Journal of Affective Disorders 176 (2015) 4855

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Gender differences and disabilities of perceived depression

in the workplace
Yuan-Pang Wang a,n, Clarice Gorenstein a,b
a
b

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

art ic l e i nf o

a b s t r a c t

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

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

Keywords:
Depression
Gender difference
Cognitive symptoms
Disability
Workplace

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

Corresponding author. Tel./fax: 55 11 2661 6976.

E-mail address: gnap_inbox@hotmail.com (Y.-P. Wang).

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

a continuum of severity, ranging from normal mood, as a symptom,

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

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 4855

being causes of disability, workday lost, and absenteeism (Nelson and

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

49

Bearing in mind the higher prevalence of depression among

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

2. Methods
2.1. Design and setting
The investigation was a cross-sectional survey on perceived depression in the workplace. This study was conducted in accordance
with guidelines of the International Chamber of Commerce (ICC) and
European Society for Opinion and Marketing Research (ESOMAR,
2013), where all workers self-reported their attitudes and perceived
symptoms of depression through Internet (Evans-Lacko and Knapp,
2014). This survey is the Brazilian branch of a multicentric survey
launched by European Depression Association (EDA) (2014).
2.2. Sampling and recruitment
Recruited from Internet sites, eligible participants were panelists of
Internet portals, service providers, online stores, airlines, communities,
etc., with audited customer databases. The sample size of 1000 participants was determined in accordance with the standard of national
representativeness for marketing and opinion research (ESOMAR,
2013). Data were weighted to adjust the representativeness of the
target prole: Brazilian residents, aged 1664 year-old, current workers, or have worked and managed within the last 12 months. We have
targeted a general population sample taking into consideration the age
stratum criterion, as currently or have been previously employed
individuals could not be selected. This approach had engaged a broad
range of socio-demographic proles by natural fallout. For targeting
the sample, there was a random extraction on needed demographics
and quotas structure on age, gender and region.
The participants were allowed to ll out only one form after
receiving an invitation email for the panel. Personal data were checked and duplicates were removed. No quotas on company size were
applied. This procedure was multisourced, closed, and by invitation
only and has followed ESOMAR's quality controls to guarantee unique participants and to avoid fraud.
2.3. Instrument
This investigation used a 13-item questionnaire elaborated by
European Depression Association (2014), which was translated
and adapted for use in BrazilianPortuguese speaking respondents

50

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 4855

(Wang and Gorenstein, 2014). The original instrument has been

applied in over 7000 workers in seven European countries (EvansLacko and Knapp, 2014). The present study reports key results
concerning selected questions that would have impact on occupational health, with focus on workers' perception of depression in
the workplace and gender difference.
All respondents had their information recorded, concerning sex,
age, marital status, working status, size of company (small, medium,
and large), highest educational level, and local of residence in Brazil
(North, Northeast, Middle-East, Southeast, and South). Eligible participants were in the age range of 1664 years, currently working or
previously employed in the past 12 months.
Following, they have to choose four among a list of 10 items
(nine symptoms/behaviors plus one open-ended item to include
other possibilities) that could indicate someone in the workplace is
depressed and indicate four attributes/symptoms associated with
depression in general. At this point, the participants were asked if a
doctor or health professional has ever diagnosed them as having
depression. If positive, they indicated the symptoms they experienced among a 10-item list and whether they continued to work in
the last time they had depression.
Using a 010 scale, from the worst to the best functioning, the
respondents have to rate the following: (a) the usual performance of
the workers holding a similar position; (b) their usual performance
during the past year when they did not experience depression; and
(c) their overall job performance when they had depression in the
last time. From a list of nine items, those depressed respondents
reported which behaviors were more than usual while still working
and which attributes/symptoms most impacted their usual work
performance.
Next, it was asked to all ever-depressed worker if s/he has ever
taken time off work because of depression? If afrmative, they informed the number of working days that have had to take off during
the last time of depression, the attributes/symptoms that had caused
it, and the reasons for taking time off. If the worker had omitted
mentioning about depression, the reasons of non-disclosure were
recorded.
2.4. Data analysis
Before descriptive analysis, results were weighted to correct for
minor discrepancies by using the random iterative method (RIM)
(Mallett, 2006) to adjust for the distribution of demographic prole
of Brazilian workers, such as age, gender, region and working status.
Hypothesis testing such as chi-square and ANOVA was adopted to
contrast difference between subgroups of the sample, respectively
for categorical and continuous data. All analyses were conducted
through SPSS version 21 software (IBM Corp., 2012). The level of
signicance of 0.05 was considered for 2-sided tests.
The investigation was conducted in accordance with condentiality codes and guidelines of the ICC/ESOMAR (2013), which were in
force in Brazil since 2009. All participants have accepted the general
terms and the privacy policies prior to complete their registration.

Regarding current working status, 79% of participants were fulltime workers, 17% part-time, and 4% was previously employed in
the past 12 months. Concerning the work position, 900 were employees and 100 managers from 100 different sized companies. Most
of companies (52%) were of large size (with more than 250 employees), 28% medium (51250 employees) and 20% small (150
employees). Almost one in ve participants (Fig. 1) reported ever
being labeled by a doctor/health professional as having depression
(n189), with a men/women ratio of 1:1.8.

Table 1
Demographic characteristics of the participants (n 1000).
Variable
Gender (%)
Male
Female
Mean age (yo., SD)
Age bracket (%)
1824 year
2534 year
3544 year
4554 year
5564 year
Marital status (%)
Married
Cohabiting
Single
Separated or divorced
Widowed
Educational level (%)
Up to 8 years
811 years
12 or more years
Region of Brazil (%)
North
Northeast
Southeast
South
Middle-West
Income per month (%)
Low a
Medium b
High c

The demographic characteristics of the sample of 1000 workers

are summarized in Table 1. The subjects were 57.3% male, with a
mean age of 36.8 years (standard deviation [SD] 11.6). The majority
was in the age bracket of 2544 years, married, with lower educational attainment (up to 8 years), medium monthly income, and
living in South region of Brazil.

Weighted proportion

589
411

57.3%
42.7%
36.8 year (11.6)

162
307
259
196
76

17.4%
30.1%
25.3%
19.2%
8.0%

423
176
329
62
6

41.2%
17.8%
33.2%
6.7%
1.1%

764
226
10

76.4%
22.6%
1.0%

75
224
129
414
158

8.0%
23.8%
7.1%
44.6%
16.4%

44
632
262

4.5%
65.2%
24.3%

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

Up to Brazilian Real (BRL) 1000.

BRL 1001 to BRL 5000.
BRL 5001 or more.

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

811 never labeled

depressed

189 ever labeled

depressed

3. Results
3.1. Demographics

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

Last time labeled

depressed

48 taken off work (25.7%)

139 kept working (74.3%)
missing data: n = 2

Fig. 1. Survey chart for participant workers (n1000).

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 4855

3.2. Perceived depression in general

When asked about the symptoms more attributable to depression
in general, the participants reported (Table 2): crying without reason
(68.9%), loss of interest (68.4%), and low mood or sadness (63.0%).
Subsequently, sleep problems (49.9%), weight and appetite change
(38.3%) were viewed as common somatic complaints of depressed
individuals. The set of cognitive dysfunctions, including the items of
difculty of concentration, or indecisiveness, or forgetfulness, was
endorsed by 33.7% of the workers as salient symptoms of depression.
Considering each gender, men viewed crying for no reason (65.4%),
loss of interest (64.5%), low mood (59.6%), and sleep troubles (48.9%)
as the most attributable symptoms to depression. Similarly, women
endorsed more loss of interest (74.0%), crying for no reason (72.3%),
low mood (67.9%), and sleep troubles (51.3%).
Despite apparent agreement on core symptoms of depression,
women have generally endorsed signicantly more number of symptoms than men (Table 2). Conversely, men perceived signicantly
more cognitive symptoms attributable to depression as a group (trouble concentrating, indecisiveness, and/or forgetfulness) than women
(39.0% vs. 26.0%; po0.0001).
Regardless of experience of previous depression, the overall perception of depressive symptoms was not signicantly different (2
0.024, p 0.88). However, when the symptoms were analyzed by
gender in accordance with previous experience of depression, everdepressed women reported that crying for no reason (p0.018) and
sleeping problems (p0.043) were important features of depression.
In contrast, never depressed women viewed more frequently loss of
interest (p0.004) and low mood (p0.02) as core features of depression than never depressed men.

3.3. Gender and perceived depression in the workplace

Female worker reported twice more depression than men, with
the male/female sex ratio of 1:1.8. In Table 3, the participants
viewed following signs and behaviors as indicators of depression
Table 2
Perceived common symptoms of depression in general endorsed by all participants
and by gender.
Men % Women
%
n1000 n 589 n 411

2; p

Low mood or sadness

Trouble concentrating
Crying for no reasonnn
Indecisiveness

63.0
21.7
68.9
9.0

59.6
25.1
65.4
11.7

67.9
16.8
72.3
5.1

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

8.7
24.8
38.3

10.2
26.7
32.9

6.6
22.1
46.0

49.9
68.4
0.2
33.7

48.9
64.5
0.3
39.0

51.3
74.0
0.0
26.0

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

Depressive symptoms

Total %

51

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

Total %

Men % Women
%
n 1000 n 589 n411

2; p

Regularly coming in late

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

16.9
42.4

18.8
43.1

14.1
41.4

3.862; 0.049
NS

15.3
24.3
30.7

16.6
27.0
31.7

13.4
20.4
29.2

NS
5.658; 0.017
NS

73.1
70.5

69.9
65.0

77.6
78.3

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

20.2
10.4
33.6
0.7

19.2
9.8
30.6
0.3

21.7
11.2
38.0
1.2

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

NS: non-signicant.

in the workplace: withdrawing from colleagues (73.1%) and crying

at work (70.5%). Making more mistakes than usual (42.4%), prolonged sick leave (33.6%), and taking more time to complete jobs
(30.7%) were also salient single behaviors that can point toward
depression. Furthermore, signicant gender different perception
was observed: men endorsed more behavior/symptoms as coming
late to work (p 0.049) and indecisiveness (p 0.017). On the other
hand, women endorsed more crying at work (p o0.0001), withdrawing from colleagues (p 0.007), and prolonged sick leave (p
0.015) than men.
Regardless gender, joint performance-related items (more mistakes than usual, more time to complete jobs, missing deadlines,
and/or falling asleep at work) were viewed by around 70% of workers as indicators of depressive behaviors. Cognitive symptoms
(indecisiveness and/or forgetfulness) accounted for 39% of the
signs of depressive behavior at work (data not shown). Although
one in ve respondents endorsed the symptom of forgetfulness,
this was the single item that was more likely reported by everdepressed participants than those never depressed ones (28.6% vs.
18.2%; p 0.001).
3.4. Impact of perceived depression and work

NS: non-signicant.
n
Among those never depressed individuals (N 811) there was a signicant
difference (2 5.452; p 0.02) between men and women (59.8% vs. 68.0%).
nn
Among those ever-depressed individuals (N 189) there was a signicant
difference (2 5.628; p 0.018) between men and women (54.8% vs. 71.4%).
nnn
Among those ever-depressed individuals (N 189) there was a signicant
difference (2 4.087; p 0.043) between men and women (45.2% vs. 60.0%).
nnnn
Among those never depressed individuals (N 811) there was a signicant
difference (2 8.211; p 0.004) between men and women (64.2% vs. 73.9%).
Cognitive symptoms encompass trouble concentrating, indecisiveness, and/or
forgetfulness.

During the last period of reported depression, the most experienced symptoms among those ever-depressed workers (n 189) were
low mood or sadness (71%) and loss of interest (71%), followed by
sleep problems (57%), crying (55%), and weight and appetite changes
(47%). Cognitive dysfunctions, considering the items of difculty of
concentration, or indecisiveness, or forgetfulness, accounted for 53%
of ever-depressed ones. Comparing gender differences, women reported signicantly more crying (70.5% vs. 34.5%; 2 24.33, po0.0001)
and loss of interest (81.9% vs. 56.0%; 2 10.08, po0.0001) than men
(data not shown).
Since the age they started working, one-third of the 189 workers
whom were ever labeled as depressed had taken time off work. One in
four (25.7%) participants reported that they had taken off work during
the last time they had been labeled depressive. Therefore, the vast
majority of depressed participants (66.774.3%) continued working in
contrast to those who have stopped working because of depressive
symptoms, irrespective of depressed period and/or gender (Fig. 1).
In last time, among those workers who remained working after
being labeled depressed by a health professional (n139), 68% reported withdrawing from colleagues, 40% taking more time to complete jobs and indecisiveness, and 37% making more mistakes and

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Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 4855

crying as typical symptoms of depression. Overt performance-related

impairments, such as taking more time to complete jobs, making
more mistakes, and/or missing deadlines, were reported by around
60% of those depressed whom continued working.
The most troublesome attributes and symptoms that had impacted on the ability to perform tasks at work were loss of interest
(59%), low mood or sadness (52%), sleep problems (44%), and trouble
concentrating (36%). Further cognitive symptoms impacted for 53% of
depressed workers. Regarding the most frequent symptoms demonstrated more than usual while still working by those depressed ones,
women reported more behavior of crying at work than men (52.8%
vs. 20.9%, po0.0001). In addition, crying for no reason in the workplace has impacted more women [W] than men [M] in the ability to
perform tasks (W: 38.9% vs. M: 13.4%; po0.001). On the other hand,
men complained more difculty for planning than women (W: 18.1%
vs. M: 37.3%; p0.011).
Among those who requested a sick leave because of depression (n 63), common attributes/symptoms directly associated with
this outcome were loss of interest (64%), low mood or sadness (62%),
sleep problems (57%), crying (51%), and trouble concentrating (36%).
The cognitive symptoms impacted for 50.8% of the workers. Signicantly more women than men reported that crying for no reason
(p0.004) was the main reason for taking off time of the job and
more men than women informed that forgetfulness (p 0.014) was
the key associated symptom for doing so (data not shown).
Reecting ever labeled depressed individuals: 63 individuals who
took off work because of depression reported a total loss of 4139
working days per year. Absenteeism calculated considering the parttime workers (n11) was 3795 days. The mean number of days outof-role was 65.7 days, being signicantly lengthier for men than
women (80.5 vs. 56.2; F4.21, p 0.045). More than half of these
workers took off 21 or more days (Fig. 2).

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

Fig. 2. Average number of days taken off work because of depressive symptoms, all
workers who taken off work (n 63) and by gender.

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

Y.-P. Wang, C. Gorenstein / Journal of Affective Disorders 176 (2015) 4855

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

53

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

Conicts of interest
All authors declare no conict of interest.

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

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

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