Too few Americans – Alabamians included – are aware of their rights to take leave for mental health and substance abuse issues, leading to financial losses, a study found.

Alabama employees lost $13.6 billion to mental health and substance abuse challenges over 5 years, according to a national survey by Renaissance Recovery, a group of treatment centers for addiction and mental health.

The group surveyed 3,002 employees about how often they had taken protected medical leave. Many reported they did not feel safe asking for medical leave and instead kept working but took time off, or reduced hours.

“(There is) a gap in awareness,” the group stated in a press release Tuesday. “driving millions of Americans to suffer in silence at work.”

Nationally, 41% of participants said their work had been disrupted by mental health or substance abuse issues. They estimated losing 16% of their income as a result. Alabamians surveyed reported losing, on average, $8,508 per person over five years, the study found. Nationally, workers who struggled with these issues said they lost about $10,968.

The Family Medical Leave Act includes mental health among conditions eligible for up to 12 weeks of unpaid, job-protected leave. Some short-term disability policies or state plans can sometimes help make up wages with FMLA, the group said.

About 30% of respondents in the study said they felt more comfortable taking medical leave for physical injury or medical issues. Only 15% said they thought mental health qualified and only 3% said they thought substance use treatment would qualify.

Workers surveyed said they worried about losing their jobs, harming their careers, or being unable to afford unpaid leave. Others said they downplayed the seriousness of their struggles.

“These misconceptions are especially concerning given how common workplace mental health struggles have become,” the group stated.

Nearly half, 41% of participants, said they had struggled with work challenges from substance abuse or mental health in the previous five years.