The Impact of Psychiatric Disorders on Employment: Results
from a National Survey (NESARC)
Inger Burnett-Zeigler•Mark A. Ilgen•
Kipling Bohnert•Erin Miller•Khairul Islam•
Received: 13 June 2011/Accepted: 12 March 2012/Published online: 27 March 2012
? Springer Science+Business Media, LLC 2012
effects of psychiatric and substance use disorders on
employment, in an employed population. The sample
included respondents to the National epidemiologic survey
on alcohol related conditions (NESARC) who were
employed at Wave 1 (N = 22,407). Bivariate and multi-
variable analyses were conducted examining the associa-
psychiatric diagnoses at Wave 1 and employment status at
Wave 2. Past year and new onset 12-month depression,
12-month bipolar, new onset 12-month drug abuse, and
12-month and new onset 12-month drug dependence were
associated with a decreased odds of being employed at
Wave 2. This study suggests that it would be beneficial for
employers to support their employees in participating in
mental health treatment. Additionally, understanding how
psychiatric disorders influence employment over the life
course might inform the development of preemptive
interventions to treat mental health symptoms.
In this study we examine the longitudinal
Substance use disorders ? Longitudinal
Employment ? Psychiatric disorders ?
The 12-month prevalence of diagnosable psychiatric dis-
orders is estimated to be between 26 and 30 % in the U.S.
general population (Kessler et al. 2005; Kessler et al. 1999;
Regier et al. 1993). The social and economic burden of
psychiatric disorders, including substance use disorders,
make them a significant public health concern in the United
States and worldwide (Dewa and Lin 2000; Lebowitz et al.
1997; Ustun et al. 2004). The 2004 World Health Orga-
nization (WHO) report found that depression is the third
leading cause of disease burden in the world, the number
one cause of disease burden among high-income countries,
and the number one cause of years lost due to disability
(8.3–13.4 % of total YLD) (World Health Organization
2008). In 2000, the costs associated with depression
included an estimated $26.1 billion for direct medical
costs, $51.5 billion for indirect workplace costs, and
$5.4 billion for suicide-related mortality costs (Greenberg
et al. 2003). Alcohol and drug abuse/dependence are also
associated with costs due to lost potential productivity
($67.7 and $14.2 billion, respectively), healthcare costs
($18.8 and $9.9 billion, respectively), disability, and an
increased risk for mortality (1.8 and 2.0, respective median
relative risks) (Eaton et al. 2008; Harwood et al. 1999).
The burden of psychiatric disorders is partially attrib-
utable to the way in which they impair occupational
functioning. Psychiatric disorders have been found to be
related to significant work impairments (Esposito et al.
2007; Kessler et al. 2001; Waghorn et al. 2005), including
absenteeism and presenteeism (Dewa and Lin 2000;
I. Burnett-Zeigler ? M. A. Ilgen ? K. Bohnert ? K. Zivin
VA Ann Arbor Healthcare System, VA Serious Mental Illness
Treatment Research and Evaluation Center (SMITREC), Ann
Arbor, MI, USA
I. Burnett-Zeigler ? M. A. Ilgen ? K. Bohnert ? K. Islam ?
Department of Veterans Affairs Health Services Research and
Development (HSR&D), Ann Arbor Center of Excellence, Ann
Arbor, MI, USA
I. Burnett-Zeigler (&) ? M. A. Ilgen ? K. Bohnert ? E. Miller ?
Department of Psychiatry, University of Michigan Medical
School, 2215 Fuller Road (11H), Ann Arbor, MI 48105, USA
Community Ment Health J (2013) 49:303–310
Esposito et al. 2007; Kessler and Frank 1997; Lerner and
Henke 2008), higher rates of disability (Broadhead et al.
1990; Conti et al. 2006), and unemployment (Lerner et al.
2004; Whooley et al. 2002a, b). Several studies have sug-
gested that the effect that psychiatric disorders have on
occupational functioning varies by diagnosis. For example,
those with affective disorders report larger average num-
bers of work loss and work cutback days than those with
other disorders (Kessler and Frank 1997). Those with mood
and anxiety disorders are more likely to report not working
in the prior week due to illness or disability than those with
substance use disorders or no disorders; however, those
with mood, anxiety, and substance use disorders have an
higher frequency of reporting one or more disability days
than those with no disorder (el-Guebaly et al. 2007).
Additionally, those with bipolar I experience significantly
more overall lost work performance than major depression
and bipolar II (Judd et al. 2008; Kessler et al. 2006). Past
research has shown that overall employment rates and full-
time employment rates are lower in those with psychiatric
or substance use disorders than those without these disor-
ders and developing a disorder can lead to an increased
likelihood of becoming unemployed (Whooley et al.
2002a, b) or retiring earlier than planned (Conti et al. 2006;
Doshi et al. 2008; Karpansalo et al. 2005; Sobocki et al.
2007). However, more research is needed to better under-
stand the differential impact that various chronic and acute
psychiatric diagnoses can have on employment outcomes
Understanding the relationship between psychiatric
disorders and employment is important as this information
could inform important policy changes that could reduce
both the economic and societal burden of these diseases.
Employers face significant costs associated with providing
healthcare to their employees and lost potential produc-
tivity of employees with psychiatric disorders. However,
prior research has shown that those who recover from an
episode of a mood or anxiety disorder have employment
rates similar to those with no history of a disorder
(Levinson and Lerner 2009) and completed treatment and
longer treatment durations among those with substance use
disorders is associated with increased rates of employment,
higher rates of full time employment, and higher earnings
(Goldklang et al. 2003; Hubbard et al. 2003; Platt 1995).
While effective treatments for psychiatric disorders can be
costly, these costs are offset by savings in lost earnings
(Zhang et al. 1999). Previous research on psychiatric dis-
orders and employment has been limited by small samples
that aren’t representative of the general population (Lerner
et al. 2004; Resnick et al. 2003; Smith et al. 2002; Smith
et al. 2005), cross-sectional methods, and poor measures of
psychiatric conditions (Kessler et al. 2001). Other literature
examining the effects of mental health has focused
primarily on serious mental illness and employment
outcomes (Lehman et al. 2002). Although these studies
typically have reported that psychiatric disorders nega-
tively influence the likelihood of employment, further
research on the longitudinal effects of psychiatric disorders
on employment is warranted. Examining longitudinal
effects is particularly important because of the potential bi-
directional relationship between psychiatric conditions and
employment. Thus, it is difficult to determine if employ-
ment preceded or followed mental health problems in
cross-sectional research. In this study we examine the
longitudinal effects of psychiatric and substance use dis-
orders on subsequent employment in an employed
Design and Study Sample
The NESARC is a prospective longitudinal survey con-
ducted by the U.S. Bureau of the Census, for the National
Institute on Alcohol Abuse and Alcoholism (NIAAA), via
computer assisted personal interviewing (CAPI). The
NESARC respondents included non-institutionalized civ-
ilians, 18 years and older, living in the U.S., including the
District of Columbia, Alaska, and Hawaii. While the focus
of NESARC was to collect data from the general U.S.
population on alcohol use disorders (AUDs), it also
assessed a variety of psychiatric conditions. Wave 1 of the
NESARC was conducted between 2001 and 2002, in which
43,093 individuals were interviewed with a response rate of
81.0 %. Wave 2 of the NESARC was conducted between
2004 and 2005, and consisted of 34,653 individuals (a
response rate of 86.7 %). Black and Hispanic households
were oversampled. For each household, one sample person
was selected randomly from a roster of persons living in
the household. In households where young adults resided
(age 18–24 years), the young adults were sampled at a
rate of 2.25 times that of other members of the household.
The NESARC sample was weighted to adjust for the
probabilities of selection of a sample housing unit or
housing unit equivalent, non-interview at the household
and person levels, the selection of 1 person per household,
and oversampling of young adults. Once weighted, the data
were adjusted to be representative of the U.S. population
for region, age, sex, race, and ethnicity, based on the 2000
Decennial Census of Population and Housing. Additional
details about survey methodology have been described
elsewhere (Grant and Dawson 2006). The sample for this
study (N = 22,407) included all Wave 1 individuals who
indicated that they were employed at that time.
304Community Ment Health J (2013) 49:303–310
Dependent variable. Our outcome measure of interest was
employment status. The NESARC asks respondents a
14-item question to describe their present employment
situation. Respondents were allowed to mark all statements
that applied to their situation. For purposes of our analyses,
we created a mutually-exclusive dichotomous employment
variable: (1) if respondents endorsed working full or part
time or had a job or business but were not working due to
injury, vacation, or absent without pay, they were consid-
ered employed; (2) if respondents did not endorse
employment but said they had been unemployed or laid off,
were a homemaker, student, ‘‘something else,’’ retired, or
disabled, they were considered unemployed. For the pur-
poses of this study, we included all individuals who were
employed at Wave 1 and examined their employment
outcomes at Wave 2.
All independent variables were assessed at Wave 1. The
key independent variables of interest were psychiatric
diagnoses. NESARC respondent diagnoses were obtained
using The National Institute on Alcohol Abuse and Alco-
holism Use Disorder and Associated Disabilities Interview
Schedule- Diagnostic and Statistical Manual, Fourth
Edition (DSM-IV) Version (AUDAIS-IV), a well-estab-
lished structured diagnostic interview designed for use by
lay interviewers (Grant et al. 2003). AUDADIS-IV has
demonstrated strong test–retest reliability in clinical and
general population studies.
For the present study, the psychiatric disorders of
interest included 12-month disorders (disorders occurring
in the last year, which may include disorders occurring
prior to the last year), and new onset 12-month disorders
(incident disorders occurring in last year but not prior). The
psychiatric disorders assessed included depression (major
depression and dysthymia), bipolar (manic episode, hypo-
manic episode), anxiety (panic disorder with agoraphobia,
panic disorder without agoraphobia, agoraphobia without
history of panic disorder, social phobia, specific phobia,
generalized anxiety disorder), alcohol abuse, alcohol
dependence, drug abuse, and drug dependence. The pres-
ence of any of these disorders was indicated by a dichot-
omous variable (yes/no).
We also included covariates that we hypothesized might
influence employment status or transitions in work status
including: age (18–29, 30–44, 45–64, 65?), gender (male,
female), race (white, black), marital status (married,
unmarried), education (high school or less, more than a
high school education), income (0–19,999, 20,000–34,999,
35,000–69,999, or 70,000?), self-reported access to health
insurance (yes, no), and self-reported health status (fair,
poor, unknown or good to excellent).
First, we described the bivariate associations between the
predictors and employment status using v2and t test tests.
Next, we conducted individual multivariable logistic
regression models that examined the likelihood of being
employed at Wave 2 for each of the diagnoses individually,
controlling for the impact of all other predictors. All
analyses were conducted using Stata 11.0. This system
implements a Taylor series linearization to adjust standard
errors of estimates for complex survey sampling design
effects including clustered data. This study reports
unweighted frequencies and weighted percentages for all
results. As a result, some percentages may differ than what
would be obtained if they were calculated by hand with the
Sample Description. Of the 43,093 NESARC respondents
in Wave 1, 65.0 % (n = 26,979) were employed. Of those,
22,407 completed the Wave 2 assessment and had non-
missing variables on the dependent and independent vari-
ables of interest and were used for all remaining analyses.
From this sample, 86.8 % of respondents were employed at
Table 1 presents the sample characteristics and the
unadjusted associations between Wave 1 respondent
demographic and psychiatric characteristics and Wave 2
employment status. In bivariate analyses, those who were
more likely to be employed at Wave 2 were male, white,
30–44 years old, married, income C$35,000, more than a
high school education, insured, and in good or excellent
health. Those who were unemployed were more likely to
report 12-month and new onset 12-month depression,
12-month and new onset 12-month bipolar, and 12-month
and new onset 12-month anxiety. Those who were unem-
ployed were more likely to report new onset 12-month drug
abuse and 12-month and new onset 12-month drug
dependence; however they were less likely to report
12-month and new onset 12-month alcohol abuse. Past year
and new onset 12-month alcohol dependence and 12-month
drug abuse were non-significant predictors of employment
status in bivariate analyses.
Table 2 presents results of the multivariable logistic
regression analysis. Diagnoses of 12-month depression
(OR = .76, 95 % CI: .64, .90), bipolar (OR = .76, 95 %
CI: .58, .99), and drug dependence (OR = .43, 95 % CI:
.24, .76) at Wave 1 predicted a decreased likelihood of
Community Ment Health J (2013) 49:303–310305
Table 1 Characteristics of those employed in Wave 1 and their employment status in Wave 2, N = 22,407
Participant characteristicsAll (%) Unemployed (%)Employed (%)P-value
White 70.16 67.6070.55
18–29 23.52 24.6123.35
30–44 38.7925.83 40.77
65? 3.4910.76 2.39
70,000? 30.5723.68 31.62
High school or less 37.8547.7836.34
More than high school62.1552.2263.66
Fair, poor, unknown7.7214.626.67
Good to excellent 92.2885.38 93.33
Physical component score (mean)53.2950.5053.74
12- month alcohol abuse
12-month Alcohol dependence0.96
No 95.9395.94 95.93
12-month Drug abuse0.57
306Community Ment Health J (2013) 49:303–310
employment at Wave 2. Additionally, diagnoses of new
onset 12-month depression (OR = .68, 95 % CI: .46, .99),
drug abuse (OR = .46, 95 % CI: .25, .87), and drug
dependence (OR = .16, 95 % CI: .04, .67) at Wave 1
predicted a decreased likelihood of employment at Wave 2.
Past year anxiety, alcohol abuse and dependence, and drug
abuse at Wave 1 were not significantly associated with
employment at Wave 2. New onset 12-month bipolar,
anxiety, alcohol abuse and dependence at Wave 1 were
non-significant predictors of employment at Wave 2.
This study examined the longitudinal effects of psychiatric
and substance use disorders on employment outcomes, in
an employed population, using a large population-based
survey. Whereas previous studies have examined the
relationships between psychiatric disorders and employ-
ment outcomes by focusing on either one disorder, or a
single point in time, this is one of the first studies to
examine the associations between mood, anxiety, and
substance use disorders and employment outcomes over
time. We found that among those who were employed, the
presence of depression, bipolar, and drug abuse/depen-
dence disorders influenced employment outcomes over
time, and the impact varied somewhat by disorder onset.
Specifically, we found that among those employed at
baseline, 12-month and new onset 12-month depression,
12-month bipolar, new onset 12-month drug abuse, and
12-month and new onset 12-month drug dependence were
associated with a decreased odds of being employed at
follow up. Alternatively, anxiety and alcohol abuse and
dependence at baseline were not significantly associated
with employment at follow up.
Several studies have reported that depression and bipo-
lar disorders are associated with significant work impair-
ments and unemployment (Esposito et al. 2007; Kessler
et al. 2001; Lerner et al. 2004; Waghorn et al. 2005;
Whooley et al. 2002a, b). The results of this study were
consistent with past research in that those who were
employed with depression or bipolar disorder at baseline
were less likely to be employed at follow up, 2–3 years
later. Prior research examining the longitudinal effects of
bipolar disorder specifically and employment found that
46.6 % of the bipolar patients examined were employed at
study baseline and follow up and 8.8 % of were employed
study baseline and unemployed at follow up (Gilbert et al.
Table 1 continued
Participant characteristicsAll (%) Unemployed (%) Employed (%)P-value
12-month drug dependence
Yes 0.541.07 0.46
No 99.46 98.9399.54
New onset depression
Yes 1.56 2.301.45
New onset bipolar disorder
Yes 0.71 0.980.66
New onset anxiety
New onset alcohol abuse
New onset alcohol dependence 0.91
Yes 0.65 0.640.65
New onset drug abuse
New onset drug dependence
Yes0.09 0.29 0.06
Community Ment Health J (2013) 49:303–310 307
2010). Similarly, another longitudinal study found that
patients with major depression, bipolar I, and bipolar II
were rated as having ‘‘severe impairment-unable to carry
out work activities’’ for a large percentage of their course
of illness and that severe work impairment was signifi-
cantly higher for those with bipolar I than those with major
depression and bipolar II (Judd et al. 2008).
In the present study 12-month and new onset 12-month
depression predicted decreased odds of employment at
follow up, however only 12-month bipolar disorder pre-
dicted decreased odds of employment at follow-up. The
course and chronicity of bipolar disorder may be an
important part of predicting occupational outcomes. Sev-
eral studies have found that among individuals with bipolar
disorder, it is the depressive symptoms that are more dis-
abling than the manic phase symptoms (Simon et al. 2008;
Zimmerman et al. 2010). While we did not distinguish
those with bipolar disorder based on manic or depressive
symptoms in this study, it is possible that those who had
new onset 12-month bipolar disorder may have been in a
manic phase and thus their functioning may not have been
as negatively impacted. It may be particularly important to
take anticipatory measures to plan for treating depressive
symptoms of patients with bipolar disorder who are in a
manic phase. Additionally, despite the availability of
effective treatments for depression, the results of this study
indicate that depression significantly interferes with long
term work functioning. It may be that these individuals are
not receiving treatment for their depression or they are not
receiving support from their employers to participate in
treatment. It would likely be beneficial for employers to
facilitate the receipt of treatment for individuals with these
disorders, particularly as past studies have shown that the
costs of treatment are negated by costs in potential pro-
ductivity losses (Zhang et al. 1999).
Several studies have reported the economic burden,
includinghealth carecosts,costsrelated tocrime,andlostin
potential productivity costs, associated with alcohol and
drug use disorders (Cartwright 2008; Eaton et al. 2008;
Harwood et al. 1999). The present study found that among
those who are employed, drug abuse and dependence at
baseline was associated with decreased odds of employment
at follow up, whereas alcohol abuse and dependence at
baseline was not significantly related to employment at fol-
disorders experience greater rates of relapse, or a course of
disruptions, than those with alcohol abuse and dependence
disorders. Additionally, there may be fewer effective treat-
ments available or greater barriers associated with receiving
treatment, for those with drug abuse and dependence disor-
ders relative to alcohol use disorders. Several studies
employment and wages have found that those who complete
time and have higher wages than those who drop out or stay
for shorter periods of time (Goldklang et al. 2003; Hubbard
et al. 2003). These findings again support the idea that it
would be beneficial for employers to support mental health
employees in order to improve on the job functioning and to
potentially facilitate job stability.
The results of this study should be considered in light of
several limitations. Recall bias may have influenced the
reporting of psychiatric symptoms. Although we make
hypotheses about the unique effects that each disorder may
have on employment over time, it is possible that some of
these individuals had comorbid psychiatric disorders, as the
disorders were not coded as mutually exclusive categories.
The results may also underestimate the impact of psychi-
atric disorders on employment as psychotic disorders such
as schizophrenia and schizoaffective disorders were not
examined. Having longer term data, with multiple follow
up points, would be helpful to further establish how fluc-
tuations in symptoms relates to changes in employment
status. Individuals who were working part-time were coded
as being ‘‘employed’’ therefore it is possible that some
individuals with psychiatric disorders were working, but
not working at their full capacity, as a consequence of a
psychiatric disorder. In this case, our estimates of those
Table 2 Adjusted models of the association between psychiatric
disorders and subsequent employment status
Diagnosis Adjusted odds ratio95 % confidence interval
Anxiety1.03 0.88, 1.21
Alcohol abuse1.31 0.99, 1.74
Drug abuse 1.010.68, 1.52
New onset 12-month
Bipolar disorder 0.770.48, 1.24
Anxiety 0.750.47, 1.18
Alcohol abuse2.220.97, 5.08
* Each model adjusted for age, sex, race, income, education, insur-
ance status, self rated health, physical component score
Bold values represent P B 0.05
308Community Ment Health J (2013) 49:303–310
experiencing work impairments as a result of psychiatric
disorders would be conservative. Similarly, some of the
individuals who were employed at baseline and unem-
ployed at follow up may have retired or discontinued
working for reasons unrelated to psychiatric disorders that
were not examined.
Despite these limitations, this is the first study of which
we are aware to examine the longitudinal effects of psy-
chiatric and substance use disorders on employment out-
comes, in an employed population using nationally
representative data. We found that depression, bipolar
disorder, and drug abuse/dependence disorders at baseline
predicted a decreased likelihood of employment at follow-
up. Additionally, disorder onset seems was important in
predicting longitudinal employment outcomes. These
findings suggest that it would be beneficial for employers
to increase efforts to engage their employees in partici-
pating in mental health treatment. These efforts may be in
the form of reducing stigma related to mental health
problems and treatment in the workplace, increasing
awareness about employee assistance programs and other
available supports, and offering employees with psychiatric
problems long term mental health support in order to
reduce the likelihood of future acutely symptomatic phases
and related impairments, Additionally, a better under-
standing of how psychiatric disorders influence employ-
ment over the life course might inform the development of
preemptive interventions to treat mental health symptoms.
Veterans Affairs, Office of Academic Affiliations, Advanced Fel-
lowship Program in Mental Illness Research and Treatment; The
Veterans Administration Health Services Research and Development
Career Development Award (CD2 07-206-1); The Department of
Veterans Affairs Health Services Research and Development
(HSR&D) Service Grant (IAC 08-099); and the National Institute on
Drug Abuse (NIDA) Grant to (1R21DA026925). This funding was in
the form of health system evaluation funds and of a career develop-
ment award and did not directly shape the design or conduct of this
specific study. The views expressed in this report are those of the
authors, and do not necessarily represent those of the VA.
This work was supported by the Department of
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