Enhancing Sleep: Strategic Tool for Improving Employee Mental Health
By Judy Gordon
Wellness Director, The Hartford
By Jenna Carl, PhD
Medical Director, Big Health
Employee mental health is one of the most significant and difficult challenges faced by many employers today. According to the National Institutes of Mental Health, neuropsychiatric disorders, including mental health conditions, are the leading cause of disability in the United States.1 For employers, the cost of depression and anxiety is double that of the next most costly health conditions. This is due to the substantial impact of mental health on healthcare expenditures, productivity, and absenteeism.2
The immense costs of mental health are due in part to the high prevalence of mental health conditions: one in five U.S. adults will suffer from a diagnosable mental health condition each year.3 Prevalence is only half of the equation; the other is insufficient or ineffective treatment, the causes of which are complex and multifaceted.
Mental health has long been underserved by the U.S. healthcare system. Prior to passage and implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA), employers could restrict mental health benefits more than medical/surgical benefits.4 The MHPAEA was a much needed step in the right direction, but significant challenges remain. An astonishing 70% of those suffering from a mental health condition in the United States do not receive treatment.5
One of the most significant barriers to treatment is the stigma surrounding mental health conditions. A national survey in 2017 found that 55% of people view depression to be a personal weakness or failing, which is, of course, erroneous.6 With stigma such a significant barrier, employers have struggled to engage their employees in seeking treatment. Traditional workplace programs, such as Employee Assistance Programs (EAPs), are generally underutilized, with utilization ranges of 2% to 5% often cited. While EAPs provide necessary and helpful services for mental health and other personal, financial and work-related problems, EAPs cannot be the sole pillar to a comprehensive employee mental health strategy.
Approximately two-thirds of individuals with anxiety and/or depression also suffer from insomnia, a chronic difficulty falling or staying asleep.7 Whereas the widely held view was that insomnia is just a symptom of anxiety and depression, recent research has revealed that insomnia is actually a significant risk factor for the development of anxiety and depression.8,9 And further clinical research is showing that treating insomnia actually reduces the symptoms of anxiety and depression, meaning sleep improvement is a strategic target for improving mental health.10,11
Like most employers, mental health has an impact on our healthcare costs, productivity, and absenteeism. Our 2016 disability data showed that behavioral health was the second most common cause of disability-related leaves, behind maternity, with depression and anxiety being the most common causes of behavioral health related leaves. The average duration of behavioral health-related leaves was 28% longer than all other claims. During the same period, 5.5% of medical spending was attributed to behavioral health claims with depression and anxiety accounting for 30% of those claims.
Similarly, poor sleep was common among our employees and that, too, had an impact on healthcare costs. Based on our 2014 health risk assessment, 40% of employees were, on average, getting less than the recommended seven hours of sleep a night, slightly more than the U.S. average of 35%.12
Reviewing medical and prescription drug claims data of employees with a prior diagnosis of insomnia or with past prescriptions for sleeping pills, revealed that about one in 10 employees had an insomnia-related claim. This is consistent with trends in the U.S. population overall. On average, these employees had healthcare expenditures 2.5 times greater than those without an insomnia claim.
Understanding that sleep is fundamental and closely linked to good mental health, we chose to implement a sleep improvement program. The goal was to proactively address mental health among employees, engaging a greater number than were being reached by the EAP. Because sleep does not carry with it the same stigma often associated with mental health conditions, we believed a sleep program offered in the workplace would attract more employees than traditional mental health programs and engage employees who might otherwise not seek help.
After reviewing the workplace sleep improvement programs available in the marketplace, we decided to partner with Big Health, a company cofounded by a leading sleep expert from Oxford University and a former insomnia sufferer. Big Health had created Sleepio, a digital sleep improvement program based on cognitive behavioral therapy (CBT) for insomnia that was validated by clinical evidence. Sleepio is now supported by 24 peer-reviewed papers in the scientific literature, including six randomized controlled trials, demonstrating its effectiveness in improving not only insomnia but also anxiety, depression and overall psychological well-being.13
In 2015, we offered Sleepio to our employees, with roughly 30% of the population engaging in the program by completing Sleepio’s online sleep test and receiving personalized sleep help. Sixty percent of sleep test completers indicated they were troubled by their sleep, one in five seriously so. Nearly 12% of the population has participated in the full CBT program for insomnia — more than double the level of engagement in EAP during the same period.
Sleepio has helped participants meaningfully improve their sleep. Participants are falling asleep faster, spending less time awake at night, and, on average, have gained seven hours of sleep a week, leading to significant reductions in the use of over-the-counter and prescription sleeping pills. Improved sleep has also led to a greater than 65% reduction in the number of employees reporting missed work and lost productivity due to poor sleep.
Most exciting is the impact the program has had on participants’ mental health. Overall, program participants reported a 74% drop in stress levels, a 56% drop in anxiety symptoms and a 54% decrease in depression based on clinically validated measures.
- Murray CJ, J Abraham, MK Ali, et al. 2013. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. Journal of the American Medical Association, 310(6), 591-606.
- Loeppke R, M Taitel, V Haufle, et al. 2009. Health and Productivity as a Business Strategy: A Multiemployer Study. Journal of Occupational and Environmental Medicine, 51(4), 411-428.
- Substance Abuse and Mental Health Services Administration (2013). Results from the 2012 National Survey on Drug Use and Health: Mental health findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805.
- CMS. Mental Health Parity and Addiction Equity Act of 2008
- Kessler RC, O Demler, RG Frank, et al. 2005. Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515-2523.
- Find Your Words. Kaiser Permanente commissioned KRC Research to conduct a 15-minute online survey among a total of 3,005 U.S. adults from August 10–16, 2017.
- Okuji Y, M Matsuura, N Kawasaki, et al. 2002. Prevalence of Insomnia in Various Psychiatric Diagnostic Categories. Psychiatry and Clinical Neurosciences, 56(3), 239-240.
- Neckelmann D, A Mykletun, AA Dahl. 2007. Chronic Insomnia as a Risk Factor for Developing Anxiety and Depression. Sleep, 30(7), 873.
- Baglioni C, G Battagliese, B Feige, et al. 2011. Insomnia as a Predictor of Depression: A Meta-analytic Evaluation of Longitudinal Epidemiological Studies. Journal of Affective Disorders, 135(1), 10-19.
- Luik A, S Bostock, L Chisnall, et al. (2017). Treating Depression and Anxiety with Digital Cognitive Behavioural Therapy for Insomnia: A Real World NHS Evaluation Using Standardized Outcome Measures. Behavioural and Cognitive Psychotherapy, 45(1), 91-96.
- Freeman D, B Sheaves, GM Goodwin, et al. (2017). The Effects of Improving Sleep on Mental Health (Oasis): A Randomised Controlled Trial with Mediation Analysis. The Lancet Psychiatry, 4(10), 749-758.
- Centers for Disease Control, Behavioral Risk Factor Surveillance System, United States, 2014.
- See www.bighealth.com/outcomes for a full list of publications.