In the great order of things in the American workplace, many a stigma has fallen. Mental illness, though, has notably lagged — retaining its air of misunderstanding. “It is seen as a weakness, and people are afraid to admit weakness, especially in the workplace, and probably with good reason” says Wharton management professor Adam Cobb. “If you think of jobs, it’s like a tournament, and the best keep moving up. And if people are hard to differentiate and all are awesome, [if] there is one thing you can do to isolate them and kick them out, we tend to do it.”

“There is a lot of stigma around mental illness,” says Peter Cappelli, Wharton management professor and director of the school’s Center for Human Resources. “There are still a lot of people who believe it is character rather than something physiological. They believe if you really wanted to fix this you could do it. I don’t think mental illness is very well understood.”

But the social dynamics around mental illness may be changing. A combination of factors have come together in recent years — including the Americans with Disabilities Act — to lead many to believe that the stigma is finally fading, perhaps even in the workplace. Americans are talking more openly about mental health — including some quite prominent Americans. “At the root of this dilemma is the way we view mental health in this country,” said Michelle Obama recently. “Whether an illness affects your heart, your leg or your brain, it’s still an illness, and there should be no distinction.” She was speaking at the March launch of “Change Direction,” a national campaign meant to encourage Americans to care for their mental health and recognize the signs of emotional distress — withdrawal, agitation, hopelessness, decline in personal care and change in personality. Significantly, the campaign targets the business and corporate community, with Booz Allen Hamilton a major partner.

“I think things are changing,” says Clare Miller, director of the Partnership for Workplace Mental Health, a project of the American Psychiatric Foundation. “I’ve been doing work in mental health since 1996 and specifically working with employers since 1999, and at the beginning we had to really talk about the connection between mental illness and the bottom line, and we still do. But I think the conversation has changed, and employers seem more focused on strategy and action and what we can do to address the issue, and that’s a real positive and an indication that things have changed.”

“There are still a lot of people who believe [mental illness] is character rather than something physiological. They believe if you really wanted to fix this you could do it.”–Peter Cappelli

Costs Obvious and Hidden

The “Change Direction” campaign took shape after the shootings at Sandy Hook Elementary School. Other horrors since, like the alleged Germanwings airline pilot suicide/mass murder incident in March, have put bold headlines around mental illness. But less noticeable are the high, ongoing costs of mental illness to society. One in five Americans lives with a diagnosable mental illness, with about $150 billion being spent annually on hospitalization, drugs and therapy. Workers with mental illness can expect to earn less than others — about $16,000 less each, or about $193 billion annually in unrealized earnings, according to a 2008 study published in the American Journal of Psychiatry. The cost to the economy of major depressive disorders alone rose to $210 billion in 2010, up from $173 billion in 2005, according to a study published in 2015 in that journal.

But mental illness carries costs that are sometimes less obvious. “It’s hard to focus on your work when your child is hallucinating,” wrote Stewart Friedman, director of Wharton’s Work/Life Integration Project, in the first sentence of a 2009 essay in the Harvard Business Review titled, “The Hidden Business Cost of Mental Illness.” Friedman knows the costs personally. He has a son who had a psychotic break at 13 and has been struggling to live with serious illness since. “I was writing about the experience I had and that millions of others have while trying to be responsible for a family member who requires urgent care that is not only time consuming, but also saps you mentally and emotionally in powerful ways.”

Friedman says that employers and workers can negotiate a relationship that can be less stressful and more productive when they talk openly about the realities of the unusual demands on an employee who is the caregiver of someone with mental illness. “It’s mainly about expectations for dealing with crisis. If your daughter broke her ankle, no one would bat an eyelash if you said you had to take her to the emergency room,” he notes. “It’s a lot different to say, ‘My son just had a psychotic episode, and I don’t know what it means to his life and the life of my family.'”

There is a “huge” caregiver burden for relatives, says David S. Mandell, director of the University of Pennsylvania’s Center for Mental Health Policy and Services Research. “You end up being care advocate, chauffer, adviser and lawyer,” he notes. “It can become a full-time job.”

While a suddenly disappearing worker creates disruption, businesses can often expect to see their understanding and generosity repaid many times over. Anne Marie Ames, who has had to take time off from work since her son became sick with debilating anxiety and depression in the 8th grade, feels an added sense of gratefulness for the flexibility her company — a major management consulting firm — has granted her. “As an employee, I work very hard because of the compassion and understanding that has been shown me. They get much more loyalty as a result of their behavior, and it would be great if more companies realized that, and that would certainly help the bottom line. I think if they were educated along those lines, a lot more people would come forward.

“My company is very much about being a diverse work place, and they mean diversity in many different ways,” she continues. “If you know anyone who has had mental illness and has gotten through it, they are much better for it; they have much more empathy and understanding, and they bring much greater value to the workforce.”

“There is at least recognition that keeping people healthy isn’t just on the physical side, but also finding ways to disengage, to recharge mental batteries and emotional health.”–Adam Cobb

Work and the Bipolar Mom

Workers see plenty of red flags standing between their mental health needs and the consequences of speaking openly about them. From employment applications that ask people to check off whether they’ve suffered from bipolar disorder and schizophrenia, to being fired after suffering breakdowns, fears are well-founded. Jennifer Marshall was the top producer in an executive search firm when, in her mid-20s, she suffered two manic episodes and was eventually diagnosed with bipolar 1 disorder. “They gave me a couple of weeks off,” recalled Marshall, “and then I got an email that said, ‘We need you to return to work or you have to resign. We have these clients and they are not being served now.’ Looking back, I remember feeling pretty sad when I read the email, thinking, ‘I put all this into the company and now this happens.’ In their defense, they had never really dealt with anything like this before.”

Resign she did, and now Marshall devotes her time to making sure that those who haven’t dealt with things like this before are getting educated. She has become a mental health advocate as the blogger Bipolar Mom (, and, with Ames, through a traveling theater show that invites people to speak about mental illness called This Is My Brave.

How does a worker with mental illness come out to an employer, and when is a good time to do it? “I am not sure I would ever tell anyone at my work that I had these issues because I wouldn’t want anyone to treat me differently,” says Cobb. “If you did, then every time you had a bad day, people would say, ‘Oh, Adam must be having a depressing spell,’ or ‘We can’t trust him because he might go off at any time.'”

“It’s very tricky, because if you put it on an application, there is a very good chance you won’t get the job,” says Cappelli. “You should not apply for jobs you can’t do, but you can say, ‘I have the following problem and need the following accommodation.” If an illness presents itself with personality issues, but does not affect job performance, “you might tell your supervisor that — ‘sometimes I might come across this way and this is why.’ And that’s a pretty smart thing to do even for someone with minor personality issues, like someone who is introverted.”

Still, deciding if and when to tell a supervisor or co-worker about mental illness requires a careful calculation. “There is so much risk because of the fear associated with extreme forms of mental illness that cause people to act violently or self-destructively that the need to cover, to mask one’s medical history, is great,” says Friedman. “So in today’s world, you mask that aspect of yourself until some form of trust is established and you make a contribution that is seen as valuable. Once you get to that point, then [you can] speak about what your special needs are.”

Stigma is a complex issue for people with mental illness, and it has several distinct effects, write Bruce G. Link and Jo C. Phelan, co-directors of Columbia University’s Center for the Study of Social Inequalities and Health — including self-devaluation, status loss and the establishment of an “us vs. them” dynamic. “Other powerful stereotypes associated with mental illness involve negative inferences about competence, cleanliness and trustworthiness,” write Link and Phelan in “Labeling and Stigma,” a chapter in The Handbook of the Sociology of Mental Health.

“There is so much risk because of the fear associated with extreme forms of mental illness … that the need to cover, to mask one’s medical history, is great.”–Stewart Friedman

“What we know about stigma is that the best way to eliminate it is have more contact with people with illness,” says Miller. “The stigma is eased when we know friends and family with that experience, and the workplace is going to be one of the last frontiers where that it going to happen. Research shows that while the public has grown in its understanding of mental illness, and that is real, if you look at the stigma measure, we’re not there yet.”

Perhaps the biggest hurdle is that people tend to conflate mental illness and violence. In a 2013 survey of 1,530 respondents taken the month after the Sandy Hook shooting, 71% said they would be unwilling to work closely on a job with someone with serious mental illness. The results were published in The New England Journal of Medicine.

Toward a Cultural Change

Still, some progress in the workplace has been significant, says Penn’s Mandell. “We have mental health parity, which requires insurance companies to cover mental health treatment. I would love to see increased use of flex time. I think we have burgeoning workplace assistance programs, but the quality of the treatment that is available is often not good.”

Good care, says Miller, means coverage for the full range of mental health problems, “to make sure the insurance benefits are there so that when [employees] have a specific illness they can get good care, because [insurance coverage] tends to focus on depression, anxiety and substance abuse.”

“People are starting to recognize the value of staying mentally healthy,” says Cobb. “You are seeing discussions on meditation at work, research into the importance of taking naps and keeping the brain healthy. There is at least recognition that keeping people healthy isn’t just on the physical side, but also finding ways to disengage, to recharge mental batteries and emotional health.”

Mandell says the arguments for doing more are persuasive. “What’s exciting is that large-scale studies are saying when you treat depression in the workplace, you get a substantial return on investment relatively quickly, so there’s a real economic argument for reducing the stigma, as long as we can provide evidence-based care for them.”

In some ways, being sensitive to the needs of workers with mental illness is no different than being there for any employee, says Friedman: “Great managers are always curious about what the needs and interests of their people are, and so we know from my research and others that we have to account for the needs and interests of people in a way that enables them to connect their goals to the goals of the organization, and the only way is through compassionate inquiry about the other. That’s what’s needed — ‘How is it going? What’s happening with you?'”

Some of this is happening. More is needed, says Friedman. “I think we are hearing more stories, more openness about the real experiences of actual people who are struggling with how they are different. The more these stories are told and heard, the easier it becomes for you to tell your story. That’s how cultural change happens.”