Journal of Affective Disorders 176 (2015) 48–55

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Research report

Gender differences and disabilities of perceived depression in the workplace Yuan-Pang Wang a,n, Clarice Gorenstein a,b a b

Institute & Department of Psychiatry (LIM-23), University of Sao Paulo Medical School, Rua Dr. Ovídio Pires de Campos 785, 05403-010 São Paulo, SP, Brazil Department of Pharmacology, Institute of Biomedical Sciences, University of Sao Paulo, Avenida Professor Lineu Prestes 1524, 05508-900 São Paulo, SP, Brazil

art ic l e i nf o

a b s t r a c t

Article history: Received 18 January 2015 Received in revised form 23 January 2015 Accepted 29 January 2015 Available online 7 February 2015

Background: Few studies have investigated gender difference and associated disability among workers. Comprehensive investigations concerning the occurrence and consequences of depression in workplace are scarce. The study aims to evaluate how workers perceive depression in workplace, as well as to examine depression-related disabilities by gender. Methods: This is a cross-sectional web-based survey of 1000 Brazilian workers recruited from Internet sources. Participants answered an online questionnaire about depressive symptoms and related consequences in the workplace. Results: Common symptoms attributable to depression were crying, loss of interest, and sadness. Almost one in five (18.9%) participants reported had ever been “labeled” by a health professional as suffering from depression. However, the majority of ever-depressed workers (73.5%) remained working. Performancerelated impairments were reported by around 60% of depressed workers who continued working. Over half of them also complained about cognitive symptoms (concentration difficulties, indecisiveness, forgetfulness), with men reporting more cognitive dysfunctions than women. One in three workers had taken off work due to depression (mean 65.7 out-of-role days), with these periods being lengthier for men than women. Limitations: Some depressive events might have occurred before working age, since the participants have self-reported the diagnosis of health professionals in past timeframe. The representativeness of recruited workers was reliant upon the availability of Internet service. Conclusions: The findings suggest that identification and management of symptoms of depression should be set as a priority in worker's health care. General and gender-related strategies to handle depression in the workplace are recommended. & 2015 Elsevier B.V. All rights reserved.

Keywords: Depression Gender difference Cognitive symptoms Disability Workplace

1. Introduction Depression is one of the leading causes of burden of disease worldwide (Murray and Lopez, 1996), but there are insufficient studies examining the effects of depression in the workplace. Individuals with depression report more decline in productivity than those without depression (Herrman et al., 2002; Kessler, 2012). As such, comprehensive data of depression-related work performance and loss productivity are major gap of health knowledge, where information on expenditure, impairment, morbidity, and accident injury is jointly combined (Oortwijn et al., 2011). Occupational health professionals are most concerned with clinical depression, a term used to describe any type of depression that produces significant personal distress and/or problems in functioning (Myette, 2008). This common disorder can manifest across

n

Corresponding author. Tel./fax: þ 55 11 2661 6976. E-mail address: [email protected] (Y.-P. Wang).

http://dx.doi.org/10.1016/j.jad.2015.01.058 0165-0327/& 2015 Elsevier B.V. All rights reserved.

a continuum of severity, ranging from normal mood, as a symptom, as a disorder, or as a disabling disease (Kessing, 2007; Bromet et al., 2011). Clinical depression can harmfully affects the employee's work satisfaction and performance, resulting in much functioning troubles at home, at school, among interpersonal relationships, and in the workplace (McIntyre et al., 2013, 2015), requiring prompt and correct diagnosis and focused treatment. Some consequences of depression in the workplace are productivity fall, take off work, and sick leave (Kessler, 2012). Annually, depression-related lost productivity costs over USD 44 billion to US employers (Stewart et al., 2003a). Lost productive time of depression vs. without depression among workers was reported as almost four folds higher: 5.6 h/week vs. 1.5 h/week, respectively (Stewart et al., 2003b). In a recent survey of European workers (Evans-Lacko and Knapp, 2014), the cost of depression due to lost productivity is projected at d 77 billion per year. Chronic pain and mental disorders are major causes of years living with disability (YLD) in general population of the Tropical Latin America (Vos et al., 2013). Both conditions are related to workplace,

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 48–55

being causes of disability, workday lost, and absenteeism (Nelson and Silverstein, 1998; Vieira et al., 2011; Barbosa-Branco et al., 2012). In Brazil, neuropsychiatric disorders ranked first among the major causes of disability (34%), followed by chronic respiratory diseases (11.2%) (Schramm et al., 2004). Examining Brazilian industrial workers, Yano and Santana (2012) have pointed out that one-year prevalence of workdays lost due to health problems affected 12.5% of individuals, with 5.5% being directly attributed to work and 4.1% being aggravated by work. According to Brazilian workers' administrative compensation database of the National Institute for Social Security (INSS) (Barbosa-Branco et al., 2011; Sousa Santana et al., 2012), five out of the 10 leading causes of compensation benefits were mental disorders and accounted for 19% of the total cost with disability benefits (Barbosa-Branco et al., 2012). For the general population in Brazil, chronic pain and mood disorders were the two conditions of highest impact, even after controlling for confounders (Andrade et al., 2013). In the month prior to the interview, 13.1% reported at least one day totally out-of-role, with an annual median of 41.4 days out-of-role. Despite this huge burden in developed countries (Alonso et al., 2011), comprehensive data of work-related depression and its associated workday loss in Latin America and Caribbean region are still limited. Traditional job-related epidemiology has placed less emphasis on women's difficulties in the workplace than men's. However, investigations on gender equality in the economic market have suggested female workers as a key susceptible group, in terms of prevalence (Conti and Burton, 1994; Kessler, 2003; WHO, 2014b), vulnerability (WHO, 2014a) and unfavorable outcome (Pudrovska and Karraker, 2014). Also, researches on occupational health have included sex as a major variable of investigation (Cohidon et al., 2010), directing the interest toward sex-related physiological response at work and reproductive function affecting work performance (Nelson and Silverstein, 1998; Artazcoz et al., 2007). From the sociological perspective, activists have claimed the discrimination against women in the workplace, with reports of sexual embarrassment, inequality on earning and labor rights (Kessler et al., 2008a; Okechukwu et al., 2014). Higher rate of depression among female workers has important implications for occupational benefit plan policy, disability management, and health professionals' training (Conti and Burton, 1994). For instance, results from 2010 census in Brazil (Instituto Brasileiro de Geografia e Estatística [IBGE], 2011) have showed the rising number of women as chief family provider, indicating growing participation of female workers in the country's economy. The reasons may be credited to a change in values regarding the role of women in modern society and to factors such as the massive entry into the labor market and the increasing level of education at the college level, combined with reduced fertility. Previous investigations on gender difference in clinical picture of depression reported this condition of different severity and manifestations, in terms of somatic vs. affective symptoms (Silverstein, 1999, 2002; Silverstein et al., 2013). Nevertheless, most studies have not controlled or matched for non-somatic symptoms, leaving a gap in the issue of gender difference in terms of somatic symptoms vs. cognitive/affective symptoms. Contradicting the view that somatic symptoms would explain gender differences in depression rates and symptom severity, Delisle et al. (2012) argued that gender differences in somatic scores of the Beck Depression Inventory-II were very small for depressed patients attending an outpatient clinic. Multivariate techniques (Carragher et al., 2011; Alexandrino-Silva et al., 2013) have showed that several depression-related behaviors and cognitive symptoms were salient features that can discriminate between gender groups. These contentious observations have suggested that gender-related characteristics may operate in shaping how depression would express in men and women, with diverse outcomes in the workplace.

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Bearing in mind the higher prevalence of depression among women, their growing participation in country's economy and widespread rate of depression in work-based societies, it is timely to argue that depression-associated disabilities also might be greater among women. Therefore, a focused investigation of gender difference in occupational settings can elucidate how depressive conditions are expressed and affect the workers, as well as to improve future strategies for dealing with these harsh outcomes. Investigation of perception of symptoms of depression can help to grasp the beliefs underlying attitudes about the causes and treatments of depression among the general public (Jorm and Griffiths, 2008). A greater understanding about how depression occurs between genders and is managed in the workplace can aid to de-stigmatize its perception and may lead to more effective outreach and education efforts in companies (Blumner and Marcus, 2009). In current investigation, we inquired workers through online survey on common symptoms of depression and their effects on labor performance. The objectives were to investigate how the workers perceive the occurrence of depression and to estimate the depression-related outcomes in occupational settings. Gender differences and disabilities of perceived depression in workplace were described to underline its implication for the employees.

2. Methods 2.1. Design and setting The investigation was a cross-sectional survey on perceived depression in the workplace. This study was conducted in accordance with guidelines of the International Chamber of Commerce (ICC) and European Society for Opinion and Marketing Research (ESOMAR, 2013), where all workers self-reported their attitudes and perceived symptoms of depression through Internet (Evans-Lacko and Knapp, 2014). This survey is the Brazilian branch of a multicentric survey launched by European Depression Association (EDA) (2014). 2.2. Sampling and recruitment Recruited from Internet sites, eligible participants were panelists of Internet portals, service providers, online stores, airlines, communities, etc., with audited customer databases. The sample size of 1000 participants was determined in accordance with the standard of national representativeness for marketing and opinion research (ESOMAR, 2013). Data were weighted to adjust the representativeness of the target profile: Brazilian residents, aged 16–64 year-old, current workers, or have worked and managed within the last 12 months. We have targeted a general population sample taking into consideration the age stratum criterion, as “currently or have been previously employed” individuals could not be selected. This approach had engaged a broad range of socio-demographic profiles by natural fallout. For targeting the sample, there was a random extraction on needed demographics and quotas structure on age, gender and region. The participants were allowed to fill out only one form after receiving an invitation email for the panel. Personal data were checked and duplicates were removed. No quotas on company size were applied. This procedure was multisourced, closed, and “by invitation only” and has followed ESOMAR's quality controls to guarantee unique participants and to avoid fraud. 2.3. Instrument This investigation used a 13-item questionnaire elaborated by European Depression Association (2014), which was translated and adapted for use in Brazilian–Portuguese speaking respondents

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(Wang and Gorenstein, 2014). The original instrument has been applied in over 7000 workers in seven European countries (EvansLacko and Knapp, 2014). The present study reports key results concerning selected questions that would have impact on occupational health, with focus on workers' perception of depression in the workplace and gender difference. All respondents had their information recorded, concerning sex, age, marital status, working status, size of company (small, medium, and large), highest educational level, and local of residence in Brazil (North, Northeast, Middle-East, Southeast, and South). Eligible participants were in the age range of 16–64 years, currently working or previously employed in the past 12 months. Following, they have to choose four among a list of 10 items (nine symptoms/behaviors plus one open-ended item to include other possibilities) that could indicate someone in the workplace is depressed and indicate four attributes/symptoms associated with depression in general. At this point, the participants were asked if a doctor or health professional has ever diagnosed them as having depression. If positive, they indicated the symptoms they experienced among a 10-item list and whether they continued to work in the last time they had depression. Using a 0–10 scale, from the worst to the best functioning, the respondents have to rate the following: (a) the usual performance of the workers holding a similar position; (b) their usual performance during the past year when they did not experience depression; and (c) their overall job performance when they had depression in the last time. From a list of nine items, those depressed respondents reported which behaviors were more than usual while still working and which attributes/symptoms most impacted their usual work performance. Next, it was asked to all ever-depressed worker if s/he “has ever taken time off work because of depression?” If affirmative, they informed the number of working days that have had to take off during the last time of depression, the attributes/symptoms that had caused it, and the reasons for taking time off. If the worker had omitted mentioning about depression, the reasons of non-disclosure were recorded. 2.4. Data analysis Before descriptive analysis, results were weighted to correct for minor discrepancies by using the random iterative method (RIM) (Mallett, 2006) to adjust for the distribution of demographic profile of Brazilian workers, such as age, gender, region and working status. Hypothesis testing such as chi-square and ANOVA was adopted to contrast difference between subgroups of the sample, respectively for categorical and continuous data. All analyses were conducted through SPSS version 21 software (IBM Corp., 2012). The level of significance of 0.05 was considered for 2-sided tests. The investigation was conducted in accordance with confidentiality codes and guidelines of the ICC/ESOMAR (2013), which were in force in Brazil since 2009. All participants have accepted the general terms and the privacy policies prior to complete their registration.

Regarding current working status, 79% of participants were fulltime workers, 17% part-time, and 4% was previously employed in the past 12 months. Concerning the work position, 900 were employees and 100 managers from 100 different sized companies. Most of companies (52%) were of large size (with more than 250 employees), 28% medium (51–250 employees) and 20% small (1–50 employees). Almost one in five participants (Fig. 1) reported ever being labeled by a doctor/health professional as having depression (n¼189), with a men/women ratio of 1:1.8.

Table 1 Demographic characteristics of the participants (n¼ 1000). Variable Gender (%) Male Female Mean age (yo., SD) Age bracket (%) 18–24 year 25–34 year 35–44 year 45–54 year 55–64 year Marital status (%) Married Cohabiting Single Separated or divorced Widowed Educational level (%) Up to 8 years 8–11 years 12 or more years Region of Brazil (%) North Northeast Southeast South Middle-West Income per month (%) Low a Medium b High c

The demographic characteristics of the sample of 1000 workers are summarized in Table 1. The subjects were 57.3% male, with a mean age of 36.8 years (standard deviation [SD] 11.6). The majority was in the age bracket of 25–44 years, married, with lower educational attainment (up to 8 years), medium monthly income, and living in South region of Brazil.

Weighted proportion

589 411

57.3% 42.7% 36.8 year (11.6)

162 307 259 196 76

17.4% 30.1% 25.3% 19.2% 8.0%

423 176 329 62 6

41.2% 17.8% 33.2% 6.7% 1.1%

764 226 10

76.4% 22.6% 1.0%

75 224 129 414 158

8.0% 23.8% 7.1% 44.6% 16.4%

44 632 262

4.5% 65.2% 24.3%

yo.: year-old; SD: standard deviation; Missed data were omitted in the tabulation. a b c

Up to Brazilian Real (BRL) 1000. BRL 1001 to BRL 5000. BRL 5001 or more.

Total sample (n = 1000; 900 workers, 100 managers)

811 never labeled depressed

189 ever labeled depressed

3. Results 3.1. Demographics

n

Ever labeled depressed in working age 63 taken off work (33.3%) 126 kept working (66.7%)

Last time labeled depressed †

48 taken off work (25.7%) 139 kept working (74.3%) † missing data: n = 2

Fig. 1. Survey chart for participant workers (n¼1000).

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 48–55

3.2. Perceived depression in general When asked about the symptoms more attributable to depression in general, the participants reported (Table 2): crying without reason (68.9%), loss of interest (68.4%), and low mood or sadness (63.0%). Subsequently, sleep problems (49.9%), weight and appetite change (38.3%) were viewed as common somatic complaints of depressed individuals. The set of cognitive dysfunctions, including the items of difficulty of concentration, or indecisiveness, or forgetfulness, was endorsed by 33.7% of the workers as salient symptoms of depression. Considering each gender, men viewed crying for no reason (65.4%), loss of interest (64.5%), low mood (59.6%), and sleep troubles (48.9%) as the most attributable symptoms to depression. Similarly, women endorsed more loss of interest (74.0%), crying for no reason (72.3%), low mood (67.9%), and sleep troubles (51.3%). Despite apparent agreement on core symptoms of depression, women have generally endorsed significantly more number of symptoms than men (Table 2). Conversely, men perceived significantly more cognitive symptoms attributable to depression as a group (trouble concentrating, indecisiveness, and/or forgetfulness) than women (39.0% vs. 26.0%; po0.0001). Regardless of experience of previous depression, the overall perception of depressive symptoms was not significantly different (χ2 ¼ 0.024, p¼ 0.88). However, when the symptoms were analyzed by gender in accordance with previous experience of depression, everdepressed women reported that crying for no reason (p¼0.018) and sleeping problems (p¼0.043) were important features of depression. In contrast, never depressed women viewed more frequently loss of interest (p¼0.004) and low mood (p¼0.02) as core features of depression than never depressed men.

3.3. Gender and perceived depression in the workplace Female worker reported twice more depression than men, with the male/female sex ratio of 1:1.8. In Table 3, the participants viewed following signs and behaviors as indicators of depression Table 2 Perceived common symptoms of depression in general endorsed by all participants and by gender. Men % Women % n¼1000 n¼ 589 n¼ 411

χ2; p

Low mood or sadness Trouble concentrating Crying for no reasonnn Indecisiveness

63.0 21.7 68.9 9.0

59.6 25.1 65.4 11.7

67.9 16.8 72.3 5.1

Forgetfulness Difficulty planning activities Changes in weight and appetite Trouble sleeping/insomniannn Loss of interest nnnn Other symptoms Cognitive symptoms

8.7 24.8 38.3

10.2 26.7 32.9

6.6 22.1 46.0

49.9 68.4 0.2 33.7

48.9 64.5 0.3 39.0

51.3 74.0 0.0 26.0

7.138; 0.008 9.908; 0.002 5.311; 0.021 12.896; o 0.0001 3.988; 0.046 NS 17.441; o 0.0001 NS 10.001; 0.002 NS 18.353; o 0.0001

Depressive symptoms

n

Total %

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Table 3 Perceived behaviors and disabilities indicating depression in the workplace by total sample and gender. Depressive symptoms

Total %

Men % Women % n¼ 1000 n¼ 589 n¼411

χ2; p

Regularly coming in late Making more mistakes than usual Missing deadlines Indecisiveness More time to complete simple jobs Withdrawing from colleagues Crying at work

16.9 42.4

18.8 43.1

14.1 41.4

3.862; 0.049 NS

15.3 24.3 30.7

16.6 27.0 31.7

13.4 20.4 29.2

NS 5.658; 0.017 NS

73.1 70.5

69.9 65.0

77.6 78.3

Forgetfulness Falling asleep at work Increased/prolonged sick leave Other behaviors

20.2 10.4 33.6 0.7

19.2 9.8 30.6 0.3

21.7 11.2 38.0 1.2

7.236; 0.007 20.652; o 0.0001 NS NS 5.935; 0.015 NS

NS: non-significant.

in the workplace: withdrawing from colleagues (73.1%) and crying at work (70.5%). Making more mistakes than usual (42.4%), prolonged sick leave (33.6%), and taking more time to complete jobs (30.7%) were also salient single behaviors that can point toward depression. Furthermore, significant gender different perception was observed: men endorsed more behavior/symptoms as coming late to work (p ¼0.049) and indecisiveness (p ¼0.017). On the other hand, women endorsed more crying at work (p o0.0001), withdrawing from colleagues (p¼ 0.007), and prolonged sick leave (p ¼ 0.015) than men. Regardless gender, joint performance-related items (more mistakes than usual, more time to complete jobs, missing deadlines, and/or falling asleep at work) were viewed by around 70% of workers as indicators of depressive behaviors. Cognitive symptoms (indecisiveness and/or forgetfulness) accounted for 39% of the signs of depressive behavior at work (data not shown). Although one in five respondents endorsed the symptom of forgetfulness, this was the single item that was more likely reported by everdepressed participants than those never depressed ones (28.6% vs. 18.2%; p ¼0.001). 3.4. Impact of perceived depression and work

NS: non-significant. n Among those never depressed individuals (N ¼ 811) there was a significant difference (χ2 ¼5.452; p¼ 0.02) between men and women (59.8% vs. 68.0%). nn Among those ever-depressed individuals (N ¼189) there was a significant difference (χ2 ¼5.628; p¼ 0.018) between men and women (54.8% vs. 71.4%). nnn Among those ever-depressed individuals (N ¼ 189) there was a significant difference (χ2 ¼4.087; p¼ 0.043) between men and women (45.2% vs. 60.0%). nnnn Among those never depressed individuals (N ¼ 811) there was a significant difference (χ2 ¼8.211; p ¼ 0.004) between men and women (64.2% vs. 73.9%). Cognitive symptoms encompass trouble concentrating, indecisiveness, and/or forgetfulness.

During the last period of reported depression, the most experienced symptoms among those ever-depressed workers (n¼ 189) were low mood or sadness (71%) and loss of interest (71%), followed by sleep problems (57%), crying (55%), and weight and appetite changes (47%). Cognitive dysfunctions, considering the items of difficulty of concentration, or indecisiveness, or forgetfulness, accounted for 53% of ever-depressed ones. Comparing gender differences, women reported significantly more crying (70.5% vs. 34.5%; χ2 ¼24.33, po0.0001) and loss of interest (81.9% vs. 56.0%; χ2 ¼ 10.08, po0.0001) than men (data not shown). Since the age they started working, one-third of the 189 workers whom were ever labeled as depressed had taken time off work. One in four (25.7%) participants reported that they had taken off work during the last time they had been labeled depressive. Therefore, the vast majority of depressed participants (66.7–74.3%) continued working in contrast to those who have stopped working because of depressive symptoms, irrespective of depressed period and/or gender (Fig. 1). In last time, among those workers who remained working after being labeled depressed by a health professional (n¼139), 68% reported withdrawing from colleagues, 40% taking more time to complete jobs and indecisiveness, and 37% making more mistakes and

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crying as typical symptoms of depression. Overt performance-related impairments, such as taking more time to complete jobs, making more mistakes, and/or missing deadlines, were reported by around 60% of those depressed whom continued working. The most troublesome attributes and symptoms that had impacted on the ability to perform tasks at work were loss of interest (59%), low mood or sadness (52%), sleep problems (44%), and trouble concentrating (36%). Further cognitive symptoms impacted for 53% of depressed workers. Regarding the most frequent symptoms demonstrated more than usual while still working by those depressed ones, women reported more behavior of crying at work than men (52.8% vs. 20.9%, po0.0001). In addition, crying for no reason in the workplace has impacted more women [W] than men [M] in the ability to perform tasks (W: 38.9% vs. M: 13.4%; po0.001). On the other hand, men complained more difficulty for planning than women (W: 18.1% vs. M: 37.3%; p¼0.011). Among those who requested a sick leave because of depression (n¼ 63), common attributes/symptoms directly associated with this outcome were loss of interest (64%), low mood or sadness (62%), sleep problems (57%), crying (51%), and trouble concentrating (36%). The cognitive symptoms impacted for 50.8% of the workers. Significantly more women than men reported that crying for no reason (p¼0.004) was the main reason for taking off time of the job and more men than women informed that forgetfulness (p¼ 0.014) was the key associated symptom for doing so (data not shown). Reflecting ever labeled depressed individuals: 63 individuals who took off work because of depression reported a total loss of 4139 working days per year. Absenteeism calculated considering the parttime workers (n¼11) was 3795 days. The mean number of days outof-role was 65.7 days, being significantly lengthier for men than women (80.5 vs. 56.2; F¼4.21, p¼ 0.045). More than half of these workers took off 21 or more days (Fig. 2).

4. Discussion Observable depressive symptoms, such as sadness, lethargy, negativity and mood changes, are hallmarks of classical depression, affecting more women than men (Weissman and Klermann, 1992; Brown and Harris, 2001; Kessler, 2003; Bromet et al., 2011). The results of this survey indicate that there were more women being labeled depressed than men during their occupational lifespan. The manifestations of depressive symptoms differ between sex, in terms of perception, frequency, and psychopathology. Women report more symptoms – more overt and somatic complaints – , but also are more liable to seek help. In contrast, men endorse fewer symptoms – but more covert and cognitive complaints – , show less help-seeking behaviors, and tend to require longer period to recover from a depressive episode. The manifestations of psychomotor and cognitive functioning seem to affect unequally both genders (Carragher et al., 2011; AlexandrinoSilva et al., 2013; Schuch et al., 2014). Possibly, as depression is more prevalent among women and as they use more health services, current nosological descriptions such as ICD (World Health Organization, 1992) and DSM (American Psychiatric Association, 2013) might have put more emphasis on symptomatic constellation of depression reported by women. Though gender-specific attitudes also have shaped general opinion of depression in workplace, the difference of manifestation of depression in occupational context has received insufficient attention from most of epidemiological surveys. Some researchers (e.g., Nolen-Hoeksema et al. (1999), Kessler (2003) and Bromet et al. (2011)) describe women as more vulnerable to depressive symptoms than men because they are more likely to experience chronic negative strain, to have a low sense of mastery, and to engage in ruminative coping. Clinically depressed women are not difficult to identify in work settings: dejected mood and loss of interest in usual activities are noticeable, along

Fig. 2. Average number of days taken off work because of depressive symptoms, all workers who taken off work (n ¼63) and by gender.

with numerous other symptoms that accompany depression. Population-based investigations underscored that depressed women used to cry more and report more loss of interest than men (Carragher et al., 2011; Alexandrino-Silva et al., 2013). While women are diagnosed mainly by exploring their feelings (Nolen-Hoeksema et al., 1999), men can be diagnosed by paying attention to their behaviors, for example, psychomotor functioning and cognitive impairments (Martin et al., 2013). The underlying mechanisms of depression might be liable to similar hormone-mediated response to stress as “tend-and-befriend” in women and “fight-or-flight” in men (Taylor et al., 2000). Male depression is widespread, deeply misunderstood, and too often misdiagnosed. Symptoms of depression are usually more covert or “masked” among men (Hart, 2001). They do not connect with others, but tend to withdraw from their peers, unwilling to self-perceive themselves as depressive unless they experience a distressing symptomatic pattern (Real, 1999; Hart, 2001). Some men express depression through frustration and anger, along with the classic symptoms of male depression like: irritability, short temper, refusal to talk, overreaction to news, dissatisfaction with meals or noise, withdrawal from friends or colleagues (Cochran and Rabinowitz, 2000). Men can run away from their depressive pain and hide – some may be drowning sorrows in alcohol and substance use until committing life-threatening suicide in extreme cases (Kilmartin, 2005; Brownhill et al., 2005). This scenario suggests the need for education to improve men's help-seeking attitudes and to enhance workers' willingness to seek specialty mental health services. Male workers should be encouraged to be aware of the common depressive symptoms and the need to look for early treatment/advice (Oliffe and Phillips, 2008). Those depressed individuals who remained working can be affected by distressing symptoms of depression, with great interference in work performance (Addis and Mahalik, 2003; Cornally and McCarthy, 2011; Farrimond, 2012). In current study, three out of four depressed workers attended work while sick, possibly resulting in huge impact for the companies. In the case of presenteeism, cognitive impairments of depression (such as indecisiveness, forgetfulness and inattention) are associated with low productivity (Martin et al., 2013). Over half of ever-depressed participants reported these covert cognitive impairments as severe symptoms of depression, which intensity is disabling enough to impact daily routine (Naismith et al., 2007). Regardless taking off work or remaining at work, male depressed workers in our study seemed to report more impact in performance due to these symptoms than women. Particularly,

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executive function, working memory, attention, and psychomotor processing were associated with diminished productivity as whole (Lee et al., 2012; Trivedi et al., 2013). Therefore, addressing cognitive dysfunction may have vital therapeutic implication in the workplace (Baune et al., 2010; Godard et al., 2012), since performance variability seemed to be better explained by cognitive functioning than severity of depression symptoms (McIntyre et al., 2013, 2015; Papakostas, 2014; Trivedi and Greer, 2014). It is no surprise that many men, although deeply depressed, go untreated (Fujii et al., 2012). The chronic course of depression may be associated with delay of care seek and lengthy time to recover from depressive episodes (Berndt et al., 1998, Conradi et al., 2011). Men are less likely to perceive depression and utilize mental health services (Fujii et al., 2012; De Visser and McDonnell, 2013). The mastery of job control and situational severity can influence on the timing of help seeking (Vashdi et al., 2012). Furthermore, only about half of workers with depression received treatment and fewer than half of treated workers received treatment consistent with treatment guidelines in a recent US study (Kessler et al., 2008b). While women display more favorable help-seeking attitudes concerning mental health needs (Kessler et al., 1981; Mackenzie et al., 2006; Coen et al., 2013), depressed men used to postpone medical care and take longer period to return to work (mean absenteeism period of 80 days). Notwithstanding, many sick leaves can be prevented if there are better policies in the companies to deal with those milder depressed employees in early stage of disability. This topic needs our attention, mainly in the business world of workplace. The recent Well-Being Index survey conducted by Gallup-Healthways among US employees has estimated the cost of incremental absenteeism due to depression as USD 23 billion (Gallup, 2014). Analyses of occupational compensation data in Brazil showed that male workers were the group of the highest health burden (Sousa Santana et al., 2012; Santana et al., 2012). Since most of depressed workers remained in the job and performance reduction cannot be easily estimated, the economic loss of presenteeism while depressed should be judiciously addressed in the companies. Under-diagnoses and under-treatment of depressed men in workplace are a red flag for the managers to implement strategies for solving negative attitudes concerning their mental health needs, shortening the delay to seek help. In addition, male workers should be encouraged to be aware of the common depressive symptoms and the need to look for timely treatment/advice. Early identification, proactive help by managers and colleagues, proper referral, and adequate resource provision are some corporate ingredients to avoid productivity fall or sick leave of those depressed workers.

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5. Conclusions Findings of the current investigation in Brazilian workforce are invaluable source to compare with other Latin America and developing countries at similar economical stage. Besides considering how depressive symptoms may affect the companies' productivity, the inclusion of variable sex in the dataset of occupational health is important to appreciate the growing participation of women in the context of market economy, allowing reducing its impact to the individual, the society, and the companies as whole. Paradoxically, although women were viewed as a vulnerable group in workplace, depressed male workers emerged as a group with more unmet needs that require extensive attention. In line with the literature, our study underscores the higher likelihood of women suffering from depression than men, whereas men take longer time than women to return to work in the case of sick leave. The disability and the burden of depression should be seriously handled in the organizations, as around one in five Brazilian workers has been labeled as suffering from depression in their active professional period. However, the stigma of mental disorders seems to haunt the workplace of many depressed individuals. Both the workers and managers appear to neglect the impact of common cognitive impairments when depressed worker remained in their activities, regardless frequent reports of deficient work productivity, with deterioration of environment climate and further negative consequences to company's efficiency. Depression must be considered an interactive relationship between individuals with their personal and environmental needs in workplace setting. The identification of this devastating and onerous condition in organizations may be greatly improved by including those covert and cognitive symptoms of depression affecting the workers. Therefore, proper tools for coping with and treating depression should be offered to the workers: well-being and awareness promotion, educational programs, suitable resource provision, explicit protective labor policies can help those workers to seek care, diminishing the fear of being dismissed in the time of economic crisis. Finally, so as to bringing back those with depression to the workplace, the current study calls for a greater integration between corporate stakeholders and academic investigations on mental health of the employees. Role of funding source H. Lundbeck A/S sponsored the survey. The Ipsos Mori Healthcare department conducted the fieldwork. Ogilvy Health PR London managed the survey, shared the data to the authors and had no further influence in the reported results, the decision of publishing, and the final content of manuscript.

Conflicts of interest All authors declare no conflict of interest.

4.1. Limitations Before extending the results to Brazilian workforce, some limitations should be pondered in the data interpretation. First, selfreported information obtained from netquest using non-standardized instruments for diagnosis of depression should be cautiously compared with surveys conducted with clinical interviews. The depressive events might have occurred before their working age in some individuals, as no assessment with standard instruments has been applied to the participants. Recall bias might have occurred, as the recovered memories for personal episode of depression in past timeframe could be reported without precision and completeness. Furthermore, uneven availability of Internet service in non-developed countries can affect the representativeness of the recruited sample. Some disadvantaged individuals and population strata that do not have access to or are unfamiliar to electronic resources might be underrepresented in the study.

Acknowledgments The current investigation was carried out in conjunction with the European Depression Association (http://www.europeandepressionday.com/idea.html).

References Addis, M.E., Mahalik, J.R., 2003. Men, masculinity, and the contexts of help seeking. Am. Psychol. 58, 5–14. Alexandrino-Silva, C., Wang, Y.P., Viana, M.C., Bulhões, R.S., Martins, S.S., Andrade, L.H., 2013. Gender differences in symptomatic profiles of depression: results from the São Paulo Megacity Mental Health Survey. J. Affect. Disord. 147, 355–364. Alonso, J., Petukhova, M., Vilagut, G., Chatterji, S., Heeringa, S., Üstün, T.B., Alhamzawi, A.O., Viana, M.C., Angermeyer, M., Bromet, E., et al., 2011. Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys. Mol. Psychiatry 16, 1234–1246. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Press, Washington DC.

54

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 48–55

Andrade, L.H., Baptista, M.C., Alonso, J., Petukhova, M., Bruffaerts, R., Kessler, R.C., Silveira, C.M., Siu, E.R., Wang, Y.P., Viana, M.C., 2013. Days out-of-role due to common physical and mental health problems: results from the São Paulo Megacity Mental Health Survey, Brazil. Clinics 68, 1392–1399. Artazcoz, L., Borrell, C., Cortès, I., Escribà-Agüir, V., Cascant, L., 2007. Occupational epidemiology and work related inequalities in health: a gender perspective for two complementary approaches to work and health research. J. Epidemiol. Community Health 61 (Suppl 2), ii39–ii45. Barbosa-Branco, A., Bültmann, U., Steenstra, I., 2012. Sickness benefit claims due to mental disorders in Brazil: associations in a population-based study. Cad. Saude Publica 28 (10), 1854–1866. Barbosa-Branco, A., Souza, W.R., Steenstra, I.A., 2011. Incidence of work and nonwork related disability claims in Brazil. Am. J. Ind. Med. 54 (11), 858–871. Baune, B.T., Miller, R., McAfoose, J., Johnson, M., Quirk, F., Mitchell, D., 2010. The role of cognitive impairment in general functioning in major depression. Psychiatry Res. 176, 183–189. Berndt, E.R., Finkelstein, S.N., Greenberg, P.E., Howland, R.H., Keith, A., Rush, A.J., Russell, J., Keller, M.B., 1998. Workplace performance effects from chronic depression and its treatment. J. Health Econ. 17, 511–535. Blumner, K.H., Marcus, S.C., 2009. Changing perceptions of depression: ten-year trends from the general social survey. Psychiatr. Serv. 60 (3), 306–312. Bromet, E., Andrade, L.H., Hwang, I., Sampson, N.A., Alonso, J., de Girolamo, G., et al., 2011. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med. 9, 90. Brown, G.W., Harris, T., 2001. Social Origins of Depression: A Study of Psychiatric Disorder in Women. Volume 2. Psychology Press, Hove, UK. Brownhill, S., Wilhelm, K., Barclay, L., Schmied, V., 2005. ‘Big build’: hidden depression in men. Aust. N. Z. J. Psychiatry 39 (10), 921–931. Carragher, N., Mewton, L., Slade, T., Teesson, M., 2011. An item response analysis of the DSM-IV criteria for major depression: findings from the Australian National Survey of Mental Health and Wellbeing. J. Affect. Disord. 130, 92–98. Cochran, S.V., Rabinowitz, F.E., 2000. Men and Depression: Clinical and Empirical Perspectives. Academic Press, San Diego, CA. Coen, S.E., Oliffe, J.L., Johnson, J.L., Kelly, M.T., 2013. Looking for Mr. PG: masculinities and men's depression in a northern resource-based Canadian community. Health Place 21, 94–101. Cohidon, C., Santin, G., Imbernon, E., Goldberg, M., 2010. Working conditions and depressive symptoms in the 2003 decennial health survey: the role of the occupational category. Soc. Psychiatry Psychiatr. Epidemiol. 45 (12), 1135–1147. Conradi, H.J., Ormel, J., de Jonge, P., 2011. Presence of individual (residual) symptoms during depressive episodes and periods of remission: a 3-year prospective study. Psychol. Med. 41, 1165–1174. Conti, D.J., Burton, W.N., 1994. The economic impact of depression in a workplace. J. Occup. Environ. Med. 36 (9), 983–988. Cornally, N., McCarthy, G., 2011. Help-seeking behaviour: a concept analysis. Int. J. Nurs. Pract. 17, 280–288. De Visser, R.O., McDonnell, E.J., 2013. “Man points”: Masculine capital and young men's health. Health Psychol. 32, 5–14. Delisle, V.C., Beck, A.T., Dobson, K.S., Dozois, D.J., Thombs, B.D., 2012. Revisiting gender differences in somatic symptoms of depression: much ado about nothing? PLoS One 7 (2), e32490. ESOMAR – World Association for Market, Social and Opinion Research, 2013. Available at: 〈http://www.esomar.org/〉. European Depression Association, 2014. The IDEA Survey. Available at: 〈http:// www.europeandepressionday.com/idea.html〉. Evans-Lacko, S., Knapp, M., 2014. Importance of social and cultural factors for attitudes, disclosure and time off work for depression: findings from a seven country European study on depression in the workplace. PLoS One 9 (3), e91053. Farrimond, H., 2012. Beyond the caveman: rethinking masculinity in relation to men's help-seeking. Health 16, 208–225. Fujii, R.K., Goren, A., Annunziata, K., Mould-Quevedo, J., 2012. Prevalence, awareness, treatment, and burden of major depressive disorder: estimates from the National Health and Wellness Survey in Brazil. Value Health Reg. Issues 1, 235–243. Gallup, 2014. Depression Costs U.S. Workplaces $23 Billion in Absenteeism. Available at: 〈http://www.gallup.com/poll/163619/depression-costs-workplaces-billion-absenteeism.aspx〉. Godard, J., Baruch, P., Grondin, S., Lafleur, M.F., 2012. Psychosocial and neurocognitive functioning in unipolar and bipolar depression: a 12-month prospective study. Psychiatry Res. 196, 145–153. Hart, A., 2001. Unmasking Male Depression. Thomas Nelson, Nashville, TN. Herrman, H., Patrick, D.L., Diehr, P., Martin, M.L., Fleck, M., Simon, G.E., Buesching, D.P., 2002. Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status, health service use and treatment of people with depressive symptoms. Psychol. Med. 32, 889–902. IBM Corp., 2012. IBM SPSS Statistics for Windows; Version 21. IBM Corp, Armonk, NY. Instituto Brasileiro de Geografia e Estatística, 2011. Censo 2010: IBGE. Available at: 〈http://censo2010.ibge.gov.br/〉. Jorm, A.F., Griffiths, K.M., 2008. The public's stigmatizing attitudes towards people with mental disorders: how important are biomedical conceptualizations? Acta Psychiatr. Scand. 118 (4), 315–321. Kessing, L.V., 2007. Epidemiology of subtypes of depression. Acta Psychiatr. Scand. Suppl. 433, 85–89.

Kessler, R.C., 2003. Epidemiology of women and depression. J. Affect. Disord. 74, 5–13. Kessler, R.C., Brown, R.L., Broman, C.L., 1981. Sex differences in psychiatric helpseeking: evidence from four large-scale surveys. J. Health Soc. Behav. 22, 49–64. Kessler, R.C., 2012. The costs of depression. Psychiatr. Clin. N. Am. 35 (1), 1–14. Kessler, R.C., Heeringa, S., Lakoma, M.D., Petukhova, M., Rupp, A.E., Schoenbaum, M., Wang, P.S., Zaslavsky, A.M., 2008a. Individual and societal effects of mental disorders on earnings in the United States: results from the national comorbidity survey replication. Am. J. Psychiatry 165, 703–711. Kessler, R.C., Merikangas, K.R., Wang, P.S., 2008b. The prevalence and correlates of workplace depression in the national comorbidity survey replication. J. Occup. Environ. Med. 50 (4), 381–390. Kilmartin, C., 2005. Depression in men: communication, diagnosis and therapy. J. Mens Health Gend. 2 (1), 95–99. Lee, R.S., Hermens, D.F., Porter, M.A., Redoblado-Hodge, M.A., 2012. A meta-analysis of cognitive deficits in first-episode major depressive disorder. J. Affect. Disord. 140, 113–124. Mackenzie, C.S., Gekoski, W.L., Knox, V.J., 2006. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment. Health 10, 574–582. Mallett, D., 2006. Sampling and weighting. In: Grover, R., Vriens, M. (Eds.), The Handbook of Marketing Research: Uses, Misuses, and Future Advances. SAGE, Thousand Oaks, CA, pp. 159–178. Martin, L.A., Neighbors, H.W., Griffith, D.M., 2013. The experience of symptoms of depression in men vs. women: analysis of the national comorbidity survey replication. JAMA Psychiatry 70, 1100–1106. McIntyre, R.S., Soczynska, J.Z., Woldeyohannes, H.O., Alsuwaidan, M.T., Cha, D.S., Carvalho, A.F., Jerrell, J.M., Dale, R.M., Gallaugher, L.A., Muzina, D.J., Kennedy, SH., 2015. The impact of cognitive impairment on perceived workforce performance: results from the International Mood Disorders Collaborative Project. Compr Psychiatry 56, 279–282. McIntyre, R.S., Cha, D.S., Soczynska, J.K., Woldeyohannes, H.O., Gallaugher, L.A., Kudlow, P., Alsuwaidan, M., Baskaran, A., 2013. Cognitive deficits and functional outcomes in major depressive disorder: determinants, substrates, and treatment interventions. Depress. Anxiety 30, 515–527. Murray, C.J.L., Lopez, A.D., 1996. The Global Burden of Diseases: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Volume 1. Harvard School of Public Health, Cambridge, MA. Myette, T.L., 2008. Research on depression in the workplace: where do we go from here? J. Occup. Environ. Med. 50 (4), 492–500. Naismith, S.L., Longley, W.A., Scott, E.M., Hickie, I.B., 2007. Disability in major depression related to self-rated and objectively-measured cognitive deficits: a preliminary study. BMC Psychiatry 7, 32. Nelson, N.A., Silverstein, B.A., 1998. Workplace changes associated with a reduction in musculoskeletal symptoms in office workers. Hum. Factors 40 (2), 337–350. Nolen-Hoeksema, S., Larson, J., Grayson, C., 1999. Explaining the gender difference in depressive symptoms. J. Pers. Soc. Psychol. 77, 1061–1072. Okechukwu, C.A., Souza, K., Davis, K.D., de Castro, A.B., 2014. Discrimination, harassment, abuse, and bullying in the workplace: contribution of workplace injustice to occupational health disparities. Am. J. Ind. Med. 57 (5), 573–586. Oliffe, J.L., Phillips, M.J., 2008. Men, depression and masculinities: a review and recommendations. J. Mens Health 5 (3), 194–202. Oortwijn, W., Nelissen, E., Adamini, S., van den Heuvel, S., Geuskens, G., Burdof, L., 2011. Social Determinants State of Art Review—Health of People in Working Age. Summary Report. European Commission Directorate General for Health and Consumers, Dublin – Ireland. Papakostas, G.I., 2014. Cognitive symptoms in patients with major depressive disorder and their implications for clinical practice. J. Clin. Psychiatry 75, 8–14. Pudrovska, T., Karraker, A., 2014. Gender, job authority, and depression. J. Health Soc. Behav. 55 (4), 424–441. Real, T., 1999. I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression. Scribner, New York, NY. Santana, V.S., Villaveces, A., Bangdiwala, S.I., Runyan, C.W., Albuquerque-Oliveira, P.R., 2012. Workdays lost due to occupational injuries among young workers in Brazil. Am. J. Ind. Med. 55, 917–925. Schramm, J.M.A., Oliveira, A.M., Leite, I.C., Valente, J.G., Gadelha, A.M.J., Portela, M.C., Campos, M.R., 2004. Transição epidemiológica e o estudo de carga de doença no Brasil. [Epidemiological transition and the study of burden of disease in Brazil]. Cien. Saude Colet. 9, 897–908 ([in Portuguese]). Schuch, J.J., Roest, A.M., Nolen, W.A., Penninx, B.W., de Jonge, P., 2014. Gender differences in major depressive disorder: results from the Netherlands study of depression and anxiety. J. Affect. Disord. 156, 156–163. Silverstein, B., Edwards, T., Gamma, A., Ajdacic-Gross, V., Rossler, W., Angst, J., 2013. The role played by depression associated with somatic symptomatology in accounting for the gender difference in the prevalence of depression. Soc. Psychiatry Psychiatr. Epidemiol. 48 (2), 257–263. Silverstein, B., 1999. Gender difference in the prevalence of clinical depression: the role played by depression associated with somatic symptoms. Am. J. Psychiatry 156 (3), 480–482. Silverstein, B., 2002. Gender differences in the prevalence of somatic versus pure depression: a replication. Am. J. Psychiatry 159 (6), 1051–1052. Sousa Santana, V., Villaveces, A., Bangdwala, S.L., Runyan, C.W., Albuquerque Oliveira, P.R., 2012. Incidence of severe work-related injuries among young adult workers in Brazil: analysis of compensation data. Inj. Prev. 18, 221–227.

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 48–55

Stewart, W.F., Ricci, J.A., Chee, E., Hahn, S.R., Morganstein, D., 2003a. Cost of lost productive work time among US workers with depression. J. Am. Med. Assoc. 289, 3135–3144. Stewart, W.F., Ricci, J.A., Chee, E., Morganstein, D., 2003b. Lost productive work time costs from health conditions in the United States: results from the American Productivity Audit. J. Occup. Environ. Med. 45, 1234–1246. Taylor, S.E., Klein, L.C., Lewis, B.P., Gruenewald, T.L., Gurung, R.A.R., Updegraff, J.A., 2000. Biobehavioral responses to stress in females: tend-and-befriend, not fight-or-flight. Psychol. Rev. 107 (3), 411–429. Trivedi, M.H., Greer, T.L., 2014. Cognitive dysfunction in unipolar depression: implications for treatment. J. Affect. Disord. 152–154, 19–27. Trivedi, M.H., Morris, D.W., Wisniewski, S.R., Lesser, I., Nierenberg, A.A., Daly, E., Kurian, B.T., Gaynes, B.N., Balasubramani, G.K., Rush, A.J., 2013. Increase in work productivity of depressed individuals with improvement in depressive symptom severity. Am. J. Psychiatry 170, 633–641. Vashdi, D.R., Bamberger, P.A., Bacharach, S., 2012. Effects of job control and situational severity on the timing of help-seeking. J. Occup. Health Psychol. 17, 206–219. Vieira, E.R., Albuquerque-Oliveira, P.R., Barbosa-Branco, A., 2011. Work disability benefits due to musculoskeletal disorders among Brazilian private sector workers. BMJ Open 1 (1), e000003.

55

Vos, T., Flaxman, A.D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., Shibuya, K., Salomon, J.A., Abdalla, S., Aboyans, V., et al., 2013. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2163–2196. Wang, Y.P., Gorenstein, C., 2014. Attitude and impact of perceived depression in the workplace. Int. J. Environ. Res. Public Health 11 (6), 6021–6036. Weissman, M.M., Klerman, G.L., 1992. Depression: current understanding and changing trends. Ann. Rev. Public Health 13, 319–339. WHO World Health Organization, 2014a. Gender and women's mental health. Available at: 〈http://www.who.int/mental_health/prevention/genderwomen/ en/〉. WHO World Health Organization, 2014b. Gender disparities in mental health. Available at: 〈http://www.who.int/mental_health/media/en/242.pdf〉. World Health Organization, 1992. ICD-10: The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, Geneva. Yano, S.R.T., Santana, V.S., 2012. Work days lost due to health problems in industry. Cad. Saude Publica 28, 945–954.