Number of Employees
Maine State Government Participates in Depression Screening and Work-Focused Intervention
Mental Health Works readers may recall an article last year describing the Work and Health Initiative (WHI) developed by Debra Lerner, PhD, Senior Scientist and Director of the Program on Health, Work, and Productivity at Tufts Medical Center Institute for Clinical Research and Health Policy Studies in Boston, Massachusetts. The WHI is a multi-component work-focused care program for employees with depression. The program supplements usual care for depression with enhanced care management, cognitive-behavioral therapy (CBT) and work-focused counseling, and measurements of presenteeism that examine functional limitations on the ability to work. The article encouraged employers to participate in the study to assess the program’s effectiveness and explained that pilot studies with employers have shown the program to be highly effective. We are pleased to share with you the experience of one employer involved in the pilot study: the State Government of Maine.
The State Government of Maine provides a number of programs and benefits to support the health and well-being of its employees. Bill McPeck, Maine’s director of employee health and safety, and his supervisor, Frank Johnson, see participating in research projects as a way to enhance the level of services available to support state employees’ health. Johnson, Maine’s executive director of the office of employee health and benefits, learned about the research initiative through Lerner and her colleagues when he was chair of the Maine Health Management Coalition, an employer coalition based in Portland, Maine.
Johnson discussed the potential benefits of participating in the research with the then commissioner of administrative and financial services and with McPeck, who has a longstanding interest in how social and emotional aspects of health affect work abilities. One potential benefit was improved care for employees with depression. Research suggests that with usual care provided in typical primary care settings, depression often is under detected and undertreated, while enhanced or collaborative care, including patient monitoring and education, improves clinical outcomes (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006; Simon, 2002). In WHI, the aim is to improve care quality and to educate participants about the effects of depression on functional abilities, work performance, and relationships. The WHI also includes clinical care management to ensure that medication side effects are appropriately addressed.
Once the state committed to the project, McPeck helped Lerner’s team communicate with Maine employees to recruit participants for the study. Both e-mails and printed materials were essential to recruitment because approximately 2,600 of the state’s employees have limited access to computers in their jobs. Communications with employees promoted the opportunity to participate in a general health screening, reinforced privacy protection measures, and assured confidentiality of results.
18–62 years old, employed 15 hours/week or more
Five of nine symptoms of depression at qualifying levels on the Patient Health Questionnaire (PHQ-9); or two qualifying symptoms of dysthymia on the PC-SAD
WLQ productivity loss of 5%, i.e., impaired work ability about 20% of the time over 2 weeks
A full description of the Work and Health Initiative research methods and results is available in the February 2012 issue of the Journal of Occupational and Environmental Medicine (Lerner et al., 2012).
Most Maine employees are familiar with health assessments through the state employees’ wellness program and by participating in similar health risk assessments. The WHI health-screening tool resembled other health risk assessments, but unlike the others, it is brief and includes questions about depression symptoms and difficulty functioning at work. Upon completing the screening, participants received an individual electronic report with information about their health.
If a participant reported depression symptoms, the person’s level of depression was compared to national and local norms. The report also provided a functional ability score in the form of an indicator that describes how well the individual can participate in important life functions, such as work, as measured by the Work Limitations Questionnaire (WLQ) (Lerner, Amick, Rogers, Malspeis, Bungay, & Cynn, 2001).
Employees whose levels of depression and work limitations made them eligible to participate in the intervention part of the study (see inset box for criteria) were provided program information online or through a toll-free number. Those who agreed to participate were randomly assigned to either a usual-care group or the WHI intervention group.
The WHI intervention included the following components:
Work-focused counseling and coaching — Structured biweekly one-hour telephone “visits” between participants and employee assistance program (EAP) counselors specially trained and supervised by the study investigators to address specific work performance difficulties related to depression;
Eight-week program duration with updated assessment of participants’ work function and depression symptoms every four weeks;
Participants completed weekly homework activities using the workbook, “Creating a Balance,” a cognitive-behavioral therapy based resource that provides strategies for managing thoughts and behaviors that may interfere with work functioning; and
Weekly supervision of EAP counselors by researchers for care coordination and case management, including counselor contacts to primary care providers, psychiatrists, and other clinicians to share concerns about medications and to report specific work impairments.
Lerner and her team worked with seven counselors from All One Health Resources, the state’s EAP provider, prior to the intervention to prepare the counselors for the structured intervention strategies. The research team also supervised the EAP counselors weekly throughout the research project for case discussions. The counselors were reimbursed through the research project for the time they devoted to the training, intervention, and case management components. The research was funded by the National Institute of Mental Health.
Participants in the WHI project had positive outcomes compared to the usual-care group on measures of at-work performance, absence, and depression severity, as well as in productivity cost savings. “When people feel better, they function better and vice versa,” says Lerner. She suggests that the work-focused intervention and the proactive care coordination with other clinicians are factors that may influence the effectiveness of the approach.
“About half of the people were on antidepressants,” Lerner says, “but many weren’t working with their doctor for medication adjustments.” Counselors encouraged participants to work with their prescribing physician and sometimes contacted as many as four other professionals involved in a participant’s care to report on the participant’s difficulties with medication adherence or concerns about side effects. Counselors reported monthly functional status and depression measures to these professionals.
The researchers found that three main kinds of problems were identified in the work-focused counseling and coaching:
Difficulty with task completion (e.g., due to distractibility or memory difficulties)
A sense of feeling overwhelmed due to ineffective coping strategies
Work disengagement and isolation
Participants worked with their counselor to identify specific cognitive and behavioral patterns that negatively affect work functioning and to develop ways to change the patterns. Examples of ineffective cognitive patterns included negative, overly self-critical thinking or thoughts of being victimized. Behavioral patterns included difficulty regulating emotions, experiencing muscle tension, and withdrawal from workplace interactions. Examples of ways to change behaviors included increasing previously enjoyed activities, using a 30-minute walk to help improve concentration, and incorporating relaxation techniques prior to anxiety-producing tasks.
The work coaching and modification component of the intervention focused on identifying barriers to effective functioning and employing individual-level strategies to address them. For example, a worker may have trouble with keeping pace throughout the workday because of sleeplessness and fatigue. In this portion of the program, the counselor may help the employee to re-organize work tasks so those that are more mentally demanding are done earlier in the day or workweek, or the counselor may help identify methods for re-energizing such as taking mini-breaks. The solutions are customized to the employee and his or her work situation.
“Participating in this kind of research has been beneficial for us as an employer,” says McPeck. He feels good about helping the researchers and points out that such projects also give organizational and health program managers “an opportunity to look at things differently, to take stock in our programs and approaches,” he says. Areas that are being examined include changes in their health risk appraisal and better ways to steer people to programs and resources. His time commitment for helping with the study was heaviest at the beginning of the project, when the screening opportunity was communicated to employees, but he felt this was not overwhelming. McPeck says the state is likely to participate in additional research in the future.
The research also was valuable to the state employees’ EAP provider. Tom Blumenthal, clinical director for All One Health Resources, said the 8-week structure of the program and telephonic delivery was different from the typical EAP model and would be difficult for an EAP to sustain without having had this advanced training. The training Lerner and her staff provided to the EAP counselors has had lasting effects, however. It raised counselors’ awareness of the need to focus on work-related issues and to advocate for appropriate medical management. Blumenthal believes the tools counselors learned and the ongoing supervision and case discussions enable them to “push beyond barriers” and to ask about work performance factors even when participants have not identified work-related issues as a reason for accessing care.
All One Health Resources’ vice president of corporate health and productivity, Barry Beder, says the chance to receive excellent training from such talented leaders in their field through this project and to work with them regularly was “like a gift” to the EAP’s staff. Their other corporate clients are experiencing difficulties with productivity issues, and this project helped the EAP develop specific strategies to address work performance and functional abilities for those clients as well.
Lerner’s research on the effectiveness of emphasizing functional abilities and work issues is an important contribution to the field. She hopes to focus next on similar programs for individuals with stressrelated work impairments and to apply programs in real-world settings to ensure ongoing sustainability of interventions. She also plans to include analysis of health claims data in future studies.
Workbook for Telephone Intervention
Creating a Balance: A Step-By-Step Approach to Managing Stress and Lifting Your Mood (Simon, Ludman, & Tutty, 2006) is a workbook developed for a structured telephone intervention program. It includes general information about depression and depression treatment, directions for identifying and increasing involvement in mood-lifting activities, information on reducing negative thoughts patterns, and tools for creating a self-care plan to keep depression and stress under long-term control.
About the Maine State Government
The State Government of Maine employs people in a wide range of roles dispersed throughout the state. Maine's principal industries include lumber, fishing, shipbuilding, textiles, paper and leather products, and farming.
Nancy Spangler, PhD, OTR/L, president of Spangler Associates, Inc., and consultant to the Partnership for Workplace Mental Health, is a prevention and health management specialist in the Kansas City, Missouri area.
Last Updated: July 2012
Gilbody, S., Bower, P., Fletcher, J., Richards, D., Sutton, A.J. (2006). Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine, 166 (21), 2314–21.
Lerner, D., Adler, D. A., Hermann, R., Chang, H., Ludman, E., Greenhill, A., . . . Rogers, W. (2012). Impact of a work-focused intervention on the productivity and symptoms of employees with depression. Journal of Occupational and Environmental Medicine, 54 (2), 128–135.
Lerner, D., Amick, B. C., 3rd, Rogers, W. H., Malspeis, S., Bungay, K., & Cynn, D. (2001). The Work Limitations Questionnaire. Medical Care, 39 (1), 72–85.
Simon, G.E. (2002). Evidence review: efficacy and effectiveness of antidepressant treatment in primary care. General Hospital Psychiatry, 24 (4), 213-224.
Simon, G.E., Ludman, E.J., & Tutty, S. (2006). Creating a balance: a step-by-step approach to managing stress and lifting your mood. Victoria, BC, Canada: Trafford Publishing.
Simon, G.E., Ludman, E.J., Tutty, Operskalski, S.B., Von Korff, M. (2004). Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment randomized controlled trial. Journal of the American Medical Association, 292 (8), 935-942.