Health policy usually focuses on the delivery of health care. But in many situations, health care alone is not enough to meaningfully improve people’s lives. One of the most common situations in which this is the case is mental illness. Nearly one in five adults, or 51.5 million people, in the United States, meets diagnostic criteria for a mental illness, which can impair functioning across a spectrum of severity, ranging from mild to moderate to severe. Yet, despite advances in the diagnosis and treatment of these conditions, and considerable progress on including mental health care in health insurance, people with mental illness—including those with moderate illnesses such as depression or anxiety—continue to be tenuously connected to work and, hence, to full participation in society.
Working With Mental Illness
Mental illnesses pose difficulties for workers because their symptoms can interfere with essential workplace skills, such as participating effectively in teams, interacting with customers and co-workers, and maintaining concentration. For people with severe illnesses such as schizophrenia or bipolar disorder—about 2 percent to 3 percent of the population—these symptoms can be disabling. But the negative effects on employment of moderate mental illness, which affects 7.5 percent to 9.0 percent of the US population, are also substantial. In the mid-2010s, for example, 77 percent of those without a mental illness participated in the labor force, but only 55 percent of those with moderate mental illness were working or actively looking for work. People with moderate mental illness who do work may have reduced productivity or interpersonal problems at their jobs, and their symptoms may lead them to miss work. The overall effect of these job challenges is that people with moderate mental illnesses have lower earnings and accumulate less work experience and fewer skills over their lives.
These labor market consequences are particularly troubling because we already have on-hand tools that would allow us to address them much more effectively. Medical treatment alone isn’t enough—but we can significantly mitigate the negative workplace consequences of illness using a combination of clinical, workplace, and policy interventions. These interventions integrate innovative programs that combine clinical care and workplace supports; workplace accommodations, which have been required under the Americans with Disabilities Act (ADA) for 30 years; and comprehensive benefits, including health insurance coverage and paid leave. Together, this framework could go beyond “usual care” and improve both mental health and workplace productivity for this population.
Exhibit 1: A combination of clinical, workplace and policy interventions working together would likely improve work outcomes and labor force participation among Americans with moderate mental illness
Source: Authors’ creation.
Clinical Treatment Combined With Workplace Interventions
Most studies examining workplace interventions have focused on depression, which affects at least 4.7 percent of adults ages 18 and older in the US. Standard, guideline-concordant treatment, including the use of antidepressants and other pharmacotherapies and psychotherapy, can be effective in reducing symptoms and improving life satisfaction and overall health for depressed workers. When treatment leads to a reduction in depressive symptoms, work impairments are reduced and work outcomes improve.
Treatment alone, however, is often not sufficient to maintain stable labor force engagement. Employees may still face difficulties after symptoms subside, and effective functioning at work can be disrupted by residual symptoms and incomplete recovery, suboptimal treatment administration or adherence, stigma, and difficulty reestablishing good work habits. Specialized interventions focused on work-related outcomes build on these clinical treatments by combining medication therapy, psycho-social treatments such as cognitive-behavioral therapy (CBT), and job coaching.
One example of such an intervention is the Work and Health Initiative (WHI), which integrates vocational and mental health improvement techniques through an Employee Assistance Program (EAP) counselor for depressed workers. Through telephone sessions, the counselor provides medical care coordination and work coaching to reduce personal or environmental barriers to effective functioning at work, developing a customized plan to change specific work behaviors, work processes, or environmental conditions. The intervention also provides work-focused CBT to help participants learn to identify the thoughts, feelings, and behaviors that are eroding their work functioning and to respond with more effective coping strategies. Randomized trials have shown that WHI works; it both reduces depression symptom severity and greatly improves areas of functioning including time management and mental-interpersonal job tasks. In the treatment group of one trial, at-work productivity improved 44 percent (compared to 13 percent in the usual care group), absence days declined by 53 percent (compared to 13 percent in the usual care group), and absence-related productivity loss improved 49 percent (compared to 11 percent in the usual care group).
Similar programs have also shown benefits in Europe, with impressive results in terms of time to full return to work and days of missed work due to incapacity. As always, the size of effects from experimental interventions may be hard to replicate in routine practice, but a review of the broader evidence suggests that interventions that combine elements of these programs with CBT-based treatment are promising.
Workplace Accommodations: The Americans With Disabilities Act
Strategies such as WHI that involve both clinical interventions and workplace supports require active employer involvement. One potential policy lever for promoting such engagement is the ADA, which requires employers to offer workplace accommodations to compensate for the disadvantages faced by people with disabilities (including mental illness-related disabilities). Individuals qualify as having a disability under the ADA if they have a physical or mental impairment that substantially limits a major life activity, such as concentrating, thinking, communicating, seeing, or hearing—all forms of impairment that are consistent with many moderate mental illnesses. Employers are required to provide reasonable accommodations—such as assistance during hiring or on-the-job, flexible scheduling and part-time work, and modified job duties and descriptions—to people with qualifying impairments. Job coaching, switching from full-time to part-time work hours, and gradual introduction of tasks—the kinds of workplace changes incorporated in the targeted interventions described above—are among the most common accommodations. Research suggests that these accommodations can be helpful in keeping people at work and in reducing disability claims.
Although the ADA offers opportunities for workplace accommodation, workers with mental illnesses have been historically much less likely to receive accommodations than employees with physical impairments, and this pattern continues today. This is partly attributable to the ambiguity surrounding what constitutes a reasonable accommodation and which accommodations will best help enable employees with psychiatric impairments fulfill their job tasks. Lower rates of workplace actions to address mental illness may also reflect real or perceived stigma. A recent survey reported by the Society for Human Resource Management indicated that more than two-thirds of employees worry that asking for help with a mental health condition would imperil their jobs, consistent with the low rates of help-seeking observed in the workplace.
Comprehensive Benefits For Workers With Mental Illness
Deployment of effective interventions that combine clinical treatment and employer supports will also require financing. Under the rules established by the Mental Health Parity and Addiction Equity Act, employer-sponsored health insurance coverage should provide access to appropriate psycho-social services, such as CBT. Many large employers already have EAPs that might provide a foundation for additional work supports. But because of the episodic nature of the mental illness, maintaining employment is also likely to require flexibility to take time off work when symptoms are exacerbated.
Under the ADA, an individual with a qualifying disability may work part-time or occasionally take time off as a reasonable accommodation if it would not impose an undue hardship on the employer. The US Department of Labor lists flexible scheduling, sick leave for reasons related to mental health, additional unpaid or administrative leave for treatment or recovery, and leaves of absence or occasional leave for therapy and related appointments as “some of the most effective and frequently used workplace accommodations.”
However, the potential help of flexible scheduling and flexible use of sick leave or other leave is quite limited when employers do not provide paid sick leave. While employees may be entitled to take time off work without losing their jobs, they will lose income. As of 2020, only 78 percent of civilian US workers are eligible for any paid sick leave. Among employed 50-year-old men with depression surveyed between 2008 and 2014, 42 percent had fewer than three days of paid sick leave available (authors’ analysis of the National Longitudinal Surveys of Youth). While several states and localities now mandate that workers have access to paid sick leave, most Americans are not covered by these mandates (although their employers may voluntarily provide paid sick leave). Congress is considering legislation that would expand mandated paid sick leave to all workers across the country (for example, H.R.1185/S. 463, the Family and Medical Insurance Leave Act, or S.840, the Healthy Families Act). Such legislation would provide a key support to efforts to increase and maintain labor force participation and workplace engagement among people with moderate mental illnesses.
We Can Do Better For People With Mental Illness By Thinking Beyond Medical Care
Health policy discussions often focus on coverage for the costs of medical care. As the circumstances of the large population with moderate mental illness suggest, medical coverage is necessary, but not sufficient, to protect people against the workplace consequences of illness. Americans with moderate mental illness typically work, but people with these conditions are at high risk of missing work or losing their jobs because of functional impairments caused by their mental health problems. Specialized interventions, such as work-focused CBT and job coaching, can mitigate some of these effects. Increasing the use of these interventions will require more than expanded insurance coverage. It will also require more aggressive use of the protections offered by the ADA and expansion of access to paid sick leave, so that workers with mental illnesses can afford to modify their schedules to fit their mental health needs and accommodate medical or therapy appointments or time for recovery.
Sherry Glied is a director of NRx Pharmaceuticals, Inc., which has a behavioral health drug in development.