In 2021, Workplace Attention Likely Will Turn to Behavioral Health

Michelle Hopkins

Transforming a year of stress into positive action

The COVID-19 pandemic and states’ responses to it created a national experience of stress and now may embolden more open discussions of mental health in the workplace than ever before, potentially leading to new behavioral health initiatives to support employees. In fact, a national business analysis forecasts that mental and emotional health will emerge as one of four leading health priorities for large employers in 2021.1

It is estimated that 40 percent of American adults experienced at least one adverse mental or behavioral health condition during the COVID-19 pandemic, including anxiety or depression (31 percent), trauma and stressor-related disorder (26 percent), or starting/increasing substance use to cope with stress or emotions (13 percent). Ideation of suicide also occurred among more than 20 percent of certain subgroups, such as young adults and employees defined by the U.S. Department of Homeland Security as essential to continue critical infrastructure operations.2

Fortunately, these unsettling statistics come with rays of hope. Millennials (born between 1981 and 1996), who represent the largest generation in the workforce, are strikingly more willing to discuss their own mental health openly.3 A national poll by the American Psychiatric Association found that 62 percent of millennials feel comfortable discussing their mental health with coworkers and supervisors compared to 32 percent of baby boomers (the poll had a margin of error of +/- 3.1 points).4 Candid discussions about mental health in the workplace offer fresh hope that more employers will explore educational and peer-support initiatives in mental health. These could mirror efforts undertaken by a scattering of companies featured in Forbes magazine in December 2019, just three months before the pandemic spread appreciably in the United States.5

Defining key words in the mental health discussion

Misunderstanding of key terms and concepts – and the stigma that can result – may contribute to mental health being seen as a difficult discussion topic in our culture and in the workplace. Let’s define some key words you’re likely to hear and use.

Many times, when people hear the term, “mental illness,” they may picture what is formally known as serious mental illness, or SMI. It helps to understand the difference between serious mental illness and any mental illness because both are mental, behavioral, or emotional disorders. Serious mental illness substantially interferes with or limits an individual’s ability to participate in major life activities. With any mental illness,  function is better because impairment may be mild, moderate, or nonexistent. Serious mental illness affects 13.1 million adults, aged 18 and older, or about 5.2 percent of all  U.S. adults. Prevalence is higher among young adults aged 18 to 25 than other age groups and higher among women than men. An estimated 51.5 million adults, or about 20.6 percent, live with any mental illness. Prevalence was again higher for women than men but fewer than 39 percent of adults aged 18 to 25 years received services for AMI in 2019, compared to 45.4 percent of adults aged 26 to 49 years and 47.2 percent of adults aged 50 and older.6

The range of impairment (nonexistent, mild, moderate, or severe) can occur among any of the major types of mental illness: anxiety disorders, major depressive disorder, bipolar disorder, schizophrenia, posttraumatic stress disorder, eating disorders, and substance abuse/addiction.  Mental illness may arise over time and as a result of factors related to genetics, environment, and lifestyle. Mental illness does not mean a person is broken or less of a person.7

But “mental health” is not illness; mental health is a person’s thinking, feeling, behavior and mood, and mental illness is an unhealthy deterioration of thinking, feeling, behavior, or mood. All people have mental health. About one-fifth of American adults have a mental illness, either episodically or chronically.

Last among our terms is behavioral health, which is an umbrella term used for mental health and substance abuse disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health as “the promotion of mental health, resilience and well-being; the treatment of mental and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities.”8

Why should employers explore behavioral health options?

Employers can get information and referral to resources on mental health, substance abuse, and behavioral health from occupational health providers like Concentra® or from the Centers for Disease Control and Prevention (CDC), the National Institute of Occupational Safety and Health (NIOSH), and SAMHSA.

Here are four compelling reasons employers should give attention to supporting employees’ mental and behavioral health:

  1. Ensure compliance with state and federal regulations
  2. Avoid declines in productivity
  3. Address employee health and health care costs
  4. Reinforce safety in high-risk industries and jobs

Ensure compliance

Individuals with mental illness are protected under the Americans with Disabilities Act (ADA), the Rehabilitation Act of 1973 and various state laws.9 Employers are required under the ADA to make reasonable accommodations of employees who divulge their mental health condition, unless it poses an undue hardship to the employer.10 The ADA prohibits discrimination based on the “perception” of a disability, so human resources professionals and managers should not try to diagnose an employee’s condition themselves.11

Avoid declines in productivity

Mental health problems that are not diagnosed or are diagnosed but not managed well can affect work performance and reduce productivity through the following12:

  • Absenteeism
  • Poor health due to comorbid physical conditions, such as high blood pressure, heart disease, ulcers, sleeping disorders, neck and back pain, and low resistance to infections
  • Increased errors, accidents, and injuries
  • Poor planning, decision making, and control of work
  • Loss of motivation and commitment, burnout

Address employee health and health care costs

Mental health conditions that are undiagnosed, untreated or poorly managed may have a significant impact on employee health and the cost of health care.

The Center for Medicaid and Medicare Services (CMS) studied different combinations of mental illness, substance use and addiction, and chronic conditions among Medicaid and Medicare enrollees and arrived at these findings13:

  • Individuals with mental illness are more likely to have chronic conditions, such as high blood pressure, diabetes, asthma, and heart disease
  • Individuals with mental illness are more inclined to use comparatively more expensive treatment alternatives like hospitalization and emergency departments than individuals without mental illness
  • Individuals with mental illness and one or more chronic conditions have health care costs that are 75 percent higher than individuals without a mental illness
  • In the case of diabetes, treatment costs are as much as four times higher for an individual who has an untreated, co-occurring mental or behavioral health condition, such as depression or alcohol addiction.

Prevention, early detection, and effective treatment of behavioral health conditions were recommended as a means to address this disproportionate cost burden.

The 2018 Milliman Research Report advocated strong integration of medical and behavioral health care as a strategy to reduce – by as much as 16.7 percent – the $406 billion additional costs of behavioral comorbidities (chronic medical and comorbid mental health/substance use disorders) in 2017. That would represent a national reduction in costs of as much as $68 billion, according to the report.14

The U.S. Government Accountability Office (GAO) is less certain of how significantly untreated behavioral health conditions may affect overall health care costs but does acknowledge that 20 of 29 limited-scope studies concluded that health care costs were higher when adults had untreated co-occurring substance use or mental health conditions.15

Reinforce safety in high-risk jobs and industries

Potential consequences of undiagnosed, untreated, or poorly managed mental illness or substance abuse are especially dire in safety-sensitive jobs and industries with high public impact, such as transportation and construction. Mental health issues have been documented as serious, and suicide is a particular concern in both of these male-dominated industries, pointing to a preeminent need for transportation and construction employers to address behavioral health.

Transportation. By occupation, transportation has the fourth-highest rate of suicide among American working-age adults. Depression and anxiety are top issues among truck drivers; also, they can experience post-traumatic stress disorder after witnessing horrific accidents without time or ability to talk to a professional counselor and to process what they’ve seen. In addition, drivers spend a lot of time alone in a confined cab space, away from friends and family, scrimping on relaxation, sleep, and nutrition. These conditions are not ideal for mental health and the trucker’s image of toughness may complicate problems further by making it hard to ask for help or initiate discussions with a supervisor. A majority of communication with drivers is by phone and text messaging, without human contact that might pick up clues about mental health status.16

Construction. Like transportation, construction is a male-dominated industry and it has its own set of factors that can erode mental health, including a work environment that is high-pressure and competitive, seasonal layoffs, the physical pain of manual labor, and separation from friends and family. According to the CDC, the construction and extraction industries have the second highest rate of suicide – 53.3 per 100,000 workers. While monitoring for physical safety has improved, mental health considerations have lagged. In construction, mental health issues can manifest as missed work days and increased injuries.17

Other industries. SAMHSA data was used to rank several professions in terms of rates of depression. Not all industries or jobs were included; for example, health care was not ranked. Nonetheless, it’s interesting to see how these professions compare with each other and especially to notice that depression knows no bounds. Any employee in any industry or organization can experience depression or other mental health concerns.

Job rankings with highest rates of depression18:

  1. Public and private transportation, 16.2 percent
  2. Real estate, 15.7 percent
  3. Social services, 14.6 percent
  4. Manufacturing, 14.3 percent
  5. Personnel services, 14.3 percent
  6. Legal services, 13.4 percent
  7. Environmental administration and waste services, 13.4 percent
  8. Organization and association administration, 13.3 percent
  9. Security and commodity brokers, 12.6 percent
  10. Print and publishing, 12.4 percent

Other findings of the data analysis were:

  • Prevalence of depression is highest in Oregon, Maine, Utah, New Hampshire, Vermont, Indiana, and Rhode Island and lowest in  South Dakota, Florida, and South Carolina.
  • Depression is rare among people in excellent physical health (3.2 percent) or very good physical health (5 percent). As physical health worsens, so does mental health: good health (7.1 percent depression prevalence) and fair to poor health (15.5 percent).
  • Educational level isn’t a significant factor. Depression was found among 5.5 percent of college graduates and 6.5 percent of high school graduates. Not completing either college or high school bumped up the rate of depression about one point.
  • Geography of residency also had little effect, with a 7.2 percent prevalence of depression in rural areas, 6.9 percent in small metropolitan areas, and 6.3 percent in large metropolitan areas.

Actions employers can take

The CDC recommends actions business leaders can take to raise awareness and increase employee access to mental health assessment tools and screening, mental health professionals, and medication. The CDC also recommends working with an occupational health or primary care clinician to incorporate questions about behavioral health in routine screenings and to make referrals to specialists, when appropriate.19, 20

Communicating support structures, policies, and programs already in place to support behavioral health is a good first step. The COVID-19 pandemic and its associated stresses enable employers to address mental health without stigma or fear of isolating or drawing attention to individuals because the COVID-19 pandemic was a shared national experience – all employees were vulnerable to its stresses.

In this seven-page guide, the CDC includes six organizations’ success stories and highlights their approaches to improving employee behavioral health. Learning from the experience of other organizations can help all employers generate strategies and programs of their own.

1 2021 Large Employers’ Health Care Strategy and Plan Design Survey by Business Group on Health, 2020    
2 Czeisler ME, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicide Ideation During the COVID-19 Pandemic – United States, June 24-30, 2020. CDC Morbidity and Mortality Weekly Report. August 14, 2020; 69:1049-1057.
3 “Millennials are the largest generation in the U.S. labor force,” Pew Research Center. April 11, 2018.  
4 “About Half of Workers Are Concerned about Discussing Mental Health Issues in the Workplace; A Third Worry About Consequences If They Seek Help,” American Psychiatric Association. May 20, 2019. 
5 “What Companies Like Google, Johnson & Johnson, RetailMeNot and SAP Are Doing to Change the Culture of Workplace Mental Health,” Mind Share Partners, contributor, Forbes. December 19, 2019.
6 Transforming the understanding and treatment of mental illness. Mental illness definitions. National Institute of Mental Health. Page updated November 2020. 
7 Mental Health Conditions. National Alliance on Mental Illness.   
8 SAMHSA Behavioral Health Integration
9 Succeeding at Work. National Alliance of Mental Illness.   
10 “Mental Illness and the Workplace,” by Theresa Agovino. Society for Human Resource Management. August 3, 2019.
11 “How to Accommodate Employees with Mental Illness,” Society for Human Resource Management. September 15, 2014.   
12 Addressing Mental Health in the Workplace Is Imperative for Healthier – and More Productive – Employees. Breaking the Silence Initiative of the American Mental Health Counselors Association. September 1, 2016.
13 SAMHSA Behavioral Health Integration.    
14 “Potential economic impact of integrated medical-behavioral healthcare,” Milliman Research Report. January 2018.
15 “Behavioral Health: Research on Health Care Costs of Untreated Conditions is Limited,” Governmental Accountability Office. February 2019.
16 “Fleets Can Support Drivers’ Mental Health Through Awareness, Communication,” Transport Topics. March 13, 2020..
17 “Mental Health in the Construction Industry,” Field Boss, September 10, 2020.
18 Depression Among Demographics and Professions,
19 Mental Health in the Workplace: Mental Health Disorders and Stress Affect Working-Age Americans. Centers for Disease Control and Prevention. Web page last reviewed April 10, 2019.    
20 Mental Health in the Workplace: Mental Health Disorders and Stress Affect Working-Age Americans - PDF. Centers for Disease Control and Prevention. Seven-page guide.