1. Economic burden of depression in South KoreaChang, SungHong, Jin-PyoCho, Maeng

Background: A recent national survey in South Korea indicated that the 12-month prevalence rate of major depressive disorder was 2.5%. Depressive disorders may lead to disability, premature death, and severe suffering of patients and their families. This study estimates the economic burden of depression in Korea from a societal perspective. Methods: Annual direct healthcare costs associated with depression were calculated based on the National Health Insurance database. Annual direct non-healthcare costs were estimated for transport. Annual indirect costs were estimated for the following components of productivity loss due to illness such as morbidity (absenteeism and presenteeism) and premature mortality. Indirect costs were estimated using the large national psychiatric epidemiological surveys in Korea. The human capital approach was used to estimate indirect costs. Result: The total cost of depression was estimated to be $4,049 million, of which $152.6 million represents a direct healthcare cost. Total direct non-healthcare costs were estimated to be $15.9 million. Indirect costs were estimated at $3,880.5 million. The morbidity cost was $2,958.9 million and the mortality cost was $921.6 million. The morbidity cost was identified as the largest component of overall cost. Conclusion: Depression is a considerable burden on both society and the individual, especially in terms of incapacity to work. The Korean society should increase the public health effort to prevent and detect depression in order to ensure that appropriate treatment is provided. Such actions will lead to a significant reduction in the total burden resulting from depression.

Social Psychiatry & Psychiatric Epidemiology, May2012, Vol. 47 Issue 5, p683-689, 7p

2. Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance.

Birnbaum, Howard G.Kessler, Ronald C.Kelley, DavidBen-Hamadi, RymJoish, Vijay N.Greenberg, Paul E.

Background: Treatment utilization/costs and work performance for persons with major depressive disorder (MDD) by severity of illness is not well documented. Methods: Using National Comorbidity Survey-Replication (2001–2002) data, US workforce respondents (n=4,465) were classified by clinical severity (not clinically depressed, mild, moderate, severe) using a standard self-rating scale [Quick Inventory of Depressive Symptomatology Self-Report

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(QIDS-SR)]. Outcomes included 12-month prevalence of medical services/medications use/costs and workplace performance. Treatment costs (employer's perspective) were estimated by weighing utilization measures by unit costs obtained for similar services used by MDD patients in claims data. Descriptive analysis across three severity groups generated χ2 results. Results: Using a sample of 539 US workforce respondents with MDD, 13.8% were classified mild, 38.5% moderate, and 47.7% severe cases. Mental health services usage, including antidepressants, increased significantly with severity, with average treatment costs substantially higher for severe than for mild cases both regarding mental health services ($697 vs. $388, χ2=4.4, P=.019) and antidepressants ($256 vs. $88, χ2=9.0, P=.001). Prevalence rates of unemployment/disability increased significantly (χ2=11.7, P=.003) with MDD severity (15.7, 23.3, and 31.3% for mild, moderate, and severe cases). Severely and moderately depressed workers missed more work than nondepressed workers; the monthly salary-equivalent lost performance of $199 (severely depressed) and $188 (moderately depressed) was significantly higher than for nondepressed workers (χ2=10.3, P<.001). Projected to the US workforce, monthly depression-related worker productivity losses had human capital costs of nearly $2 billion. Conclusions: MDD severity is significantly associated with increased treatment usage/costs, treatment adequacy, unemployment, and disability and with reduced work performance. Depression and Anxiety, 2010. © 2009 Wiley-Liss, Inc.

Depression   & Anxiety (1091-4269) , Jan2010, Vol. 27 Issue 1, p78-89, 12p, 6 Charts

3. Presenteeism and absenteeism: Differentiated understanding of related phenomena.

Eric GosselinLouise Lemyre and Wayne Corneil

In the past it was assumed that work attendance equated to performance. It now appears that health-related loss of productivity can be traced equally to workers showing up at work as well as to workers choosing not to. Presenteeism in the workplace, showing up for work while sick, seems now more prevalent than absenteeism. These findings are forcing organizations to reconsider their approaches regarding regular work attendance. Given this, and echoing recommendations in the literature, this study seeks to identify the main behavioral correlates of presenteeism and absenteeism in the workplace. Comparative analysis of the data from a representative sample of executives from the Public Service of Canada enables us to draw a unique picture of presenteeism and absenteeism with regards not only to the impacts of health disorders but also to the demographic, organizational, and individual factors involved. Results provide a better understanding of the similarities and differences between these phenomena, and more specifically, of the differentiated influence of certain variables. These findings provide food for thought and may pave the way to the development of new organizational measures designed to manage absenteeism without creating presenteeism.

Journal of Occupational Health Psychology, Vol 18(1), Jan, 2013. pp. 75-86

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4. The Association of Treatment of Depressive Episodes and Work Productivity

Dewa, Carolyn SThompson, Angus HJacobs, Phillip

Objective: About one-third of the annual $51 billion cost of mental illnesses is related to productivity losses. However, few studies have examined the association of treatment and productivity. The purpose of our research is to examine the association of depression and its treatment and work productivity. Methods: Our analyses used data from 2737 adults aged between 18 and 65 years who participated in a large-scale community survey of employed and recently employed people in Alberta. Using the World Health Organization's Health and Work Performance Questionnaire, a productivity variable was created to capture high productivity (above the 75th percentile). We used regression methods to examine the association of mental disorders and their treatment and productivity, controlling for demographic factors and job characteristics. Results: In the sample, about 8.5% experienced a depressive episode in the past year. The regression results indicated that people who had a severe depressive episode were significantly less likely to be highly productive. Compared with people who had a moderate or severe depressive episode who did not have treatment, those who did have treatment were significantly more likely to be highly productive. However, about one-half of workers with a moderate or severe depressive episode did not receive treatment. Conclusions: Our results corroborate those in the literature that indicate mental disorders are significantly associated with decreased work productivity. In addition, these findings indicate that treatment for these disorders is significantly associated with productivity. Our results also highlight the low proportion of workers with a mental disorder who receive treatment.

Canadian Journal of Psychiatry, Dec2011, Vol. 56 Issue 12, p743-750, 8p, 3 Charts

5. Using the interaction of mental health symptoms and treatment status to estimate lost employee productivity.

Hilton, Michael F.Scuffham, Paul A.Vecchio, NerinaWhiteford, Harvey A.

Objective: In Australia it has been estimated that mental health symptoms result in a loss of $ AU2.7 billion in employee productivity. To date, however, there has been only one study quantifying employee productivity decrements due to mental disorders when treatment-seeking behaviours are considered. The aim of the current paper was to estimate employee work productivity by mental health symptoms while considering different treatment-seeking behaviours. Method: A total of 60 556 full-time employees responded to the World Health Organization Health and Work Performance Questionnaire. This questionnaire is designed to monitor the work productivity of employees for chronic and acute physical and mental health

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conditions. Contained within the questionnaire is the Kessler 6, a scale measuring psychological distress along with an evaluation of employee treatment-seeking behaviours for depression, anxiety and any other emotional problems. A univariate analysis of variance was performed for employee productivity using the interaction between Kessler 6 severity categories and treatment-seeking behaviours. Results: A total of 9.6% of employees have moderate psychological distress and a further 4.5% have high psychological distress. Increasing psychological distress from low to moderate then to high levels is associated with increasing productivity decrements (6.4%, 9.4% and 20.9% decrements, respectively) for employees in current treatment. Combining the prevalence of Kessler 6 categories with treatment-seeking behaviours, mean 2009 salaries and number of Australian employees in 2009, it is estimated that psychological distress produces an $ AU5.9 billion reduction in Australian employee productivity per annum. Conclusions: The estimated loss of $ AU5.9 billion in employee productivity due to mental health problems is substantially higher than previous estimates. This finding is especially pertinent given the global economic crisis, when psychological distress among employees is likely to be increasing. Effective treatment for mental health problems yields substantial increases in employee productivity and would be a sound economic investment for employers.

Australian & New Zealand Journal of Psychiatry, Feb2010, Vol. 44 Issue 2, p151-161

6. The excess cost of depression in South Australia: a population-based study

Hawthorne, GraemeCheok, FridaGoldney, RobertFisher, Laura

Objective: To establish excess costs associated with depression in South Australia, based on the prevalence of depression (from the Primary Care Evaluation of Mental Disorders (PRIME-MD)) and associated excess burden of depression (BoD) costs. Method: Using data from the 1988 South Australian (SA) Health Omnibus Survey, a properly weighted cross-sectional survey of SA adults, we calculated excess costs using two methods. First, we estimated the excess cost based on health service provision and loss of productivity. Second, we estimated it from loss of utility. Results: We found symptoms of major depression in 7% of the SA population, and 11% for other depression. Those with major depression reported worse health status, took more time off work, reported more work performance limitations, made greater use of health services and reported poorer health-related quality-of-life. Using the service provision perspective excess BoD costs were AUD$1921 million per annum. Importantly, this excluded non-health service and other social costs (e.g. family breakdown, legal costs). With the utility approach, using the Assessment of Quality of Life (AQoL) instrument and a very modest life-value (AUD$50 000), the estimate was AUD$2800 million. This reflects a societal perspective of the value of illness, hence there is no particular reason the two different methods should agree as they provide different kinds of information. Both methods suggest estimating the excess BoD from the direct service provision perspective is too restrictive, and that indirect and societal costs ought be taken into account. Conclusions: Despite the high ranking of depression as a major health problem, it is often unrecognized and undertreated. The findings mandate action to explore ways of reducing

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the BoD borne by individuals, those affected by their illness, the health system and society generally. Given the limited information on the cost-effectiveness of different treatments, it would seem important that resources be allocated to evaluating alternative depression treatments. 

Australian & New Zealand Journal of Psychiatry, Jun2003, Vol. 37 Issue 3, p362-373, 12p

7. Severity of depression and magnitude of productivity loss.

Arne Beck, A. Lauren Crain, Leif I. Solberg, Jürgen Unützer, MD, Russell E. Glasgow, Michael V. Maciosek, Robin Whitebird, PhD,

Purpose: Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship between depression symptom severity and productivity loss among patients initiating treatment for depression. Methods: Data were obtained from patients participating in the DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction) initiative, a statewide quality improvement collaborative to provide enhanced depression care. Patients newly started on antidepressants were surveyed with the Patient Health Questionnaire 9-item screen (PHQ-9), a measure of depression symptom severity; the Work Productivity and Activity Impairment (WPAI) questionnaire, a measure of loss in productivity; and items on health status and demographics. Results: We analyzed data from the 771 patients who reported being currently employed. General linear models adjusting for demographics and health status showed a significant linear, monotonic relationship between depression symptom severity and productivity loss: with every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65% (P < .001). Even minor levels of depression symptoms were associated with decrements in work function. Full-time vs part-time employment status and self-reported fair or poor health vs excellent, very good, or good health were also associated with a loss of productivity (P < .001 and P = .045, respectively). Conclusions: This study shows a relationship between the severity of depression symptoms and work function, and suggests that even minor levels of depression are associated with a loss of productivity. Employers may find it beneficial to invest in effective treatments for depressed employees across the continuum of depression severity. 

Annals of Family Medicine, Vol 9(4), Jul-Aug, 2011. pp. 305-311.

8. Unemployment, Job Retention, and Productivity Loss Among Employees With Depression.

Lerner, Derbra. Alder, David. Change, Hong

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Objective: This study comprehensively assessed the work outcomes of employees with depression. Methods: We collected baseline and six-month follow-up survey data from 229 employees with depression and two employee comparison groups: a group of healthy patients for the control group (N=173) and a group with rheumatoid arthritis (N=87), a frequent source of work disability. Outcomes included new unemployment and, within the employed subgroup, job retention (versus job turnover), presenteeism (that is, diminished on-the-job performance and productivity), and absenteeism. Results: At the six-month follow-up, persons with depression had more new unemployment--14 percent for persons in the dysthymia group, 12 percent for persons in the major depression group, and 15 percent for persons in the group with both dysthymia and major depression, compared with 2 percent for persons in the control group and 3 percent for persons in the rheumatoid arthritis group. Among participants who were still employed, those with depression had significantly more job turnover, presenteeism, and absenteeism. Conclusions: In addition to helping employees with depression obtain high-quality depression treatment, new interventions may be needed to help them to overcome the substantial job upheaval that this population experiences.Psychiatric Services, Vol 55(12), Dec, 2004. pp. 1371-1378.

9. Interactions between job stressors and social support: Some counterintuitive results.

Kaufmann, Gary M., Beehr, Terry A.

Job stressors (underutilization of skills, quantitative workload, and job future ambiguity) and social support (tangible and emotional support from supervisor, coworkers, and nonjob sources) were used to predict psychological and physiological strains (job dissatisfaction, boredom, workload dissatisfaction, depression, heart rate, and blood pressure) and organizational consequences (absenteeism and job performance) among 102 hospital nurses (mean age 37.4 yrs). Based on previous theory and research, social support was expected to moderate the relationship between stressors and strains so that stressors would be less strongly related to strains in the presence of strong social support than under conditions of less social support. Several interactions were found, but all were in the direction opposite from predictions (i.e., social support strengthened the positive relationship between stressors and strains). This result contradicts most theories and models of job stress and social support.

Journal of Applied Psychology, Vol 71(3), Aug, 1986. pp. 522-526

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10. Increase in work productivity of depressed individuals with improvement in depressive symptom severity.

Trivedi, Madhukar H.

Objective: The authors sought to identify baseline clinical and sociodemographic characteristics associated with work productivity in depressed outpatients and to assess the effect of treatment on work productivity. Method: Employed depressed outpatients 18–75 years old who completed the Work Productivity and Activity Impairment scale (N = 1,928) were treated with citalopram (20–40 mg/day) in the Sequenced Treatment Alternatives to Relieve Depression study. For patients who did not remit after an initial adequate antidepressant trial (level 1), either a switch to sertraline, sustained-release bupropion, or extended release venlafaxine or an augmentation with sustained-release bupropion or buspirone was provided (level 2). Participants’ clinical and demographic characteristics and treatment outcomes were analyzed for associations with baseline work productivity and change in productivity over time. Results: Education, baseline depression severity, and melancholic, atypical, and recurrent depression subtypes were all independently associated with lower benefit to work productivity domains. During level 1 treatment, work productivity in several domains improved with reductions in depressive symptom severity. However, these findings did not hold true for level 2 outcomes; there was no significant association between treatment response and reduction in work impairment. Results were largely confirmed when multiple imputations were employed to address missing data. During this additional analysis, an association was also observed between greater impairment in work productivity and higher levels of anxious depression. Conclusions: Patients with clinically significant reductions in symptom severity during initial treatment were more likely than non responders to experience significant improvements in work productivity. In contrast, patients who achieved symptom remission in second-step treatment continued to have impairment at work. Patients who have demonstrated some degree of treatment resistance are more prone to persistent impairment in occupational productivity, implying a need for additional, possibly novel, treatments. 

The American Journal of Psychiatry, Vol 170(6), Jun 1, 2013. pp. 633-641.

11. Productivity Losses Among Treated Depressed Patients Relative to Healthy Controls

Suellen Curkendall, PhD, Kimberly M. Ruiz, EdM, Vijay Joish, PhD, and Tami L. Mark, PhD

Objectives: Estimate the productivity-related cost of depression in anemployed population.Methods:By using administrative data, annual shortterm disability (STD) and absenteeism costs ($2005) were compared forpatients with depression and treated with antidepressants and for a matchedcontrol group without depression. Results: Mean annual STD costs were$1038 among treated depressed patients versus $325 among controls and$1685 among a subgroup of severely depressed treated patients versus $340among their controls. After controlling for demographic and employmentcharacteristics, treated patients with depression had STD costs that were

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$356 higher per patient and those with severe depression had costs that were$861 higher. The marginal impact of treated depression on absenteeism was$377. Conclusions: Even when depressed patients are treated with antidepressants, there are substantial productivity losses. Therapies that can better manage depression may provide opportunities for savings to employers.

Journal of Occupational and Environmental Medicine, Vol 52(2), Feb, 2010. pp. 125-130.

12. What does research tell us about depression, job performance, and work productivity?

Lerner, Debra

Objective: To assess the work impact of depression. Methods: A review of research articles published since 2002, reporting on the magnitude and/or nature of depression's impact on work. Results: This research is characterized by the use of three outcome indicators (employment status, absenteeism, and presenteeism metrics) and three research designs (population-based, workplace, and clinical). The literature documents that, compared to non-depressed individuals, those with depression have more unemployment, absences, and at-work performance deficits. Methodological variation makes it difficult to determine the magnitude of these differences. Additionally, the research suggests that the work impact of depression is related to symptom severity and that symptom relief only partly reduces the adverse work outcomes of depression. Conclusions: Research has contributed to knowledge of the multidimensional work impact of depression. Further developing intervention research is an important next step.

Journal of Occupational and Environmental Medicine, Vol 50(4), Apr, 2008. pp. 401-410.

13. The Effect of Improving Primary Care Depression Management on Employee Absenteeism and Productivity: A Randomized Trial.

Rost, Kathryn

Objective: To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years. Setting and Subjects: Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening. Research Design: Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves. Results: Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of $1982 per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over

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2 years at an estimated annual value of $619 per depressed full-time equivalent. Conclusions: This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees. 

Medical Care, Vol 42(12), Dec, 2004. pp. 1202-1210.

14. Health and Productivity as a Business Strategy:A Multiemployer StudyRonald Loeppke, MD, MPHMichael Taitel, PhDVince Haufle, MPHThomas Parry, PhDRonald C. Kessler, PhDKimberly Jinnett, PhD

Objective: To explore methodological refinements in measuringhealth-related lost productivity and to assess the business implications ofa full-cost approach to managing health. Methods: Health-related lostproductivity was measured among 10 employers with a total of 51,648employee respondents using the Health and Work Performance Questionnaire combined with 1,134,281 medical and pharmacy claims.Regression analyses were used to estimate the associations of healthconditions with absenteeism and presenteeism using a range of models.Results: Health-related productivity costs are significantly greater thanmedical and pharmacy costs alone (on average 2.3 to 1). Chronicconditions such as depression/anxiety, obesity, arthritis, and back/neckpain are especially important causes of productivity loss. Comorbiditieshave significant non-additive effects on both absenteeism and presenteeism. Executives/Managers experience as much or more monetizedproductivity loss from depression and back pain as Laborers/Operators.Testimonials are reported from participating companies on how thestudy helped shape their corporate health strategies. Conclusions: Astrong link exists between health and productivity. Integrating productivity data with health data can help employers develop effectiveworkplace health human capital investment strategies. More research isneeded to understand the impacts of comorbidity and to evaluate the costeffectiveness of health and productivity interventions from an employerperspective.

Journal of Occupational and Environmental Medicine, Vol 51(4), Apr, 2009. pp. 411-428.

15. Course of depression, health services costs, and work productivity in an International Primary Care Study

Simon, Gregory E.

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The The Longitudinal Investigation of Depression Outcomes (LIDO) Study examined the outcomes and economic correlates of previously untreated depression among primary care patients in Barcelona, Spain; Be'er Sheva, Israel; Melbourne, Australia; Porto Alegre, Brazil, St. Petersburg, Russia; and Seattle, USA. 968 patients (aged 18-75 yrs) with current depressive disorder completed assessments of depression severity at baseline and 9 mo, and assessments of health services utilization and work days missed at baseline, 9 mo, and 12 mo. Patients with more favorable depression outcomes had fewer days missed from work; this relationship did not reach the 5% level of statistical significance at any site, and reached the 10% significance level only at Porto Alegre. Patients with more favorable depression outcomes also had lower health services costs, but this relationship reached the 5% significance level only in St. Petersburg. While the lack of statistical precision does not permit definitive conclusions, these findings are consistent with recent studies showing that recovery from depressionis associated with lower health services costs and less time missed from work due to illness.

General Hospital Psychiatry, Vol 24(5), Sep-Oct, 2002. pp. 328-335.

16. Which presenteeism measures are more sensitive to depression and anxiety?

Sanderson, Kristy

Background: Lost productivity from attending work when unwell, or "presenteeism", is a largely hidden cost of mental disorders in the workplace. Sensitive measures are needed for clinical and policy applications, however there is no consensus on the optimal self-report measure to use. This paper examines the sensitivity of four alternative measures of presenteeism to depression and anxiety in an Australian employed cohort. Methods: A prospective single-group study in ten call centres examined the association of presenteeism (presenteeism days, inefficiency days, Work Limitations Questionnaire, Stanford Presenteeism Scale) with Patient Health Questionnaire depression and anxiety syndromes. Results: At baseline, all presenteeism measures were sensitive to differences between those with (N=69) and without (N=363) depression/anxiety. Only the Work Limitations Questionnaire consistently showed worse productivity as depression severity increased, and sensitivity to remission and onset of depression/anxiety over the 6-month follow-up (N=231). There was some evidence of individual depressive symptoms having a differential association with different types of job demands. Limitations: The study findings may not generalise to other occupational settings with different job demands. We were unable to compare responders with non-responders at baseline due to anonymity. Conclusions: In this community sample the Work Limitations Questionnaire offered additional sensitivity to depression severity, change over time, and individual symptoms. The comprehensive assessment of work performance offers significant advantages in demonstrating both the individual and economic burden of common mental disorders, and the potential gains from early intervention and treatment. 

Journal of Affective Disorders, Vol 101(1-3), Aug, 2007. pp. 65-74.

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17. Recovery from depression, work productivity, and health care costs among primary care patients.

Simon, Gregory E.

Conducted a secondary analysis of data from a randomized trial conducted at 7 primary care clinics of a Seattle area HMO. 290 adults with major depression beginning antidepressant treatment completed structured interviews at baseline, 1, 3, 6, 9, 12, 18, and 24 mo. Interviews examined clinical outcomes (Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-III-R), employment status, and work days missed due to illness. Medical comorbidity was assessed using computerized pharmacy data, and medical costs were assessed using the HMO's computerized accounting data. Using data from the 12-mo assessment, patients were classified as remitted (41%), improved but not remitted (47%), and persistently depressed (12%). After adjustment fordepression severity and medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain paid employment and reported fewer days missed from work due to illness. Patients with better 12-mo clinical outcomes had marginally lower health care costs during the second year of follow-up. Recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs.

General Hospital Psychiatry, Vol 22(3), May-Jun, 2000. pp. 153-162.

18. Do Antidepressants Reduce the Burden Imposed by Depression on Employers?

Greener, Mark J.

The ability to perform paid or unpaid work is integral to an individual's quality of life. Therefore, we performed a systematic literature review to examine the impact of depression and its treatment on occupational outcomes. This review found absenteeism from work to be markedly higher among depressed employees and productivity to be dramatically undermined by some symptoms of depression. Gaps in the published literature point to the need for future economic and clinical analyses to include work-related outcomes. Published studies showed that antidepressants can enhance work-related outcomes by alleviating affective symptoms. However, the pharmacological properties of antidepressants may produce differential effects that influence work-related outcomes in other ways. For example, TCAs, but not SSRIs, produce sedation and impair cognitive function in ways that could undermine work-related outcomes. Formal analyses are required to quantify whether the improved social functioning, motivation and vigilance that may be associated with some newer antidepressants translate into improved work-related outcomes. Although few published studies have directly quantified the cost benefit of managing depression and associated lost productivity, existing studies that directly assessed work-related outcomes have suggested that treating depression is cost effective. Gaps in the published literature imply that the impact of depression and antidepressants on occupational outcomes has been understudied. This reflects, in part, the fact that antidepressant studies lasting

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4 or 6 weeks are unlikely to capture the impact of treatment on work-related measures. In addition, the current evidence base is fraught with other methodological limitations. The effect of depression on non-paid employment also requires further assessment. In conclusion, the efficacy of antidepressants on work-related outcomes should be measured in clinical trials that have an adequate design and a suitable follow-up period, and included in health technology assessments. Until such studies are available, the evidence base supporting the use of antidepressants will remain incomplete. 

CNS Drugs, Vol 19(3), 2005. pp. 253-264.

19. Depression in the workforce: The intermediary effect of medical comorbidity.

McIntyre, Roger S.

Background: It is amply documented that mood disorders adversely affect job satisfaction, workforceproductivity, and absenteeism/presenteeism. It is also well documented that mood disorders are an independent risk factor for several chronic medical disorders (e.g., obesity, diabetes mellitus, cardiovascular disease). Emerging evidence indicates that the workforce dysfunction associated withdepression is partially mediated by medical comorbidity. Methods: We conducted a PubMed search of all English-language articles published between 2005 and July 2009 with the following search terms: major depressive disorder and depression, cross-referenced with work productivity, disability, economic cost, absenteeism, presenteeism, and medical comorbidity. Articles selected for review were based on adequacy of sample size, the use of standardized experimental procedures, validated assessment measures, and overall manuscript quality. Results: Mood disorders are the most impairing condition amongst working adults. It is estimated that approximately 35-50% of employees withdepression will take short-term disability leave at some point during their job tenure. Moreover, 15-20% of the workforce will receive short-term disability benefits during any given year; the annual income of individuals affected by depression is reduced by approximately 10% when compared to unaffected employees. Chronic stress-sensitive conditions independently contribute to workforce maladjustment and associated disability. The mood disorder population is differentially affected by several stress-related medical conditions resulting in greater impairment in the workforce. Conclusion: Disability modelling in the depressed employee has emphasized the complex interrelationship between depressive symptoms, workforce stress, and consequent disability. A more refined model must include the effects of chronic medical conditions as a powerful mediator and/or moderator of workforce impairment. Multidisciplinary interventions have been demonstrated to reduce, but not eliminate workforce disability related to depression, underscoring the need for elucidating other modifiable factors. Screening, treatment, and prevention initiatives need to target chronic medical conditions in depressed employees in order to reduce overall workforce disability. 

Journal of Affective Disorders, Vol 128(Suppl 1), Jan, 2011. pp. S29-S36.

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20. Cost of Lost Productive Work Time Among US Workers With Depression 

Walter F. Stewart

Context Evidence consistently indicates that depression has adversely affected work productivity. Estimates of the cost impact in lost labor time in the US workforce, however, are scarce and dated.Objective To estimate the impact of depression on labor costs (ie, work absence and reduced performance while at work) in the US workforce.Design, Setting, and Participants All employed individuals who participated in the American Productivity Audit (conducted August 1, 2001–July 31, 2002) between May 20 and July 11, 2002, were eligible for the Depressive Disorders Study. Those who responded affirmatively to 2 depression-screening questions (n = 692), as well as a 1:4 stratified random sample of those responding in the negative (n = 435), were recruited for and completed a supplemental interview using the Primary Care Evaluation of Mental Disorders Mood Module for depression, the Somatic Symptom Inventory, and a medical and treatment history for depression. Excess lost productive time (LPT) costs from depression were derived as the difference in LPT among individuals with depression minus the expected LPT in the absence of depression projected to the US workforce.Main Outcome Measure Estimated LPT and associated labor costs (work absence and reduced performance while at work) due to depression.Results Workers with depression reported significantly more total health-related LPT than those without depression (mean, 5.6 h/wk vs an expected 1.5 h/wk, respectively). Eighty-one percent of the LPT costs are explained by reduced performance while at work. Major depression accounts for 48% of the LPT among those with depression, again with a majority of the cost explained by reduced performance while at work. Self-reported use of antidepressants in the previous 12 months among those with depression was low (<30%) and the mean reported treatment effectiveness was only moderate. Extrapolation of these survey results and self-reported annual incomes to the population of US workers suggests that US workers with depression employed in the previous week cost employers an estimated $44 billion per year in LPT, an excess of $31 billion per year compared with peers without depression. This estimate does not include labor costs associated with short- and long-term disability.Conclusions A majority of the LPT costs that employers face from employee depression is invisible and explained by reduced performance while at work. Use of treatments for depression appears to be relatively low. The combined LPT burden among those with depression and the low level of treatment suggests that there may be cost-effective opportunities for improving depression-related outcomes in the US workforce.

JAMA. 2003;289(23):3135-3144. doi:10.1001/jama.289.23.3135.

21. Effect of Major Depression on Moment-in-Time Work Performance

Philip S. Wang

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OBJECTIVE: Although major depression is thought to have substantial negative effects on work performance, the possibility of recall bias limits self-report studies of these effects. The authors used the experience sampling method to address this problem by collecting comparative data on moment-in-time work performance among service workers who were depressed and those who were not depressed. METHOD: The group studied included 105 airline reservation agents and 181 telephone customer service representatives selected from a larger baseline sample; depressed workers were deliberately oversampled. Respondents were given pagers and experience sampling method diaries for each day of the study. A computerized autodialer paged respondents at random time points. When paged, respondents reported on their work performance in the diary. Moment-in-time work performance was assessed at five random times each day over a 7-day data collection period (35 data points for each respondent). RESULTS: Seven conditions (allergies, arthritis, back pain, headaches, high blood pressure, asthma, and major depression) occurred often enough in this group of respondents to be studied. Major depression was the only condition significantly related to decrements in both of the dimensions of work performance assessed in the diaries: task focus and productivity. These effects were equivalent to approximately 2.3 days absent because of sickness per depressed worker per month of being depressed. CONCLUSIONS: Previous studies based on days missed from work significantly underestimate the adverse economic effects associated with depression. Productivity losses related to depression appear to exceed the costs of effective treatment.

The American Journal of Psychiatry, VOL. 161, No. 10

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