Psychological symptoms and subsequent sickness absence

  • Berend Terluin
  • Willem van Rhenen
  • Johannes R. Anema
  • Toon W. Taris
Original Article



Mental health problems are associated with sickness absence (SA). The present study aimed at establishing which symptoms—distress, depression, anxiety, or somatization—at which symptom levels were associated with SA frequency and duration. Moreover, a number of possible confounders or effect modifiers were taken into account.


A survey was completed by 3,678 employees of a large Dutch telecom company. Symptoms were measured using the Four-Dimensional Symptom Questionnaire (4DSQ). SA data were registered by the company’s occupational health service during the 12 months’ period following the survey. Poisson regression was used to analyze the number of SA spells (SA frequency). Negative binomial regression was used to analyze the total number of SA days (SA duration).


In the bivariate analyses distress, depression, anxiety, and somatization impacted on SA frequency and duration. In the multivariate analyses, anxiety and depression turned out not to be directly associated with SA, suggesting that the effect of anxiety and depression was due to the association between anxiety/depression and distress/somatization. Regarding the SA frequency, the rate ratio for ‘subclinical’ distress was 1.13 (95% CI 1.03–1.25), for ‘clinical’ distress 1.26 (1.08–1.47), for ‘subclinical’ somatization 1.34 (1.23–1.46), and for ‘clinical’ somatization 1.69 (1.46–1.95). Regarding the SA duration, the count ratio for ‘subclinical’ distress was 1.15 (95% CI 0.91–1.44), for ‘clinical’ distress 1.50 (1.04–2.16), for ‘subclinical’ somatization 1.34 (1.10–1.64), and for ‘clinical’ somatization 1.45 (1.04–2.03).


Somatization and distress are key to understand why depression and anxiety are related to SA.


Depression Anxiety Somatoform disorders Distress Absenteeism 


Conflict of interest

BT is the copyright owner of the 4DSQ and receives copyright fees from companies that use the 4DSQ on a commercial basis (the 4DSQ is freely available for non-commercial use in health care and research). BT received fees from various institutions for workshops on the application of the 4DSQ in primary care settings.


  1. Ahola K, Kivimäki M, Honkonen T et al (2008) Occupational burnout and medically certified sickness absence: a population-based study of Finnish employees. J Psychosom Res 64:185–193. doi: 10.1016/j.jpsychores.2007.06.022 CrossRefGoogle Scholar
  2. Andrea H, Beurskens AJHM, Metsemakers JFM et al (2003) Health problems and psychosocial work environment as predictors of long term sickness absence in employees who visited the occupational physician and/or general practitioner in relation to work: a prospective study. Occup Environ Med 60:295–300. doi: 10.1136/oem.60.4.295 CrossRefGoogle Scholar
  3. Borritz M, Rugulies R, Christensen KB et al (2006) Burnout as a predictor of self-reported sickness absence among human service workers: prospective findings from three year follow up of the PUMA study. Occup Environ Med 63:98–106. doi: 10.1136/oem.2004.019364 CrossRefGoogle Scholar
  4. Bourbonnais R, Mondor M (2001) Job strain and sickness absence among nurses in the province of Québec. Am J Ind Med 39:194–202. doi: 10.1002/1097-0274(200102)39:2<194:AID-AJIM1006>3.0.CO;2-K CrossRefGoogle Scholar
  5. Broadhead WE, Blazer DG, George LK et al (1990) Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 264:2524–2528CrossRefGoogle Scholar
  6. Bültmann U, Huibers MJH, van Amelsvoort LGPM et al (2005) Psychological distress, fatigue and long-term sickness absence: prospective results from the Maastricht Cohort Study. J Occup Environ Med 47:941–947. doi: 10.1097/01.jom.0000172865.07397.9a CrossRefGoogle Scholar
  7. Bültmann U, Rugulies R, Lund T et al (2006) Depressive symptoms and the risk of long-term sickness absence: a prospective study among 4747 employees in Denmark. Soc Psychiatry Psychiatr Epidemiol 41:875–880. doi: 10.1007/s00127-006-0110-y CrossRefGoogle Scholar
  8. Clarke DM, Smith GC (2000) Somatisation: what is it? Aust Fam Physician 29:109–113Google Scholar
  9. Dewa CS, Lin E (2000) Chronic physical illness, psychiatric disorder and disability in the workplace. Soc Sci Med 51:41–50CrossRefGoogle Scholar
  10. Duijts SFA, Kant IJ, Landeweerd JA et al (2006) Prediction of sickness absence: development of a screening instrument. Occup Environ Med 63:564–569. doi: 10.1136/oem.2005.024521 CrossRefGoogle Scholar
  11. Duijts SFA, Kant IJ, Swaen GMH et al (2007) A meta-analysis of observational studies identifies predictors of sickness absence. J Clin Epidemiol 60:1105–1115. doi: 10.1016/j.jclinepi.2007.04.008 CrossRefGoogle Scholar
  12. Emmanuel E, St John W (2010) Maternal distress: a concept analysis. J Adv Nurs 66:2104–2115. doi: 10.1111/j.1365-2648.2010.05371.x Google Scholar
  13. Eriksen W, Bruusgaard D, Knardahl S (2003) Work factors as predictors of sickness absence: a three month prospective study of nurses’ aides. Occup Environ Med 60:271–278. doi: 10.1136/oem.60.4.271 CrossRefGoogle Scholar
  14. Goldberg DP, Gater R, Sartorius N et al (1997) The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 27:191–197CrossRefGoogle Scholar
  15. Hackett RD, Bycio P (1996) An evaluation of employee absenteeism as a coping mechanism among hospital nurses. J Occup Organ Psychol 69:327–338CrossRefGoogle Scholar
  16. Hensing G, Wahlström R (2004) Sickness absence and psychiatric disorders. Scand J Public Health 32(Suppl 63):152–180. doi: 10.1080/14034950410021871 CrossRefGoogle Scholar
  17. Hensing G, Alexanderson K, Allebeck P et al (1998) How to measure sickness absence? Literature review and suggestion of five basic measures. Scand J Soc Med 26:133–144. doi: 10.1080/14034949850153662 Google Scholar
  18. Hilton MF, Scuffham PA, Sheridan J et al (2008) Mental ill-health and the differential effect of employee type on absenteeism and presenteeism. J Occup Environ Med 50:1228–1243. doi: 10.1097/JOM.0b013e31818c30a8 [Published: November 2008]CrossRefGoogle Scholar
  19. Horwitz AV, Wakefield JC (2007) The loss of sadness. How psychiatry transformed normal sorrow into depressive disorder. Oxford University Press, New YorkGoogle Scholar
  20. Janssen N, Kant IJ, Swaen GMH et al (2003) Fatigue as a predictor of sickness absence: results from the Maastricht cohort study on fatigue at work. Occup Environ Med 60(Suppl 1):i71–i76. doi: 10.1136/oem.60.suppl_1.i71 CrossRefGoogle Scholar
  21. Jenkins R (1985) Minor psychiatric morbidity in employed young men and women and its contribution to sickness absence. Br J Ind Med 42:147–154. doi: 10.1136/oem.42.3.147 Google Scholar
  22. Kessler RC, Frank RG (1997) The impact of psychiatric disorders on work loss days. Psychol Med 27:861–873. doi: 10.1017/S0033291797004807 CrossRefGoogle Scholar
  23. Kivimäki M, Sutinen R, Elovainio M et al (2001) Sickness absence in hospital physicians: 2 year follow up study on determinants. Occup Environ Med 58:361–366. doi: 10.1136/oem.58.6.361 CrossRefGoogle Scholar
  24. Kivimäki M, Leino-Arjas P, Kaila-Kangas L et al (2007) Increased absence due to sickness among employees with fibromyalgia. Ann Rheum Dis 66:65–69. doi: 10.1136/ard.2006.053819 CrossRefGoogle Scholar
  25. Kouzis AC, Eaton WW (1994) Emotional disability days: prevalence and predictors. Am J Public Health 84:1304–1307CrossRefGoogle Scholar
  26. Krantz G, Ostergren PO (2002) Do common symptoms in women predict long spells of sickness absence? A prospective community-based study on Swedish women 40 to 50 years of age. Scand J Public Health 30:176–183. doi: 10.1177/140349480203000303 CrossRefGoogle Scholar
  27. Kristensen TS (1991) Sickness absence and work strain among Danish slaughterhouse workers: an analysis of absence from work regarded as coping behaviour. Soc Sci Med 32:15–27CrossRefGoogle Scholar
  28. Kruijshaar ME, Hoeymans N, Bijl RV et al (2003) Levels of disability in major depression: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). J Affect Disord 77:53–64. doi: 10.1016/S0165-0327(02)00099-X CrossRefGoogle Scholar
  29. Laitinen-Krispijn S, Bijl RV (2000) Mental disorders and employee sickness absence: the NEMESIS study. Soc Psychiatry Psychiatr Epidemiol 35:71–77CrossRefGoogle Scholar
  30. Lexis MAS, Jansen NWH, van Amelsvoort LGPM et al (2009) Depressive complaints as a predictor of sickness absence among the working population. J Occup Environ Med 51:887–895. doi: 10.1097/JOM.0b013e3181aa012a CrossRefGoogle Scholar
  31. McNamee R (2005) Regression modelling and other methods to control confounding. Occup Environ Med 62:500–506. doi: 10.1136/oem.2002.001115 CrossRefGoogle Scholar
  32. Middleton H, Shaw I (2000) Distinguishing mental illness in primary care. We need to separate proper syndromes from generalised distress. BMJ 320:1420–1421. doi: 10.1136/bmj.320.7247.1420 CrossRefGoogle Scholar
  33. Moons KGM, Royston P, Vergouwe Y et al (2009) Prognosis and prognostic research: what, why, and how? BMJ 338:1317–1320. doi: 10.1136/bmj.b375 CrossRefGoogle Scholar
  34. Niedhammer I, Goldberg M, Leclerc A et al (1998) Psychosocial factors at work and subsequent depressive symptoms in the Gazel cohort. Scand J Work Environ Health 24:197–205Google Scholar
  35. Ridner SH (2004) Psychological distress: concept analysis. J Adv Nurs 45:536–545. doi: 10.1046/j.1365-2648.2003.02938.x CrossRefGoogle Scholar
  36. Suija K, Kalda R, Maaroos HI (2009) Patients with depressive disorder, their co-morbidity, visiting rate and disability in relation to self-evaluation of physical and mental health: a cross-sectional study in family practice. BMC Fam Pract 10:38. doi: 10.1186/1471-2296-10-38 CrossRefGoogle Scholar
  37. Terluin B (1996) De Vierdimensionale Klachtenlijst (4DKL). Een vragenlijst voor het meten van distress, depressie, angst en somatisatie [The four-dimensional symptom questionnaire (4DSQ). A questionnaire to measure distress, depression, anxiety, and somatization]. Huisarts Wet 39:538–547Google Scholar
  38. Terluin B, van Rhenen W, Schaufeli WB et al (2004) The four-dimensional symptom questionnaire (4DSQ): measuring distress and other mental health problems in a working population. Work Stress 18:187–207. doi: 10.1080/0267837042000297535 CrossRefGoogle Scholar
  39. Terluin B, Van Marwijk HWJ, Adèr HJ et al (2006) The four-dimensional symptom questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 6:34. doi: 10.1186/1471-244X-6-34 CrossRefGoogle Scholar
  40. Terluin B, Brouwers EPM, van Marwijk HWJ et al (2009) Detecting depressive and anxiety disorders in distressed patients in primary care; comparative diagnostic accuracy of the four-dimensional symptom questionnaire (4DSQ) and the hospital anxiety and depression scale (HADS). BMC Fam Pract 10:58. doi: 10.1186/1471-2296-10-58 CrossRefGoogle Scholar
  41. Väänänen A, Toppinen-Tanner S, Kalimo R et al (2003) Job characteristics, physical and psychological symptoms, and social support as antecedents of sickness absence among men and women in the private industrial sector. Soc Sci Med 57:807–824CrossRefGoogle Scholar
  42. van Rhenen W, Blonk RWB, Schaufeli WB et al (2007) Can sickness absence be reduced by stress reduction programs: on the effectiveness of two approaches. Int Arch Occup Environ Health 80:505–515. doi: 10.1007/s00420-006-0157-9 CrossRefGoogle Scholar
  43. Virtanen M, Vahtera J, Pentti J et al (2007) Job strain and psychologic distress: influence on sickness absence among Finnish employees. Am J Prev Med 33:182–187. doi: 10.1016/j.amepre.2007.05.003 CrossRefGoogle Scholar
  44. Welch K (2009) Generalized linear models using SPSS. Ann Arbor, MI: University of Michigan. Accessed 5 April 2011

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Berend Terluin
    • 1
  • Willem van Rhenen
    • 2
  • Johannes R. Anema
    • 3
  • Toon W. Taris
    • 4
  1. 1.Department of General Practice, EMGO Institute for Health and Care ResearchVU University Medical CenterAmsterdamThe Netherlands
  2. 2.ArboNedUtrechtThe Netherlands
  3. 3.Department of Social MedicineVU University Medical CenterAmsterdamThe Netherlands
  4. 4.Department of Work and Organizational PsychologyUtrecht UniversityUtrechtThe Netherlands

Personalised recommendations