/Assist program at Ernst & Young in Cleveland.
coverage. Lots of companies have an EAP and pharmacy benefit,
but few connect the two so that an individual who applies for
[prescription] reimbursement might also get [information] about
an outreach program, Collins says.
example, when an employee on anti-depressant medication receives
her Explanation of Benefits letter, she could also receive a brochure
on EAP counseling.
employees about depression. Employees know how to buy cars,
but not how to buy health careand we should teach them,
says Stone. When you are depressed and tell your primary
care provider about it, often his first response is to write a
prescription for Paxil. Are you asking the same well-thought-out
questions that you would if you were buying a car?
recommends that employees ask such questions as: