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Revealing the Dark Side of Clinical Depression

April 1, 1995
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Bill is a programmer/analyst in data processing for a major American bank. A few years ago, he hospitalized himself for clinical depression. He stayed for three weeks while the medication the hospital prescribed took effect and he learned a new way to manage his behavior to influence his feelings.

Bill is one of 17.6 million Americans who suffer from this debilitating disease. Yet, only one in three people within the work force who have clinical depression seeks treatment as Bill did, according to the Massachusetts Institute of Technology (MIT). This has wide implications for corporate America. According to a study of depression in the workplace reported in December 1993 by MIT, clinical depression costs employers approximately $44 billion a year in direct costs and lost productivity (see "The Economic Burden of Depression").

Indeed, when an employee suffers from clinical depression, a silent thief is consuming sick days and robbing your workplace of productivity. A clinically depressed employee simply can't perform to capacity. The employee can't think clearly, may take no pleasure in his or her work and can't contribute effectively to the efforts of a team.

According to Lori Altshuler, a physician at the UCLA Neuropsychiatric Institute in Los Angeles, a person who has untreated depression may suffer a diminished ability to process information or may feel that every part of the job is overwhelming. Symptoms may include headaches, fatigue, lethargy or anxiety, to the point where the person calls in sick.

Mana Kelly, a certified employee assistance professional, adds that a person with depression may show a decrease in motivation, isolate him or herself from co-workers, fail to contribute in meetings, avoid eye contact and show changes in personal appearance. He or she also may demonstrate low energy, lose concentration and the ability to follow directions, break into tears or present a generally "flat" (emotionless) demeanor.

You may have noticed someone at your company suffering from these things, but have felt too constrained by laws governing what you can and can't discuss with the employee to confront him or her. Is there anything you can do?

Yes, according to directors of employee assistance programs (EAPs), psychologists who specialize in depression, insurance company psychiatrists and employees who have fought their way back from clinical depression to full productivity. But like many good outcomes, this one requires planning.

What is clinical depression?
Jonathan Aronoff, a psychologist in private practice in Stockbridge, Massachusetts, describes clinical depression like this: A person who normally operates on five or six cylinders now is operating on two or three. According to Rockville, Maryland-based National Institutes of Mental Health, "the highest overall age of onset [of clinical depression] is between 25 and 44, with an increasing rate for those born after 1945... ." The rate of clinical depression for women is roughly double that of men. For bipolar disorder—depression alternating with bouts of mania (excessive "highs")—the rates are about the same for men and women.

A tendency to depression appears to run in families, so some people are more vulnerable to depression when major life stresses affect them. Researchers report that either chemical events in the brain, or life circumstances, can trigger depression. For example, the event that led Bill to treatment for depression occurred at work. He had always been ambitious for a management position, but when he achieved his goal, he discovered that his career success contrasted with his internal unhappiness. He suffered from anxiety and fear of confronting issues, problems that affected his work performance. Bill discussed the situation with his boss, and the two decided that Bill would step down. "It was devastating to my self-image. Part of who I am was gone. I got transferred to a more analytical job, but the feelings snowballed."

A bout of depression such as Bill's can last a few weeks to a few years; normally, Altshuler explains, untreated depression lasts from six months to a year. People suffering from depression do usually return to their regular state of functioning intermittently, but a subsequent episode quite often is more severe. Bill, for example, had been in and out of counseling several times, and even tried antidepressant medication once. The side effects of that first medication, however, were worse for him than the depression itself, so he abandoned the medication. His untreated depression returned at regular intervals, and each time it returned it was worse.

What's more, Altshuler emphasizes that if a person has been clinically depressed one time, the likelihood of recurrence is 50%. If a person has been clinically depressed twice, the chances it will happen again is 75%. And if the depression occurs a third time, there's a 90% chance that it will recur.

Ironically, most depressed people don't recognize at first that they're depressed. Kelly says that by the time depressed employees reach the company's Employee Assistance Program, they're usually in considerable mental pain. Kelly has directed the EAP for Rosemead-based Southern California Edison for eleven years and reports that, as with many physical ailments, most clinically depressed people don't seek treatment until it hurts badly.

Fortunately, clinical depression is very treatable. Richard Kunnes, president of Prudential Psychiatric Management in Roseland, New Jersey, explains that although every person requires individual treatment, in most cases—especially moderate to severe depression—the patient responds best to a combination of medication and therapy.

Antidepressant medications do work, under proper supervision in a treatment plan. Normally the medications need three to six weeks to take effect, so early intervention is important. Altshuler explains that the literature on clinical depression tells us that if the person is in a clinically depressed state, a good response to medication is likely.

There's a wide range of antidepressant medications appropriate for differing biochemistries. And, in fact, the more mild cases don't require medication, Kunnes says. Also, not one professional interviewed for this article recommended medication alone, although all stated clearly that therapy alone may work. If there is to be medication, therefore, it must be with therapy or, in the long term, the investment in medication is wasted. Treatment with medication and therapy helps the patient return to work more quickly.

With appropriate treatment, the employer can expect most employees to return to work in about a month; there's no reason to think that the employee will be unable to return at all. Some patients have difficult adjustments to medications and may need three or four months, but they're likely to return to full productivity.

Kunnes also stresses appropriate follow-up. A patient who has returned to work following treatment for clinical depression needs to be seen once a month or once every two months, and may need to continue medication for a long time.

Treatment must be made available.
If one of your employees were diagnosed today as clinically depressed, would your health insurance plan cover the costs of medication? What about therapy? A combination of both?

Benefits managers bemoan the percentage of the health-care dollar that goes for mental-health coverage. Some say that mental-health treatment represents as much as 15% of their health-care costs. Because of this, and because mental-health treatment is so unlike a surgical procedure or a course of antibiotics—no clear beginning and end points, no confidence that it will ever be "over"—many benefits managers severely limit coverage.

In addition, an increasing number of managed-care companies are limiting coverage. Bob Bruner of Community Action/EAP, a national EAP based in San Bernardino, California, explains that managed-care companies have sold human resources managers on the idea that they're going to limit expenditure of benefit dollars by limiting access to psychotherapy.

Some of these managed-care companies limit expenditure without notice. One EAP professional interviewed for this article, for example, described a company that has negotiated a health-care plan with its provider, an HMO, contracting for coverage for up to twenty sessions of psychotherapy per employee. But without the company's knowledge, the HMO, upon receipt of a first claim, contacts the psychotherapist providing treatment and tells the professional that if the employee receives more than eight therapy sessions, the HMO will drop the therapist from its approved provider list. Not only is the company not receiving the benefit it pays for, but such an arrangement precludes effective treatment for most employees suffering from clinical depression, and adds greater cost to the corporate health-care budget. If an employee needs medication and therapy but under a particular managed-care agreement receives medication only, the depression is likely to recur and ultimately cost the company more money than full, effective treatment would cost in the first place.

Imagine the consequences of being denied treatment for Bert, a management consultant with an advanced professional degree who was guiding a large project for a major firm. Bert was waking up at three or four a.m., unable to get back to sleep, then suffering from mental dullness at work. Recognizing signs that no one else could see, Bert was motivated to seek treatment before the scenario he feared actually developed: that he would make a major gaffe and have to leave the organization. Edward Dunbar, Bert's psychologist in Los Angeles, says something along those lines certainly was possible had Bert not sought treatment when he did. Through early intervention and treatment, however, Bert learned the skills he needed to focus his concerns about feedback and performance more effectively, and continued his 60-hour workweek. He believes that the employer never saw the problem before the intervention, or during the treatment. Bert was able to continue functioning as a key person in the organization, a partner in a happy marriage and an effective member of the community during treatment.

But for every Bert, is there another employee who abuses the system? Of course there are some, but no one interviewed for this article felt that occasional abuse was cause to not offer mental-health benefits to employees. Southern California Edison's Kelly states, "Some people know how to manipulate the system, but there are many people who honestly need treatment. There are ways to make a difference, alternatives to simply seeing someone as a bad employee. I firmly believe that our employees are our best resource. If we don't take care of them, we're not taking care of business."

How the human resources professional can plan for a good outcome.
Because receiving treatment is so important for workers who have clinical depression, one of the most important things an HR person can do is ensure that the company's health-insurance covers effective treatment. If the insurer has a financial incentive not to treat, or to provide medication but no therapy, the insurer isn't serving your long-term interests.

Next it's important for HR to create an environment conducive for workers to receive help. Clinical depression often is widely misunderstood as a character flaw rather than as an illness, so it's imperative to provide training to all managers and supervisors about the disease, as well as how to observe, confront and refer the employee to your company's employee assistance program or similar available services.

If you have an EAP, arrange for EAP professionals to provide training in stress management, change management and related topics so that they become familiar and trusted. Fox, Inc. in Beverly Hills, California, brings an EAP counselor onsite once a week for confidential visits at the workplace. Usage of the EAP program soared when Fox began the practice. Regular visits also help managers feel more comfortable making a referral or calling the EAP to ask for advice in planning a confrontation with an employee whose performance has fallen off. Emphasize that the goal of these actions is to return an efficient employee to work, not to "dump" a "bad" employee.

It's also important to provide easy access to care because the clinically depressed person isn't able to function at his or her highest level. Make it easy for the manager to refer, and for the employee to contact the EAP independently. Provide a phone—and privacy—for that purpose.

Prudential Psychiatric Management gives members a 24-hour, seven-day-a-week toll-free telephone number answered by a mental-health professional. When an employee calls, if the person isn't suicidal, the mental-health professional refers him or her to an appropriate therapist whose office is within 20 minutes of the caller, then sets up the initial appointment for the caller so that the employee doesn't have to "cold call" the therapist.

Prudential's Kunnes emphasizes that easy access works only when the employer has adequately informed employees about the EAP's use, so distribute literature to all employees that explains how to contact the EAP or the psychiatric management service. (Dunbar's patient Bert sought help through his spouse's EAP because his own employer didn't provide information about how to use its EAP, and his spouse's company did. Without that resource, would he have sought treatment and avoided a major problem?)

What's more, an employee who is unaware of the EAP or psychiatric services benefits may turn to workers' compensation claims or lawsuits to address the problem of a deteriorating work relationship that has triggered his or her depression. This is especially true in a company going through downsizings. Employees at risk of depression will feel the impact more severely during this period, even if they keep their jobs. In one company cited by Bruner, 11% to 15% of the employees who had just survived a layoff filed workers' compensation claims. These claims and lawsuits are more expensive than treatment and neither helps to get at the real problem of depression.

Along with setting up the structure for workers to get help—providing adequate insurance coverage and an accessible EAP or other service—it's imperative that HR intervene. That doesn't mean diagnosing or asking the employee about his or her mental state, but rather helping the depressed worker's manager deal with work performance.

Managers and HR professionals should focus on changes in behavior. They should not try to diagnose the cause of an employee's performance problems, but base comments on observable behavior. Example: "I'm seeing these changes in your ability to do your job." Kathy Bruner of Community Action/EAP stresses that "human resources professionals need to know how to do appropriate observation and appropriate confrontation." They don't need to learn to diagnose clinical depression. She explains that the last thing an HR professional needs to be saying is, "You know, you need counseling."

If the depressed employee is a supervisor, the human resources person needs to acknowledge that the supervisor's depression affects the whole work group. According to psychologist Aronoff, a depressed supervisor will have difficulty organizing, leading, and identifying and following through with tasks—the essence of a supervisor's job. Supervisees and colleagues may become anxious, confused and apathetic.

There are clear guidelines that are within the law for confronting workers, says Kathy Bruner. No manager or HR person should play amateur clinician, she stresses, but they need to initiate a conference about the employee's performance. The language of clinical depression shouldn't be part of the conference; if the employee brings up the feelings involved, the manager or HR person should listen, but not judge or comment.

One mistake that some managers and human resources practitioners make is assuming that because clinical depression is covered under the Americans with Disabilities Act, they must immediately make accommodations for a person with this diagnosis. Kathy Bruner says don't do this: Use the EAP to validate the disability, with or without reference to the precise diagnosis, but stay focused on whether the employee is fulfilling all the essential functions of the job. Once the manager loses sight of that, Bruner explains, the clouds move in. Discussions of reasonable accommodation are appropriate only if the employee asks for it, with support from the psychotherapist.

Proper treatment reaps positive outcomes.
Thoughtful intervention from managers and HR people is key. Bill believes that the people around him in his work and home life gave him the courage to deal with the root cause. He began a course of medication and therapy. "That's where the work really gets done—in therapy," he insists. "Your behavior has to change. How you act affects how you feel, how you feel affects how you act. I think I act differently now, and that's been hard to learn."

Bob Bruner cites another example of positive results from a managerial confrontation with an employee whose eleven-year marriage was ending in divorce, whose mother had just died, and whose two young children were out of control. She was having panic attacks and was confused at work. Her job performance deteriorated, causing her supervisor to meet with her and issue a disciplinary memo. Because of good publicity and employer support for the employee assistance program, the employee turned to her EAP for help. She received medication and therapy, is again feeling in control of her life, and is now fulfilling all the essential functions of her job.

Bob Bruner explains that the constructive confrontation model—confront the employee with the behavior and give him or her the opportunity to do something about it—often saves the employee and changes the behavior so that productivity no longer is a problem. He points out that if a manager postpones the confrontation out of fear of hurt feelings or putting more pressure on an employee who's already struggling, the problem gets worse.

Once a depressed person is in treatment, the company needs to take some pressure off the employee. UCLA's Altshuler stresses that employers must recognize when dealing with an employee facing clinical depression that the employee already feels devastated, embarrassed, stigmatized. If the human resources professional knows the diagnosis, Altshuler suggests that simply acknowledging that the employee is facing biochemical events that must feel overwhelming can offer the employee immense relief.

Karen Z. agrees. The 30 year-old human resources development consultant found herself struggling with depression three years ago. She couldn't sleep, was eating poorly, couldn't make decisions and found no joy in anything. On the advice of her psychotherapist, she considered antidepressants.

When Karen began medication, she told her manager. At the time, her manager seemed not to know what to say, but Karen noticed that from then on, every time she made a questionable decision, her supervisor pushed and probed the decision past the point of Karen's comfort.

Karen transferred to a new department and found her new environment more comfortable and supportive. Again, she elected to tell her manager—and the department's vice president—about her diagnosis and treatment. "When I told them about the medication, they were primarily concerned about me, about Karen. It was clear: they cared about Karen."

They didn't ask about her treatment. Instead, they gave Karen steady feedback on her performance. "At one point, I got feedback from my manager that a memo was taking me a long time. I looked at how other things were going and decided I should increase the dose of the medication. Suddenly, I could write memos much faster. The feedback was that important, and that reliable."

After offering performance feedback, the HR person must respect the employee's confidentiality. After his hospitalization, Bill returned gradually to his full work responsibilities, and didn't have to explain anything to his colleagues. "I had to work my way back into the flock. No one ever talked about it to me and I didn't bring it up." His absence and treatment weren't the focus; performance issues were.

How has Bill's performance changed? "I'm certainly a lot more comfortable with what I do. Data processing at my company is an unstable environment, but now I seem to be able to roll with the punches. My employer has been in a large cost-cutting process, something that could create a lot of anxiety, but my wife and others say I'm dealing with it now. I've learned that pretending there wouldn't be a layoff isn't the same as dealing with it. In fact, my attitude has probably contributed to my survival at the bank. I've maintained a high level of productivity and a good mental attitude." Although Bill lost his father a few months ago in the midst of the major layoff at the bank, he feels that he now has the skills to keep an even emotional keel.

Karen reports that her performance now is at the highest level of her life. "My bad days now are better than my best days used to be. I feel much sharper than I did before. There's a world out there." Karen now runs an independent human resources consulting business.

Both Karen and Bill hoped that by telling their stories they might help human resources professionals understand depression as a workplace issue from the inside. Their advice to HR managers is to recognize that in each employee's life, work and home issues are intertwined, and the spur to get into treatment has to come from one of them. What helped them the most is that their supervisors spoke to them frankly—and often—about their performance.

Personnel Journal, April 1995, Vol. 74, No. 4, pp. 121-127.

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