Barsky et al. have made a compelling argument that the current laws in place to protect employees who are trying to maintain gainful employment while also managing and/or seeking care for common psychiatric conditions are only successful some of the time and do not adequately cover the range of situations in which employees are likely to find themselves.Reference Barsky, Frank and Glied¹ Adequate support of employees is likely to be even more critical in this era in which increased attention is being paid to the effects of the COVID-19 pandemic and other stressful world events on the prevalence and course of mental and behavioral health conditions.Reference Dos Santos, Pico-Perez and Morgado²

Depression is already the leading cause of disability worldwide,³ and having a co-morbid psychiatric disorder along with a physical disability amplifies the degree of impairment associated with that disability.Reference Mather, Ropponen and Mittendorfer-Rutz⁴ What can get missed in the assessment of a patient’s working abilities when a psychiatric disorder that compromises them is present, however, is that disability itself is a bad outcome.Reference Shuey and Wilson⁵ Individuals who are kept out of the work force by a health condition are likely to live in poverty regardless of whether they qualify for disability benefits, and they face important social disadvantages, too, including a higher risk of social isolation.Reference Tough, Siegrist and Fekete⁶ The economic disadvantages may be especially critical for younger adults, who can lose out on important opportunities to lay the groundwork for a successful career and remain disadvantaged upon returning to the workplace even after a temporary disability ends.⁷

As with virtually any other problem related to health and health outcomes, prevention and early intervention are therefore key.Reference Kupfer, Frank and Perel⁸ Policies (such as Title I of the Americans with Disabilities Act that Barsky et al discuss) that facilitate early access to treatment and support, especially for individuals with mild to moderate conditions, likely can do more to improve long-term health outcomes (and economic outcomes), than policies that only facilitate access to care when symptoms have already become so severe that the disability associated with them has reached a certain threshold.

Perhaps not enough attention is paid to the problem of presenteeism. As Barsky et al. explained, presenteeism occurs when an employee with a (usually mild or moderate) health condition is functioning well enough to go to work and ostensibly perform their job duties but does so in a way that is less productive or effective than they ordinarily would. Presenteeism does not necessarily trigger a referral for treatment or support services. Instead, employers and/or managers commonly interpret presenteeism as a sign that the employee is sub-par, and this in turn can lead to fewer opportunities for thriving (in the best of cases), and disciplinary actions and/or termination (in the worst).Reference Chisholm, Sweeny and Sheehan⁹ Thus, a lack of recognition and support for mild and moderate behavioral health conditions perpetuates a cycle in which small problems can become big problems, and potential opportunities to prevent the devastating outcome of disability are missed.

Some employers do seem to be recognizing the importance of facilitating access to mental health treatment and support for employees with range of needs, including those with mild and sub-clinical concerns. Appropriate support does not necessarily need to start with or even involve a leave of absence in many (or most) cases, and there is a potential value in simply ensuring that access to behavioral health services is an expected part of the working environment.

A potentially important emerging trend in this area is the expansion of employer-sponsored access to Internet-based or mobile technology-based mental health treatments.Reference Powell, Bowman and Harbin¹⁰ Although treatment that is accessed through a mobile app is not a replacement for traditional psychiatric or psychological care, it is much more scalable, and it can be highly effective for many individuals, particularly those with mild to moderate conditions, and particularly when it adheres to protocols consistent with cognitive behavioral therapy (CBT).Reference Yasinki and Rauch¹¹ Although that there may be pitfalls to relying on employers to sponsor care, some governments have gotten behind this effort as well. A notable example is the Health Service Executive, Ireland’s national health service, which partnered with a vendor to make internet-based CBT (iCBT) available for free to all Irish residents starting in 2021.¹²

It is important to remember that there is a shortage of qualified behavioral health providers who can provide care in the way that those who are seeking treatment traditionally expect them to, and there is a shortage for a reason.Reference Kuehn¹³ Traditional psychiatric and psychological care is labor-intensive, and a lot of people need it. There may not be a one-size-fits-all solution to maximizing the working population’s ability to be happy, healthy, and productive, but ensuring that policies and procedures around employee mental health pay attention to prevention and early intervention as well as mitigating steps in cases that are more advanced would be a step in the right direction.