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 In many industrialized countries, the rising administrative and insurance costs of mental disorders in the workplace have prompted burgeoning interest in the interrelations between work and mental health and how best to minimize the impact on the individual and the employer (1,2). Epidemiologic data, especially longitudinal etiologic research, can provide information to inform early intervention and mental health promotion in the workplace. This review covers both the descriptive and social epidemiology of depressive and anxiety disorders in the workforce because evidence from both is essential for a whole-of-community response to the high population burden of mental disorders. Descriptive epidemiology describes the distribution of mental disorders in the population as well as the associated disability. Our review reports on prevalence (the percentage of the working population who meet criteria for a common mental disorder) and participation (the percentage of persons with those disorders who are working). “Work disability” is a general term meaning interference in ability to perform in the work role. Among the employed population, work disability captures both lost productivity arising from being unable to attend work, referred to as absenteeism, and lost productivity arising from attending work while unwell, referred to as “presenteeism.” In epidemiologic research, absenteeism is usually measured via self-report by asking respondents to indicate the number of days they were absent from work for health reasons or the number of days they were unable to perform usual activities (known as loss days). There is good correspondence between self-reported days and administrative records of absenteeism (3). Absenteeism has also been expanded to include missed hours from work (4). Presenteeism is a newer concept, and varying methods have been used to quantify it. Indirect attempts have included creating proxy measures from existing symptom and quality-of-life questionnaires (5) and defining it as simply the absence of sick leave in persons with health conditions (6,7). Measures that assess presenteeism directly are of interest here; their descriptions and psychometric properties are available in 2 recent reviews (8,9). These direct measures include measures analogous to loss days, asking about the number of days in which activities were impaired (cutback days). Cutback days have also been refined to include adjustments for perceived quantity and quality of work (10). Other presenteeism measures assess interference in specific work tasks such as concentration and interacting with colleagues and customers (11,12). Social epidemiology examines the social determinants of health. There is an established link between lower socioeconomic status and mental disorders, which reflects both childhood life experiences and short-term influences in adulthood (13,14). This latter finding indicates that a review of those aspects of the work experience that are associated with common mental disorders can identify specific targets that may be amenable to intervention. Several models have been proposed to explain socioeconomic inequalities in health in the workforce, with the dominant approaches focusing on aspects of the psychosocial work environment (15). To distinguish this article from recent reviews on the social epidemiology of work and mental health (16–20), we focus on new areas of investigation and new evidence for established areas of investigation. Since there are various dimensions on which “good” jobs can be distinguished from “bad” jobs (21), we include factors related both to the nature and to the type of work as indicators of job quality. Two new descriptors of the nature of work are included: underemployment (22), which refers to lack of sufficient work in terms of hours or earnings, and organizational justice (23), which is a dimension of the psychosocial work environment referring to fairness of workplace processes. We also include recent evidence for more established models of the psychosocial work environment and health, namely, the effort–reward imbalance model and the job control–demand model (15). Another new area of investigation is whether atypical employment is a health risk (24). Atypical employment encompasses any form of nonpermanent work, including casual, seasonal, temporary, and fixed-term work. Our review concludes with the implications of the epidemiologic evidence for identifying targets for prevention and early intervention for the working population. MethodScope of the Review This review covered observational studies in large, representative, community-based samples taken either from the general population or from workplaces. In most instances, this excluded specially selected populations such as employed persons receiving treatment and smaller samples. We restricted evidence to the peer-reviewed, published, English-language literature to the end of June 2005. To distinguish from ill-defined psychological distress or stress as an outcome, we first restricted studies to those that used a recent psychiatric diagnostic classification system. We then supplemented gaps in the literature with epidemiologic studies that used standardized screening tools such as the GHQ or the CES-D. Since we aimed to inform areas for intervention, we initially included only social epidemiologic studies that examined a potential causative association (with a minimum of 2 measurement points with control for baseline mental health and other confounders). For longitudinal studies with multiple time points, we excluded findings from earlier waves (for example, 25) in favour of similar findings incorporating the most recent wave. Similarly, we excluded papers from the same data set testing partial aspects of psychosocial models (for example, 26) in favour of those testing the whole model. Studies of job insecurity and related areas (for example, 27,28) were not individually reviewed because this construct is a component of both job control–demand and effort–reward imbalance. A consequence of all these exclusions is that the studies reviewed were generally published in the past decade or so. Search Strategy Search terms and key words included the following, with their variants where relevant (for example, employment, employed): mental disorder, depression, anxiety (as well as the individual disorders such as social phobia and panic disorder), work, employment, labour, occupation, industry, work disability, and related general terms (such as lost productivity) as well as specific terms for absenteeism (such as work loss) and presenteeism (such as work cutback, on-the-job disability), effort–reward imbalance, job control, job demand, organizational justice or equity, employment type, and atypical employment. We located most studies from Medline and Psycinfo, although we also searched Socindex and Econlit. We checked reference lists for omitted studies. We determined data presentation by the numbers of relevant studies located, as discussed in the next section. Studies are presented in chronological order, grouped by general population and workplace samples. ResultsDescriptive Epidemiology: Prevalence and Participation Five national or regional surveys reported the prevalence of mental disorders according to a recent classification system (Table 1) (29–33). Prevalence tended to be slightly higher in the NEMESIS study because of the 12-month time frame (32), whereas it was much lower in the Australian analysis because of restriction to the full-time workforce (31). As in the general population, simple phobia was the most common disorder in the workforce, followed by depression. Variation by occupation was examined in 3 of the studies, with 2 finding minimal significant differences by standard occupational classifications (29,31). Without adjusting for confounders, the NCS reported lower rates of depression among professionals and craftspeople and higher rates among clerical or sales workers and labourers (30). Higher rates of most anxiety disorders were reported for clerical workers, whereas lower rates were reported for professionals, managers, and craftspeople.
Although epidemiologic studies universally report a greater risk of nonparticipation in the workforce for individuals with mental disorders, actual participation rates are rarely reported, so we calculated rates from published data where possible. These participation rates varied somewhat by type of disorder. The highest participation occurred among individuals with depression, simple phobia, social phobia, and GAD. Just over 40% of Australians worked full-time, but this proportion dropped to less than one-third among individuals with current depressive or anxiety disorder and to less than one-fifth among those with dysthymia (31). A second analysis in the Australian survey showed participation rates in any employment of 58.6% among individuals with any affective disorder and 53.1% among those with any anxiety disorder, which were similar to comparable studies (34). The British survey showed that individuals with current neurotic disorder who worked were more likely to work full-time than part-time, which reflected the general population trend (33). Descriptive Epidemiology: Work Disability Of the recent psychiatric population studies previously mentioned, all but the British study used some form of the loss and cutback days measures to assess work disability; Table 2 summarizes these results. The studies varied as to how these questions were posed. Three studies assessed the number of days over the past month during which respondents were completely unable to do usual activities (loss days) as well as the number of days in which activities were reduced (cutback days) (29–31). The Ontario survey included a third component: days in which respondents were able to function normally but only with extreme effort (extra effort days) (29). The NEMESIS survey asked explicitly about days absent from work but did not assess cutback days (32). The prevalence of loss days was very high in the NEMESIS survey, largely because of the 12-month time frame for disability. After adjustment for age and somatic illness, it appeared that depression, dysthymia, and simple phobia were associated with significantly greater risk of any loss days, but in men only. Controlling for sex, age, and educational attainment, a second analysis of baseline mental health and baseline work loss found excess loss days of 28.9 for mood disorders and 17.6 for anxiety disorders (35). No disorder in the NCS was significantly associated with loss days (30), whereas depression was associated with more loss days in Australia (with adjustment for physical comorbidity) (31) but fewer in Ontario (with physical and mental comorbidity excluded) (29). We observed a more consistent pattern for cutback days: all disorders were significantly associated in the NCS; depression and GAD, in Australia; and anxiety alone, in Ontario. The Ontario study reported the strongest association of affective and anxiety disorders with extra effort days (data not shown).
Cutback days are a crude measure of presenteeism, but the evidence did indicate that depression and anxiety disorders were more strongly associated with this form of work disability. We explored this further by reviewing epidemiologic studies that used more sophisticated measures of presenteeism in conjunction with a standardized measure of mental health. We located only 2 studies meeting the inclusion criteria (36,37), so we also included another study that met all the criteria except that it was in a selected population (38,39) (Table 3). Each study used a different measure of presenteeism. The Work and Health Interview (36) and the HPQ (4) capture the total amount of lost productive time owing to absenteeism and presenteeism. Both measures obtain subjective ratings of lost productivity owing to presenteeism, which is then converted into equivalent lost days. Presenteeism days and absenteeism days added provide a summary measure of total lost productive time. The WLQ provides a domain-based assessment of presenteeism. It has 25 items that assess 4 specific areas of work function: mental-interpersonal skills, physical demands, time demands, and output (12).
The findings for depression varied somewhat across the 3 studies. Lerner and colleagues found a significant association with both presenteeism and absenteeism (38,39). Stewart and colleauges found a very strong association with presenteeism and a small association with absenteeism (36). Wang and colleagues (37) found no association with presenteeism but a significant association with absenteeism and total lost productive time. GAD was not significantly associated with either form of work disability. Wang and colleagues adjusted for mental disorder comorbidity, which would be expected to attenuate the relation. Two studies allowed estimation of the relative impact of absenteeism compared with presenteeism, yielding very different results. Stewart and associates found that 86% of total lost time associated with major depression was due to presenteeism (36), whereas Wang and associates found that only 25% was due to presenteeism (37). The domain-based measure in the third study also allowed additional investigation of the nature of the relation between presenteeism and depression symptoms, an area that has received very little investigation (38,39). Depression symptoms related to concentration and tiredness or sleep were each associated with impaired functioning in mental-interpersonal skills, time demands, and output. Social Epidemiology Table 4 presents longitudinal studies that examined the association of selected indicators of nature of work with a standardized mental health outcome measure (23,40–45). Underemployment was defined as involuntary part-time work or working for a wage at or below the poverty level (40,41). Two large general population surveys showed that underemployment was an independent risk factor for worsening mental health, suggesting that a suboptimal job may contribute to depression (the social causation hypothesis) (40,41). Dooley and colleagues also tested whether persons with a history of depression were more likely to move into underemployment (the selection or reverse causality hypothesis) and found no support for this hypothesis (40).
There is also strong evidence that an unfavourable psychosocial work environment is an independent risk factor for depressive and anxiety symptoms. The job-control model posits that jobs with high demands (such as workload, time pressure, and role conflict) and those low in control (with low autonomy and authority) increase stress and, hence, risk for psychiatric ill health (20). High social support (social integration, low isolation) may buffer this effect. In a general population panel study (42) and 3 workplace cohort studies (43–45) involving a total of more than 30 000 participants, jobs with low autonomy (skill discretion) and those with high demands increased the psychiatric risk by 24% to 63%. Two of these studies used middle-aged respondents from specific industries (the civil service and the gas and electricity sector) (43,44). A newer approach to conceptualizing work environment posits that work is a social contract where employees have expectations of benefits arising from work effort (effort–reward) (15). When this contract is not reciprocated, referred to as an effort–reward imbalance, the work environment can act as a stressor. Effort includes responsibility, workload, and time pressures, whereas reward includes money, esteem, and career opportunities (such as promotion and job security). We located one relevant longitudinal study meeting our inclusion criteria (43). A perceived effort–reward imbalance increased psychiatric risk in the civil service cohort, especially among men, where the risk was more than doubled. For men, either effort or low reward was also a significant psychiatric risk. A new dimension of the psychosocial work environment has recently been explored as a predictor of mental health in the workplace. “Organizational justice” refers to fairness of workplace processes and is usually conceptualized as having 2 components: procedural justice, meaning accuracy and inclusion of decision-making processes; and relational justice, meaning polite and considerate treatment by supervisors. We located only 1 longitudinal study that examined the association of organizational justice with a standardized measure of mental health (23,46,47). We present here results from the analysis that used a standardized measure of mental health (2 other analyses in the study used a single item of self-reported doctor-diagnosed clinical depression). Both low procedural and low relational justice were associated with increased risk among women of significant depressive and anxiety symptoms, as measured by the GHQ, but only procedural justice was significantly related for men, more than doubling the risk. The final area of review concerns atypical, compared with permanent, employment. We found 6 studies with standardized measures of mental health (48–53), 3 of which were longitudinal (48,49,51). Given the diversity of atypical work and the small number of studies, we present all the studies in Table 5. Three types of atypical work were examined in the longitudinal studies: seasonal or casual, fixed-term, and subsidized jobs for persons moving off unemployment support. The analysis of 10 years of data from the British Household Panel Survey found a cross-sectional association between GHQ caseness and casual or seasonal work, compared with permanent work, but this was only significant for men in the longitudinal analysis (48). There were not enough respondents to examine the type of work to which a person moved; thus, a move from permanent to casual, or vice versa, was not explicitly tested. Almost all the cross-sectional studies reported significantly worse health among individuals in atypical employment. The exception was for fixed-term employment, where there was no significant association cross-sectionally (50) and significantly lower risk of GHQ caseness among women after controlling for baseline mental health (49). However, there was evidence for a selection effect because individuals with worse mental health were less likely to obtain full-time work in a 2-year follow-up.
DiscussionWe reviewed the recent descriptive and social epidemiology of mental disorders in the workplace, examining prevalence, participation, work disability, and the etiologic influence of selected work factors. The most common mental disorders in the workforce were simple phobia and depression, which are also the most common disorders found in the general population. Large population surveys have established that many individuals with current depressive and anxiety disorders are actively engaged in the workforce, although fewer than one-third were found to be in full-time work. The studies we reviewed did not specifically examine reasons for nonparticipation, but previous research has indicated similar correlates to those in the general population (54–56). In the national and regional psychiatric surveys, depressive and anxiety disorders tended to have a stronger association with cutback days (akin to presenteeism) than with loss days (akin to absenteeism). Two of 3 additional epidemiologic studies replicated this pattern of a stronger association with presenteeism than with absenteeism. We did not review evidence from some other epidemiologic sources because of their reliance on nonstandardized measures of mental health and presenteeism; nonetheless, they also reported an association of presenteeism with various indicators of depression (57–60). The tendency of people with depression to continue to come to work despite their illness represents a hidden cost of depression. There are many reasons why a person may choose to work through their illness, relating to internal factors (such as stoicism) and external factors (such as workplace culture that discourages taking sick leave) (7). In the case of depression, contributing factors could also include a lack of recognition that depression is the cause of ill health or fear of stigma if the reasons for sick leave were to be disclosed. Both these situations could be addressed by mental health literacy interventions that encourage recognition of symptoms and treatment seeking. Numerous cross-sectional studies, and fewer longitudinal studies using nonstandardized measures of mental health, have shown an association of mental disorder with job control–demand as well as with effort–reward imbalance (16–18,20). Our review demonstrated that this association is also present in large, community-based longitudinal studies that used standardized measures of mental health. Organizational justice is a recent addition to the work and health literature. Procedural justice was found to be the important component of organizational justice in the onset of GHQ cases among both sexes, with relational justice being significant for women only. Outcome may depend on the type of mental health measure used. In an earlier analysis from the study that included organizational justice, looking only at female staff, relational justice did not predict new cases of self-reported, doctor-diagnosed clinical depression (47). The small number of studies to date suggest that the impact of organizational justice on mental health is largely independent of job control and demand (23,47). We found some evidence for poorer mental health among atypical workers. The mechanism of this association remains poorly understood, although it has been hypothesized to stem from poorer work conditions and environments in atypical, compared with permanent, jobs (61). Perceived job insecurity may mediate the effect of atypical work with mental health (62). Reducing the Current and Future Burden of Mental Disorders in the Workforce What are the implications of the epidemiologic evidence for identifying targets for prevention and early intervention as a complement to clinically focused interventions? Targets can include specific subpopulations of the workforce that may be at higher risk as well as particular features of the work environment itself. At-Risk Populations. The evidence did not indicate a clear pattern of prevalence varying by occupation. The evidence for type of employment was mostly cross-sectional and thus is still preliminary. Nonetheless, with the exception of fixed-term contract workers, atypical workers were more likely to report depression than were permanent workers. This suggests that atypical workers may be a particular target group for clinically oriented intervention such as case identification and treatment referral, simply because there is some evidence that individuals suffering from depression are more likely to be in this type of employment. Given that atypical workers are likely to work fewer hours than permanent workers and may be less engaged with their workplace, reaching this group will be challenging. Workplace Environmental Targets. Workers exposed to adverse psychosocial work environments have increased risk for developing significant psychiatric symptoms. A handful of attempts based on the control–demand model have been made to modify work environments to improve health; none have been made based on the effort–reward or organizational justice models (17,20). This is not surprising, given that extensive work is still being undertaken on the nature, measurement, and health consequences of these constructs. Interventions aimed at broad modification of the organizational environment have met with mixed success (63). Nonetheless, current knowledge suggests specific targets for intervention. In terms of control and demand, we know that a situation of low control combined with high demand is detrimental to mental health. Interventions can include encouraging employee control over timing of work tasks, redesigning jobs to reduce time pressures, and clarifying expected duties and outcomes. Regarding the effort–reward model, restoring a balance between efforts and rewards may have positive mental health consequences. Possible interventions are additional reward schemes, supervisor training in transmitting praise for good work, clear pathways to promotion, and access to training for career development (17). As for organizational justice, the fairness and transparency of decision-making processes was most consistently related to onset of significant depressive and anxiety symptoms. Interventions can include allowing clarification and additional information, ensuring adequate representation by affected parties, adequately justifying decisions, and communicating to staff the information used to make a decision so that they are informed of its completeness and accuracy. The magnitude of the association of the psychosocial work environment with mental health and the direction of causality suggest a role for adding environmental interventions to workplace-based treatment interventions. If a person’s work environment has been a significant contributor to their poor mental health, receiving treatment and then returning to a toxic work environment may set them up for relapse. Very little is known about how the quality of a job affects the short- and long-term outcome for individuals returning to work after an episode of mental illness. Promoting Productivity. In most instances, improving working environments or targeting at-risk groups in the workforce will require strong support and commitment from employers. Providing employers with economic evidence of the net benefit could encourage this approach. The evidence reviewed here favoured depression and anxiety as having a stronger association with presenteeism than with absenteeism. The tendency of individuals with depression to come to work while unwell supports targeting workplaces with a screen-and-treat approach to reduce the economic cost of mental disorders (4). A clear implication of this finding is that assessing presenteeism will provide a more realistic estimate of the magnitude of lost productivity and the potential benefits of treatment. When linked to the cost of treatment, this approach would allow estimation of whether treatment costs are offset by reduced costs from increased productivity (64). The cost-effectiveness of treatment related to work performance has been demonstrated in primary care (65,66) and in the general population for work-loss days (67). This approach to productivity enhancement will likely benefit from specific strategies targeting the workplace environment, given that an adverse work environment is also associated with lost productivity (68). Labour Economy Targets. Finally, 2 of the work factors reviewed here represent broader economic trends in the labour market: underemployment and atypical employment. Reducing underemployment would require longer-term labour strategies aimed at creating jobs that can offer sufficient working hours. To date, there is insufficient evidence to warrant targeting the reduced use of atypical work contracts on mental health grounds. However, there is certainly sufficient evidence to warrant further investigation into both the possible existence of an etiologic association and the pathways by which this influence may operate. This line of research is further justified by the increasing prominence of atypical employment in most industrialized countries (24). ConclusionMany individuals with current depressive and anxiety disorders actively participate in the workforce, making the workplace an ideal setting for increasing access to appropriate treatment. However, there is high-quality evidence that some aspects of the work environment itself may be detrimental to mental health. Clinical treatment alone may be insufficient to reduce the individual and economic impact of mental disorders in the workplace. Public health approaches to risk reduction should target particular aspects of job quality. Specific strategies may be needed to reach subpopulations of the workforce at increased risk for poorer mental health. Funding and SupportThis paper was supported by a National Health and Medical Research Council Public Health (Australia) Fellowship (ID 290538) to Dr Sanderson. References1. Goetzel RZ, Ozminkowski RJ, Sederer LI, Mark TL. The business case for quality mental health services: why employers should care about the mental health and well-being of their employees. J Occup Environ Med 2002;44:320–30. 2. World Health Organization, International Labour Organization. Mental health and work: impact, issues, and good practices. 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