Bill lived in an almost constant sense of dread. At work he was distracted by his worries about his children, who were having problems in school and about his deteriorating relationship with his wife. He worried about having enough money to pay the bills. At night he lay awake ruminating about falling behind at work and missing deadlines. He was too tired when he got to work to get much done. He knew he was in trouble and considered getting help. But he didn’t want to use his company’s employee assistance program (EAP) for fear that word would get back to his boss, jeopardizing his job and possible promotion. He did not want to take advantage of mental health coverage he had through work because the co-pay seemed high and he was already stretched thin financially. He had also heard that it wasn’t easy to get the necessary authorization from the managed care company his employer contracted with and that even with authorization it was hard to find someone in the network who was good and was available. He thought of talking with his personal physician, but he lived in a small town and didn’t want the staff in the doctor’s large group practice to know that he was losing it. For that matter, he didn’t want the doctor to know. He didn’t want anyone to know.
Bill was one of the 60% of Americans with a diagnosable mental or substance use disorder who do not get treatment. Had he gotten treatment from his primary care physician, he would have had about 1 chance in 8 of getting “minimally adequate care.” Had he made it to a mental health professional—who are in terribly short supply—he would have had a 1 in 2 chance of getting minimally adequate care.1
The difficulty people with mental or substance use disorders have getting good treatment is a major reason why there is now widespread agreement that the American mental health system is inadequate and in need of vast improvement. Unfortunately, proposals for improvement rarely include the workplace, despite the facts that over 50% of the people who live in America get health and mental health insurance coverage through employers2 and more than half of American workers have access to behavioral health services at work or at their unions through employee assistance programs, onsite behavioral health clinics, disability management programs, and a variety of health and mental health promotion initiatives.3 Workplace mental health funding and services are a vital part of the American mental health system.
Of course, improving publicly funded mental health and substance abuse (“behavioral health”) services is extremely important. But to improve access, increase utilization, and raise the quality of behavioral health services, it is also critical to improve services funded and/or provided by employers.
Not all workplace mental health issues have been ignored in efforts to reform the American behavioral health system. The issue of parity—the demand for equal coverage of behavioral and physical health services—has been in the forefront of advocacy efforts for several decades. Sadly, it remains a major concern despite the fact that the Affordable Care Act mandates parity because there are significant problems of implementation.4
It is undoubtedly essential to get these problems resolved, but will that result in increased use of behavioral health services by those who need them? In theory, reducing co-pays and eliminating limits (“caps”) on care that is paid for by health plans will remove a major barrier to use of mental health services. But some research has called this assumption into question5, and it is clear that cost is not the only reason why many people who need help do not get it.
Other reasons why working people and their families may not get access to good care include:
- Shortages of clinically and culturally competent providers
- Personal reluctance to get professional help due to:
- Fear that use of mental health services will not be confidential and will affect employment and promotion
- Embarrassment about having behavioral health problems and needing help
- Lack of realization that personal emotional distress may be a mental disorder
- Denial that drinking or using drugs has become a problem.
- Benefit design features in addition to lack of parity that create barriers to utilization and quality care including:
- Use of managed care to hold down utilization
- Reliance on credentials rather than on quality measures to develop networks of behavioral health providers
- Failure of some plans to cover family members as well as workers
- Lack of integration of physical and behavioral health coverage and treatment.
Sophisticated employers, unions, and benefits consultants are aware of these issues and try to address them.6,7
For example, mental health education to help workers identify the need for professional help and to reduce embarrassment and shame regarding having behavioral health problems (reduce stigma) has always been a major component of EAPs. Much education has also been devoted to assuring workers that visits to EAPs and treatment for behavioral health disorders is confidential.
Workplace health promotion (aka “wellness”) initiatives have also been around for decades. These include stress management, substance abuse prevention, anti-smoking campaigns, education about nutrition, opportunities for exercise, discussions about managing with young children and with disabled older parents, etc.
There have also been a number of “depression initiatives” over the past couple of decades.8 More and more employers realize that depression is a cause of vast lost productivity, drives up health care costs, and increases risks of disability. To head off these losses to their bottom line, some have emphasized the importance of primary care providers screening for depression. Some have remodeled managed care to emphasize getting depressed workers into high quality treatment rather than holding down utilization and using inexpensive providers regardless of quality. In addition, some employers and health insurance companies have worked on sharing information between the physical and behavioral health sides of their health plans. For example, some health plans routinely send letters to members with heart conditions suggesting the need for screening for depression, a common and dangerous concomitant of heart disease.
All this is impressive and undoubtedly helpful. But it has not had the widespread impact that is necessary to substantially increase the access to high quality treatment that many people in the American workforce need. To do so, our nation will need to find new ways to improve workplace mental health services as well as to enhance publicly funded services.
Michael Friedman is retired but continues to teach at Columbia University and to write about behavioral health and about aging. He is the founder and former director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City. He can be reached at mf395@columbia.edu.
References
- Wang, P. et al. “12-Month Use of Mental Health Services in the United States: Results of the National Co-Morbidity Survey Replication”. Archives of General Psychiatry, June 2005.
- U.S. Census Bureau. “Highlights Regarding Health Insurance 2013”. http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/highlights.html
- U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). “Workplace Policies and Programs Regarding Alcohol and Substance Abuse”. The National Survey on Drug Abuse And Health Report. August 7, 2014.
- Burns, J. “Not Making Sense of Mental Health Parity Rules.” Managed Care. February, 2014.
- Goldman, H. et al. “Behavioral Health Insurance Parity for Federal Employees.” New England Journal of Medicine. March 30, 2006.
- Finch, R. et al. Center for Prevention and Health Services. An Employer’s Guide to Behavioral Health Services: A Roadmap and Recommendations for Evaluating, Designing, and Implementing Behavioral Health Services. National Business Group on Health; 2005.
- NAMI-NYC Metro. “Mental Health in the Workplace”. 2015 http://www.naminycmetro.org/Advocacy/MentalHealthintheWorkplace/tabid/121/Default.aspx
- Levy, J. et al. “Integrating Depression Screening and Management with Primary Care in New York City: Lessons Learned From the Multi-Payer One Voice Initiative.” Northeast Business Group on Health. 2014. http://www.nebgh.org/resources/NEBGH_OneVoiceBriefFINAL-062014.pdf
