Depression & Anxiety in the Great Recession
The Jefferson Center for Mental Health is the proverbial safety net, a community nonprofit that caters mostly to the uninsured, the elderly, the homeless, the poor.
Lately, though, a different patient profile has emerged: "Middle-class people whose financial foundation has sort of collapsed in free fall," is how Dan Fishbein, the center's corporate business director, puts it. "To give you an example, I remember specifically a couple of Realtors who called in. No job. No income. I assume they had savings, but they're really dealing with free fall, and they might not have insurance. Three or four years ago you'd never see them."
The economic impact of the recession has been well documented: national unemployment hovering at 10 percent; one in four homeowners owing more on their houses than they're worth; foreclosures looming for many; family breadwinners working two part-time jobs that pay less than the job they lost, without benefits.
Less discussed has been the recession's impact on mental health since the toll on personal finances and jobs turned severe in late 2008.
"We normally serve about 5,000 to 6,000 people a year," says Jeanne Oliver, chief communications and development officer at Jefferson Center. "We surpassed that last year, and I believe our actual admissions per month are up about 40 percent."
Recognizing the stress the recession has put on people and their families, the Jefferson Center in April 2009 launched a program called Jefferson Center Partners, offering up to 10 counseling sessions for $5 per session for people dealing with mental-health issues related to the economy.
Similarly, the Mental Health Center of Denver has seen its role as a community safety net widen to include a more mainstream demographic. Last year, MHCD treated 13,500 people - 2,000 more than the previous year.
"There are people who we typically wouldn't see who have wound up on our doorstep," says Dr. Carl Clark, CEO of MHCD, who still practices as a psychiatrist. "People who have lost their jobs, they've lost their homes, they've become homeless for the first time in their life, and the result of all that is people having mental health problems that they never expected to have."
The increased demand for behavioral-health services becomes understandable in the context of the national unemployment rate - 9.7 percent nationally, 7.5 percent in Colorado - when you consider the view of Dr. Ted Wirecki, a Denver psychiatrist and former medical director of Anthem Behavioral Health.
"For people who don't have a job and who want to work ... next to major marital problems that's the biggest stressor there is," Wirecki says. "So if you have any kind of pre-existing depression/mental illness and you do lose that job ... it doesn't tend to cause mental illness, but it tends to exacerbate it for those patients who have a pre-existing condition."
One positive development for those who still do have a job - and health insurance - is the federal Mental Health and Substance Abuse Parity Law, which went into effect in October 2009 and became mandatory upon the first renewal period for health-insurance plans - January of this year for most. The new law is a stricter and more encompassing version of the 1996 Mental Health Parity Act.
Simply put, the "parity law" requires health plans to offer mental health and substance abuse coverage that is equal to the plan's coverage of medical-surgical benefits in terms of coverage-dollar limits, hospital-stay limits and co-payments. The law applies only to companies with more than 50 employees. It also only applies to insurance plans that offer mental-health and substance abuse coverage.
While health officials view it as a step toward better mental-health care, the predictable concern for most companies is cost. Dr. Doug Nemecek, national medical director for CIGNA Behavioral Health, estimates that the typical plan will increase total medical costs by about 0.4 percent. Inadequate mental-health-care treatment could cost a company more in the long run. As Nemecek points out, "Depression and other mental health issues can have a huge negative impact on an employee's productivity."
Untreated mental-health disorders cost the U.S. economy $80 billion annually in lost productivity, sick leave and unemployment, according to a report by the Commission on Mandated Health Insurance Benefits presented in March 2007. Using Colorado Department of Labor Figures, the commission estimated the losses within the state at $886 million in lost productivity and $170 million in medical costs associated with untreated depression.
No doubt, the recession has at least exacerbated problems for those prone to anxiety or depression. Unemployed Americans are four times more likely than those with jobs to report symptoms of severe mental illness such as major depression, according to a survey released in October 2009 that was conducted for Mental Health America, the National Alliance on Mental Illness and the Depression is Real Coalition. And yet the point in which a person becomes unemployed and thus most vulnerable to mental health issues is also the point when health insurance disappears, although self-funded COBRA plans provide a temporary extension of coverage.
From an emotional standpoint, a job provides more than money. "They're not things we generally think about when people go to work, but it has to do with social connections and relationships and involvement," Clark of MHCD says. "And if all that starts to get strained, even people who still have their jobs might not experience the kind of usual support they got from their work like they did in the past."
Indeed, a term has even emerged to describe the problems of those who keep their jobs amid their company's work-force reductions: layoff survivor syndrome.
Though not a formal diagnosis, Jodi Prohofsky, senior vice president/operations at CIGNA, describes layoff survivor syndrome as a combination of guilt, fear of being next to fall, confusion, and the stress of handling what's often an increased workload in a downsized workplace.
One way companies are tending to their workers' behavioral-health needs is through Employee Assistance Programs, which are funded by the employer. EAPs typically allow employees up to three confidential behavioral counseling sessions at no cost. Either the problem is resolved, or a more serious condition is identified, and a course of behavioral-health treatment recommended.
Employee Assistance Programs have also come into play for companies going through work-force reductions that want the help of a mental-health professional to do it. In what's known as a critical-incident stress debriefing, the EAP provider will send in a mental-health professional to meet in group and individual settings with employees impacted by a work-force reduction.
"Employers know these are difficult messages to deliver," says CIGNA's Prohofsky. "They don't want to deliver them, but they have to. So we provide help in terms of the best way to phrase things, to help people get through the message. Employees are, of course, dealing with the message itself."
Requests for "layoff services" such as critical-stress debriefings from CIGNA's corporate clients more than doubled from 2008 when there were 227 requests, to last year when the number soared to 479.
Bill Lindsay is president of the Lockton Benefit Group-Colorado, the division of a worldwide insurance broker that represents more than 500 employers in Colorado. Lindsay says EAPs have been a positive step for companies addressing behavioral health, an issue with a history of neglect in the workplace.
"Mental health needs are not being discussed openly and frequently," Lindsay says. As a contrast, he cites the shooting earlier this year at Deer Creek Middle School in Littleton in which two children were injured and says, "Immediately there's a recognition that we need to bring in counselors; we need to do things to try to help people. But that, in our society, unfortunately, is more of an exception rather than the rule. And it usually rotates around fatalities as opposed to just daily stress that people are under. But clearly individual stress levels are increased.
"I think if you went and polled Toyota employees today, they would be very concerned about their financial future, very concerned about their employment just because of what's happening at Toyota. Does that translate for some people into the need for mental-health services? I think absolutely it does. But seldom in my experience do companies connect the dots."
Littleton-based Mines & Associates is a 26-year-old business psychology firm that provides employee assistance programs, managed mental health care and other services to more than 400 companies, including about 300 in Colorado. CEO Robert Mines says he has seen a 50 percent increase in utilization of his firm's services in the last year and a half.
"We get data on every company and their employees that we work with," Mines says. "We've seen a significant increase in people with financial stress coming in. Just through the roof. They're either seeing our mental-health counselors related to their anxiety, or they're seeing our financial consultants."
Mines & Associates has also introduced programs for people who survive layoffs, "to help them cope with increased workloads they have, as well as their loss issues related to their colleagues leaving."
While Mines doesn't believe demand for mental-health care has overwhelmed the industry, he also points out, "All our people have insurance. It's the uninsured group that's probably the one that's had the most difficult time - the people who have been laid off."
And as Lockton's Lindsay points out, "The corollary to that is also valid: In most cases employers don't go through a RIF (reduction in force) unless financially they've got some challenges. For them to provide a more extensive outplacement counseling service is going to cost them money. So it works both ways. It works against the participant, but it also is a challenge for the employer who is trying to deal with this issue."
Bob Brown sees the issue of behavioral health care from two sides, as a trustee of the Colorado Contractors Trust, a self-funded group health benefit plan for contractors; and as chairman of Brown-Schrepferman Co., a commercial building contractor founded in Denver in 1889 by Brown's great grandfather, Alexander Brown.
Mines & Associates manages the employee assistance program or behavioral health component of Colorado Contractors Trust. Brown says use of the EAP is up only slightly and attributes that increase to workers foreseeing a layoff coming. "A lot of these people are taking advantage of the health insurance they have before they lose it completely," he says.
Brown, 55, knows well the feeling of recession-induced stress. Eighteen months ago his firm boasted three superintendents, 12 to 20 people in the field and four employees in the office. Now he says, "We're down to no superintendents, nobody in the field and 1½ in the office.
"It's been going on like that for the better part of a year and a half," Brown says. "It's hard on me to have to look at them knowing I'm going to have to let them go next week. You kind of second-guess everything you've been doing for the last 30 years. And it's hard on them.
"They realize we kept them on as long as we possibly could," Brown says. "But when the work ran out, they all understood. Not that they liked it, but they understood."
Brown says it makes business sense for the Colorado Contractors Trust's health plan to embrace mental-health care. "There is more of an emphasis on it to make sure all the people you've got working for you are, I guess, mentally stable. If they've got problems, I mean alcohol, drugs, personal relationships, depression ... you don't need those problems brought to the job. It's somewhat of a safety issue along with everything else. Over the years I think mental health has sort of been brought to the forefront of everybody's conscience. Maybe there are not so many people who are as bashful as they were before about something like that."
Back at Jefferson Center for Mental Health, patient intakes were up by 100 in February compared to a year earlier, a 25 percent increase, according to Tom Olbrich, director of access and emergency services at the center.
"Not all those are directly the result of the downturn in the economy, but a lot of them are," Olbrich says. "They're people who used to have health insurance but now don't. So they're coming to us."
Olbrich has seen the center take calls in recent months from a 40-something former mortgage banker with suicidal thoughts who had lost his health insurance and whose COBRA period had expired; a laid-off secretary now working two lesser-paying jobs and distraught that her two children have to spend most of their time with relatives; and a Realtor who hadn't sold a house in six months and was fraught with anxiety and insomnia.
"Somebody asked me once what's the worst thing mental health centers do," says Olbrich, who has worked at Jefferson Center for 12 years. "I think sometimes we get people who come in because they're depressed because they've lost their job, and we treat the depression. Which is what we do. But they still don't have a job, so they need support and resources in terms of how to address those issues as well."
Olbrich identifies three groups impacted in varying degrees by the recession: those who still have a job but have seen their investments or retirement plans diminished; others whose two-family incomes have been cut in half by a layoff and who can't provide for their children or themselves the way they used to.
"Then there's the third group," Olbrich says, "where there's a loss of job, loss of all income, home foreclosures ... folks who had adjustable mortgages and suddenly they're in big trouble because they can't meet the mortgage payments. They are more desperate because they're on the brink of losing their home or have lost their home. Those are the ones we're seeing now for sure here that we didn't use to see."