Data Prompt State of Tennessee to Take on Depression

When Benefits Administration, with the State of Tennessee’s Department of Finance and Administration, examined health data for their employee population, they were surprised at what they found. The deep dive into data led the administration to take action using a proactive behavioral health program developed by a Tufts University researcher. The joint effort has shown positive results.

Benefits Administration’s program directors use their healthcare utilization data to work with their health plans in targeting health education and disease management programs. Like many employers, their employees tend to use high levels of healthcare for chronic illnesses. In fact, the State’s costs for treating conditions such as diabetes, coronary artery disease, hypertension, and arthritis have been higher than national norms. In contrast, they found that their costs for treating depression tended to be lower than those in other state and local government health plans, as well as other national plans.

When John Allen, director of Benefits Administration’s behavioral health services, examined the data, he concluded that depression was likely being under-detected and under-treated. Allen worked with Debra Lerner, PhD, Director of the Program on Health, Work and Productivity at Tufts Medical Center, to craft and test a pilot program for identifying and treating employees with depression who also are high utilizers of medical services. The innovative system uses a short-term work-focused intervention involving educating employees and their personal healthcare providers about how depression affects the employee at work, providing work-focused cognitive–behavioral therapy (CBT), and targeting small changes the employee can make at work that may improve performance.

Work-Focused Intervention Components

Lerner has focused her research career on measuring work loss related to a variety of health conditions, including depression, through a tool called the Work Limitations Questionnaire (WLQ; Lerner et al., 2001). More recently, Lerner has studied short-term programs that help employees who have depression with addressing their occupational functioning rather than strictly focusing on symptoms or targeting medical improvement (Lerner et al., 2012; Lerner et al., 2015). Employees with depression may find work challenging at times because the condition can have cognitive, social, emotional, and even physical effects. Consequently, depression can interfere with a person’s ability to focus on tasks, stay organized, keep pace with the work routine, and use effective communication skills and other abilities that influence work performance (Wang et al., 2004). Her novel employee-centered intervention program, called “Be Well at Work,” focuses on restoring work-related functional abilities that play a critical part in work performance (e.g., time management, balancing workload, and completing work on time) and provides support for difficult interactions with co-workers and supervisors.

Lerner’s team first helps identify individuals with depression symptoms and work limitations through web-based screenings that are promoted by the employer through a variety of workplace communications, including e-mail, the employee assistance program (EAP) newsletter, benefits communications, and monthly calls with benefits coordinators. (See the recruitment flyer “Engaging Members.” Note: Lerner suggests that using language like “managing stress” and “feeling better” is effective for recruiting participants with depression.) The State of Tennessee employees who (1) were high utilizers of healthcare, (2) screened positive for depression, and (3) screened positive for work limitations received immediate reports of their screening results and were invited to participate in phone-based Be Well at Work interventions. The interventions were led by specially trained providers, referred to as “advocates,” most of whom had EAP counseling backgrounds. The master’s-level advocates provided biweekly 50-minute telephone-based interventions over a period of 4 months to help workers change thoughts and behaviors that often accompany depression and that may interfere with work functioning. Care coordination services were also provided to link employees to healthcare providers. The Be Well at Work advocates provided monthly updates to the individual’s physician to help in coordinating the patient’s medical care and better align employee, counselor, and physician treatment goals. The updates resemble lab tests, with results covering mental health and functional status changes.

An innovative component of the program involves using work-focused coaching for problem solving and skill building to address job-related concerns. Lerner says that the advocates help guide employees on ways to discuss changes to work routines (e.g., start times or work breaks) or environmental conditions (e.g., excess noise and distraction), when needed and if feasible. The advocates may help the individual in adopting a range of possible compensatory strategies (e.g., memory aids, such as written rather than verbal-only instructions, or weekly work goal reviews).

The State of Tennessee’s Be Well at Work program was completed in July 2016. As in Lerner’s other studies, preliminary results show improvements in mental health and work performance. Longer term follow-ups will determine whether the program also helped reduce medical care costs.

Lerner’s work-focused intervention for depression has yielded significant improvements for other employers in previous studies as well. For example, in her work with the State of Maine, at-work productivity loss declined by an average of 34% in the treatment group but only an average of 3% in the usual care group, whereas productivity loss due to absenteeism improved by an average of 43% in the treatment condition but actually worsened by an average of 100% for workers receiving usual care (Lerner et al., 2012). Furthermore, the average total productivity cost savings of the program was more than $6,000 per participant annually, based on at-work productivity gains and reductions in absence. (See the employer case study about the Maine’s state government featuring Lerner's work here.)

Another telephone-based CBT study in the workplace with multiple employers (Lerner et al., 2015) showed positive results by lowering at-work productivity loss and reducing absences and depressive symptoms. The annualized marginal improvement in work productivity per participant in the program was also more than $6,000, and the program yielded a cost–benefit ratio of $6.19 for every dollar spent.
Lerner suggests that these kinds of programs are very easy for employers to implement given their flexible design and high adaptability. “By collaborating with the Tufts team, employers have been able to implement this model with minimal effort. The intervention can be done at home or at work—any location where the person has access to the Internet and a telephone,” she notes.

When employers recognize the high costs of presenteeism and absenteeism associated with depression and the stigma and other barriers that often prevent employees from seeking care, they may be interested to know that these kinds of intervention programs are being used. “This is a new area,” says Lerner, “but employers and EAPs should feel secure knowing that the Be Well at Work program has been subjected to rigorous testing and is evidence-based.”

Andrea Dowdy, D.C., Tennessee’s director of clinical services in Benefits Administration, finds the telephone-based model for this implementation to be one of its strengths. “People are sometimes hesitant to get help for a condition like depression,” she says. “The intervention allows people to have a more anonymous interaction, at a convenient time, and to feel safe and secure in their own setting.” The State of Tennessee is discussing ways to scale up this pilot program, which involved 300 employees, and they plan to offer it to all members through their current EAP.

Takeaways for Employers

Depression in working populations is treatable, as evidenced by Lerner and other researchers. Effective management of employee depression is shown to result in reduced absenteeism and presenteeism and a positive return on investment to companies, yet employers have not universally adopted these interventions. Employers play a critical role in ensuring that individuals have access to high-quality care, and they should strongly consider adding depression management programs to their benefits plans. This represents not only an important public health investment but also a sound business investment. “There are now ways for working people with depression to improve their productivity and depression symptoms. EAPs can add value by focusing on productivity improvement, rather than just symptom reduction,” says Lerner. “If you help people to be activated, they can be more informed and motivated participants in the care process.”

Here are several basic steps that employers can take to ensure effective care management:

1. Examine your healthcare utilization data and request that your health plan compare your data to other similar industry benchmarks. Compare depression data to other conditions.

2. Consider adding a depression screener—as well as a general mental health screener—to your annual health risk assessment. Screening is an essential part of detection, and undiagnosed, depression can wreak havoc on individuals’ emotional, physical, and occupational lives. Routine screening for depression is now recommended by the U.S. Preventive Services Task Force.

3. Work with your EAP and your health plan to determine whether there can be a coordinated approach to care management for employees accessing services. Additionally, while CBT is widely popular, determine whether work-focused coaching strategies are a part of your plan’s depression program. Work coaching programs are unique in that they are more centered on skill development and problem solving in the workplace rather than solely on symptom reduction. Research suggests that a work-specific component may be key in helping employees cope more effectively with depression on the job.

4. Include mental health information in your health communications. Consider having a centralized hub for health information that allows access by family members.

5. Implement an awareness program with your employees, such as the Partnership’s free communications programs, Right Direction and ICU. A knowledgeable and supportive environment fosters the likelihood that workers will feel comfortable seeking needed help.

Tools used for screening:

The Patient Health Questionnaire, depression module (PHQ-9; Kroenke, Spitzer, & Williams, 2001).

The Work Limitations Questionnaire for presenteeism (functioning at work) and absenteeism (Lerner et al., 2001).

John Allen and Debra Lerner presented on their joint efforts at the 2016 Integrated Benefits Institute’s annual conference in San Francisco. See presentation slides here.

About the State of Tennessee

State government is the largest employer in Tennessee, with approximately 43,500 employees in the three branches of government. The State of Tennessee has approximately 1,300 different job classifications in areas such as administrative, health services, historic preservation, legal, agriculture, counseling, and medical. Higher education includes two systems. The University of Tennessee (with its four campuses and three institutes) and the Tennessee Board of Regents system (with its six universities, 13 community colleges, and 27 colleges of applied technology) have 29,500 benefits-eligible employees.

Nancy Spangler, PhD, OTR/L, president of Spangler Associates, Inc., and consultant to the Partnership for Workplace Mental Health, is a prevention and health management specialist in the Kansas City, Missouri, area.

Emily A. Kuhl, PhD, owner and operator of Right Brain/Left Brain, LLC, is a consultant to the Partnership for Workplace Mental Health and a medical writer and editor in the Washington, DC, area.

Last Updated: November 2016