An Executive Guide to Workplace Depression

Author(s): Joseph Kline, Jr. and Lyle Sussman

Source: The Academy of Management Executive (1993-2005), Vol. 14, No. 3, Themes:
Structure and Decision Making (Aug., 2000), pp. 103-114
Published by: Academy of Management
Stable URL: http://www.jstor.org/stable/4165663
Accessed: 08-04-2016 00:18 UTC

REFERENCES
Linked references are available on JSTOR for this article:
http://www.jstor.org/stable/4165663?seq=1&cid=pdf-reference#references_tab_contents
You may need to log in to JSTOR to access the linked references.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
http://about.jstor.org/terms

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted
digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about
JSTOR, please contact support@jstor.org.

Academy of Management is collaborating with JSTOR to digitize, preserve and extend access to The
Academy of Management Executive (1993-2005)

This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
? Academy of Management Executive, 2000, Vol. 14, No. 3

......................................................................................................................................................................

An executive guide to
workplace depression

Joseph Kline, Jr., and Lyle Sussman

Executive Overview
Whether coping with their own lives or managing the lives of others, executives face
the reality of major depression. Unfortunately, mental illness generally, and depression
specifically, are not as well understood as physical disabilities. The general public
continues to hold prejudices and misconceptions regarding the cause and treatment of
depression. In this article we summarize relevant literature addressing these prejudices
and misconceptions and analyze the major issues managers should consider when
dealing with depressed employees. We offer four prescriptions for balancing the
conflicting demands imposed by the law with concern for the employee, the safety of
others, and shareholder value.
* a ..........- . . ...* ....... .................... .. . ......-.... - @@ @ . .. . . . . .. . * * . .- .- . . .. . . .. .- .--- . . e e-v .. . . vv v v .- . . .. . . .. . *** .. . v v . .- . . . ** . . .. . e--

And yet the dread and despair I had been infirmity, cloaking it behind personal time, sick
feeling for many weeks hovered around my time, and vacation.3 The root cause of depression's
head like a black cloud-following me stigma, like the root cause of any other popular
wherever I went ... I found myself seeking a misconception, is lack of understanding and accu-
kind of quiet solitude as far away from my rate information. Such information reveals, for
friends and coworkers as possible . .. I instance, that:
couldn't understand why I could no longer
perform the simplest tasks ... It was as if I * depression is the seventh most common cause of
was paralyzed. Having always been a per- adult deaths;4
fectionist, it was difficult for me to grasp * more than one in six Americans will suffer an
why I was suddenly so totally useless and episode of major depression in their lifetimes;5
unproductive.' * depression costs society $44 billion yearly;6
* depression-related absenteeism costs busi-
Can anyone truly understand the "dread and de- nesses $11.7 billion yearly;7
spair" experienced by another? This question is at * managed care's reliance on primary care gate-
the heart of a serious and misunderstood illness- keepers results in inadequate detection and
major depression. More than 30 percent of the pop-
treatment of major depression.8
ulation still hold the antiquated belief that the
mentally ill simply lack the will to help them-
Depression is not only a societal problem. It has
selves.2 Proponents of this misconception also tend
profound implications for managers as well. Aside
to minimize the gravity and consequences of de-
from dealing with the societal norms and personal
pression. The stigma attached to depression is
prejudices associated with mental illness, manag-
probably in part responsible for the shame and
ers must also balance the conflicting demands im-
embarrassment that so often accompanies the
diagnosis. posed by the Americans with Disabilities Act
(ADA),9 along with humanitarian concerns for the
troubled employee, against the constant need to
The Scope of Depression improve shareholder value. In an increasingly liti-
The stigma of depression thrives in the workplace. gious society, managers often find themselves try-
Eighty-four percent of 4,000 HR professionals sur- ing to help the employee without hurting the com-
veyed believe that depressed workers hide their pany.

103

This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
 104 Academy of Management
The purpose of this article is to help managers
deal with the conflicting demands created by the
depressed employee. Specifically, we summarize
In an increasingly litigious society,
managers often find themselves trying to
help the employee without hurting the
company.
and highlight four major issues affecting organi-
zational and managerial responses to employee
depression. First, we define depression and high-
light its prevalence in the workforce. Second, we
summarize the direct, indirect, and noneconomic
costs of employee depression. Third, we summa-
rize the latest clinical data concerning the treat-
ment of depression. Finally, we discuss the contro-
versial effects of managed care on the diagnosis
and treatment of depression, and the consequent
implications for corporate health plan choices. We
then synthesize these summaries into four pre-
scriptions managers should consider when bal-
ancing compassion for the employee with the need
to protect and enhance shareholder value.
What is Major Depression?
Major depression is a serious and frequently chro-
nic mood disorder characterized by one or more ma-
jor depressive episodes in the absence of mania or
hypomania.10 The disorder is better known to the
general public by the term clinical depression.
The Diagnostic and Statistical Manual of Mental
Disorders,"I commonly called DSM-IV, is the diagnos-
tic bible of the mental health community. It defines a
major depressive episode by specific criteria that go
well beyond the concept of sadness. Diagnostically,
major depression exists either as a single episode or
in recurrent forms. Once an individual experiences
the first episode, there is a 50-percent chance of a
second episode months to years later.'2 With each
episode, the risk of future episodes increases.
Diagnosis of depression
The DSM-IV specifies that the diagnosis of major
depression requires the presence of five signs and
symptoms,'3 including either a depressed mood or
markedly diminished interest or pleasure in all or
most activities. Additional signs and symptoms must
be present from a list that includes marked psy-
chomotor retardation or agitation (slowed or agitated
movements, for example); significant appetite or
weight change; significant changes in sleep; fatigue
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Executive August
or loss of energy; problems thinking, concentrating,
or deciding; feelings of worthlessness; excessive or
inappropriate guilt; and thoughts of death or suicide.
Finally, the signs and symptoms must be present for
at least two consecutive weeks. Because it takes time
for depressed individuals to actually recognize that
they are depressed and need help, it is extremely
rare for a patient to be evaluated before this two-
week period has elapsed.
Difficulty in concentrating may be one of the most
prominent symptoms in affected workers. A de-
pressed employee may be unable to think clearly,
process information well, or contribute effectively in
groups.'4 Turner extends the list of job-related signs
of depression to include decreased productivity, mo-
rale problems, lack of cooperation, safety problems,
accidents, absenteeism, complaints of constant fa-
tigue, complaints of unexplained aches and pains,
and alcohol and drug abuse.15
Demographics of depression in the workplace
Depression knows no boundaries. The disease can
strike executives as easily as entry-level workers,
but with more devastating effects on the business.
The organizational consequences of depression
may be exacerbated as a function of the overrep-
resentation of men in the upper echelons of most
companies. With their need to reflect a strong ex-
terior and to exude control, depressed men are
more likely than women to deny their illness. Since
signs of helplessness are considered unmanly,
men are more likely to hide their illness, thereby
sliding deeper into depression.'6
How common is major depression? According to
the National Comorbidity Survey, a landmark epi-
demiological study of 8,098 15- to 54-year-olds, ma-
jor depression is the second most common mental
illness in the United States, after alcoholism.'7 Al-
most 13 percent of men and 21 percent of women
will experience at least one episode of major de-
pression during their lifetimes. Episodes of major
depression occur most commonly in victims of ma-
jor depressive disorder.'8 The likelihood of an in-
dividual's having a major depressive episode in
any 12-month period-known as the 12-month
prevalence-is about eight percent for men and 13
percent for women.
When employees are able to confidentially dis-
cuss their depression, the scope of this problem
comes into sharper focus. One Dayton, Ohio, hos-
pital opened a depression hotline for its 1,800 em-
ployees, and in a short time received over 200 calls,
an 11-percent response rate.'9 These percentages
support the 12-month prevalence rate of major de-
pressive episodes. In 1988 aznd 1989, Westinghouse
 2000 Kline and
conducted clinical interviews with 1,879 of its em-
ployees to assess the prevalence of depression in
its workplace.20 The findings were sobering. Nine
percent of male workers and 17 percent of female
workers admitted to having suffered an episode of
major depression in the previous year, and lifetime
prevalence rates were 23 percent and 36 percent,
respectively. Over 50 percent of the affected work-
ers in the study claimed that their work was ad-
versely affected during their depressive episodes.
The Costs of Depression
As with most significant problems confronting
managers, workplace depression has both eco-
nomic and noneconomic costs. Only the former are
typically revealed in spreadsheets, financial ra-
tios, and year-end reports.
Economic costs of depression
In 1994, almost $1 trillion was spent for health care
in the United States.2' Businesses picked up 30
percent of that tab. The direct costs to businesses
are those associated with the diagnosis and treat-
ment of employee illness or injury, including em-
ployer health insurance premiums, Medicare,
workers' compensation, temporary disability in-
surance, and in-house health services. These costs
represent approximately a nine-percent premium
on total wages.
Indirect costs of illness and injury are more dif-
ficult to identify and quantify. Moreover, they are
traditionally ignored in discussions of health care
costs, but represent the largest portion. The total
societal cost of depression in 1990 was estimated to
be almost $44 billion per year.22 Three-fourths of
that amount, however, were indirect costs, primar-
ily from productivity losses and lost wages be-
cause of time away from work.23
Specifically, the indirect costs of depression in-
clude diminished and lost work performance, ab-
senteeism, accidents, and comorbid or coexisting
conditions resulting from depression. Comorbidity
occurs, for example, when depressed employees
self-medicate their depression with alcohol, thus
gaining a second, comorbid disorder in need of
treatment. Employee incapacitation and absentee-
ism because of depression result in annual losses
of $12.1 billion and $11.7 billion, respectively. An-
other $7.5 billion is lost as a result of depression-
related suicides.
Work cutback is reputed to be even more prob-
lematic than absenteeism.24 Three percent of male
and 4.5 percent of female workers interviewed in
the Epidemiologic Catchment Area Study reported
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Sussman 105
having at least one day in the previous three
months during which they were unable to main-
tain their normal work activities because of emo-
tional problems.25 Depression also decreases the
employability of many workers: One study found
that the employment rates for male and female
workers with recent psychiatric illnesses were re-
duced by 11 percent.26 These figures clearly dem-
onstrate the significance of the indirect costs of
depression.
Direct versus indirect costs
Restricting managerial focus to direct costs results
in significant distortion of both the total economic
consequences of depression and the appropriate
organizational response. If management considers
only the direct costs of an illness, the least expen-
sive response to the illness is not to treat it. But if
the focus is broadened to include the indirect costs
of the illness, a different decision may be more
economically sound. In short, the cost of treating
the illness may be less than the economic impact
of the untreated illness.
In short, the cost of treating the illness
may be less than the economic impact of
the untreated illness.
The Americans With Disabilities Act
When the ADA was enacted into law in 1990, it sent
shock waves throughout the business community.
Because the act mandated that employers provide
reasonable accommodations for disabled workers,
managers were forced to rethink their prejudices
and policies. Moreover, they had to consider the
economic consequences of providing those accom-
modations. Prior to the act, employers were some-
times capricious in their handling of the temporary
and permanent disabilities caused by mental ill-
ness. The ADA, however, forced employers to seri-
ously consider their existing policies, or lack
thereof.
Regardless of the spirit of the law, its letter gen-
erates considerable debate among employees, em-
ployers, and governmental agencies. The ADA has
created a growth industry for attorneys willing and
able to debate the nuances of such terms as "dis-
ability," "impairment," "major life activity," "sub-
stantially limits," "qualified person with disabili-
ty," "reasonable accommodation," and "undue
hardship."27
Perhaps the most compelling evidence of both
 106 Academy of Management
the incidence of depression in the workforce and
the role of ADA is the increasing number of official
complaints reported by the Equal Employment Op-
portunity Commission. The agency began tracking
complaints in 1994. In the 1995 budget year, the
commission received almost 1,400 complaints re-
lated to depression in the workplace, a 52-percent
increase over the preceding year.28
Human resource staffs often experience confu-
sion when accommodating employees who experi-
ence psychiatric disabilities.29 The ADA forbids
employers from discriminating against mentally
ill workers if they are otherwise qualified, and
mandates that employers take reasonable steps to
accommodate them. The problem, however, is that
disabilities associated with major depression and
other mental illnesses are not always obvious to
others. This invisibility creates an obstacle in es-
tablishing accommodation parity. The lack of eas-
ily observable evidence of impairment makes it
more difficult for managers to accept the reality of
a disability resulting from a mental illness.
Businesses must contend with the economic costs
of accommodations for disabled employees, but the
actual cost may be insignificant. Several studies on
psychiatric-based accommodations have concluded
that accommodations cost nothing in the majority of
cases.30 For example, one study demonstrated that
only one case in 322 requests for accommodations
actually cost the company anything-and that cost
was $25. Most employers who have made accommo-
dations report coming out ahead on costs. Typical
accommodations include reducing the employee's
pressure and responsibility, and reallocating duties.
Although many depressed employees will be tempo-
rarily disabled and on leave until their antidepres-
sant medication takes effect, most do not require any
accommodations.3'
Typical accommodations include
reducing the employee's pressure and
responsibility, and reallocating duties.
Noneconomic costs of depression
Only a portion of the costs of depression can or
should be measured in economic terms. Violent acts
directed against the self and others are even greater
consequences of depression, and may affect the
business more profoundly than the economic conse-
quences of depression. Suicide attempts, completed
suicides, and workplace violence are the principal
noneconomic costs of undetected, inadequately
treated, or untreated depression.
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Executive August
Suicide
Suicidal thoughts are a frequent symptom of major
depression. No symptom of depression evokes
more urgent psychiatric referrals from other men-
tal health professionals than suicidal ideation,
and for good reason. Over 50 percent of all suicides
are committed by individuals in a major depres-
sive episode.32 Approximately 15 percent of un-
treated individuals suffering from major depres-
sion eventually succumb to this tragic, final act of
violence.33 In treated individuals, this percentage
may fall as low as three percent, a dramatic ben-
efit of treatment.
The risk of suicide appears to be greatest in the
first three months of an episode of major depres-
sion and the first five years of recurrent major
depression.34 Particular stressors keyed to the life
cycle can become precipitants for depression and
the final precipitants for suicide in a depressed
individual.35 In the 20- to 40-year-old age group,
interpersonal conflicts, separation, and rejection
are most common. After age 40, economic problems
prevail. Medical problems gain increasing impor-
tance after 60 years of age. Psychological autop-
sies of suicide completers reveal that a large per-
centage received inadequate treatment or none at
all.
Violence toward others
Over two million workers are physically assaulted
in the workplace every year.37 Although family
members and customers initiate many of these
assaults, depressed coworkers cannot be over-
looked as another causal agent. Emerging expla-
nations of workplace violence suggest that isolat-
ing the specific situational and psychological
causes of employee violence is problematic at
best, and must incorporate multiple, interacting
predictors.38 Moreover, one might intuitively pre-
sume that depressed individuals, deep within their
well of dread and despair, would be the least likely
perpetrators of such acts. The evidence, however,
does not bear this out. In fact, one study suggests
that depressed individuals may be responsible for
one-third of the violent acts committed in the work-
place.39
Finally, the risk that depressed employees pose
to themselves, coworkers, and customers raises the
specter of financial and economic costs of lawsuits
and litigation. Employers are increasingly held li-
able for acts of workplace violence, most often on
the basis of negligent hiring and retention of vio-
lent employees. The legal argument posits that the
employer is deemed liable if the court determines
 2000 Kline
that the company knew the employee was violent
or that the hiring practices were inadequate.40
Treating Major Depression
Most episodes of major depression are respon-
sive to treatment.4' Moderate and severe cases,
with symptoms beyond the minimum threshold
necessary for diagnosis, will likely require med-
ication in addition to psychotherapy and, at a
minimum, deserve a psychiatric evaluation. An-
tidepressant medication is effective in 60 to 80
percent of those cases. Mild cases may be re-
sponsive to psychotherapy alone. However, indi-
viduals with mild levels of depression are much
less likely to seek treatment, because their symp-
toms are less debilitating.
Most episodes of major depression are
responsive to treatment.
Unfortunately, neither therapy nor medication
work overnight. The fastest response typically
occurs with medication. The antidepressant re-
sponse evolves over several weeks and most pa-
tients return to work free of symptoms as early as
a month after the initiation of treatment.42 With
the newer classes of antidepressants such as
Prozac, side effects are uncommon and generally
do not adversely affect work. Antidepressant
treatment is usually continued at least four to six
months after symptom resolution. In the case of
recurrent episodes, treatment is usually contin-
ued indefinitely.43
A widely cited Rand study measuring improve-
ment in symptoms and overall functioning found
that the combination of psychotherapy and antide-
pressant medication proved to be the most effec-
tive form of treatment.44 The superiority of com-
bined-modality treatment has been confirmed in
several subsequent investigations.45 Of particular
importance is the study by Thase et al., which
reviewed treatment outcomes for 600 depressed
patients. The study demonstrates that combined-
modality treatment is clearly superior for more se-
vere cases, while psychotherapy alone is effective
for milder cases of major depression.
As discussed earlier, suicidal thoughts are a
common symptom of major depression. When the
depression is successfully treated, suicidal think-
ing and intent resolve as well. Evidence shows, not
surprisingly, that inadequate doses of antidepres-
sants may contribute to suicide in depressed pa-
tients by ineffectively treating the depression.46
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
and Sussman 107
These findings emphasize the importance of rapid
detection and effective treatment of major depres-
sion.
Treatment and time
Managerial responses to employee depression too
often reflect a poor understanding of and unrea-
sonable expectation for the time required for suc-
cessful treatment. Although an antidepressant typ-
ically produces a faster treatment response than
psychotherapy, its response time is far greater
than the few days it normally takes for an antibi-
otic to treat an infection. Biology dictates the tem-
poral course of antidepressant action. Antidepres-
sants produce molecular changes in the brain,
which take place only after several weeks of treat-
ment.
The symptoms of a moderate or severe episode
of major depression may render an employee in-
capable of working until the antidepressant takes
effect. If these employees try to continue working
during this period, their productivity will be notice-
ably diminished. The senior author witnessed nu-
merous cases in which employees with moderate
or severe depressions were virtually harassed by
their managers to get them to return to work during
the initial weeks of antidepressant treatment. Such
behavior rarely facilitates treatment and may be
counterproductive, heightening the patient's feel-
ings of guilt and worthlessness.
Some patients do not respond to the initial med-
ication regimen. In such cases the psychiatrist will
probably increase the dose, change medications,
or add an augmenting agent, each requiring sev-
eral weeks to evaluate its therapeutic effect.47 As-
suming employee compliance with treatment, the
length of these evaluation intervals is contingent
on the severity of the patient's illness and idiosyn-
cratic response to medication.
Depression and Managed Care
The summary of clinical treatment of depression
must be analyzed against a backdrop of the insur-
ance plan screening and paying for the treatment.
Because a substantial portion of employees with
diagnosed depression are covered by managed-
care plans, we highlight the major implications of
both the constraints and opportunities created by
those plans.
Origin and benefit of managed care
The concept of managed care originated as a re-
action to skyrocketing health-care costs. Managed
 108 Academy of Management
care appears to offer a reasonable, albeit some-
times frustrating, alternative to fee-for-service
plans that earlier dominated the marketplace.
When considering only the direct costs of health
care, managed care makes sense, and employers
have generally embraced the concept. For exam-
ple, before the introduction of managed mental
health in one company, costs were rising 30 per-
cent per year. After switching to managed care, the
employer saw direct costs drop by over 40 percent
in the first year.48
An additional benefit of managed care may re-
sult from the shortened hospital stays typical of
these plans. When employees require long-term
disability care because of mental illness, their
probability of returning to work is three times
higher if they are enrolled in a health maintenance
organization (HMO).49 We might hypothesize that
shortened hospital stays reduce the degree to
which the depressed employee can sink deeper
into a sick role.50 However, this conclusion must be
tempered by considering managed care's potential
threats to quality of care.
Quality of care
The quality of patient care under managed-care
plans is a frequently debated issue in the health-
care community. Many health-insurance plans, es-
pecially managed-care plans, limit the number of
mental-health visits per year.5' Since the employ-
er's goal is to return the depressed employee back
to productive work as quickly as possible, such
caps on visits are questionable if they prevent the
employee from receiving adequate treatment.
Moreover, because of the potential for suicide, the
debate over the true effects of cost containment is
especially significant and poignant.
Durham claims that quality, as determined by
patient outcomes, does not suffer in managed men-
tal-health care.52 According to this report, cost sav-
ings are achieved by reducing hospital admissions
and lengths of stay, using providers with less
training-master's-level psychologists and psychi-
atric nurse practitioners rather than doctoral-level
psychologists and psychiatrists-and relying on
group versus individual care.
As would be expected, less-trained providers are
positive in their assessment of managed care,
since they directly benefit from this strategy.53 Doc-
toral-level providers-M.D.s, Ph.D.s, and Psy.D.s-
not surprisingly, are less enthusiastic. These clini-
cians allege that managed care produces savings
by denying needed services, focusing on cost sav-
ings rather than patient care, axnd systematically
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Executive August
undertreating patients by restricting access to
more highly trained professionals.54
Gatekeepers, psychiatrists, and collaboration
The 1996 RAND study suggests that managed care
may have degraded the detection and treatment of
depression by its reliance on primary-care doctors
to determine which depressed patients will be re-
ferred to a psychiatrist.55 Psychiatrists see only 10
percent of depressed patients in prepaid health
plans, contrasted with 22 percent in fee-for-service
plans. Furthermore, the study suggests that pri-
mary-care doctors underprescribe antidepressants
and that nonmedical mental-health providers un-
derutilize psychiatrists. This underutilization may
be the consequence of a reluctance to make refer-
rals to psychiatrists. Antidepressant treatment of
depressed individuals is significantly more likely
if the patient is under the care of a psychiatrist.
One study reported that only 16 percent of de-
pressed patients under medical care received an-
tidepressants, while 60 percent were prescribed
antidepressants in psychiatric care.56
The 1996 RAND study suggests that
managed care may have degraded the
detection and treatment of depression by
its reliance on primary-care doctors to
determine which depressed patients will
be referred to a psychiatrist.
The superior outcomes of patients treated by
psychiatrists may not be without a premium. The
RAND study estimates that the cost of depression
treatment by primary-care physicians is about
$1,500 per patient.57 This figure is considerably
lower than the $3,000-$4,000 per patient typical for
psychiatric care alone or in collaboration with
other mental-health specialists. The study sug-
gests that better outcomes appear to require
higher direct costs of treatment necessitated by
patients' receiving specialized psychiatric care.
More recent evidence, however, challenges the
premise that psychiatric care is actually more ex-
pensive. In an important study conducted at a
prominent managed mental-health company,
treatment of depression based solely on psychiat-
ric care proved to be more efficient and signifi-
cantly less expensive than collaborative care in
which a psychiatrist provides medication while a
nonpsychiatrist provides psychotherapy.58 A study
analyzing the actual direct cost differential be-
tween private psychiatric and collaborative treat-
 2000 Kline and
ment confirmed these findings. The results demon-
strated that psychiatric care alone was less
expensive than collaborative care in all cases and
provided better monitoring of the pharmacologic
effects of treatment.59
A study sponsored by Unum Life Insurance Com-
pany of America also found that limiting access
and imposing nonpsychiatric gatekeepers actually
increases costs.60 The data focused on psychiatric
disabilities between 1992 and 1995 at 277 compa-
nies with a minimum of 300 employees. The find-
ings showed that fee-for-service plans, where
gatekeepers typically are absent, had 36 percent
lower claim rates. Furthermore, in companies with
health plans that impose strict annual or lifetime
limits on outpatient mental-health visits, the claim
rates soared to almost four times those in compa-
nies without such limits.
Perhaps the most important factor affecting the
relative efficacy of managed care in the treatment
of depression is the probability of the successful
initial diagnosis. Before a major depression can be
treated, it must be detected. It may seem unlikely
that an illness as devastating as major depression
could go unrecognized, but several studies have
shown that such diagnostic misses are actually
quite commonplace in nonpsychiatrists' offices.
According to the 1989 RAND Corporation study,6'
depression goes undiagnosed in about half of de-
pressed patients by primary-care physicians in
fee-for-service plans. This figure rises to 58 percent
when the patient has prepaid care, where primary-
care physicians are the principal gatekeepers. In
these settings, the volume of patients is greater
and time spent with each patient is less. In con-
trast, mental-health professionals detect depres-
sion greater than 78 percent of the time.
Direct and indirect costs of treating depression
Regardless of the specific data one cites or policy
position one supports on the effectiveness of man-
aged care in treating depression, one finding is
unequivocal. The productivity loss due to depres-
sion is significantly greater than the estimated
cost of treating the illness.62 Estimates suggest that
the depressed employee who goes untreated costs
the company twice what treatment costs per year.63
Thus, analogous to our earlier discussion of direct
and indirect costs of depression, the direct cost
savings achieved under managed care may be
outweighed by the increase in indirect costs that
managed care creates as a result of poor detection
and inadequate treatment of depression by non-
psychiatrists. We should point out that the in-
crease in the indirect cost is less likely to be borne
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Sussman 109
by insurance providers than by the employer and
employee. This appears to be a case where man-
aged care saves money, and someone else pays.
Estimates suggest that the depressed
employee who goes untreated costs the
company twice what treatment costs
per year.
Prescriptions
The preceding summaries underscore the conflict-
ing pressures managers face in balancing the
need for compassion with the need for enhancing
shareholder value. In this section, we offer four
prescriptions for achieving that balance.
Educate about depression
Organizations generally and managers specifi-
cally should make greater efforts to educate their
workforce about depression, remove the stigma
of depression from the workplace, and ensure
a supportive work environment for depressed
employees.
Managers must ensure that depressed employ-
ees find a supportive work environment unen-
cumbered by stigma.64 As a first step, employers
must educate both themselves and their work-
force about depression. One of the simplest
methods is to circulate a newsletter, article, or
brochure describing the signs, symptoms, and
prevalence of major depression. The company
can also organize formal talks or lectures about
the disorder. Since antidepressant medications
are so often a part of treatment, these sessions
should be conducted preferably by a psychiatrist
or nurse practitioner knowledgeable about anti-
depressants.
These instructional activities accomplish three
very important goals. First, they give employees
sufficient knowledge to recognize depression in
themselves and coworkers. Second, accurate infor-
mation about depression diminishes its stigma.
Many people believe that the stealth-like nature of
mental illness represents a curtain behind which
may lurk a madman. Such egregious misconcep-
tions are dispelled only by accurate information.
The inability to recognize depression and the
stigma attached to it prevent most depressed indi-
viduals from seeking treatment. Finally, depres-
sion-focused education increases the likelihood
that the employees who seek treatment will find a
supportive work environment.
 110 Academy of Management
The inability to recognize depression and
the stigma attached to it prevent most
depressed individuals from seeking
treatment.
The importance of such an environment cannot be
overstated. If most of the coworkers of a depressed
employee consider antidepressant medication a
crutch, and the doctor prescribes medication that
must be taken during work hours, then the depressed
employee is less likely to take it for fear of being
discovered and ridiculed. Managers play an impor-
tant role in creating a supportive work environment.
They set the tone of the work environment and will
be watched closely by subordinates. A manager who
behaves as though the depressed employee is shirk-
ing his or her responsibilities fosters similar atti-
tudes in the work group.
Managers must also develop an increased toler-
ance for the time course of treatment. Incessant
questioning about when the depressed employee
will return to work could be interpreted as harass-
ment. A more helpful approach is to have periodic
updates from the psychiatrist or the HR profes-
sional who is in contact with the treating doctor. In
the treatment of the seriously depressed patient,
the psychiatrist typically determines the appropri-
ate date the employee is functionally able to return
to work.
Many health plans specify a copay for mental
health visits as much as two times or more the
copay for nonmental-health medical visits. In-
creasing access means simplifying the process by
which the employee moves from recognition of his
or her problem to treatment and eliminating finan-
cial obstacles for that treatment. If the company
has an Employee Assistance Program (EAP), the
employee should have ready access to such ser-
vices. Of course, there should never be any reluc-
tance to allow employees time off for their first
visit to a mental-health professional. Many indi-
viduals look for reasons not to initiate treatment.
Employee denial should be recognized as a barrier
to effective treatment, and management must sup-
port depressed employees who seek treatment.
Facilitate contact with health professionals
The human resources department should facilitate
the initial contact between the depressed em-
ployee and a mental health professional and coor-
dinate the stakeholder team.
The stakeholders are the employee, his or her
manager, and the treatment professional. Depend-
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Executive August
ing on the specifics of the insurance coverage and
the availability of an EAP, the stakeholder team
might also include a representative from the insur-
ance company and a representative of the EAP.
The purpose of this team is to gather all of the
information required for HR and the employee's
supervisor to devise the accommodation plan.65
For mental illnesses such as major depression, the
team must be aware that the accommodation may
not be a one-time event. Rather, because of the
recurrence and treatment time that so many men-
tal illnesses require, the team will often be en-
gaged in an evolving process.
Throughout this process, maintaining contact
with the employee's psychiatrist is beneficial to all
involved. The manager gains a better understand-
ing of the clinical situation, the employee is as-
sured that the employer receives accurate informa-
tion, and the physician gains access to information
that affords improved evaluation of treatment ef-
fectiveness and readiness to resume work.
Redesigning workspaces and technological inter-
faces are relatively easy accommodations for or-
ganizations to conceive and structure. Moreover, the
inherent rationale for this restructuring usually is
understood implicitly when the employee under
question has a physical disability. Creating accom-
modations for the mentally ill employee, however,
may not be as implicitly understood or accepted.66
HR can and should play a lead role in helping all
organizational members accept the reality that de-
pression is a disease in the same legal and moral
sense that diabetes is a disease, and that the or-
ganization has both a legal and social responsibil-
ity for accommodating the disabled employee.
Finally, given the inherent social stigma associ-
ated with mental illness, all discussions with and
about the employee must be conducted within the
general guidelines of protecting the employee's
rights and maintaining privacy. Medical records,
performance evaluations, and documentation of
coaching, counseling, or psychotherapy sessions
should be disclosed only to members of the treat-
ment team. Without the guarantee of confidentiality
and protection of employee rights, any managerial
attempt to help the employee is likely to be futile.
Foster awareness of symptoms
Organizations generally and managers specifically
should be aware of situations and life circumstances
that may precipitate employee depression and pro-
actively establish policies that encourage the report-
ing of any indications of harm to self or others.
Suicide and violence toward others are often the
result of inadequate detection, recognition, and re-
 2000 Kline
sponse to either veiled or explicit threats. Manag-
ers must be alert to any signs of disturbed emo-
tions or thinking in their subordinates and rapidly
respond with appropriate action-referrals or noti-
fication of security or police. Managers should err
on the side of control and intervention and be cer-
tain of organizational support for such actions. Em-
ployees may criticize such actions as overreac-
tions, but it is obviously better to apologize for
heavy-handed HR policies than to attend funerals
and hold traumatic press conferences.
The most obvious warning signs of impending
suicide and other forms of violence are often pro-
vided by employees themselves. Before suicides
and other violent acts are committed, perpetrators
frequently mention their disturbed intentions to
coworkers and friends. Managers must insist that
coworkers immediately report any suggestions of
potential violence made by employees. Responses
should be decisive, notifying either the EAP or
higher levels of management. Better safe than
sorry should be the motto of all managers and the
organization as a whole.
Managers should never underestimate the un-
predictability and potential for harm represented
by irrational thought.67 One variant of major de-
pression includes such psychotic symptoms as de-
lusions (false beliefs), hallucinations (seeing
things or hearing voices), or irrational behaviors.
Moreover, it is not uncommon for depressed indi-
viduals to turn to alcohol or drugs in an attempt to
self-medicate. Alcohol and the class of drugs
known as minor tranquilizers or benzodiazepines
(Valium, Ativan, Xanax) are well known for their
disinhibiting effects on behavior,68 and can some-
times transform suicidal thoughts into suicidal
acts.
Moreover, it is not uncommon for
depressed individuals to turn to alcohol
or drugs in an attempt to self-medicate.
Managers must remain vigilant to the emotional
well-being of their subordinates. Particular note
should be made of dramatic changes in behavior,
significant personal losses, financial disasters,
and serious medical problems affecting their em-
ployees. Any of these situations in the life of a
depressed employee increases the risk of suicide,
and each warrants timely and empathic follow-up
by the manager.
The Center for Disease Control recently reported
on a model program initiated by the U.S. Air Force
to reduce the stigma of depression in its ranks and
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
and Sussman 111
provide easier access to professional care.69 The
impetus for the program was the high rate of sui-
cide among its 350,000 personnel, accounting for 23
percent of all deaths. In 1995, the Air Force imple-
mented a suicide prevention program that resulted
in a decline of suicides from 16 per 100,000 in 1994
to nine per 100,000 in 1998. That rate was expected
to decline to 2.2 per 100,000 in 1999.70 In comparison,
the rate of suicide in the United States overall is 11
to 12 per 100,000.71
The Air Force program relies on military leaders,
medical providers, attorneys, and chaplains to
monitor Air Force personnel for risk factors of de-
pression and suicide. When such individuals are
identified, the monitors facilitate access to appro-
priate mental-health providers. The Air Force ex-
perience is a splendid example of the effectiveness
of organizationally sponsored programs for de-
pression awareness and suicide prevention. The
Air Force now has the lowest suicide rate of all
the military services and a fraction of the rate for
the general population.
The Air Force case represents a situation where
the monitors are employed by the same organiza-
tion. Most organizations in both the private and
public sector, however, rely not only on internal
monitors but on external ones as well. Thus the
coordinating and integrating function of HR dis-
cussed earlier is even more important where mon-
itors may be external.
Promote effective treatment
Organizations generally and managers specifi-
cally should understand the direct and indirect
costs of employee health care, disseminate that
knowledge to subordinate managers, and be pre-
pared to take the lead in promoting health insur-
ance reforms that minimize obstacles to diagnosis
and appropriate treatment of major depression
and other mental disorders.
Managed care in its current form requires de-
pressed employees to see their primary-care physi-
cian as a first step. This procedure, however, may not
always guarantee treatment. Some individuals are
reluctant to report their depression to their regular
doctor because of embarrassment or shame. Compa-
nies should at least ensure that their health plans
provide employees the option of calling a mental
health provider directly. Most current managed-care
plans, however, do not permit full coverage for such
access policies. The data we summarized suggest
that these changes will pay substantial dividends
and enable more people experiencing major depres-
sion in the workforce to be recognized, treated, and
returned to normal productivity.
 112 Academy of Management
Employers must always be cost-conscious if they
are to carry out responsibly their duties as stock-
holders' agents. But social and moral responsibil-
ity cannot be ignored in the process. Business
leaders must be willing to spend more money on
depression education and provide easier access to
treatment for those employees suffering from ma-
jor depression and other mental illnesses. Evi-
dence is mounting that relaxing access and treat-
ment barriers can actually save money when the
indirect costs of depression to the company are
considered.72 And, of course, it is socially and mor-
ally responsible for the organization to do so.
The distinction between the direct and indirect
costs of health care is extremely important for ex-
ecutives and managers to understand if economi-
cally sound decisions about employee health
plans are to be made. Most businesses have tradi-
tionally focused only on direct, out-of-pocket costs,
which significantly understate the true costs of
employee depression. Using only direct costs, com-
panies are likely to assume that minimizing the
costs of employee health can be accomplished by
measures that curtail treatment.
The largest portion of health-care costs is indirect.
Cost-control measures that target restricting and
containing treatment are generally counterproduc-
tive and are likely to increase the indirect and total
costs of employee health. To lower total cost, busi-
nesses must be prepared to bear the additional di-
rect cost of increased employee access to health
care. Only by pursuing a strategy that promotes
treatment and increases direct cost can businesses
lower indirect costs and, in turn, total cost.
Only by pursuing a strategy that
promotes treatment and increases direct
cost can businesses lower indirect costs
and, in turn, total cost.
Managed-care companies, like all businesses, are
driven by the profit motive. Our review of the litera-
ture suggests that using psychiatrists exclusively to
treat those depressed employees who require anti-
depressant medications lowers the cost of treatment.
If future studies confirm this finding, then managed-
care companies will quickly modify their pattern of
professional resource utilization to realize these po-
tential savings. The managed-care industry, how-
ever, will be unlikely to voluntarily pass on these
savings to their clients. Only business executives
who are knowledgeable about health-care cost struc-
ture will successfully negotiate the sharing of those
potential savings. It behooves executives to clearly
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Executive August
understand the implications of any cost that repre-
sents a nine-cent premium on every wage dollar, as
do employee health expenditures.
Informed Teamwork
Clinically depressed people may feel "dread and
despair," and believe they are alone and hopeless.
Yet in reality they need not and should not be
alone. Similarly, executives need not be alone in
their desire to help depressed employees.
Insurance providers, health-care professionals,
HR staffers, and EAP representatives form the nu-
cleus of a support team that should always be
available to executives. As our analysis suggests,
however, executives must be informed members of
that team, critically assessing treatment options
and outcomes.
Old habits die hard. Only by the strong, visible,
and enlightened support of executives at the high-
est levels can companies implement the necessary
changes in mental-health policies and attitudes
that we have outlined. These changes should pro-
vide economic benefits to companies by lowering
total health-care cost, enhancing productivity, and
improving employee job satisfaction. Applying the
four prescriptions will help managers balance the
need for compassion with the need for enhancing
shareholder value. Achieving this balance will al-
low depressed employees and their organizations
to regain their full potential.
Endnotes
' Caudron, S., & Hayward, D. R. 1996. HR to the rescue: Teach
downsizing survivors how to thrive. Personnel Journal, 75(1): 46.
2 The cost of depression in the workplace. 1995. Canadian
Manager, 20(4): 26-27.
3Brady, T. 1997. AMA's mental diagnosis (American Manage-
ment Association). Management Review, 86(10): 59-63.
'Stuart, P., 1992. Tracing workplace problems to hidden dis-
orders. Personnel Journal, 71(6): 82-92.
5Kessler, R., McGonagle, K., Zhao, S., Nelson, C., Hughes, M.,
Eshleman, S., Wittchen, H., & Kendler, K. 1994. Lifetime and
12-month prevalence of DSM-III-R psychiatric disorders in the
United States. Archives of General Psychiatry, 51(1): 8-19.
6Hall, R. C., & Wise, M. G. 1995. The clinical and financial
burden of mood disorders: Cost and outcome. Psychosomatics
36: Sll-S18.
7Greenberg, P. F.; Finkelstein, S. N.; & Berndt, E. R. 1995.
Economic consequences of illness in the workplace. Sloan Man-
agement Review, 36(4): 26-39.
8 Wells, K. B., Sturm, R., Sherbourne, C. D., & Meredith, L. S.
1996. Caring for depression: A RAND study. Cambridge, MA:
Harvard University Press.
9 Americans with Disabilities Act of 1990, 42 U.S.C.A. ?12 101 et
seq. (West, 1993).
10 Diagnostic and statistical manual (DSM) of mental disorders
(4th ed.). 1994. Washington: American Psychiatric Association.
1' DSM, op. cit.
 2000 Kline and
12 Jefferson, J. W., & Greist, J. H. 1994. Mood disorders. In R. E.
Hales, S. C. Yudofsky, & J. A. Talbot (Eds.), The American Psy-
chiatric Press textbook of psychiatry (2nd ed.): 465-494. Washing-
ton: American Psychiatric Press.
13 Symptoms represent the subjective experiences of an indi-
vidual, while signs represent the objective observations of the
physician. Fatigue is a symptom, because an individual feels it.
Psychomotor retardation, in contrast, is a sign, because the
physician observes it.
14 Breuer, N. L. 1995. Revealing the dark secret of clinical
depression. Personnel Journal, 74(4): 121-127.
15 Turner, S. 1995. Identifying depression in the workplace.
HRMagazine, 40(10): 82-84.
16 Real, T. 1998. I don't want to talk about it: Overcoming the
secret legacy of male depression. New York: Fireside.
17 Kessler, R., McGonagle, K., Zhao, S., Nelson, C., Hughes, M.,
Eshleman, S., Wittchen, H., & Kendler, K. 1994. Lifetime and
12-month prevalence of DSM-III-R psychiatric disorders in the
United States. Archives of General Psychiatry, 51(1): 8-19.
18 Episodes of major depression occur also in bipolar disor-
der, which formerly was called manic-depressive disorder and
includes both manic and depressive episodes. The terminology
is somewhat confusing. Major depression and bipolar disorders
are mental illnesses. A major depressive episode, however,
denotes the specific periods of depression that occur in victims
of major depression and bipolar disorder. When there is no
history of manic or hypomanic episodes, a diagnosis of major
depression is always made.
19 DeBrosse, J. 1996. Companies find depression aid. Dayton
Daily News, December 16: 1B.
20Business and Health, 1994. Employers take action in the
fight against depression; imaginative new programs begun by
U.S. businesses are helping depression sufferers get the treat-
ment they need. 12(4) (Suppl. A): 16-20.
21 Greenberg et al., op. cit.
Hall & Wise, op. cit.
Greenberg et al., op. cit.
24Kessler, R. C., & Frank, G. 1997. The impact of psychiatric
disorders on work. Psychological Medicine, 27: 861-873.
25 Robbins, L. N., & Regier, D. A. 1991. Psychiatric disorders in
America: the epidemiologic catchment area study. New York:
Free Press.
26 Ettner, S. L., Frank, R. G., & Kessler, R. C. 1997. The impact
of psychiatric disorders on labor market outcomes. Industrial
and Labor Relations Review, 51(1): 64-81.
27 Silbergeld, A. F., & Williams, V. L. 1995. Accommodating
mental disabilities under the ADA: Limitations on employer
liability. Employment Relations Today, Summer: 125-135.
28 Masters, B. A. 1998. Depression gets its day in court; more
area sufferers are seeking relief. Washington Post, March 27: B 1.
29 Breuer, N. L. 1997. Must HR diagnose mental disabilities?
Workforce, 76(10): 30-37.
30Meltsner, S. 1998. Psych disabilities: What's real, what's
protected. Business and Health, 16(6): 46-53.
31 Mancuso, L. 1995. Achieving reasonable accommodation
for workers with psychiatric disabilities: Understanding the
employer's perspective. American Rehabilitation, 21(1): 2-14.
32 Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. 1974. One
hundred cases of suicide: Clinical aspects. British Journal of Psy-
chiatry, 125: 355-373; Dorpat, T. L., & Ripley, H. S. 1960. A study of
suicide in the Seattle area. Comprehensive Psychiatry, 1: 349-359.
Ghosh, T. B., & Victor, B. S. 1999. Suicide. In R. E. Hales, S. C.
Yudofsky, & J. A. Talbot (Eds.), The American Psychiatric Press
textbook of psychiatry (3rd ed.): 1383-1404. Washington: American
Psychiatric Press. Bipolar disorder, chemical dependence, schizo-
phrenia, panic disorder, and borderline personality disorder also
account for many of the 30,000 suicides that occur each year.
This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms
Sussman 113
33 Ghosh, T. B., & Victor, B. S. 1994. Suicide. In Hales et. al.
(Eds.), (2nd ed.), op. cit., 1251-1271.
34 Ibid.
35 Rich, C. L., Warsradt, G. M., & Nemiroff, R. A. 1991. Suicide,
stressors, and the life cycle. American Journal of Psychiatry, 148:
524-527.
36 Isometsa, E. T., Henriksson, M. M., Aro, H. M., Heikkinen,
M. E., Kuoppasalmi, K. I., & Lonnqvist, J. K. 1994. Suicide in major
depression. American Journal of Psychiatry, 151: 530-536; Isa-
csson, G., Boethius, G., & Bergman, U. 1992. Low levels of anti-
depressant prescription for people who later commit suicide: 15
years of experience from a population-based drug database in
Sweden. Acta Psychiatrica Scandinavica, 85(6): 444-448.
37 Thompson, J. 1995. Psychiatric disorders, workplace vio-
lence, and The Americans with Disabilities Act. Hamline Law
Review, Fall: 25-79.
38Griffin, R. W., O'Leary-Kelly, A., & Collins, J. (Eds.) 1998.
Dysfunctional behavior in organizations, Part A: Violent and
deviant behavior, Vol. 23. Stamford, CT: JAI Press.
39Feldman, T. B., & Johnson, P. W. 1994. Violence in the work-
place: a preliminary report on a workplace violence database.
Unpublished paper: August 10. This study was reported in
Zugelder, M. T., & Maurer, P. C. 1999. Dangerous directives? Lia-
bility and the unstable worker. Business Horizons, 42(1): 45-54.
40 Zugelder et al., op. cit.
41 Jefferson & Greist, op. cit.
42 Breuer, 1997, op. cit.
43 Jefferson & Greist, op. cit.
44 Wells et al., op. cit.
45 Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. FR.,
Pilkonis, P. A., Hurley, K., Grochocinski, V., & Kupfer, D. J. 1997.
Treatment of major depression with psychotherapy or psycho-
therapy-pharmacotherapy combinations. Archives of General
Psychiatry, 54: 1009-1015; Reynolds, C. F., Frank, E., Perel, J. M.,
Imber, S. D., Cornes, C., Miller, M. D., Mazumdar, S., Houck, P. R.,
Dew, M. A., Stack, J. A., Pollock, B. G., & Kupfer, D. J. 1999.
Nortriptyline and interpersonal psychotherapy as maintenance
therapies for recurrent major depression: A randomized con-
trolled trial in patients older than 59 years. Journal of the Amer-
ican Medical Association, 281: 39-45. Keller, M. E., McCullogh, J.
E., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J.,
Markowitz, J., Nemeroff, C. B., Russell, J. M., Thase M. E., Trivedi,
M. H., & Zajecka, J. 2000. A comparison of nefazodone, the cog-
nitive behavioral-analysis system of psychotherapy, and their
combination for the treatment of chronic depression. The New
England Journal of Medicine, 342: 1462-1470.
46 Isacsson et al., op. cit.
47 Jefferson & Greist, op. cit.
48 Goldman, W., McCulloch, J., & Sturm, R. 1998. Costs and use
of mental health services before and after managed care.
Health Affairs, 17(2): 40-52.
49 Best's Insurance News, 1997. Easier access to mental health
services cuts claims. October 16.
50 Campbell, R. J. 1989. Psychiatric dictionary (6th ed.). New
York: Oxford University Press. In some patients, hospitalization
offers temporary relief from personal responsibilities and " . . . a
way of gaining sympathy and the help of others." Such patients
offer no protests to longer hospital stays and may actually
contribute to them by unconsciously prolonging recovery.
" Greenberg et al., op. cit.
52 Durham, M. L. 1998. Mental health and managed care.
Annual Review of Public Health, 19: 493-505.
53 Thomas, S. A., & Hargett, T. 1999. Mental health care: A
collaborative, holistic approach. Holistic Nursing Practice, 13(2):
78-85.
54 Miller, I. J. 1996. Managed care is harmful to outpatient
mental health services: A call for accountability. Professional
 114 Academy of Management Executive August

Psychology-Research and Practice, 27: 349-363; Domino, M. E.,
Salkever, D. S., Zarin, D. A., & Pincus, H. A. 1998. The impact of
managed care on psychiatry. Administration & Policy in Mental
Health, 26(2): 149-157.
55 Wells et al., 1996, op. cit.
56 Isometsa et al., op. cit.
57 Wells et al., 1996, op. cit.
58 Goldman, W., McCulloch, J., Cuffel, B., Zarin, D. A., Suarez,
A., & Burns, B. J. 1998. Outpatient utilization patterns of inte-
grated and split psychotherapy and pharmacotherapy for de-
pression. Psychiatric Services, 49: 477-482.
59 Dewan, M. 1999. Are psychiatrists cost-effective? An anal-
ysis of integrated versus split treatment. The American Journal
of Psychiatry, 156: 324-236.
60Best's Insurance News, op. cit.
61 Wells, K. B., Hays, R. D., Burnam, M. A., Rogers, W., Green-
field, S., & Ware, J. E. 1989. Detection of depressive disorder for
patients receiving prepaid or fee-for-service care. Results from
the Medical Outcomes Study. Journal of the American Medical
Association, 262: 3298-3302.
62 Ettner et al., op. cit.
63Vernarec, E. 1998. The high costs of hidden conditions.
Business and Health, 16(1): 19-23.
64 Stuart, op. cit.
65 Breuer, 1997, op. cit.
66 Hall, F. S., Hall, E. L., Reno, J., Anderson, T. C., Dryer, D.,
Barocas, V. S., & Scalia, F. 1984. The ADA: going beyond the law;
executive commentary. The Academy of Management Execu-
tive, 8(1): 17-34.
67 Griffin et al., op. cit.
68 Tardiff, K. 1999. Violence. In Hales et al. (Eds.), (3rd ed.): op.
cit, 465-494.
69 Wall Street Journal, 1999. Air Force suicide rates show
significant decline. November 26: A12.
70 Cooper, M. 1999. USA: U.S. Air Force suicides cut by 80
percent-study. Reuters English News Service, November 24.
Retrieved from Dow Jones Publication Library.
71 Ghosh & Victor, op. cit.
72 Best's Insurance News, op. cit.; Ettner et al., op. cit.

Joseph Kline, Jr., is a board-certi- Lyle Sussman is a professor of

fied psychiatrist at NorthKey management at the University of
Community Care in Covington, Louisville. His research on com-
KY. He received his Ph.D. in munication, employee coaching
physiology and biophysics, and and counseling, and executive
M.D., and an M.B.A. with distinc- development has appeared in
tion, all from the University of leading academic and practitio-
Louisville. He practices commu- ner joumals. He has conducted
nity psychiatry and conducts re- seminars in Canada, Mexico, Eu-
search on mental illness in the rope, and the Far East. His ap-
workplace, difficult employees, plied management books, Smart
bumout, and the application of Moves and Smart Moves for Peo-
the theory of constraints to ple in Charge, have been trans-
health-care organizations. Con- lated into 13 languages. Contact:
tact: jklineOl@aol.com. lylesussman@louisville.edu.

This content downloaded from 168.176.5.118 on Fri, 08 Apr 2016 00:18:50 UTC
All use subject to http://about.jstor.org/terms