Int Arch Occup Environ Health

DOI 10.1007/s00420-016-1178-7

ORIGINAL ARTICLE

The association between loss of work ability and depression:

a focus on employment status
Sang Ah Lee1,2 · Yeong Jun Ju1,2 · Kyu‑Tae Han1,2 · Jae Woo Choi1,2 ·
Hyo Jung Yoon1,2 · Eun‑Cheol Park2,3 

Received: 17 June 2016 / Accepted: 26 October 2016

© Springer-Verlag Berlin Heidelberg 2016

Abstract  Conclusions  We found that those who lost their ability to

Purpose Work-related factors are one of the known risk
factors for depression. Given that the ability to work is con-
sidered an important aspect of well-being and health status,
we investigated the association between the loss of work
ability and depression. We further examined the association
stratified by employment status.
Methods We used data from the Korea Welfare Panel
Study. The dependent variable of the present study was
depression, which is measured by the Center for Epide-
miologic Studies Depression Scale. Work ability transition
from the previous year was divided into three categories:
maintained, loss, and complete loss. A linear mixed-effects
model was performed for the analysis.
Results  The work ability loss group (β = 2.071, p < 0.0002)
and the work ability completely loss group (β  = 2.651,
p = 0.015) had higher depression scores compared to those
who maintained their work ability from the previous year.
Specifically, those who lost their work ability and their job
(β  = 3.685, p  = 0.0068) had the highest depression scores
compared to those who maintained their work ability and job.
Electronic supplementary material  The online version of this
article (doi:10.1007/s00420-016-1178-7) contains supplementary
material, which is available to authorized users.
* Eun‑Cheol Park
ecpark@yuhs.ac
1 Organization for Economic Cooperation and Development
Department of Public Health, Graduate School Yonsei
University, Seoul, Republic of Korea
2 ple in 2013 (OECD 2015). Given that depression could
Institute of Health Services Research, Yonsei University,
Seoul, Republic of Korea
3 tributes to mortality, prevention from the onset of depres-
Department of Preventive Medicine, Yonsei University
College of Medicine, 50 Yonsei‑ro, Seodaemun‑gu,
Seoul 120‑752, Republic of Korea
work may be at risk of depression, and this finding was par-
ticularly prominent among those who also became unem-
ployed. Therefore, psychological support is needed for
these individuals to overcome the negative influence of the
loss of work ability.
Keywords  Depression · Unemployment · Work ability ·
Mental health
Introduction
Depression is considered a global public health concern
due to its prevalence worldwide. It is estimated that 350
million people have been affected by depression. In addi-
tion, on average, one in 20 people reported that they had
felt depression during the past year according to the World
Mental Health Survey, which is conducted in 17 countries.
Depression has several negative consequences; according
to the World Health Organization, depression is predicted
to become one of the leading causes of disability-adjusted
life years (DALYs) lost by the year 2030, both globally
and regionally (Marcus et al. 2012). Depression could also
be the primary motive for suicide; it is estimated that, in
2012, nearly 804,000 deaths worldwide (11.4 per 100,000
people) were due to suicide (World Health Organization
2015). South Korea has the highest suicide rate among
(OECD) countries, with nearly 30 deaths per 100,000 peo-
contribute to suicidal behavior, which significantly con-
sion is imperative, as is the need to determine the causes of
depression.

13

Depression may come from various factors, includ-
ing loss of a spouse, life stress, social isolation, loneli-
ness, and health factors such as disease or loss of physical
function (Salzman and Shader 1979). Specifically, work-
related factors could also contribute to depressive moods
(Tennant 2001). Among work-related factors, the ability to
work is considered an important aspect of well-being and
health status (Tavakoli-Fard et al. 2016). The work ability
of employees is defined as the degree of a worker’s physi-
cal and mental status that enables them to meet the expec-
tations of their occupation or job (Escorpizo 2008), and is
considered a useful indicator for measuring social health
of the economy and economic growth (Escorpizo et al.
2007). Loss of work ability is primarily affected by disease
or aging. Due to the increase in chronic health conditions
among employees and the accompanying economic burden
on not only the employees themselves, but also the organi-
zations where they work and the society at large, the impact
of health on an employed person’s ability to work is consid-
ered an important matter (Freid et al. 2012). The work abil-
ity of employees is associated with their work productivity;
therefore, work ability loss due to health-related factors
leads to reduced work productivity in an organization. Evi-
dence from the USA suggests that approximately $260 bil-
lion is lost each year due to work ability loss associated with
health-related problems (Mitchell and Bates 2011). In addi-
tion, the effect of aging on work ability is also important,
particularly in South Korea, which is aging faster than any
other developed country (Statistics Korea 2013). However,
many studies focus on determining the risk factors associ-
ated with loss of work ability or its economic consequences,
whereas few studies consider the effect of loss of work abil-
ity on the elderly or as related to industrial accidents. There-
fore, in-depth study regarding the impact of work ability
loss on an individual’s psychological status is needed, given
the seriousness of depression as a public health issue.
The purpose of this study was to examine the associa-
tion between work ability loss and depression. Workers with
reduced work ability could be related to long-term or perma-
nent absence due to illness, early retirement, or unemployment
status (Lagerveld et al. 2010). Hence, we further examined the
association between loss of work ability and depression strati-
fied by employment status after loss of work ability.
Methods
Study population
We used data from the Korea Welfare Panel Study
(KOWEPS) collected from 2012 to 2013. KOWEPS
is a nationwide longitudinal study published annually,
which began in 2006 with 18,856 participants from 7072
13
Int Arch Occup Environ Health
households. In the present study, data from 2013 were con-
sidered baseline (n  = 17,984), and data from 2012 were
included as lagged data in the baseline. We excluded partic-
ipants under 20 years old (n = 3694), as well as those who
did not have both a job (n = 6544) and the ability to work
(n = 2739) and those who have depression as chronic dis-
ease (n = 126). We also excluded those who have depres-
sive moods in 2012 measuring by CES-D scale (n = 1927).
We also excluded participants who did not follow up from
2012 or who were missing from the 2013 data. Cases with
missing values were then excluded, and our final study
population was 5241 individuals.
Variables
The dependent variable of the present study was depres-
sion, which is measured by the Center for Epidemiologic
Studies Depression (CES-D) Scale. The CES-D Scale is
useful for measurement of the current level of depres-
sive symptoms, focusing on an affective component,
and depressive mood (Radloff 1977). The original ver-
sion of CES-D Scale has 20-item questionnaire of cogni-
tion of depressive moods. Instead of this original version,
KOWEPS used CES-D 11 which is a reliable abbreviated
form of CES-D 20 Scale (Kohout et al. 1993; Pun et al.
2016; Asamsama et al. 2015). CES-D 11 has 11-item ques-
tionnaire of cognition of depressive moods evaluating a
past week on a four-point scale (0: less than one time per
week, 1: two to three times per week, 2: four to five times
per week, 3: more than six times per week): (a) ‘No appe-
tite,’ (b) ‘I felt that I was living well,’ (c) ‘I felt depressed
considerably,’ (d) ‘I felt difficulty in doing everything,’ (e)
‘I could not sleep well,’ (f) ‘I felt lonely,’ (g) ‘I thought that
I was living without complaint,’ (h) ‘I felt that people did
not treat me warmly,’ (i) ‘I felt sad,’ (j) ‘I felt people didn’t
like me,’ and (k) ‘I did not have courage to do something.’
We used the total score of the 11 items, with a higher score
indicating more depressive moods (The Korean Institute for
Health and Social Affairs 2013).
Work ability status was investigated by self-reported
questionnaire in the KOWEPS, and we created the work
ability transition variable, which is the primary independent
variable, by comparing work ability status compared to the
previous year. Work ability transition was measured using
three categories: maintained, loss, and completely loss, as
determined by self-reported work ability status compared
to the previous year. The maintained group was defined as
those who maintained their work ability and did not have
any difficulty performing at the worksite. The loss work
ability group was defined as those who lost their work abil-
ity slightly and had some difficulty performing at the work-
site (able to telecommute). The completely loss group was
defined as those who lost their work ability considerably
Int Arch Occup Environ Health
and had difficulty performing work (only able to do simple
housework) or did not have any ability to work due to dis-
ability, injury, disease, or aging (not able to do housework).
We measured employment status transition to determine
whether someone maintained or lost their work; those who
maintained their employment status from the previous year
were categorized in the ‘maintained group,’ while those
who lost their job and did not work were categorized in the
‘loss group.’
Age, gender, education, marital status, income, indus-
trial accident compensation insurance, number of chronic
diseases, smoking status, and alcohol consumption status
(measured by AUDIT score) were used as covariates. With
respect to age, we set adults (older than 20 years) as the
study population, including those aged 65 years and over.
According to an OECD report, South Korea has the fourth
highest rate of working people aged 65 years and over
(Organisation for Economic Co-operation Development
2014). Therefore, we included working people of age 65
and older into the study population. Education was catego-
rized into four groups: elementary school or less, middle
school, high school, and college or more. Marital status
was categorized into three groups: married–cohabitating,
married–non-cohabitating (divorced or separated, and
widowed), and unmarried. Income was separated as quar-
tiles, and industrial accident compensation insurance was
divided into those who received compensation and those
who did not receive compensation. Smoking status was cat-
egorized into current smoker and non-smoker, and alcohol
consumption into high-risk alcohol consumer, alcohol con-
sumer, and non-consumer.
Statistical analysis
We performed Student’s t test and analysis of variance
(ANOVA) to examine the general characteristics of the
study population and to compare values and standard devi-
ations. A linear mixed-effects model was performed to ana-
lyze the relationship between work ability transition and
depressive moods while controlling for the covariates. The
linear mixed model is used for analyzing longitudinal data.
The model is able to consider within-subject correlation,
which is often observed in longitudinal data. In the present
study, results from the model can be interpreted so that as
β increases, depression rate increases. In addition, sub-
group analyses for employment status transition and gender
were conducted to examine differences in relevant degree.
Moreover, we conducted additional analyses of the associa-
tion between work ability transition and each item of the
CES-D 11. All statistical tests were two-sided, and calcu-
lated p values less than 0.05 were considered significant.
All analyses were conducted using SAS version 9.4 (Cary,
North Carolina, USA).
Results
Table 1 shows the general characteristics of the study par-
ticipants (n  = 5241). Of these 5241 participants, 98.1%
(n  = 5142) maintained their work ability from the pre-
vious year, 1.4% (n  = 72) lost work ability, and 0.5%
(n  = 27) completely lost their ability to work. The mean
CES-D Scale scores were 2.41 ± 3.53, 5.51 ± 4.89, and
7.00 ± 5.62 in the maintained work ability group, the ‘loss’
work ability group, and the ‘completely loss’ work abil-
ity group, respectively. Additionally, 92.5% (n  = 4846)
maintained their employment status compared to the pre-
vious year, while 7.5% (n  = 395) lost their employment
status. Participants who maintained their working sta-
tus had a mean CES-D Scale score of 2.37 ± 3.47, while
those who lost their employment status had a mean score of
3.76 ± 4.75.
Table  2 presents the results from the linear mixed-
effects model, showing depression scores of the study par-
ticipants according to work ability transition after adjust-
ing for all covariates. We found that the ‘loss’ work ability
group (β = 2.071, p = 0.0002) and the ‘completely loss’
work ability group (β  = 2.651, p  = 0.015) had higher
depressive mood scores compared to those who maintained
their work ability (reference group). Regarding employ-
ment status transition, those who lost their job compared
to the previous year (β = 0.706, p = 0.002) showed higher
depression scores than those who maintained their work-
ing status.
The association between work ability transition and
depression by employment status transition and gender is
shown in Table 3. Those with ‘loss’ work ability had higher
depression scores in both the maintained (β  = 1.361,
p  = 0.006) and loss (β  = 4.123, p  = 0.008) employment
status groups compared to those who maintained their work
ability, and job loss group had a higher score. Apart from
working status, men (β  = 4.487, p  = 0.026) had higher
depression scores when they had completely lost work
ability compared to those who maintain their work ability.
Women had higher depression scores when they lose work
ability (β = 2.396, p = 0.002).
Additionally, we examined the association between the
work ability transition, working status transition, and each
item of CES-D 11 Scale and suggested it at the supplemen-
tary section (S1–S3).
Discussion
We examined the association between the loss of work abil-
ity and depression and investigated the different degrees
of association according to employment status. Among
our study population, individuals with work ability loss
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 Int Arch Occup Environ Health

Table 1  General characteristics Variables CES-D 11

of study population according to
t test and ANOVA N (%) Mean ± SD p value

Work ability transition <0.001

 Maintain 5142 (98.11) 2.41 ± 3.53
 Loss 72 (1.37) 5.51 ± 4.89
 Complete loss 27 (0.52) 7.00 ± 5.62
Working status transition 0.0002
 Maintain 4846 (92.46) 2.37 ± 3.47
 Loss 395 (7.54) 3.76 ± 4.75
Gender <0.001
 Male 2881 (54.97) 2.11 ± 3.30
 Female 2360 (45.03) 2.92 ± 3.89
Age 0.4496
 20–29 346 (6.60) 2.36 ± 3.76
 30–39 995 (18.98) 1.86 ± 3.22
 40–49 1351 (25.78) 2.10 ± 3.13
 50–59 1154 (22.02) 2.42 ± 3.44
 60–69 707 (13.49) 2.88 ± 3.64
 70+ 688 (13.13) 3.84 ± 4.61
Educational level 0.6977
 Elementary school or less 978 (18.66) 3.71 ± 4.14
 Middle school 605 (11.54) 2.79 ± 3.84
 High school 1778 (33.92) 2.26 ± 3.38
 College or over 1880 (35.87) 1.93 ± 3.24
Income <0.001
 Q1 (low) 760 (14.50) 4.32 ± 4.80
 Q2 1294 (24.69) 2.89 ± 3.74
 Q3 1462 (27.90) 2.06 ± 3.11
 Q4 (high) 1725 (32.91) 1.70 ± 2.86
Marital status 0.0096
 Married–cohabiting 3941 (75.20) 2.30 ± 3.44
 Married–non-cohabiting 592 (11.30) 3.86 ± 4.23
 Unmarried 708 (13.51) 2.29 ± 3.64
Chronic diseases <0.001
 Nothing 3011 (57.45) 1.99 ± 3.09
 Prescribed less than 3 months 218 (4.16) 2.50 ± 3.76
 Prescribed more than 3 months and less 104 (1.98) 2.28 ± 3.02
than 6 months
 Prescribed more than 6 months 1908 (36.41) 3.25 ± 4.17
Current smoker 0.002
 Yes 1273 (24.29) 2.34 ± 3.49
 No 3968 (75.71) 2.52 ± 3.63
Alcohol consumption 0.0016
 High-risk consumer 341 (6.51) 2.75 ± 4.14
 Consumer 2908 (55.49) 2.19 ± 3.23
 Non-consumer 1992 (38.01) 2.85 ± 3.96
Industrial accident compensation insurance 0.3498
 Yes 17 (0.32) 3.47 ± 6.00
 No 5224 (99.68) 2.47 ± 3.59
Total 5241 (100.00) 2.48 ± 3.60

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Int Arch Occup Environ Health

Table 2  Factors associated Variables CES-D 11

with depression according to a
linear mixed-effects model β SE 95% CI p value
Lower Upper

Work ability transition

 Maintain Ref.
 Loss 2.071 0.555 0.983 3.159 0.000
 Complete loss 2.651 1.093 0.509 4.793 0.015
Working status transition
 Maintain Ref.
 Loss 0.706 0.226 0.264 1.148 0.002
Gender
 Male Ref.
 Female 0.784 0.120 0.549 1.018 <0.001
Age
 20–29 Ref.
 30–39 −0.258 0.251 −0.750 0.233 0.303
 40–49 −0.059 0.275 −0.597 0.479 0.831
 50–59 −0.079 0.287 −0.642 0.484 0.783
 60–69 −0.342 0.319 −0.968 0.284 0.284
 70+ −0.176 0.352 −0.865 0.513 0.617
Educational level
 Elementary school or less 0.221 0.207 −0.185 0.627 0.286
 Middle school 0.086 0.198 −0.302 0.474 0.663
 High school 0.017 0.119 −0.217 0.252 0.884
 College or over Ref.
Income
 Q1 (Low) 1.888 0.223 1.451 2.324 <0.001
 Q2 0.933 0.133 0.672 1.194 <0.001
 Q3 0.318 0.107 0.108 0.528 0.003
 Q4 (high) Ref.
Marital status
 Married–cohabiting Ref.
 Married–non-cohabiting 0.492 0.190 0.120 0.864 0.010
 Unmarried 0.100 0.186 −0.265 0.465 0.591
Chronic diseases
 Nothing Ref.
 Prescribed less than 3 months 0.402 0.243 −0.075 0.878 0.099
 Prescribed more than 3 months and less than 6 months −0.125 0.284 −0.683 0.432 0.660
 Prescribed more than 6 months 0.693 0.124 0.450 0.936 <0.001
Current smoker
 Yes 0.403 0.125 0.158 0.647 0.001
 No Ref.
Alcohol consumption
 High-risk consumer 0.729 0.242 0.255 1.203 0.003
 Consumer 0.035 0.110 −0.180 0.249 0.753
 Non-consumer Ref.
Industrial accident compensation insurance
 Yes Ref.
 No −0.783 1.270 −3.271 1.706 0.538

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 Int Arch Occup Environ Health

Table 3  Subgroup analyses of the effect of work ability transition or productivity due to the loss of work ability. Therefore,
stratified by working status transition and gender according to a linear this situation could cause low self-esteem or depression.
mixed-effects model
Third, chronic disease, which could cause work ability
Variables CES-D 11 loss, may have affected depressive moods. Among many
β SE 95% CI p value factors affecting work ability, health problems, including
musculoskeletal disease, diabetes, disability, or at least one
Lower Upper
chronic disease, may interfere with work ability (Mitchell
Working status transitiona and Bates 2011; Radloff 1977; Schultz and Edington 2007;
 Maintain Pendo 2009; Rodbard et al. 2009). Also, physical function
  Maintain Ref. loss due to chronic disease is recognized as one of the con-
  Loss 1.361 0.498 0.386 2.337 0.006 tributors to depression (Salzman and Shader 1979) due to
  Complete loss 2.804 1.283 0.290 5.317 0.029 the stress from coping with the chronic disease or dimin-
 Loss ished self-efficacy (Moussavi et al. 2007). This psychologi-
  Maintain Ref. cal status further contributes to withdrawal from rehabilita-
  Loss 4.123 1.561 1.064 7.182 0.008 tion or social activities (Lee 2006), leading to isolation of
  Complete loss 2.944 1.522 −0.039 5.927 0.053 the individual, which makes it more difficult to overcome
Genderb work ability loss.
 Male Apart from the contribution of work ability itself to
  Maintain Ref. depression, we found that those who lost their ability to
  Loss 1.750 0.797 0.189 3.311 0.028 work had significantly higher depression scores when they
  Complete loss 4.487 2.009 0.550 8.423 0.026 also lost their employment. Even though someone may lose
 Female the ability to work due to health problems, there are some
  Maintain Ref. cases in which these individuals can sustain work even
  Loss 2.396 0.773 0.881 3.911 0.002 after becoming unhealthy or losing their job, whether com-
  Complete loss 1.513 1.176 −0.791 3.817 0.198
pulsory or not. The case of maintaining working status after
a reduction in work ability could be divided into presen-
a
  Adjusted for age, gender, educational level, income, marital status, teeism (on-the-job productivity) and absenteeism (Schultz
chronic diseases, current smoker, alcohol consumption, and industrial and Edington 2007). Both of presenteeism and absenteeism
accident compensation insurance
b
could have negative influence on mental health. In the case
  Adjusted for age, educational level, income, marital status, chronic
diseases, current smoker, alcohol consumption, employment status of presenteeism, people could feel discouragement due to
transition, and industrial accident compensation insurance reduced performance (Conway et al. 2014). In the case of
absenteeism, absence due to illness is connected to not only
impaired career opportunities and self-image, but also other
comprised 1.4% (n  = 72), and those who completely lost negative consequences such as inactivity, social isolation,
their work ability accounted for 0.5% (n = 27). Our find- and decreased well-being (Ockander and Timpka 2001,
ings revealed that those in the work ability loss group had 2003; Judiesch and Lyness 1999). These previous data
higher depression scores than those in the maintained work could explain our result that those with loss of work abil-
ability group, and the depression score was much higher ity that also maintained their working status had a higher
when someone completely lost their ability to work, such depression score.
that they could not do housework. These effects were much However, there are those who lose their ability to work
more severe in the job loss group compared to the job as well as their employment status, finally becoming unem-
maintained group. ployed. According to the results of this study, unemploy-
In the present study, those who lost the ability to work ment status with loss of work ability had significantly
showed higher depressive moods. The first explanation of higher depression scores compared to those who main-
this result may be related to a sudden loss of the ability to tained their employment status even after loss of work
work. Herein, we recorded the ability to work in reflection ability. Loss of work ability could result in loss of work-
upon the previous year. Therefore, the loss of work abil- ing status (Belgrave et al. 1987; Lindbohm et al. 2014),
ity may have occurred suddenly. According to a previous and according to previous meta-analysis studies, job loss
study, this sudden loss of work ability leads to a chronic itself has negative effects on mental health (McKee-Ryan
stress, lower self-esteem, and depression, because those et al. 2005; Paul and Moser 2009). A previous study that
who lose work ability suddenly face difficulties in accept- investigated a work-injury population found that those who
ing the sudden change (Park and Park 2012). Second, we were unemployed after an accident had significantly higher
suspect that our results reflect reduced work performance depressive moods compared to those who were employed

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Int Arch Occup Environ Health
(Kim 2010). Similarly, a study of breast cancer survivors
found that non-employed survivors had higher anxiety lev-
els compared to employed survivors (Comino et al. 2003).
These results could be explained by the following conse-
quences: societal, financial, and psychological (Zijlstra
and Nijhuis 2014); work is the vital factor in meeting eco-
nomic and social needs (Bethge et al. 2009). Financially, a
job assures income (Witte 1999), enabling people to earn
money, while job loss means loss of income, and could
be the beginning of a stressful situation with individual
or societal factors. With respect to societal aspects, full
retirement from working status has a negative influence on
health status both physically and mentally (Sugisawa et al.
1997), and job loss means a loss of opportunity to form
social relations (Witte 1999), which is strongly associated
with mental health (Cohen 2004; Melchior et al. 2003).
This loss of social interactions makes people feel that they
are not part of society, which may result in low self-esteem,
depressive moods, and eventually preoccupation with feel-
ings of being isolated from society (Black 2008; Hulshof
2009). Moreover, job loss is also a lost opportunity for
structured time, as well as the opportunity to spend time
on personal endeavors (Witte 1999). Therefore, it could be
suggested that these financial and societal consequences
due to loss of employment status may aggravate depressive
moods of those who lose their ability to work.
Our study has several limitations. First, we exam-
ined work ability through a self-reported answer to a sin-
gle question, which could be inexact and not examine the
boundaries of each category. Second, it is possible that we
did not include all covariates that may affect depression.
Third, employment status cannot be distributed into presen-
teeism or absenteeism because we used only one question
to determine whether or not an individual maintained their
job status compared to the previous year. Fourth, depres-
sion could not be specified as mild, moderate, or severe. In
addition, even though we excluded individuals with depres-
sion as a chronic disease and those with depressive moods
at the baseline year, there remains the possibility of hid-
ing depressed symptoms due to the self-reported method.
Accordingly, there is the possibility for social desirability.
Also, there is the possibility of reverse time order due to
the same reason. Nevertheless, our study’s strength is in the
use of nationally collected data, which can be considered
representative. Moreover, we excluded participants who
had already lost their ability to work or who were unem-
ployed by using longitudinal data, and we determined their
change of work ability and working status compared to the
previous year. Therefore, we could examine the short-term
effect of loss of work ability and working status. To the
best of our knowledge, this is the first attempt to examine
the impact of work ability loss on depression, focusing on
change in employment status.
In conclusion, we found that those who lost their ability
to work could be at risk of depression, particularly those
who also lost their employment. Current support for those
who lose their work ability or employment usually focuses
on economic aspects and does not offer support focused
on mental health. Rehabilitation for return to work is
needed; however, according to our results, those who lose
their ability to work could be experiencing depression,
which may make returning to work more difficult (Lind-
bohm et al. 2014). Therefore, psychological support also
needs to be considered when providing support to these
individuals.
Acknowledgements  A number of colleagues from the Department of
Public Health and the Graduate School of Yonsei University provided
advice for this manuscript.
Compliance with ethical standards 
Conflict of interest  The authors declare no conflict of interest.
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