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Is Work - And School - Driving Us Crazy?

The worst thing for your mental health may be going to work or school. The other worst thing may be staying home.

These are tough times, and Corporate America, Corporate Canada, and Corporate Everywhere Else have a lot to be scared of. What’s new this time, however, is that psychiatric disability now represents the third-highest concern among employers, according to a 2000/2001 survey by business consultants Watson Wyatt. The same survey also reported that 86 percent of employers found psychiatric disability difficult to deal with. Ironically, the monster they fear could well be the monster they helped create, such are the hazards of the modern workplace.

A 2003 AdvancePCS Center for Work and Health survey estimated that depression in the work place costs employers $44 billion a year. Twenty percent of the costs were due to absenteeism while 80 percent could be attributed to "presenteeism," ie reduced on-the-job productivity. Depression was estimated to result in 5.6 hours a week of lost productivity. The numbers do not include short and long term disability.

Reuters reports on a 2000 Gallup Poll that found 80 percent of US workers feel stress on the job and nearly half said they needed help in coping with it. Twenty-five percent have felt like screaming or shouting due to job stress, 14 percent felt like striking a co-worker, and 10 percent worried about a colleague becoming violent. Stress accounts for some $300 billion a year lost by US business in the form of absenteeism and other costs, and is often a prelude to depression.

Why Depression and a Career Don't Mix

Untreated depression can be a career-buster. A San Francisco VA Medical Center study of 2,335 young adults earning at least $25,000 found 33 percent with depressive symptoms in 1991 reported new unemployment during the next five years compared to 21 percent of those without depression. Over the same period, seventeen percent with depressive symptoms reported lowered income below $25,000 in the same period vs seven percent without depression.

The NY Times in 2004 reported on a University of Michigan survey of 443 depressed workers that found that only 41 percent felt they could acknowledge their illness and still get ahead in their careers. Only 14 percent had taken advantage of employee assistance programs for workers who suffered from depression. Eighty-two percent of the depressed workers had difficulty concentrating, 83 percent lacked motivation, 24 percent complained of chronic physical pain, and 50 percent missed one to three days of work because of their illness.

At a session of the 2002 Depression and Bipolar Support Alliance annual conference in Orlando, Daniel Conti PhD, director of the employee assistance program at Bank One, which has been an innovator in encouraging its workers to get treatment for depression, talked about the many issues surrounding mental health at work:

At Bank One, in 1989, psychiatric disabilities (mostly depression) were the seventh-leading cause of short-term disability (STD) and fourth in STD days. By 2000, the figures were number two in both categories (number one is pregnancy and childbirth). "We’re not an anomaly," Dr Conti reports. "Psychiatric disabilities are jumping in this country," at a pace that outstrips physical disabilities.

Part of the reason is depression tends to strike people in their productive years, as opposed to say heart disease, which takes its major toll in late life. Also, greater public and physician awareness and improved disability management programs have resulted in more people seeking treatment. Another factor is more women in the workforce, but public enemy number one appears to be today's work environment, with no end of potential stressors. Stress is now accepted as the most commonly endorsed health risk. A 1997 UNUM/Johns Hopkins study found that companies with mergers involving layoffs reported 33 percent higher mental illness claims. The jobs that are most toxic are those with high responsibility and low control.

Vast numbers of us now working in information technology or customer service have more to fear from depression, which affects our ability to think and relate to people, than many types of physical injuries. An ad for a teller, for instance, reads: "Superior interpersonal skills ...handle delicate issues ... create enthusiasm."

"What would depressive illness do to that?" Dr Conti asks.

Once an employee has left his or her job, returning to work is very difficult. "Run like hell [from disability], if you can," Dr Conti advises. "Leave the job only if you have to, if you can no longer perform the job." Disability, he points out, is set up to provide job protection for an employee too ill to work. It is not curative, and will not make the job less stressful. Once away from the workplace, motivation for activity drops, with predictable results. Unfortunately, "we teach people to become disabled."

Achieving the opposite - enabling employees to stay on their jobs - is clearly a work-in-progress.

Do's and Don'ts of Depression and Work

At the same session, Dr Conti advised: build relationships at work, ensure a life outside of work, and find a way out if the workplace is toxic. Disclosing your illness to your boss or colleagues may or may not be appropriate. Two of the biggest mistakes, he said, are saying nothing, and walking around with a signboard with, "Ask me about my depression." A woman fearful of disclosing her depression to a male supervisor might hint at something gynecological, as men will run away from that, he advised.

If disability is appropriate, Dr Conti advised structuring days to include activity with other people, and include work issues in therapy. In returning to work after a disability, find out if it's possible to gradually go back to full time.

Depression and the Bank One Experience

In June 2001, the Wall Street Journal devoted a major portion of its feature pages to depression in the workplace. Among other things, it looked at the experience of Dr Conti's Bank One Corp, a Chicago-based company that is regarded as having an enlightened policy regarding depression care for its employees. In 1991, Bank One discovered that treating depression cost the company's health plan nearly as much as to treat heart disease. Even more pronounced was depression's impact on absenteeism, with its employees losing 10,859 workdays over a two-year period compared to high blood pressure which resulted in 947 work days lost and diabetes which accounted for 795 days lost.

In response, Bank One developed an early intervention program involving manager and employee workshops and hiring a staff psychologist. The company also reduced out-of-pocket expenses for the first 12 therapy visits in its self-insured plan. But the HMOs involved with Bank One have been a disappointment, and the emphasis on short term therapy and quickly returning to work has created a revolving door of those who relapse. Ironically, Bank One's attempt to combat depression has resulted in four times as many employees on short term disability for depression over the 1989 rate. But Dr Conti told the Wall Street Journal: "In the long run, it will pay off in lower numbers of serious cases and more productive workers. People will get help earlier and arrest the disease in earlier stages."

Meanwhile ...

A UK study published in 2000 identified British professionals as the most depressed and unhealthy group of managers in the world, beating out the Romanians, Bulgarians, Taiwanese, and Chinese.

A major part of the blame can be laid at the doorstep of the US. The UK has Americanized faster than any other country during the 80s and 90s, jettisoning their traditional support networks in the process, as a new generation of employees sought to become masters of their destinies by working harder and smarter in an increasingly less secure world. US managers share many of the same problems as their British counterparts, but seem better able to cope because of community support, according to the study.

All this is spelled out in an article in the Sunday Guardian. As well as having the longest work hours in Europe, Britain shares the highest divorce rate with Denmark. Office bullying is on the rise, along with long-term sick leave and staff turnover. According to Alyssa Armstrong of Bupa, the healthcare company which commissioned the study: "People are reluctant to say anything. They hide the signs at first. You can be irritable and be drinking more yet still maintain a professional front at first. They don't want anybody to think they are wimps."

Says one middle manager: "I am at the end of my tether ... I have no life. We are like zombies." More testimony follows, of people driven to the breaking point. "The worst thing is," says one, "you start thinking the abnormal is normal."

But wait, there's more to this than meets the eye. A lottery winner opts to keep working because she "loves her job." A beauty contest winner elects to keep her day job for the same reason. This other side of work is spelled out in an opinion piece by Richard Reeves in the same edition of the
Guardian: "Work has become our national obsession," he writes. "Whether we are damning the impact of work on our health, our families, our time, or celebrating its new-found flexibility, rewards and opportunities, we are talking, writing and thinking about work like never before."

He notes the average wage in the UK has increased 57 percent in the past decade, maternity leaves are getting more generous, a third of firms offer sabbaticals, two-thirds allow work to be done from home, and four of ten UK workers claim to be "very satisfied" with their jobs, more than France, Germany, Italy, or Spain.

The workplace has also become a social club. Author Shere Hite estimates that 62 percent of women and 71 percent of men have had an affair with a colleague. And many would rather not balance work and family, for fear of work becoming "less interesting, exciting and involving."

Of course, if you love what you're doing it's really not work. Hopefully, our neurotransmitters appreciate that distinction.

Meanwhile, On Campus

“For the last five years I’ve been on a roller coaster ride of emotions with manic highs and depressive lows. I entered my senior year of high school at the top of my class. I ended it barely graduating. “

In Sept 2004, fifth year Stanford senior Adam Kahn addressed a new student orientation event focusing on diversity. He told the incoming class of ‘08 about the illness that caused him to be booted out of his dream university.

“The fall of my freshman year was rough,” he reported. “I was overmedicated due to an incompetent psychiatrist back home. I was a zombie and could barely stay awake past 11 pm. I was out of practice academically given my disastrous senior year of high school. I was still not turning my papers in on time.”

In his junior year, with mounting incompletes and failed course to his record, he was placed on academic suspension. At home, he went from bad to worse, and enrolled in a special treatment program.

“At times it felt like I would never make it back.” he related. “At times it felt like I was too far gone.” But slowly, based on skills he learned in treatment, he learned to take control of his life. He was able to complete some of his incompletes from home and prove to the school that I was well enough to return a quarter early. “More importantly, I was able to prove to myself that I was well enough to return a quarter early from my suspension.”

This time there was no margin of error for screw-ups. “I’d be lying if I said life is easy for me,” he confessed. “My bipolar disorder does a lot to make me who I am. On the other hand, it is not who I am. It does not define me like it once did. When I joked with a friend about how I was speaking today about being crazy, she said Adam, ‘I know you’re crazy, but there are many more things than just one that make you who are, and they all count.’”

Adam went on to graduate and enroll in grad school, with a brilliant life to look forward to.

My student journey was every bit as problematic as Adam's. Depression had been a constant in my life since junior high, but no one back in the sixties thought kids could be depressed. The depressions worsened in college, around the same time my manias began to make an appearance. No red flags went off. To my teachers and parents, I was simply a lazy and under-achieving student. College age is typically the age of first onset for bipolar, often brought on by social and academic pressures and lack of attention to sleep. In my case, the result was a lot of failing grades and incompletes and a fast-track to drop-out status. Six years in the wilderness elapsed before I resumed my studies.

Mental illness has recently become a major concern on college campuses in the US, especially in the wake of the well-publicized suicide of MIT student Elizabeth Shin in the early 2000s, and more recently the Virginia Tech tragedy.. Since 1950, the suicide rate has more than doubled for college-age women and tripled for college-age men. According to three surveys reported in US News and World Report, 30 percent of US colleges experienced a suicide over a one-year period, 9.5 percent of students say they have seriously contemplated suicide, and 1.5 percent have made the attempt.

The same article cites an American College Health Association survey reporting that 76 percent of students felt "overwhelmed" while 22 percent were sometimes so depressed they could not function. The situation is borne out by a survey of counseling center directors, 85 percent who report an increase in severe psychological problems over the past five years. Students have grown up in an era of the disintegrating American family, the US News article notes, but they are also more used to therapy and are more likely to seek help. In the past, many kids with severe mental problems would never have made it to college, but today, thanks to new medications, they are potential clients of college counseling services.

Student depression is of particular concern. A National Mental Health Association survey reports that 10 percent of college students have been diagnosed with depression. According to Richard Kadison MD, chief of the Mental Health Service at Harvard, in an interview with Psychiatric News:

"So many students have their first incidence of depression while in college, and they are completely surprised by it. They think that it is just that they have become lazy or that they have a sleep problem."

Harvard is one of many colleges that have dramatically increased the budgets and staffing for their counseling services. Nevertheless, according to Mark Reed MD, director of counseling and human development at Dartmouth’s College Health Service, in the same Psychiatric News article:

"College mental health is one area that is really underserved." Counseling is typically limited to several visits, with students often not seeing the same psychiatrist or therapist twice.

Then there is the delicate issue of whether to include the parents in the loop. Colleges generally regard students as adults, with the counselor-client, psychiatrist-patient relationship as sacrosanct.

Yet, there is an obligation to break confidentiality if the client/patient poses a danger to him or herself or others. Federal law grants students rights of privacy, but also allows schools to contact parents if the health and safety of a student is at risk. MIT’s decision not to alert Elizabeth Shin’s parents may have been justified based on widely-held assumptions at the time. But that was then. MIT would almost certainly respond differently today. What used to be a terrible dilemma for college administrators, one hopes, is now an obvious no-brainer.

Updated Feb 15, 2008