Employer Mental Wellness Guide

Confident man in group therapy session

Mental illness is a leading cause of disability among globally mobile workers. Learn more about how to help keep employees supported, well and working.

Exciting as it can be, moving abroad to work is also fraught with stress. Employees end up separated from family and social networks in the midst of a wholly unfamiliar culture. They find themselves having to replace—or even live without—many of the goods and services they left behind. In developing regions, global employees might also face a variety of situations, from traffic to food preparation, that are more complicated or even more dangerous than what they’re accustomed to.

A leading cause of disability

These stress factors can give rise to mental distress, one of the leading causes of disability among employees working abroad.

Mental distress describes a range of conditions that create problems with the way people think, feel or behave. Anxiety disorders, post-traumatic stress disorder (PTSD), depression, bipolar disorder, and schizophrenia make up the main types of mental distress.1

These aren’t rare conditions. Combined with substance use disorders, mental illness is more common than diabetes, HIV/AIDS and tuberculosis.2 Worldwide, it affects over 450 million people,3 with two-thirds suffering from depression.4

Now take a subset of that population and relocate them to an unfamiliar working and living environment. Small wonder that, in the last several years, employees on corporate assignments suffer from depression and anxiety at a rate two-and-a-half times that of people at home.5

“Expat blues” and other mental health problems don’t always originate from relocation and expat life, however. At any given time, globally mobile employees—as with the broader population—are subject to a variety of mental health issues across a continuum of severity. Some may be unaware of their condition. Others do know, and some control it with medication and/or therapy. Employers must consider their level of support across all of these scenarios to improve the chances of a successful assignment.

The economic impact

Whatever the options available to employers, doing nothing may be the least attractive. Mental illness is expensive to treat, consuming more than half of every healthcare dollar.6 It’s also a drag on productivity: Absenteeism is 5% higher among people with mental health problems.7 All told, according to a recent WHO-led study, depression and anxiety disorders cost the global economy about US$ 1 trillion in lost productivity each year.8

Neither can employers rely on governments to fill the breach. On average, the world’s nations allocate just 3% of their total health budgets to mental health. Even in high-income countries, only about half of those suffering from depression end up getting treatment.9

More insidiously, economic concerns can keep employees from seeking treatment in the first place. Global employees may hesitate to approach management or HR for help, fearing it could harm their careers. And they might avoid treatment in any case, to avoid jeopardizing their licensing or other professional qualifications. Even in developed countries with comparatively advanced resources, the stigma of mental illness can be strong.

Stigma aside, the absence of strong mental health benefits may impede companies’ ability to attract talent to their global mobility programs. Those who have well-controlled conditions may be reluctant to relocate to an area where mental health resources are scarce or their medications may not be available. 

But all these costs are either high level or qualitative. What really brings it home for employers is the cost of incomplete assignments. The average expat assignment costs US$311,000 per year and about 40% of them fail—mostly due to fallout from culture shock.10 Suppose, then, that a company has an expat workforce of just 100 employees. Slashing the failure rate by just 10% could add nearly US$1.25 million directly to the bottom line.

Proactive support

Despite the potential payoffs, the 2018 Cigna 360° Well-Being Survey found that one in two workers claim they are not offered support from their employers in dealing with stress or have a formal workplace wellness program in place.11

By taking a mindful approach to mental health and wellness, employers can de-stigmatize mental distress in the workplace and enable globally mobile employees to be proactive about their own well-being. The specific initiatives an employer can take are limited only by the imagination. However, many organizations offer one or more of the following:

  • Behavioral health assessments. These can help employers identify potential health risks and guide employees to resources that can help. Ideally, such assessments are tailored to the employee’s native language and culture, and certified for quality by a well-recognized authority.
  • Online health improvement programs. Web-based programs can help global employees make sustainable lifestyle changes in support of their mental health. Examples include stress resilience, sleep quality, improved nutrition and physical activity.
  • Well-being challenges. Social-network based programs can draw global employees into teams that work together to improve their mental health. They can track their actions through a scoring system and compete in a fun and dynamic way.
  • Telephonic health coaching. For global employees, personalized, one-on-one wellness support can be just a phone call away. Each coach stays with the same employee to help them change unhealthy behaviors for good.
  • An employee assistance program (EAP). Licensed clinicians can help globally mobile employees and their families with emotional, behavioral, and other issues. Counselors can meet with employees in person, by telephone, or via live chat.

Are wellness initiatives like these effective? In a recent study, researchers at the University of California Los Angeles put 281 volunteers through a 12-week health improvement program. Participants completed an in-depth assessment of their physical and emotional health, with scores based on a percentile ranking. By the end of the program, mental health had improved 19 percentile points among the study group.12

Getting the lay of the land

Not every condition will respond to these methods, however. Sometimes, the only option is for employees to seek medical care in the area of their assignment.

The environment for this can be diverse. A 2016 study published in the medical journal Neuropsychiatric Disease and Treatment offers an enlightening roundup:

Different regional studies revealed different views. Pacific Islanders, for example, considered mental illness as a result of family conflicts. According to a study on Jewish population, mental illness is seen as an opportunity to receive divine messages, a means of forgiveness, and to improve their souls. However, there are some cultures, mostly Southeast Asians, who perceive that supernatural forces/phenomena are responsible for mental health issues and consider them the result of wrath or denial of spirit or deities. This notion of supernatural or parapsychological phenomenon is not limited to Asia. Some Western cultures hold this idea too. A study conducted in Switzerland, with psychiatric patients, revealed that demons were considered the main cause of mental health problems. A South Asian study revealed that people there perceive mental illness as natural part of the suffering that is predestined for them.13

Under the circumstances, mental health isn’t an area that global employers should leave to chance. They could be the only support that overseas employees might have. Consider that according to the World Health Organization, 60 countries have not even one psychiatrist per 100,000 people.14 This might explain why psychiatric emergency is one of the most common medical reasons for air evacuation.15

A proactive assessment of each assignment region’s mental health resources is the first step in looking after the psychological well-being of global employees. Areas to survey include:

  • Medical facilities. In many countries, hospitals and clinics can be few and far between. And even where modern, well-kept facilities are available they may be lacking in critical equipment, skilled staff, and safety protocols. Map out the locations of quality facilities where employees on assignment can go for mental health care.
  • Medication. The cost and availability of certain medications can vary widely by region. Another hazard: counterfeit drugs, a problem everywhere but particularly in emerging economies. Make sure employees are well-versed in how to get the medications they need, including the names and locations of trusted pharmacies.
  • Clinicians and support staff. Local provider networks should include qualified professional help in a stigma-free environment. A common language is essential so that employees can communicate important information about symptoms, current medications, allergies, and more.  
  • Local laws. Employees in distress may turn to illicit substances in an effort to self-medicate. They also may act out in ways that draw attention from local law enforcement.  Inform employees about drug laws in their assignment area as well as actions they can take when feeling overwhelmed.
  • Emergency transport. Global employees assigned to developing regions can face medical emergencies where care is reachable only by air. Verify that medical evacuation is part of their mental health benefit, and have a well-documented process in place for repatriating employees if necessary.

Prevention or proactivity, as always, are key. Employers can do their part by scouting out the mental health resources of assignment locations, vetting them in advance, and clearly communicating among employees the process to follow for accessing care.

Sounds complicated? It is. But employers can save themselves considerable effort by tapping into the expertise and network of a global healthcare provider. Attributes to look for include a global reach, expertise in the needs of globally mobile employee populations and the ability to fine-tune plans and programs to each region where employees are assigned.

Progress on mental health is ongoing. Although employers have translated much of this progress into enhanced support for employees, global employees often fall through the cracks. This group’s mindset for adventure might play a part—what could possibly keep them down? But in the end, even the toughest of explorers must acknowledge their humanity. Meanwhile, by shoring up their capabilities in mental wellness, employers can mitigate the effects of travel-related stress for employees and help them keep small problems from turning into big ones while abroad.

Mental health initiatives around the world

The world’s cultures have different ways of dealing with mental wellness. Here’s a sample of global practices that global employees might experience.

Zimbabwe. Although depression and anxiety are well-understood in Zimbabwe, a lack of resources has prompted them to deal with the challenges creatively. After screening patients, primary care providers send at-risk patients to a “friendship bench” where a culturally-familiar health authority provides cognitive behavioral therapy.16

Singapore. The Mindset Learning Hub, a job placement and training center, matches employers with people recovering from mental illness who are acquiring skills and certifications through the center.17

Argentina. With more psychologists per capita than anyplace else in the world, Argentineans value talk therapy less as an intervention for illness than as an essential part of maintaining good health—alongside diet and exercise.18

Dubai. The Dubai Health Authority’s “Happy Lives, Healthy Communities” initiative is part of a longer-term strategy to promote early intervention, provide a continuum of care, and eliminate the taboo associated with mental illness.19

Australia. Headspace is the Australian government’s response to depression, anxiety and other mental health issues among children and teens. The program’s mix of online and physical wellness centers offer access to services from doctors, psychologists, social workers and employment specialists.20

Interested in learning about how Cigna can support your workforce?

1 “What is mental illness,” Action on Disability Within Ethnic Communities, 31 October 2017, https://healthreach.nlm.nih.gov/document/123/What-Is-Mental-Distress.

2 “How countries are failing to integrate people with mental illness into society,” by Martin Koehring, The Huffington Post, 7 April 2017, https://www.huffingtonpost.com/entry/how-countries-are-failing-to-integrate-people-with_us_58e7d2d6e4b0acd784ca57ca.

3 “Lessons from the world's cities on protecting our mental health,” by Moitreyee Sinha, World Economic Forum, 11 January 2018, https://www.weforum.org/agenda/2018/01/lessons-from-world-cities-protecting-mental-health/.

4 “Depression,” World Health Organization, 22 March 2018, http://www.who.int/news-room/fact-sheets/detail/depression.

5 “The Mental Health Status of Expatriate versus U.S. Domestic Workers: A Comparative Study,” by Sean D. Truman, David A. Sharar, and John C. Pompe, International Journal of Mental Health, Winter 2011-2012,  http://chestnutglobalpartners.org/Portals/cgp/Publications/ExPat%20Mental%20Health%20Paper%20-%20May%202011.pdf.

6 Valentic, https://www.ehstoday.com/health/study-links-workplace-wellness-programs-and-mental-health.

7 “Mental Health and Productivity at Work: Does What You Do Matter?,” by Melisa Bubonya, Melisa, Deborah A. Cobb-Clark and Mark Wooden, Melbourne Institute Working Paper No. 16/16, 18 April 2016, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2766100.

8 “World Mental Health Day 2017,” World Health Organization, http://www.who.int/mental_health/world-mental-health-day/2017/en/.

9 “ ’Depression: let’s talk’ says WHO, as depression tops list of causes of ill health,” World Health Organization, 2 June 2018, http://www.who.int/news-room/headlines/30-03-2017--depression-let-s-talk-says-who-as-depression-tops-list-of-causes-of-ill-health.

10 “How can employers reduce the risks when sending employees overseas?,” Punter Southall Health & Protection, 12 December 2017, https://www.personneltoday.com/pr/2017/12/how-can-employers-reduce-the-risks-when-sending-employees-overseas/.

11 “Future Assured: 2018 Cigna 360° Well-Being Survey,” Cigna, 9 July 2018, https://wellbeing.cigna.com/international/360survey/#_blank.

12 “Study Links Workplace Wellness Programs and Mental Health,” by Stefanie Valentic, EHS Today, 10 October 2016, https://www.ehstoday.com/health/study-links-workplace-wellness-programs-and-mental-health.

13 “Beliefs and perception about mental health issues: a meta-synthesis,” by Fahad Riaz Choudhry et al., Neuropsychiatric Disease and Treatment, 31 October 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096745/.

14 “Global Health Observatory (GHO) data: Mental health,” World Health Organization, http://www.who.int/gho/mental_health/en/.

15 “International travel and health: Psychological health,” World Health Organization, http://www.who.int/ith/other_health_risks/psychological_health/en/.

16 “The friendship bench,” Friendship Bench Zimbabwe, https://www.friendshipbenchzimbabwe.org/.

17 “More Singaporean firms hiring those with mental health issues,” by Toh Ee Ming, South China Morning Post, 27 March 2017, https://www.scmp.com/news/asia/southeast-asia/article/2082390/more-singaporean-firms-hiring-those-mental-health-issues.

18 “Almost everyone in Buenos Aires is in therapy,” by Olivia Goldhill, Quartz, 17 July 2016, https://qz.com/734450/almost-everyone-in-buenos-aires-is-in-therapy/.

19 “Dubai's mental health strategy to remove stigma, empower patients,” by Asma Ali Zain, Wknd, 12 May 2018, https://www.khaleejtimes.com/lifestyle//health-fitness/dubais-mental-health-strategy-to-remove-stigma-empower-patients.

20 “Welcome to Headspace,” National Youth Mental Health Foundation, Australian Government Department of Health,  https://headspace.org.au/.

Confident corporate woman overlooking the cityscape