Mind field: almost everyone agrees that depression is a disease that endangers millions of lives and livelihoods and costs businesses billions of dollars each year. But what should businesses do about it? That's where the arguments begin

Workforce, Sept, 2003 by Andy Meisler

EMPLOYEE A, WHOSE ABSENCES are increasing and whose work performance is deteriorating, is urged by his supervisor to visit the company's employee-assistance program. The EAP counselor--a licensed psychologist--notices that A is distracted and listless. His questions reveal that A is experiencing severe insomnia, feelings of hopelessness and thoughts of suicide. The employee is referred to a psychiatrist connected to the company's health plan.

On his first hour-long visit, the psychiatrist delves deeper into A's background and symptoms. The physician asks whether A has a family history of mental illness. He diagnoses clinical depression, prescribes an antidepressant and explains that depression is an illness with roots in both brain chemistry and life stresses. He tells A that modern antidepressants take several weeks to "kick in" but are usually--though not always--effective. The doctor also cautions that the drugs often have side effects, including drowsiness, weight gain and sexual dysfunction. Over the next three months they meet for an hour each week, 12 sessions, so that the psychiatrist can monitor the medication, answer A's questions and conduct a short, focused course of psychotherapy.

Employee B, plagued by pain, fatigue and other symptoms, sees her primary-care physician for a checkup. After a 15-minute appointment, the physician finds nothing physically wrong and asks her to fill out a short mental-health-oriented questionnaire. The form is faxed to a company specializing in behavioral health care, which grades it and informs the primary-care physician that the patient's answers indicate clinical depression. The physician calls B, visits with her briefly and prescribes an antidepressant.

A week later, B receives an early-evening phone call from a counselor at the behavioral-health company who might be a social worker, a nurse or an uncredentialed health-care worker. During the first call, the counselor asks whether B is taking her medication and gauges her current state of mind in a 10- to 15-minute visit. If it appears that B's depression is becoming dangerously worse, the counselor can ask for advice from his superiors. The counselor makes three more semi-scripted phone calls over the next six months. During that time, B is also mailed a series of six pamphlets explaining the nature of depression, the effectiveness and drawbacks of antidepressants, and other strategies for coping with the illness.

Both eases are hypothetical. But each represents the ideal course of treatment espoused by one of two warring factions in the mental-health industry. Along with the advent of managed care has come a decrease in relative and absolute terms in the amount that employers contribute to their employees' behavioral health care. From 1988 to 1997 the average dollar amount, adjusted for inflation, dropped from $151.54 to $69.61 per employee per year and from 6.1 to 3.1 percent of total health-care expenditures. "And that trend has continued," says Ed Hustead of The Hay Group, the consulting firm that conducted the survey. The mental-health coverage experienced by Patient A, it's been calculated, will raise health-care premiums by as much as 5 percent. The treatment received by Patient B, bundled together with similar programs for conditions like heart disease, asthma and diabetes, will cost from $1 to $5 per employee per month. Still, proponents insist that savings associated with improved worker productivity will make it essentially "cost neutral." As a workforce executive, which course of treatment would you consider to be more effective for you or a coworker? Which would be more cost-effective for the company? The answers are as complicated and elusive as the dangerous illness behind them.

FIGHTING A STEALTH EPIDEMIC

These facts are not in dispute:

* Depression is a widespread illness. According to a recently published study in the Journal of the American Medical Association, 16.2 percent of the U.S. adult population will experience major depression at some time in their life; 6.6 percent suffered an episode in the past year.

* Depression is a major drain on business productivity and profits. Another recent JAMA-published study calculated that depressed workers cost their employers $44 billion each year: 19 percent of that because of increased absenteeism but a surprising 81 percent because of "presenteeism"--defined as employees who show up for work but perform tit only a fraction of their capabilities.

* Depression is poorly diagnosed. For a variety of reasons, including the stigma still attached to the disease, only 33 percent of all depression sufferers, according to the same study, receive medication for their disease.

Dr. Jerome Vaccaro, a psychiatrist and CEO of PacifiCare Behavioral Health in Laguna Hills, California, says, "Yes, it's badly undertreated. Even psychiatrists and psychologists, when they see hopeless, helpless patients, miss the diagnosis more than half the time. But we've got data to show that we're driving that figure down." Like similar companies nationwide--including Wausau Benefits and Magellan Behavioral Health--PacifiCare is a specialized mental-health subcontractor to larger health insurance companies, assisting HMOs and PPOs in offering programs like the one used by Patient B. "They're practical, they work, and the best of them bring together the best science of depression medicine," Vaccaro says. The plans cut traditional paid-by-the-hour mental-health specialists--psychiatrists and psychologists--out of the loop.