Workplace Streess, Depression, and the Overuse of Antidepresant Drugs in the Workplace
An Interview with Dr. Richard Lippin, an Expert on Occupational and Environmental Medicine
Dr. Cohen: Dr. Lippin, for many years you have been concerned about stress and depression in the workplace and the use of antidepressants medications. Why?
Dr. Lippin: As an administrator and doctor in occupational health settings for over 30 years, I've seen many depressed workers. This is a huge, growing, well-documented problem. Of the 47 million Americans who suffer from depression, probably over 70% or about 33 million are part of the nation's workforce. Depression costs employers $44 billion a year in lost productive time including $17 billion representing direct lost work days (absenteeism) and even more economic losses from workers who appear at work but underperform ("presenteeism"). The World Federation of Mental Health stated that mental, neurological and behavioral disorders are rising so fast that they will outrank vehicular accidents, AIDS, and violence by 2020 as a primary cause of work years lost. From my own experience in various occupational health clinics, I have personally witnessed a marked increase in workers' use of antidepressant medications, especially over the past 15 years after the first SSRIs (selective serotonin reuptake inhibitor) drugs such as Prozac were introduced. Also, there are proven trends about consumption of antidepressants by the public, which can be extrapolated to US workers since a large percentage of the American public works. Of the 290 million people in American, about 48%, or 139 million, are officially in the nation's workforce. Antidepressants are one of the top-selling groups of medications perennially. In the US Department of Defense, for example, SSRIs represent the third most costly group of medications.
Dr. Cohen: Why is this occurring?
Dr. Lippin: Two conditions contribute to the problem: time compression and job loss or the fear of job loss. Time compression means a requirement for doing more work in less time. The US National Institute for Occupational Safety and Health (NIOSH) states that in the last 2 decades, the average work year for prime-age working couples has increased by nearly 700 hours. This is the equivalent of squeezing an extra 17.5 weeks of work annually into their already full schedules. The result is that high levels of emotional exhaustion at the end of the workday are the norm for 25-30% of the workforce. Moreover, twenty-six percent of US workers take no vacation at all. Another study found that dual-income couples chat an average of just 12 minutes a day! US workers have overtaken the industrious Japanese as the hardest working developed nation on the planet.
Dr. Cohen: What about people's fear of losing their jobs?
Dr. Lippin: Although the last 7 months have looked a bit brighter, between 1973 and 1996 Americans lost more that 43 million jobs. Three million were lost just between 2000 and January of 2004. People are getting paid much less in their new jobs than in the jobs they lost. Outsourcing of jobs overseas has not only affected the heavy industry and blue-collar manufacturing sectors, but also the white-collar internet sector.
Dr. Cohen: Those are depressing numbers. Don't antidepressant medications have a role for workers experiencing depression because of these issues?
Dr. Lippin: I personally do not believe that people who suffer the loss of a job or who fear losing a job generally need antidepressant medications, at least not as an initial intervention. Yet, as I monitor the activities of primary care physicians, I observe antidepressants being routinely prescribed as the first treatment. The problem with this approach is that there are other proven nondrug methods that work equally well or better, such as counseling or psychotherapy, stress reduction, exercise methods, and others which may also be more cost-effective. Prevention also is important. Prevention involves the way work is organized in workplaces throughout this country. Overall, I believe antidepressants are over-marketed by the drug industry and over-prescribed by doctors, and this broad trend involves workers and their doctors. Finally, the use of medications raises workplace safety issues for the workers themselves and for co-workers and the public, especially when side effects or interactions with other medications occur.
Dr. Cohen: Is there any attempt to prevent side effects by individualizing doses so that people do not get overmedicated?
Dr. Lippin: There is little attempt to individualize doses. The emphasis is on prescribing the drug to keep the patient functioning at work. Performance trumps health in a large majority of situations. Of course, primary care doctors themselves are under increasing time constraints that do not allow time for individualized dosing. This is aggravated by the aggressive marketing of the drug industry that targets advertising not just to physicians. Last year, the pharmaceutical industry spent a whopping $2.6 billion in direct-to-consumer advertising in print and electronic media. My worker patients tell me about the ads all the time. Compounding these is our fragmented health care system where doctors do not have time to communicate with each other. This results in people receiving multiple medications to an excessive degree. Regarding antidepressants themselves, I have made some observations. Many patients experience the anxiety or frank agitation that are so common with these drugs when used at excessive doses. Many others develop dizziness or weakness or cannot concentrate. They are usually on multiple medications including at least one or more psychiatric drugs including antidepressants.
Dr. Cohen: Are there some groups that are most affected by these issues?
Dr. Lippin: Yes. Women, blue-collar workers and older workers. These groups suffer from higher rates of work-related depression. Contributing factors are lower wages for women and blue-collar workers, failure of wages to keep up with inflation, erosion of benefits, and fear of job loss. This economic insecurity increases anxiety and depression. Also, because women and blue-collar employees generally work at lower levels, they have less control over daily work tasks. Older workers have more illnesses and hence take more medications. Finally working single parents, especially women, have less time for counseling or other interventions, which probably increases the need for antidepressants. It is almost as if they have "no time to be depressed," not even to normally grieve after a loss. Patients have told me this. The time pressures on working single parents are huge and well-documented.
Dr. Cohen: What could companies do to minimize the problems that contribute to stress and depression among workers?
Dr. Lippin: Much more than they are doing now! First, they need to better measure and manage stress, depression, and medication use at the workplace. This is in the companies' best economic interest. Tools and technology exist to do this, but most companies have been fearful of stepping up to the proverbial plate. For example, most corporate and government testing policies focus on tracking for illegal drugs and alcohol, but hardly ever for prescription drugs. Yet, the costs of stress, depression, and overmedication, in addition to an aging workforce, require that companies address these issues more effectively. Companies' in-house medical directors are uniquely poised to lead. A few visionary corporate leaders recognize that the future belongs to companies that measure, manage, and maximize their human assets. I can only hope that more companies do so during my lifetime. Improved measurements would be a good practical start. The tools are there to do so.
Dr. Cohen: What should companies do with workers who become depressed? Do antidepressant medications have any role?
Dr. Lippin: Antidepressants play an important role in the total management of depressed patients. Antidepressants save lives and help depressed patients function. My concern, and I believe your work, relate to their excessive use, not individualizing doses, not educating patients and doctors on preventing and handling side effects, not avoiding or recognizing drug interactions, and not adequately using nondrug therapies such as counseling or stress reduction or social interventions. At the same time, pharmaceutical companies need to evolve into total health companies that address medical problems more broadly instead of simply measuring their success by drug sales.
Dr. Cohen: Why is this so important?
Dr. Lippin: Work is central to people's lives. This is true not only for practical reasons such as paying for necessities such as food and shelter and providing for one's family, but also because a person's work gives meaning to life. I believe none of us should ever completely retire. Getting up in the morning and doing some meaningful work, whether it pays money or not, is one of the most under-recognized and under-studied issues in determining people's overall health. It is because work is so important to our health and identity that work stress takes such a toll physically and psychologically. We must find a way to let people do their jobs, do them well, and do them without nonstop, excessive hourly demands and the constant worry about losing one's job.
*Richard A. Lippin M.D., is a Fellow of the American College of Occupational and Environmental Medicine. He has practiced Occupational Medicine for over 30 years in a variety of Corporate, Private and Government settings. Dr. Lippin was Chairman of the American College of Occupational and Environmental Medicine (ACOEM) Mental Health Committee from 1996 to 2001. In 1997 he was the only Occupational Physician appointed to serve on a US National Institute for Occupational Safety and Health (NIOSH) Research team charged with developing a national research agenda on the impact of work stress and organization of work on US worker health and safety. He is board certified in Preventive Medicine and resides in Southampton, Pennsylvania.
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