Matters of the Mind

In the midst of the medical-epidemiological nightmare that is the COVID-19 pandemic, which has resulted in the largest economic downturn since the Great Depression, serious concerns are now being raised about the mental-health implications of these significant life events.

The relationship between mental health and physical and financial health is indeed profound and intimate. We recently took a deep dive through The Hartford’s short-term disability (STD) claims, examining the impact of co-morbid mental/behavioral/psychological conditions on claim durations as a measure of recovery time. Over the last four years, for every major diagnostic category, the presence of a secondary, or co-morbid, psychological diagnosis resulted in significantly longer disability-recovery time. Across musculoskeletal, cancer, neurological, and even skin disorders and pregnancy claims, the presence of a secondary mental-health diagnosis made recovery more challenging in every case. It can be applied to workers’ compensation claims as well.

Notably, mental-health challenges often start out small, but then snowball into bigger problems if not addressed properly from the beginning. Many STD claims start out as intermittent leaves under the Family and Medical Leave Act (FMLA) or related state-leave law. Faced with a stressor, the employee initially tries to cope by taking a few hours or a few days off as needed, but is then forced to request longer periods of time off in terms of an STD claim if the stressor cannot be contained and mental health deteriorates further. This suggests that intervening early, during the intermittent FMLA stage, may improve recovery time, or even prevent some conditions from developing to the point that extended time off is needed via a disability claim.

FMLA is a federal leave entitlement for many American workers. If the eligible employees follow proper procedures, including providing the necessary information (which, incidentally, does not include divulging the nature of the medical or psychological condition), employers must approve this leave with few exceptions. Moreover, employers may not direct the employee’s care, such as requiring that they see a particular doctor or clinic to approve the FMLA leave. Beyond that, there is nothing in the FMLA law that prevents employers from making assistance available, which, of course, employees are free to accept or not.

As a foundation to the present study, The Hartford carried out a small proof-of-concept pilot in which it offered assistance to those employees who requested FMLA time off for a divulged mental-health condition. The assistance consisted simply of providing these employees with information on how to access their employee assistance program (EAP) and other relevant available reference material. For those who accepted the information (referred here as those who “engaged”), their FMLA durations turned out to be 18 percent shorter. For those who subsequently filed STD claims, their STD durations were similarly shorter—but this was a small pilot.

The Hartford has now completed a larger follow-up study in partnership with a large multi-national employer client, UPS. Employees requesting FMLA on the basis of a mental-health challenge were contacted early on by a behavioral-health clinician, who offered assistance with finding helpful resources. Most FMLA requests were based on issues related to “stress/anxiety/panic,” with “depression” as the next most frequent basis. Overall, depression turned out to have a larger impact than stress. Employees filing for leaves associated with depression averaged five more days on FMLA than did those filing on the basis of stress (37 percent longer). Those who subsequently filed an STD claim remained out of work twice as long for approved depression STD claims than those out of work for stress (50 versus 25 days). This particular outcome is not surprising. Depression is usually more deeply ingrained, while stress is more often situational. We have found consistently that STD claimants with a primary physical diagnosis who also presented with depression as a secondary or co-morbid condition take longer to recover than those with anxiety or stress as a co-morbidity.

The impact of employee engagement on FMLA durations was similar to that in the earlier pilot: For employees with stress/anxiety/panic, engagement with the clinician resulted in three fewer leave days (18 percent) on average, while there was no clear impact of engagement on leave durations for depression.

However, the impact of employee engagement grew more apparent over time, once a leave extended to an STD claim, and was much greater for absences associated with depression than stress. While 17 percent of leaves due to stress subsequently transitioned to approved STD leaves, 50 percent of the leaves due to depression transitioned to STD leaves. For employees with stress leaves, engagement with The Hartford’s clinician during the FMLA leave period resulted in those employees who transitioned to an approved STD leave returning to work 22 days earlier than those who did not engage during the FMLA leave period. However, engaged employees out of work due to depression returned to work from STD leave an average of 31 days earlier, as compared to those who were “not engaged,” a very notable 76-percent improvement.

In sum, when employees apply for an FMLA leave and disclose that their leave is based on mental-health challenges, be prepared for those issues to cause extended absences if not addressed with helpful interventions, particularly if they are based on depression. Offering assistance early may have a small impact on the leave durations (particularly for “stress” leaves), but the larger impact will be helping the employee with an earlier successful return to work.

These results largely replicate our earlier, smaller pilot with a different employer. We conclude that even a very light touch from a behavioral health clinician very early in the “continuum of absence” can have a significant impact downstream on helping employees return to work sooner. Why would such a small measure—in this case, the primary information was how to contact the employee assistance program—have such a large impact? Many employers offer generous benefit plans, and human resources professionals often spend considerable time and energy educating employees about available employee benefits. But employees are busy and are often unable to appreciate the variety of company benefits available to them, such that by the time they need the information, it may take too much time and effort to find it. The required effort may be particularly challenging when they are under stress or depressed, yet that is when they need the information most urgently.

Those working in the workers’ compensation space, not disability, may be asking if these findings have any relevance for their own situations. In previous articles and presentations, we have argued that there are more similarities than differences regarding the impact of STD and workers’ compensation injuries, and that it may be advisable for workers’ compensation professionals to learn from strategies developed by their STD colleagues, and vice-versa. Studies show that mental-health comorbidities, and depression in particular, result in significant delays in recovery from physical injuries, even minor injuries. While it is difficult to quantify the significance of psychological co-morbidities in workers’ compensation because, in most states, these are not considered compensable claims and often are not even recorded, it is possible to get a sense of their importance by looking at the impact of anti-depressant and anti-anxiety prescriptions on the cost and duration of workers’ compensation claims.

According to a California WCI research update, in the California workers’ compensation system in 2018, psychoactive medications accounted for 8.3 percent of all prescriptions. A recent study entitled “Association of Opioid, Anti-Depressant, and Benzodiazepines With Workers’ Compensation Cost: A Cohort Study,” which appeared in Occupational and Environmental Medicine further quantified the impact of depression and anxiety on recovery times and cost for workers’ compensation injuries. Having anti-depressants prescribed was associated with an additional $22,318 in medical costs and $50,911 in total claim costs, respectively. The effect on total paid workers’ compensation costs associated with anti-depressant prescription was greater in magnitude than all other drug classes. In fact, anti-depressant prescriptions were associated with a three-fold increase in the likelihood that the workers’ compensation claim would cost more than $100,000.

So, how might we apply these findings to workers’ compensation cases? It has long been documented that the employers play a critical role in the recovery of their employees. Injured workers who feel supported by their employer get back to work much faster, and supervisors, in particular, can have an enormous impact. When supervisors call employees after an injury to inquire how they are doing, it would be advisable to add a few sentences to the conversation to make sure they know the employee-assistance program number to call if they feel increased stress, worry, fear, or depression while they progress through their recovery (which many of them will experience). Sometimes the simplest, least costly solution is the one that works best.

Authors’ note: We are grateful for the unwavering support of UPS for this project, and most particularly of UPS Health Plans Supervisor Wendy Gilleland. We also thank Hartford BH Clinician Lourdes Zapata, Team Lead Brenda Shaffer, Business Analyst David Greenberg, and Senior Client Relationship Manager MJ Harris—all of whom were critical to the project.