Stephen Sokoler, founder & CEO of Journey.
Many employers think about mental health costs backward. They focus on therapy sessions, psychiatric visits, medications and claims. Those costs are visible, easy to track and show up neatly in reports.
But those costs occur after an employee asks for help. Over the past decade, I have spoken with hundreds of employers about the mental health of their workforces. One pattern has become increasingly clear to me: Leaders can usually tell me exactly what they spend on therapy and mental health claims, but they have a much harder time quantifying the productivity, manager time and turnover costs that accumulate while employees are struggling silently.
I’ve found that the largest mental health costs typically occur beforehand—during the weeks and months when someone is struggling, disengaged, distracted, burned out or considering leaving, yet has not sought support. By the time an employee begins treatment, the organization may have already absorbed months of hidden costs. According to the World Health Organization (WHO), “An estimated 12 billion working days are lost every year to depression and anxiety at a cost of $1 trillion per year in lost productivity.” For many employers, the most expensive phase of a mental health challenge is the gap between suffering and support.
Consider a common example: An employee begins experiencing anxiety during a period of increased workload and stress. They continue showing up to work every day, but concentration slips. Decision-making slows. Collaboration becomes harder. They withdraw from colleagues. Their manager notices something seems off but isn’t sure what to do.
Six months later, the employee finally reaches out for support. The therapy appointment may be the first mental health cost the employer can see, but it is far from the first cost the employer has paid. During those six months, it is likely that performance declined, projects slowed and co-workers absorbed additional work, not to mention that healthcare costs may have risen. The employee may have considered leaving the organization or sought treatment for stress-related physical symptoms—all before a single mental health claim was ever submitted.
The Mental Health Iceberg
In many cases, depression and other mental health challenges present in healthcare settings through physical symptoms, including headaches, sleep problems, gastrointestinal symptoms and general aches and pain, rather than through an explicit mental health complaint. Most of these costs never appear on a mental health utilization report.
This creates a mental health iceberg. Above the waterline are the costs: Employers can see therapy visits, psychiatric care, EAP utilization and mental health claims. Below the waterline are the costs that are harder to measure but can be far more expensive, such as:
• Reduced productivity
• Poor decision-making
• Absenteeism
• Presenteeism
• Turnover
• Manager time
• Team conflict
• Safety incidents
• Burnout
Research has found that presenteeism—the loss of productivity that occurs when employees are physically present but mentally struggling—can account for a substantially larger share of employer mental health costs than absenteeism. An employee who misses three days of work is visible. An employee who is operating at 60% capacity for six months is not. Yet the second scenario is likely far more expensive.
A common reason why organizations miss these costs is that most workplace mental health strategies were designed around treatment. Employees are offered an EAP, therapy benefit or mental health app and encouraged to use it if they need support. The assumption is that people will raise their hand.
Unfortunately, many never do.
Even as conversations about mental health have become more common, stigma remains a significant barrier to care. Others simply do not recognize that what they are experiencing warrants professional support until their situation has worsened. As a result, organizations wait for employees to self-identify. And waiting is expensive.
Imagine applying the same approach to physical health. What if we ignored high blood pressure until someone had a heart attack? What if we waited until diabetes resulted in hospitalization? Most healthcare leaders would view that as a failure of prevention. Yet that is how much of workplace mental health operates today.
This is why I believe the greatest opportunity for leaders is not simply improving access to care—it is reducing the time between when an employee starts struggling and when they receive support.
Asking The Right Questions
In many ways, employers have spent the past two decades optimizing for access. They ask questions like:
• “How many providers are in the network?”
• “How quickly can employees get an appointment?”
• “How many counseling sessions are available?”
These are important questions, but they all assume the employee has already decided to seek help. If I had to recommend one specific healthcare metric leaders should focus on, it might be this: How long does your average employee struggle before receiving meaningful help?
I’ve found that this shift in mindset can change the conversation entirely. Instead of asking your leadership team, “How quickly can we get someone into therapy once they ask for help?” begin by asking, “How can we identify and engage people earlier?” The answer may include manager training, better data, proactive outreach, peer support, improved benefits design, workplace culture initiatives or new technologies that help identify risk before it becomes crisis.
The specific approach matters less than the underlying principle: Earlier intervention is almost always less costly than delayed intervention.
Conclusion
Employees often struggle for months before seeking support, and organizations absorb the cost of that delay every day. I believe we as business leaders should work together to ensure the next generation of workplace mental health is defined by identifying struggling employees early and engaging them before problems escalate, not just offering bigger provider networks or faster therapy appointments.
Because the largest mental health costs rarely occur during treatment—they occur before treatment ever begins.
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