To the best of our knowledge, this is the first study to examine the impact of depression on workplace productivity across a diverse set of countries, in terms of both culture and GDP. Previous research on the economic case for tackling depression in the workplace is mainly relevant for Western countries and high-income countries. These findings suggest the impact of depression in the workplace is considerable across all countries, both in absolute monetary terms and in relation to proportion of country GDP. In other words, depression is an issue deserving attention, regardless of a country’s economic development, national income or culture [19–21]. Moreover, with the growth in non-communicable diseases globally—with mental illnesses contributing substantially—the scale of the problem is likely to increase (Bloom et al. [22]).

Although the impact of depression on workplace productivity is universal, there were significant inter-country differences in terms of the prevalence of employees with depression taking time off work, number of days taken off, level of presenteeism and ratio of presenteeism to absenteeism. Most previous studies have been conducted in western or high-income countries, and thus, this study provided an opportunity to explore global similarities and differences. Our study provides higher estimates of work productivity costs compared with previous US studies [8, 23, 24]; however, these studies were based on samples collected more than a decade ago, and there were some methodological differences. We found lower overall productivity costs (in relation to proportion of GDP) associated with depression in Asian countries compared to the US. One driver of lower costs was the lower prevalence of employees diagnosed with depression in Asian countries. In line with previous epidemiological research [25, 26], Asian countries had the lowest prevalence of diagnosis of depression and this may be due to a true difference and/or measurement bias. In the case of the present study, differences could also be due to lower diagnostic rates or a cultural reluctance to disclose depression. Previous research from Japan found a significant relationship between depression (as identified by a psychiatric epidemiological survey using the WHO Composite International Diagnostic Interview [27]) and lower presenteeism, but did not identify a significant relationship between presence of depression and absenteeism [9]. It may be that our sample identified a relationship between depression and absenteeism in Japan as our criteria for depression identified individuals with more severe depression, given they had to receive a diagnosis by a medical professional (Brown et al. [28]; Bebbington et al. [29]) and that there is a high threshold of depression severity which warrants absenteeism in Japan.

We found that presenteeism rates varied according to country characteristics. Individuals living in a country with a higher prevalence of depression diagnoses had higher levels of presenteeism. It may be that prevalence of depression diagnoses also reflects comfort in seeking treatment and or disclosing one’s diagnosis. Previous research has shown that a cultural context which is more open and accepting of mental illness is associated with higher rates of help-seeking, antidepressant use and empowerment, and lower rates of self-stigma and suicide among people with mental illness (Evans-Lacko et al. [30]; Schomerus et al. [31]; Lewer et al. [32]). We also know that openness and support by managers in the workplace are associated with more social acceptance for employees with depression [33]. Thus, it seems that sociocultural and workplace attitudes which promote acceptance and openness about depression could also be important for improving workplace productivity of employees with depression; further research is needed to understand whether this may be at least partially mediated by increased treatment and help-seeking.

Differences in absenteeism and presenteeism were related to economic climate and per capita GDP. Greater reluctance to disclose one’s depression to an employer due to a fear of losing one’s job was related to lower levels of presenteeism. For both absenteeism and presenteeism, this seemed to depend on per capita GDP, in that individuals living in countries with higher per capita GDP who did not disclose their depression to their employer, because they feared losing their job, had higher levels of presenteeism and absenteeism; however, this only reached the level of a trend for absenteeism. Thus, in higher income countries, individuals with depression who experience added stress due to the economic climate may cope through taking time off of work, as this might be more acceptable when the economy is stable, as there is likely to be a stronger social safety net. On the other hand, in lower income countries, individuals who fear disclosing their depression because they may lose their job do not feel comfortable taking time off of work. Consequently, they may remain at work, but have lower levels of productivity, and this is reflected in their relatively lower levels of presenteeism. Some variation may also be due to the fact that the probability of people with depression being employed varies by country and we do not know about differences in the experiences or rates of unemployed people with depression across countries. There is a paucity of data on unemployment rates of depressed persons, though we know that people with mental illness are at a considerable employment disadvantage; for example, in OECD countries, there is a difference in unemployment rate of around 30 percentage points for those with a severe mental disorder and 10–15 percentage points for those with a moderate disorder, when compared to those with no disorder [34]. We also know that adverse labor market conditions and stigmatizing attitudes have a disproportionately negative impact on employment of individuals with mental illness [35]. This difference may be even greater in lower and middle income countries [36].

We also found that absenteeism and presenteeism were associated with individuals’ characteristics. Higher income and education were associated with lower levels of absenteeism. This is supported by previous research, including a large European survey of employed individuals [33] and a meta-analysis of work strain which showed that individuals with higher status occupations had lower levels of absenteeism, and this may be due to their greater financial and interpersonal resources to deal with adverse circumstances [37]. Interestingly, our analyses showed that higher levels of income were associated with higher levels of presenteeism, which would be in line with the importance of financial support. Higher levels of education, however, were associated with lower levels of presenteeism. It is possible that individuals with higher levels of education have a more cognitively demanding job and, therefore, may feel more severely impacted by the cognitive impairments associated with depression (Schultz [38]). Some research has shown that among employees with depression, presenteeism was lower among individuals with jobs involving strong judgement and communication skills [39].

Strengths and limitations

To the best of our knowledge, this is the first study to examine workplace productivity associated with depression across a diverse range of countries using a common methodology. Our findings come from a unique data set including employees and managers from eight countries, with information on their personal experiences and perceptions of depression in the workplace. Nevertheless, there are several limitations. Diagnosis of depression was based on self-report, and we were not able to control for clinical characteristics, such as severity and/or type of symptoms, and response rates were relatively low. However, the characteristics of respondents are in line with other epidemiological research, as study respondents reporting a diagnosis of depression were more likely to be female, divorced and working part-time. In addition, prevalence of depression diagnosis was lowest in Asian countries. In addition, as the survey only asked about lifetime experience of depression, we had to derive annual prevalence rates from secondary sources. We used estimates from nationally representative psychiatric epidemiology surveys available for each country.

We used the human capital approach to estimate productivity costs, which is still the most commonly used approach across health economics; however, it assumes a societal perspective, and therefore, the associated costs are higher than when using other methods such as friction costs calculations [40, 41]. National mental health policies, employment assistance programs available in the workplace and other policies could be important factors which help explain relationships between depression and productivity in the workplace, and it is a limitation that we have not included this information in our analyses; however, this was beyond the scope of this paper. Additional limitations are that data from this study did not include information on variables such as functioning and work roles, or number and duration of depressive episodes, all of which might be related to workplace productivity.