Lessons from the 2003 SARS Epidemic: Employers can act now to flatten the mental illness curve

COVID-19 has already altered fundamental corporate best practices and assumptions and could have broader consequences in several key arenas, including mental health benefits and overall employee wellbeing strategies. The number of confirmed COVID-19 cases exceeds 1 million, and over 50,000 lives have been lost. Mood disorders and anxiety-related illnesses are concurrently increasing as a health crisis becomes an economic one. Month-long quarantines are exacerbating loneliness and substance abuse. In the first three months of 2020, over 250,000 people died by suicide (the 2019 annual rate was about 800,000 persons according to the World Health Organization). In many instances mental and physical health are correlated, and U.S. insurers already warned of potential 40% increase in premiums.

All of us and every employer will be impacted — there will be more mental health leaves, more so-called “presenteeism” (people at work but unable or unwilling to focus on tasks), and more employees and family members in distress. Already strained mental health care systems will be overwhelmed. Employees will require and demand more mental health support from employers. Employers will need to provide them to keep employees engaged and productive — and act proactively today to adapt plans, policies and communication to lessen the current pandemic’s impact on everyone’s mental health.

A Cautionary Tale from SARS 2003: “To be obsessive is the minimum. To be paranoid, the standard.”

Within eight months of being first reported in China’s Guangdong province in November 2002, 8,437 SARS cases had claimed 813 lives, many of them young and many healthcare providers. Its psychological impact was dramatic and had enduring consequences that were likely appreciated only by countries directly affected by that relatively contained outbreak.

One year after the SARS outbreak, in 2003, survivors still reported heightened levels of stress and psychological distress, including post-traumatic stress and related disorders. Mood disorders increased dramatically during the epidemic, as did reports of headaches, insomnia, fatigue, and inability to concentrate. Those whose friends or relatives were infected, and those who worked or lived in SARS-ravaged areas, reported 50% higher rates of related illnesses. A study conducted in China reported that negative SARS-related information increased individuals’ perception of their risk and led to what was deemed irrational nervousness or fear.[i] A fifth of survivors reported washing their hands more than 15 times a day to relieve their anxiety — even after the epidemic was controlled. Women were twice as likely to be affected as men.

By some accounts, 50% of recovered SARS patients showed anxiety and 20% were fearful.[ii] Some patients experienced a form of PTSD that disrupted daily activities. Some problems could have arisen from complications of SARS medications, such as ribavirin and corticosteroid. Some patients had hair loss, major memory loss, impaired concentration, and depression. A medical practitioner in Hong Kong and SARS survivor attempted suicide because complications from drugs made him unable to work.[iii] Children who lost a parent to SARS were particularly affected.[iv]

Governments and various institutions set up hotlines, including the Department of Social Work of the Chinese University of Hong Kong and the Evangelical Lutheran Church Social Service-Hong Kong, a non-governmental welfare organization. Dedicated services were introduced to provide counseling and education support for children.[v]

Despite these efforts, however, regional SARS paranoia outlived the virus. It contributed to the worsening of the crisis and its after-effects. Heightened racist incidents against Asians were reported around the world, a phenomenon not uncommon today, according to news reports that cite the purported origins of COVID-19. Within China, the stigma of SARS resulted in lingering prejudice against those who recovered from it. People anecdotally kept their distance from former colleagues who recovered from fevers (a SARS symptom) even if they were not diagnosed with SARS; people avoided dining with colleagues who had recovered from SARS. Workers reported getting fired because they or their family members had had SARS, or because they had lived in a building where someone had had the disease. Post-SARS discrimination extended to Singapore, Taiwan, and Vietnam. The director of health at the time of the outbreak warned that discrimination could discourage possible future SARS sufferers from seeking medical attention in time.

What should change with mental health benefits — both from a plan design standpoint and from a company policies standpoint?

1) Do not relegate mental health benefits to be an afterthought: mental health risks drive medical and pharmacy trends. Mental health conditions can manifest themselves in a multitude of ways, adding greater acuity to a variety of different clinical morbidities. It is therefore essential for employers to look for benefit management partners who focus on population management with a risk-orientation versus a condition-orientation. This will give employers and their benefit management partners a greater chance of identifying clinical (and financial) risk in the population irrespective of the condition-orientation. The implications of mental health on arguably the entire continuum of health benefits (including medical, pharmacy, dental, disability, etc.) have been well documented over the years. The related challenges resulting from COVID-19 will test the efficacy of managing each component of that continuum effectively. Each component of that benefit continuum will need to be managed with a heightened level of precision and account for underlying mental health considerations. One of the largest drivers of Medicaid trend, especially in “dual-eligibles” (individuals qualifying for both Medicare and Medicaid) is the use of the pharmacy benefit to treat behavioral health conditions, including substance abuse. If our review of the impact of SARS 2003 is a guide, we could potentially see the need for healthcare benefits for large commercial employers to resemble those provided by Managed Medicaid plans to address the confluence of behavioral and pharmacy benefits in the overall coordination of care.

2) Revisit mental health benefits to encourage telemedicine with mental health professionals. With COVID-19, telemedicine adoption has finally arrived, not as an afterthought but as an important platform of primary care. As employees get progressively more comfortable with telemedicine and as quarantine efforts necessitate its use, many will hopefully become comfortable with engaging a mental health professional the same way. As yet, however, the adoption of mobile health tools is nowhere close to where it needs to be. COVID-19 will likely change that. While this will improve overall employee engagement in their own mental health, it is also a lower cost option than WHAT for the employer. Provider contracting strategies should also be more deliberate as it pertains to mental health providers and their ability to increasingly offer mobile engagement options. Employees and mental health providers should be encouraged to do the same.

3) Decrease stigma and encourage people to get help and counseling. Making a dent in mental health outcomes requires reducing the stigma associated with declaring that a mental health problem exists. Stigma and fear of retribution prevent many of us from reaching out to supervisors and colleagues. Nearly all of us will be mentally scarred by COVID-19. This is a perfect time to remind employees that, as swimmer and 28-time Olympic medal holder Michael Phelps often repeats, “It’s okay not to be okay.” Many companies have employee assistance programs that have been underutilized: creating greater awareness around those programs and encouraging employees to use them will play a critical role in gaining employee acceptance of the need for professional help. Some of us can be more dispassionate about connecting with a clinical over the phone versus an in-person visit. Empower people to call and have a conversation. Early intervention is key. And now while people are restricted to their homes, it’s now more important to have that mental health support in place to combat loneliness, family discord, and substance abuse.

4) Communicate clearly about resources, plans, and intentions:

• Remind people of the benefits they have/ are available through various programs. Many employers already provide benefits such as telehealth or online counseling. However, as mentioned earlier, these are often underutilized, and now may just be the right time to engage new users to benefits already being paid by the employers.
• Clarify steps and costs to access mental health assistance. Consider covering copay costs for high risk employees, or employees going through financial hardship.
• Explain what new programs are being considered, perhaps related to major sources of stress such as financial distress and emergency support. Consider a needs assessment survey to identify potential issues, and then address them early.
• Reiterate the leadership’s commitment going forward. Communicate regularly and compassionately.

COVID-19 is a great opportunity for us to come together as a society and as employers, and to revisit the criticality of mental health hygiene in our companies and communities at large.

Sources

[i] Shi K, Lu JF, Fan HX, Jia JM, Song ZL, Li WD, et al. Rationality of 17 cities’ public perception of SARS and predictive model of psychological behavior. Chin Sci Bull. 2003;48:1297–303 10.1360/03wc0304).

[ii] Fifteen percent of the SARS recovered cases needed psychological counseling [in Chinese]. MingPao. 2003. Jul 12 [cited 2003 Aug 17]. Available from: http://hk.news.yahoo.com/030711/12/sx83.html. (Orthopedic examination on all rehab cases. Victims complained on improper medications [in Chinese]. MingPao. 2003. Oct 10 [cited 2003 Oct 17]. Available from: http://hk.news.yahoo.com/031009/12/uox2.html).

[iii] SARS recovered medical practitioner jump due to economic difficulties [in Chinese]. MingPao. 2003. Oct 6 [cited 2003 Oct 17]. Available from: http://hk.news.yahoo.com/031005/12/ulsp.html [Ref list.

[iv] Spouse of SARS victims commit suicide after the announcement of the Report of the HA Review panel on the SARS outbreak [in Chinese]. MingPao. 2003. Oct 5 [cited 2003 Oct 17]. Available from: http://hk.news.yahoo.com/031004/12/uldf.html.

[v] “Call for Attention to Psychological Reactions to SARS/’ Press Release, April 4, 2003, online at www.cuhk.edu.hk/ipro/pressrelease/030404e). Leung, Terry & Wong, Hung. (2005). Community Reactions to the SARS Crisis in Hong Kong: Analysis of a Time-Limited Counseling Hotline. Journal of Human Behavior in the Social Environment. 12. 1–22. 10.1300/J137v12n01_01.

Authors: Karthik Ganesh (EmpiRx Health), Carin-Isabel Knoop (Harvard Business School) & John A. Quelch (University of Miami), Authors of Compassionate Management of Mental Health in the Modern Workplace, (2018). We welcome feedback and input as we all learn together. Please reach out to us at kganesh@empirxhealth.com, cknoop@hbs.edu and jquelch@bus.miami.edu and share widely.