Keep it to yourself? The costly stigma of mental illness

Sixteen years after the Americans with Disabilities Act (ADA) passed, workers with mental illness still face a disheartening choice: keep their health problems a secret at work, or risk being shunned, passed over, paid up to one-third less, or even fired, according to a new study conducted by the School of Health Management and Policy at the W. P. Carey School of Business.

Sixteen years after the Americans with Disabilities Act (ADA) passed, workers with mental illness still face a disheartening choice: keep their health problems a secret at work, or risk being shunned, passed over, paid up to one-third less, or even fired, according to a new study.

Telling the boss is seen as so risky that "the vast majority" of workers with mental illness still hide their condition, said Professor Marjorie Baldwin, an economist with the School of Health Management and Policy at the W. P. Carey School of Business and co-author of the study, "Perceived vs. Measured Stigma Against Workers with Mental Illness."

For the study, she and fellow researcher Steven Marcus (University of Pennsylvania) analyzed National Health Interview Survey-Disability Supplement data on employed people ages 18 to 65 diagnosed with mood disorders (severe depression, for example), anxiety disorders (obsessive-compulsive disorder, phobias, etc.) and psychotic disorders (such as schizophrenia).

In a separate study, Baldwin and co-author Rebecca White (a doctoral student in the School of Family and Social Dynamics) conducted in-depth interviews with workers in competitive jobs who were suffering from serious mental illness. They found that despite the ADA's job discrimination protection, most workers with mental illness say the real-life cost of going public is too high. Why?

Social stigma: the price of accommodation

Let's say someone struggling with severe depression needs to leave early every Tuesday and Thursday for medical appointments. A person with a social phobia might ask to wear an iPod while working to shut out the buzz of co-worker interaction. An employee with obsessive-compulsive disorder may need a private cubicle, because sharing with a messy co-worker impedes his productivity.

But telling even one person — such as the appropriate supervisor — can start a chain reaction. Even if employee privacy rules are followed, reports are filed, work schedules altered, co-workers shuffled, job duties redistributed, special arrangements made. These are visible events, that may trigger rumors or resentment among co-workers.

Baldwin's study indicates that resentful or spooked co-workers may begin to avoid the mentally ill person; the shunning can also involve higher-level management, affecting training opportunities, promotions, transfers, raises and more.

Numerous studies of attitudes toward persons with different types of health conditions show that societal stigma and discrimination against those with mental illness is widespread. For instance, Australian researchers asked respondents to rank how acceptable they find people diagnosed with health problems including diabetes, blindness, epilepsy, paraplegia, alcoholism, cerebral palsy and AIDS. Respondents ranked people with mental illness near the bottom, finding them more acceptable than only AIDS sufferers.

The dollar cost of going public

But Baldwin's study is the first to statistically link going public with sharply lower wages. Here's how she did it. First, she set up a "control group" of workers, all people without mental illness. Next, she divided mentally ill workers into two groups: those who reported no job-related "stigma or discrimination" (possibly because they had not disclosed their health problems to the employer), and those who did report job-related, post-disclosure stigma or discrimination. We'll call them "Group A" and "Group B."

Here's what she found. The control group earned an average $12.70 per hour. Group A earned an average of $10.82 an hour. Group B earned an average of $9.15 an hour. After crunching the numbers, she found that persons with mental illness earn 85 percent of their non-disabled peers' wages, even when they don't report suffering stigma or discrimination.

And persons with mental illness who complain of stigma or discrimination earn even less — 72 percent of their non-disabled peers' wages. But Baldwin worried that other factors such as the impact of medically related leaves of absence, geographic wage differences, or union contracts were distorting the wage comparisons. So she crunched the numbers again, "controlling for all the contributing factors, to isolate actual discrimination."

This time around, the wage gap between the control group and Group A showed "no significant difference," according to Baldwin. But the wage gap between the control group and Group B worsened. Mentally ill people who complain of job-related stigma or discrimination after disclosing their health problems earn just 69 percent of their non-disabled peers. As Baldwin noted, "this is evidence that stigma against workers with mental illness translates to poorer outcomes in the labor market.

Staying quiet has its price, too

While it's not surprising that so many mentally ill workers stay mum, keeping a disabling medical condition secret is dangerous, too. That's because the ADA's anti-discrimination protection is triggered when a worker tells an employer about his or her disability — in this case, severe mental illness — and asks to have that disability accommodated.

"This becomes a problem if the worker's symptoms worsen, or he or she can no longer function as the same level," Baldwin explained. "The mental illness is no longer hidden; it becomes visible through the behavioral symptoms. The worker may lose his or her job without the protections of the ADA." There's another twist to this scenario. Say a worker wants to stay mum about his or her health problems, even if doing so means surrendering ADA protection down the line.

But coping with symptoms secretively may hurt the worker's perceived job performance. For example, a bus driver who's often late to work due to OCD-related rituals — checking that all appliances are unplugged and the door is locked over and over again — may make up a series of excuses when a supervisor notices repeated tardiness.

Instead of being accommodated, the bus driver is branded "unreliable" in her next performance review, because the employer is in the dark. Once the performance review nixes the bus driver's promotion to a preferred route, it's too late to say "I'm late because I have OCD" and demand ADA protection.

Among the workers interviewed by Baldwin and White was a police officer with bi-polar disorder who began adding his own opinions as he typed up crime reports, personalizing what should have been straight-forward descriptions of what occurred. He also fell behind on his paperwork, talked incessantly and began keeping an increasingly messy office.

First, co-workers reacted with sneering comments and jokes at his expense, then began avoiding him. They also complained to the supervisor. Managers in other departments told his supervisor to fire him. Like many co-workers inconvenienced by a fellow employee's mental illness, other police officers didn't want him to return to their unit.

"Mental illness can change workplace relationships, if co-workers have little understanding of the illness. This can bring down morale and foster resentment," Baldwin said. Many of the 20 employees told Baldwin they had not asked for or received any accommodation for their mental disability, even though further questioning revealed they were being accommodated.

An example is a woman who needs scheduling flexibility so she can attend to frequent doctor appointments. The supervisor goes out of his way to accommodate these requests, which exceed company policy. But when asked about the appointments by researchers, the employee said she was one of the company's best workers and they were happy to do what they can for her.

Facilitating this employee's doctor appointments results in some indirect costs, from the supervisor's time to co-worker resentment over her ease in getting more time off, Baldwin said. But she found that accommodating a mentally ill employee's condition carries less direct financial cost than assisting a physically disabled worker, who may need a special headset or a wheelchair ramp built.

Some researchers have estimated that accommodating the majority of employees who disclose mental illness incurs direct costs less than $100 initially and on an ongoing, monthly basis. But Baldwin noted that the bulk of costs of accommodations for a worker with mental illness are likely to be indirect costs."

Many mentally ill employees devise their own accommodations without attracting attention, although their ability to do so is limited in some job settings. For instance, a sales manager with severe anxiety found he relaxed and could focus after taking a short walk around the building. When the office got too loud and rowdy, he'd duck out for a little fresh air, arousing no notice.

Another worker reported taking clients on impromptu field trips to parks, movie theatres and other places when she found herself unable to function in the office. "Unfortunately, someone who works on an assembly line just can't do that," Baldwin points out. The key to making these employee-initiated job accommodations work is having enough job flexibility to make the adjustments without reducing productivity.

Bottom Line

• Numerous studies of attitudes toward persons with different types of health conditions show that societal stigma and discrimination against those with mental illness is widespread.
• Going public with a mental illness has been statistically linked to sharply lower wages.
• Keeping a disabling mental illness secret is also dangerous, as the ADA's anti-discrimination protection is only triggered when a worker reports the disability to the employer and asks to have that disability accommodated.
• The bulk of the costs of accommodations for a worker with mental illness are likely to be indirect costs.