The Economics Of Gender And Mental Illness

194 Pages·2004·1.27 MB·English

by  D.E. Marcotte

CONTENTS
LISTOFCONTRIBUTORS vii
INTRODUCTION
DaveE.MarcotteandVirginiaWilcox-Gök 1
GENDERDIFFERENCESINMENTALDISORDERSINTHE
U.S.NATIONALCOMORBIDITYSURVEY
RonaldC.Kessler 7
EARLYONSETDEPRESSIONANDHIGHSCHOOL
DROPOUT
VirginiaWilcox-Gök,DaveE.Marcotte,FarahFarahati
andCareyBorkoski 27
GENDERDIFFERENCESINTHELABORMARKET
EFFECTSOFSERIOUSMENTALILLNESS
PierreKébreauAlexandre,JosephYvardFede
andMarshaMullings 53
MENTALILLNESS:GENDERDIFFERENCESWITH
RESPECTTOMARITALSTATUSANDLABOURMARKET
OUTCOMES
NielsWestergaard-Nielsen,EsbenAgerbo,TorEriksson
andPrebenBoMortensen 73
MENTALHEALTHANDEMPLOYMENTTRANSITIONS
CaroleRoanGresenzandRolandSturm 95
v
vi
GENDER-SPECIFICPATTERNSOFEMPLOYMENTAND
EMPLOYMENTTRANSITIONSFORPERSONSWITH
SCHIZOPHRENIA:EVIDENCEFROMTHE
SCHIZOPHRENIACAREANDASSESSMENT
PROGRAM(SCAP)
DavidS.Salkever,EricP.SladeandMustafaKarakus 109
THEROLEOFGENDERINACOMPANY-WIDEEFFORT
TOEXPANDANDDESTIGMATIZEMENTALHEALTH
TREATMENT
AnthonyT.LoSasso,RichardC.Lindrooth
andIthaiZ.Lurie 133
GETTINGMENANDWOMENRECEIVING
DEPRESSION-RELATEDSHORT-TERMDISABILITY
BENEFITSBACKTOWORK:WHEREDOWEBEGIN?
CarolynS.Dewa,JeffreyS.HochandPaulaGoering 155
INSURANCESTATUSOFDEPRESSEDLOW-INCOME
WOMEN
AllisonA.Roberts 177
LIST OF CONTRIBUTORS
EsbenAgerbo NationalCenterforRegisterResearch,
UniversityofAarhus,Denmark
PierreKe´breau HealthServicesResearchCenterand
Alexandre DepartmentofEpidemiologyandPublic
Health,SchoolofMedicine,Universityof
Miami,USA
CareyBorkoski DepartmentofPublicPolicy,Universityof
Maryland,BaltimoreCounty,USA
CarolynS.Dewa CentreforAddictionandMentalHealth,
HealthSystemsResearch&ConsultingUnit,
UniversityofTorontoDepartmentof
Psychiatry,Canada
TorEriksson CenterforCorporatePerformance,Aarhus
SchoolofBusiness,Denmark
FarahFarahati ProgramforAssessmentandTechnologyand
Healthcare,McMasterUniversity,Canada
JosephYvardFede HealthServicesResearchCenter,Schoolof
Medicine,UniversityofMiami,USA
PaulaGoering CentreforAddictionandMentalHealth,
HealthSystemsResearch&ConsultingUnit,
UniversityofToronto,Departmentof
Psychiatry,Canada
CaroleRoanGresenz RANDCorporation,USA
JeffreyS.Hoch DepartmentofEpidemiologyand
Biostatistics,UniversityofWesternOntario,
Canada
vii
viii
MustafaKarakus DepartmentofHealthPolicyand
Management,BloombergSchoolofPublic
Health,JohnsHopkinsUniversity,USA
RonaldC.Kessler DepartmentofHealthCarePolicy,Harvard
MedicalSchool,USA
RichardC.Lindrooth DepartmentofHealthAdministrationand
Policy,MedicalUniversityofSouth
Carolina,USA
AnthonyT.LoSasso InstituteforPolicyResearch,Northwestern
University,USA
IthaiZ.Lurie InstituteforPolicyResearch,Northwestern
University,USA
DaveE.Marcotte DepartmentofPublicPolicy,Universityof
Maryland,BaltimoreCounty,USA
PrebenBoMortensen NationalCenterforRegisterResearch,
UniversityofAarhus,Denmark
MarshaMullings HealthServicesResearchCenter,Schoolof
Medicine,UniversityofMiami,USA
AllisonA.Roberts DepartmentofEconomics,LakeForest
College,USA
DavidS.Salkever DepartmentofHealthPolicyand
Management,BloombergSchoolofPublic
Health,JohnsHopkinsUniversity,USA
EricP.Slade DepartmentofHealthPolicyand
Management,BloombergSchoolofPublic
Health,JohnsHopkinsUniversity,USA
RolandSturm RANDCorporation,USA
Niels CenterforCorporatePerformance,Aarhus
Westergaard-Nielsen SchoolofBusiness,Denmark
VirginiaWilcox-Go¨k DepartmentofEconomics,Northern
IllinoisUniversity,USA
INTRODUCTION
Dave E. Marcotte and Virginia Wilcox-Go¨k
The past quarter-century has seen research on the economic impacts of mental
illnessflourish.Innovationsinmeasurementandthereleaseofseveralcommunity-
based and often nationally representative data sets containing valid and reliable
diagnosticinformationhaveenabledresearcherstomakesubstantialadvancesin
understandingthemyriadwaysthatmentalillnessimpactstheeconomiclivesof
the ill and their families. Among the most interesting and persistent findings in
thisliteratureisthatmentalillnessaffectswomenandmendifferently.Notonlydo
womenandmenhaveverydifferentratesofprevalenceforvariousdiseases,but
mentalillnessisalsocommonlyfoundtohavedifferenteffectsintheireconomic
lives.
Researchintothewaysinwhichmentalillnessshapestheeconomiclivesofthe
illhasidentifiedimportantgenderdifferencesthroughoutthelifecycle.Beginning
duringadolescence,mentalillnessamongfamilymembersappearstohavediffer-
enteffectsonboys’andgirls’educationalattainment.Duringadulthood,women
often withdraw from the labor market more quickly than do men when afflicted
withmentalillness.Amongthosewhoareemployed,earningslossesduetomen-
talillnessareoftenfoundtovarybygender.Further,womenandmenundertake
treatmentformentalillnessatdifferentrates,andthismayaffecttheirabilityto
maintainproductivelivesastheyadapttotheirillnesses.
Thedimensionsalongwhichtheexperiencesofmenandwomenwithmental
illnessdifferarenumerous,asarethedata,methodsandeconomistswhohavestud-
iedthetopic.Whilegenderhassooftenbeenfoundtobeanimportantdeterminant
ofprevalenceandoutcomesofmentalillness,economistshaverarelyfocusedon
genderdifferencesasacentralelementoftheiranalyses.Inthisvolume,ouraimis
todirectthefocusofresearchintheeconomicsofmentalhealthmoresquarelyon
TheEconomicsofGenderandMentalIllness
ResearchinHumanCapitalandDevelopment,Volume15,1–6
©2004PublishedbyElsevierLtd.
ISSN:0194-3960/doi:10.1016/S0194-3960(04)15001-4
1
2 DAVEE.MARCOTTEANDVIRGINIAWILCOX-GO¨K
thetopicofgender.Eachpaperinthisvolumeeachprovidesinsightintotheways
inwhichwomenandmenareafflictedandaffectedbymentalillnessinthelabor
market; highlighting both differences and similarities. It is our intention that by
compilingasetoffirst-ratepapersthatfocusongender,wecanfacilitateamore
complete understanding of the patterns and economic consequences of mental
illnessoverthelifecourse.
Wehopethattheresearchcompiledherein,asindividualpapersandasacol-
lection, will provide the reader with a richer understanding of the prevalence of
mental disorders, the educational, employment and earnings impacts of psychi-
atricdisease,andprospectsfortreatingandprovidingaccesstohealthcareforthe
mentally ill. Accordingly, we have organized this volume along just these lines:
prevalence,effectsofdisease,andtreatmentandaccesstocare.
ThevolumebeginswithastudybyKesslerthatreportsongenderdifferences
inpatternsofmentalillnessintheUnitedStatesfromtheNationalComorbidity
Survey(NCS).TheNCSisthefirstnationallyrepresentativedatasetthatallows
estimationof12-monthandlifetimeratesofprevalenceofmentalillnessaswellas
theassessmentofdemographic,social,andeconomiccorrelatesofprevalence.The
NCSemployedamodifiedversionoftheWorldHealthOrganization’sComposite
International Diagnostic Interview (CIDI) to make diagnoses using the criteria
definedbytheDiagnosticandStatisticalManual,3rdedition,revised(DSM-III-
R). The structured diagnostic interview is used by non-clinicians and has been
shown to be a reliable and valid instrument for measuring mental illness. While
Kesslerfindssmalldifferencesintheoverallratesofprevalenceofmentalillness,he
reportssubstantialdifferencesinprevalencefornearlyallspecificillnesses.Most
notably,womenaresubstantiallymorelikelytosufferfrommooddisordersand
anxietydisorders,whilemenweremorelikelytohavesubstanceabuseandconduct
andantisocialbehaviordisorders.Kesslerreportsthatamongtheill,womenare
muchmorelikelythanmentoreportseekingprofessionalhelpfortheirpsychiatric
problems.Hepresentssomeevidencethatthisisbecausewomencanmorereadily
perceiveneedforsuchhelp.Finally,Kesslernotesthatitistroublingthatwomen
haveequallypersistentandseverehistoriesofmentalillness,despitetheirhigher
rateoftreatment.Thisleavesopenimportantquestionsaboutgenderdifferences
intherapeuticefficacy.
Thenextpaperfocusesonunderstandingeconomiceffectsofmentalillnessat
anearlystageofthelifecycle.Wilcox-Go¨k,Marcotte,FarahatiandBorkoskipoint
outthatwhilewehavecometounderstandtheemploymentandearningseffects
ofmentalillnessfairlywell,littleisknownabouttheimpactofadolescentmental
illnessoneducationalattainment.UsingtheNCSdata,Wilcox-Go¨ketal.estimate
the effects of depression on the likelihood of dropping out of high school. They
do so because high school dropout is known to be associated with substantial,
Introduction 3
and growing, earnings losses during a person’s working life, and claim that this
focus provides an indication of heretofore little examined indirect labor market
costs of depression. To identify the effects of adolescent depression on dropout,
Wilcox-Go¨ketal.focusonthesub-groupwithonsetbeforetheageof16(theage
to which most states make attendance compulsory), dropping from the analysis
thosewithonsetbetween16and18.Comparingtheserespondentstoareference
groupwithoutearlyonsetmentalillness,theauthorsfindthatdepressionamong
boysisassociatedwithasubstantiallyelevatedriskforhighschooldropout,butthe
sameisnottrueforgirls.WhileWilcox-Go¨ketal.findthatearlyonsetofalcohol
disorders increases the risk of high school dropout for both sexes, they report
evidencethatthiscannotbeattributedtothecomorbiditybetweendepressionand
alcoholdisorders.
ThepaperbyAlexandre,FedeandMullingsanalyzestheeffectsofmentalillness
and labor supply. Making use of data from the first-ever wave of the National
HouseholdSurveyonDrugAbusetoincludemeasuresofseriousmentalillness,
the authors estimate effects of mental illness on unemployment and the number
of workdays skipped among the employed. Alexandre et al. attempt to identify
the labor supply effects of mental illness by exploiting measures of religiosity
as instruments for serious mental illness. They find that serious mental illness
substantially increases the risk of unemployment among men, but not women.
The authors suggest this pattern is likely the result of women dropping out of
the labor force altogether when afflicted with mental illness, not to the lack of
anemploymenteffect.Thiswouldbeentirelyconsistentwithpreviousresearch.
Equallysuggestiveofanegativeeffectonlaborsupply,Alexandreetal.findthat
among those who remain employed, the seriously mentally ill miss more work
dayseachmonth,likelybecauseofthedisabilitiesimposedbyillness.
Thenextpaperprovidesauniquelookattherelationshipbetweenpsychiatric
illnessandemploymentandearnings,aswellasthelikelihoodofmarriage(orco-
habitation).Westergaard-Nielsen,Agerbo,ErikssonandMortensonusedatafrom
theDanishLongitudinalLaborMarketRegister,whichisacompilationofvarious
administrativedatacontaininginformationonincomeandunemployment,among
other things, for a 5% sample of the Danish adult population. The data provide
observationsonmorethan200,000persons,andtracksthemfornearly2decades,
from 1976 to 1993. The authors have merged these data with an administrative
datasetcoveringalladmissionsintopsychiatricinpatienthospitalsinDenmark;
providinginformationonlengthofstayanddiagnosis.Westergaard-Nielsenetal.
makeuseofamatchedcontrolgroupdesigntoexaminepatternsofemployment
andmarriagebeforeandafterapsychiatrichospitaladmissioncomparedtopattern
forobservationallysimilarbuthealthypeers.Theauthorsfindthatthementallyill
sufferemploymentandearningslossesmanyyearspriortoadmission.Theyfind
4 DAVEE.MARCOTTEANDVIRGINIAWILCOX-GO¨K
nosubstantialdifferencesbetweenmenandwomeninthelikelihoodofmaintain-
ingemployment,thoughtheyfindthatmensufferrelativelylargeearningseffects.
The authors suggest this may be due to differences in the extent to which jobs
accommodate or are impeded by mental illness. Other possibilities include gen-
derdifferencesindiseaseorseverity,oraccesstotreatment.Westergaard-Nielsen
etal.alsofindthatdifferencesbetweencasesandcontrolsgrowmostrapidlyjust
priortoadmission,butthenstabilizeintheyearsfollowingadmission.Ahopeful
interpretation of this last finding is that treatment prevents further decay in the
economicandsociallivesoftheill.Ontheotherhand,theillneverrecovertheir
pre-admissionlevelsofemploymentandearningsvis-a`-viscontrols.
Thenextpaperhelpsprovidesomecontextonemploymenttransitionsandmen-
talhealththat,amongotherthings,isusefulforinterpretingtheAlexandreetal.
andWestergaard-Nielsenetal.papers.Inthispaper,GresenzandSturmmakeuse
oftheHealthcareforCommunitiesdatatoanalyzetherelationshipbetweenmental
healthandtransitionsbetweenemployment,unemploymentandbeingoutofthe
labor force. The authors exploit panel features of the data to examine employ-
ment transitions between waves and their relationship with recent mental health
episodesasmeasuredattheinitialinterview.GresenzandSturmfindinteresting
andimportantdifferencesbetweentheemploymenttransitionsofwomenandmen
subsequent to an episode of mental illness. Most notably, they find that women
recentlysufferinganepisodeassociatedwithdepressionorananxietydisorderare
more likely to drop out of the labor force altogether. Interestingly they are also
morelikelytorejointhelaborforceiftheywereoutofthelaborforce.Formen,
however,thereisnotthispatternofexitingthelaborforce.Nonetheless,Gresenz
andSturmfindthatmenwithanxietyordepressivedisordersarelesslikelytofind
employment.
Inthefinalpaperinthevolumetoexamineemploymentconsequences,Salkever,
SladeandKarakusexaminegenderdifferencesinemploymentpatternsandtran-
sitionsamongpersonswithschizophrenia.Theyanalyzedatafromalargescale
surveyconductedatsixsitesaroundtheUnitedStates:theSchizophreniaCareand
AssessmentProgram(SCAP).SCAPisalongitudinalstudy,soparticipantswere
interviewedatsixmonthintervalsoveraperiodofuptothreeyears.Notsurpris-
ingly,employmentratesandemploymentstabilityarequitelowamongthosewith
schizophreniacomparedtothegeneralpopulation.Importantly,Salkeveretal.find
that among those with schizophrenia, women are more likely to have long-term
periods of non-employment, and are more likely to lose a job if employed. The
authorsfindthatamongschizophrenics,educationhasalargerpositiveeffecton
thelikelihoodofemploymentforwomen.But,women’semploymentchancesare
alsomorenegativelyaffectedbynegativesymptomsofdisease.Salkeverandhis
colleagues speculate that this may be related to gender differences in the types
Introduction 5
ofjobsthosewithschizophreniahold:perhapswomenholdjobsthatrequirein-
terpersonalratherthanmanualskills,andhencenegativesymptomsimposemore
importantlimitationsontheirjobperformance,onaverage.Whiletheauthorsdo
not have the data to test this hypothesis, their results serve to both answer and
raiseimportantquestionsaboutthewaysinwhichwomenandmensufferingfrom
debilitatingmentalillnessexperiencethelabormarketdifferently.
Each of these papers on labor market impacts of mental illness confirm some
importantfindingsofpreviousresearch,andeachraisesimportantquestions,too.
A particular value of these papers is that they each utilize new or novel data to
examinethisrelationship,therebycontributingimportantnewperspectiveintothe
existingbodyofknowledge.
Thenextthreepapersalsomakeuseofuniqueandexcellentdata,andprovide
unusualinsightintotherelevanceofgenderinmentalhealthservicesutilization,
re-employment after disability leave, and also access to health insurance among
poor,depressedwomen.Thefirstofthesepapersmakesuseofdatafromamulti-
nationalU.S.communicationsandelectronicscompany,employingaround75,000
workersintheU.S.thatimplementedachangeinmentalhealthbenefits.Inthis
paper,LoSasso,LindroothandLuriedescribeachangeinhealthinsurancebenefits
atthiscompanythatreducedco-paymentsformentalhealthtreatment,provided
employees access to a network of mental health providers which included non-
physicianspecialists,andadoptedeffortstode-stigmatizementalhealthtreatment.
Theauthorsfoundsignificantincreasesinthelikelihoodthatemployeesinitiated
mentalhealthtreatmentsubsequenttothebenefitchange,andmostofthiswasthe
resultofincreasesintheuseofnon-physicianmentalhealthspecialists.LoSasso
et al. found no differences in the way women and men responded to the benefit
change.Whilewomenweremorelikelytoinitiatementalhealthtreatmentpriorto
andafterthebenefitchange,bothmenandwomenincreasedtheirratesofmental
health care utilization subsequent to the change in the company’s mental health
benefitpackageandde-stigmatizationeffort.Takenasawholetheauthors’findings
providecauseforoptimismthatbothworkingmenandwomencanbeencouraged
toseekmentalhealthtreatment.
Inthenextpaper,Dewa,HochandGoeringexaminegenderdifferencesinout-
comesfromshort-termdepression-relateddisabilityleave.Theauthorsmakeuseof
administrativerecordsfromthreemajorfinancialcompaniesinCanada,together
employing some 63,000 worker (about 12% of Canadian workers in the indus-
try).Dewaetal.compileddatafromeachcompany’sshort-termdisabilityclaims,
prescriptiondrugclaimsandoccupationalhealthdepartmentrecords.Theauthors
usedthedatatoexaminehowworkexperience,occupation,depressionsymptoms,
recommendedclinicalguidelineuseofantidepressantsalongwithgenderaffected
twokeyoutcomes:useofanti-depressantmedicationduringthedisabilityepisode,