Workplace Symptoms of Dual DiagnosisGoal: To find symptoms of depression that may appear in the workplace masked as other behavior. An Axis I disorder that may be present in the workplace is depression. In fact, according to a study in the Journal of Clinical Psychiatry, one in every ten employees suffers from depression, which accounts for 200 million lost workdays per year. Depression can present itself in the workplace in many forms, including:· The quantity or quality of a person’s work may be lower than what it had been in the past;· A person may not care to join in company-sponsored events, or feel like there is little reason to be happy at work;· A person who used to have very good attendance and promptness is often late to work or meetings, or doesn’t show up at all;· A person’s uncooperative demeanor towards others seems to be beyond his or her control;· Ability to solve problems or think outside-the-box is reduced;· There is less drive to accomplish goals;· Conversation often includes complaints about aches and pains;· A person may give up easily and think there is no use or hope in the work he or she is doing;· There may be a noticeable gain or loss of weight;· Thinking is disturbed and the person may have trouble focusing and staying on task. He or she may be having a hard time remembering facts or making decisions;· A person who had always derived pleasure from coworkers and the work done together may no longer view his or her workplace as somewhere he or she enjoys being (Depression).

It is very important that employers are trained to recognize these behaviors as possible symptoms of depression. They can do this by privately meeting with the employee and expressing concerns regarding his or her behaviors as it relates to job performance. Assuring the employee of his or her value to the company may make the employee more apt to open up and consent to seeking help. In addition to absenteeism from work, a newly-coined phenomenon, presenteeism, is accountable for untold problems in the workplace. Presenteeism occurs when a person is at work while at less than full mental or physical health, resulting in decreased productivity and below-normal work quality. A group of researchers at Stanford University created and tested their 34-Item Stanford Presenteeism Scale (SPS-34) on 175 county health employees in an effort to identify characteristics of presenteeism. This resulted in the SPS-6 Scale which uses identified characteristics to measure health and productivity (Koopman 2002). A second study at Stanford concluded that the SPS demonstrates a high degree of reliability and validity and may be ideal for employers who want a single scale to measure health-related productivity in a diverse employee population. Bipolar disorder, formerly known as manic depression, interrupts normal moods with manic and major depressive episodes. Between manic and depressive states, most people with bipolar disorder return to their typical level of functioning. This can be very confusing to coworkers and managers in the workplace. A recent study at Ralph H. Johnson Department of Veterans Affairs Medical Center in Charleston, South Carolina studied 106 patients to see whether patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance abuse disorder alone. Of the 106 patients, 18 had bipolar disorder alone, 39 had substance use disorders alone, and 49 had both bipolar and substance use disorders. The study concluded that despite significant functional impairment among patients with comormid bipolar and substance use disorders, these patients had significantly fewer psychiatric outpatient visits than those with bipolar alone, and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone. More disturbing, the study found that compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal (Verduin). Tracey Wright-Riley, RN, is a disability manager at the University of Michigan Health System. She cautions that the negative stigma of mental health often prevents people from seeking help in the workplace. To compound things, 65% of those with bipolar disorder refuse to admit they have it until they have been suffering between ten and fifteen years. 50% of people with schizophrenia cannot acknowledge they have the disorder. Finally, sometimes the brain cannot know that it has a disorder. Instead, their behavior might mirror that of a disinterested, unmotivated or confrontational employee (Wright-Riley). Wright-Riley was confronted by a manager who voiced concerns about one of her star employees. Before the employee’s recent dimished job performance, absenteeism, and conflict with coworkers and supervisors, this employee had always been a model employee. She is well educated, and had always been self-motivated and goal oriented. Her sudden change in behavior was causing concern in her department. The manager had issued written discipline in an effort to correct the behavior. The manager went to Wright-Riley to see what else could be done. Wright-Riley met with the employee and identified severe symptoms of depression. The employee agreed to enter outpatient day treatment for her depression, and was put off work on a Family and Medical Leave of Absence for three and a half weeks. After a short period of reduced work hours, the employee was able to ease back into a full time schedule much better equipped to deal with her depression and the personal problems that were the underlying cause. This intervention saved a good employee’s employment while saving the company thousands of dollars in recruiting and training a replacement if the employee had been terminated for poor work performance. The astute perception by the manager who reached out for help before terminating the employee is what employers need to encourage in their managers and supervisors (Wright-Riley). Depression and alcohol abuse disorders know no boundaries. They can affect any socio-economic group of people. The Americans with Disabilities Act (ADA) of 1990 addresses the problem of disabilities among medical school students due to substance abuse or mental illness. Included in the ADA’s definition of disability is the recovery from alcoholism and addiction, as well as active alcoholism that does not adversely affect performance. To qualify for ADA protection, the student must meet all requirements for admission to a medical school, be able to fulfill the requirements of a medical education – with or without reasonable accommodations – and pose no direct risk of substantial harm to the health and safety of others. An eight-year study at the University of Louisville concluded that 20% of their medical students had sought psychiatric consultation and treatment for reasons such as adjustment, mood, anxiety, compulsive and dependent personality disorders. In addition, alcohol and drug addictions represent 80% to 94% of all cases investigated by state physician impairment programs (Aristeiguieta).

Financial Impact on Businesses Due to Dual DiagnosisGoal: To show statistics that tie impact of dual diagnosis in the workplace to a decreased financial bottom line of businesses. When dual diagnosis in the workplace is left unrecognized, and therefore untreated, it can financially impact the company’s bottom line. The U.S. Department of Health, Education and Welfare notes that, on average, a woman with the onset of bipolar disorder at age 25 will experience a 9-year reduction in life expectancy, and a loss of work-related productivity of 14 years. However, with treatment, this same woman can regain 6.5 years of life expectancy and ten years of work productivity. Mercer Human Resource Consulting conducted a survey of the Canadian Mental Health Association in Toronto. Those surveyed were 134 Ontario-based public and private sector organizations, 44% of which have more than 500 employers. The survey covered the period February 2003 to February 2003. 68% of the employers reported increased employee absence and 61% reported decreased productivity related to mental health conditions. In addition, 4% to 12% of payroll costs in Canada are contributed to disability claims or leaves of absence due to mental illness. Even with these staggering statistics, only 7% of the employers have trained managers to identify and address mental health issues. Many human resources departments are caught in a situation where upper management pressures them to just cut costs, without addressing the root cause driving increased costs (Gonzalez). Depression, which is the cause of 80% of psychiatric disabilities, is responsible for $24 billion in lost productivity and workdays in America. Mental illness is the primary diagnosis in 10% to 20% of all disability claims. Because of the link between depression and other disabling health problems, it is also the secondary diagnosis in up to 65% of all disability claims. Joseph F. Braunstein, senior vice president of CIGNA Group Insurance, says that programs that focus on treating and accommodating workers with mental disabilities can help businesses reduce productivity losses significantly (Braunstein). Disability leaves of absence for dual diagnosis and depression alone are costing companies disproportionately more benefit dollars than disability leaves needed for other types of diagnoses. A group of researchers from Tuft-New England Medical Center in Boston, MA studied the work outcomes of employees with depression. They collected baseline and six-month follow-up survey data from 229 employees with dual diagnosis, and two comparison groups: 1) control group of healthy patients, and 2) a group with rheumatoid arthritis, which is a frequent source of work disability. The outcomes studied were 1) new unemployment, 2) job retention, 3) presenteeism, and 4) absenteeism. At the six month follow-up, the employees with depression had more new unemployment – 14% for those with dysthymia, 12% for those with major depression, and 15% for those with the dual diagnosis of dysthymia and major depression. This compares with 2% in the control group and 3% for those with rheumatoid arthritis (Lerner). The costs associated with absenteeism are staggering. However, with enhanced care for depressed workers, the associated annual economic benefit is estimated at $1,982 per depressed full time employed worker. Absenteeism is reduced by 22.8% in all depressed workers, and by 28.4% in consistently employed depressed workers (Rost).

What Businesses Need to do to Manage Dual Diagnosis in the WorkplaceGoal: To list ways employers can proactively and reactively help employees with mental health issues. Employers need to first figure out if they are creating or contributing to mental illness in their workplace. Then they need to train supervisors and managers to recognize the symptoms of mental illness and, finally, provide preventative and collaborative case management programs to alleviate the problem and reduce its exposure to increased costs. A recent Mercer study reveals that 90% of employers say their workers are facing increased workloads. 68% of employers notice an increase in absenteeism and 64% said emotional tension is prevalent among their employees. Employers with poor management practices like placing unreasonable demands on their employees, while ignoring their concerns about stress and doubts about job security, are building an atmosphere that can lead to depression and anxiety disorders. Such practices cost companies $33 billion in lost productivity a year (Moxley). It will take some very basic preventative steps and a commitment from management to address mental health issues in the workplace that will decrease the problems of dual diagnosis in the workplace. There must be improved communication between employees and supervisors or managers to remove the stigma of mental health issues. However, the supervisors and managers need to be trained to understand mental illness and substance abuse disorders so that they are not afraid of it when they speak with employees. It is unlikely that these disorders will be treated if employees feel stigmatized by it. Regular communications regarding mental health benefits, perhaps at open enrollment meetings where other healthcare benefits are outlined, will send the message that it is acceptable to seek mental health help. The United States Air Force Chief of Staff was alarmed at the high rate of suicide among Air Force personnel. He conducted a study, and concluded that employees suffering from mental health challenges were reluctant to get help. He launched a communication campaign to encourage employees to seek help in times of emotional pain and trauma, and to stress that this philosophy was embraced by those in the highest levels of the military. After the communication program was put into place, the suicide rate between 1994 and 2002 dropped by 50% (Workplace). President Bush, when establishing the New Freedom Commission on Mental Health, said, “Stigma leads to isolation, and discourages people from seeking the treatment they need. Political leaders, health care professionals and all Americans must understand and send this message: Mental disability is not a scandal; it is an illness. And, like physical illness, it is treatable, especially when the treatment comes early.” Supervisors and managers need to reassess workloads to ensure unreasonable demands are not placed on some employees. Regular and consistent performance reviews that communicate not just what the employee is doing wrong, but what he or she is doing right improve communications. If they include self-reviews in the process, the supervisor or manager can see if there is an unequal distribution of tasks. The World Health Organization encourages employers to take an active interest in creating an environment that sustains optimal mental health in the workplace. They suggest employers follow these eight steps:1. Develop manager awareness of mental health issues.2. Identify common goals and positive aspects of work processes. 3. Create a balance between job demands and occupational skills. 4. Provide training in social skills throughout the organization. 5. Develop a workplace environment that supports the social and psychological health of employees. 6. Make provisions for counseling. 7. Enhance employees’ work capacity. 8. Teach managers to employ early rehabilitation strategies (Depression).

Employee Assistance Programs (EAP) can be a literal lifeline to someone who is suffering with mental illness and a substance abuse disorder.

Passive, ill-informed employers make EAP providers rich, according to Terry Dunivin, owner of Ann Arbor Consultation Services, an EAP provider. Employers pay for EAP plans, and then don’t use them to their full potential. It is up to the employer to request a copy of the plan’s Summary Plan Description to see just what they are paying for. Some EAP providers will be only too happy to sit back and collect a company’s monthly premium for doing little to nothing. They are not eager to remind companies to use the products they’ve paid for. Most EAP plans are not one-faceted plans offering counseling for employees and their families. Very basic plans can cost $24-$36 per employee (total employees, not just those opting for the plan), and often include consultation and onsite training for supervisors and managers regarding managing performance, policies, training/organizational development, and career development. If not included in the basic plan, for an additional fee, and EAP will align with a company’s other providers, such as occupational health, disability and wellness. Employers can design utilization reports that give data to confirm the value it is receiving from the plan. Using these reports, the company can respond to specific issues like retention of employees, the fear of layoffs, and needed training. The data on the reports may also support adding additional services to the company’s existing EAP plan (Dunivin).

Goal: To outline how employers must partner with mental health care professionals to design supported employment for those with dual diagnosis. Employers can be a productive component of dual diagnosis treatment. Often, people with dual diagnosis are so demoralized by the impact of two severe illnesses that they do not think about working and do not believe they can recover. Goals that are defined by a patient and his or her mental health provider can be supported by the employer and incorporated into the patient’s recovery plan. In the Rehabilitation Act Amendments of 1986, supported employment was defined as competitive work in integrated work settings with follow-along supports for people with the most severe disability. Supported employment has been carried out in many ways, but research gives specific coordinating guidelines for mental health providers and employers to affect better employment outcomes:1. Encourage people with dual diagnosis to consider working. Employment is often a stepping-stone to recovery, providing structure to the person’s day, meaningful goals, self-esteem, finances, and sober friends. Those in supported employment often become motivated to pursue abstinence if they have a job. 2. Include substance abuse in the vocational profile. Mental health care givers often interview present and former employers so they can collaboratively put together a relevant vocational profile. Working together, the caregivers and the employer can determine jobs the person can and cannot do, based on symptoms or severity of the dual diagnosis. 3. Find a job that supports recovery. Employment can be stressful, so planning a job for a person with dual diagnosis depends on information from the vocational profile. People can have specific triggers that tend to promote their substance abuse. 4. Help develop a plan to manage money. Ready cash in the pocket can prove to be a stimulus for substance abuse. The health care worker and the employer can work together to encourage direct deposit of a person’s paycheck into bank accounts. 5. Use a team approach to integrate mental health, substance abuse, and vocational services. For people with dual diagnosis, integration of treatment and rehabilitation is more effective than non-integrated plans. The health care worker and the employer can ensure a multidisciplinary treatment team from a consistent core of providers that will promote recovery from both substance abuse and mental illness (Becker).When a person with dual diagnosis is going to be returning to work, CIGNA Group Insurance and CIGNA Behavioral Care agree it will take a concerted effort between the mental health provider and the employer. They list eight steps employers must take to successfully return the person to work:1. Focus on returning the employee to work at the level they were functioning before the disability, whenever possible. This may include a period of reduced hour work.2. Assess the employee’s life situation. Any treatment and return-to-work plan must address psychosocial factors as well as the illness itself. The employer would not want to place the employee in an area where substance abuse triggers abound. 3. Adjust workplace conditions and job requirements to assist a disabled employee’s transition back to the workplace. CIGNA Group’s experience illustrates that most accommodations are simple and much less expensive than employers fear. 4. Concentrate on the employee’s strengths and abilities rather than a particular aspect of the illness. 5. Address those symptoms that are disabling rather than dwelling on the overall illness. 6. Address both medical and behavioral components in case management. 7. Assure that needs of both employer and employee are met in return-to-work programs. 8. Establish and promote employee assistance programs, which increase productivity and help employees address issues before they become serious enough to affect productivity and availability for work (CIGNA).

What the Employee Diagnosed with Dual Diagnosis Can Do to Get HelpGoal: To show different ways employees can access their EAPs. EAPs are designed to make access by those in need easy, convenient, and, sometimes, fun. The tradition EAP will offer a toll-free number people can access 24 hours a day. Most plans will have these calls answered by a licensed behavioral health professional that is a certified EAP coaching specialist. Most plans also have a web-based tool people can access to find answers to questions from ‘How do I research a nursing home for my aging parents’ to ‘I’m having trouble with my supervisor.’ From these sites, modules on topics like depression, stress and anxiety, and substance abuse can be read and printed (Pacificare). EAPs are IPOD-friendly, too. Ceridian, a provider of EAP services, has converted its online advice pamphlets and tip sheets into a format that workers can burn onto a CD or download onto an MP3 player. This enables people who favor portable electronics to listen to information where and when they choose. If information is more readily available, it’s more likely to be embraced (Cummins).