key: cord-0766552-rtrqgj10
authors: Wu, Ashley; Roemer, Enid Chung; Kent, Karen B.; Ballard, David W.; Goetzel, Ron Z.
title: Organizational Best Practices Supporting Mental Health in the Workplace
date: 2021-10-06
journal: J Occup Environ Med
DOI: 10.1097/jom.0000000000002407
sha: 8f0b3968867fb276a41c1289f66c8af1a2044a94
doc_id: 766552
cord_uid: rtrqgj10

OBJECTIVE: To provide a narrative review of best and promising practices for achieving exemplary mental health in the workplace as the foundation for the inaugural Carolyn C. Mattingly Award for Mental Health in the Workplace. METHODS: Research was drawn from peer-reviewed articles using the search terms associated with workplace mental health. RESULTS: Eight categories of best practices were identified: (1) culture, (2) robust mental health benefits, (3) mental health resources, (4) workplace policies and practices, (5) healthy work environment, (6) leadership support, (7) outcomes measurement, and (8) innovation. CONCLUSION: The review provided the scientific backing to support criteria developed for the Carolyn C. Mattingly Award for Mental Health in the Workplace. By recognizing organizations that apply evidence-based practices in their health and well-being programs, the Mattingly Award may inspire employers to adopt best practices.

T he mental health and well-being of employees have become an increasing concern among employers, especially in response to the COVID-19 pandemic. Over a year after the virus was first discovered, employees continue to fear that they will be exposed to, or spread, the disease to family members, coworkers, friends, or strangers with whom they come in contact. 1, 2 Additional pandemicrelated stressors, including high ambiguity and uncertainty, social isolation due to physical distancing measures, changes in both work and domestic responsibilities, and concerns regarding financial and job security, have further affected employee mental health. 3 According to a recent survey conducted during the COVID-19 pandemic, workers reported an increase in mental health symptoms, including heightened feelings of guilt (24%), insomnia (38%), irritability (50%), sadness (53%), and emotional exhaustion (54%). 4 The toll of mental illness severely impacts the economy. For example, depression was estimated to cost the US economy $210.5 billion (2010 USD) with about half that sum paid for by employers. 5 Depression often occurs concurrently with other chronic conditions, amplifying its economic burden on employers and healthcare systems. Around 60% of the cost of depression is directed at treating comorbid conditions like cardiovascular diseases and diabetes. 6 The predominantly adult population in the workforce has also been shown to develop higher rates of anxiety, substance use, and mood disorders in comparison to other demographic groups. 7 Work is one of the leading causes of stress for adults in the United States 8 and job-related stress is linked to poor mental health. These workplace stressors, including long working hours, poor social support, and unclear management and work roles, are connected to increased risk for various negative mental health outcomes. 9 The debilitating effects of poor mental health go beyond the direct costs of treatment and include even larger indirect costs related to lost productivity, such as through absenteeism and presenteeism (ie, performance decrements while continuing to work). To quantify the global cost of poor mental health, indirect costs incurred from absenteeism and presenteeism were estimated to be $1.7 trillion annually in 2010 and direct costs added an additional $0.8 trillion, with these costs expected to double by 2030. 10 As the importance of promoting good mental health has become increasingly clear, employers are seeking guidance on action steps they can take that are comprehensive, evidence-based, and cost-effective.

However, it is often difficult for employers to gauge the mental health needs of their employees due to the stigma that still exists related to mental health conditions. Stigma tends to create mental barriers barring employees from speaking up or seeking help. Although widely available, mental health services offered by employee assistance programs (EAPs) are often underutilized. The fear of facing discriminatory behavior from coworkers and superiors, social exclusion, and being perceived as lacking in competence are some of the reasons preventing employees with mental health conditions from seeking the help they need. This can negatively impact employee performance, interpersonal relationships, and workplace well-being. 11 Heightened attention surrounding this issue led to a public health summit in 2016 at the Johns Hopkins Bloomberg School of Public Health (JHSPH) titled: Mental Health in the Workplace. Representatives from various professional disciplines highlighted the issues and gaps in current workplace mental health practices. At the summit's conclusion, a collective call to action was announced to advance workplace mental health, and a list of recommendations was offered to inform further research and actions employers can take. 12 The consortium's recommendations included: 1) developing a quantitative scorecard for measuring mental health in the workplace, 2) shaping workplace cultures to value mental health and well-being, 3) enhancing the dissemination and accessibility of workplace mental health information, and 4) establishing an award to recognize exemplary programs and incentivize employer participation in mental health initiatives.

This paper focuses on the fourth recommendation: developing evidence-based criteria for the Carolyn C. Mattingly Award for Mental Health in the Workplace (Mattingly Award) created in partnership by JHSPH and The Luv u Project. 1 By recognizing exemplary efforts to promote workplace mental health, the award would elevate the reputation and brand of employers practicing corporate social responsibility and encourage other organizations to create a culture of mental health and well-being.

The process of this literature review was based on recommendations by experts in workplace mental health and practitioners at organizations with a strong track record of supporting mental health efforts in the workplace. An outcome-oriented approach was applied in building the criteria for winning the Mattingly Award.

To establish best and promising practices for the Mattingly Award, a literature search was conducted focused on mental health in the workplace and EAPs from both academic and industry sources. Most articles were peer-reviewed in scientific journals published in English during the period of 2000 to 2019. Studies excluded were those that only focused on workplace wellness without considering the mental health aspect of the program. Studies with results not specific to populations in the United States, or containing intervention carried out in non-workplace settings, were also omitted. Studies not specific to the United State were omitted because of the uniqueness of employee benefit schemes in the United State. For example, in the United StateS, health benefits for working-age adults are predominantly employer-funded, with employees bearing a significant burden of out-of-pocket costs; and mental health parity laws compel equal coverage for physical and mental health benefits.

The following terms were used to identify relevant articles: workplace mental health, EAPs, workplace interventions, workplace best practices, mental health services in the workplace, worker health, depression and anxiety in the workplace, and occupational stress management interventions. All search terms were adapted for each database. The following electronic databases were searched: Google Scholar (2000-2021), PsychINFO (2000 PsychINFO ( -2021 , and SCO-PUS (2000-2021). Articles were initially screened based on relevant titles, and each article was examined and evaluated based on the above inclusion and exclusion criteria.

A plethora of sources was consulted to inform the framework for the review. The main sources referenced included models of psychologically healthy workplaces that focus on the broad set of evidence-based practices and psychological principles employers can use to boost workers' overall well-being and organizational functioning. [13] [14] [15] [16] The Mattingly Award was designed to be built on the foundation of these broad-based psychologically healthy workplace practices, with a specific focus placed on workplace mental health programs. Behavioral definitions for psychologically healthy workplace practices were noted based on real-world best practices. To qualify for the Mattingly Award, the applicant would first meet baseline criteria for general psychologically healthy workplace practices, which would then make the organization eligible for consideration for the Mattingly Award. Although best practices and award criteria were evaluated through a largely US-centric perspective, standards and references included in this paper shall provide a meaningful baseline against which multinational companies can evaluate their global programs, with the exception of health benefits coverage and access to providers are unique to the US workforce.

The CDC Worksite Health ScoreCard 17 served as another primary reference, especially for award criteria that involve workplace mental health benefits, stress management, and substance use disorders. Special attention was given to evaluating the strengths and weaknesses of different EAPs, as it has been noted that underutilization of EAPs may underscore the shortcomings of workplace mental health programs. Therefore, several EAP association websites were examined and referenced, including the EASNA as well as the Health Enhancement and Research Organization (HERO).

Reviewing best practices in organizations with substantial mental health support for their employees helped create a baseline against which existing practices could be judged. The main source referenced for establishing benchmarks and best practices were the American Heart Association Mental Health Report, 7 and specifically its company mental health program summaries section. If organizations wish to expand their focus beyond the scope of the United States, global norms and benchmarks including those available from WHO would be included in the vetting process for recognition of best practice programs.

With the evidence accumulating that a psychologically healthy workplace is linked to higher job satisfaction, motivation, and work performance, as well as reductions in turnover and healthcare costs for companies, 16 Mattingly Award program developers established criteria to be applied for the selection of best practice workplaces. Each of these criteria alone is limited in its effectiveness to improve employee well-being. However, when combined into a comprehensive program, there is sufficient evidence that a multi-component approach leads to favorable outcomes related to employee health and well-being.

Our review of literature and discussions with subject matter experts informed the development of the following eight Mattingly Award criteria (See Table 1 ).

The importance of organizational culture is often overlooked, as most companies with previously established organizational structures already have recurrent behavioral patterns in the form of distinct power relationships and political structures, that are deeply embedded in their workplace environment. 18 These behavioral patterns will then influence other organizational variables and behaviors in the workplace. These variables may include the physical and social environment of the workplace, the workplace's values and norms, and the ''unconscious assumptions that make up the culture of an organization.'' 18 Thus, establishing a strong culture of mental health can make a difference in the awareness, utilization, and impact of programming efforts to build a mentally healthy workforce. Organizational culture includes components such as leadership and management behaviors, official policies or guidance documents, and common practices and expectations. Together, these reflect the shared values of the organization and can create an environment that is supportive (or unsupportive) of employee mental health. 19 

Concurrent with having strong cultural support, companies need to provide robust health plan coverage for mental health services. Overly narrow mental health provider networks and high out-of-pocket costs are major deterrents for people seeking mental health treatment and often result in long-term suffering and further deterioration of their health. 20 These components include providing access to a large pool of mental health providers; offering a broad range of covered mental health benefits; reducing or eliminating cost-sharing for treatments; and eliminating unreasonable service limits such as the number of outpatient sessions covered, lifetime spending caps, and restrictive rules concerning prescription medication.

To comply with the MHPAEA requirements, companies are required to offer parity across physical and mental health treatments to address employee needs. 21 In addition, the Affordable Care Act built on the MHPAEA by expanding its requirements to include guaranteed access to mental health services for individual and small-group plans, mandated mental health and substance use disorder services as one of ten ''essential health benefits,'' and established a requirement for many insurance plans to cover preventive services such as mental health screenings. 22 A report published by the Congressional Budget Office noted private insurance companies pay 13% to 14% less for mental healthcare coverage than Medicare, despite paying 12% more than Medicare when covering services by other physician specialties, highlighting the growing gap of inadequate mental health coverage, resulting in higher cost-sharing payments. 23 Addressing this cost barrier is one of the keys to ensuring employees can afford needed mental health treatment. In addition to improving worker health, access to high-quality mental health services is also associated with positive organizational outcomes. For example, the treatment of depression has been shown to result in about a 40% to 60% reduction in absenteeism/presenteeism. 24 

For employees experiencing challenges, both personal and work-related, companies often provide mental health counseling and support services through their EAPs. Depending on the EAP provider, scope of service offerings, program utilization, alignment with organizational culture, and the quality of care, EAP outcomes may vary. 25 What originated as a program to address alcohol misuse in the workplace has expanded to include a myriad of services such as clinical assessments, brief counseling, and referral to community resources that provide counseling services including those focused on financial wellness. 26 Over time, EAPs have evolved from their original models by expanding the types of services provided, partnering with insurance carriers, and offering mobile applications and telemedicine to ensure wider dissemination and accessibility of services to employees and dependents. 27 This has helped destigmatize mental health help-seeking behaviors and elevated the role EAPs play in managing behavioral health risks. 25 Companies that emphasize mental health in the workplace have EAPs that cover counseling, substance use treatment, and referrals to providers that are available and accept the company's insurance benefits. One of the main problems companies still face with EAPs is their low utilization rates. 28 Although a majority of civilian workers in organizations with 100 or more employees have access to an EAP 29 and despite substantial evidence indicating that EAPs increase the well-being of employees who actively use the services, 30 utilization averages just 2% for basic EAPs bundled with other benefits, and 8% for more comprehensive full-service EAPs. 31 A strong EAP program encourages utilization to ensure employee needs are met and that employees who require help are aware of, and can access, the services provided. In terms of assessing whether employee mental health needs are being met, EAP usage alone would not be a sufficient indicator, multi-method assessment is required to contextualize usage of EAP services within a healthy or unhealthy company culture.

Workplace stress has been identified as one of the biggest sources of employee anxiety and depression, and chronic stress can Increased awareness, utilization, and satisfaction with mental health programs and resources Improved employee mental health and well-being outcomes Reduction in stigma related to mental health Innovation Incorporation of technology or non-traditional programs/services that yield positive mental health outcomes Removal of barriers, making resources easily available Creative communication strategies even have prolonged negative impacts on one's psychological and physical well-being. 32 A study examining EAP impact on clinical outcomes demonstrated employees that accessed EAP services fared better clinically than those who did not. 33 To address the needs of diverse workforce populations, EAP professionals are trained to identify and address underlying issues that negatively affect employee mental health. 33 Aside from offering EAPs, employers may also provide other types of stress management programs designed to alleviate symptoms of stress and anxiety and improve blood pressure and cholesterol levels. 34 They can be stratified into several categories: CBT, relaxation/meditation/mindfulness techniques, organization/system restructuring, multimodal, or alternative interventions. 35 As workplace stress is directly linked to safety, health, and well-being outcomes, employers are focusing more attention on organizational factors that induce stress and are developing programs to address these stressors. 36 Work-related stress stems from various sources, such as heavy workloads, lack of autonomy and control, work-life conflict, increased technological demands, and unpredictable schedules. 36 Ways to prevent and reduce stress include ensuring workload aligns with employee capabilities and resources, providing opportunities for career development, and improving communication and management support at the supervisor level. 37 

Preventing and addressing accidents and injuries, sexual harassment, discrimination, workplace violence, and bullying/ incivility is critical to creating a psychologically healthy and safe work environment. Discrimination, harassment, and bullying in the workplace can provoke psychological and physiological stress responses, resulting in chronic health conditions. 38 Imbalance in gender or racial composition of the workplace may also influence employee experiences of injustice, such as unequal treatment or limited opportunities. 39 Toxic work behaviors can cause long-term distress from negative emotions, resulting in increased staff turnover, decreased job satisfaction, and poor work performance and attrition, which can be destructive to employees and organizations alike. 40 Policies and training can help reduce or eliminate such toxic behaviors in a timely manner. Including training on normative behaviors and consequences related to bullying, harassment, and discrimination in workplace orientation programs, and educating employees about their right to confidentially report these issues to human resources personnel, 41 can improve the fit between employee expectations and organizational practices as well as empower employees with mental health conditions. 42 In terms of preventing injuries, ergonomic office design concepts need to be taken into consideration. The office location, layout, and workspace have the potential to impact workers' mental and physical well-being. 43 By optimizing the fit between employees and work environments through the system and job design, occupational risk factors for musculoskeletal, mental, and cardiovascular health could be minimized. Work-related musculoskeletal injuries like lower back pain and tendonitis resulting from physically strenuous jobs, often cause chronic health problems and disability in later stages in life. Protective ergonomic factors include promoting health-conscious attitudes, coworker support, reduction in repetitive work, and better work postures. 44 

Creating a supportive work culture is crucial in enhancing individual mental health. To establish this, there need to be strategies in place that involve changing the ''physical surroundings and social, economic, or organizational systems'' to promote and enhance workplace mental health. 45 Supportive work environments provide opportunities for social connectedness and self-care. Creating an inclusive and connected work environment is a social process that involves organizational responsiveness to achieve mutual understanding and make accommodations for people with mental health conditions. 42 Availability of opportunities for stress recovery and mental recharge such as having quiet rooms on-site to rest in, as well as breaks from work including vacation days, work-free weekends, and ''real'' lunch breaks is found to be associated with positive mood, less fatigue and a decrease in employee burnout. 46 Modifying the physical and social environment helps cultivate a culture that is conducive for workers to thrive and promotes overall well-being. 47 In addition, a holistic work environment is one that provides adequate support to meet employees' nutrition and fitness needs, for instance, having healthy food choices in staff cafeterias and providing nutrition education. Not every workplace has the capacity to provide on-site fitness facilities, but employers can lower the barriers to exercise by providing subsidized fitness club memberships or conducting activity challenges. 7 According to a study that examined employee health using the validated SF-36 mental health scale, participants of workplace wellness programs demonstrated reduced stress levels, improved social satisfaction, increased energy levels, and improvement in self-efficacy and quality of life upon program completion. 48 

Consistent and open leadership support plays an important role in influencing workplace climate and employee attitudes toward mental health. Workplace mental health policies cannot be implemented without the support of company leadership at all levels of the organization. The emphasis that leaders place on improving mental health in the workplace consequently shapes employee perceptions of the company's commitment to health promotion. 49 Making mental health an integral part of corporate leadership is an important step in destigmatizing mental health issues. Training for leaders to address work performance issues facilitates the development of active channels of communication for employees to learn about mental health benefits, resources, and the importance of emotional well-being. Educating leaders in tailoring their management style to the needs of employees is key to bridging the gap between employee mental health needs and resources available to address those needs. Because employees may feel reluctant to openly discuss their mental health challenges, leaders can take the initiative of modeling desired behaviors and providing support services to address workplace stressors and psychological impediments to individual and team well-being.

Implementing positive leadership practices can serve as a foundation for building and maintaining a positive organizational climate. Having workplace leaders take on roles of wellness champions can be encouraging to employees when they are facing mental health issues. Not only can this improve recognition of mental health problems and promote help-seeking behavior but also increases the likelihood of effective treatment delivery. 50 Managers at all levels can demonstrate supportive supervision techniques by bringing employees together to actively identify and address sources of stress and help mediate work-life conflicts. 36 This has been shown to be associated with positive impacts on employee job satisfaction, physical health, and workplace productivity. 36 

To establish the impact of organizational mental health efforts, it is crucial to measure employee mental health and wellbeing outcomes. Indicators of success can include increased EAP awareness, utilization of and satisfaction with available resources, and a reduction in stigma related to mental health. Currently, there are no standardized guidelines on what is viewed as ''success'' metrics in a workplace mental health program. Success can be measured in terms of the programs, policies, and environmental supports that promote a healthy company culture; engagement with and satisfaction with one's job, supervisors, and colleagues; enrollment in health-promoting programs and services; and reduced incidence of mental health problems, as well as improvement in psychological well-being indicators. It is important that employers clearly state their overall goals and objectives for such programs ahead of time and continue to monitor the key metrics linked to those goals and objectives continuously throughout the life of the program. The Mattingly Award will focus on the key structure, process, and outcome measures reflective of exemplary workplace mental health programs.

Stigma reduction programs aim to improve mental health knowledge, attitudes, and behaviors regarding mental illness in the workplace. Discrimination against those suffering from mental illness is still rampant in workplace settings as illustrated by a study reporting that 47% of the general public expressing an unwillingness to work with people diagnosed with depression, and 30% unwilling to socialize with them. 51 Concerns about disclosing mental health status are often related to ''fear of social exclusion, lack of opportunities for advancement, and over-inferring of mistakes to illness.'' 52 Positive outcomes indicate healthy work cultures that are encouraging, humanizing, and emphasize employee well-being. Conversely, negative outcomes may reflect unhealthy work cultures that include high stress, unmanaged risk factors, hazardous or unpleasant work conditions, and in more extreme cases, discrimination, harassment, and dysfunctional power dynamics that can devolve into violent or otherwise hostile work environments. Evaluation of these outcomes can be carried out using simple assessment tools and surveys that determine employee overall well-being and the effectiveness of workplace interventions. Assessment tools can be categorized into psychosocial, organizational, and environmental categories. Examples of psychosocial tools include surveys such as PHQ-9, GAD-7, self-reported stress, and resilience measures; organizational tools may include the CDC Worksite Health ScoreCard, 53 the HERO Scorecard, 54 and the Workplace Health Achievement Index 55 promoted by the American Heart Association. Environmental assessments focus on identifying and addressing workplace health and safety hazards and may include ensuring that workspaces are ergonomically designed to avoid injury, eliminating exposures to chemical or biological toxins, providing personal protective equipment such as N95 face masks and protective clothing, and implementing adequate security measures to reduce the risk of workplace violence.

The ubiquity of technology and the increased interconnectivity of the modern world has given rise to several innovative approaches to address workplace mental health. Some of these initiatives focus on technological approaches, whereas others are more theory-based and grounded in removing barriers and making resources more accessible.

The rise of tele-mental health innovations is one interesting by-product of telehealth technologies. Increasingly, companies are turning to mobile apps that focus on training mindfulness, enhancing cognitive performance, and addressing work-related stressors. 56 E-health interventions have been observed to be targeted, guided, and present a low risk of bias in addressing depression and anxiety symptoms. There is growing evidence that mobile platforms can achieve favorable results in delivering care. 56 Many employers expect that these technological innovations will target unaddressed needs resulting from the underutilization of EAPs, by empowering employees to track and monitor their mental health needs, as well as connect them with relevant resources while ensuring privacy. 50 With more employers increasing emphasis on behavioral health offerings to meet the health needs of employees and their families, 57 there is a growing demand for novel solutions that help increase awareness and access to care resources. With healthcare mobility solutions becoming increasingly cost-efficient and integrated as a part of primary care, employers can offer behavioral health services at the workplace by partnering with providers in developing tailored mental health plans that meet each organization's unique preventive and care solutions. 57 

The goal of the Mattingly Award is to recognize best practices in mental health in the workplace and encourage employers to develop organizational cultures that support and promote positive well-being. This review of best practices was used to develop the Mattingly Award criteria for evaluating applications.

Based on the findings, the criteria for the award have been determined and categorized into eight elements that serve as the baseline for developing a scoring system for the award. The scoring system will provide applicant organizations feedback on their use of evidence-based mental health practices in their workplaces and consider their performance relative to their peers using the criteria outlined.

The Mattingly Award, which will launch in 2022, is intended to incentivize organizations to demonstrate social responsibility and improve workplace performance and well-being by encouraging a positive workplace mental health culture.

In this review, we highlighted the prevalent yet underaddressed issue of mental health in the workplace, identified eight categories of best practices, and developed criteria for the Carolyn C. Mattingly Award for Mental Health in the Workplace. We acknowledge the lack of discussion on organizations of different sizes is currently a limitation of our study due to the complexity of organizational structures. Companies should seek to address the issue of employee mental health in ways that are tailored to their specific organizational challenges and best fit the identified needs of their employees. For instance, organizations of smaller sizes need not follow the same standards as multinational corporations. A targeted approach by each company tailored best to their employees' needs would be more effective than one that offers an extensive selection of options that do not address any of the highlighted needs. The best program will be one that addresses the larger cultural issue of creating a work environment that supports employee mental health while providing services or benefits at low or no cost. As our recognition program advances with more materials and input from companies of different sizes, industries, and workforce, our criteria would be further adjusted. As health and wellness services and their financing vary by country, the current focus of the award is placed on US-based initiatives. A similar approach should be applied in future research that takes a global focus to gain a deeper understanding of the cultural differences across nations and needed customization to address workplace mental health.

Promoting positive mental health in the workplace is a complex process that requires collaboration across several leadership levels. While work can play a positive role in contributing to worker well-being, it can also become harmful and toxic when there is a lack of social support and unhealthy organizational culture. Therefore, by recognizing employers that put in place intentional efforts to protect the well-being of their workers and promote a culture of health, the Mattingly Award hopes to inspire more organizations to adopt best practices in mental health for their own employees.

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