Depression Is A Choice

The old adage of “take two pills and call me in the morning” apparently doesn’t apply to depression anymore. Increasingly, those who suffer from depression are taking the pills—but 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 professionals—especially since incidents of depression are on the rise.

“Depression 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, N.Y.

Depression’s effect on the workforce is both broad and deep.

Depression 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.

“When you’re 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 you’re 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 don’t care and you start treating people in an aggressive, angry manner,” Curtiss says.

Of 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 Chicago.

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 and therapy.

Treatment Options
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.

“Medication 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.”

Medication 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.

It wasn’t 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.

In the 1960s, selective serotonin reuptake inhibitors (SSRIs) were developed. While this class of drugs—which includes Prozac, Zoloft, Paxil and Celexa—still carries serious side effects, it has a negligible risk of overdose.

“Typical anti-depressant medications help improve mood, increase the sense of pleasure, help with energy and make people feel more hopeful,” says Leahy.

Unfortunately, many patients stop taking the medications before they get better because of the side effects: mainly sexual dysfunction and weight loss or gain.

And 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.

“In 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-depressant—which also may be ineffective.

“Even 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.

The study was based on interviews with doctors as well as sales data, Daley says.

Curtiss, 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.

Another potential problem is that the majority of individuals on anti-depressant medication receive prescriptions through their primary care physicians—who 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 care.

“Depression 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.

“This 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.

What to Do?
The problem is that HR professionals shouldn’t get involved in dictating or advising employees on how to treat depression—or 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 resource—never to treat!”

Also, you must be careful about how you broach the subject with the employee. “Making statements like ‘It seems to me you’re 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 discussion—“You don’t seem to be yourself lately”—and suggesting that the worker use the EAP.

“The 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.

Kenneth 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 you’re comfortable with this.’ Set the expectation that you’ll follow up, and the employee is far more likely to make the appointment.”

HR professionals should not make employees feel they are being unduly pressured to make use of the program, however.

Set 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,” he says.

Combine 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.

Coordinate 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.

For example, when an employee on anti-depressant medication receives her Explanation of Benefits letter, she could also receive a brochure on EAP counseling.

Educate employees about depression. “Employees know how to buy cars, but not how to buy health care—and 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?”

Stone recommends that employees ask such questions as: