Abstract
Background:
Major Depressive Disorder (MDD) has been shown a high prevalence and debilitating mental health. Most of the burden comes from reduced work functioning and frequent or long-term absenteeism.
Aims:
Describe psychosocial functionality in sample of workers with MDD and observe associated factors with sick-leave.
Methods:
Cross-sectional study. Participants were 172 formal workers with MDD according to Mini International Neuropsychiatric Interview. They were classified as active (n = 76) or in sick leave (n = 96). Functionality Assessment Short Test (FAST) was used and the variables were: personal, clinical, and occupational characteristics. Descriptive, bivariate and hierarchical multivariate analyses were conducted; significant with p < .05.
Results:
Most of the sample was female and
Conclusion:
Introduction
Major Depressive Disorder (MDD) is a debilitating mental health condition that affects more than 300 million people worldwide (World Health Organization [WHO], 2017). In Brazil, it is estimated that 5.8% of total population experience MDD during a 12-month period (WHO, 2017). MDD is also the leading cause of disability as measured by Years Lived with Disability (YLD) and accounts for 4.46% of the total Disability Adjusted Life Years (DALY; GBD 2016 Brazil Collaborators, 2018). The impairment levels associated with MDD are higher when compared with those associated with other severe chronic conditions such as cancer, diabetes, and heart disease (Kessler, 2012).
Over the last two decades, interest in MDD reduced functioning has increased due to its great adverse effects on society. About 50% to 60% of the total economic burden of MDD results from reduced work functioning and frequent or long-term absenteeism (Evans-Lacko & Knapp, 2016).
Multiple domains of functionality are typically impacted in MDD, including the ability to perform activities of daily living, the ability to form and maintain interpersonal relationships, and work productivity (McKnight & Kashdan, 2009).
Available data suggest that impaired functioning in patients with MDD may persist even after improvement in depressive symptoms (IsHak et al., 2016). Residual symptoms, especially cognitive impairment and social dysfunction, have been shown to be major mediators of relapse and occupational impairment in patients with remitted MDD (Hammer-Helmich et al., 2018; Woo et al., 2016).
In the workplace, age above 50, MDD severity, personality traits and work characteristics like job strain and lack of autonomy are the main factors associated to work impairment and absenteeism (Johnston et al., 2019; Lagerveld et al., 2010; Lerner et al., 2010).
For workers, being unable to perform occupational activities, such as sick leave or disability retirement, is a valid measure of poor functioning and health (Evans et al., 2015). However, poor awareness and social stigma affect the worker’s access to quality care for MDD (Saragoussi et al., 2017), which perpetuates the symptoms and dysfunctionality vicious cycles.
These findings show functioning as an important indicator of health and treatment success, especially at workplace. Assessing functionality is also an invaluable strategy to mitigate MDD burden. Despite the accumulating evidence of functional deficits in MDD, mainly in the workplace, research on impact on functionality in workers samples is a topic in a nascent stage, especially when it comes to the multidimensional aspects of the construct.
To our knowledge, there are no studies in Brazil that have evaluated psychosocial functionality in MDD workers and the associated factors with sick leave. This study was carried out to contemplate this gap. It has been organized in the following way: First, procedures and methods are delineated. Then, a description and comparison regarding global and each domains of psychosocial functionality between groups are provided. Afterwards, considerations on personal, clinical and occupational factors associated to sick leave are discussed.
Our hypotheses are: (a) impairments in cognitive and interpersonal functionality are significantly worse in sick-leave group; (b) sick leave is associated with clinical severity and negative psychosocial factors at work.
Materials and methods
This is a cross-sectional study. The sample was composed of 172 formal workers at a public university in São Paulo, Brazil, aged 18 years and older. They were approached in a waiting room of an occupational service unit at the university and details about the research were briefly explained by the researcher.
Retired workers, illiterate, and those who were unable to understand the questions were excluded. Those with any medical-surgical disease that may impact functionality, for example, Parkinson, arthritis or any psychiatric disorder other than current MDD could not participate as well.
Participants were screened for currently MDD, as well as other psychiatric illnesses, with the Mini International Neuropsychiatric Interview (M.I.N.I.; Amorim, 2000), a brief diagnostic interview, which is designed to detect 17 common DSM-IV diagnoses (American Psychiatric Association [APA], 2002). Participants were considered currently depressed if they reported diagnostic criteria for depression over the last 2 weeks according to MINI. They also asked about previous MDD episodes which were considered recurrent, if the answer was yes with, at least, 2 months free of symptoms between the episodes.
Severity of MDD was assessed by the Hamilton Scale for Depression with 17 items, a semi-structured clinical interview whose scores range from 0 to 54. A score until 7 is qualified as euthymic, 8 to 13 as mild, 14 to 18 as moderate, and more than 19 as severe (Freire et al., 2014). All workers were asked if they had been on current antidepressant treatment for, at least, 12 weeks and/or on treatment for a clinical disease for the last year.
All the participants were classified according to occupational impairment. Those who were working regularly or had been in sick leave for a short period (less than 30 days) in the previous 120 days, due to depressive symptoms were classified as ‘active’. Workers were classified as ‘sick-leave’ if they were totally unable to work due to depressive symptoms, and were recommended to be in sick leave for, at least, consecutive 30 days at the moment of the interview. They were entitled to sick leave after a legal medical assessment. In this study, the occupational impairment was the dependent variable.
Eligible respondents were asked questions about socioeconomic features like age, marital status, and schooling (a. Without a high school diploma; b. With a high school diploma). They also asked questions regarding physical activities (regularly, which means at least once a week; and not regularly), smoking (yes and no), and patterns of alcohol (according to Alcohol Use Identification Test – AUDIT) dichotomized into until two drinks/occasion and three or more drinks/occasion (Lima et al., 2005).
In relation to occupational variables, the workers were classified according to occupational area, that is, Health Care, Education, and Management. Afterwards, they expressed their subjective view on variables such as social support at work, autonomy on the working process, night shift work, if they liked the work they usually did, and their perceived resilience to work adversities and stress.
The quality of these variables was measured using yes/no questions. However, autonomy on the working process was measured by a Likert rating scale where the intensity is linear from hardly ever, frequently, and always.
When it comes to functionality, the measured was made by the Brazilian version of the Functioning Assessment Short Test (FAST) regarding the last 15 days (Cacilhas et al., 2009). FAST is a clinician-administered interview, which was originally designed in Spanish and translated to English and Brazilian Portuguese (Rosa et al., 2007). It was evaluated in a Brazilian sample with MDD with good psychometric properties (Cronbach alpha .98 and Kappa > 0.84; Prado et al., 2019).
FAST assess the six main impairing domains in mental disorders (Rosa et al., 2007):
Autonomy: capacity of doing things alone and taking her/his own decision;
Occupational functioning: efficiency and performing tasks at work;
Cognitive functioning: solving problems alone, learning new information, and concentrating;
Financial issues: capacity of managing the finances in a balanced way;
Interpersonal relationships: relations with friends, family and social activities engagements;
Leisure time: capacity of performing physical activities (exercise, sports) and enjoying hobbies.
The interviewer measures worker impairment on a 4-point scale, with 0 indicating no difficulties and 3 severe impairment. Domain-specific composite FAST ratings are derived from the mean scores in each domain (i.e. autonomy [0–12], occupational dysfunction [0–15], subjective cognitive dysfunction [0–15], financial issues [0–6], interpersonal relationships [0–18], and leisure time [0–6]). Total FAST score is employed as an indication of overall psychosocial functioning, indicated by the sum of FAST subdomains (0–72). Overall and domain-specific FAST composite scores are used as outcomes in linear regression analyses.
The instrument measures solely the level of functioning, without taking symptoms into account. Data may be provided by the subjects themselves and/or their families.
Participants signed the Free and Informed Consent (FIC) and were granted the right to quit the research at any time without any penalties. The information of the participants was maintained confidential pursuant to the provisions of the Declaration of Helsinki.
Data was obtained through a face-to-face interview conducted by only one researcher, a psychiatrist trained on data collection, using the tools. Workers were interviewed for approximately 90 minutes.
The period considered in this study was from 2016 to 2017.
Statistical analyses
The descriptive measures, the absolute frequencies, percentages, measures of central tendency, and dispersion were calculated using techniques of descriptive and inferential statistics. Fisher’s exact test was performed to assess the relations between the dependent variable (occupational impairment: sick-leave or active) and each selected covariates (sociodemographic, clinical, and occupational). Subsequently, Man-Whitney test was used to ascertain whether there was a statistically significant difference between depressive workers groups in terms of means and Standard Deviation (SD) of global and each FAST domain scores. A p-value <.05 was considered statistically significant.
In the multivariate analysis, the hierarchical logistic regression model was used to evaluate the interrelationship between the independent variables and the sick leave. The inclusion of variables followed the conceptual model hierarchy, selecting at first the variables of the distal group, and at second the intermediate group, both with p ⩽ .1 in the bivariate analysis. Only the variables that obtained p ⩽ .05 remained in the multivariate model. Then, the variables of the proximal group (clinical, life style, and personality) that obtained p ⩽ .05 in bivariate were added to multivariate analysis. The odds ratio (OR) and the confidence interval of 95% (95% CI) were calculated.
The missing data were imputed in the modal category of each variable. All analysis was performed in the statistical software STATA 13.0.
Results
The response rate was 97.1% and the final sample corresponded to 76 active workers and 96 in sick leave.
In our sample, most individuals were female (73.83%), under 50 years old (52.32%), married (72.26%), and did not have a high school diploma (68.6%). The descriptive characteristics of the sample and associations with occupational outcomes are presented in Table 1, based on bivariate analysis.
Overall sample characteristics according occupational outcome group (n = 172).
Fisher test (p < .05).
One drink contains 13 g of ethanol.
Bold numbers show statistically significant results.
There was no significant difference between the groups with or without occupational impairment in terms of gender, marital status, and schooling. As expected, bivariate analyses pointed that workers in sick leave were older than the active ones (69.94% at the age of 50 and older; p < .05). In relation to lifestyle, the sick leave group was less physically active (76.9% was not involved with regular physical activities, p < .05). No significant difference was found in terms of tobacco use. A reverse situation was found in terms of alcohol consumption pattern. Surprisingly, the sick absence group has a lower pattern of alcohol consumption (36.25% with until two drinks/occasion in active versus 53.74% in sick absence, p < .05).
When it comes to occupational variables, significant differences between the groups were found in terms of autonomy at working process with results showing that the sick-leave group has higher portion of low autonomy (11.46% vs. 88.54%, p < .05). In response to the question ‘Do you like your job?’, most of those who answered ‘no’ were in the sick-leave group (88.88% vs. 11.11%, p < .05), indicating that enjoying the work is an essential characteristic to avoid sick leave. Finally, most of the sick leave group reported having low resilience to work adversities (77.14% vs. 22.76%, p < .05).
Regarding functionality and in accordance with FAST (see Table 2) the most notable finding is that all functionality domains were impacted in MDD subjects. They showed impairments with different gradations. Those in sick leave presented the highest scores (p < .05), with revealed considerable dysfunctionality in this group.
Comparison of psychosocial functioning in MDD workers with and without sick leave (N = 172).
SD = standard deviation; p50 = median.
Man-Whitney test (p < .05).
The most glaring discrepancy between the two groups was found in occupational domain (active mean = 3.71 vs. sick leave mean = 15, p < .05). This is justified by the FAST instruction manual that recommends assign maximum score on this subscale in case of sick leave. In contrast, the smallest difference between the measures was observed in the leisure subscale (active mean 2.71 vs. sick absence mean 3.13 and p50 = 3, p < .05).
When it comes to the cognitive domain, although the sick leave group had higher mean scores (active mean 3.71 vs. sick absence mean 4.96, p < .05), the medians had very close values (active 4 vs. sick absence 5). On the other hand, the domains of autonomy and interpersonal relationships presented sufficiently distinct measures of central tendency (means without overlapping values after application of the SD). We may infer that they are functional domains, which better represent the incapacity for work construct.
Clinical characteristics of MDD workers, according to occupational outcomes are shown in Table 3. Data from this table revealed that the groups are sharply distinct. They have a significant positive correlation among the following: sick-leave and severity MDD, clinical comorbidity, and MDD subtype. There was no significant association with being under specific treatment (p > .05). When MDD severity is closely observed below, one may notice that most severe cases (87.35%) are in sick leave. Conversely, moderate and light cases are predominant in the active group (95.65% and 62.85%, respectively). These findings corroborate the hypotheses drawn in the present investigating, which asserts that depression severity would be directly associated with occupational impairment.
Clinical characteristics of MDD workers, according occupational outcomes (n = 172).
Fisher test (p < .05).
Regarding the sick-leave group, presenting clinical comorbidity was two folded more prevalent (67.05% vs. 32.95%, p < .05). This indicates that suffering from two or more sicknesses worsens functionality scores and impacts occupational performance.
Considering MDD subtypes, both presented similar current MDD prevalence (50.59% in sick-leave ones). On the other hand, in the sick-leave group, higher prevalence of recidivate MDD was observed (55.21% vs. 44.79%, p < .05).
An analysis of the combined influence of the independent variables by the multivariate multinomial and hierarchical logistic regression was shown in Table 4.
Multivariate multinomial and hierarchical logistic regression analyses with adjusted odds ratio (OR) with 95% confidence interval (CI) for sick leave in MDD workers (N = 172).
OR = odds ratio; Ref. = reference.
Statistical significance p ⩽ .1; **p ⩽ .05.
It is worth highlighting that, for this analysis, the variables initially selected were the ones pertaining to the distal block followed by the intermediate block, both associated with sick leave in the bivariate analysis with p ⩽ .1.
Therefore, the distal variables were gender, age bracket, marital status, and schooling. At this level, it is noticed that only age grade and schooling remained associated with sick leave.
The intermediate variables were autonomy at the working process, night shift work, enjoy the work, perceived stressful work, perceived social work support, and deal with family problems. At this level, autonomy at the work, stressing work, enjoy the work, and having family problems remained associated with the outcome.
Finally, the proximal block of variables selected to conjoint analysis with preview ones were those associated with sick leave in the bivariate analysis with p ⩽ .05.
This block was compound with clinical, lifestyle, and personality characteristics. At this level, only MDD severity, tobacco use, and resilience to work adversities remained associated with sick leave.
The final results of multivariate and hierarchical analysis showed that age bracket 50 to 54 increases by nine times the risk of sick leave (OR 9.10; 95% CI [1.75–47.24]); and age bracket 55 and more increases the risk by eight times (OR 8.61; 95% CI [1.33–55.77]). Having autonomy at the working process increases by 16 the risk for the outcome (OR 16.88; 95% CI [2.23–127.96]), followed by perceived stressing work (OR 6.76; 95% CI [1.73–26.46]), and deal with family problems (OR 3.09; 95% CI [1.03–9.30]). Enjoying the work was an incisive protective factor by reduces the risk of sick leave (OR 0.03; 95% CI [1.03–9.30]).
In relation to proximal variables, moderate/severe MDD increases by 86 the risk for sick leave (OR 86.32; 95% CI [7.57–984.43]), followed by smoking (OD 9.61; 95% CI [1.62–57.06]). Perceived resilience to deal with adversities at work is also a protective factor reducing the outcome rink by 75% (OR 0.25; 95% CI [0.08–0.78]).
Discussion
Depression is one of most prevalent condition in the working population, which may result in important impairment in employment, reduced work performance, and absenteeism (Evans-Lacko & Knapp, 2016; Mehta et al., 2014). Acknowledging the relevance of the relationship between MDD and work incapacity is mandatory, as well as carrying out investigations that aim to analyze the impact of depression on functionality, considering samples of workers.
The focus of this study was to examine psychosocial functioning in MDD workers with and without sick leave. Global and domains of autonomy, occupational, finances, cognitive, interpersonal relations, and leisure were contemplated.
Additionally, we observed sick leave relations with sociodemographic, clinical, and occupational variables.
This analysis highlights how domain-based functionality study can contribute to a more nuanced understanding of a MDD absenteeism research and help clinicians to make decisions about workers’ rehabilitation and their ability to return to work.
As expected, our findings revealed a significant relationship between psychosocial functionality and occupational outcomes with worse scores of impairments in the sick leave group.
Analysis of individual domains of functionality showed that there were no differences amongst domains and all of them are associated with sick leave. A recent meta-analysis presented consistent evidence that corroborates the fact that MDD is associated to significant deficits, such as cognition, autonomy and occupational performance (Castaneda et al., 2008).
Cognitive functionality is highly significant in the contemporary world and is essential for the performance of many occupational tasks. Previous research has indicated that cognitive impairments (concentration difficulties included) are negatively associated with work productivity (Lerner et al., 2004), given its impact on planning, decision making, and completing tasks (McClintock et al., 2010). Johnston et al. (2019) observed that cognitive symptoms had a dramatic impact on presenteeism. However, they were comparatively less important in predicting absence than physical symptoms, such as sleep difficulties and psychomotor changes. In contrast, Lam et al. (2012) identified that cognitive difficulty is a core functionality cluster that interferes most with days missed from work besides the cluster of tired/sleep problems. Cognitive function is a complex construct, which explains the inconsistent findings above. In the present study, MDD sick-leave group had the worst scores regarding cognitive functionality (p = .03).
Regarding autonomy domain, the sick-leave group also presented the worst mean scores (p = .00). According to FAST, this function is defined as the ability to have an independent life and take decisions, individually. Parallel researches suggest that autonomy difficulties are associated with cognitive impairments and with the core symptoms of depression (disinterest and depressed mood; Bortolato et al., 2014; McClintock et al., 2010). Similar to our findings, previous studies described impairments in problem solving and decision making in a MDD sample (Jaeger et al., 2003). It is understanding that the subjects that lack autonomy and are depended on others to take actions (plan and preview ways to solve problems) have compromising occupational performance, especially when it comes to activities done individually.
Depression directly impacts the quality of interpersonal relationships and social support (Jaeger et al., 2003). Subjects with MDD commonly feel frustrated, tend to be socially distant and isolated (Saragoussi et al., 2017). In the workplace, sick leave alone may be considered an embarrassment itself. It promotes stress and feeds a vicious circle of incapacities. Therefore, the fact that the worker is in sick leave negatively impacts her self-esteem and interpersonal relations.
As literature reveals, this investigation observed that the sick-leave group had worse scores considering interpersonal relationships, when compared with the active group.
The occupational subscale was the one that presented the most significant discrepancy, regarding the group mean (active mean 3.71 vs. sick leave mean 15, p < .05). According to FAST manual, the maximum score is given for sick-leave situations. Consequently, this domain is the most representative, when it comes to work incapability. On the other hand, the subscales finances and leisure were the ones with the least specific items for MDD. Although it was significant, this might be the reason for the slight discrepancy among the groups.
These findings suggested that sick leave plays an important role as a good health indicator. It is also a good representative of psychosocial functionality construct. In the workplace, multiple abilities are necessary to maintain occupational functionality and they should have cumulative effects and dynamic interactions.
One of the highlights of the present investigation is the fact that it uses samples of tenure-granted and formal workers, when assessing functionality. This method is scarcely explored in literature. A longitudinal investigation with a sample of formal workers with and without MDD observed the worst scores in MDD groups, regarding functionality in all subscales presented in WHO Health and Work Performance. The depressive participants showed the highest sick-leave rates after being followed up for 8 weeks (Woo et al., 2016).
Romera et al. (2010) carried out a cross-sectional study and appreciated functionality from Social and Occupational Functioning Assessment Scale (SOFAS) perspective in a MDD sample. Those with the most considerable functional impairments had the highest means in sick leave for the past 12 months. As other studies with similar methodologies, the present investigation observed that applying an objective tool to assess functionality is an invaluable strategy to monitor incapability and return to work processes.
In MDD, functionality recovering and return to work processes have a time-lag effect. Improvements in depression does not mean immediate return to work. These findings highlight the importance of inquiring about the impact of MDD on functionality and monitoring this recovery systematically, in an integrated and supportive manner that incorporates evidence-based support.
Regarding sick-leave associated factors, we observed that the association between aging and occupational impairment is well established in literature (Ahola et al., 2011; Holma et al., 2012; Vlasveld et al., 2012). Our results showed that the sick-leave group was older than the active one. We also found that individuals who are over 50 have nine times higher risk for sick leave (adjusted OR 9.10; 95% CI [1.75–47.24]). Additionally, those who are 55 or older have eight times higher risk for sick leave (OR 8.61; 95% CI [1.33–55.77]).
These findings mirror a longitudinal investigation on MDD subjects that pointed out that being over 50 consisted of a risk factor to occupational disability (Cornelius et al., 2011). Aging while working is a synonym of having more abilities and experience. It may be especially true for workers who are 55 or older. Notwithstanding, the modern working organizations demand that workers have a high performance. This opposes to the natural physiological aging process since the elderly are technologically outdated in comparison with the youth.
Schooling was associated with sick leave in bivariate analysis. Nevertheless, it did not remain in multivariate ones. A systematic review on the MDD work incapability predisposing factors noticed that gender, marital status, and schooling were not associated with absenteeism (Dewa et al., 2014).
Regarding clinical associated factors, our findings revealed the direct relation between MDD severity and sick leave (p = .01). The results of multivariate analysis showed that moderate/severe severity increases by 86 times the risk of sick leave (OR 86.31; 95% CI [7.57–984.43]). Previous studies showed that MDD severity was the most incisive risk factor, considering occupational impairments (Johnston et al., 2019; Lam et al., 2012; Lerner et al., 2010). MDD severity has also a strong effect across both presenteeism and absenteeism (Beck et al., 2011).
Therefore, it is important to highlight that MDD is an underdiagnosed health condition that is also undertreated which leads to unfavorable prognostic. This assertion corroborates the fact that depression is a silent disease, and it consists of an unbearable heavy burden (Romera et al., 2010). When it comes to working scenarios, actions aiming to change this reality must contemplate the adequate identification of the cases by occupational services and offer more efficient treatments. A systematic review suggested that treatment greatly improves workplace outcomes like absenteeism and presenteeism (Snyder, 2013).
When it comes to MDD subtype, recidivate MDD was the most prevalent in the sick leave group in bivariate analysis (p = .00). Nevertheless, it did not remain in multivariate ones. A systematic review on disability onset showed strong evidence that the recidivate depressive episode was associated with an increased risk of work disability (Lagerveld et al., 2010).
This investigation also revealed that the sick-leave group had higher clinical comorbidity rates in bivariate analysis (p = .00). Similar findings were presented in studies that pointed out a positive association between sick leave and the presence of at least one clinical comorbidity (McKnight & Kashdan, 2009; Saragoussi et al., 2017). Despite this specific finding did not remain in multivariate analysis, it is possible that it is being represented by smoking cigarettes. Our study results showed that cigarette smokers have a nine times higher risk of sick leave (OR 9.61; 95% CI [1.62–57.06]). Because smoking worsens general health, its relation with absenteeism seems plausible. Conversely, MDD severity might trigger unhealthy behavior and cause absenteeism. Longitudinal studies that contemplate these questions are necessary.
The present study observed a relation between occupational factors and sick leave in MDD. In bivariate analysis, the active group more frequently reported enjoying the work and having working process autonomy. In multivariate analysis, surprisingly, having autonomy at working process increases 16 times the risk for sick leave (OR 16.88; 95% CI [2.23–127.96]).
Prior research with Canadian nurses showed a strong relation among high autonomy in the working process, greater work satisfaction, and fewer work absence (Holma et al., 2012). Autonomous workers may modify their working processes according to the challenges they face. As they can take decisions, they remain active. It is important to point that, in public services, the autonomy may be representative of lack of manager support and adverse work circumstances that demand that worker face the problems alone.
Evidence regarding occupational aspects was largely lacking. Single studies suggested that adverse psychosocial factors at work, such as high job strain, lack of social support and vulnerable labor market position were associated with absenteeism (Enns et al., 2015).
In our sample, we noticed that perceived stressing work showed six times higher risk of sick leave (OR 6.76; 95% CI [1.76–26.46]). A similar result was obtained in a study that found that stressing work was a risk factor to absenteeism in workers sample with MDD in Finland (Ahola et al., 2011).
In contrast, enjoying the work decreases the risk factor to sick leave in 70% (OR 0.03; 95% CI [0.00–0.51]). Our literature review has not shown a relation between enjoying the work and sick leave in MDD samples, exclusively. Studies about work-related factors associated with sick leave are scarce. More research is needed to demonstrate the role of these factors in MDD sick leave and absenteeism. Our results together suggest that workers with MDD may benefit from work-focused interventions, especially new approaches and techniques that mitigate stress at work and make the job more interesting.
Another relevant finding was the fact that active workers were more resilient and could deal with the adversities at work. Additionally, we found that being resilient at work reduces the risk of sick leave by 75% (OR 0.25; 95% CI [0.08–0.78]). This highlights the impact of personality traces on functionality. Some authors pointed out that MDD behavioral impairments are influenced by self-motivation and the ability to overcome difficulties (Jaeger et al., 2003). MDD subjects are used to having less affective and cognitive resources to face working adversities and feed the impairment cycle. Therefore, the worker’s own perception is to be taken into consideration, since one’s performance is quite a subjective construct. We have not found studies on the relation between resilience and working impairment. This does not imply that it is not relevant, but that more high-quality studies are needed to demonstrate the role of resilience in MDD sick leave.
This study has some limitations. Firstly, it is a cross-sectional study, which makes mapping causal relations considerably challenging. The findings are restrictedly related to the sample of formal workers of a public university in São Paulo. In comparison with the working Brazilian population in general, they have higher schooling and are older, which impedes data generalization.
Secondly, just one researcher was responsible for collecting the data and carrying out the procedures. Nevertheless, convenient sample was necessary to collect data and ensure the minimum number of subjects for this study. The researcher is a clinical psychiatrist, who has extensive professional experience in the field. Regarding selection bias, measurement bias was minimized by the interview design. It had closed ended questions and objective instruments that were validated considering the research variables.
Subjectivity is an intrinsic characteristic of mental health investigations. Occupational characteristics were delineated subjectively, taking the interviewee’s perspective. MDD subjects usually face mood disturbance and it might have influenced the answers and enhanced limitations. Notably, the sample of this study consisted essentially of civil servant of a public university who were granted tenure. The fact that they could not be dismissed mitigated presenteeism and enhanced outcome reliability.
Conclusion
In this study, we described psychosocial functionality in MDD formal workers and observed factors which were associated with sick leave. In MDD, the impairments in functionality and absenteeism are responsible for most of the burden the disease presents. Therefore, further understanding them is relevant.
Our findings have extended our knowledge regarding the important role of sick leave as a valid measure of poor functioning and heath. Thus, sick leave is closely associated with personal, clinical, and occupational factors. Taken together, these results have several practical applications. They point to the fact that effective strategies to reduce absenteeism ought to involve diagnosis and efficient treatment.
Finally, promoting monitoring and rehabilitation programs is mandatory to reduce MDD burden. These programs must be subject centered and focus on personal strategies that help them cope with adversities, mitigate stress, and increase satisfaction at work. Therefore, testing interventions that focus on supporting MDD workers regarding return-to-work process is urgently needed.
