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How breaking down mental illness stigma can improve your bottom line

by Sarah Nogues & Jason Finucan

Originally published under the title “Economic Evaluations of Workplace Mental Health Interventions: A Critical Review” in the Canadian Journal of Administrative Sciences, 2018.

A WORKPLACE PAYS IN PROFITS

ABOUT THE AUTHORS

A StigmaZero workplace pays in profits 2

SARAH NOGUES

Sarah Nogues is an expert in work-life balance and workplace flexibility issues. Her field research has led her to understand the needs and motivations of particular groups of workers, such as employed caregivers and older workers.

Her paper “The Right to Request Flexible Working: A Policy Instrument for Employed Caregivers?”, which explores the effects and implications of this new labour legislation in liberal countries, was accepted for publication in the journal Canadian Public Policy.

Sarah is a Masters candidate in UQAM’s (Université de Québec à Montréal) School of Management Sciences, with a major in human resource management, and has a background in sustainable development and arts.

ABOUT THE AUTHORS


JASON FINUCAN

Mental health advocate, stigma fighter, published author, professional speaker and founder of StigmaZero, Jason is also the instructor of the Create Your StigmaZero Workplace program offered within The StigmaZero Online Training Academy (www.stigmazero.com).

As someone who has experienced both a major physical illness (heart defect leading to open heart surgery in 1988) and a major mental illness (bipolar disorder leading to hospitalization in 2005), Jason shares his personal experiences with impactful storytelling techniques. These moving stories can be found as part of our academy programs, through his inspirational keynotes, and in his book Jason: 1, Stigma: 0 – My battle with mental illness at home and in the workplace.

Jason aims to make this difficult topic accessible and consumable, so he blends his stories with rigorous research in order to mobilize knowledge and perspective. His goal is for everyone to understand this important topic so they are empowered to make a real change and ultimately join in the effort to realize his vision for a future without stigma.

This is a mental health movement – and Jason wants you to be a part of it.

http://www.stigmazero.com


EXECUTIVE SUMMARY

What does stigma have to do with my profits?

Mental illness and stigma are two of the biggest causes in reduced productivity and lost profits. And yet, no one is talking about them in these terms.

In this paper we aim to address the elephant in the room. How much is mental illness stigma really costing your business and what can be done about it? It’s a stark reality and while the numbers are staggering, the outlook is far from grim. We will take a closer look at:

• The reality of mental illness in the workplace• The impact of mental illness and stigma on your profits• How employers and employees can help eradicate stigma

It’s time for employers to see stigma surrounding mental illness as not only an HR issue but also a financial issue.

We’re here to show you how mental health initiatives can benefit everyone. It’s better for your employees, it’s better for teamwork and it’s better for your bottom-line.


INTRODUCTION

Whether it is depression, a drug addiction or cancer, any person who has the subjective sensation of experiencing an undesirable diseased state is considered as having an illness.1, 2, 3 In any given year, approximately one in five Canadians live with a mental illness, and two of every nine workers experience a mental illness that likely affects their work productivity.4, 5

The costs of mental illness to society and to workplaces have been documented, mostly in terms of direct costs associated to health care expenditures.

However, indirect costs incurred from lost productivity due to mental illnesses are known to be even greater.6 Globally, it is estimated that mental illnesses cost at least $50 billion each year to the Canadian economy.7, 8

Concerns about mental illness in the workplace are increasing, in Canada and elsewhere.9, 10, 11 As a result, some employers have adopted programs aimed at reducing the incidence of mental illnesses in their organizations, such as mental health promotion interventions, as well as screening and treatment for employees.12, 13 However, recent studies have shown the persistence of discriminatory and stigmatizing attitudes against people with a mental illness among Canadian and US employers.14, 15 As a matter of fact, mental illnesses rank among the least known and the most stigmatized medical conditions.16, 17

Stigma, which involves “processes of labelling, stereotyping, social exclusion, loss of status, and discrimination,”18 has been identified as representing a significant portion of the overall costs of mental illnesses.19 Without denying the fact that in some cases serious mental illnesses impact individual’s ability to work, there is emerging evidence that employers are experiencing negative economic outcomes because of mental illness-related stigma.20, 21, 22



In light of these statements, our paper critically appraises relevant literature to document the following:

• Costs resulting from mental illnesses and stigma• The economic outcomes of initiatives aimed at reducing them

Thus, we hope to provide Canadian employers with a better understanding of an issue which does (or will) concern all of them.23

It is estimated that mental illnesses cost at least $50 billion each year to the Canadian economy.

We assessed peer-reviewed academic literature using economic, business and health databases, such as EBSCO host, ABI Inform, Econlit, PubMed, Scopus, Google Scholar, etc., using key words such as: ‘mental illness,’ ‘workplaces,’ ‘Canada,’ ‘stigma,’ ‘business case,’ ‘return on investment,’ ‘costs,’ ‘interventions,’ etc. We also looked into different government and independent data sources such as Statistics Canada, Public Health Canada, Mental Health Commission of Canada (MHCC), World Health Organization (WHO), Organization for Economic Co-operation and Development, etc.

We first searched for studies directly tackling the return on investment (ROI) of initiatives aimed at reducing mental illness-related stigma in Canadian workplaces. Since we found no such study, we expanded our research to other countries and looked for cost analyses of initiatives aimed at reducing the incidence of mental illnesses in general. A few studies matched these criteria, and we have included the most pertinent ones.

We then broadened our criteria to the general organizational improvements of initiatives aimed at reducing mental illness incidence and stigma among workplaces and included the most relevant studies. We also found interesting studies about the ROI of investing in more health expenditures at the macro level. Then, we selected among relevant secondary literature covering mental illness, stigma, return to work, organizational culture, work-life balance, among other pertinent sub-themes.

Regarding costs incurred by employers as a result of mental illness and stigma, our paper will mostly focus on indirect (productivity) cost, since those are often hardly visible to employers as opposed to direct (health care) costs.

Intangible costs resulting from the pain and suffering of living unhealthy lives will also be mentioned in this paper, in order to give an accurate estimation of the true disease costs.41


METHOD

WHAT IS MENTAL ILLNESS?

Public Health Canada defined mental illness as “alterations in thinking, mood or behavior associated with significant distress and impaired functioning.”24 Mental illnesses can be grouped in the following categories: mood disorders, anxiety disorders, psychotic disorders, disorders of childhood and adolescence, cognitive impairment and substance use disorders.25 However, our purpose is not to specifically address one illness in particular, which is why we use the general reference “mental illness/es,” which are, as the Mental Health Commission of Canada refers to them, “a range of behaviors, thoughts and emotions that can result in some level of distress or impairment in areas such as school, work, social and family interactions and the ability to live independently.”26 Mental illness, however, must be distinguished from “psychological distress,” which according to the OECD is “a phenomenon that can concern everybody from time to time.”27 The exact causes of mental illnesses have not yet been established, and even though an illness is usually referred to as the subjective experience of having an undesirable diseased state,28, 29 one should not conclude that mental illnesses are merely subjective since they are the result of physical reactions.30


MENTAL ILLNESS IN CANADA

Prevalence of mental illness

According to a 2012 survey by Statistics Canada, 9.1 million individuals had suffered from any mental illness during their lives.42 More than 3 million people had experienced a major depressive episode during their lives, and about the same proportion of the population had experienced suicidal thoughts.43 According to a study led by RiskAnalytica, almost 1 in 5 Canadians live with a mental illness each year.44

As opposed to physical illnesses, most mental illnesses start early in life45, 46 with a peak during early adulthood.47 People are thus more likely to experience a mental illness during their first years of employment. In 2011, 21.4% of the working population in Canada experienced some form of mental illness, which represents two out of every nine workers.48 As the population ages and as people stay longer in employment, the proportion of persons with a mental illness is expected to increase.49

Moreover, in 2012 approximately 11 million Canadians aged 15 or more reported having a family member with a mental health problem, and were more likely themselves to report having health problems of their own compared to the rest of the population.50 These statements show that mental illness is highly prevalent in our society, and is likely to reach anyone either directly or indirectly.51


1 mental disability claim represents about

$18,000... twice as expensive as a phyical-related claim


The costs of mental illness

Estimates show that at least $50 billion are lost because of mental illnesses each year in Canada.52, 53 This cost comprises direct costs from health care expenditures as well as indirect costs incurred from lost productivity. With a conservative calculating approach, it is expected to reach $307 billion in 2041, with a cumulated cost of more than $2.53 trillion over those 30 years.54, 55

Health care expenditures

Health care costs are high: one mental illness disability claim represents about $18,000, which is twice as expensive as a physical-related claim.56 Mental illness is also associated with short-term and long-term disability, and disability claims for a mental illness in Canada account for 30% of all work-related claims, which represents approximately $30 billion each year.57

This cost is strongly related to employer expenditures, since employers are the first private contributors to private health care in Canada, with employer-sponsored insurance coverage.58, 59 In 2006, Canadian employers spent 8 dollars per capita in health care.60

Lost productivity

However, indirect costs incurred from mental illnesses are likely the most costly to employers.61, 62, 63 In Canada, employers collectively lose $6.4 billion each year in wage-based productivity, and a cumulative cost of more than $198 billion is expected by 2041 in lost productiv-ity.64 There are many layers behind these big figures to consider: worldwide, 4 to 15 working days are missed each year per capita because of depression, and 8 to 24 days because of anxiety.65 Presenteeism, which is the practice of coming to work despite illness, is known to be even more costly than absenteeism.66, 67 It represents a daily equivalent of 11 to 25 missed days for depression and 12 to 26 for anxiety disorders.68 In Canada, 500,000 employees miss work each week because of mental illness, comprising approximately 355,000 disability cases due to mental and/or behavioral disorders plus approxi-mately 175,000 full-time workers absent from work due to


“One in three respondents had been confronted by the suicidal distress of an employee.”


mental illness according to calculations by the Centre for Addiction and Mental Health.69

Impact on co-workers

Other indirect costs are to be taken into account, such as the fact that long-term sick leaves tend to trigger negative secondary effects on co-workers and supervisors, such as misconduct, legal problems and workplace conflicts.70, 71

Co-morbidity

Also, even if mental illnesses are rarely accepted as oc-cupational diseases, they are very frequently associated to co-morbidity,72 and thus are likely to trigger physical injuries which add to the burden of employers.

Suicide

Moreover, employers are at risk of dealing with the dire human and financial costs of the suicide of a staff member: nearly 4,000 Canadians die by suicide each year, which is the second leading cause of death for people aged 15 to 34.73 In 2000, the value of lost production due to premature mortality was estimated to be around $2 billion CAD.74 In a recent poll led in the province of Quebec, one in three respondents had been confronted by the suicidal distress of an employee, and in 16% of cases suicide was committed on site.75 At the employer level, the costs of one suicide in the workplace can be tremendous, especially in terms of post-traumatic stress disorders among other members of staff, which in Quebec lead to the longest disability leave periods.76

Caregiving

Finally, it should be noted that indirect costs also comprise caregiving for a person with a mental illness, in terms of cash out as well as opportunity costs, since caregiving is sometimes the equivalent of a full-time job.77 According to the Alzheimer’s Society, caregivers of persons with dementia collectively lose 11 million in income each year and 227,720 full-time equivalent employees in the workforce.78 Without appropriate support in the workplace, caregiving is also costly to Canadian businesses.79


“No workplace is immune to poor employee mental health.” Transition

Such tremendous costs may make employers think twice about hiring persons with a mental illness - or their caregivers. However, many mental illnesses are invisible at first sight and therefore hard to detect by recruiters. Thus, employers can hardly avoid this reality, not to mention the obligation to conform to employment equity and human rights,80 and the legal risks involved in breaching them. Moreover, workplace factors such as stressful working conditions can actually reveal, and in some cases cause, mental illnesses.81 Thus, as authors Dimoff & Kelloway expressed: “just as no Canadian is immune to mental health problems, no workplace is immune to poor employee mental health.”82 These statements point to the fact that employers have a major role to play when it comes to mental illness.


EMPLOYERS HAVE A ROLE TO PLAY

Literature shows that workplaces can cause mental illnesses but, at the same time, can be part of one’s recovery.83, 84 These are two reasons why employers are accountable for employee mental health in their organizations.

Workplaces can trigger mental illnesses

The exact causes of mental illnesses remain uncertain. However, some strong evidence has been established.

If we take the example of depression, there is substantial evidence that factors such as stressful life events, among which workplace stressors rank high, play a major role in triggering this illness.85 Simply put, in the context of a job, stress is the result of an individual’s perception that demands exceed his or her capacities, and is character-ized by the perception of a lack of control. Workplace stressors can manifest in a great number of ways: a heavy workload, tight deadlines, being exposed to abusive customers, feeling undervalued, etc. – all of which have the potential to result in instances of depression and anxiety, as well as physical illnesses.86 Thus, employees who undergo uncontrollable stressful life events, such as a work environment that prevents them from achieving a satisfying work-life balance, are at risk of depression. Generally speaking, stress is likely to generate a mental illness in people who are subject to specific disorders.87

Another identified trigger of depression is personal beliefs.88 For instance, an employee who persistent-ly doubts his or her competency is at a higher risk of depression. These types of beliefs are much more likely to be produced by workplaces, since work is a crucial component of one’s identity and self-esteem,89 and since workplaces produce beliefs that strongly influence the attitudes and behaviors of each member of an organiza-


28.8%of Canadians reported their work as being ‘quite a bit stressful’ or ‘extremely stressful’


tion or department.90 Thus, since Canadians spend ap-proximately 40 hours a week at work,91 and since mental illnesses are partly caused by environmental factors, a work environment that involves psychosocial risks is likely to cause the emergence of a mental illness in someone.92

Yet, between 2011-2012, 28.8% of Canadians aged between 15 and 75 reported their work as being ‘quite a bit stressful’ or ‘extremely stressful.’93 Low control, which is a main characteristic of stress, predicts higher rates of sickness absence, as well as mental illnesses.94 In Quebec, chronic stress injuries accepted by the CNESST represented a mean of 268.6 lost days, and cost an average $22,753 CAD in income replacement benefit.95 As authors Wilson and Wilkerson96 stated: “chronic job stress is a form of social climate change that melts the resilience and well-being of employees,” further reinforcing that such continuous stress is far from ideal.

However, if employers have the power to create working conditions that undermine employees’ health, they can also improve it.

Workplaces can help employees recover

Workplaces can also be a source of remedy for mental illness.97 One indicator for this is that unemployed people show higher psychological distress, anxiety disorders and suicide rates than people who are employed.98, 99

How can employers limit the consequences of mental illnesses? Support and education is key.

Perceived organizational support (POS) encourages people to adopt healthier behaviors, such as consist-ently taking their medication, eating healthy food, or not drinking alcohol.100 It is negatively linked to both workplace stressors (heavy workload, exposure to abusive customers, etc) and their consequences (anxiety, depression, etc).101 POS also plays a great part in return to work after a disability leave for a mental illness, since gradual and flexible return to work is recognized by prac-titioners as a step in the rehabilitation of an individual with mental illness.102, 103


“Workplace social support, and especially supervisor social support, has proven to bring relief to the symptoms of employees with a mental illness.”


Employee perception of being supported, which predicts better mental health, is dependent on many factors. Among them, supervisor support and flexibility rank high.104,105 In fact, perceived supervisor support is highly likely to determine the way one is going to perceive how he or she is supported by their organization as a whole.106 Hence the crucial role of supervisors’ attitudes towards mental illnesses at work: in 2014, the principal cause for chronic stress in Quebec workplaces was the supervisor in 42% of cases, which is a higher proportion than in 2013. It is then followed by co-workers and ex co-workers (28.2%).107 Workplace social support, and especially supervisor social support, has proven to bring relief and ease to the symptoms of employees with a mental illness.108, 109

Transition

In their literature review, authors Dimoff and Kelloway suggest that preventing the development of mental illnesses in the workplace avoids two main negative consequences for businesses, namely: employees going on disability leaves, and letting go of employees, possibly in breach of human rights.110 But there is more to it: emerging evidence shows that interventions which prevent and reduce the incidence of mental illnesses in workplaces appear to be cost-effective.

WHAT IS WORKPLACE SOCIAL SUPPORT?

In a work context, social support has been defined as “the degree to which individuals perceive that their well-being is valued by workplace sources, such as supervisors and the broader organization in which they are embedded.”38 It typically involves two dimensions: “(a) being cared for and appreciated; and (b) having access to direct or indirect help,”39 which are also referred to as emotional support and instrumental support. Adding to the concept of perceived organ-izational support (POS), scholars use the concept of perceived supervisor support (PSS), since supervisors have been identified as the actors having the greatest influence on employee well-being in organizations.40


COST-EFFICIENCY OF MENTAL HEALTH INITIATIVES

Now that we are aware of the costs associated with mental illness, and aware that employers hold a responsibility in this respect, we are going to expose the economic worth and return on investment of taking action.

Actions at a global level

In Canada, an analysis was conducted by RiskAnalytica experts to present the health and economic gains that should be expected from investing in better mental health interventions across the country.111 In a scenario where policy initiatives could reduce the incidence of mental illness by an average of 10%, after 10 years $4 billion CAD could be saved on health and social care costs for mental health problems and illnesses, and after 30 years this could amount to $22.4 billion CAD of savings each year.112 A combination of different scenarios would represent a cost savings of $14 billion CAD in 2031 and $27 billion CAD in 2041. These estimates do not tackle indirect costs, while according to author Putnam “the greatest return on investment with depression initiatives is regained productivity.”114

To our best knowledge, the most convincing study about the return on investment of mental health interventions at a global scale was led by the World Health Organiza-tion.115 It has shed a light on the global cost-effectiveness of investing in treatment for mental illnesses, in terms of labor market participation and work productivity. The aim of this study was to show the global return on investment of a scaled-up treatment for depression and anxiety. In the absence of such a scaled-up treatment, 12 billion work days are missed each year across the 36 largest countries in the world, which represents $925 billion USD annually. The cost-efficiency estimates were calculated from 2016 to 2030 at a 3% discount rate. The net present


12 billion work days are missed each year... which represents

$925BNUSD annually


value (NPV) of the intervention represented $91 billion USD for depression and $56 billion USD for anxiety. In terms of productivity, the gains for all 36 countries represented a NPV of $399 billion USD. When the intrinsic benefits are included, namely the value of the 43 million additional healthy lives as a result of the treatment, this represented a benefit-cost ratio (BCR) of 2.3-3.0 and 3.3-5.7, and a NPV of $310 billion USD.

These studies show that at a macro level, investing in more treatment and prevention policies are cost-effective to society and businesses as a whole. However, they do not target the pay-offs of initiatives at the workplace level. In this respect, it appears that employers have some leeway in reducing the costs linked to mental illness: between $2.97 billion CAD and $11 billion CAD could be saved annually as a result of organizational changes that would make work environments less detrimental to employees’ mental health,116 one might wonder what is worth implementing, and what is not. Even though reliable economic evaluations at the workplace level are rare, in part because presenteeism remains hard to measure effectively,117, 118 a few studies have evaluated the cost-efficiency of adopting mental health-related programs in a business context.

Actions at the organizational level

Across the literature reviewed, the most widespread mental health related workplace initiatives are stress-management techniques and global health promotion onsite.119 Prevention practices, or mental health promotion in the workplace, are usually set at the or-ganizational level and thus cover all employees. These initiatives encompass a vast number of practices in the field of work environment and ergonomics, the field of work organization - for instance the availability of flexible working arrangements, career progression opportuni-ties and stress audits, as well as access to gyms, onsite canteens, among others.120, 121, 122

In the UK, a study showed the ROI of a multi-component health promotion strategy for a white-collar employer with 500 employees, compared to taking no action.

The entire intervention cost £40,000, and the net benefit after one year was £347,722, since productivity losses (absenteeism and presenteeism) cost employer £387,722 that year.

This represents an annual ROI of more than 9 to 1. This example shows that prevention strategies can lead to a quick ROI.

We found no data about the ROI of prevention strategies in Canadian companies. However, one study reported successful results from a three-year worksite interven-tion promoting health in a large financial organization counting between 500-1,000 employees, based mainly in Quebec.123 In addition to a decline in the rates of anxiety and depression and other poor health behaviors such as smoking, absenteeism in the organization declined by 28% and turnover declined by 54% in the same period. Qualitative data shows that this intervention was perceived as very successful by all staff.

Studies measuring the efficiency of health promotion programs and interventions in terms of productivity are still rare.124 However, a number of studies have measured the cost-efficiency of employee screening and treatment for mental illnesses such as depression and anxiety disorders.


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Study based on 500 employees


Actions at the employee level

Workplace interventions can also specifically target employees who have a mental health problem. At this level, initiatives range from “modifying workloads, providing therapies, relaxation and meditation training, exercise program, journaling, biofeedback and goal setting.”125 Available data regarding the ROI of initiatives at this level essentially focus on therapy or medication treatment. As we are going to show, the latter seem particularly cost-effective to businesses.

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A UK study led in a company with 500 white-collar employees showed that investing in onsite screening and cognitive behavioral therapy (CBT) for employees with depression or anxiety was cost-effective to the employer, who bore all the costs of the intervention. It involved an initial cost of £20,676, but was offset the first year with a saving of £17,508 in absenteeism and £22,868 in presenteeism. The payoff thus amounted to £19,700 after the first year, with a ROI of 4,7%. At year 2, the payoff amounted to £63,578, with a ROI of 207%. Over a period of two years and at a 10% discount rate, the NPV of this investment was thus worth £51,656 pounds.126 (See figure 1.1)

In the US, one study investigated the ROI of an enhanced treatment for depression, compared to usual care for 198 workers of diverse companies and positions.127 This study was particularly recognized by peers for the high quality of its methodology.128 It showed that benefits from increased productivity after the first year were $2,100 USD per participant, and $5,500 USD after the second year. (See figure 1.2) Since the intervention cost $735 USD per participant during the first year and $353 USD at year two, the net benefits respectively amounted to $30 and $257 USD per participant on an annual basis. The estimated ROI of this intervention was 302% over a two-year period. The authors also highlighted that even in the worst-case scenario, and when employers would pay first-dollar costs, they would still gain 1.00 to 1.20 for every dollar invested in the intervention.

More recently, a study involving 19 US employers and 380 employees showed that a telephone-based in-tervention comprising CBT for people with depression

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brought companies a marginal improvement in work productivity of $6.05 USD per participant on an annualized basis and a BCR of $6.19 USD for every dollar invested.129

These cost analyses show that workplace interventions, especially those involving employee screening for treatment, bring economic gains to employers.

Of course, the transferability of these studies cannot be guaranteed to any workplace since much depends on the type of industry and workplace characteristics such as a turnover rates and skill requirements.130 Yet we have shown that investing in screening and treatment has brought a positive ROI to US and UK employers, in different types of businesses.


One situation has consistently proven to be problematic: return to work.

Transition

Across the literature, one situation has consistently proven to be problematic: return to work. A paper reviewing different studies about the effectiveness of varied mental health programs in a job context revealed that, when it comes to return to work interventions, only one study out of six showed a positive ROI.131 The most reliable studies showed that the intervention outcomes did not offset the investment. Even though the reasons for these statements were not explicitly accounted for in these studies, it is not a bold assumption to suggest that employees with a mental illness are likely to be reluctant to return to work.132,

133 Indeed, the fact that one might get valuable help from a mental health professional does not take away the stress of going back to a work in a climate where mental illness is the object of negative attitude and beliefs, or perceived as such. This suggests that one crucial component of mental illnesses in the workplace remains unsolved, namely, stigma.


STIGMA: A MAJOR HURDLE

Some have argued that studies tackling the cost-efficiency of initiatives to prevent and treat mental illness in the workplace do not identify which component of a given intervention is exactly a factor of success.134,

135 In our view, and that of others,136 one major reason why these studies are hardly transferable is because they fail to account for how willing employees are to take part in these intervention plans. Indeed, there are barriers to implementing onsite treatments: employees might not trust data will be kept anonymous or how it will be dealt with in the human resource department, thus potentially hampering their career.137 Consequently, for interven-tions involving employee screening to work, people need to be willing to disclose their mental illness. Yet, chances are they are not, because of stigma.138, 139, 140

WHAT IS STIGMA?

Stigma is “a multi-component concept involving processes of labelling, stereotyping, social exclusion, loss of status and discrimination, all taking place within a context of differential power between the stigmatizing and stigmatized group.”31 It further involves “the erroneous association of mental illnesses with something disgraceful or shameful,”32 and has been qualified as a “second disease” in addition to the actual illness.33 In the work context, stigma can be defined as “a disposition (…) to act in a discrimi-natory manner towards persons with mental illness,” which can occur without the organizational actors being conscious about the existence of mental illness in their company or team.34, 35 This means that an organization and its staff might engage in stigmatizing attitudes without even knowing it. The literature further distinguishes between three levels of stigma: ‘structural stigma’ refers to the discrimina-tion embedded in policies and practices at a macro level; ‘public stigma,’ namely stereotypes, prejudice and discrimination which have negative repercussions on individuals with a mental illness; and ‘self-stigma,’ which refers to the internalization of public negative attitudes towards mental illness, as well as the individ-ual’s personal beliefs.36, 37

Stigma and unemployment

The first component of mental illness-related stigma one might have to face is employment discrimination. Even though they are protected by the Canadian Human Rights Act, there is evidence of employment discrimination toward people with mental illness in Canada. Unemploy-ment rates rank high among them, compared to the rest of the population: in 2002, 82% men 70% women whose mental health was self-rated as good or excellent were working, compared to 64% and 59% of those who rated themselves as having rather poor or poor mental health.141 More recently, the employment rate of people who have been diagnosed as having an anxiety disorder and/or a mood disorder by a professional was 71% according to the most recent estimates, which is more than 10% lower than the national average of 82.5%.142 If we only consider the cases of people with serious mental illnesses, the employment rate is considerably lower and estimated between 10% and 30%.143

Without denying the fact that serious mental illnesses contribute to lowering the overall employment rate for people with a mental illness in general, and the fact that in some cases a serious mental illness might prevent one from being able to work at least temporarily, studies show the existence of employment discrimination among recruiters towards persons with any mental illness: in a US study, people with a mental illness who reported being stigmatized were effectively discriminated against in terms of salary, compared to those who did not report being stigmatized.144

Another clue of such discrimination is that employers are more likely to hire somebody with a physical injury than a mental illness: in a literature review, 8 in 10 studies found that employers were reluctant to hire a person with a mental illness compared to physically injured applicants.145

For instance, one study showed that employers were 7 times more likely to hire somebody in a wheelchair


than someone with a mental illness.146 Moreover, if most employers appear willing to hire somebody with a mental illness in surveys, few of them do so in practice.147

In Canada, a study has shown the existence of prejudiced attitudes in employment recruiters with wide-spread, false assumptions such as people with a mental illness are not able to fulfil job-related tasks or job social require-ments; that working is not healthy for people with a mental illness; or that mental illnesses are not “legitimate” or “real” illnesses, especially when, upon advice of their physician, employees ask for flexible working arrangements.148 In a study led in Northern Ontario, people with a mental health condition reported feeling “stuck in the mud” and struggling to find a job, with the strong perception that they were discriminated against by employers.149

Employment discrimination is only one facet of the global stigma surrounding people with a mental illness, since employees also face stigma in employment.

Stigma in the workplace We have seen that stigma involves discrimination, which is rooted in the behavior of others preventing access to opportunities for the stigmatized group. Stigma is visible in the attitudes and behaviors of other people. For example, in the workplace, one might perceive stigma among co-workers when they are jealous of accommo-dations such as one individual taking longer breaks, with the assumption that mental illness is not a real illness and that one uses it as an excuse, as shown in a study led in Canada.150 Equally, one might think a workplace is stig-matizing when words such as crazy, kook or nutcase, are applied to people with a mental illness.151 However, the most significant consequence of stigma is not the mere fact of one’s co-worker being jealous or rude, but the silencing power it has on the employees who bear the illness and the reinforcing of their sense of guilt about their own mental illness. This is what literature refers to as “self-stigma.” Actually, the mere fact of NOT talking about mental illnesses in a workplace contributes to stigma and self-stigma, because where mental illnesses are silenced, it reinforces the idea that it is better not to talk about it.152


“The most significant consequence of stigma is... the silencing power it has on the employees who bear the illness.”

Thus, “visible” stigma might only be the tip of the iceberg. It is likely to be internalized by its bearers, and may operate even when other people are not prejudiced against people with a mental illness.153, 154 Frequently, people have strong underlying assumptions regarding their mental illness, especially when they haven’t realized they are ill or haven’t sought help yet.155 They might, for example, be convinced that if their co-workers knew about their illness, they would lose credibility in their eyes and would be rejected, that they would be the object of gossip and would face unfair treatment, or they might simply think that others do not care nor want to know about their being ill.156

There are indeed many reasons why one would not want to disclose their mental illness in the workplace157,

158 in some contexts, self-disclosure can actually lead to negative reactions and discrimination from co-workers because of the use of an accommodation that is perceived as unfair.159 A study involving more than 2,000 Ontarian workers revealed that about 38% would not disclose a mental health problem to their manager, and this proportion was much higher (54.6%) among the respondents who currently experienced depression. The major reason of non-disclosure was the fact that it might negatively impact their careers. Finally, when asked if they would be concerned if work would be affected if a colleague had a mental health problem, 64.7% of the workers who did not experience depression and 60.4% of the workers who did experience depression answered yes.

From an economic point of view, non-disclosure of a mental illness is a major problem to employers and to society: not only does stigma prevent employees from seeking help and being receptive to workplace interven-tions aimed at helping them160, 161 but it also leads to several other undesirable and costly situations for employers.


about

38%would not disclose a mental health problem to their manager

Costs of Stigma

Given that 2 out of every 9 Canadian workers experience a mental illness each year162 and given the prevalence of employment discrimination and stigma, Canadian employers are likely to face the following costs:

Lost Productivity

» Underperformance

First of all, when public stigma becomes internalized by an individual, it results in lower self-esteem and self-effica-cy,163 which in turn is likely to hamper one’s productivity at work. That being said, absenteeism, which is a traditional indicator for mental illness, might only be the tip of the iceberg: it is likely to be only a symptom of a deeper un-derperformance, which is all the more likely to occur when employees conceal their mental illness, thus making perceived stigma yield “a high proportion of hidden costs to employers that are not readily evident from health or disability claims data.”164

» Impaired decision making

Non-disclosure of a mental illness for fear of being stigmatized means that the mental illness remains unknown by managers. This in turn leads to inadequate management practices, with the assumption that employees who are actually ill have poor work ethics.165 Managers are then likely to set unachievable goals, thus triggering more financial and human costs. Some employees who give “stress” as a reason for their absences, for fear of being labelled with a mental illness, might in fact be undergoing a much more serious mental health condition.166


Cost of staff turnover, recruitment and training

Perceived supervisor support is linked to turnover.167 A supervisor perceived as stigmatizing can hardly be perceived as supportive by a person with a mental illness, who will most likely have increased intentions of leaving his job. In Quebec, a study showed that out of 43 persons who had been on a disability leave because of a mental illness, only 21 had returned to work, amongst whom only 8 had returned to the same employer.168

Reputation costs

Simply put, given the prevalence of workers with a mental illness in Canada, perceived stigma in the workplace increases the chances of employees speaking in negative terms of their employer instead of talking about them in a good way.169

Lost profit

Employment discrimination means depriving people from financial independency, which in turns deprives companies from potential consumers.170

Lawsuits

Discrimination on the basis of one’s disability is prohibited by the Canadian Human Rights Act. In the past several decades, Canadian tribunals have become increasing-ly protective of human rights,171 even to the detriment of economic rights of employers in the eyes of some.172 In cases involving human rights, tribunals thus tend to be harsher than in the past, even when employers bring sensible economic arguments. In case of a lawsuit, employers need to be very careful in proving they had absolutely no other choice than to act in a discriminatory manner towards the employee.


Health insurance

Given that employers are the first contributors to private health care,173, 174 and given the high prevalence of comorbidity associated with mental illnesses,175 delays in seeking treatment caused by stigma are, to say the least, not in employers’ best interest. Non-treatment or under-treatment weigh heavier on health insurances and result in higher premiums for businesses.176, 177 As suggested by Canadian authors Szeto & Dobson,178 effective anti-stigma interventions may increase the ac-ceptability of treatment-seeking and thus reduce the length of disability leaves.

Taxes

In the same vein, US authors Gelb & Corrigan179 remind us that employers are taxpayers, including to hospitals. Despite a health tax exoneration in most Canadian provinces, Quebec employers must contribute the Health Services Fund, from 2.7% to 4.26% depending on their total payroll.180 Moreover, since January 1st 2014, Ontario private employers whose payroll exceeds $5 million CAD are no longer entitled to the Employer Health Tax exoneration.181

Premature death/suicide

One should also note that severe work stress has proven to be an important predictor of suicide, “especially when combined with individual characteristics and poor social support”182 which comprises organizational and supervisor support. In Japan, where the concepts of death because of overwork (known as “karoshi”) and suicide because of overwork (“karojisatsu”) were created, a study showed that low control at work multiplied by four the risk of committing suicide.183 This study showed that the majority of the victims had suffered from the following: low social support, high psychological demand, low decision latitude, and long working hours.158, 185 These factors are an expression of a lack of instrumental and emotional support in the workplace.


A StigmaZero workplace pays in profits 32A StigmaZero workplace pays in profits 32

There is a clear business case pertaining to the costs of stigma, and evidence shows that mental illness-related stigma is costly to businesses. Our next and last section briefly reports on which measures are recommended to reduce stigma in workplaces.

Measures to tackle stigma

Nation-wide public initiatives have been launched to increase public awareness about stigma, however, these are of limited effect.186 Many have stated that the best level to set anti-stigma interventions is at work.187, 188, 189 At the workplace level, US author Corrigan190 has indicated three types of strategies:

» Education

These strategies aim to “challenge the myths of mental illness with factual information,” and should be focused on a specific diagnosed group as opposed to mental illness in general. These are the most wide-spread initiatives tackling stigma.

» Protest

These strategies involve appealing to moral values to have people stop stigmatizing.

» Contact

These strategies involve having staff members meet other workers with a mental illness.

It is our belief that all three strategies must be initiated in order to change the culture of stigma that exists in workplaces, a culture which is greatly exacerbating the costs and lost productivity related to mental illness. In addition, studies have shown that employers who had previously been in contact with employees bearing a mental illness were more likely to hire an applicant with a mental illness than those who had not.191

Finally, one innovative HR solution described by Australian author De Lorenzo should also reported here:192



» Buffer Stage Policies

These policies are HR tools designed to tackle the concealment of mental illnesses in workplaces. They consist of an interval step between the statement of reduced employee productivity by managers and the activation of a formal performance improvement plan, that may aggravate the employee’s (hidden) ill-health. Under such policies, employees can choose to disclose their illness to a designated member of HR or to keep it hidden, and benefit from reduced hours or a leave of two or three months.


CONCLUSION

Organizational culture does not change overnight

To date, economic evaluations about the return on investment of workplace interventions aimed at reducing the incidence of mental illnesses in the workplace have mostly focused on treatment interventions, which appear to be cost-effective.

However, evidence shows they are more likely to bring returns in stigma-free environments. Studies reveal the existence of stigma in Canadian workplaces, and employers might not be aware of it since it is much likely to be rooted in deep underlying assumptions that are hard to detect at first sight. It is a matter of organizational culture, which does not change overnight.

Having reviewed all relevant studies, we assert that an effective method of implementing the education, protest and contact strategies to reduce workplace stigma, as detailed above, is to engage a professional speaker and consultant who is able to combine the facts around mental illness with inspirational stories about real-life experiences while addressing leadership, HR and employees alike. Individuals who currently harbor stigmas toward mental illness are far more likely to respond positively to someone who has personally experienced mental illness, and the workplace stigma that surrounds it, rather than a physician or academic offering neutral education on the topic.

To conclude, as authors Gelb and Corrigan193 put it: “decreasing mental illness costs means reducing the stigma associated with them.”

One thing is sure: doing nothing is costly.


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(2000). Stigmatizing Attributions About Mental Illness. Journal of Community Psychology, 28(1), 92-102. Page 92. 191. Sharac, J., P. McCrone, S. Clement & G. Thornicroft (2010). The Economic Impact of Mental Healt Stigma and Discrimination: A Systematic Review. Epidemologia e Psichiatria Sociale, 19(3), 223-232. 192. De Lorenzo, M.S. (2013) Employee Mental Illness: Managing the Hidden Epidemic. Employee Responsibilities and Rights Journal, 25, 219-238. Page 231. 193. Gelb, B.D. and P.W. Corrigan (2008). How managers can lower mental illness costs by reducing stigma. Business Horizons, 51, 293-300. Page 293.

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