Illustration by Jasper Rietman
There are plenty of days when Eliza can't manage to get herself out of the house. On others, she can't even get out of bed. And in between, she often can't sleep, can't concentrate and can't remember things. She definitely can't hold down a job. At least not right now.
Deep thoughts this week:
1. Mental illness is costing us hundreds of billions in obvious ways.
2.And hundreds of billions in less obvious ones.
3. We may need to spend money to save money.
Eliza, who asked that I not disclose her last name, successfully battled depression for most of her life. She persevered through college and graduate school and worked steadily for more than a decade as a pharmacist. Then, about two years ago, she suffered from an unusually debilitating stretch in which she didn't respond to antidepressants, and her insurance company refused to pay for experimental treatments that her doctors recommended. Now in her 40s, she has become one of the more than 1.4 million Americans on the federal disability rolls for mood disorders. She also receives Medicaid, food stamps and fuel assistance. "I never wanted a handout," Eliza told me last month, adding that she has held on to her pharmacy license in the hope that her condition may yet improve. "I would give anything to get out of this and go back to where I was before."
Mental illness has been an increasingly significant health concern over the past several decades, but it's now becoming an economic one too. The number of Americans who receive Social Security Disability Insurance for mental disorders has doubled during the past 15 years. Eliza is now one of an estimated 11.5 million American adults with a debilitating mental illness, on whom the country spends about $150 billion annually on direct medical costs — therapy, drugs, hospitalizations and so forth. But the biggest blow to the overall economy are the many hidden, indirect costs. People with serious mental illness earn, on average, $16,000 less than their mentally well counterparts, totaling about $193 billion annually in lost earnings, according to a 2008 study published in The American Journal of Psychiatry. And many mentally ill workers, who are more likely to miss work, also suffer from what social scientists call presenteeism — the opposite of absenteeism — in which they are very likely to be less productive on the job when they show up.
Reduced earnings and a lower likelihood of being, or staying, married compound the problem. The mentally ill are at higher risk of poverty than their peers, which subsequently increases their need for other public safety-net services like food stamps and subsidized housing. Their use of those services, according to one recent estimate, probably costs taxpayers another $140 billion to $160 billion a year. All together, our cumulative mental-health issues — depression, schizophrenia and bipolar disorder, among others — are costing the U.S. economy about a half-trillion dollars. That's more than the government spent on all of Medicare during the last fiscal year.
With a major expansion of health insurance slated to take effect next year under Obamacare, policy makers are obsessing over how to bring down such costs. But listening to Eliza talk about getting back to work, it was hard not to wonder whether the best way to cut the long-term costs associated with mental illness was, paradoxically, to spend more money on directly treating it now. Economists refer to this as the cost offset, and it's sort of like a return on an investment that comes from helping mentally ill people become more productive and less dependent on taxpayers.
There is evidence that suggests this might work. A study published in 2007 in The Journal of the American Medical Association, for example, enrolled depressed employees at 16 large companies in a randomized controlled trial. Some of them received telephone outreach, care management and optional psychotherapy, while others received their usual care. The employees in the "enhanced care" group not only worked longer weeks than those in the other group but also demonstrated greater job retention. Those increases in hours on the job brought companies an average annual value of $1,800 per worker, which was estimated to exceed the cost of both the outreach program and the roughly 10 additional mental-health specialty visits made by subjects in the treatment group. Another study conducted at 12 primary-care facilities found increased productivity and reduced absenteeism for patients who received enhanced treatment.
Catherine Rampell is an economics reporter for The Times. Adam Davidson is off this week.
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