‘Work is a motivator in life’ Strategies in managing work participation among highly educated employees with depression

Abstract

BACKGROUND:

Work participation among employees with depression is hampered due to cognitive impairments. Although studies show higher levels of work disability among people with a lower education, highly educated employees may encounter specific challenges in fulfilling their work role due to the cognitive impairments of depression, as they often perform cognitively demanding jobs. There is little knowledge about their challenges and opportunities with regard to work participation.

OBJECTIVE:

To investigate how highly educated employees with depression manage work participation by focusing on their views on opportunities and challenges in fulfilling their work role.

METHODS:

Eight individual interviews with highly educated employees with depression were conducted. Transcripts were analysed using qualitative content analysis.

RESULTS:

The analysis revealed four categories: struggling with acknowledging depression and disclosure; fear of being stigmatised at work; work is a motivator in life; and striving to fulfil the work role at the expense of private life activities.

CONCLUSIONS:

Highly educated employees with depression need guidance regarding the disclosure of information about health issues and work ability. To successfully manage their work role, they need a clear plan with outlined tasks, demands and goals. Healthcare professionals and workplaces should support them in setting limits with regard to work tasks and working hours.

Keywords

Mental disorders vocational rehabilitation disclosure qualitative interview qualitative content analysis

1 Introduction

Work participation among employees with depression is often hampered, as depression impairs psychosocial and cognitive functioning which adversely affects the ability to work [1]. In Europe, 10 per cent of employees have been absent from work due to depression with a mean of 35.9 sick days during a depressive episode [2]. Studies suggest that work can contribute to the treatment and rehabilitation of mental disorders including depression by contributing with a sense of normality, feelings of being wanted and valued and by improving self-esteem [3 –6]; it can therefore be important to maintain attachment to the workplace when living with a depression.

Highly educated employees with depression have been estimated to have an approximately 30 per cent lower level of absenteeism compared to lower educated employees with depression [7]. This have been explained as a result of better coping strategies among people with a higher education [8, 9]. Yet, only a few studies have focused on how highly educated employees with depression manage their work participation. A meta-synthesis shows that perfectionism and a strong work identity appeared to be more common among women with common mental disorders and a moderate to high educational level and/or white-collar jobs, e.g., decline to perform work tasks even when time was short, explaining that perfectionism was rooted in a understanding of the different roles they had to fulfil both as women and as a good worker; thus indicating that they perceived other challenges in managing work participation than lower educated, such as difficulties with setting limits [10, 11].

The cognitive symptoms of depression, such as memory loss, reduced reaction time and concentration, indecisiveness and forgetfulness, are the most prominent being present up to 94%of the time during a depressive episode [12]. People with a higher education may encounter specific challenges in fulfilling their work role when they have cognitively demanding jobs requiring concentration, decisiveness and rapid understanding of situations and responses, which are all skills that may be impaired due to the cognitive symptoms of depression [7].

People with mental illness often find themselves in a dilemma about disclosing their mental health problems at work [13]. Some choose to keep their mental health problems a secret to avoid discrimination and stigmatisation, while others are open about their issues, which allows them to request adjustments in the workplace [13, 14]. Corrigan & Watson [15] differentiate between public stigma, i.e. when the general population endorses prejudice and manifests discrimination toward people with mental illness, and self-stigma, i.e. the internationalisation of negative stereotypes of people with mental illness. A study showed that willingness from both the employer and employee to engage in and commit to the vocational rehabilitation process is essential in dealing with depression in a workplace context [16]. Highly educated employees with depression are less likely to disclose their depression to their employer compared with lower educated employees with depression [17]; therefore they might have an unmet need for support from the workplace. Yet, there is a lack of knowledge on how highly educated employees with depression deal with their depressive symptoms in a work life context, and there is a lack of studies that seek in-depth understanding of the opportunities and challenges that highly educated employees with depression encounter in managing their work participation.

Strategies for managing work participation among employees with depression, such as deciding to stay at work or go on sick leave, rely on disorder-related factors, e.g. depressive symptoms and severity, personal factors such as education, self-esteem and values, and environmental factors such as low workplace support, stigma and prejudices towards mental disorders [4 , 18–21]. Thus, whether or not a person is at work is the result of a complex set of factors including work-related and personal factors. The expanded ICF model by Heerkens et al. [22] focuses on the individual work functioning, and includes the environmental and personal factors, as contextual factors influencing individual health work disability. Although the influence of the personal and the work-related factors on work participation among employees with depression is widely acknowledged, existing studies have primarily focused on the disorder-related factors [21, 23]. Therefore, the model is usable as a framework to grasp work participation as this dynamic concept being influenced by factors related to the disorder, the person, and the work environment [22 , 25]. To uncover the strategies used by highly educated employees with depression in managing work participation, there is a need for focusing on the single employee in the context of working life and for investigating their opportunities and challenges in fulfilling the work role.

Therefore, the aim of the present study was to investigate how highly educated employees with depression manage work participation by focusing on their views on opportunities and challenges in fulfilling their work role.

2 Methods

2.1 Setting

The study was carried out in two Danish regions, the Central Denmark Region and the Capital Region of Denmark, in a work life context of people with a higher educational level and depression.

2.2 Participants

Eight employees were included using purposive sampling: employees with a higher education, depression and attachment to the labour market were selected [26]. Inclusion criteria:

Having a higher educational level, minimum at Master’s level (ISCED-niveau-7-8 [27])

Being diagnosed with depression by a general practitioner, psychiatrist or medical specialists in psychiatry (ICD-10: F32-F33.9 [28])

Employed while being diagnosed with depression during the last 18 months

Danish or English speaking

Employees were recruited through general practitioners, medical specialists in psychiatry, psychologists, human resource consultants in organisations with primarily highly educated employees, social case workers in municipal departments of social affairs and employment, and recruitment posters submitted to various institutions with highly educated employees. In this way different channels were used in the recruitment process, which increased the heterogeneity of participants in terms of depression severity and strategies for managing work participation, e.g. being open about having a depression and decisions regarding sick leave and employment. This made it possible to capture the various ways in which depression manifests itself among highly educated employees with depression, strengthening the external validity of the results. Relevant participants were asked to contact the first author CNL (MScPH, PhD Fellow in Health Sciences) by phone or email, who provided oral information on the study. When the employees were identified as information-rich cases in compliance with the inclusion criteria, and agreed to participate, the time and place for an interview was scheduled. The main characteristics of the included employees are presented in Table 1.

Table 1
Main characteristics of the participants

ID Gender Age Highest educational attainment Current job function Partner status, children Residence (Region) Current treatment of depression Work status

P1 Male 40 Master’s degree Teaching at a university, public sector Single, no children Central Denmark Region Recently stopped medication Have hourly paid work, seeking more work hours in his specialised field

P2 Male 36 PhD Teaching at a professional Bachelor’s education, public sector Married, two children Central Denmark Region Anti-depressants, consultations with a psychologist Have full-time work, obtained new job without assistance from vocational service providers

P3 Male 52 Master’s degree Teaching at a professional Bachelor’s education, public sector Married, one child Central Denmark Region Anti-depressants Returned to work with work adjustments involving administrative work tasks, but seeking other jobs

P4 Female 56 PhD Associate professor at a university, public sector Married, two children Capital Region of Denmark Anti-depressants, consultations with a psychiatrist Returned to work with work adjustments involving less hours of teaching and reduced working hours

P5 Female 66 Master’s degree General practitioner, private sector Divorced, three children Capital Region of Denmark Anti-depressants Part-time employment in general practice

P6 Female 36 Master’s degree Consultant in an information technology company, private sector Married, two children Central Denmark Region Anti-depressants, consultations with a psychologist On long-term sick leave, preparing for gradual return to work

P7 Female 66 Master’s degree Playwright and instructor at a theatre, private institution Divorced, two children Capital Region of Denmark Consultations with a psychiatrist Recently retired at the request of the workplace due to numerous sick days in one year, wishes to become engaged in voluntary work

P8 Female 35 Master’s degree Consultant in an insurance company, private sector Divorced, two children Capital Region of Denmark Anti-depressants, consultations with a psychiatrist Full-time employment with a desire to get promoted in the company

ID	Gender	Age	Highest educational attainment	Current job function	Partner status, children	Residence (Region)	Current treatment of depression	Work status
P1	Male	40	Master’s degree	Teaching at a university, public sector	Single, no children	Central Denmark Region	Recently stopped medication	Have hourly paid work, seeking more work hours in his specialised field
P2	Male	36	PhD	Teaching at a professional Bachelor’s education, public sector	Married, two children	Central Denmark Region	Anti-depressants, consultations with a psychologist	Have full-time work, obtained new job without assistance from vocational service providers
P3	Male	52	Master’s degree	Teaching at a professional Bachelor’s education, public sector	Married, one child	Central Denmark Region	Anti-depressants	Returned to work with work adjustments involving administrative work tasks, but seeking other jobs
P4	Female	56	PhD	Associate professor at a university, public sector	Married, two children	Capital Region of Denmark	Anti-depressants, consultations with a psychiatrist	Returned to work with work adjustments involving less hours of teaching and reduced working hours
P5	Female	66	Master’s degree	General practitioner, private sector	Divorced, three children	Capital Region of Denmark	Anti-depressants	Part-time employment in general practice
P6	Female	36	Master’s degree	Consultant in an information technology company, private sector	Married, two children	Central Denmark Region	Anti-depressants, consultations with a psychologist	On long-term sick leave, preparing for gradual return to work
P7	Female	66	Master’s degree	Playwright and instructor at a theatre, private institution	Divorced, two children	Capital Region of Denmark	Consultations with a psychiatrist	Recently retired at the request of the workplace due to numerous sick days in one year, wishes to become engaged in voluntary work
P8	Female	35	Master’s degree	Consultant in an insurance company, private sector	Divorced, two children	Capital Region of Denmark	Anti-depressants, consultations with a psychiatrist	Full-time employment with a desire to get promoted in the company

2.3 Ethics

Before giving written consent, employees were informed orally and in writing about the aim of the study, participation and ethical formalities. The employees were informed that they could discontinue the study at any time. The employees were anonymised in all documents used for further processing, and personal information was kept confidential and destroyed when no longer needed. Prior to interviewing, ethical considerations were undertaken, e.g. if suicide or other types of self-harm were considered a risk, the employee’s general practitioner or psychiatrist should be contacted in cooperation with the employee; however, this did not become relevant. No employees withdrew from the study. The study was registered with the Danish Data Protection Agency (no. 2014–41–3574).

2.4 Data collection

Individual semi-structured interviews [29] were conducted by CNL. On the employee’s request, the interview took place in the employee’s home, in a meeting room at the employee’s workplace or at Aarhus University. Each interview lasted 60–90 minutes and were conducted from June 2017 to January 2018. The semi-structured interview guide comprised five themes: background information about the employee; depressive symptoms and work participation; workplace culture and environment; home environment and personal relations; and the future, so the themes corresponds to the assumptions based on the background literature on depression and work participation, thereby strengthening the internal validity. The comprehensive interview guide is provided in the Appendix. To make the employee feel safe in participating and sharing their view, CNL contacted the employee by telephone, text message or email depending on the employee’s request prior to the interview to establish a relation. When meeting the employee for the interview, a slow and casual beginning was strived for using small-talk to make the employee feel comfortable in the situation. During the interview, the employees’ need for time to think and reflect was facilitated through silence and calmness in the situation to await and stimulate further elaboration. This allowed the employee to nuance and clarify their views. Based on the employees’ responses, other themes describing the employees’ opportunities and challenges managing work participation were pursued.

All interviews were digitally recorded. After interviewing, immediate impressions and considerations were noted in a logbook. The interview process was concurrently discussed with MB (MA, PhD in Medicine, Professor) to strengthen the reliability of the data collection.

2.5 Analysis

Interviews were transcribed verbatim, including pauses, laughter and changes in breathing, tone of voice or vocal pitch [30]. The transcripts were analysed using inductive content analysis methodology [31 –36], which was conducted in four steps. Firstly, CNL read the transcripts to obtain an overall impression of the interviews and noted initial analytical considerations into a logbook. Secondly, meaning units from all interviews were extracted using two analytical questions: 1) what are the opportunities among highly educated employees with depression in managing work participation? and 2) what are the challenges among highly educated employees with depression in managing work participation? In the initial coding process, CNL and STK (RN, MCN, PhD Fellow in Health Sciences) independently extracted meaning units from one interview using the two analytical questions and discussed their coding decisions. Both CNL and STK are experienced in qualitative content analysis. CNL has experience in public health research, while STK has experience in psychiatric nursing; thus, the two coders were able to capture different aspects of the aim involving disorder-related and contextual factors. After the initial coding, CNL and STK independently coded one interview, and compared their decisions; the inter-coder agreement was 63%[35]. Diverging interpretations concerned the interpretation of aspects being an opportunity or a challenge. CNL and STK discussed all diverging interpretations of aspects, which gave render to further clarification and understanding of the employees’ strategies for managing work participation; subsequently, CNL coded all interviews. Thirdly, the extracted meaning units were analysed focusing on resemblance in meaning and were composed into four descriptive categories. During categorisation, the logbook was used to situate the meaning units in context that captured the latent content. Fourthly, these categorised meaning units were compared to identify meaningful patterns which were comprised into two explanatory themes. The analytical process was conducted in dialogue between CNL, MB, STK and CVN (MD, PhD in Medicine, Professor) to strengthen the validity and reliability of meaning units, categories and themes [31, 34].

3 Results

The analysis revealed four categories describing the employees’ views on opportunities and challenges in managing work participation: ‘Struggling with acknowledging depression and disclosure’, ‘Fear of being stigmatised at work’, ‘Work is a motivator in life’ and ‘Striving to fulfil the work role at the expense of private life activities’.

3.1 Struggling with acknowledging depression and disclosure

Depressive symptoms are repressed and disclosure at work is avoided in trying to maintain control over the situation, which limits opportunities to receive targeted support.

Depression is viewed as a weakness of character that should be hidden and dealt with as a personal issue. When having prejudices and negative perceptions about people with depression, help-seeking is avoided to dissociate oneself from negative stereotypes of people with depression, e.g. as being lazy or weak. In trying to maintain control over the situation, the depression is kept secret and it is assumed that one should be able to deal with depression alone: “I am so afraid of becoming a couch potato who can’t do anything. That must be my greatest fear. That I have to ask for help and so? No, I can handle it by myself, right.” (participant (p)8).

Depression is considered a threat to one’s work image and sick leave due to depression is viewed as a defeat when depression is understood as a self-induced plague. Working becomes a strategy to deal with a threatened work identity by keeping depression at a distance. To uphold a strong work identity and image at the workplace, sick leave is deliberately avoided and the depression is kept secret: “I don’t think that you will get it [a promotion] if you call in sick with a depression, then it is for sure that it does not come as easy, as if you can hide it.” (p8).

Performing at work briefly compensates for low self-esteem. Neglecting depressive symptoms by upholding the current work pace results in worsening of symptoms, and in the long run, sick leave becomes unavoidable and results in feelings of loss of control: “It [depression] could not disappear by working, it could not disappear, or it could not be kept at a distance I would say. And then it is like a tsunami that just overflows” (p4).

3.2 Fear of being stigmatised at work

While longing for support and acceptance from co-workers and employer, there is an unmet need for support from the workplace due to fear of stigmatisation. Understanding and acceptance from the workplace are desired to alleviate feelings of being wrong.

Disclosure is avoided due to fear of being stigmatised by co-workers and employer. Instead, life events such as having young children or recently having been divorced, or other mental health conditions such as stress, are used as explanations for negative moods or behaviour changes to fulfil a need for understanding and acceptance from the employer and co-workers: “So everybody knows about the divorce. But it is not so many I talk to about it being difficult or so. . . And nobody knows that I see a psychiatrist and get medication” (p8). On the contrary, openness about depression at work gives the employer and co-workers the opportunity to fulfil the employee’s need for support at work: “When you ’ve told colleagues how you feel, then people can be aware that there are some things you cannot manage” (p2). Social contact or activities with co-workers and employers during team meetings or coffee breaks is difficult to participate in because of feelings of being useless and unable to meet employers’ and co-workers’ expectations. Isolating oneself and cutting oneself off from the support of co-workers and employers by calling in sick or working at home are used as strategies to ease feelings of being a burden: “When I tried to ask for help [at the workplace], I got this feeling of being wrong, that I am burdensome, that I need lots of help (. . .) and then I didn’t feel like being there.” (p6).

3.3 Work is a motivator in life

Work establishes structure in everyday life, distracts from depression and evokes feelings of being useful. Yet, the positive effect of work is obstructed by being unable to meet work demands.

Viewing work as an activity that contributes with meaning and substance in life provides opportunities for managing work participation. When job tasks and demands comply with individual values and ability to work, the work activity is therapeutic and alleviates depressive symptoms. The ability to master the work role evokes feelings of being esteemed and useful to others: “To be able to perform tasks and inspire others, and then of course to be affirmed that you are capable of doing things. That is definitely also a part of it” (p4). Work structures the day and being at work distracts from the depression. It is possible to perform at work despite cognitive deficits due to depression, e.g. lack of concentration and indecisiveness, when being routinised at the workplace and in the work tasks. Having work tasks that provide the opportunity to work from home and are not defined by clearly-defined criteria for success on a daily basis make it possible to continue participation in full-time employment despite depression. Although a lack of clear criteria for success is difficult to manage, providing a feeling of being unable to succeed: “The problem is that there aren’t any clearly defined success criteria at all for what I do. Therefore, nobody knows when I am a success and when I am not.” (p8).

Work tasks that demand social contact, such as teaching students, patient care, or teamwork with co-workers, can be both a challenge and an opportunity. On the one hand social contact is challenging as it is energy-intensive and thus can seem insurmountable. On the other hand, scheduled meetings and appointments with others expecting one’s appearance provide a purpose for the day and impose positive feelings of being a part of something bigger than oneself. Just getting up in the morning and starting the day is found to be difficult when there are a lack of clearly formulated expectations for the work day, e.g. clear job tasks, goals and task to complete: “If I feel tired in the morning and I am not forced to go at work, then I have a tendency to stay at home, and then I might not do what I should or if there isn ’t anything I have to prepare for the next day, then I will postpone it.” (p2).

3.4 Striving to fulfil the work role at the expense of private life activities

Perfectionism and high expectations of oneself as a worker provide difficulties in withdrawing from work activities which impose an imbalance in daily life.

Taking pride in fulfilling the work role and showing self-confidence in the ability to perform the work tasks are used as strategies to battle a threatened work identity and low self-esteem. A strong work identity and commitment to work impose high expectations to oneself as a worker. Depressive symptoms are intensified when feelings of failing in the work role occur: “I would like to be able to say to myself that alright this I was capable of, I proved successful, I managed to get it [work tasks] away, I am not, I am not. . . It should not be a part of my self-understanding that I am person who could not handle it” (p2). In trying to fulfil own expectations, it is difficult to withdraw from work activities, as it becomes a question of being a failure or a success in life. As a result, performing at work during the weekdays is prioritised, while practical tasks at home and social activities with friends and family are neglected: “I have had many weekends the past year, where I have just been tired. And then it affects my family because it influences my mood (. . . ) because I think I use a lot of energy, that is, I mobilise a lot of resources during the weekdays” (p2).

Acknowledging individual needs and taking account of individual functioning, such as levels of energy during the day, reflecting on how to prevent relapse and bend to it, provide opportunities to stay at work despite depression. Therapeutic consultations with a psychologist, medical treatment, mindfulness and psychical activity evoke the ability to reconsider daily routines and personal values: “I practiced mindfulness while reflecting about how to prevent a relapse” (p5).

4 Discussion

The comparative analysis (32) of the four categories revealed two themes explaining how highly educated employees with depression manage work participation: ‘Dealing with depression as a private issue, but longing for support at work’, and ‘working to ease depressive symptoms, while struggling to fulfil the work role’. The themes explain how secretiveness about depression at work is used to avoid stigma attached to depression, while meanwhile an unmet need for support from the workplace is hampering work participation. Working becomes a means to deal with a threatened work identity and to compensate for low self-esteem. Work has a high priority in life for highly educated people in the sense that it provides opportunities for manging work participation, although challenges are encountered when being unable to meet high expectations to oneself.

4.1 Dealing with depression as a private issue, but longing for support at work

The fear of being stigmatised by co-workers and employer led to the depression being kept secret, which obstructed opportunities to receive targeted support. This is in accordance with the comprehensive literature on stigma linked to depression at the workplace and the recognition of stigma as an important barrier for disclosure at work [13 , 38]. The depression was kept secret and changes in behaviour or negative mood were instead explained by going through a divorce or stress. Such a strategy is in line with a study that found that people with affective disorders faced dilemmas regarding disclosure to co-workers and employers due to fear of being stigmatised [14]. This is also in line with Corrigan & Rao [39] who stated that non-disclosure was a feature of self-stigma; therefore initiatives to overcome the internalisation of negative stereotypes of people with depression should be established to enhance the opportunities for the workplace to meet the needs of employees with depression in managing work participation.

Our results showed that sick leave and openness about depression was avoided when aiming for a promotion because of a fear of being considered incompetent due to depression. In this way, stigma can be a work-related factor, i.e. where the workplace holds negative attitudes towards employees with depression [40, 41]. This relates to the expanded ICF model drawing attention to the work-related factors influencing individual functioning and health [22, 25]. Thus, there is a need for establishing and supporting norms about disclosure at work, and employees with depression may need guidance regarding disclosing information about their health issues and work ability. In accordance, Hielscher & Waghorn [42, 43] identified a need for evidence-based tools to facilitate better disclosure decisions and better management of employee’s health information in workplace settings.

4.2 Working to ease depressive symptoms, while struggling to fulfil the work role

Being at work was found to be positive, since the work activity itself and being in social contact with others distracted from the depression, and highly educated employees with depression therefore continued to work despite depression. Accordingly, studies highlighted the benefits of working, explaining that work promotes health by being an escape from illness [3, 44]. However, the results showed that highly educated employees with depression continued to work so as to ease a threatened work identity and to compensate for low self-esteem, but depressive symptoms were intensified when being unable to meet high expectations to oneself. A study on employees with mental illness showed that fulfilling the work role evoked feelings of being accepted and valued, while receiving benefits or being unemployed was shameful, which complied with existing socio-cultural norms and values [4]. Thus, as work participation is a mean to strengthen self-esteem and evoke positive feelings of being useful, the importance of developing effective interventions to ensure that employees with depression escape the need for full-time sick leave is underscored.

The results from the present study revealed that perfectionism and high expectations to oneself as a worker made it difficult to withdraw from work activities, and avoiding sick leave was used as a strategy to ease a threatened work identity, live up to high standards and to comply with the societal norms and values which expect individual contribution to the labour market. In accordance, a study showed that highly educated women with mental health problems feared setting limits at work because they found it socially unacceptable [45]. Thus, the lower levels of absenteeism among highly educated employees with depression compared to lower educated employees with depression can be explained by personal characteristics such as perfectionism and high expectations towards oneself [7]. To overcome difficulties with setting limits in working life, there is a need for external support from healthcare professionals to define and schedule work tasks and hours in collaboration with the employee and the workplace, e.g. by providing fixed work tasks and goals and expecting the employee’s appearance at scheduled working hours during the week. Co-workers, union representatives or employers can provide continuous support in the single employee’s working life ensuring compliance with the employee’s plan for work participation [23].

The results showed that having a job function with the opportunity to work from home and without clear success criteria provided opportunities to continue work participation despite cognitive symptoms, but depressive symptoms were intensified when feeling unable to fulfil the work role.

Thus, the importance of focusing on cognitive deficits in relation to an employee’s work tasks and demands needs attention in the workplace. In line with this, a study showed that even though depression was found to have a larger impact on physical, cognitive and social work demands than arthritis, musculoskeletal pain, diabetes, asthma, heart disease and irritable bowel syndrome, those with depression were least likely to receive adjustment of cognitive demands [46]. Since employers usually have the authority to implement work adjustments, supporting employers with a wider understanding of depression is recommended with focus on the importance of individualising work tasks and demands in relation to individual work ability [10 , 47].

4.3 Methodological considerations

The interview guide was based on predefined assumptions to strengthen the internal validity, and the employees were given the opportunity to clarify their perspectives through the use of different types of interview questions [30]. Examples of the use of questions in conducing the interviews are provided in Table 2.

Table 2
Use of questions in conducting interviews

Types of interview questions Questioning during interview (examples from interviews illustrated with quotes)

Direct questions “What are your expectations to your future work life?” (interview with P3^a)

Indirect questions “What if you imagine that it was one of your co-workers or friends?” (interview with P4)

Specifying questions “What was your considerations in telling your workplace about it?” (interview with P4)

Interpreting questions “What I hear you are saying is that you find it very good to get out and have something scheduled?” (interview with P5)

Follow-up questions “What do you mean when you say ‘real disease’?” (interview with P1)

Probing questions “Now that you are talking about your family I was wondering; how do you talk with your family and friends about your depression?” (interview with P2)

Types of interview questions	Questioning during interview (examples from interviews illustrated with quotes)
Direct questions	“What are your expectations to your future work life?” (interview with P3^a)
Indirect questions	“What if you imagine that it was one of your co-workers or friends?” (interview with P4)
Specifying questions	“What was your considerations in telling your workplace about it?” (interview with P4)
Interpreting questions	“What I hear you are saying is that you find it very good to get out and have something scheduled?” (interview with P5)
Follow-up questions	“What do you mean when you say ‘real disease’?” (interview with P1)
Probing questions	“Now that you are talking about your family I was wondering; how do you talk with your family and friends about your depression?” (interview with P2)

^aParticipant ID.

To strengthen the reliability and validity of the meaning units, categories and themes, two coders independently coded the interview transcripts and their diverging interpretations were considered as an integrated part of the analytical process.

Eight employees were included, which were considered sufficient to develop trustworthy results in compliance with the qualitative approach. This is argued as all interviews lasted for 1–1.5 hours allowing depth during interviews, where different types of interview questions gave the employees opportunity to clarify their perspectives (Table 2). The inclusion of more employees could have contributed with further variation in the data material, yet, the sample size is not considered a limitation, rather focus is turned towards the main characteristics of the employees providing implications for the transferability of the results and for further research. The age of the employees ranged from 35 to 66 years, thus the employees had work experience, and results may not be transferable to unemployed or to young people without longer work experience. Three of the employees were male; and four of the employees were employed in the public sector, and four in the private sector. All received either medical treatment or therapy, or had recently stopped at the time the interview was held. Thus, the findings were based on results obtained in both men and women with wide range of ages, employments and courses of illness. Depression was the primary disorder of the employees, but some of the employees could also have had other mental health conditions, as depression often exists in co-occurrence with other mental health conditions [48]. Employees with severe depression might have abstained from participating in an interview, since the interview situation can seem intense as it requires interpersonal contact and awareness to be able to respond to questions. When transferring the results, it should be considered that the study focused on how employees dealt with their depression in a work context, and the results is not concerned with the possible work-environmental predictors of depression. In this way, the study provides a unique insight into the views of highly educated employees with depression by uncovering their strategies in managing work participation. This knowledge is useful in developing initiatives promoting work participation among employees with depression and cognitively demanding work functions.

4.4 Implications for practice

Since highly educated employees with depression kept their depression secret due to fear of being stigmatised, while longing for support at work, there is a need for a change in norms concerning disclosure of depression at the workplace. Also, initiatives that target stigma and aim to promote willingness and engagement of both the employer and the employee to deal with depression at the workplace are warranted. Healthcare professionals and workplaces should support employees with depression in setting limits with regard to work tasks and working hours.

4.5 Implications for research

There is a need for research focussing on initiatives that can be used to support employees with mental disorders in disclosing relevant information about their work ability in a workplace setting. Furthermore, studies may attempt to provide knowledge about how employees with depression can be best supported when considering their terms of employment, working conditions and content of work tasks, e.g. the benefits and the challenges of having a job function with the opportunity to work from home, since this may either decrease the ability to conduct work tasks among employees with depression or actually increase the opportunities to fulfil the work role depending on the individual and the terms of employment. To supplement the employee perspective, studies investigating the viewpoints of other vocational rehabilitation stakeholders, e.g. employers, co-workers, union representatives and human resources are warranted [49].

5 Conclusion

There is a need for establishing norms about disclosure at work, and employees with depression may need guidance regarding the issue of disclosing information about their health issues and work ability. Healthcare professionals and employers should support employees with depression in setting limits with regard to work tasks, demands and goals.

Footnotes

Acknowledgments

This work was supported by the Department of Public Health at Aarhus University and the Jascha Foundation. The authors would like to thank those who helped with recruiting relevant employees for this study. Furthermore, a sincere thank you goes to the employees for their willingness to participate and share their perspectives.

Conflict of interest

None to report.

Supplementary data

The Appendix is available from .

References

Greer

, Kurian

, Trivedi

. Defining and measuring functional recovery from depression. CNS Drugs. 2010;24(4):267–84.

European Depression Association. IDEA: Impact of Depression at Work in Europe Audit - Final Report. 2012.

Dunn

, Wewiorski

, Rogers

. The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study. Psychiatr Rehabil J. 2008;32(1):59–62.

Leufstadius

, Eklund

, Erlandsson

. Meaningfulness in work - Experiences among employed individuals with persistent mental illness. Work. 2009;34(1):21–32.

Honey

. The impact of mental illness on employment: Consumers’ perspectives. Work. 2003;20(3):267–76.

Wisenthal

, Krupa

, Kirsh

, Lysaght

. Insights into cognitive work hardening for return-to-work following depression: Qualitative findings from an intervention study. Work. 2019;62(4):599–613.

Evans-Lacko

, Knapp

. Global patterns of workplace productivity for people with depression: absenteeism and presenteeism costs across eight diverse countries. Soc Psychiatry Psychiatr Epidemiol. 2016;51(11):1525–37.

Gallo

, Matthews

. Understanding the association between socioeconomic status and physical health: Do negative emotions play a role? Psychol Bull. 2003;129(1):10–51.

Twenge

, Campbell

. Self-Esteem and Socioeconomic Status: A Meta-Analytic Review. Personal Soc Psychol Rev. 2002;6(1):59–71.

10.

Thisted

, Nielsen

, Bjerrum

. Work Participation Among Employees with Common Mental Disorders: A Meta-synthesis. J Occup Rehabil. 2018;28:452–64.

11.

Nielsen

MBD

, Rugulies

, Hjortkjaer

, Bültmann

, Christensen

. Healing a vulnerable self: exploring return to work for women with mental health problems. Qual Health Res. 2013;23(3):302–12.

12.

Conradi

, Ormel

, De Jonge

. Presence of individual (residual) symptoms during depressive episodes and periods of remission: A 3-year prospective study. Psychol Med. 2011;41(6):1165–74.

13.

Brohan

, Henderson

, Wheat

, Malcolm

, Clement

, Barley

, et al. Systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace. BMC Psychiatry. . 2012;12(1):11.

14.

Porter

, Lexén

, Johanson

, Bejerholm

. Critical factors for the return-to-work process among people with affective disorders: Voices from two vocational approaches. Work. 2018;60(2):221–34.

15.

Corrigan

, Watson

. Understanding the impact of stigma on people. World Psychiatry. 2002;16-20.

16.

Thisted

, Labriola

, Vinther Nielsen

, Håkonsen

, Bjerrum

. Understanding depression as a workplace issue: Clarifying employers’ attitudes to manage employees with depression. Work. 2020;65:857–68.

17.

Evans-Lacko

, Knapp

. 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. 2014;9(3):e91053.

18.

Lemieux

, Durand

, Hong

. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil. 2011;21(3):293–303.

19.

Nielsen

MBD

, Bültmann

, Madsen

IEH

, Martin

, Christensen

, Diderichsen

, et al. Health, work, and personal-related predictors of time to return to work among employees with mental health problems. Disabil Rehabil. 2012;34(15):1311–6.

20.

Sallis

, Birkin

. Experiences of work and sickness absence in employees with depression: an interpretative phenomenological analysis. J Occup Rehabil. 2014;24(3):469–83.

21.

Lagerveld

, Bültmann

, Franche

, van Dijk

FJH

, Vlasveld

, van der Feltz-Cornelis

, et al. Factors associated with work participation and work functioning in depressed workers: a systematic review. J Occup Rehabil. 2010;20(3):275–92.

22.

Heerkens

, Engels

, Kuiper

, Van der Gulden

, Oostendorp

. The use of the ICF to describe work related factors influencing the health of employees. Disabil Rehabil. 2004;26(17):1060–6.

23.

Thisted

, Labriola

, Vinther Nielsen

, Kristiansen

, Strøm

, Bjerrum

. Managing Employees’ Depression from the Employees’, Co-workers’ and Employers’ Perspectives. An Integrative Review. Disabil Rehabil. 2018;1-14.

24.

Wade

. Rehabilitation - a new approach. Part two: the underlying theories. Clin Rehabil. 2015;29(12):1145–54.

25.

Heerkens

, De Brouwer

CPM

, Engels

, Van Der Gulden

JWJ

, Kant

. Elaboration of the contextual factors of the ICF for Occupational Health Care. Work. 2017;57(2):187–204.

26.

Patton

. Research and Evaluation Methods. 3rd ed. Thousand Oaks: SAGE Publications; 2002.

27.

UNESCO-UIS. International Standard Classification of Education ISCED 2011. UNESCO Institute for Statistics; 2012. pp. 1-84.

28.

World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva; 1994.

29.

DiCicco-Bloom

, Crabtree

. The qualitative research interview. Med Educ. 2006;40(4):314–21.

30.

Brinkmann

, Kvale

. Interview: Det kvalitative forskningsinterview som håndværk [Interview: Learning the craft of qualitaive research interviewing]. 2. udg. København: Hans Reitzels Forlag; 2015.

31.

Schreier

. Qualitative content analysis in practice. London: SAGE; 2012. pp. 1–272.

32.

Dey

. Qualitative Data Analysis. A User-Friendly Guide for Social Scientists. London: Routledge; 1993.

33.

Elo

, Kyngäs

. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.

34.

Elo

, Kääriäinen

, Kanste

, Pölkki

, Utriainen

, Kyngäs

. Qualitative Content Analysis: A Focus on Trustworthiness. SAGE Open. 2014;4(1):10

35.

Mayring

. Qualitative content analysis. Theoretical Foundation, Basic Procedures and Software Solution. Austria; 2014. pp. 1-143.

36.

Hsieh

H-F

, Shannon

. Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15(9):1277–88.

37.

Owen

. To tell or not to tell: Disclosure of a psychiatric condition in the workplace. Boston University; 2004.

38.

Evans-Lacko

, Knapp

. 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. 2014;9(3).

39.

Corrigan

, Rao

. On the Self-Stigma of Mental Illness: Stages, Disclosure, and Strategies for Change. Can J Psychiatry. 2012;57(8):464–9.

40.

Pattyn

, Verhaeghe

, Sercu

, Bracke

. Public stigma and self-stigma: differential association with attitudes toward formal and informal help seeking. Psychiatr Serv. 2014;65(2):232–8.

41.

Mendel

, Kissling

, Reichhart

, Bühner

, Hamann

. Managers’ reactions towards employees’ disclosure of psychiatric or somatic diagnoses. Epidemiol Psychiatr Sci. 2015;24(2):146–9.

42.

Hatchard

. Disclosure of mental health. Work. 2008;30:311–6.

43.

Hielscher

, Waghorn

. Managing Disclosure of Personal Information: An Opportunity to Enhance Supported Employment. Psychiatr Rehabil J. 2015;38(4):306–13.

44.

Hvalsøe

, Josephsson

. Characteristics of meaningful occupations from the perspective of mentally ill people. Scand J Occup Ther. 2003;10(2):61–71.

45.

Verdonk

, de Rijk

, Klinge

, de Vries

. Sickness absence as an interactive process: Gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns. 2008;73(2):300–6.

46.

Munir

, Jones

, Leka

, Griffiths

. Work limitations and employer adjustments for employees with chronic illness. Int J Rehabil Res. 2005;28(2):111–7.

47.

Nieuwenhuijsen

, Verbeek

A M JH

, de Boer

E M AG

, Blonk

B RW

, van Dijk

H FJ

. Supervisory behaviour as a predictor of return to work in employees absent from work due to mental health problems. Occup Env Med. 2004;61(10):817–23.

48.

Gorman

. Comorbid depression and anxiety spectrum disorders. Depress Anxiety. 1997;(4):160–8.

49.

Loisel

, Durand

, Berthelette

, Vézina

, Baril

, Gagnon

, et al. Disability Prevention. New Paradigm for the Management of Occupational Back Pain. Dis Manag Heal Outcomes. 2001;9(7):351–60.