At some point in 2002, Lisa Snyder's Prozac stopped working for her. All of a sudden, Ms. Snyder, who had managed her depression effectively since she was a teenager, started having trouble concentrating on the math required to do her job reconciling accounts at a bank.

Shortly thereafter, she started regularly crying at work and pacing the building just to control her nerves. "It got to the point where I just could not function," said Ms. Snyder, now 38. "Just the littlest things would build up and become huge problems."

The next few years brought months of unemployment, two stints on short-term disability, a new job, shock treatments and stimulation treatments for the vagus nerve -- a cranial nerve that deals with sensory and motor functions -- that eventually got her depression back under control.

For the last year, she's been working full time at a natural-gas company in West Virginia, seeing a psychiatrist only once every other month.

	Dan Marsula, Post-Gazette Click photo for larger image.

For Ms. Snyder and her company, it's a success story, but one that illustrates the often messy intersection between mental health illnesses and the workplace, where issues of leave and accommodation for illnesses such as depression are far more complicated than for a broken leg or pneumonia.

A study by Mental Health America found that depression costs U.S. businesses at least $44 billion per year in absenteeism, lost productivity and direct treatment costs.

And under the Family and Medical Leave Act, employees with mental illnesses are more likely to use unscheduled, intermittent leave -- an issue identified in a federal government report last month as the top concern of employers.

"The employer needs to balance between what they need to run their businesses and the impact of those needs on employees," said Eric Smith, an employment lawyer in the Pittsburgh office of Philadelphia-based law firm Schnader Harrison Segal & Lewis. "It's an art rather than a science."

As part of that art, some companies are taking a proactive approach. At PPG Industries, the Downtown-based company has been running an education program to help identify depression in its employees since 2003. In the year after the program kicked off, the number of employees coming to the Employee Assistance Program for depression counseling increased about a third.

At the University of Pittsburgh Medical Center, the Employee Assistance Program does seminars on recognizing and managing depression in the workplace, both internally and at other businesses. Doctors at the EAP also can serve as "ombudsman" between employees and their managers to figure out the proper accommodations to deal with a mental illness.

"We're trying to move away from the idea of just troubled people," said Richard Citrin, vice president of EAP solutions and work life services for the UPMC Health Plan. "Regular situations that happen to regular people manifest themselves in the workplace, just like they do at home or in any environment."

Signs of depression or other mental illness might include absenteeism, tardiness, missed deadlines, sloppy work or social withdrawal, said Dr. Citrin. "You might have an employee [who] used to contribute in meetings and volunteer for extra work, and now [the employee] might say things about being tired, or may be more forgetful in the short term," he said. "It's about recognizing when an employee's performance starts to diminish and seeing it in that framework."

Depression can hit women particularly hard. A study by the National Mental Health Association and American Women's Health Association found that depression affects more than one in five women, with depressed woman reporting that the illness manifested itself at work in the form of crying, avoiding contact with co-workers, hiding in the office or the bathroom and leaving work early or not returning from lunch.

There's an incentive for businesses to try to catch mental illnesses earlier rather than later, because the earlier an employee gets treatment, the better chance of keeping them as a productive employee.

One difference between mental and physical illnesses, said psychiatrist Alan Axelson, is that mental health patients tend to wait longer before getting treatment. Someone who might go to the doctor immediately with a bump on his toe might wait until an anxiety disorder has reached crippling proportions before seeking treatment.

"The particular difficulty for psychiatric patients is that there is a sense of stigma," said Dr. Axelson, who used to direct psychiatric services for Highmark and is now in private practice. "Individuals don't feel comfortable sharing their difficulties and sometimes the problem can get quite severe. It works against the employer and the employee."

Workplaces also have to adjust their expectations to accommodate employees who are transitioning back into work after treatment. "You might want to give a person, upon returning to work, smaller projects that are more manageable," said Dr. Citrin. "People have to perform -- we don't lose sight of that; but it's a lot cheaper to retain a quality employee than to hire a new one."

Ms. Snyder credits part of her successful return to work to her company allowing her to take two days off every other week for adjustments to her vagus nerve stimulation dosage.

She also notes that with the successful treatment of her depression, her physical health has improved as well. In 2006, she went to the doctor 32 times for nonmental health issues such as a sinus headache or stomachache; this year, she's been to doctors only four times, with at least two of the appointments for routine matters.

Generally, the stigma of mental illness has lifted considerably in the past five to 10 years, say psychiatrists, as celebrities ranging from Oprah Winfrey to Patty Duke have opened up about their own experiences.

But in the workplace, the stigma often remains. Because she's taken occasional days off to deal with problems that were mental and not physical, Ms. Snyder believes that she's viewed as being unreliable.

And part of that stigma comes because there are real difficulties for businesses, especially small businesses or small work units, that have to deal with unscheduled absences.

"What ... drives employers completely batty is episodic, intermittent leave," which is what more typically occurs as opposed to prolonged absences by people with mental illnesses, said Mr. Smith, at Schnader Harrison.

Under the Family and Medical Leave Act, most employees are entitled to take up to 12 weeks of such leave on an unpaid basis. If the leave is exhausted, which Mr. Smith says rarely happens when it's taken on an intermittent basis, employers can terminate an employee under the Americans with Disabilities Act only if they can prove that the employee's condition causes the company an "undue hardship."

Even Ms. Snyder agrees that the issue of mental health can get sticky in the workplace.

"When you call in sick, it's not like a cold or a sore throat -- it's not something tangible that you can say, 'I'm sick and I need a day off,' " she said. "I'm not asking to get special treatment, but maybe a little more understanding."