Beskæftigelsesudvalget 2019-20
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Workplace
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
http://oem.bmj.com/
on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Original article
Impact of depressive symptoms on worklife
expectancy: a longitudinal study on
Danish employees
Jacob Pedersen ,
1
Sannie Vester thorsen,
1
Malene Friis andersen,
1
therese n Hanvold,
2
Vivi Schlünssen,
3
Ute Bültmann
4
►
additional material is
published online only. to view
please visit the journal online
(http://dx.doi.org/10.1136/
oemed-2019-105961).
1
the national research center
for the Working environment,
copenhagen, Denmark
2
StaMi - the national institute
of Occupational Health, Oslo,
norway
3
Department of Occupational
Medicine, Danish ramazzini
centre, aarhus University
Hospital, aarhus, Denmark
4
Health Sciences, community
and Occupational Medicine,
University of groningen,
University Medical center
groningen, groningen, the
netherlands
Correspondence to
Dr Jacob Pedersen, nationale
Forskningscenter for
arbejdsmiljo, copenhagen
2100, Denmark; [email protected]
received 16 May 2019
revised 30 august 2019
accepted 7 September 2019
ABSTRACT
Objective
Depressive symptoms are associated with
sickness absence, work disability and unemployment,
but little is known about worklife expectancy (Wle). this
study investigates the impact of depressive symptoms on
the Wle of a large sample of Danish employees.
Methods
We used occupational health survey data of
11 967 Danish employees from 2010 and linked them
with register data on salary and transfer payments
from 2010 to 2015. Depressive symptoms were self-
reported using the Major Depression inventory. We
used multistate data and a life table approach with cox
proportional hazard modelling to estimate the Wle of
employees, expressed by time in work, unemployment
and sickness absence. Separate analyses were conducted
for sex and employees with a voluntary early retirement
pension scheme. Using age as time axis, we used
inverse probability weights to account for differences
in educational level, sector, body mass index, smoking
habits and loss of employment during sickness absence.
Results
the Wle of employees reporting depressive
symptoms was shorter compared with those not
reporting depressive symptoms; that is, the expected time
in unemployment and sickness absence was longer, while
the expected time in work was shorter. the shorter Wle
was most pronounced in women; for example, a 40-year-
old woman with depressive symptoms can expect 3.3
years less in work, 0.8 years more in unemployment and
0.7 years more in sickness absence. employees with a
voluntary early retirement pension scheme showed an
even lower Wle.
Conclusions
Our study showed a meaningful impact of
depressive symptoms on the Wle of Danish employees
using a multistate framework.
Key messages
What is already known about this subject?
►
Depressive symptoms have a negative impact
on social and work functioning, productivity,
and labour market affiliation.
►
Worklife expectancy is a useful measure to
inform preventive policies and practices.
What are the new findings?
►
Our study, applying a multistate framework
with a life course perspective, showed that
depressive symptoms have a significant impact
on worklife expectancy.
►
Employees reporting depressive symptoms
spend less time in work and more time in
sickness absence and unemployment compared
with employees not reporting depressive
symptoms.
►
The worklife expectancy of employees with an
early retirement pension scheme and depressive
symptoms is shorter compared with those
without this pension scheme.
How might this impact on policy or clinical
practice in the foreseeable future?
►
Our findings underline the need for effective
policies and interventions to prevent depressive
symptoms in the working population to add
more healthy and productive years to the
working life.
INTRODUCTION
© author(s) (or their
employer(s)) 2019. re-use
permitted under cc BY-nc. no
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite:
Pedersen J,
thorsen SV,
andersen MF,
et al.
Occup Environ Med
epub
ahead of print: [please include
Day Month Year]. doi:10.1136/
oemed-2019-105961
Mental disorders are the leading cause of disease
burden worldwide
1
and affect individuals, families,
workplaces and society. Recently, the European
Working Conditions Survey showed that up to
17% of the general working population reported
scores indicative of depression.
2
Work and health
surveillance data in Denmark showed that more
and more employees report depressive symptoms,
from 8.5% in 2012 to 9.0% in 2014, 10.9% in
2016, and 11.0% in 2018, respectively.
3
Depressive
symptoms are associated with unemployment and
with substantial work impairment in terms of lost
workdays and reduced productivity.
4–10
With an onset early in life, mental health prob-
lems are associated with a disproportionally
high burden of disease among young people and
may have devastating effects on the whole life
course.
11 12
Therefore, means to promote mental
health and well-being of people of all ages are
becoming increasingly important to maintain a high
labour market participation.
13 14
Despite the negative impact of depressive
symptoms on labour market affiliation and work
participation, it is today not clear to what extent
depressive symptoms impact the worklife expec-
tancy (WLE), a measure crucial to set priorities for
preventive policies and practices. WLE is an estima-
tion of the expected time within the labour market
until retirement. Since the 1970s, WLE has gained
1
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
 BEU, Alm.del - 2019-20 - Bilag 90: Orientering om NFA artikel om betydningen af depressive symptomer for arbejdslivslængden, fra beskæftigelsesministeren
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Workplace
data on labour market affiliation in 2010–2015 from the Labour
Market Accountant Register (LMAR) by Statistics Denmark.
The DWECS started in 1990 and had repeated waves every
fifth year until 2010. Each wave contains a representative sample
of the Danish population aged 18–59 years.
25
For the present
study, we used DWECS data from 2010, including a total of
14 453 respondents (48% response).
26
Of the respondents,
11 967 (83%) answered the questions on depressive symptoms.
LMAR contains information on all Danish citizens with a
labour market affiliation from 2008 onwards. LMAR contains
daily salary payments and daily payments of all major social
benefits on an individual level. The Personal Income Register
was used to identify respondents who had joined the volun-
tary ERP scheme (n=4205 respondents, 35%). Information on
mortality was retrieved from the Danish Death Register.
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
http://oem.bmj.com/
on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Figure 1
the multistate model with the seven states: work, sickness
absence, unemployment, disability retirement pension (disability), early
retirement pension scheme, temporary exclusion from the labour market
(temporary out) and permanent exclusion from the labour market
(permanent out). the eight transitions of primary interest are represented
by non-interrupted arrows (Pedersen and Bjorner
20
).
Depressive symptoms
Depressive symptoms in 2010 were measured once with the
12-item Major Depression Inventory (MDI), with scores
ranging between 0 and 50.
27 28
The MDI has been validated in
both the general population and among patients in the clinical
setting.
27 29 30
In the present study, an MDI score of ≥21 was
used to identify employees with a depressive symptom level,
indicative of mild depression.
31 32
increasing attention as models based on multistate models and
transition probabilities have been developed.
15–22
In the present study on the impact of depressive symptoms
on WLE, the concept of WLE was expanded to capture next
to the labour market state, ‘work’ and also ‘unemployment’
and ‘sickness absence’ before retirement, as recently proposed
by Pedersen and Bjorner.
20
The expansion of the WLE concept
corresponds with the flexible Danish labour market and allows
more detailed analyses of transitions between labour market
states among employees with depressive symptoms. Hence, the
aims of this study were to investigate the impact of depressive
symptoms on the WLE of occupationally active male and female
employees. As the Danish system offers a voluntary and very
common early retirement pension (ERP) scheme, which may
affect the WLE of employees with depressive symptoms, sepa-
rate analyses were conducted for employees with the voluntary
ERP scheme.
Labour market affiliation
Labour market affiliation was measured by seven labour market
states based on the longitudinal registrations of the LMAR
register: work, unemployment, sickness absence, disability
retirement pension, ERP temporary out of the labour market
,
and permanently out of the labour market. The
work
state
reflects the periods when a person receives salary payments and
no other major social benefit. The
unemployment
state concerns
the periods when a person receives any type of social benefit for
unemployment, given the condition that the person is available
for work. The
sickness absence
state reflects the periods when
a person is long-term sick-listed and receives sickness absence
benefits (defined as >21 consecutive days before 2012 and
>30 days after 2012). The
disability retirement pension
state
concerns the time after a person had been awarded disability
pension because he/she is not able to work, for example, due to
a chronic illness. The
ERP
state is at hand when an ERP scheme
member voluntarily retires. The
temporary out of the labour
market
state concerns periods of maternity leave, education and
emigration, and also periods without registration of any income.
The
permanently out of the labour
market state concerns the
time when a person receives any type of old-age pension (except
for ERP) and death.
METHODS
Jurisdictional context: the Danish labour market
The Danish labour market is characterised by a flexicurity system
with high labour market participation rates (71% for women and
75% for men),
23
low formal employment protection, generous
and accessible social benefits, and a high turnover of the work-
force.
24
The official retirement age in Denmark is currently 65
years, but the system also allows earlier retirement. Possibili-
ties of early retirement concern ‘disability retirement pension’,
which is accessible for all, gradual retirement with labour market
affiliation on special terms (eg, flex-job), and voluntary ‘early
retirement pension’. The voluntary ERP scheme is an insurance
and saving scheme. Employees pay a part of their salary for 30
years to be able to retire as early as 5 years before the official
retirement age.
Covariates
Baseline information on educational level (basic school, high
school, vocational school, short and medium higher educa-
tion, bachelor’s and long higher education) and sector (manu-
facturing, construction, graphical, transport and wholesale,
commerce, service, agriculture, caretaking and health, education
and research, finance and public offices and administration, and
private offices and administration) was obtained from Statistics
Denmark in 2010. Additional baseline information on body mass
index (BMI) (underweight: BMI <18.5; normal: BMI between
18.5 and 24.9; overweight: BMI between 25.0 and 29.9; and
obesity: BMI >29.9) and smoking (smoker, non-smoker) was
derived from DWECS 2010. In addition, information from
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
Study design
This longitudinal study uses data on depressive symptoms from
the Danish Work Environment Cohort Study (DWECS).
25
DWECS data on depressive symptoms are linked with register
2
 BEU, Alm.del - 2019-20 - Bilag 90: Orientering om NFA artikel om betydningen af depressive symptomer for arbejdslivslængden, fra beskæftigelsesministeren
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Workplace
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
http://oem.bmj.com/
on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Figure 2
Worklife expectancy in years for employees without erP scheme, by depressive symptom level (MDi ≥21), sex and age. erP, early retirement
pension; MDi, Major Depression inventory.
LMAR was used for a repeated adjustment of the employment
status during periods of sickness absence only.
among employees with the ERP scheme (n=4205) (see online
supplementary material figure and tables).
All analyses included stabilised inverse probability weights for
an even distribution of the covariates. The weights were esti-
mated for each data record using the dichotomous depressive
symptom level as the dependent variable in a logistic regres-
sion. For each one-hundredth of age, we estimated a matrix,
containing the instantaneous hazard of all 18 transitions and the
7 instantaneous state occupation probabilities. This was done for
each group of ERP sex and for those with an MDI score below
,
21. We used the Chapman-Kolmogorov equation and the instan-
taneous hazard matrixes to gain the transitions specific baseline
hazards and the state occupation probabilities. We estimated the
expected state duration as the area under the state occupation
probability curves until 65 years of age, with different initial ages
of 40–60 years by 5-year intervals. The analysis so far corre-
sponds to using a multistate life table approach.
We used a Cox regression on the long format multistate data
with the dichotomous depressive symptom level as the only vari-
able and a reference value of below 21 on the MDI. We included
the stabilised weighting and performed a separate Cox regression
by ERP status and sex. We then used the estimates from the Cox
regression to adjust the respective instantaneous hazard matrixes
of the individuals with an MDI score below 21. After this, we
repeated the rest of the above-specified procedure to gain the
expected state duration of individuals with an MDI score equal
to or above 21. The 95% confidence limits were calculated using
the Greenwood variance. In the Cox regression, the transitions
towards the absorbing states were collapsed into one transition
to secure a high number of events.
3
Statistical analyses
Multistate modelling was used to analyse the transition prob-
abilities for the labour market affiliation model using age as
the underlying time axis, going from 18 to 65 years in steps of
hundredths. The work, unemployment, sickness absence and
temporary out of the labour market states were considered
recur-
rent states,
that is, several and repeated transitions from or to
these states are possible. The disability retirement pension state,
the ERP state and the permanently out of the labour market state
were all considered
absorbing states,
as it is not possible to go
back to the recurrent states when a transition to one of these
states has occurred. A person enters the model by left truncation
at the age of answering the DWECS survey and exits the model
by right censoring, which happens when the follow-up period
ends or the person turns 65 years.
Figure 1
shows the multistate model with boxes illustrating
the labour market states and arrows showing the possible tran-
sitions. The temporary out of the labour market state and the
permanently out of the labour market state are included to
ensure independent censuring, as the probability of, for example,
leave due to education, receiving old-age pension and even death
may not be independent of the level of depressive symptoms.
Therefore, these transitions cannot be considered as censuring.
To investigate the WLE by depressive symptom level, we
followed the procedure introduced by Pedersen and Bjorner.
20
The initial analyses included only employees without the ERP
scheme (n=7762). Additionally, the analyses were repeated
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
 BEU, Alm.del - 2019-20 - Bilag 90: Orientering om NFA artikel om betydningen af depressive symptomer for arbejdslivslængden, fra beskæftigelsesministeren
2126558_0004.png
Workplace
Table 1
Characteristics of employees without the ERP scheme
(n=7762)
Women
n (%)
Total (n)
Age group (years)
18–29
30–39
40–49
50–59
60–64
Highest educational level
Basic school
High school
Vocational school
Short and medium higher education
Bachelor’s and long higher education
Not available
Sector
Manufacturing
Constructions
Graphic
Transport and wholesale
Trade
Service trade
Agriculture
Social security and health
Education and research
Finance, public offices and administration
Private offices and administration
Not available
BMI
Obesity (BMI >29.9)
Overweight (BMI between 25.0 and 29.9)
Normal (BMI between 18.5 and 24.9)
Underweight (BMI <18.5)
Not available
Smoking
Smoker
Non-smoker
Not available
Depression by MDI score
Depression (MDI ≥21)
No depression (MDI <21)
913 (22.5)
3138 (77.5)
600 (16.2)
3111 (83.8)
915 (22.6)
3083 (76.1)
53 (1.3)
961 (25.9)
2706 (72.9)
44 (1.2)
477 (11.8)
947 (23.4)
2413 (59.6)
131 (3.2)
83 (2)
464 (12.5)
1457 (39.3)
1711 (46.1)
28 (0.8)
51 (1.4)
236 (5.8)
19 (0.5)
21 (0.5)
170 (4.2)
161 (4)
140 (3.5)
10 (0.2)
972 (24)
280 (6.9)
291 (7.2)
187 (4.6)
1564 (38.6)
460 (12.4)
170 (4.6)
30 (0.8)
335 (9)
77 (2.1)
209 (5.6)
40 (1.1)
205 (5.5)
211 (5.7)
215 (5.8)
194 (5.2)
1565 (42.2)
577 (14.2)
561 (13.8)
1144 (28.2)
1056 (26.1)
636 (15.7)
77 (1.9)
625 (16.8)
384 (10.3)
1296 (34.9)
694 (18.7)
647 (17.4)
65 (1.8)
1072 (26.5)
1184 (29.2)
1251 (30.9)
472 (11.7)
72 (1.8)
843 (22.7)
972 (26.2)
1198 (32.3)
614 (16.5)
84 (2.3)
4051
Men
n (%)
3711
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
http://oem.bmj.com/
on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
All analyses were conducted with SAS V
.9.4 software using
PROC PHREG and custom-made coding.
RESULTS
Baseline characteristics
Table 1
shows the baseline characteristics of 7762 employees
without the ERP scheme. The average age of the study popu-
lation is 39 (SD 11) years, with slightly more women than men
(52% vs 48%). The majority of employees finished vocational
education. Most women worked in the social security and health
sector, while most men worked in manufacturing. Women more
often reported depressive symptoms than men (23% vs 16%).
Online supplementary table 1 shows the baseline characteris-
tics of 4205 employees with the ERP scheme. The average age of
these employees is 52 (SD 8) years, and 57% were men. Again,
the majority of employees finished vocational education and are
employed in social security and health (39% women) or manu-
facturing (17% men). Women more often reported depressive
symptoms than men (17% vs 11%).
Depressive symptoms and WLE
Figure 2
shows the sex-specific WLE for the 7762 employees
without the ERP scheme, expressed as time in work, unemploy-
ment and sickness absence (in years). The WLE is shown by
depressive symptom level for age 40–60 years.
Table 2
shows the
corresponding WLE estimates.
The WLE results in
table 2
show that, for example, a
40-year-old man without depressive symptoms has a total WLE
of 21.6 years, of which 19.9 years were in work, 1.3 years in
unemployment and 0.7 year in sickness absence. For a woman
of the same age with depressive symptoms, the WLE is 2.3 years
shorter in work (12%), while the time in unemployment and
sickness absence is 0.9 years (69%) and 0.6 year (53%) longer,
respectively. Overall, the WLE is on average 5% shorter for
women and 1% shorter for men reporting depressive symptoms.
When looking at the separate labour market states, women and
men with depressive symptoms showed an average shorter time
in
work
of 16% and 13%, respectively. The expected time in
unemployment
was 60% longer for women and 66% longer for
men with depressive symptoms, and the expected time in
sick-
ness absence
was 58% longer for women and 72% longer for
men, respectively. The shorter expected time in
work
is signifi-
cant, when comparing the confidence limits of women with and
without depressive symptoms for the age of 40 years. For other
ages and sex, the confidence limits in
table 2
show no significant
differences in the expected time in
work, unemployment
and
sickness absence.
Overall, the results show a stable tendency of
shorter time in work, longer time in unemployment and longer
time in sickness absence for all analysed age groups.
Online supplementary figure 1 shows the results for employees
with the ERP scheme. The results in online supplementary table
2 show that, for example, a 40-year-old woman with depressive
symptoms can expect 4.7 years less in work than a 40-year-old
woman without depressive symptoms, and 0.2 more years of
unemployment and 0.4 more years of sickness absence. Simi-
larly, a 40-year-old man can expect 5 years less in work, 0.2
years more in unemployment and 0.4 more in sickness absence.
The average decrease in time in work is 21% for both women
and men. The average increased time in unemployment is
23% for women and 18% for men, and the average increased
time in sickness absence is 59% for women and 79% for men,
respectively. The decrease in expected time in
work
is statisti-
cally significant, when comparing the CI for employees with
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
BMI, body mass index; ERP, early retirement pension; MDI, Major Depression Inventory.
The final estimates express the average expected time in work,
unemployment and sickness absence. The time sum will always be
lower than the absolute difference between the selected age and
the official old-age pension age because of different (working)
life courses, including, for example, periods of temporary
labour market leave for education, receiving disability pension
and early deaths. As the WLE of employees aged 18–39 years
is more uncertain compared with older employees, reflecting a
looser labour market affiliation with several periods of mater-
nity leave and education, we only show the WLE of employees
older than 40 years (figure
2
and online supplementary figure 1),
although all ages were included in the matrix estimations and the
Cox regression analyses. The use of inverse probability weights
implies that for a comparison of the WLE between groups, an
identical distribution of the listed covariates is assumed.
4
 BEU, Alm.del - 2019-20 - Bilag 90: Orientering om NFA artikel om betydningen af depressive symptomer for arbejdslivslængden, fra beskæftigelsesministeren
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Workplace
Table 2
WLE in years of employees without the ERP scheme, by depressive symptom level (MDI ≥21), sex and age
Sex
Female
Age
40
45
50
55
60
Male
40
45
50
55
60
MDI score
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
Work (95% CL)
17.9 (16.5–19.2)
14.6 (13.1–16.1)
14.3 (13.1–15.5)
11.8 (10.5–13.1)
10.5 (9.5–11.5)
8.7 (7.5–9.8)
6.7 (5.9–7.5)
5.6 (4.7–6.5)
3.3 (2.7–3.8)
2.9 (2.3–3.5)
19.6 (18.5–20.7)
17.3 (15.9–18.7)
15.6 (14.6–16.5)
13.6 (12.4–14.8)
11.5 (10.6–12.3)
9.9 (8.9–11.0)
7.6 (6.9–8.2)
6.6 (5.8–7.4)
3.8 (3.3–4.2)
3.3 (2.8–3.9)
−13.2
−13.2
−13.9
−12.8
−11.7
−12.1
−16.4
−17.1
−17.5
Diff (%)
−18.4
Unemployment (95% CL)
1.3 (0.5–2.1)
2.1 (0.9–3.2)
1.1 (0.4–1.8)
1.7 (0.7–2.8)
0.9 (0.3–1.6)
1.4 (0.5–2.3)
0.8 (0.2–1.4)
1.3 (0.4–2.1)
0.6 (0.1–1.1)
1.0 (0.3–1.8)
1.3 (0.5–2.0)
2.2 (1.1–3.4)
1.3 (0.5–2.1)
2.2 (1.1–3.3)
1.1 (0.4–1.7)
1.8 (0.9–2.7)
0.8 (0.2–1.3)
1.3 (0.6–2.1)
0.6 (0.2–1.0)
1.0 (0.4–1.6)
66.7
62.5
63.6
69.2
69.2
66.7
62.5
55.6
54.5
Diff (%)
61.5
Sick (95% CL)
1.0 (0.3–1.8)
1.7 (0.7–2.8)
0.9 (0.2–1.5)
1.4 (0.5–2.3)
0.8 (0.2–1.4)
1.2 (0.4–2.1)
0.6 (0.1–1.1)
0.9 (0.2–1.6)
0.3 (-0.1–0.8)
0.5 (-0.1–1.2)
0.7 (0.1–1.3)
1.3 (0.4–2.3)
0.7 (0.1–1.3)
1.2 (0.3–2.2)
0.7 (0.1–1.3)
1.2 (0.3–2.1)
0.7 (0.2–1.2)
1.1 (0.4–1.9)
0.4 (0.0–0.8)
0.7 (0.1–1.2)
75.0
57.1
71.4
71.4
85.7
66.7
50.0
50.0
55.6
Diff (%)
70.0
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
http://oem.bmj.com/
on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
CL, confidence limits; Diff, per cent difference in WLE between MDI scores by sex and age; ERP, early retirement pension; MDI, Major Depression Inventory; WLE, worklife
expectancy.
and without depressive symptoms, for all age groups and sexes.
For the expected time in
unemployment
and
sickness absence,
no significant differences were found for employees with and
without depressive symptoms or for male and female employees.
Table 3
shows the results of the respective Cox regression on
the long formatted multistate data. The results show that women
with depressive symptoms have a significantly higher risk of
having a transition from work to sickness absence and unem-
ployment, and more than a threefold risk of a transition from
work/unemployment/sick to disability, when compared with a
woman without depressive symptoms. Women additionally have
a significantly lower probability of a transition from sickness
absence to work (32%) and from unemployment to work (25%).
The results show that men with depressive symptoms also have
a significantly higher risk of a transition from work to sick
(70%) and unemployment (50%), and more than a fivefold risk
of a transition to disability pension, when compared with men
without depressive symptoms. The results additionally show that
men have less probability of transitioning from unemployment
to work (29%).
The results in online supplementary table 3 for women and
men with the ERP scheme were similar to those for employees
without the ERP scheme (table
3).
Online supplementary table
3 shows that women and men with depressive symptoms have
almost a twofold probability of early retirement by the ERP
scheme when compared with women and men without depres-
sive symptoms.
DISCUSSION
The present study is, to the best of our knowledge, the first to
examine the impact of depressive symptoms on WLE. Most
previous studies have investigated the impact of depressive
symptoms on sickness absence and unemployment separately,
without a multistate framework or a life course perspective.
Our study showed that depressive symptoms may have a life-
long impact on labour market affiliation. A 40-year-old man
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
reporting depressive symptoms without ERP will spend approx-
imately 2 years less in work before retirement compared with a
man not reporting depressive symptoms. In women, the corre-
sponding difference in time less in work is 3 years. In addition to
lost time in work, our study showed that a 40-year-old employee
reporting depressive symptoms will on average receive 1.5 more
years of unemployment and sickness absence benefits compared
with an employee not reporting depressive symptoms.
The study also provided suggestive evidence that employees
in the Danish ERP scheme and reporting depressive symptoms
will retire even earlier; that is, a 40-year-old man or woman will
spend 5 years less in work compared with employees without
ERP The receipt of unemployment and sickness absence benefits
.
is 0.6 years in those with ERP compared with 1.5 years in those
,
without ERP indicating that employees may use the ERP scheme
,
to avoid unemployment and long-term sickness absence benefits.
While our findings are in concordance with previous studies
on mental health problems and associated sickness absence and
unemployment,
33–36
we demonstrated for the first time how
many years of active labour market participation are lost when
reporting depressive symptoms. Likewise, we also showed for the
first time how many years of the worklife employees reporting
depressive symptoms are expected to be in unemployment and/
or sickness absence.
Our study further showed that employees reporting depres-
sive symptoms have less time in work, and more time in unem-
ployment and sickness absence, for both men and women. The
labour market affiliation of men and women is different in most
countries; for example, men retire at an older age than women,
and women have more sickness absence than men.
37
Our study
indicates that depressive symptoms partly may explain the sex
difference in labour market affiliation, as women more often
report depressive symptoms than men. The findings addition-
ally suggest a slight difference between younger men and women
reporting depressive symptoms, with even less time in work for
the women than the men.
5
 BEU, Alm.del - 2019-20 - Bilag 90: Orientering om NFA artikel om betydningen af depressive symptomer for arbejdslivslængden, fra beskæftigelsesministeren
2126558_0006.png
Workplace
Table 3
Estimates of the Cox proportional hazard model for
employees without the ERP scheme
Transition
Work to sick
Work to unemployment
Work to TO
Work/sick/unemployment/TO
to disability
Work/sick/unemployment/
TO to PO
Sick to work
Sick to unemployment
Sick to TO
Unemployment to work
Unemployment to sick
Unemployment to TO
TO to work
TO to sick
TO to unemployment
MDI
score
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
<21
≥21
Women
HR (95% CL)
1.59 (1.04–2.45)*
1.00 (–)
1.36 (1.05–1.77)*
1.00 (–)
1.15 (1.01–1.30)*
1.00 (–)
3.65 (2.26–5.88)*
1.00 (–)
0.90 (0.49–1.66)
1.00 (–)
0.68 (0.49–0.93)*
1.00 (–)
1.20 (0.88–1.64)
1.00 (–)
1.33 (0.98–1.81)
1.00 (–)
0.75 (0.60–0.92)*
1.00 (–)
1.12 (0.82–1.53)
1.00 (–)
0.70 (0.59–0.83)*
1.00 (–)
1.00 (0.87–1.15)
1.00 (–)
2.23 (1.45–3.41)*
1.00 (–)
1.31 (1.07–1.60)*
1.00 (–)
Men
HR (95% CL)
1.70 (1.10–2.65)*
1.00 (–)
1.50 (1.10–2.03)*
1.00 (–)
1.15 (0.97–1.36)
1.00 (–)
5.28 (2.92–9.54)*
1.00 (–)
0.82 (0.36–1.88)
1.00 (–)
0.71 (0.49–1.01)
1.00 (–)
1.03 (0.61–1.74)
1.00 (–)
0.72 (0.46–1.14)
1.00 (–)
0.71 (0.54–0.95)*
1.00 (–)
0.97 (0.59–1.61)
1.00 (–)
0.58 (0.47–0.71)*
1.00 (–)
1.09 (0.88–1.34)
1.00 (–)
0.98 (0.56–1.72)
1.00 (–)
1.17 (0.88–1.55)
1.00 (–)
Occup Environ Med: first published as 10.1136/oemed-2019-105961 on 3 October 2019. Downloaded from
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on October 4, 2019 at National Institute of Occupational
Health - DNLA. Protected by copyright.
Additionally, the prognostic nature is based on the theoret-
ical assumption that by cumulating the behaviour of certain
employees with the same profile and of different ages, one can
create a profile-specific behavioural pattern that represents all
ages.
Several covariates, for example, smoking and BMI, may act
as confounders and/or mediators of depressive symptoms and
may have influenced the results. Assuming that, for example, a
high BMI leads to depressive symptoms, then a part of the WLE
effect caused by depressive symptoms may be removed by using
a weighted sample also based on BMI.
Our findings on the significant impact of depressive symptoms on
WLE are relevant for both public and occupational health profes-
sionals and policymakers as the level of depressive symptoms in the
general working population in Europe is high and increasing.
2
The
time lost in productive work and the increased time in unemploy-
ment and sickness absence for employees with depressive symp-
toms underline the need for integrating a life course perspective
to work and health research and practice.
38
A recent systematic
review and meta-analysis identified three randomised controlled
trials examining the effectiveness of psychological and educational
interventions for the prevention of depression at the workplace
with moderate effect, but low quality of evidence.
39
CONCLUSION
The findings showed that the WLE was shorter for women and
for men reporting depressive symptoms. The time in work was
shorter, while the time in unemployment and sickness absence
was longer. Moreover, employees with an ERP scheme spend
less time in unemployment and sickness absence. The findings
underline the need for effective workplace interventions for
preventing and/or reducing depressive symptoms in the working
population to maintaining employees’ mental health during the
entire working life.
Contributors
JP wrote the original manuscript draft, designed the study and
conducted the analysis. SVt, MFa, tnH and VS helped write the manuscript and
contributed to the interpretation of the results. UB oversaw the study design
and interpretation of the results, and helped write the final manuscript. the
corresponding author had full access to all the data and had final responsibility to
submit for publication.
Funding
this study was funded by the nordforsk project grant (iD: 76659) and
by the national research centre for the Working environment in Denmark. the
funder of the study had no role in study design, data collection, data analysis, data
interpretation or writing of the report.
Competing interests
none declared.
Patient consent for publication
not required.
Ethics approval
according to Danish law, research studies that use solely
questionnaire and register data do not need approval from the national committee
on Health research ethics (Den nationale Videnskabetiske Komité).
Provenance and peer review
not commissioned; externally peer reviewed.
Data availability statement
Data may be obtained from a third party and are
not publicly available.
Open access
this is an open access article distributed in accordance with the
creative commons attribution non commercial (cc BY-nc 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Jacob Pedersen
http://orcid.org/0000-0003-4429-3485
Ute Bültmann
http://orcid.org/0000-0001-9589-9220
*5% significant.
CL, confidence limits; ERP, early retirement scheme; MDI, Major Depression Inventory; PO,
permanently out; TO, temporary out.
Strengths and limitations
Our study has several strengths. The multistate approach is
unique as it includes permanent and multiple recurring labour
market states over a period of 5 years among a large sample
of Danish employees.
26
This allowed us to examine time-
varying effects, while adjusting for several important poten-
tial confounders. The study also has limitations. Depressive
symptoms are only measured at baseline. For a more realistic
approach, multiple individual measurements of depressive symp-
toms during follow-up should be taken into account. Moreover,
depressive symptoms were self-reported, but showed a clear
association with the prospectively collected information about
labour market affiliation, that is, less time in work. Furthermore,
we cannot rule out that other unknown causes or unmeasured
constructs may impact labour market affiliation, for example,
the presence of supportive family members or the inclusiveness
of the particular workplace. Information on chronic diseases,
comorbid with depressive symptoms, or recent life events may
also have improved our estimates. Although our study is based
on a relatively large sample of Danish employees and includes
several covariates, the results should be repeated on larger
sample sizes and in another jurisdictional context.
Even though the WLE estimates are prognostic in nature,
they cannot be related to significant changes in the labour
market which did not also happen during the follow-up period.
6
Pedersen J,
et al. Occup Environ Med
2019;0:1–7. doi:10.1136/oemed-2019-105961
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