The authors have read the journal's policy and have the following conflicts: SEL and MK received consulting fees from Lundbeck. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.
Conceived and designed the experiments: SEL MK. Analyzed the data: SEL. Wrote the paper: SEL MK.
Depression is experienced by a large proportion of the workforce and associated with high costs to employers and employees. There is little research on how the social costs of depression vary by social and cultural context. This study investigates individual, workplace and societal factors associated with greater perceived discomfort regarding depression in the workplace, greater likelihood of employees taking time off of work as a result of depression and greater likelihood of disclosure of depression to one's employer.
Employees and managers (n = 7,065) were recruited from seven European countries to participate in the IDEA survey. Multivariable logistic regression models were used to examine associations between individual characteristics and country contextual characteristics in relation to workplace perceptions, likelihood of taking time off work and disclosing depression to an employer.
Our findings suggest that structural factors such as benefit systems and flexible working hours are important for understanding workplace perceptions and consequences for employees with depression. However, manager responses that focus on offering help to the employee with depression appear to have stronger associations with positive perceptions in the workplace, and also with openness and disclosure by employees with depression.
This study highlights the importance of individual, workplace and societal factors that may be associated with how people with depression are perceived and treated in the workplace, and, hence, factors that may be associated with openness and disclosure among employees with depression. Some responses, such as flexible working hours, may be helpful but are not necessarily sufficient, and our findings also emphasise the importance of support and openness of managers in addition to flexible working hours.
According to the most recent Global Burden of Disease 2010 statistics, depression ranks as a leading cause of disability
By far, the greatest contributor to the overall economic impact of depression is loss in productivity
The strong evidence for links between depression and impaired work performance contrasts with beliefs reported by employers. A recent survey of 500 employers in the UK showed that nearly half of respondents felt that employees “suffering from stress are able to work effectively at all time points”
The workplace context and attitudes of employees and managers may be important for how individuals experience depression in the workplace or make decisions around disclosure or taking time off from work. Societal beliefs, cultural context, national and local policies, and employment and related regulations may also influence decisions made by employers or reactions from employees in response to an employee with depression. In this study we investigate individual, workplace and societal factors that might be associated with greater perceived discomfort regarding depression in the workplace. We examine whether and how these factors are associated with: (i) greater likelihood of employees taking time off work as a result of depression; and (ii) greater likelihood of disclosure of depression to their employer.
For this study, we performed secondary data analysis on the IDEA (Impact of Depression in the Workplace in Europe Audit) survey data which were collected to gain insight on levels of awareness of the identification, impact and burden of the cognitive symptoms of depression across Europe for European Depression Day. Participants were recruited for the IDEA survey through an online market research panel. Before joining the panel, participants went through a screening process to validate their personal data which included: removal of duplicates, validation of name and surname through name/gender match or mismatch/misspelling as compared to library of names, country validation based on IP address (internet protocol address used to identify unique users), validation of town and zip/postal code according to official lists, checking for valid correlations between sociodemographic data (gender, age of parents and children) and validation of contact information. Individuals who worked in advertising and/or market research, and those aged under 16 years old were excluded.
Selected panel members were invited to participate in the survey through Ipsos MORI (
We used data from the IDEA survey to describe the overall population prevalence of managerial responses to employees with depression. Managers who said that they had one or more employees with depression in the past were asked how they responded to the employee. Potential responses included: (i) Offered a different work pattern (flexible working, leave etc.); (ii) avoided talking to them about it; (iii) encouraged them to talk to a healthcare professional and (iv) discussed with them and asked if there was anything I [the manager] could do to help.
Estimates of the country replacement ratio were obtained via the OECD
Sociodemographic characteristics (gender, age, marital status, education and working status) and attitudes and beliefs about depression were analysed for respondents with versus without a prior diagnosis of depression. A small proportion of respondents (1.7%) refused to answer the question regarding depression diagnosis. Individuals who refused vs. did not refuse to answer were compared based on sociodemographic characteristics and there were no significant differences except that individuals with a university education were more likely to refuse answering the question (p = 0.046). Reported prevalence of depression diagnoses and overall attitudinal and welfare/benefit characteristics are then presented by country.
Among individuals who reported a prior diagnosis of depression, two multivariable logistic regression models were used to examine (i) factors associated with a greater likelihood of employees taking time off work as a result of depression and (ii) likelihood of disclosure of depression to one's employer. A third multivariable logistic regression model investigated factors associated with greater perceived discomfort regarding depression in the workplace, now looking at all respondents. Country contextual characteristics were computed as an average rating for each country across respondents, and each variable was standardized (i.e., z score was computed). Post-stratification weights, based on gender, age and region, which were aligned with nationally representative figures, were used in all analyses. We used generalized estimating equations (GEE) with robust variance estimates to model within-country correlations
This study was classified as exempt by the King's College London, Psychiatry, Nursing, and Midwifery Research Ethics Subcommittee as this was secondary data and was fully anonymised. Data collection was performed independently by Ipsos MORI in accordance with the standards of ESOMAR, AIMRI and EFAMRO in Europe and are in line with the data protection act 1998. Data were collected as part of a market research survey and are hosted with the market research agency Ipsos MORI. All data for the market research survey are anonymous and did not include any personal information. No minors or children were involved in the study and written consent was obtained. Data can be provided upon request.
Socio-demographic and attitudinal characteristics of employees who did vs. did not report a previous diagnosis of depression are described in
Weighted percentages (95% Confidence interval) | |||
Individuals reporting experience of depression n = 1,412 | Individuals reporting no experience of depression n = 5,534 | p-value | |
Gender | <0.001 | ||
Male | 42.4 (39.8, 44.9) | 57.8 (56.4, 59.1) | |
Female | 57.7 (55.1, 60.2) | 42.2 (40.9, 43.5) | |
Age (years) | <0.001 | ||
16–24 | 7.1 (5.3, 8.9) | 10.8 (9.8, 11.8) | |
25–44 | 51.3 (48.5, 54.0) | 51.4 (50.0, 52.8) | |
45–64 | 41.7 (38.9, 44.4) | 37.8 (36.4, 39.2) | |
Marital status | |||
Single | 26.3 (23.8, 28.7) | 26.4 (25.3, 27.6) | |
Married/cohabitating | 59.7 (56.7, 61.8) | 64.9 (63.7, 66.2) | |
Divorced Separated | 12.7 (10.9, 14.4) | 7.1 (6.4, 7.8) | |
Widowed | 1.3 (0.7,1.7) | 0.6 (0.4, 0.8) | |
Refused | 0.6 (0.2, 1.1) | 0.9 (0.7, 1.2) | |
Education | <0.001 | ||
Secondary school or earlier | 7.7 (6.3, 9.1) | 7.4 (6.7, 8.1) | |
Professional qualification | 21.3 (19.2, 23.5) | 22.3 (21.2, 23.4) | |
Higher education (below university) | 20.5 (18.4, 22.6) | 19.0 (18.0, 20.1) | |
University degree | 36.9 (33.4, 39.4) | 36.8 (35.6, 38.1) | |
Refused | 13.5 (11.7, 15.3) | 14.4 (13.5, 15.3) | |
Working status | <0.001 | ||
Full time | 71.0 (68.6, 73.3) | 77.2 (76.1, 78.4) | |
Part time | 23.4 (21.2, 25.6) | 17.6 (16.6, 18.6) | |
Previously employed in last 12 months | 5.7 (4.5, 6.9) | 5.2 (4.6, 5.8) | |
Responses to attitude items | <0.001 | ||
Ranked depression as most disabling | 21.2 (18.9, 23.4) | 14.6 (13.7, 15.5) | |
Ranked depression as least disabling | 13.6 (11.8, 15.5) | 16.7 (15.7, 17.6) | |
Beliefs about symptoms of depression | <0.001 | ||
Low mood | 92.7 (91.4, 94.1) | 87.6 (86.7, 88.6) | |
Loss of interest in daily activities | 83.4 (81.3, 85.4) | 55.8 (54.5, 57.2) | |
Trouble sleeping/insomnia | 81.9 (79.7, 84.0) | 71.7 (70.4, 72.9) | |
Crying for no reason | 74.7 (72.3, 77.1) | 71.7 (70.4, 73.0) | |
Trouble concentrating | 67.3 (64.7, 69.9) | 53.8 (52.3, 55.2) | |
Changes in weight/appetite | 65.2 (62.5, 67.9) | 53.1 (51.7, 54.5) | |
Difficulty planning day to day activities | 66.0 (63.4, 68.6) | 55.8 (54.4, 57.2) | |
Indecisiveness | 55.4 (52.7, 58.1) | 40.8 (39.4, 42.2) | |
Forgetfulness | 47.0 (44.2, 49.7) | 28.9 (27.6, 30.2) |
p-values show significance level of Pearson's Chi square test.
Weighted percent (95% Confidence Interval) | ||||||||
Denmark (n = 1013) | France (n = 1003) | Germany (n = 1001) | Great Britain (n = 1002) | Italy (n = 1017) | Spain (n = 1008) | Turkey (n = 1021) | p-value | |
Prevalence of employees reporting a diagnosis of depression | <0.001 | |||||||
Females | 20.7 (16.7, 24.7) | 23.2 (19.4, 27.0) | 24.7 (20.8, 28.7) | 36.1 (31.6, 40.5) | 17.2 (13.5, 20.9) | 26.1 (22.1, 30.2) | 32.4 (27.3, 37.5) | |
Males | 18.1 (14.1, 22.1) | 15.9 (12.7, 19.1) | 14.5 (11.5, 17.6) | 18.8 (15.5, 22.0) | 9.2 (6.9, 11.6) | 17.5 (14.4, 20.7) | 19.4 (15.5, 23.2) | |
Days off of work due to depression | <0.001 | |||||||
0 | 51.9 (42.5, 61.3) | 50.9 (43.5, 58.4) | 44.4 (36.67, 52.1) | 46.8 (40.4, 53.2) | 56.6 (47.4, 65.9) | 53.2 (46.1, 60.3) | 76.6 (69.7, 83.5) | |
1–10 | 14.2 (7.8, 20.7) | 13.1 (8.1, 18.2) | 9.8 (5.2, 14.5) | 13.5 (9.1, 17.9) | 24.0 (16.0, 32.0) | 17.3 (11.9, 22.8) | 7.1 (3.8, 10.3) | |
11–20 | 7.9 (3.9, 12.0) | 12.0 (7.1, 16.8) | 13.7 (8.3, 19.1) | 7.6 (4.2, 11.0) | 7.8 (2.8, 12.8) | 6.1 (2.7, 9.5) | 4.2 (1.4, 7.0) | |
20+ | 25.9 (18.5, 33.4) | 24.0 (17.6 (30.4) | 32.1 (24.8, 39.3) | 32.1 (26.1, 38.1) | 11.5 (5.5, 17.5) | 23.4 (17.4, 29.4) | 12.1 (6.0, 18.3) | |
Offered help | 51.2 (46.7, 55.8) | 44.5 (40.3, 48.7) | 38.7 (33.6, 43.9) | 53.0 (48.3, 57.8) | 39.7 (35.0, 44.4) | 56.2 (51.8, 60.6) | 55.2 (49.3, 61.1) | <0.001 |
Offered flexible working pattern | 12.5 (9.7, 15.4) | 10.0 (7.5, 12.5) | 8.5 (5.6, 11.4) | 11.9 (8.8, 14.9) | 7.5 (4.9, 10.0) | 9.3 (6.7, 11.8) | 13.6 (10.0, 17.1) | <0.001 |
Encouraged talking to a healthcare professional | 29.6 (25.3, 33.9) | 41.5 (37.3, 45.6) | 28.1 (23.4, 32.9) | 39.8 (35.1, 44.4) | 38.5 (33.8, 43.1) | 44.9 (40.5, 49.3) | 35.5 (30.1, 40.9) | <0.001 |
Avoided talking about it | 1.8 (0.7, 2.9) | 5.3 (3.4, 7.2) | 7.8 (4.9, 10.6) | 3.3 (1.6, 4.9) | 12.4 (9.3, 15.6) | 6.1 (4.0, 8.2) | 9.3 (5.7, 12.8) | <0.001 |
Replacement ratio (OECD) |
40 | 49 | 41 | 29 | 23 | 42 | 22 | <0.001 |
In this case, replacement ratio refers to gross replacement rates by level of individual earnings specifically including employment insurance and unemployment assistance benefits obtained via OECD.
p-values show significance level of Pearson's Chi square test.
Adjusted GEE parameter estimates Odds Ratio (95% CI) | |
Gender | |
Female | |
Male | Reference |
Age | |
45–64 | 0.97 (0.65, 1.46) |
25–44 | 0.87 (0.62, 1.21) |
16–24 | Reference |
University education | |
Yes | 1.04 (0.85, 1.26) |
No | Reference |
Diagnosed with depression | |
Yes | 1.02 (0.95, 1.08) |
No | Reference |
Working in a larger company | 1.03 (0.98, 1.08) |
Country prevalence of manager reactions to someone with depression | |
Offered help to employee | |
Offered flexible working pattern | |
Encouraged them to talk to a healthcare professional | 0.94 (0.88, 1.01) |
Avoided talking about it | |
Replacement ratio (OECD) |
In this case, we examine respondents who endorsed ‘It would make other employees feel uncomfortable in response to the survey question: If someone in your workplace suffered with depression, what impact, if any, do you think it would have?
* = p<0.05,
** = p<0.01,
*** = p<0.001.
Adjusted GEE parameter estimates Odds Ratio (95% CI) | |
Gender | |
Female | 0.84 (0.67, 1.06) |
Male | Reference |
Age | |
45–64 | 1.25 (0.80, 1.93) |
25–44 | 1.20 (0.81, 1.77) |
16–24 | Reference |
University education | |
Yes | |
No | Reference |
Working in a larger company | 1.05 (0.99, 1.11) |
Country prevalence of manager reactions to someone with depression | |
Offered help to employee | |
Offered flexible working pattern | |
Encouraged them to talk to a healthcare professional | |
Avoided talking about it | |
Replacement ratio (OECD) |
* = p<0.05,
** = p<0.01,
*** = p<0.001.
Adjusted GEE parameter estimates Odds Ratio (95% CI) | |
Gender | |
Female | |
Male | Reference |
Age | |
45–64 | |
25–44 | |
16–24 | Reference |
University education | |
Yes | |
No | Reference |
Working in a larger company | |
Country prevalence of manager reactions to someone with depression | |
Offered help to employee | |
Offered flexible working pattern | |
Encouraged them to talk to a healthcare professional | |
Avoided talking about it | 1.03 (0.95, 1.12) |
Replacement ratio (OECD) |
* = p<0.05,
** = p<0.01,
*** = p<0.001.
Depression is experienced by a large proportion of the workforce and associated with high costs to employers; however, there is little research on factors which may influence the experience of having and coping with depression in the workplace and how this may vary by cultural setting across Europe. This study highlights the importance of both individual and sociocultural factors which may be associated with how people with depression are perceived and treated in the workplace, and hence, factors which may impact on openness and disclosure among employees with depression.
Our findings suggest that structural factors such as benefit systems and flexible working hours are important for workplace perceptions and employee outcomes; however, it seems that manager responses which focus on offering help to the employee with depression have the strongest association with positive perceptions in the workplace and also, openness and disclosure of employees with depression. Other research has emphasised the importance of positive attitudes in relation to social acceptance of people with mental illness as a key driver of stigma and has shown a direct link between these attitudes and the experiences of people with mental illness. For example, one study found that greater prevalence of comfort in talking to people with mental health problems among the public was associated with lower self-stigma, perceived discrimination and higher empowerment among people with mental health problems living in that country
Our study also identified other manager responses which were associated with employee outcomes and general workplace perceptions. A higher prevalence of managers avoiding talking with the employee about the problem was associated with a lower likelihood of taking time off work. This may indicate a general ignorance around depression. For instance, the data suggested that respondents lacked understanding of the symptoms and experience of depression, as respondents tended to associate depression more with affective symptoms, such as low mood, rather than cognitive symptoms, such as difficulty concentrating, indecisiveness and forgetfulness. Avoidance, however, may also result from prejudice and negative beliefs, and avoidance has been shown to be especially harmful in relation to employment of people with serious mental illness
Interestingly, offering flexible working hours was also associated with a lower likelihood of taking time off work, a lower likelihood of disclosure and a higher likelihood of discomfort around depression in the workplace. Although it may be helpful for the employee to have the opportunity to work flexibly as they are recovering from an episode of depression, this strategy might also suggest that the problem could be solved in the workplace or through organisational strategies, and does not necessarily promote social inclusion or reduce stigma against people with depression. Importantly, a higher prevalence of managers encouraging employees to talk to a healthcare professional was the only factor associated with a higher likelihood of employees taking time off work as a result of their depression. It may be that this strategy signifies a culture which supports dealing with depression outside of the workplace through the support of health professionals. It is interesting to note that although flexibility in working arrangements and offering help or increased benefits may be recommended to support employees, they are not necessarily universally positive and so it may also be important to consider wider-ranging and indirect effects
In terms of individual characteristics, females were more likely to feel comfortable with the issue of depression in the workplace and also to disclose their own depression to their employer. This is in line with previous research which suggests that females tend to have less stigmatising attitudes about people with mental illness
To understand the social impact of depression in the workplace, it is important to investigate perceptions of employees and managers alongside experiences of employees with depression and their relationship. For example, knowing someone with a mental illness is associated with better attitudes and less discriminatory behaviour; however, it is contingent upon disclosure of a mental illness, which is also influenced by social acceptance
This study begins to fill an evidence gap by identifying important societal factors which promote positive perceptions about people with depression in addition to openness and disclosure. A recent review of the literature identified nine factors associated with disclosure of a mental illness in an employment setting; however, all of the identified studies were from the USA and they tended to focus on individual factors (e.g., gender, severity of symptoms, diagnosis) or were performed within supported employment rather than mainstream employment settings
This study addresses a gap in the literature in terms of developing our understanding of social and cultural factors associated with depression in the workplace. Our findings come from a unique dataset including both employees and managers from seven countries across Europe, and information on their personal experiences of depression or their general perceptions of depression in the workplace. Although diagnosis of depression was based on self-report and we were not able to control for clinical characteristics, such as severity and/or type of symptoms, the characteristics of respondents with or without depression are in line with other epidemiological research. For instance, study respondents reporting a diagnosis of depression were more likely to be female, divorced and working part time. Individuals who reported never having a diagnosis of depression were more likely to be married, in the youngest age group (16–24) and working full time
Additional limitations are that data from this study did not include information on variables such as ethnicity or migration which might also be related to social exclusion in employment settings, in addition to mental illness and a low response rate. This study lacks detail on clinical characteristics, functioning and work roles, meaning that we could not explore how these might be related to consequences of or reactions to depression in the workplace. For instance, it could be that the consequences of certain workplace attitudes and/or practices might differ by severity of depression and future research might explore the complexity of these relationships and whether, for example, openness and support might be more important for someone who experiences chronic episodes of depression. As we include a mixture of aggregate country characteristics in addition to individual characteristics, this is a partial ecological study. Although we feel that it is important to explore the relationship between individual and cultural factors in this case, the results should be interpreted with due caution.
A strength of the study is that it draws on data from seven countries, but this does not necessarily mean that the findings are generalisable. Finally, these data were cross-sectional, so it was not possible to examine the pathway or mechanism by which, for example, disclosure or manager response is related to workplace perceptions or directly impacts on an employee with depression.
Previous research has noted that absenteeism and early retirement as a result of mental illness, especially depression, seem to be increasing across Europe
We would like to acknowledge Lundbeck and IPSOS Mori for sharing the IDEA survey data.