Journal of Affective Disorders Reports 10 (2022) 100388

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Journal of Affective Disorders Reports

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Research Paper

The relationship between cognitive flexibility, depression, and work

performance: Employee assessments using cognitive flexibility tests
Toshiki Fukuzaki *, Shinya Takeda
Department of Clinical Psychology, Tottori University Graduate School of Medical Sciences, Yonago, Tottori, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Cognitive flexibility is a frontal lobe function, and some scholars have indicated that it is linked to
Cognitive flexibility depression. The Cognitive Flexibility Test (CFT) is a neuropsychological test that can easily and promptly
Cognitive Flexibility Test (CFT) measure cognitive flexibility within a short amount of time. This study focuses on healthy younger workers to
Depression
determine the associations between their cognitive flexibility, depression, and performance at work.
Neuropsychological test
Methods: The absolute absenteeism and the absolute presenteeism of a group of 80 regular employees were
Workers
Work performance measured, and the employees were administered the Verbal Fluency Test (VTF), the CFT-A and CFT-B, the Beck
Depression Inventory-II (BDI-2), and the World Health Organization Health and Work Performance Question­
naire (WHO-HPQ). Google Forms were used to measure the BDI-2, absolute absenteeism, and absolute pre­
senteeism, and online interviews were conducted on Zoom to collect answers to the CFT and the Verbal Fluency
Test (VFT).
Results: No significant age-related differences appeared in the number of responses obtained for the CFT-A and
CFT-B from subjects grouped according to the decades they represented, ranging from the 20s to the 50s. In
addition, the CFT-A and CFT-B did not indicate significant correlations between the BDI-2 and absenteeism and
presenteeism.
Limitations: Small sample, online vs. in person assessments due to COVID-19.
Conclusion: The results suggest that the function of cognitive flexibility is relatively stable and is unaffected by
age brackets. The study also found no links between the cognitive flexibility of healthy young workers, the state
of depression, or their work performance.

1. Introduction
Depression is a highly prevalent psychiatric disorder, showing a 12-
month incidence of approximately 6% (Kessler and Bromet, 2013) and a
lifetime occurrence of 15–18% (Bromet et al., 2011). Some scholars also
predict that depression will be the most common mental illness affecting
daily life in 2030 (Murray et al., 2012). Therefore, the treatment of
depression will become a more important issue on a global scale than
ever before.
Depression causes a variety of cognitive deteriorations. Studies have
also verified that cognitive disorder remains a risk factor for recurrence
even after the remission of depression, inhibiting the remedial effects of
psychotherapy, and causing a decline in social functioning (Porter et al.,
2013). Depression increases the risk of suicide: a study has reported that
patients diagnosed with major depression who have attempted suicide
indicated a marked decrease in cognitive functions such as attention and
memory, compared to patients with major depression who have not
(Keilp et al., 2014). Such reports found that depression is exacerbated by
the cognitive decline associated with the condition. Therefore, research
on drug therapies has advanced in recent years to the direct treatment of
cognitive function (Mclntyre et al., 2014; Mahableshwarkar et al.,
2015).
Depression is often associated with disorders of the frontal lobe. A
study conducted a cognitive function meta-analysis of people who have
experienced depression: compared to the healthy group, the group of
patients diagnosed with depression suffered from significant frontal lobe
disorders such as executive function and attention. They also tended to
display similar difficulties even after the remission of their depression
symptoms (Rock et al., 2014). Cognitive flexibility is a significant
function of the frontal lobe (Miyake et al., 2000). It represents the
vibrancy of an individual’s ideas and denotes a person’s ability to
change perspectives. A decrease in cognitive flexibility renders it

* Corresponding author.
E-mail address: toshiki-fukuzaki@tottori-u.ac.jp (T. Fukuzaki).

https://doi.org/10.1016/j.jadr.2022.100388
Received 3 March 2022; Received in revised form 3 June 2022; Accepted 7 July 2022
Available online 9 July 2022
2666-9153/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
T. Fukuzaki and S. Takeda
difficult for individuals to change their thought processes and view­
points. Hence, people become fixated on specific ideas and flexible
thought becomes impossible (Dajani and Uddin, 2015). In such a con­
dition, people cannot respond adaptively to problems occurring in their
living environments. The fact that cognitive inflexibility overlaps with
symptoms associated with depression and that the escalation of
depression corresponds to an increase in cognitive inflexibility has been
verified (Deveney & Deldin, 2006; McClintock et al., 2010). Therefore,
the function of cognitive flexibility may be deemed an essential indi­
cator for evaluating the severity of depression and the effects of thera­
peutic efforts.
However, no extant studies using cognitive flexibility as an indicator
to assess the severity of depression and the effect of treatments have
been noted, perhaps because no existing neuropsychological test can
quickly and expediently assess cognitive flexibility. Neuropsychological
tests evaluating cognitive flexibility include the Wisconsin Card Sorting
Test (WCST; Milner, 1963) and the Verbal Fluency Test (VFT; Lezak
et al., 2012). However, these tests present certain difficulties in their use
to evaluate the severity of depression and the effects of therapeutic ef­
forts. The WCST takes about 30 minutes to complete and is also stressful
for the testee. Therefore, it is not deemed appropriate for a depressed
patient whose primary symptom is a depressed mood and who experi­
ences psychomotor inhibition. There are two types of VFT: one involves
listing many words beginning with a specific letter; the other asks re­
spondents to list many words belonging to a particular category. The
VFT relies on knowledge pertaining to the semantic memory of a testee
(Shao et al., 2014), and it may not accurately capture the cognitive
flexibility of respondents.
Therefore, the authors of the present study developed a Cognitive
Flexibility Test (CFT), a neuropsychological test that can easily and
rapidly assess cognitive flexibility (Takeda and Fukuzaki, 2021). It asks
the testee to suggest purposes for which an object may be used that differ
from its original function. Thus, it requires the testee to alter the
pre-established conception of an object, such as a plastic bottle or a
ballpoint pen, to another perspective. Previous studies by Takeda and
Fukuzaki (2021) have used the CFT and investigated its usefulness with
elderly subjects, but have not tested its facility for the assessment of the
cognitive flexibility of younger age groups. The peak age of onset for
depression is at a young age, and the early onset of depression tends to
become chronic (Yap et al., 2014). Therefore, the authors of this study
applied the CFT to subjects ranging in age from the 20s to the 50s. The
resulting score ranges were examined in this study to test associations
with depression. The investigation targeted individuals engaged in
regular employment because the age range between the 20s and the 50s
generally denotes the working years of individuals. Besides depression,
the present investigation also attempted to determine the associations
between the CFT result and work performance because previous studies
have demonstrated a close correlation between depression and work
performance (Suzuki et al., 2014; Suzuki et al., 2015).
2. Methods
2.1. Subjects
The subjects comprised 80 adults: 40 men and 40 women (Range of
age: 22-59 years). All subjects were Japanese. A supervisor registered
with AGEKKE Co. Ltd. was engaged to select the subjects. Subjects were
incentivized with incentives from AGEKKE Co. The selection criteria
stipulated people in their 20s to 50s monitored by AGEKKE who were
regular employees, and who were willing to consent to their participa­
tion in the study. Exclusion criteria were established as people who
found it difficult to communicate using language. Groups of 20 people
(10 men and 10 women) were formed to conform to the four decade-
wise age classifications designated between the 20s and 50s.
2
Journal of Affective Disorders Reports 10 (2022) 100388
2.2. The procedure used to test cognitive flexibility
The CFT is categorized into two versions, A and B. The instructions
issued to subjects in this study were based on Takeda and Fukuzaki
(2021). The A version read, “If you use a plastic bottle for purposes other
than ‘drinking,’ please list as many possible ways in which it can be used
as you can.” A hint was provided if the subject did not respond after 10
seconds: “For example, ‘Put azuki beans in the bottle and use it as a
musical instrument.’” The B version instructed, “If you use a ballpoint
pen for purposes other than ‘writing,’ please list as many possible ways
that it can be used as you can.” A hint was provided if the subject did not
respond after 10 seconds: “For example, ‘use it as a bookmark for a
book.’” If a purpose devised by a subject could not be understood, the
researchers asked, “What do you do with that?”
The time limit for both CFT-A and CFT-B was set at 2 minutes, and
the number of purposes offered by respondents within that time was
computed as the score. The following score criteria were also applied for
this study.
• A purpose different from the original function was counted in the
score (for example, “placing a ballpoint pen in a chest pocket as a
decoration” was deemed different from the pen’s original function of
writing, so this answer would score a point).
• A given answer was not added to the score tally if it did not alter the
principal purpose of the object and involved merely a different way
of using the pen or bottle for writing or drinking (for example, no
point was awarded to answers such as “carrying a plastic bottle” or
“selling a ballpoint pen”).
• When a superordinate and a subordinate concept was listed by sub­
jects, only the latter was added to the score (for example, an answer
including ideas such as “use a plastic bottle in a handicraft class,”
“make a rocket,” and “make a ship,” would score 2 points because the
first purpose represented a superordinate concept, and the second
and third ideas were subordinate).
• A point was awarded to an answer listing a function different from
the original purpose for an attachment of the concerned object (for
example, “drawing a circle with the lid of a plastic bottle” would
score a point).
• A point was added if a devised purpose involved the use of multiple
plastic bottles/ballpoint pens or envisioned the act of cutting the
object (for example, answers such as “pile plastic bottles to make a
floating ring” or “use two ballpoint pens as chopsticks” would score a
point each).
• No point was added for unclear purposes (for example, responses
such as “swinging,” “throwing,” or “stepping” on a plastic bottle
would not earn points). On the other hand, the answer “play with the
plastic bottle by swinging it around” would score a point because the
purpose was clear).
• Answers that assumed the original function would not earn points
(for example, the response “tuck a ballpoint pen behind my ear so
that I can use it any time” would not add to the respondent’s score
because it was premised on the primary function of writing).
The CFT test is stopped if: (ⅰ) no answer was given within 20 seconds
of giving a hint to the subject; or (ⅱ) no other answer was given within 20
seconds of the subject having given an answer, according to Takeda and
Fukuzaki (2021).
2.3. Assessments
Subjects were asked about age, sex, marital status, the highest level
of completed education, and occupational roles. According to the In­
ternational Standard Classification of Occupation, which classifies oc­
cupations based on skill level and specialization (International Labour
Office, 2012), we categorized occupational rules. Subjects chose one of
nine options for their occupation: manager; professional; technician or
T. Fukuzaki and S. Takeda Journal of Affective Disorders Reports 10 (2022) 100388

associate professional; clerical support worker; service or sales worker;
craft or related trade worker; plant or machine operator or assembler;
skilled agriculture, forestry or fishery workers; and other. We consoli­
dated those nine categories into four: managers, non-manual workers
(professional, technician and associate professional, clerical support
worker, service and sales worker), manual workers (craft and related
trade worker, plant and machine operator and assembler, and skilled
agriculture, forestry or fishery workers), and others. In addition, we
asked them about a type of device they used to connect online.
The absolute absenteeism and the absolute presenteeism dimensions
of the World Mental Health Japan (WMHJ) version of World Health
Organization Health and Performance Questionnaire (WHO-HPQ) short
version were used in this study to measure work performance (Kawa­
kami et al., 2020). World Health Organization Health and Work Per­
formance Questionnaire (WHO-HPQ) is the instrument that can measure
absenteeism and presenteeism (Kessler et al., 2003). However, the
Japanese version has not been tested for reliability and validity (Suzuki
et al., 2014; Suzuki et al., 2015). WMHJ Survey conducted in 2002–2006
included some items from the short version of WHO-HPQ (Kawakami
et al., 2005). The items in the WMHJ version of WHO-HPQ are slightly
different from the Japanese version translated by Suzuki et al (Suzuki
et al., 2014; Suzuki et al., 2015), the WMHJ version of WHO-HPQ has
been examined for its psychometric properties, such as test-retest reli­
ability and construct validity (Kawakami et al., 2020).
Absenteeism refers to the adverse effects of physical and mental
disorders on attendance due to outcomes such as absence, late arrival,
and early departure from work. Absolute absenteeism is calculated by
the difference between actual and standard working hours over the last
four weeks. Higher calculated values denote greater adverse effects on
attendance. The calculation formula is
2.4. Ethical considerations
Subjects received the explanations that data gathered in this study
would be analyzed so that individuals could not be identified, only those
who consented would be analyzed, and no disadvantages would arise
because of consenting or not consenting to participate in the study. The
informed consent of subjects was then obtained. This study was
approved by the Institutional Review Board of the Faculty of Medicine,
Tottori University. The study was conducted in accordance with the
ethical standards laid down in the 1964 Declaration of Helsinki.
2.5. Statistical analyses
A one-way analyses of variance (ANOVA) was initially performed to
examine the differences in the CFT, BDI-2, absenteeism, presenteeism,
and VFT scores based on the age groups of the respondents. Next,
Pearson’s product-moment correlation coefficient was calculated to
examine the correlations between the age, CFT, BDI-2, absenteeism,
presenteeism, and VFT. IBM SPSS Statistics ver. 26 was employed for the
analyses. The significance level was set at 5%.
3. Results
3.1. Characteristics of the target of the analysis
The subject characteristics are summarized in Table 1. The average
age of the respondents was 39.4 years (standard deviation 10.7), and
around 60% of them were university graduates. Non-manual workers
accounted for 80%, and 10% of the subjects were managers.

4 × standard working hours per week − Hours worked in the last four weeks 3.2. Average CFT for each age group
Presenteeism describes circumstances in which people keep working
Table 2 displays the mean and standard deviation of each index
despite suffering from physical and mental disorders but their ability to
pertaining to the respective age groups. The CFT-A results for respective
perform their work and productivity decline. The scores for absolute
subject age groups were computed as: 6.0 ± 3.2 for the 20s, 5.8 ± 2.9 for
presenteeism span 0 to 10 points and are calculated by assessing the
the 30s, 5.9 ± 3.1 for the 40s, 6.0 ± 1.9 for the 50s, and 5.9 ± 2.8 for all
overall work performance over the previous four weeks (28 days) and
subjects. The CFT-B outcomes for the respective age groups were
multiplying that number by 10. A score of 0 signifies the lowest measure
calculated as: 2.8 ± 2.5 for the 20s, 2.9 ± 1.9 for the 30s, 4.1 ± 2.5 for
of work performance and 100 symbolizes the highest.
the 40s, 3.6 ± 1.8 for the 50s, and 3.3 ± 2.2 for all subjects.
The Beck Depression Inventory-2 (BDI-2; Beck et al., 1996) was
The examination of age-related differences in the number of answers
administered to assess the depression scores of subjects. The BDI-2 is a
tendered for the CFT yielded no significant distinctions for the CFT-A (F
self-reported questionnaire widely used in clinical and research settings
[3, 76] = 0.03, ns) or the CFT-B (F [3, 76] = 1.41, ns).
to screen for depression and assess its severity. The validity or reliability
of the Japanese version of the BDI-2 was investigated and confirmed
(Kojima et al., 2002). The BDI-2 consists of 21 items, with scores ranging Table 1
Sociodemographic characteristics of the total employee sample (N=80).
from 0 to 63. The total score indicates the extent of depressive symp­
toms. The BDI-2 score of 0–13 indicates minimal symptoms, 14–19 mild N %
symptoms, 20–28 moderate symptoms, and 29–63 severe symptoms Age
(Beck et al., 1996). Mean (SD) 39.4 (10.7)
The VFT (Lezak et al., 2012) was utilized to measure the fluency. The Sex
Men 40 50.0
VFT is a task that requires cognitive flexibility among frontal lobe Women 40 50.0
functions (Parker and Crawford, 1992). The higher the number of re­ Marital status
sponses in one minute, the higher the fluency (Lezak et al., 2012). In Unmarried 23 28.8
Japan, the task of naming nouns that begin with "ka" is common. Married 52 65.0
Divorce 5 6.3
Therefore, in this study, subjects were asked to list as many nouns
Highest level of completed
beginning with the sound of “ka” as they could in one minute. Both the education
English (Harrison et al., 2000) and Japanese (Ito and Hatta, 2006) Graduate school graduate 9 11.3
versions of the VFT have demonstrated high test-retest reliability and University 46 57.5
validity as a task for assessing frontal lobe function. Vocational school/college 13 16.3
graduate
Incidentally, the answers on sociodemographic characteristics, work High school graduate 12 15.0
performance, and the BDI-2 were collected on Google Forms. CFT and Occupational roles
VFT were obtained through online Zoom interviews on the day of the Managers 8 10.0
survey. Non-manual workers 67 83.8
Manual workers 4 5.0
Others 1 1.3

SD: Standard Deviation.

3
T. Fukuzaki and S. Takeda Journal of Affective Disorders Reports 10 (2022) 100388

Table 2
ANOVA of CFT, BDI-2, absenteeism, presenteeism, and VFT scores based upon participant age groups (N=80).
Twenties (Range: 22-29) Thirties (Range: 30-38) Forties (Range: 40-49) Fifties (Range: 50-59) Total (Range: 22-59) F p value
n=20 n=20 n=20 n=20 N= 80
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

CFT-A 6.0 (3.2) 5.8 (2.9) 5.9 (3.1) 6.0 (1.9) 5.9 (2.8) 0.03 0.994
CFT-B 2.8 (2.5) 2.9 (1.9) 4.1 (2.5) 3.6 (1.8) 3.3 (2.2) 1.41 0.246
BDI-2 9.7 (8.3) 7.8 (4.9) 9.1 (5.1) 11.1 (8.4) 9.4 (6.9) 0.79 0.502
Absenteeism1 -17.3 (45.5) -21.7 (26.0) -21.7 (59.2) -8.6 (51.7) -17.3 (46.7) 0.34 0.797
Presenteeism2 70.0 (15.2) 71.5 (15.0) 71.0 (12.9) 68.0 (17.4) 70.1 (15.0) 0.21 0.891
VFT 11.0 (3.9) 9.7 (4.5) 11.7 (2.2) 10.1 (2.4) 10.6 (3.4) 1.36 0.261

ANOVA: Analysis of Variance; CFT: Cognitive Flexibility Test; BDI-2: Beck Depression Inventory-2; VFT: Verbal Fluency Test.
1
Absenteeism refers to the adverse effects of physical and mental disorders on attendance due to outcomes. The calculation formula is "4 × standard working hours
per week − Hours worked in the last four weeks".
2
Presenteeism describes circumstances in which people keep working despite suffering from physical and mental disorders but their ability to perform their work
and productivity decline.

The examination of age group-based differences in the number of
answers obtained for the BDI-2 (F [3, 76] = 0.79, ns), absenteeism (F [3,
76] = 0.34, ns), presenteeism (F [3, 76] = 0.21, ns), and the VFT (F [3,
76] = 1.36, ns) also yielded no significant differences apropos all
indices.
3.3. The relationships between the CFT and BDI-2, Absenteeism,
Presenteeism, and VFT
Pearson’s product-moment correlation coefficient was computed to
examine the relationships between the CFT and BDI-2, absenteeism,
presenteeism, and VFT (Table 3). The results indicated a significant
moderate correlation for the CFT-A and the CFT-B (r = 0.56, p < 0.001).
The findings also revealed significant moderate correlations between the
CFT-A and VFT (r = 0.42, p < 0.001) as well as the CFT-B and VFT (r =
0.41, p < 0.001). No significant correlation was observed between the
CFT-A or CFT-B and BDI-2, absenteeism, and presenteeism (all n.s.).
4. Discussion
In summary, there were two main findings from the current study.
First, there were no significant age-related differences in cognitive
flexibility scores. Second, cognitive flexibility did not significantly
associate with depression and work performance.
This study administered the CFT to workers, showed age-group-
related score plots, and examined the associations between cognitive
flexibility, depression, and work performance. The average values
calculated in this study for the subjects are noted as BDI-2 = 9.4,
Absenteeism = − 17.3, and Presenteeism = 70.1. Depression was
equivalent to the average values for each scale (Kojima et al., 2002);
absenteeism and presenteeism with respect to work performance both
evinced good values (Kawakami et al., 2020). Therefore, it may be
asserted that the workers surveyed in this study were relatively healthy.
First, a moderate relationship was ascertained between both CFTs
and the VFT. These results support the previous study focusing on the
elderly (Takeda and Fukuzaki, 2021). The outcomes of the present study
suggest that CFTs are also appropriate tools for younger workers and can
aptly assess the cognitive flexibility of the frontal lobe.
The average number of answers obtained from all subjects for the
CFT-A was 5.9 ± 2.8; no difference was observed in this number ac­
cording to age groups. The same tendency was noted for the CFT-B; the
average number of answers received from all subjects was 3.3 ± 2.2 and
no difference was noted in this number by age group. These results
approximate the findings of Takeda and Fukuzaki’s study (2021) tar­
geting healthy older people in their 60s (CFT-A: 6.6 ± 2.1; CFT-B: 3.9 ±
1.9). In other words, the function of cognitive flexibility is relatively
stable in people between their 20s and 60s. Therefore, when evaluating
the cognitive flexibility of young people using CFT, the results obtained
in this study are considered to be criteria that may be used to assess the
appropriate functioning of a subject’s cognitive flexibility.
On the other hand, CFT-A and CFT-B yielded no relationship between
absenteeism or presenteeism and depression or work performance,
suggesting that cognitive flexibility does not predict or indicate
depression or work performance in healthy young workers. However,
the subjects in this study were healthy young workers, and their BDI-2
scores may have shown a floor effect. Therefore, it seems premature to
conclude that depression is not associated with cognitive flexibility
based on the lack of correlation with CFT. A previous investigation
reporting the association between depression and cognitive flexibility
attended to patients diagnosed with major depressive disorder (Deve­
ney and Deldin, 2006). A follow-up study of depressed patients who had
received inpatient treatment also found that patients with poorer WCST
results at admission to the hospital evinced poorer social and occupa­
tional outcomes three months after discharge (Withall et al., 2009).
These outcomes suggest that the assessment of cognitive functions
focusing specifically on cognitive flexibility can offer appropriate

Table 3
Pearson’s product-moment correlations between age, CFT, BDI-2, absenteeism, presenteeism, and VFT scores (N=80).
Age CFT-A CFT-B BDI-2 Absenteeism Presenteeism VFT

Age –
CFT-A .03 –
CFT-B .20 .56 *** –
BDI-2 .12 -.02 .06 –
Absenteeism1 .08 -.15 -.04 .12 –
Presenteeism2 -.03 -.01 -.11 -.15 .00 –
VFT -.05 .42 *** .41 *** -.07 -.11 .00 –

CFT: Cognitive Flexibility Test; BDI-2: Beck Depression Inventory-2; VFT: Verbal Fluency Test.
***
p<.001
1
Absenteeism refers to the adverse effects of physical and mental disorders on attendance due to outcomes. The calculation formula is "4 × standard working hours
per week − Hours worked in the last four weeks".
2
Presenteeism describes circumstances in which people keep working despite suffering from physical and mental disorders but their ability to perform their work
and productivity decline.

4
T. Fukuzaki and S. Takeda
prognostic value for depressed patients. Therefore, CFTs must be con­
ducted for a group of respondents clinically diagnosed with depression.
Then, we need to examine whether the clinical group would tender a
reduced number of answers offered and whether significant differences
could be observed in results obtained from the clinically diagnosed
group vis-à-vis a healthy cohort. The assessment of cognitive flexibility
through CFTs could represent an appropriate neuropsychological test for
the evaluation of recovery from depression or for prognostic uses if it is
observed that the clinical group offer a significantly smaller number of
answers than the healthy group or if the number of answers provided for
the CFTs is found to vary according to the severity of depression.
This study acknowledges some limitations. First, the sample size was
small. In addition, a face-to-face neuropsychological test could not be
performed for this study because of the COVID-19 pandemic. Thus, the
CFTs and the VFT were administered online using Zoom. No significant
obstacles such as interruptions or malfunctions in electronic devices or
communication occurred in the process of administering the tests.
However, the possibility of bias interference cannot be ruled out because
the study was conducted online. To validate the cognitive flexibility
using the CFT, one must ensure not only validity but also reliability of
CFT. However, the reliability of the CFT could not be examined in this
study; future studies are required to evaluate the test-retest reliability of
the CFT. On the other hand, the subjects in this study were limited to
full-time workers. Compared to full-time workers, informal workers are
reported to be more likely to exhibit depressive symptoms (Nielsen
et al., 2021). Therefore, the relationship between depression and
cognitive flexibility may differ from the present study when non-regular
workers are included. Future studies should examine this point.
CFTs were administered on young adult regular workers grouped
according to age-related decades between the 20s and the 50s. The re­
sults of all age groups approximated the findings of studies conducted on
people in their 60s (Takeda and Fukuzaki, 2021). The findings thus
indicate that the function of cognitive flexibility is relatively stable in
individuals ranging in age from the 20s to the 60s. This study also found
that cognitive flexibility is not associated with depression or work per­
formance in healthy young workers.
Data availability statement
Research data are not shared due to privacy or ethical restrictions.
Role of funding source
This research was supported by AMED under grant number
JP20de0107002.
Author Statement
This work was carried out in collaboration with all authors. Author
TF designed the study, managed the analyses of the study, and prepared
the draft of the manuscript. Author ST worked with TF on the data
collection and checked the logic of the paper and edited it in English. All
the authors read and approved the final manuscript.
Declaration of Competing Interest
The authors proclaim no conflict of interest.
Acknowledgments
We thank all the individuals who participated in this study.
References
Beck, A.T., Steer, R.A., Brown, G., 1996. Beck depression inventory–II. APA PsycTests.
https://doi.org/10.1037/t00742-000.
5
Journal of Affective Disorders Reports 10 (2022) 100388
Bromet, E., Andrade, L.H., Hwang, I., Sampson, N.A., Alonso, J., de Girolamo, G., de
Graaf, R., Demyttenaere, K., Hu, C., Iwata, N., Karam, A.N., Kaur, J.,
Kostyuchenko, S., Lépine, J.P., Levinson, D., Matschinger, H., Mora, M.E.,
Browne, M.O., Posada-Villa, J., Viana, M.C., Williams, D.R., Kessler, R.C., 2011.
Cross-national epidemiology of DSM-IV major depressive episode. BMC Med. 9, 90.
https://doi.org/10.1186/1741-7015-9-90.
Dajani, D.R., Uddin, L.Q., 2015. Demystifying cognitive flexibility: Implications for
clinical and developmental neuroscience. Trend. Neurosci. 38 (9), 571–578. https://
doi.org/10.1016/j.tins.2015.07.003.
Deveney, C.M., Deldin, P.J., 2006. A preliminary investigation of cognitive flexibility for
emotional information in major depressive disorder and non-psychiatric controls.
Emotion 6, 429–437. https://doi.org/10.1037/1528-3542.6.3.429.
Harrison, J.E., Buxton, P., Husain, M., Wise, R., 2000. Short test of semantic and
phonological fluency: normal performance, validity and test-retest reliability. Br. J.
Clin. Psychol. 39, 181–191. https://doi.org/10.1348/014466500163202.
International Labour Office, 2012. International standard classification of occupations:
Structure, group definitions and correspondence tables. https://www.ilo.org/wcms
p5/groups/public/@dgreports/@dcomm/@publ/documents/publication/wcms
_172572.pdf.
Ito, E., Hatta, T., 2006. Reliability and validity of verbal fluency tasks. Jpn. J.
Neuropsychol. 22, 146–152 in Japanese.
Kawakami, N., Inoue, A., Tsuchiya, M., Watanabe, K., Imamura, K., Iida, M., Nishi, D.,
2020. Construct validity and test-retest reliability of the World Mental Health Japan
version of the World Health Organization Health and Performance Questionnaire
Short Version: a preliminary study. Ind. Health. 58, 375–387. https://doi.org/
10.2486/indhealth.2019-0090.
Kawakami, N., Takeshima, T., Ono, Y., Uda, H., Hata, Y., Nakane, Y., Kikkawa, T., 2005.
Twelve-month prevalence, severity, and treatment of common mental disorders in
communities in Japan: preliminary finding from the World Mental Health Japan
Survey 2002–2003. Psychiatry Clin. Neurosci. 59, 441–452. https://doi.org/
10.1111/j.1440-1819.2005.01397.x.
Keilp, J.G., Beers, S.R., Burke, A.L., Melhem, N.M., Oquendo, M.A., Brent, D.A., Mann, J.
J., 2014. Neuropsychological deficits in past suicide attempters with varying levels
of depression severity. Psychol. Med. 44, 2965–2974. https://doi.org/10.1017/
S0033291714000786.
Kessler, R.C., Barber, C., Beck, A., Berglund, P., Cleary, P.D., McKenas, D., Pronk, N.,
Simon, G., Stang, P., Ustun, T.B., Wang, P., 2003. The World Health Organization
Health and Work Performance Questionnaire (HPQ). J. Occup. Environ. Med. 45,
156–174. https://doi.org/10.1097/01.jom.0000052967.43131.51.
Kessler, R.C., Bromet, E.J., 2013. The epidemiology of depression across cultures. Annu.
Rev. Public Health. 34, 119–138. https://doi.org/10.1146/annurev-publhealth-
031912-114409.
Kojima, M., Furukawa, T.A., Takahashi, H., Kawai, M., Nagaya, T., Tokudome, S., 2002.
Cross-cultural validation of the Beck Depression Inventory-II in Japan. Psychiatry
Res. 110, 291–299. https://doi.org/10.1016/s0165-1781(02)00106-3.
Lezak, M.D., Howieson, D.B., Bigler, E.D., Tranel, D., 2012. Neuropsychological
Assessment, 5th edn. Oxford University Press., New York.
Mahableshwarkar, A.R., Zajecka, J., Jacobson, W., Chen, Y., Keefe, R.S.E., 2015.
A randomized, placebo-controlled, active-reference, double-blind, flexible-dose
study of the efficacy of vortioxetine on cognitive function in major depressive
disorder. Neuropsychopharmacol 40, 2025–2037. https://doi.org/10.1038/
npp.2015.52.
McClintock, S.M., Husain, M.M., Greer, T.L., Cullum, C.M., 2010. Association between
depression severity and neurocognitive function in major depressive disorder: a
review and synthesis. Neuropsychol 24, 9–34. https://doi.org/10.1037/a0017336.
Mclntyre, R.S., Lophaven, S., Olsen, C.K., 2014. A randomized, double-blind, placebo-
controlled study of vortioxetine on cognitive function in depressed adults. Int. J.
Neuropsychopharmacol. 17, 1557–1567. https://doi.org/10.1017/
S1461145714000546.
Milner, B., 1963. Effects of different brain lesions on card sorting. Arc. Neurol. 9, 90–100.
https://doi.org/10.1001/archneur.1963.00460070100010.
Miyake, A., Friedman, N.P., Emerson, M.J., Witzki, A.H., Howerter, A., Wager, T.D.,
2000. The unity and diversity of executive functions and their contributions to
complex “frontal lobe” tasks: a latent variable analysis. Cogn. Psychol. 41 (1),
49–100. https://doi.org/10.1006/cogp.1999.0734.
Murray, C.J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A.D., Michaud, C., Ezzati, M.,
Shibuya, K., Salomon, J.A., Abdalla, S., Aboyans, V., Abraham, J., Ackerman, I.,
Aggarwal, R., Ahn, S.Y., Ali, M.K., Alvarado, M., Anderson, H.R., Anderson, L.M.,
Andrews, K.G., Atkinson, C., Baddour, L.M., Bahalim, A.N., Barker-Collo, S.,
Barrero, L.H., Bartels, D.H., Basáñez, M.G., Baxter, A., Bell, M.L., Benjamin, E.J.,
Bennett, D., Bernabé, E., Bhalla, K., Bhandari, B., Bikbov, B., Bin Abdulhak, A.,
Birbeck, G., Black, J.A., Blencowe, H., Blore, J.D., Blyth, F., Bolliger, I.,
Bonaventure, A., Boufous, S., Bourne, R., Boussinesq, M., Braithwaite, T., Brayne, C.,
Bridgett, L., Brooker, S., Brooks, P., Brugha, T.S., Bryan-Hancock, C., Bucello, C.,
Buchbinder, R., Buckle, G., Budke, C.M., Burch, M., Burney, P., Burstein, R.,
Calabria, B., Campbell, B., Canter, C.E., Carabin, H., Carapetis, J., Carmona, L.,
Cella, C., Charlson, F., Chen, H., Cheng, A.T., Chou, D., Chugh, S.S., Coffeng, L.E.,
Colan, S.D., Colquhoun, S., Colson, K.E., Condon, J., Connor, M.D., Cooper, L.T.,
Corriere, M., Cortinovis, M., de Vaccaro, K.C., Couser, W., Cowie, B.C., Criqui, M.H.,
Cross, M., Dabhadkar, K.C., Dahiya, M., Dahodwala, N., Damsere-Derry, J.,
Danaei, G., Davis, A., De Leo, D., Degenhardt, L., Dellavalle, R., Delossantos, A.,
Denenberg, J., Derrett, S., Des Jarlais, D.C., Dharmaratne, S.D., Dherani, M., Diaz-
Torne, C., Dolk, H., Dorsey, E.R., Driscoll, T., Duber, H., Ebel, B., Edmond, K.,
Elbaz, A., Ali, S.E., Erskine, H., Erwin, P.J., Espindola, P., Ewoigbokhan, S.E.,
Farzadfar, F., Feigin, V., Felson, D.T., Ferrari, A., Ferri, C.P., Fèvre, E.M.,
Finucane, M.M., Flaxman, S., Flood, L., Foreman, K., Forouzanfar, M.H., Fowkes, F.
T. Fukuzaki and S. Takeda
G., Fransen, M., Freeman, M.K., Gabbe, B.J., Gabriel, S.E., Gakidou, E., Ganatra, H.
A., Garcia, B., Gaspari, F., Gillum, R.F., Gmel, G., Gonzalez-Medina, D., Gosselin, R.,
Grainger, R., Grant, B., Groeger, J., Guillemin, F., Gunnell, D., Gupta, R.,
Haagsma, J., Hagan, H., Halasa, Y.A., Hall, W., Haring, D., Haro, J.M., Harrison, J.E.,
Havmoeller, R., Hay, R.J., Higashi, H., Hill, C., Hoen, B., Hoffman, H., Hotez, P.J.,
Hoy, D., Huang, J.J., Ibeanusi, S.E., Jacobsen, K.H., James, S.L., Jarvis, D.,
Jasrasaria, R., Jayaraman, S., Johns, N., Jonas, J.B., Karthikeyan, G., Kassebaum, N.,
Kawakami, N., Keren, A., Khoo, J.P., King, C.H., Knowlton, L.M., Kobusingye, O.,
Koranteng, A., Krishnamurthi, R., Laden, F., Lalloo, R., Laslett, L.L., Lathlean, T.,
Leasher, J.L., Lee, Y.Y., Leigh, J., Levinson, D., Lim, S.S., Limb, E., Lin, J.K.,
Lipnick, M., Lipshultz, S.E., Liu, W., Loane, M., Ohno, S.L., Lyons, R.,
Mabweijano, J., MacIntyre, M.F., Malekzadeh, R., Mallinger, L., Manivannan, S.,
Marcenes, W., March, L., Margolis, D.J., Marks, G.B., Marks, R., Matsumori, A.,
Matzopoulos, R., Mayosi, B.M., McAnulty, J.H., McDermott, M.M., McGill, N.,
McGrath, J., Medina-Mora, M.E., Meltzer, M., Mensah, G.A., Merriman, T.R.,
Meyer, A.C., Miglioli, V., Miller, M., Miller, T.R., Mitchell, P.B., Mock, C.,
Mocumbi, A.O., Moffitt, T.E., Mokdad, A.A., Monasta, L., Montico, M., Moradi-
Lakeh, M., Moran, A., Morawska, L., Mori, R., Murdoch, M.E., Mwaniki, M.K.,
Naidoo, K., Nair, M.N., Naldi, L., Narayan, K.M., Nelson, P.K., Nelson, R.G.,
Nevitt, M.C., Newton, C.R., Nolte, S., Norman, P., Norman, R., O’Donnell, M.,
O’Hanlon, S., Olives, C., Omer, S.B., Ortblad, K., Osborne, R., Ozgediz, D., Page, A.,
Pahari, B., Pandian, J.D., Rivero, A.P., Patten, S.B., Pearce, N., Padilla, R.P., Perez-
Ruiz, F., Perico, N., Pesudovs, K., Phillips, D., Phillips, M.R., Pierce, K., Pion, S.,
Polanczyk, G.V., Polinder, S., Pope 3rd, C.A., Popova, S., Porrini, E., Pourmalek, F.,
Prince, M., Pullan, R.L., Ramaiah, K.D., Ranganathan, D., Razavi, H., Regan, M.,
Rehm, J.T., Rein, D.B., Remuzzi, G., Richardson, K., Rivara, F.P., Roberts, T.,
Robinson, C., De Leòn, F.R., Ronfani, L., Room, R., Rosenfeld, L.C., Rushton, L.,
Sacco, R.L., Saha, S., Sampson, U., Sanchez-Riera, L., Sanman, E., Schwebel, D.C.,
Scott, J.G., Segui-Gomez, M., Shahraz, S., Shepard, D.S., Shin, H., Shivakoti, R.,
Singh, D., Singh, G.M., Singh, J.A., Singleton, J., Sleet, D.A., Sliwa, K., Smith, E.,
Smith, J.L., Stapelberg, N.J., Steer, A., Steiner, T., Stolk, W.A., Stovner, L.J.,
Sudfeld, C., Syed, S., Tamburlini, G., Tavakkoli, M., Taylor, H.R., Taylor, J.A.,
Taylor, W.J., Thomas, B., Thomson, W.M., Thurston, G.D., Tleyjeh, I.M., Tonelli, M.,
Towbin, J.A., Truelsen, T., Tsilimbaris, M.K., Ubeda, C., Undurraga, E.A., van der
Werf, M.J., van Os, J., Vavilala, M.S., Venketasubramanian, N., Wang, M., Wang, W.,
Watt, K., Weatherall, D.J., Weinstock, M.A., Weintraub, R., Weisskopf, M.G.,
Weissman, M.M., White, R.A., Whiteford, H., Wiebe, N., Wiersma, S.T., Wilkinson, J.
D., Williams, H.C., Williams, S.R., Witt, E., Wolfe, F., Woolf, A.D., Wulf, S., Yeh, P.H.,
Zaidi, A.K., Zheng, Z.J., Zonies, D., Lopez, A.D., AlMazroa, M.A., Memish, Z.A.,
2012. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21
Journal of Affective Disorders Reports 10 (2022) 100388
regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study
2010. Lancet 380, 2197–2223. https://doi.org/10.1016/s0140-6736(12)61689-4.
Nielsen, H.B., Gregersen, L.S., Bach, E.S., Dyreborg, J., Ilsøe, A., Larsen, T., Pape, K.,
Pedersen, J., Garde, A.H., 2021. A comparison of work environment, job insecurity,
and health between marginal part-time workers and full-time workers in Denmark
using pooled register data. J. Occup. Health. 63, e12251. https://doi.org/10.1002/
1348-9585.12251.
Parker, D.M., Crawford, J.R., 1992. Assessment of frontal lobe function. In: Crawford, J.
R., Parker, D.M., McKinlay, W.W. (Eds.), A handbook of neuropsychological
assessment. Erlbaum, London, pp. 267–291.
Porter, R.J, Bowie, C.R., Jordan, J., Malhi, G.S., 2013. Cognitive remediation as a
treatment for major depression: A rationale, review of evidence and
recommendations for future research. Aust. N. Z. J. Psychiatry. 47, 1165–1175.
https://doi.org/10.1177/0004867413502090.
Rock, P.L., Roiser, J.P., Riedel, W.J., Blackwell, A.D., 2014. Cognitive impairment in
depression: a systematic review and meta-analysis. Psychol. Med. 44, 2029–2040.
https://doi.org/10.1017/S0033291713002535.
Shao, Z., Janse, E., Visser, K., Meyer, A.S., 2014. What do verbal fluency tasks measure?
Predictors of verbal fluency performance in older adults. Front. Psychol. 5, 772.
https://doi.org/10.3389/fpsyg.2014.00772 eCollection 2014.
Suzuki, T., Miyaki, K., Sasaki, Y., Song, Y., Tsutsumi, A., Kawakami, N., Shimazu, A.,
Takahashi, M., Inoue, A., Kurioka, S., Shimbo, T., 2014. Optimal cutoff values of
WHO-HPQ presenteeism scores by ROC analysis for preventing mental sickness
absence in Japanese prospective cohort. PLoS One 9, e111191. https://doi.org/
10.1371/journal.pone.0111191.
Suzuki, T., Miyaki, K., Song, Y., Tsutsumi, A., Kawakami, N., Shimazu, A., Takahashi, M.,
Inoue, A., Kurioka, S., 2015. Relationship between sickness presenteeism (WHO-
HPQ) with depression and sickness absence due to mental disease in a cohort of
Japanese workers. J. Affect. Disord. 180, 14–20. https://doi.org/10.1016/j.
jad.2015.03.034.
Takeda, S., Fukuzaki, T., 2021. Development of a neuropsychological test to evaluate
cognitive flexibility. Yonago Acta Medica 64 (2), 162–167. https://doi.org/
10.33160/yam.2021.05.003.
Withall, A., Harris, L.M., Cumming, S.R., 2009. The relationship between cognitive
function and clinical and functional outcomes in major depressive disorder. Psychol.
Med. 39 (3), 393–402. https://doi.org/10.1017/S0033291708003620.
Yap, M.B., Pilkington, P.D., Ryan, S.M., Jorm, A.F., 2014. Parental factors associated
with depression and anxiety in young people: a systematic review and meta-analysis.
J. Affect. Disord. 156, 8–23. https://doi.org/10.1016/j.jad.2013.11.007.