Employers need to take action on mental health benefits

Health benefit plan insurers have seen a significant swelling in the number of Canadians tapping into mental-health benefits. While mental health and well-being are certainly being touted by employers as a top priority, workers continue to struggle.   

In conversation with Sun Life’s director, mental health solutions, Dr. Sam Mikail, and Beneva’s national senior advisor, best practices, special projects and health continuum support, Daniel Dufour, we learn how recognition is the path to amplifying well-being.  

An uptick in disability claims owing to mental health stressors had begun prior to the COVID-19 pandemic. However, the ensuing turbulence has caused a significant increase in those figures.   

As per Mental Health Research Canada, among Canadians, almost two-fifths (39 percent) of respondents to a survey felt the economic downturn was affecting their mental health. Those with lower incomes or who were in financial trouble were more likely to have high anxiety and depression. 

Most employers and insurers are seeing a sharp increase in disability claims due to mental disorders. What factors are driving this trend? 

Mikail: Certainly, the pandemic had a significant impact on people’s mental health. Biologically, there has been the impact of long-haul COVID on cognitive functioning, energy level, sleep patterns, respiratory function, and mood. There were also significant disruptions to our healthcare system, including limited access to primary care, delays in treatment and diagnostic procedures, and so on – all of which had a marked impact on stress levels and overall health. 

Psychologically, there were multiple factors, including the effects of social isolation, having to miss out on significant life events, increased caregiving demands, increases in substance use as a means of coping, the demands of adapting to working from home, and for many people, the deaths of loved ones due to COVID infections, with the added sorrow of not being able to attend funerals.  Economically and socially, there was the impact of mass layoffs, job insecurity, closure of schools, and other disruptions. 

However, the increase in rates of disability due to mental disorders began prior to the pandemic, and has continued. To make the point, in 2016 claims due to mental disorders accounted for 33 percent of all LTD claims. That number rose steadily to 38 percent in 2019, the year before the pandemic, and was at 42 percent in 2022.  

Disability claims due to mental disorders are higher among younger employees than older employees. Data from Stats Canada also tells us that rates of episodic disability are higher among women than men. So, really, there is no one factor acting alone that accounts for these trends. 

Dufour: Progress in mental health has allowed professionals to better diagnose, intervene in, and treat mental health disorders. As an example, mental health diagnostic categories in the DSM – the Diagnostic and Statistical Manual of Mental Disorders – largely increased between its first edition in the ‘50s and the revised edition of the DSM-5-TR in 2022.  

Everything has become more rapid. New technologies have multiplied interruptions at work. As changes occur more rapidly, our adaptability period is shorter, which generates more stress. The stress response is a normal reaction of our bodies – this is what we call the fight or flight response. It is why we survived prehistorically even with the threat of mammoths! But these days, it is very rare for our lives to be in such danger.  

When stress becomes chronic, health problems appear. Many scientists think that our bodies’ stress response was not designed to be constantly activated. When health problems are not addressed at the right time with the right treatment, there may be medical complications, increasing the likelihood of individuals taking disability leave. 

The economic climate is not easy, especially since the pandemic. Recent statistics have reported that one out of four Canadians is unable to cover an unexpected expense of $500. One in three Canadians reported that it was difficult to meet their financial needs. 

In terms of reported mental health disability claims, the pandemic has worsened the statistics.  

Finally, less stigma can explain a part of the increase over the past few years. In the ‘90s, there was in many insurance policies a limitation clause of two years specific to mental health. The limitation was applied to a person who suffered from “a nervous or neurotic illness,” unless this person was committed to a psychiatric institution. The ‘90s were not that long ago! 

Although progress has been made and there is less stigma around mental health disorders, there is still a long way to go to break taboos. For example, who's going to talk openly about taking antidepressants? If, however, you're taking anti-inflammatories for a back problem, antihypertensives, or any other medication for a physical problem, it's not a big deal. 

Suicide is another taboo topic. There isn’t enough conversation about it, but it's the second-leading cause of death among young people, following accidents. 

Financial burdens can be considered a greater taboo. We know that financial problems affect mental health. Do you know many individuals who will reveal to their colleagues or managers that they are in debt and that it is affecting them? 

We hear a lot about the importance of early detection and intervention in managing mental health conditions. What makes that so important? 

Mikail: The simplest answer is that research has shown this to be the case in numerous clinical trials. There are biological reasons for this.    

For example, in the case of substance use disorders, over time an individual may develop a tolerance for a substance, which in turn creates a physiological dependence that results in a need for a higher dose of the substance in order to avoid the unpleasant effects of withdrawal.   

Mood disorders, such as anxiety and major depressive disorder, are among the most prevalent mental disorders, and one of the leading causes of disability worldwide. Findings from a number of clinical trials suggest that major depressive disorder is associated with increased inflammation that affects brain signaling patterns that can alter an individual’s mental processes. Naturally, the longer that inflammation persists, the more severe the symptoms become, and the more effort is needed clinically to return the individual to a state of well-being. 

We can easily find ourselves using a narrow set of coping strategies across many situations in which those strategies don’t apply, are ineffective, or make things worse. Early intervention guards against those pitfalls by ensuring we are applying the right solution to the situation.   

Dufour: Employers and plan sponsors have a key role to play, as there are many services that can be offered in support of employees. It's important to have an integrated approach to the overall health continuum model. Briefly, this continuum can be summarized in three parts.  

The first is “healthy and at work.” This person doesn’t have any health disorders, so the objective at this point is to maintain the positive condition and promote good life habits to avoid disorders. If you draw a parallel with traffic lights, this first is the green light, where everything is correct. We want to maintain this.  

In the second part of the continuum, the person is still at work but experiencing health risk factors or health disorders. The goal here is to prevent the condition from worsening in order to prevent sick leave or a disability. Again, if we draw a parallel with the traffic lights, we’re on yellow. 

Finally, the third part of the health continuum is when the person is on sick leave or disability. Here the traffic light is red. The goal at this step is to help the person recover their health as quickly as possible and to facilitate their reintegration at work.  

Plan sponsors and group insurance plans provide many services that can be offered at different steps of this health continuum. It's important to have a good understanding of all the services and to support employees. 

Moreover, good management practices will promote health, but unhealthy management practices worsen it. It's essential to integrate a good culture of health and wellness at work at all levels of the organization and to promote the services included in the group insurance plan. 

The mental health landscape has become increasingly confusing for the average consumer. There are so many different types of practitioners and treatments, and many people don’t know where to begin or what type of treatment will be most helpful for their particular needs. How can people make their way through the confusion? 

Mikail: You’re right. The mental health landscape has changed dramatically in the last few decades. On the plus side, people have far more choice today than they did 20 or 30 years ago. But the growth in available options has contributed to more confusion. 

When people are unsure where to begin when seeking a specialized health service, we generally recommend starting with the primary care physician. A significant percentage of Canadians don’t have a regular family doctor and are reliant on either walk-in clinics or, in more extreme cases, hospital emergency departments. The difficulty with that is that practitioners in those settings don’t have the benefit of knowing the person’s individual or family history, and that is often critical to making the right diagnosis and recommending the appropriate treatment. 

It is important to match the treatment to the individual’s needs and disposition. That requires a nuanced approach to selecting the right practitioner.   

My suggestion is, when a person is seeking psychological treatment, they should call several practitioners first and ask some key questions to make an informed decision. To start with, be sure the practitioner is a regulated health professional. That means they hold a license issued by a provincial/territorial regulator that has been established by the Ministry of Health and Long-Term Care. Belonging to a professional association is not the same thing, and is not enough on its own. 

Questions to ask include: Does your scope of practice include diagnosis? Can you tell me a bit about your approach to treatment and what I can expect? What does the research say about that form of treatment? I have been feeling X or need help with Y – can you tell me about your experience in working with those concerns? 

Dufour: Presently we have an abundance of information on many aspects, which is very confusing to wade through. This is where insurers have a role to play by explaining the services available and how to use them. Insurers must support plan sponsors with their integration into the health continuum because it can be complex. 

It's not always easy for many employers to have a good understanding of the all the services, which is why education is very important. Often, services are available, but people may not know of their existence or how to use them.  

Employers have also a role to play in preventing psychological health problems. They must provide a healthy work environment to reduce health risk factors at the source. To do this, primary prevention is essential. 

What adds to confusion on the part of an employee is that it is not easy for someone to accept a disability for mental health and to live with what others will think. In summary, it’s important to have an integrated approach to the health continuum and offer the right care or service at the right time.

The pandemic was a real catalyst in the growth of virtual healthcare.  Is this a trend that is likely to continue? And if so, within the context of mental health, how does it compare to in-office treatment? 

Dufour: Yes, technology has opened the door to virtual healthcare and created new possibilities. Telemedicine is a service available on a smartphone. Someone with minor health problems can easily have access to a doctor and obtain a medical prescription. In these instances, virtual appointments can be very useful for both physical conditions and mental health conditions.  

Several doctors have noted that patients prefer in-person therapy, and while virtual technology exists and is available, not everyone has access to it, [while some] still hold the traditional preference to meet the professional face-to-face. 

Employee assistance programs also allow virtual consultations, not only for psychological reasons but [also for] financial and legal issues. For those with a demanding schedule, it is also a good approach. Some members of the younger generations prefer virtual therapy.  However, virtual healthcare is not one-size-fits-all. Given the lack of access to care, and the long wait times, it is complementary to in-person care. Sometimes it's a mix of both approaches that will be the most efficient. 

Mikail: It’s useful to first define what we mean by virtual healthcare.  Healthcare, and mental healthcare in particular, can be delivered virtually in several ways. 

For example, there are numerous wearable devices now that track physiological and behavioural indices. Today, wearable devices are sophisticated and can track heart rate, blood pressure, arrhythmia, blood glucose levels, movement during sleep, wrist temperature, walking speed, and walking or running distance and so on – all of which can be correlated to various dimensions of health and forwarded to a person’s healthcare provider. Numerous apps are also available that keep track of the symptoms and symptom severity of several mental disorders, send reminders to do a breathing and relaxation exercise, and record substance use.  

There are also apps and web-based platforms that offer self-guided modules for the management of mood and anxiety disorders, grief, chronic pain, etc. Many of these include aides for meditation, mindfulness, or relaxation exercises geared toward regulating emotions and reducing distress levels.   

Virtual care can also take the form of traditional psychotherapy delivered by a clinician to an individual, couple, or group, using a secure video-conferencing platform. Many benefits plans offer reimbursement for this treatment. 

In the case of psychological assessment, we’ve also witnessed impressive advances in the development of traditional psychological assessment instruments that can now be administered remotely through video conferencing platforms. 

In the very near future, we are likely to see increasing use of artificial intelligence to perform diagnoses more quickly and reliably than can be done by practitioners. 

At this juncture, apps are not regulated, but Health Canada is looking at creating a regulatory process to assess mental health apps in a manner equivalent to the regulation of new drugs or medical devices, and many have not been shown to be effective when held up to empirical scrutiny.   

The module-based platforms are showing some promise, particularly for disorders that fall in the mild to moderate severity range. But what the research also shows is that there is a high dropout rate for these treatments.  

The evidence for the use of video-based psychotherapy suggests that outcomes are on par with in-person treatment. Of course, certain precautions must be in place, like ensuring the person is in a private and quite space, having a safety plan in place in the event of a crisis, and having a backup plan in the event of technology failure.  In my own practice, I find that most people I see are asking for and prefer to come in-person unless geographic distance, illness, mobility, or other circumstances are significant barriers.  

Conclusion  

The Canadian Psychological Association (CPA) recommends that mental health coverage in EHC plans should be between $3000–$4500 annually. That is the amount needed to cover the cost of 15 to 20 sessions of psychotherapy, which is what research suggests is needed to treat a first episode of depression.   

However, according to the latest data provided by Sun Life, based on 2020–2021 numbers, only eight percent of plan members had access to the CPA-recommended coverage levels. One-third of plan members had access to coverage for fewer than four sessions annually – which essentially amounts to what is needed for an assessment and preliminary discussion about a proposed treatment plan – and no coverage for actual treatment.