Mental Health in the Workplace: Strategies and Tools to Optimize Outcomes

By Michelle B. Riba

This book offers a guide to better understanding models of workplace mental health, as well as best practices for mental health professionals, employee assistance groups, employers and employees alike.

The cost of depression at the workplace is staggering, both in terms of absenteeism and productivity loss while at work, and in terms of human and family suffering. Depression is highly prevalent and affects employees’ concentration, decision-making skills and memory, contributing to accidents and quality issues. Analyses indicate that the returns on investment for workplace mental health programs are significant, with employers reporting lower productivity-related financial losses and less need staff turnover due to mental health conditions. The book also addresses substance use and misuse, and ways to address such problems.

• Language: English
• Publisher: Springer
• Release date: Feb 13, 2019
• ISBN: 9783030042660

Book preview

© Springer Nature Switzerland AG 2019

Michelle B. Riba, Sagar V. Parikh and John F. Greden (eds.)Mental Health in the WorkplaceIntegrating Psychiatry and Primary Carehttps://doi.org/10.1007/978-3-030-04266-0_1

1. Healthy Minds at Work: Challenges and Strategies for Businesses

John F. Greden¹  , Rosalind Garcia-Tosi¹   and Anne White Harrington¹  

(1)

University of Michigan Depression Center, Ann Arbor, MI, USA

John F. Greden

Email: [e-mail]

Rosalind Garcia-Tosi (Corresponding author)

Email: [e-mail]

Anne White Harrington

Email: [e-mail]

1.1 Introduction

1.2 Terminology

1.2.1 Stress and Anxiety

1.2.2 Depressive Illnesses

1.2.3 Workplace Suicides

1.2.4 Substance Misuse

1.3 Costs

1.3.1 Economic Costs

1.3.2 Noneconomic Costs and the Impact of Family Members with Mental Health Issues

1.3.3 Investment

1.4 Challenges Business Leaders Must Seek to Overcome

1.4.1 A Single-Lens Focus

1.4.2 Stigma and Distrust

1.4.3 Organizational Impediments

1.5 Recommended Actions for Business Leaders to Consider

1.5.1 Provide Comprehensive and Tailored Programs that Enhance Prevention

1.5.2 Facilitate Organizational Engagement

1.5.3 Develop a Supportive Team Culture

1.5.4 Encourage Self-Help Behaviors

1.5.5 Create Effective Internal Marketing to Counteract Stigma

1.5.6 Join Partnerships and External Campaigns

1.5.7 Use Existing Internal and External Human Resource and Employee Assistance Programs

1.5.8 Undertake Appropriate Assessment and Evaluation

1.6 Healthy Minds at Work Programs: The Time Is Now

References

Abstract

Depressed, anxious, stressed, sleep-deprived, or substance-using workers are unproductive, accident-prone, and plagued by mistakes, sick leave, and departures. Workplace mental health issues are huge cost burdens for businesses. CEOs, managers, supervisors, human resource teams, boards of directors, and employees and their families all crave solutions. The contributors to this book collaborated to create a roadmap for business leaders and staff members to address the problems and costs of unhealthy minds at work. This introductory chapter summarizes big picture challenges and strategies. Authors of subsequent chapters review the most important workplace clinical problems and evidence-based programs to help overcome stigma; when and where to turn for clinical help when necessary; advice about structuring policies, benefits, and educational programs and supports to enhance employee utilization; how to best train and utilize supervisory and peer-to-peer interventions; and strategies for monitoring cost-effectiveness. For businesses that accept the challenge, establishing and sustaining comprehensive workplace mental wellness programs will become points of pride and profitability.

Keywords

Workplace wellnessSupervisor trainingResiliencyWell-beingAbsenteeismPresentismUnhealthy minds at workMental health stigmaWorkplace mental health guidelinesEAP—employee assistance program

1.1 Introduction

One of my employees told a co-worker that he had depression, couldn’t sleep, and didn’t want to go on living. That message came to me as his manager. What should I do?

I want to include mental health in our wellness program to reduce absenteeism, but I don’t know how to do it or how to measure outcomes. Can you give me some ideas?

How can I present a solid cost/benefit business case for mental health interventions to my CEO?

Questions such as these are increasingly asked in workplaces throughout the world. They stem from unhealthy minds at work, one of the most costly and perplexing challenges that business leaders confront on a daily basis [1, 2]. Depressed, anxious, stressed, sleep-deprived, or substance-using workers are unproductive, accident-prone, and plagued with mistakes, sick leave, and departures. CEOs, managers, supervisors, human resource teams, boards of directors, and employees and their families all seek solutions.

The contributors to this book respond to the need for solutions by creating a roadmap for business leaders and their staff to address the problems and costs of unhealthy minds at work. This introductory chapter addresses big picture challenges and strategies for tackling workplace mental health concerns. Authors of subsequent chapters go into depth on specific types of problems, challenges, and approaches for improving workplace mental health.

1.2 Terminology

A number of terms used throughout this book require brief explanations. Workplaces are broadly defined as any place where people do their jobs. The term unhealthy minds include individuals who suffer from depression, anxiety, bipolar illness, substance misuse, stress, sleep deprivation, and an array of related conditions. Some use the term mental illnesses to describe such problems; others prefer brain-behavior illnesses. For purposes of brevity in this chapter, we are subsuming all under the terms mental health issues or unhealthy minds. When multiple diagnostic illness categories coexist, these are known as comorbidities.

Employees who struggle with mental health issues also are at greater risk for medical illnesses such as hypertension, heart diseases, and diabetes, cognitive errors, and orthopedic problems [3, 4]. Among the commercially insured population, 85% of individuals who are diagnosed with major depression have at least one other additional serious medical condition, and 30% have four or more conditions [5]. The most effective workplace programs are those designed to holistically meet the needs of employees by seeking to attack all major problems. Mental health issues must be included.

This book is useful for many audiences—business, academic, and clinical. Its primary purpose is to establish the parameters and best practices for health promotion and prevention strategies that can be implemented in the workplace. Business leaders and their staff members thus can identify approaches and tools that have direct applicability to their companies. In addition, this book addresses the fuller intellectual context of the intersection between mental health issues and the workplace, providing academics and clinicians a framework for inquiry, intervention, and research direction.

Best practices in the workplace include programs to overcome stigma; guidance about where to turn for clinical help when necessary; how to structure policies, benefits, and environmental supports and make them appealing to employees; and how to create and sustain appropriate community partnerships to counteract these issues. To provide perspective, the most important clinical problems for workplaces will be reviewed briefly before addressing challenges and strategies.

1.2.1 Stress and Anxiety

Everyone occasionally becomes worried, apprehensive, fearful, and distracted, often because of environmental stressors. When such symptoms become constant and severe, clinicians may refer to them as anxiety disorder or generalized anxiety disorder. Sleep becomes difficult. Pleasures and enjoyments cease to be attractive. Voices sometimes quiver, tremulousness may occur, and people feel jittery. At such levels, anxiety interferes with work, home life, and health. Self-medication with alcohol or over-the-counter sleep aids often is pursued. Stress and anxiety are statistically the most common mental health complaints in the workplace. These will be addressed in further detail in Chap. 8.

1.2.2 Depressive Illnesses

World Health Organization (WHO) data confirm that major depressive disorder (MDD) is the leading cause of disability worldwide [6]. Depressive symptoms include feeling sad, hopeless, worthless, having thoughts of suicide, and loss of interest and pleasure. Such symptoms are commonly accompanied by an array of physical manifestations such as unexplained pains, difficulty sleeping or sleeping too much, reductions or increases in appetite, loss of interest and pleasure, impaired sexual interest or functioning, and difficulty concentrating.

Depressive illnesses impact approximately one of every six people in their lifetime so they are common in the workplace. Despite high prevalence and disabling impact, persistent stigma often keeps these treatable illnesses hidden. Globally, more than 300 million individuals suffer from depressions or bipolar illnesses [7, 8]. This largely explains why depressions are the leading causes of disability and associated corporate illness costs in the United States [9, 10].

Major depressive disorder has well-established genetic underpinnings. Onsets peak between ages 15 and 24 [11]. Initial episodes often resolve spontaneously when stressors lessen, but if unrecognized or untreated, new recurrences follow and become closer together, more severe, and more difficult to eradicate.

Workplaces pay a huge price for unrecognized and unresolved depressions and anxiety. Chisholm and his colleagues estimate that across the 36 largest countries in the world, more than 12 billion days of lost productivity are attributable to depression and anxiety disorders every year for a total of $925 billion. This is equivalent to 50 million years of work. They further estimate that the subsequent global economic impact is between $2.5 and $8.5 trillion in lost output, a figure that is expected to double by the year 2030 unless effective programs are instituted [12]. These staggering figures should set off alarm bells among business leaders. Over 17.5 million US adults experienced depressive disorders in 2017 [6]. The economic burden of depression in the United States, limited to estimates, has been suggested to be $210 billion [2].

1.2.3 Workplace Suicides

One of the more tragic encounters for supervisors and co-workers occurs when a fellow worker dies by suicide. Approximately 70–80% of deaths by suicide are linked with depressions and substance use, but stress, family tragedies, financial concerns, substance misuse, and sleep disturbances often play a role. When an employee dies by suicide, efforts to hide or disguise the cause of death usually fail. Rumors permeate the workplace setting. The communication team begins to be distrusted and anger becomes a seething problem. Sometimes the death of one worker by suicide stirs up similar conflicts and anguish among other workers who are similarly but often silently struggling with their depressions or substance use and additional contagion suicides follow. The consequences of such sequences are poisonous to workplace morale and productivity. Absences, conflicts, and other problems accelerate. While difficult to convey, once family consent is obtained, the truth is preferable. Mortali and Moutier’s Chap. 10 details comprehensive workplace suicide prevention initiatives designed to save lives and to respond appropriately should a suicide occur. While workplace fatalities have been steadily declining since 1992, suicide rates have risen considerably, even among women [13, 14]. In some regions of the United States, rates have skyrocketed, partially attributable to opioid and other substance misuse.

1.2.4 Substance Misuse

Opioid use, overuse, and dependency have become an epidemic in the United States [15]. Use of that word is not an exaggeration. Driven by clinicians’ desires to alleviate the pains of surgery, dental procedures, accidents, and other medical illnesses, the common use of large opioid prescription amounts for medications such as fentanyl, OxyContin, oxycodone, codeine, and tramadol has led to growing drug dependency and addiction, often starting within several weeks of use. Such use produces associated brain changes, increased risk of depression, and a virtual epidemic spike in suicide and overdose deaths [16]. Workers and family members would benefit greatly by learning that such medications should only be prescribed in limited amounts. These problems have become so severe that workplaces are advised to develop special educational programs and drug-collection events to enable workers to turn in unused prescription medications.

1.3 Costs

1.3.1 Economic Costs

As already summarized, the financial consequences of workplace mental health issues are complex and disturbing. Depression and related illnesses in the workplace are directly linked with the following: higher rates of absenteeism and presenteeism [17], costly staff turnover, production down time and inefficiencies, higher medical costs, and the turmoil that follows virtually every workplace suicide [18–22]. Financial consequences often are the driving forces that prompt business leaders to launch workplace programs. Data are available to show that successful treatments of depression decrease economic consequences of depression in the workplace [17]. Grazier’s Chap. 2 is devoted to economic consequences in the workplace.

1.3.2 Noneconomic Costs and the Impact of Family Members with Mental Health Issues

Workplace costs of depressions, anxieties, sleep disturbance, and substance misuse are not only economic. Human, personal costs are more difficult to quantify but contribute to performance and personnel turmoil in workplace settings. Mental health problems don’t respect boundaries, and should the problems start at home or with family and friends, they tend to drift to work as well. If the problems are linked to job stresses, they affect not only the worker but also the workers’ spouses, friends, children, parents, partners, communities, and co-workers. And if those problems exist among others at home, the helplessness and pain a loved one experiences is immense and distracting. Unless recognized and aided, personal issues such as threats of divorce, financial difficulties, shortcomings in paying bills, debt, troubled children, and legal issues commonly impact the workplace venue as well as personal lives.

1.3.3 Investment

Workplace health programs require investment if they are to be effective. As described by Grazier in Chap. 6, these generally constitute a modest portion of a company’s resources. Effective programs improve productivity, job performance, and the physical and emotional health of the workforce [23], as well as reducing personnel recruitment and replacement costs, and available evidence strongly suggests initial and sustained investments produce ongoing favorable returns [24. Nevertheless, strategies for assessing return on investment for workplace wellness programs should be part of the planning and evaluation process as part of every annual review.

1.4 Challenges Business Leaders Must Seek to Overcome

The following section highlights selected major challenges business leaders and their teams face in addressing mental health in the workplace.

1.4.1 A Single-Lens Focus

Mental health interventions are provided by a variety of professionals in the workplace. Unfortunately, different professionals tend to become isolated in their respective silos. Health providers, human resource leaders, nurses, employee assistance program personnel, and others with different professional degrees characteristically deliver different types of interventions. They see the issues through their own lenses and have different perceptions about what constitutes a comprehensive package… and what works. Thus, different disciplines are understandably inclined to believe that their approach is the most important, sometimes even the only one that is needed. This viewpoint is usually misguided.

To illustrate, abundant data reveal that many with anxiety or depressions will benefit from cognitive behavioral therapy, mindfulness, various types of individual or group therapy, or medications [17]. No single approach, however, works for everyone. Combinations of interventions from different team members often produce the best results, and sometimes the apparent causes are not solely a mental health issue. For example, some individuals with sleep apnea may become significantly depressed and then become normal again with the aid of continuous positive airway pressure (CPAP) devices. Human resource (HR) experts, employee assistance personnel (EAP) members, medical teams, supervisors, outside consultants, and leaders must recognize and buy into being part of an integrated team so that the organization can ideally address the array of health issues. Only then will desired results be achieved and sustained.

1.4.2 Stigma and Distrust

Many employees who suffer from depression or related conditions fear they will be penalized for reporting and seeking help [25]. Some workers hesitate to even use words like depression or anxious. When workplace programs are not designed to be healing, preventive and supportive, and repeatedly explained as such, these workers’ fears may be justified. Employee disclosure to supervisors who are not properly trained about how to communicate with employees who express a desire for help can lead to the struggling employee being micromanaged; being bypassed for promotion; having supervisors attribute mistakes to illness; being the subject of gossip, exclusion, or ridicule; or being perceived as incompetent, dangerous, or unpredictable [26]. Rather than enhancing resolution of symptoms, such exchanges can exacerbate depression and anxiety and lead to more absences, lower productivity, presenteeism, and even higher company costs.

Stigma and distrust also lead to underutilization of the in-house experts who are there to help. HR departments and EAPs provide support, but they are frequently underutilized. Estimates suggest the use of EAPs ranges from 1% to 5% of employees [27]. More information on stigma and employee use of company resources is available in Chap. 8.

1.4.3 Organizational Impediments

In many larger businesses, health issues are handled by a variety of departments and agencies. Without sufficient coordination, this can lead to failure to establish or integrate comprehensive interventions and resultant competition among silos. Unless educational campaigns reach all constituents, employees may lack information about available information and resources. Challenges can be exacerbated when supervisors and employees are left out of day-to-day implementation or when there is inadequate or invisible top-down leadership. Finally, financial hurdles may impede program development and implementation.

1.5 Recommended Actions for Business Leaders to Consider

Creating effective workplace programs is a bit like creating a mosaic. It requires taking the pieces and integrating them into a beautiful picture. Not only do the components have to be individually effective, they must also be held in place by a frame of critical characteristics. Business leaders are encouraged to consider the benefits of programs that have the following evidence-based characteristics.

1.5.1 Provide Comprehensive and Tailored Programs that Enhance Prevention

While not completely achievable, the ultimate aim of workplace mental health programs is to prevent problems whenever possible. The term prevention is best subdivided into primary, secondary, and tertiary prevention [28].

Primary prevention efforts are proactive and intended to prevent exposure to a known risk factor or to enhance an individual’s tolerance or resilience [29]. Lectures by prominent speakers on peer support, exercise, sleep, addictions, nutritional aspects, and stress management are all examples [30–33].

Secondary prevention initiatives aim to counteract, reduce, or even eliminate the impact of disease or injury that has already developed. Secondary interventions require detection and treatment of problems as early as possible to minimize consequences, chronicity, and in workplace settings, the enormous economic costs. Fundamental components include routine screening programs and supervisor and manager training to enable supervisors to detect, refer, help monitor, and aid employees for seeking help for such problems as depression, sleep apnea, or opioid dependence and suicide risk awareness and intervention training [29, 34].

Tertiary prevention initiatives are designed to lessen the problems and consequences of ongoing illnesses or injuries. Tertiary interventions are designed to treat and manage an existing condition and minimize its impact on daily functioning [29]. For example, companies might initiate care facilitator programs to deliver interventions with immediate benefit to employees’ well-being, such as referrals to sleep apnea clinics, depression programs, or opioid withdrawal programs.

The most effective workplace mental health programs are comprehensive, incorporating components from all three levels of prevention. Team members must adopt strategies to enhance trust, lessen stigma, and emphasize preventative, educational, medical, behavioral, exercise, nutritional, and related modalities. Programs must offer a variety of mental health information, formats, and services in order to reach a broad range of employees.

Programs must be tailored. All businesses are unique; workplace programs should feel as if they are designed to fit beautifully to the nature of the work, adapted to geographic location, and tailored to community culture. A one-size program will never fit all. Initiatives must be appropriate to the region of the country, demographics of employee populations, array of languages spoken, and/or country where the program is implemented. The staff members or outside consultants that are involved with promoting wellness, educating, and delivering preventive care must be doing so collaboratively. In designing the Healthy Mind at Work program, the University of Michigan Depression Center (UMDC) identified a number of components under each level of prevention, recognizing that components need to be adapted to particular companies and contexts. Such programs quickly become partnerships.

1.5.2 Facilitate Organizational Engagement

Effective programs engage constituents at all levels. Top-down leadership and commitment are vital. In most companies, supervisors and managers are the front line of early detection, prevention, education, and referral when necessary. These groups are so important in breaking through silence and stigma that they are addressed separately in the sections below.

1.5.2.1 Leaders

The most effective programs emerge when workplace leaders buy into, prioritize, and monitor behavioral health programs. Bosses must be on board from inception and lead the way. Rather than solely relying on employees’ reactions to the company’s efforts, leaders should recognize that they can help drive and maintain positive changes by providing a supportive environment [23]. The following are examples of how executives can demonstrate an all in approach:

Appearing at scheduled presentations by speakers

Participating in occasional educational programs of supervisors

Lending support to destigmatization marketing efforts

Meeting with HR, EAP, medical teams, and external consultants to plan and publicize programs

Celebrating accomplishments

Inviting outside spokespersons

Should bosses fail to be visible or endorse overall efforts to address workplace mental health issues, their absence from the cause may simply intensify stigma (if this boss isn’t willing to be associated with this, I certainly don’t want to be).

To achieve the on board reputation, bosses need to understand and understandably convey the big picture nature of the problems and the consequences of not addressing them. They need to grasp the requirements for preventive strategies—what works and what does not. They must know how to identify and support a team and feel part of that team. Leaders need to be involved in planning steps to measure accomplishments and reward successes. They must develop strategies to overcome known traditional barriers as summarized in this chapter and discussed in detail in subsequent chapters. In most workplace settings, they must effectively and sometimes repeatedly delegate that expectation to their discipline leaders and back them when there is opposition.

1.5.2.2 Supervisors and Managers

Supervisors and managers are pivotal in addressing mental health concerns. Other than family members and selected peers, the supervisor is best positioned to witness, supportively grasp the degree of the problem, and refer as soon as emerging clues begin to surface. The earlier, the better.

Key principles such as the following can be taught in brief, inexpensive training courses for supervisors and managers.

Symptoms, causes, and immediate next steps for behavioral and mental health problems can be taught in brief sessions. Aims are to enhance the supervisor’s fundamental understanding of key principles to enable recognition and consideration of next steps and whether any urgency is required.

Initial interactions are crucial. These are the moments when workers are helped or stigma is heightened. Managers can be taught to be listeners and supportive and to convey that they will strive to be a resource to help achieve prompt improvements for the struggling employee.

Proper terminology is fundamental in creating trust between managers and employees. A next-step message is that these are illnesses, they are treatable, and we’ll work with you to get you the needed help. Let’s get started.

Outcome expectations should be optimistic but realistic. Improvement is the aim. The cruel fact is that no clinical or educational programs have ever yet been developed that quickly eradicate and eliminate mental health issues from workplaces. Symptoms are unlikely to go away overnight. Similar to preventing and handling problems such as diabetes, hypertension, back pain, and other medical concerns, the focus for healthy minds at work must be on educating, identifying, addressing, and lessening the problems produced by depressions, bipolar illnesses, anxiety, sleep issues, substance abuse, and drug abuse and improving work problems in the process.

Data show that training managers improves workplace mental health. Milligan-Saville and her colleagues conducted perhaps the first randomized controlled trial of manager training that found a significant decreased rate of work-related sick leave among managers who received a brief half-day, 4-h training [34].

The sooner the better should be the norm for referrals. These should include instructions about where to turn and how to forge links. EAP and human resource personnel are important partners in these steps.

Follow-up is essential. Part of the supervisory intervention is to encourage follow-up and indicate what they will inquire during the subsequent days to determine how things are going. An overall aim is to have employees feel as if they made the right choice in conveying their problem in the first place.

Providing such in-depth training for supervisors and managers can be done briefly, sometimes in several half-day sessions. The training program itself promotes workforce well-being. Even brief managerial training has been shown to significantly improve interventions, strategies, and outcomes for employees who are struggling with mental health issues [1, 34]. Jenkins and Harvey elaborate on this in Chap. 4.

1.5.2.3 Peers

Having peers help colleagues in distress is an effective way of both counteracting stigma and increasing help-seeking. Effective programs that train and mobilize peers abound in a variety of settings. Among the military, peers (buddies) have been shown to counteract stigma, PTSD, depression, and suicide thoughts and plans [30]. Among high school and college students, peer support programs increased the following: knowledge about depression, confidence in ability to identify and refer struggling peers, and willingness to seek help [32, 33]. Peer support programs in the workplace involve respected individuals who are trained to identify concerns among colleagues and to help them gain access to resources. Peer-to-peer programs have the potential to increase mental health literacy, reduce stigma, offer support, and promote help-seeking in the workplace.

1.5.2.4 Spokespersons

Prominent spokespersons are commonly invited by corporations and others to counteract stigma and encourage help-seeing by describing their own successful struggle against mental illnesses. They describe their own history or that of a family member with problems such as depression, PTSD, anxiety, substance misuse or combinations of these, talk openly about how they struggled, eventually sought help, achieved improvements, and emerged with increased functioning, greater happiness, and better performance in their jobs or professions. Spokespersons usually report they have found that sharing their story helps them feel better by helping others who are similarly battling brain-behavioral illnesses. The most effective spokespersons speak with frankness and honesty; they offer appropriate but not excessive details about their successful treatments, the steps they are now taking to help others, and why they do so. They use accurate terms such as brain illnesses; they respect confidentiality; and when personal, they accurately describe and summarize stresses. Spokespersons convey that continuous efforts, professional help, and support systems are required for them to maintain wellness. They also may describe the behavioral, medical, and unhealthy mind consequences that reappeared should they have previously failed to sustain their wellness efforts.

Not all spokespersons need to have struggled with clinical problems. Well-known individuals who lead or direct implementation of effective programs in their domains represent another type of spokesperson. Examples are college or professional coaches, military officers, organizational leaders, philanthropic leaders, and corporate and business executives. They can aid workplaces by describing how they helped overcome unhealthy minds at work in their lives. Selection of spokespersons is best tailored to each organization’s needs. As Shaw describes in Chap. 5, the British Broadcasting Corporation (BBC) introduced a strategic approach to finding storytellers and champions within the BBC for internal communications, videos, and literature. As with athletes or performers who have conquered their struggles, their names and reputations attract initial interest; their information and message counteract stigma and ignorance.

Listening to spokespersons occasionally stirs up latent conflicts or an increased desire to seek help for symptoms. Thus, presentations by spokespersons should be planned in consultation with psychiatry or mental health consultants. It may be advisable to have such experts join the presentations, ideally also being joined by company leaders. Such participation illustrates leadership buy-in and helps integrate the efforts of the entire network.

1.5.2.5 Champions

It is important to recruit company leaders and respected, credible employees to champion mental health programs. Examples include the CEO, board members, medical director, CFO, union officials, EAP directors, and human resource leaders. Culture change can occur when individuals talk openly about mental health and promote the support services available. Champions demonstrate organizational support for wellness initiatives. Champions are typically in a good position to identify successes on the individual, group, and organizational level and to craft appropriate celebrations.

1.5.3 Develop a Supportive Team Culture

Disciplinary or program silos must be confronted and replaced by team orientations. A culture of health generally involves creating a team feeling that we are in this together. The initiative must become part of the company’s culture, infused into all aspects of company life [23].

A parallel example of culture change occurred through the University of Michigan’s Athletes Connected program (http://​athletesconnecte​d.​umich.​edu/​). Athletes are encouraged and urged to be strong and endure. Should problems develop, many athletes are afraid to seek help for depression and related conditions for fear of being perceived as weak by their teammates and coaches. Stigma is a starting point. Counteracting this in a frontal attack, programs such as Athletes Connected have shown that changing an athletic department culture is possible and that positive results are contagious. Stigma is reduced so that student athletes feel comfortable seeking help and supporting each other. Coaches learn to help foster an