BEU, Alm.del - 2021-22 - Bilag 338: Orientering om Ny NFA-undersøgelse om arbejdsmarkedstilknytning for lønmodtagere med depression og/eller angst

Beskæftigelsesudvalget 2021-22
BEU Alm.del Bilag 338
Offentligt

International Archives of Occupational and Environmental Health

https://doi.org/10.1007/s00420-022-01906-z

ORIGINAL ARTICLE

The linkage of depressive and anxiety disorders with the expected

labor market affiliation (ELMA): a longitudinal multi‑state study

of Danish employees

Jacob Pedersen

· Elisabeth Framke

1,2

· Sannie Vester Thorsen

· Kathrine Sørensen

· Malene Friis Andersen

Reiner Rugulies

· Svetlana Solovieva

Received: 28 March 2022 / Accepted: 29 June 2022

Abstract

Objective

Depressive and anxiety disorders are prevalent among employees in general. Still, knowledge regarding the con-

tribution of these disorders to the dynamics of the labor market in terms of working time, sickness absence, and unemploy-

ment is scarce. We aim to quantify the linkage of depressive and anxiety disorders with labor market participation using the

expected labor market affiliation method (ELMA), in a large sample of Danish employees.

Methods

We combined three survey waves on occupational health with six high-quality national registers in

= 43,148

Danish employees, of which the 2012 survey contributed 29,665 person years, the 2014 survey 33,043 person years, and the

2016 survey 35,375 person years. We used the new ELMA method to estimate the multi-state transition probabilities and

2-year expected time in work, sickness absence, and unemployment. Depressive and anxiety disorders were assessed by the

Major Depression Inventory and the SCL-ANX4 scales, respectively. We adjusted for multiple variables by applying inverse

probability weighting in groups of gender and age.

Results

Depressive and anxiety disorders among employees link to reduced labor market affiliation by significantly changed

transitions probabilities between the labor markets states, viewed as reduced working time by 4–51 days (in two years),

increased time in sickness absence by 6–44 days (in two years), and unemployment by 6–12 days (in two years) when com-

pared to employees without depression or anxiety disorders. The results were most pronounced for women employees and

for employees with both depression and anxiety disorders.

Conclusions

The study reveals detailed insight into what extent depression and anxiety disorders influence the labor market

affiliation, in terms of the complex interrelation between working time, sickness absence, and unemployment. The study

emphasizes the importance of preventing and handling depressive and anxiety disorders among employees for strengthening

work participation.

Keywords

Multi-state · Work · Sickness absence · Unemployment · Mental disorders

Introduction

Depressive and anxiety disorders were the two most com-

mon mental disorders in the European region in 2015, with

44.3 million and 37.3 million individuals, respectively, being

affected (World Health Organization–Regional Office for

Europe

2019),

and among the top ten leading causes of dis-

ability (Vos et al.

2016).

In Denmark, mentally ill health

is increasing. The Danish health authorities have measured

an increase in the mental illness from 2010 until the latest

measurement in 2021, in particularly among the young and

the women (Danskernessundhed.dk

2021).

In 2015, anxiety

was the third most frequent among new cases of illness, next

Vol.:(0123456789)

Jacob Pedersen

[email protected]

National Research Centre for the Working Environment,

Copenhagen, Denmark

The Danish Multiple Sclerosis Registry, Copenhagen

University Hospital, Copenhagen, Denmark

Finnish Institute of Occupational Health, Helsinki, Finland

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International Archives of Occupational and Environmental Health

to diabetes and ischemic heart disease. Depressive disorders

caused 703 DALY’s per 100.000 individuals and anxiety

disorders for 481 DALY’s, hence, the disease burden of the

disorders in Denmark is similar to other high-income coun-

tries (Sundhedsstyrelsen

2022).

There is evidence of high co-occurrence of depression

and anxiety, with approximately half of adults diagnosed

with a depressive or anxiety disorder exhibiting these disor-

ders simultaneously (Lamers et al.

2011).

However, knowl-

edge of the comorbid effect of these two prevalent mental

disorders on labor market affiliation is sparse. Until now, it

has been shown that depression and anxiety among work-

ers increase the risk of sickness absence from work (Vir-

tanen et al.

2011)

and the risk of recurrent sickness absence

(Knudsen et al.

2013)

and imply increased time in sickness

absence (Koopmans et al.

2010).

In a large Finish study,

it has been shown that early onset of depressive and also

anxiety disorders (individuals between age 15 and 25 years)

significantly decreases the likelihood of having secondary

or higher education, decreases the work-life course likeli-

hood of being employed, and increases the risk of having

a total income below the median earning level (Hakulinen

et al.

2019).

Multi-state modeling has proven to be an important tool

for better understanding the dynamics of the labor market

(Lie et al.

2017;

Pedersen et al.

2020;

Robroek et al.

2020)

including studies of mental diseases in terms of depression

(Pedersen et al.

2019).

The expected Labor Market Affilia-

tion method (ELMA), recently developed by Pedersen (Ped-

ersen et al.

2021),

relies on multi-state modeling of the labor

market system, by the estimation of transitions probabilities

and the expected state durations. In addition, the ELMA

method provides the means to include time-dependent vari-

ables, weights, and multilevel adjustment.

The aim of the study is to quantify the impact of depres-

sive and anxiety disorders on labor market participation

for a large sample of Danish employees. We do this utiliz-

ing the ELMA method in a prospective study to analyze

the transitions between multiple labor market outcomes

among employees with and without depressive and anxiety

disorders.

Methods

Study design and source population

This longitudinal study uses a linkage of registers and survey

data on depressive and anxiety disorders from three suc-

cessive waves of the Danish Work Environment and Health

questionnaire (WEHD) conducted in the years 2012, 2014,

and 2016 (Johnsen et al.

2019;

Thorsen et al.

2019).

The

linkage was conducted by an encrypted version of the central

person register number (CPR-Administration

2021).

All

WEHD responders, aged 18–64 years, were included and

followed in registers for two years from the day they filled

in the questionnaire.

The WEHD surveys were linked with the following reg-

isters, provided by Statistics Denmark: (1) Danish Labor

Market Accountant (LMA) register, (2) Register of Work

Absences (RoWA), (3). Education register, (4) Emigration

and Immigration register and (5) Death register. The LMA

payments, including unemployment, sickness absence, dis-

ability pension, pension, and all salary payments reported

to the tax authorities from 2008 onwards.

The RoWA register is a linkage of the Absence and

Employment -register (FRAN) and the Periods of Absence

-register (FRPE), both from Statistics Denmark. FRPE

includes information about sickness absence spells already

from the first day of absence and FRAN includes date-based

employment information of both the employees with and

without sickness absence spells (Thorsen et al.

2019).

The

RoWA register contains records of both public and private

employees. The date-based records of sickness absence

spells are complete for all public employees and for all

large private companies with more than 250 employees.

The RoWA contains a yearly weighted sample of middle-

sized companies with 10–250 employees. This means

that RoWA is covering approximately 37% of all private

employees in Denmark (Thorsen et al.

2019).

The RoWA

does not include small private companies with less than

10 employees. Small companies represent a large part of

private companies (approx. 260,000 small private compa-

nies exist in Denmark) and they are not represented in our

study (Smvdanmark.dk

2018).

The RoWA register contains

weights for making the private sample representative to all

private employees in companies with 10 employees or more.

The Education register contains records of the highest edu-

cation level completion for all Danes. The Emigration and

Immigration register contains dates on all emigrations and

immigrations in Denmark. The Death-register includes dates

for all deceased Danes.

The linkage contains individual and date-based informa-

tion on labor market affiliation and individual characteristics

retained from the surveys etc.

Study sample and data preparation

The WEHD data included 67 053 individuals of which 63

912 (95.3%) individuals were eligible for the current study.

Receivers of disability pension or retires at the start of the

follow-up period (n = 2 945), individuals older than 64 years

at the start of the follow-up (n = 195, 28% women), and not

found in the LMA register (n = 1) were excluded.

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In the RoWA register (i) all records for public employ-

ment has the weight one, and (ii) all records for private

employment have a specialized weight that is constructed

by Statistics Denmark based on the sampling probability

according to the yearly weighted sample of companies.

RoWA only include records of individuals in employment,

but in this study the weights were carried forward in the

LMA register, to include periods of unemployment, etc., but

only until a new employment period.

Records from the LMA register that could not be linked

to private or public employment in the RoWA register

were deleted (~ 7%. 0.6 million records). Similarly, records

of private employments without a weight (9%), and pub-

lic employment period with a specialized weight (0.1%)

were deleted. Moreover, records with missing answers on

questions regarding depression or anxiety were deleted

(N = 3021).

Since an individual may have attended one, two, or three

survey waves (hence 2012, 2014, and 2016)—multiple

follow-up periods are possible. The final sample contains

59,540 follow-up periods—of the

= 43,148 individuals,

77% participated only in one survey, 8% participated in two

of the three survey waves, and 15% participated in all three

survey waves.

For the analyses, the study sample was divided into four

subsamples according to age and gender. The two age groups

were 18–47 years and 48–64 years, the division was at the

median age. The division into only two groups was to secure

a sufficient number of individuals in each subgroup.

and the SCL-ANX4 scale are presented in supplementary

material A.

Covariates and weights

The analyses included seven covariates that have been used

in previous studies on mental health and labor market affili-

ation in relation to self-perceived stress, life course analysis

of depression symptoms, and psychiatric work disability

(Thorsen et al.

2019;

Pedersen et al.

2019, 2021;

Virtanen

et al.

2011).

The covariates are associated with adverse

health outcomes, possible through selection, e.g. selection

into part-time work, or through causation, e.g. smoking and

sickness absence.

Four of the variables were taken from the WEHD sur-

vey data: (1) working time arrangement (part-time: < 37 h

per week; full time: ≥ 37 h per week), (2) body mass index

(BMI, kg/m

) (underweight: BMI < 18.0; normal weight:

18.5 ≤ BMI < 25.0; overweight: 25.0 ≤ BMI < 29.9; and

obese: BMI ≥ 29.9), (3) smoking (current smoker vs. for-

mer or never smoker), and (4) disease treatment—in terms

of a dichotomous variable indicating whether the individual

had been treated for one of the following diseases (no/yes):

asthma, diabetes, atherosclerosis or blood clot in the heart,

blood clot in the brain (cerebral hemorrhage), cancer, back

diseases, migraine, or other long-term diseases. One variable

was obtained from the FRAN register: employment sector

(private/public), and one variable were obtained from the

education registers: the highest accomplished education

(low/middle/high). The last variable “number of survey

waves” was constructed to account for the number of WEHD

survey waves the individual had attended – “1 of 3”, “2 of

3”, and “3 of 3”. All covariates were determined at base-

line but the level of education and employment sector was

moreover allowed to change during the follow-up period.

Depressive and anxiety disorders

Depressive disorders were measured with the 12-item Major

Depression Inventory (MDI), with the sum score ranging

between 0 and 50 (please see supplementary material A)

(Bech et al.

2001;

Olsen et al.

2003).

The MDI has been

validated in both the general population and among patients

in the clinical setting (Bech et al.

2001;

Cuijpers et al.

2007).

In accordance with a clinical validation study by Bech (Bech

et al.

2015),

we categorized study participants as having a

depressive disorder, if they scored ≥ 21 on the MDI-scale,

indicating a mild to severe level of depression.

Anxiety was measured by the SCL-ANX4 scale contain-

ing four questions. In accordance with a clinical validation

study by Christensen (Christensen et al.

2005),

we catego-

rized study participants with an anxiety disorder, if at least

three out of the four dichotomized anxiety symptoms were

present on the SCL-ANX4 scales.

Next, we categorized the respondents into four groups:

(1) Neither depressive nor anxiety disorders, (2) Depres-

sive disorder without anxiety disorder, (3) Anxiety disor-

der without the depressive disorder, 4) Both depressive and

anxiety disorders. The questions regarding the MDI scale

Labor market affiliation

The labor market affiliation was modeled by seven mutu-

ally exclusive labor market states based on the longitudinal

registrations of the LMA and the RoWA registers, illus-

trated by boxes in Fig. 1. Of the seven states, four were

categorized as recurrent states- meaning that individuals

may enter and leave this state multiple times—transitions

are illustrated by arrows in Fig. 1: (1) Work, reflecting the

periods of receiving salary payments and not simultane-

ously registered as sick-listed. (2) Sickness absence, for

periods when the individual is registered as sick-listed by

the employer and for periods of sickness absence benefit

payments. (3) Unemployment, for periods, when a person

received any type of social benefit related to unemploy-

ment, given the condition that the person is immediately

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Fig. 1

The multi-state model including the prevalence of each transi-

tion per 1000 individuals, for men (M) and for women (W). Transi-

tions as arrows, recurrent states as white boxes, and absorbing states

as gray boxes. Example—during the follow-up period men experi-

enced approx. 3,144,700 transitions from work to sickness absence

available for work if such opportunity arises. (4) A tem-

porarily out state, for periods when an individual was not

in the work, sickness absence, or unemployment states but

had the possibility of returning to those states. This state

contained, for example, periods of maternity leave, emi-

gration, education, and periods with no registration. The

three remaining states were all-absorbing states, mean-

ing that no further transitions were possible after the first

entry to the state: (5) disability pension when receiving

disability retirement pension due to personal disability. (6)

Retirement with age retirement pension or the voluntary

retirement pension. (7) Death (supplementary material B,

contains a short introduction to the Danish labor market

and social system).

Statistical analysis

We used the ELMA method developed by Pedersen (Ped-

ersen et al.

2021),

for analyzing the transition probabilities

between the states of the multi-state model and for esti-

mating the expected state durations during follow-up. The

ELMA incorporates both time-dependent variables and

time-dependent weights in terms of e.g. inverse probability

weights. SAS 9.4 software was used for the ELMA analy-

sis including the procedure PHREG and otherwise custom-

made code.

For each subsample of gender and age groups, we esti-

mated the time-dependent baseline probability for every

transition of the multi-state model according to the reference

value of the covariates. The transitions probabilities for the

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non-reference values were estimated by adjusting the corre-

sponding baseline probabilities with estimates derived from

Cox-proportional hazard regression. The Cox-regressions

were conducted on the entire multi-state model with the data

arranged in a long format (de Wreede et al.

2010).

We tested

the proportional hazard assumption of the cox-regression

by visual inspection of the transition probability curves and

found them satisfactory. Based on the transition probabili-

ties we estimated the state probabilities and then the state

durations – from day one and until day 730 (two years). An

analysis of variance was then conducted on five hundred

re-samples, assuming normally distributed state duration.

To increase the strength of the area estimation, all varia-

bles except for the combined depressive and anxiety disorder

variable, were incorporated into the model as inverse prob-

ability weights. A combined weight was incorporated into

the Cox regression and the area estimation, as a multiplica-

tion of the weights from the employment register and the

inverse probability weight. For light comparison with and

control of the ELMA results, a crude estimate of the time

spent in each state was made. This was done by summing the

time spent in each state during the follow-up period and then

dividing it by the number of individual follow-up periods.

Results

Table 1 shows that—the study sample consisted of 25,392

women (59%) and 17,756 men (41%). Combined depres-

sive and anxiety disorders were more frequently reported by

women than men. Depression without anxiety was the most

frequent among young women.

Figure 1 shows that the transitions between the work and

the sickness absence states were the most frequent during

follow-up, with the highest prevalence being for women.

Transitions between work and unemployment were less fre-

quent than the transitions between work and the temporar-

ily out state. Moreover, the transitions between work and

temporarily out states were most prevalent among women.

The prevalences of transitions to the absorbing states were

generally very low.

Table

show that—during the two-year follow-up—

working individuals with both depressive and anxiety dis-

orders had the highest hazard ratios. Few exceptions were

seen—for 18–47 years old working women and 48–64 years

old working men. Working 18–47 years old women with

anxiety and no depressive disorders had a higher risk of

being unemployed than similar-aged women with both

depressive and anxiety disorders, but with overlapping con-

fidence intervals (HR 1.91 for anxiety and 1.64 for both dis-

orders). The risk of sickness absence was somewhat similar

among 18–47 years old women with depressive disorders

alone or in combination with anxiety (HR 1.33 and 1.31,

respectively). Working women with depressive disorders

alone or in combination with anxiety had a higher risk of

unemployment than working women reporting solely anxi-

ety disorders (HR 1.28 for anxiety, 1.60 for depression, and

2.18 for both disorders). The reference group are similarly

aged employees of the same gender without depression or

anxiety disorders.

Table 3 shows that—during the two-year follow-up—men

without depressive and anxiety disorders were expected to

have 694 (aged 18–47 years) and 670 (aged 48–64 years)

working days, respectively (Table 3). The corresponding

value for working time expectancy among women was 658

(aged 18–47 years) and 660 (aged 48–64 years) working

days. Figure 2 shows that the expected working time was

significantly decreased for all groups with depressive and/

or anxiety disorders, except for women with solely anxiety

disorders aged 48–64 years. For men aged 48–64 years, a

lesser decrease in working time was observed for individu-

als with depressive disorders, than those with anxiety dis-

orders and those with both disorders. The number of sick-

ness absence days and unemployment days were higher for

individuals with either depressive or anxiety disorders, or

with both disorders, and days in work were fewer. Individu-

als with both disorders experience the highest number of

sickness and unemployment days and there was a tendency

for depressive disorders to be associated with more sickness

and unemployment days than anxiety disorders. The refer-

ence group are similarly aged employees of the same gender

without depression or anxiety disorders.

During the two-year follow-up, the expected working

time of men with depressive and anxiety disorders was

reduced by 33 and 38 days for the younger and older age

group, respectively. Reduction in the expected working time

among older men experiencing anxiety disorders without

depressive disorders was larger than among younger men

with the same disorders (by 29 and 14 days for the aged

48–64 and 18–47 years, respectively). The expected time

of early retirement (supplementary table C) was + 32 days

for women and + 27 days for men – when compared with

similar-aged employees of the same gender without depres-

sion or anxiety disorders.

Discussion

In this longitudinal study, we examined a two-year labor

market participation of employees after reporting depres-

sive and/or anxiety disorders. By using the novel ELMA

method on three waves of the WEHD survey linked to six

national registers, we found that working individuals with

depressive and anxiety disorders had a higher risk of sick-

ness absence and unemployment. Moreover, when sickness

absent, they had a higher risk of being unemployed, and

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International Archives of Occupational and Environmental Health

Table 1

Descriptive baseline

characteristics at the start of the

first follow-up period

Age group (years)

Total—n (mean age)

Men

18–47

8971 (37.2)

(%)

Depressive/anxiety

No/No

No/Yes

Yes/No

Yes/Yes

Working time

Full-time

Part-time

Not available

Body mass index

Underweight

Normal

Overweight

Obesity

Not available

Smoking

Non-smoker

Smoker

Not available

Disease treatment

Yes

Employment sector

Private

Public

Highest educational level

Short

Medium

Long

Not available

Number of survey waves

1 of 3

2 of 3

3 of 3

6537 (72.9)

283 (3.2)

1472 (16.4)

679 (7.6)

7907 (88.1)

942 (10.5)

122 (1.4)

40 (0.4)

4192 (46.7)

3456 (38.5)

1189 (13.3)

94 (1)

7036 (78.4)

1927 (21.5)

8 (0.1)

7152 (79.7)

1819 (20.3)

5588 (62.3)

3383 (37.7)

979 (10.9)

3662 (40.8)

4294 (47.9)

36 (0.4)

7036 (78.4)

816 (9.1)

1119 (12.5)

48–64

8785 (55.6)

(%)

6767 (77.0)

347 (3.9)

1002 (11.4)

669 (7.6)

8050 (91.6)

580 (6.6)

155 (1.8)

19 (0.2)

3118 (35.5)

4167 (47.4)

1423 (16.2)

58 (0.7)

6959 (79.2)

1823 (20.8)

3 (0)

6072 (69.1)

2713 (30.9)

5218 (59.4)

3567 (40.6)

1395 (15.9)

3972 (45.2)

3355 (38.2)

63 (0.7)

6681 (76.1)

619 (7.0)

1485 (16.9)

Women

18–47

13,494 (37.0)

(%)

8789 (65.1)

609 (4.5)

2633 (19.5)

1463 (10.8)

8640 (64.0)

4686 (34.7)

168 (1.2)

312 (2.3)

8044 (59.6)

3184 (23.6)

1655 (12.3)

299 (2.2)

10,982 (81.4)

2503 (18.5)

9 (0.1)

9720 (72.0)

3774 (28.0)

4051 (30.0)

9443 (70.0)

895 (6.6)

4876 (36.1)

7691 (57.0)

32 (0.2)

10,416 (77.2)

1360 (10.1)

1718 (12.7)

48–64

11,898 (55.2)

(%)

8378 (70.4)

547 (4.6)

1780 (15.0)

1193 (10.0)

7558 (63.5)

4118 (34.6)

222 (1.9)

183 (1.5)

6346 (53.3)

3537 (29.7)

1674 (14.1)

158 (1.3)

9536 (80.1)

2340 (19.7)

22 (0.2)

7890 (66.3)

4008 (33.7)

2876 (24.2)

9022 (75.8)

1570 (13.2)

4731 (39.8)

5561 (46.7)

36 (0.3)

9002 (75.7)

839 (7.1)

2057 (17.3)

when unemployed or sickness absent, they had less chance

of returning to work. Overall, employees with either depres-

sive or anxiety disorders had during the next two years less

working time, more sickness absence time, and more unem-

ployment time, compared to individuals without depressive

and anxiety disorders.

The decrease in working time and increase in sickness

absence and unemployment times were more pronounced

among employees reporting a combination of depressive and

anxiety disorders than employees having only one type of

the disorders. Among those with both types of disorders,

women had a larger working time decrease and a larger

increase in sickness absence and unemployment than men.

In the group with solely depressive disorders, and no anxiety

disorders, women compared to men had twice the decline

in working time and approximately twice the increase of

sickness absence time. In the group with solely anxiety dis-

orders, women in the young age group had a higher increase/

decrease than men, but in the old age group men had higher

increase/decrease than women.

Young men and women with either depressive or anxi-

ety disorders had comparable changes in the labor market

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International Archives of Occupational and Environmental Health

Table 2

Hazard ratio and 95% confidence interval for transitions between the three main states: work, sickness absence, and unemployment, by

gender and age-group

Transition

Depressive/

Anxiety

Men

Aged 18–47 years

HR (95% CI)

Work to Sickness absence

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Work to unemployment

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Sickness absence to work

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Sickness absence to unemployment

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Unemployment to work

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Unemployment to sickness absence

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Women

Aged 48–64 years

HR (95% CI)

1.00 (–)

1.39 (1.15–1.68)

1.35 (1.21–1.50)

1.53 (1.30–1.81)

1.00 (–)

1.63 (0.77–3.44)

1.63 (0.96–2.76)

1.39 (0.81–2.37)

1.00 (–)

0.92 (0.58–1.48)

0.92 (0.69–1.22)

0.64 (0.48–0.86)

1.00 (–)

1.66 (0.33–8.42)

1.53 (0.56–4.13)

2.34 (1.11–4.94)

1.00 (–)

0.98 (0.56–1.69)

0.45 (0.25–0.81)

0.42 (0.23–0.76)

1.00 (–)

0.14 (0.02–1.25)

0.44 (0.12–1.60)

0.74 (0.35–1.56)

Aged 18–47 years

HR (95% CI)

1.00 (–)

1.20 (1.10–1.32)

1.33 (1.25–1.42)

1.31 (1.18–1.46)

1.00 (–)

1.91 (1.05–3.45)

1.32 (0.93–1.87)

1.64 (1.13–2.39)

1.00 (–)

0.85 (0.59–1.23)

0.77 (0.64–0.92)

0.56 (0.46–0.68)

1.00 (–)

1.83 (0.92–3.66)

1.91 (1.22–2.99)

3.30 (1.86–5.84)

1.00 (–)

1.18 (0.67–2.08)

0.62 (0.46–0.82)

0.58 (0.43–0.79)

1.00 (–)

1.19 (0.62–2.27)

1.11 (0.67–1.83)

1.87 (1.03–3.40)

Aged 48–64 years

HR (95% CI)

1.00 (–)

1.12 (1.02–1.24)

1.30 (1.22–1.38)

1.49 (1.34–1.66)

1.00 (–)

1.28 (0.72–2.28)

1.60 (1.09–2.34)

2.18 (1.50–3.15)

1.00 (–)

0.87 (0.69–1.11)

0.60 (0.48–0.75)

0.52 (0.44–0.61)

1.00 (–)

1.43 (0.68–3.03)

1.49 (0.91–2.44)

2.46 (1.11–5.47)

1.00 (–)

0.85 (0.42–1.73)

0.69 (0.47–1.02)

0.67 (0.43–1.03)

1.00 (–)

1.51 (0.86–2.65)

1.26 (0.76–2.08)

1.87 (1.10–3.20)

1.00 (–)

1.12 (0.97–1.29)

1.25 (1.11–1.40)

1.33 (1.16–1.54)

1.00 (–)

1.54 (0.61–3.86)

1.15 (0.62–2.11)

1.89 (1.03–3.46)

1.00 (–)

0.77 (0.54–1.10)

0.73 (0.60–0.90)

0.45 (0.32–0.65)

1.00 (–)

0.60 (0.09–3.90)

0.98 (0.46–2.11)

1.07 (0.46–2.49)

1.00 (–)

0.47 (0.30–0.75)

0.72 (0.45–1.14)

0.75 (0.47–1.22)

1.00 (–)

0.76 (0.17–3.47)

0.44 (0.16–1.23)

1.51 (0.73–3.13)

Dep.

Depressive,

Anx.

Anxiety,

Hazard Ratio,

Confidence Interval,

Ref.

Reference

5% Significant

affiliation. In the oldest age group, the change in labor

affiliation appeared to be more pronounced among men

with anxiety disorders than men with depressive disorders

and likewise, depressive disorders appeared to relate to

more lost working time and increased sickness absence,

etc. than anxiety disorders among women.

The crude mean tends to underestimate the reference

level of working time and time of sickness absence when

compared to the ELMA estimate. But for confirmation of

the results, the ELMA and crude estimates generally point

in the same direction.

Comparison with previous studies

Our study is the first to apply the ELMA multi-state

approach to explore the linkage of depressive and anxiety

disorders with the labor market affiliation. Earlier studies

have usually focused on depression and either analyzed

only single transitions e.g. from work to long-term sickness

absence or disability pension (Hjarsbech et al.

2011;

Holma

et al.

2012;

Thorsen et al.

2013),

focused on recurrent sick-

ness absence (Knudsen et al.

2013),

or taken a life course

perspective to quantify the effect on working life expectancy

BEU, Alm.del - 2021-22 - Bilag 338: Orientering om Ny NFA-undersøgelse om arbejdsmarkedstilknytning for lønmodtagere med depression og/eller angst

Work

ELMA

Days (95% CI)

Days

Days (95% CI)

Days

Days (95% CI)

Crude

ELMA

Crude

ELMA

Days

Sickness absence

Unemployment

Crude

Temporary out

ELMA

Days (95% CI)

Crude

Days

694.4 (692.3:696.4)

– 14.3 ( – 17.1: – 11.4)

– 14.6 ( – 17.5: – 11.7)

– 33.2 ( – 36.1: – 30.4)

670.3 (667.9:672.8)

– 29.1 ( – 32.6: – 25.6)

– 13.4 ( – 16.9: – 9.9)

– 37.6 ( – 41.1: – 34.2)

657.7 (655.2:660.2)

– 23.8 ( – 27.3: – 20.3)

– 29.2 ( – 32.8: – 25.7)

– 47.2 ( – 50.8: – 43.7)

660.0 (657.5:662.6)

– 4.1 ( – 7.8: – 0.5)

– 28.1 ( – 31.8: – 24.5)

– 50.6 ( – 54.2: – 47.0)

582.3

+ 7.6

– 28.6

– 42.0

578.9

– 8.3

– 13.0

– 40.5

611

– 18.6

– 35.1

– 63.3

625.3

– 17.3

– 32.5

– 63.8

10.1

+ 3.5

+ 9.5

+ 17.9

15.7

+ 6.0

+ 12.3

+ 26.7

23.2

+ 6.8

+ 16.9

+ 34.7

25.2

+ 5.8

+ 24.0

+ 42.3

13.3 (11.9:14.6)

+ 5.7 (3.8:7.7)

+ 9.6 (7.7:11.5)

+ 24.4 (22.5:26.3)

19.6 (18.2:21.0)

+ 10.7 (8.7:12.7)

+ 8.3 (6.4:10.3)

+ 27.3 (25.3:29.3)

26.6 (25.0:28.2)

+ 9.7 (7.5:12.0)

+ 18.0 (15.7:20.2)

+ 30.3 (28.1:32.5)

29.3 (27.5:31.1)

+ 5.9 (3.3:8.4)

+ 29.1 (26.5:31.6)

+ 43.8 (41.3:46.4)

4.3 (2.9:5.6)

+ 2.8 (0.9:4.7)

+ 3.7 (1.8:5.6)

+ 5.2 (3.3:7.1)

3.2 (1.4:5.0)

+ 4.8 (2.3:7.3)

+ 9.3 (6.8:11.8)

+ 10.2 (7.7:12.7)

6.2 (5.1:7.4)

+ 3.0 (1.3:4.6)

+ 6.0 (4.3:7.7)

+ 10.2 (8.5:11.8)

5.4 (4.1:6.7)

+ 2.3 (0.5:4.1)

+ 7.2 (5.4:9.0)

+ 12.1 (10.3:13.9)

5.1

+ 2.2

+ 3.2

+ 9.9

4.1

+ 4.3

+ 4.2

+ 0.4

6.2

+ 4.6

+ 6.4

+ 11.7

5.3

+ 2.2

+ 7.5

+ 10.9

14.5 (13.3:15.7)

+ 5.2 (3.6:6.9)

+ 0.3 ( – 1.3:2.0)

+ 1.5 ( – 0.2:3.1)

3.6 (2.0:5.2)

+ 6.7 (4.4:8.9)

+ 1.2 ( – 1.0:3.5)

+ 8.2 (6.0:10.4)

36.9 (35.2:38.7)

+ 11.5 (9.0:14.0)

+ 3.4 (0.9:5.9)

+ 5.2 (2.7:7.7)

3.3 (2.0:4.6)

– 1.6 ( – 3.5:0.2)

+ 2.6 (0.8:4.4)

+ 5.4 (3.6:7.2)

14.7

+ 5.8

+ 4.1

+ 5.5

4.4

+ 2.5

+ 3.6

+ 10.2

35.8

+ 9.6

+ 4.0

+ 6.1

4.2

– 2.6

+ 1.7

+ 4.7

International Archives of Occupational and Environmental Health

Table 3

The ELMA and Crude mean results (in days incl. 95% confidence interval) of the expected change ( ±) in two year by the duration of working time, sickness absence, unemployment,

and temporarily out when compared to the absolute duration time of individuals without depressive and anxiety disorders (reference). Grouped by gender, age, and by disorder: anxiety, depres-

sive, or both. Supplementary tables (A), shows the additional results of the three absorbing states

Gender

Age

Depressive/anxiety

Men

18–47 years

48–64 years

Women

18–47 years

48–64 years

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Dep. No/Anx. No (ref.)

Dep. No/Anx. Yes

Dep. Yes/Anx. No

Dep. Yes/Anx. Yes

Dep.

Depressive,

Anx.

Anxiety,

ELMA

Expected Labor Market Affiliation

5% significant

BEU, Alm.del - 2021-22 - Bilag 338: Orientering om Ny NFA-undersøgelse om arbejdsmarkedstilknytning for lønmodtagere med depression og/eller angst

International Archives of Occupational and Environmental Health

Fig. 2

The ELMA results by the expected duration (±) in two year

of working time, sickness absence, unemployment, and temporarily

out (days) when compared to the absolute duration time of individu-

als without depression and anxiety. Grouped by gender, age, and the

combination of disorders

(Pedersen et al.

2019;

Hakulinen et al.

2019).

Other studies

focus on the economic consequences and find significantly

decreased income levels and production loss among workers

having depressive symptoms or disorders—with addition-

ally subsequent risk of unemployment (Stewart et al.

2003;

Whooley et al.

2002).

Like previous studies, we found that depressive and/

or anxiety disorders were associated with an increased

risk of sickness absence among working men and women,

and a decreased likelihood of returning to work (Knudsen

et al.

2013;

Virtanen et al.

2011).

In line with the study

by Andreeva (Andreeva et al.

2015),

we found that depres-

sion increases the likelihood of transitioning from work to

unemployment among women. Moreover, we found that

young men and women in both age groups—with anxiety

and depressive disorders—had an increased risk of unem-

ployment. In contrast to Jefferis (Jefferis et al.

2011)

our

results were statistically significant even when adjusting for

education level and employment sector.

The present study found reduced working and increased

sickness absence and unemployment time for individuals

having depressive disorders during a 2-year follow-up. The

BEU, Alm.del - 2021-22 - Bilag 338: Orientering om Ny NFA-undersøgelse om arbejdsmarkedstilknytning for lønmodtagere med depression og/eller angst

International Archives of Occupational and Environmental Health

result are in line with the life course study by Pedersen

(Pedersen et al.

2019)

on the impact of depression on work-

ing life expectancy and working-years loss, and (Banerjee

et al.

2017)

in terms of estimated absenteeism from work for

employees with mental illness.

The results suggest a prevention potential in relation to

reducing the loss of working time for employees reporting

depressive and anxiety disorders by lowering the risk of sick-

ness absence. However, there exists only a spared number of

intervention studies with a positive proven effect (Henderson

et al.

2011;

Nexø et al.

2018).

One of such studies contains a

method by which employers screen the employees for mental

health disorders, to decrease the symptoms, gain higher job

retention, and gain more hours working (Wang et al.

2007).

The results additionally indicate a potential for reducing the

time in sickness absence, by increasing the likelihood of

returning to work – especially for sick-listed employees hav-

ing both depression and anxiety disorders. Here stigmatiza-

tion may be an obstacle for the sick-listed and the employer

to overcome, as the sick-listed may find it difficult to seek

help and the employer may have difficulties handling the

return to the workplace if not familiar with the disorders of

the employee (Gronholm et al.

2017).

Strengths and limitations

The study strengths include a large study population of Dan-

ish employees from three survey waves, and the flexibility

of the ELMA method made it possible to examine different

aspects of the labor market affiliation—including adjustment

for time-dependent variables and weights.

An additional strength is the use of all lengths of sickness

absence. Most comparable register studies rely on registra-

tions of long-term sickness absence benefits, which in Den-

mark concerns sickness absence of more than 30 continuous

days.

The study includes limitations for consideration: (i) The

sample represents a wide variety of Danish employees and

the study is likely to be generalizable to the Danish work-

force, and find use particular in countries with a comparable

labor market system e.g. the Scandinavian countries. How-

ever, some caution should be taken on the WEHD, due to

the lack of response from men, young employees, and peo-

ple with many sickness absence days (Thorsen et al.

2018,

2019;

Johnsen et al.

2019)

and due to the limits of the RoWA

2018).

(ii) Only a few transitions to the disability pen-

sion and other pension states were observed during a 2-year

follow-up, nevertheless, there is a small possibility of over-

estimating the time spent in those states, as these states in

the model were absorbing. (iii) To secure sufficient statistical

power throughout the analysis the study did not distinguish

between full-time and part-time unemployment and sickness

absence, though the Danish system contains both. Instead,

all time in these states was treated only as full-time. This

potentially overestimates the reduction in working time and

similarly overestimates the time in sickness absence, as some

of the time will be productive (part-time at work) and not

full-time sickness absence. (iv) The use of survey data on

depressive and anxiety disorders may cause non-response

bias as individuals may find the depression and anxiety ques-

tions irrelevant or choose not to answer. (v) Additionally, the

classification of variables, including disease by the survey

data, does not allow for individual variable shifts during fol-

low-up. This may cause misestimation, as, for example, the

severity of the baseline level of depression and/or anxiety

disorders may fluctuate during follow-up and possibly fade

out. (vi) The study relates to the Danish social system and

labor market system, which means that comparisons with

other countries should be made with caution. However, the

results may still make room for cross-country consideration

on employees experiencing depressive and/or anxiety disor-

ders. (vii) Moreover, it is likely that the results can be driven

by additional causes not included in the study. For exam-

ple, the study does not include information on the severity

of the disorders, medication side effects, or person-related

crises. Additionally, the use of the self-reported disorders

instead of diagnosis-specific information suggests a risk of

misclassification as the presence of each disorder has not

been confirmed by a psychiatrist or doctor (viii) In addition,

the study does not contain any information about previous

mental states before baseline, which makes it difficult to

determine and include a possible duration of depressive and/

or anxiety disorders up to baseline.

Conclusion

This study provides detailed new knowledge on the link-

age between depressive and anxiety disorders with the labor

market affiliation among Danish employees. Using the

ELMA method we show that depressive and anxiety dis-

orders are associated with noticeable loss of working time

and increase of time in sickness absence and unemployment.

The relationship was higher for employees with both disor-

ders compared to employees with only one, it was higher for

women compared to men, and it varied by age. The result

of our study, i.e. how many lost workdays depression and

anxiety causes, is an easily understandably number also for

non-researchers. The loss in workdays, increase in sick days

etc. highlight the importance of the prevention and handling

of depression and anxiety disorders in the workplace and

identifying employees with these disorders even though the

cause may not be work-related. Further use of these numbers

will, in future studies, be to calculate the cost of depression

and anxiety for both the industry and society.

BEU, Alm.del - 2021-22 - Bilag 338: Orientering om Ny NFA-undersøgelse om arbejdsmarkedstilknytning for lønmodtagere med depression og/eller angst

International Archives of Occupational and Environmental Health

Supplementary Information

The online version contains supplemen-

tary material available at

https://doi.org/10.1007/s00420-022-01906-z.

Author contributions

JP wrote the original manuscript draft, designed

the study, and conducted the analysis. EF, SVT, KS, MFA, and RR

contributed to writing the manuscript and the interpretation of the

results. SS oversaw the study design and interpretation of the results,

and contributed to writing the final manuscript. The corresponding

author had full access to all data and had final responsibility to submit

for publication.

Funding

The study was supported by the Nordic Council of Ministers

(grant number 101250) (JP, SS). The funders of the study had no role

in study design, data collection, data analysis, data interpretation, or

writing of the report. The corresponding author had full access to all

the data and had the final responsibility to submit for publication.

Data availability

The SAS code can be shared upon reasonable request

by authorized researchers after application to the NRCWE. Data is

available on the Researcher access at Statistics Denmark, see

www.

dst.dk/en/TilSalg/Forskningsservice.

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Declarations

Conflict of interest

The authors declare they have no conflicts of inter-

est to disclose.

Ethical approval

According to Danish law, research studies that use

solely survey and register data do not need approval from the National

Committee on Health Research Ethics (Den Nationale Videnskabetiske

Komité).

Open Access

This article is licensed under a Creative Commons Attri-

bution 4.0 International License, which permits use, sharing, adapta-

tion, distribution and reproduction in any medium or format, as long

as you give appropriate credit to the original author(s) and the source,

provide a link to the Creative Commons licence, and indicate if changes

were made. The images or other third party material in this article are

included in the article's Creative Commons licence, unless indicated

otherwise in a credit line to the material. If material is not included in

the article's Creative Commons licence and your intended use is not

permitted by statutory regulation or exceeds the permitted use, you will

need to obtain permission directly from the copyright holder. To view a

copy of this licence, visit

http://creativecommons.org/licenses/by/4.0/.

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