Co-morbid depression is associated with poor work outcomes in persons with cardiovascular disease (CVD): A large, nationally representative survey in the Australian population

Depression and cardiovascular disease (CVD) are leading causes of health and economic burden globally [1]. By 2020, it is predicted that major depressive disorder (MDD) and coronary heart disease (CHD) will be the leading two global causes of disease burden [2]. A common medical co-morbidity, depression often co-exists with CVD. Depression can manifest before or after CVD onset leading to a range of poorer outcomes including decreased medication adherence, greater suicide risk [3], poorer health service utilisation, CHD risk factor profiles, survival [4] and some work outcomes [5]. Co-morbid mental and physical health conditions are highly prevalent in developed countries, such as the United States (US), United Kingdom (UK) and Australia [6], therefore the impact of co-morbid MDD and CVD on industry is likely to be great. However, to date, the burden of, and interaction between, this condition at the societal level remains unclear.

Poor health has been associated with both work absenteeism and presenteeism (attending work while sick). It is also the case that individuals with chronic conditions are less likely to be in full-time employment than those without [7]. Despite the benefits of active employment such as greater positive affect, less negative affect and fewer somatic complaints [8], people with a chronic condition are more likely to leave employment and retire early. Indeed, heart disease and depression have been reported as the two leading chronic diseases that contribute to labour force non-participation in developed countries [7]. The co-morbid burden of depression and other chronic conditions (e.g. musculoskeletal disorders [9]) on workforce participation has already been established; Baune (2007) demonstrated that MDD co-occurring with any medical disorder was strongly associated with lower full-time working status [10]. However, less is known about the specific burden of co-morbid MDD and CVD and how these two conditions interact to influence various aspects of working life. Indeed, when the impact of co-morbid MDD and a range of chronic conditions (including CHD) have been explored, co-morbid MDD has been shown to approximately double the likelihood of increased functional disability and work absence [11]. While elevated functional impairments may result from these conditions interacting rather than acting independently, evidence of such an effect remains inconsistent. Previous studies have shown a synergistic effect of co-morbid MDD and chronic physical conditions (e.g. diabetes) on functioning [12], but not on work absenteeism [11]. Further research is required to determine the nature of the relationship between MDD and CVD on key work outcomes.

The aim of the paper is to examine (i) the association of co-morbid MDD with work outcomes (workforce participation, work functioning and workplace absenteeism) in persons with and without CVD; and (ii) the way in which MDD and CVD interact to impact on work outcomes.

Table 1 displays the distribution of participants across disease groups, by workforce participation status and hours worked per week. The key characteristics of each group are displayed in Table 2. Those with MDD had the youngest mean age (36.7 years) while those with CVD only had the oldest mean age (62.1 years). Those with co-morbid MDD and CVD comprised the lowest proportion of males, followed by the MDD group. The co-morbid MDD and CVD group also reported: lowest proportion of excellent to good self rated physical and mental health and lowest frequency of physical activity over the previous week, the lowest proportion of participants with a normal BMI, the highest proportion of participants in lower socio-economic deciles and who exhibited moderate to high psychological distress. Those with MDD only comprised the highest proportion of smokers and non-married participants, and individuals with a normal BMI range. This group reported the highest frequency of physical activity in the previous week (Table 2). While the gender distribution for the prevalence of depression was relatively equal across the MDD only and MDD/CVD groups, there was a slightly greater proportion of women reporting MDD. This is consistent with the existing literature suggesting that affective disorders are more common in women than men [26].

Our research findings demonstrate that major depression which co-occurs with CVD is associated with poor work outcomes, including reduced workforce participation and greater work functioning impairments and workplace absenteeism. For all outcomes, those with co-morbid CVD and MDD experienced greater impairment than those with either condition by itself. While no significant interactive effects were found between MDD and CVD on work participation or absenteeism, a synergistic relationship was observed between MDD and CVD on workforce functioning, indicating that the combined effect of these conditions on functioning is greater than the sum of the effects of depression and CVD when they occur independently. To our knowledge, this is the first time the burden of, and interaction between MDD and CVD, specifically, has been explored on work outcomes at the population level.

Our findings are consistent with cross-sectional studies conducted in Europe [10], Northern America [23] and Australia [9] in which other co-morbid populations have also demonstrated poorer work outcomes. For example, Baune (2007) found that MDD co-occurring with any medical disorder was strongly associated with lower full-time working status and significantly more disability days [10]. Further, our findings add to others in this field, by confirming a synergistic effect of co-morbid MDD and chronic physical conditions on functioning [12], but not work absenteeism [11].

The synergistic relationship observed between MDD and CVD on work functioning, but not participation or absenteeism, suggests the negative effects of this co-morbidity are most pronounced for functional outcomes. Previous studies in MDD and diabetes populations [12] also support this finding. It would be expected that depression impacts mental functioning and CVD impacts physical functioning, and that cumulatively, the conditions combine to impede overall functioning. However, the interaction we observed between MDD and CVD on functioning may be a result of depressive symptoms exacerbating perceived impairment due to CVD, or may reflect greater physical symptom severity which can impede mental and physical components of functioning; essential for work productivity. That is, those who are depressed may have more severe forms of the disease. Further research is required to disentangle the association between this co-morbidity and mental and physical functioning.

There are several explanations for our finding of poorer work outcomes in those with co-morbid MDD and CVD. While its cross-sectional design precludes us from making causal inferences about the association between co-morbid mental and physical conditions and workforce status, we speculate that employment status may be influenced by both internal and external factors. As depression is a recognised risk factor for CVD [28] and stress is a shared risk factor for depression and CVD [29], stress may, in fact, act as a mediator in this relationship. Alternatively, risk factor clustering could exacerbate the effects of both CVD and MDD. For example, individuals with MDD may be more likely to report alcohol and tobacco use [30] and poor dietary regimes [31] and physical activity levels [32]; many of which occur simultaneously. Indeed, these behaviours can impede recovery after a CVD event, increase the risk of cardiac events and contribute to the physiology which underlies disease progression.

Moreover, we observed significant age-related effects of this co-morbidity on workforce participation; those under 36 years reported more pronounced reductions in participation than those aged 36-65 years, and no significant reductions were observed for those over 65 years. There are several possible explanations for this finding. For example, individuals who have experienced this co-morbidity at a young age may have: more chronic symptoms with greater severity, greater difficulty managing their conditions due to competing interests (such a child rearing), or different disease management or treatment plans compared with their older counterparts. Further, since depression can manifest either before or after CVD onset, and order of onset has been shown to result in differential outcomes [33], it is possible that the clinical course of MDD and/or CVD and their associated outcomes, differs in younger persons compared with older individuals.

This study has the following strengths. Compared with most other existing studies [34], our study used a valid psychiatric diagnostic instrument to assess MDD. While a diagnostic interview is time consuming, it is a more accurate method for the classification of depression than self-report methods. Another strength of our study is its robustness due to the use of a large probability sample from the general population. However, some study limitations should also be acknowledged. Self-report measures were used to define participants' CVD status which may have led to recall bias, misclassification or incorrect identification of CVD. This may have resulted in an under-reporting of CVD and thus a possible dilution of the CVD effect. Similarly, it is possible that MDD may have also been under-reported; a study of NSMHWB non-responders revealed non-response may be associated with mental illness for younger individuals and males [14]. However, the representativeness of this sample has been reported previously [14]. A further limitation of the study is the large CIs and SEs resulting from small numbers of employed participants with both co-morbid depression and CVD.

More research is needed to further understand the inter-relationships and the implications for developing effective prevention and intervention programs for people with co-morbid CVD and MDD. Longitudinal cohort studies have the potential to reveal both the long-term and causal impact of depression and CVD on workforce retention, early retirement and disability, as observed in international studies [35]. Future longitudinal studies should investigate whether this trend is comparable for individuals with co-morbid MDD and CVD. Further, randomised controlled trials that aim to improve vocational outcomes of individuals with co-morbid depression and CVD are required. To date, existing trials in this area have focused more on clinical outcomes, over psychosocial or functional outcomes such as employment. Several of these trials have, however, demonstrated positive effects of depression management on mental health functioning in those with CVD [36]. While it is likely that these benefits extend to vocational functioning, there is limited evidence to support this. Several studies in this area are currently exploring the impact of depression management after a cardiac event on work outcomes [36, 37]. As it is likely that the relationship between disease and employment status is bi-directional, interventions could be of a work-based nature, where occupational programs have the potential to improve disease management, or alternatively, of a psychological nature, where treating depression is likely to enhance both work and psychological outcomes in those with CVD.

It has been argued that the occupational rehabilitation needs of people with co-morbid depression and chronic conditions are currently being underestimated [38]. Our findings highlight that those exhibiting co-morbid MDD and CVD are at high risk of functional impairments and work absenteeism. This should be considered by the relevant health professionals working in this field (psychologists, occupational therapists, cardiologists and rehabilitation nurses). The implementation and evaluation of targeted interventions in this population which facilitate work resumption, retention and productivity have the potential to be individually, organisationally and economically advantageous. Given the emergence of co-morbid psychological distress and chronic disease as a growing public health issue affecting workers in Western economies [39], mental and physical medical co-morbidities need to be prioritised given their prevalence and subsequent burden.