Long Absence from Work Due to Sickness among Psychiatric Outpatients in Japan, with Reference to a Recent Trend for Perfectionism.

BACKGROUND: Sick leave from work due to psychiatric disorders is a major public health problem, not only in Japan but also worldwide. As males and females in Japan tend to differ in their approach to work, a gender difference in perfectionism might be expected. We investigated the background factors leading to long-term absence from work due to sickness among psychiatric outpatients in Japan.
METHODS: We surveyed 73 psychiatric outpatients who were absent from work for a long time (POAWs) and 228 employees without long-term sickness absence as controls. GHQ-30, NEO-FFI, MPS, RSS and questionnaires inquiring about background factors, including relationships with others, was used, and the data were compared between males and females.
RESULTS: Male POAWs had a significantly higher tendency for depression and perfectionism than the controls, but in females this difference was not significant. With regard to personal relationships of POAWs, males had worse relationships with superiors and colleagues, whereas females had worse relationships with superiors, colleagues, and family.
CONCLUSIONS: The data suggested that male workers exhibiting perfectionism tend to undertake too much work and become exhausted when trying to cope with complex human relationships in the workplace. Female workers having the double burden of family commitment and perfectionism tend to be isolated in terms of personal relationships, leading to exhaustion both in and outside the workplace.

Introduction

Sick leave from work due to psychiatric disorders is a major public health problem, not only in Japan but also worldwide. Recently in Japan, the concept of lifetime employment has collapsed and the work situation for employees has changed dramatically. As even major companies can go bankrupt or undergo restructuring, emphasis is now being placed on efficiency and individuals are being differentiated according to ability. Currently in Japan, employees face greater levels of stress than was the case previously, due to this adverse change in the business environment. This has led to an increase in the number of individuals with depression and in the incidence of suicide due to overwork, both of which have become major social issues. Workers who cannot adjust to this increased work stress frequently become psychiatric outpatients due to depression and other conditions. The number of patients complaining of mood disorder is estimated to have almost tripled from 280,000 to 800,000 over the fifteen years between 1990 and 2005 (1). The annual number of suicides has exceeded 30,000 annually for the last twelve years. Although the increase in depression among employees has been attributed to stress, this is probably too simplistic. As psychosocial working conditions and family-related factors exert different effects on work, causes of maladjustment to work presumably differ.

On the other hand, there has been some discussion with regard to which factors has the most influence on maladjustment and depression, such as psychological stress in or outside the workplace, personality traits or characteristics, and so on. Among the characteristics of individuals, perfectionism can be a reason for maladjustment to work, and also for development of depression. As males and females in Japan tend to differ in their approach to work, a gender difference in perfectionism might be expected. However, it is unclear whether perfectionism leads to maladjustment in both males and females, and whether there is also a gender difference in this respect. Therefore, we considered that it would be informative to investigate the factors that actually cause maladjustment among employees and are responsible for mental illness.

Materials and Methods

We surveyed 73 psychiatric outpatients who were absent from work (POAWs) for less than 8 weeks and belonged to F3 and F4 of ICD-10 (2) between September 2007 and August 2009 at the Department of Psychiatry, The Jikei University School of Medicine. As controls, we also surveyed 228 employees (150 males and 78 females) who had never been absent from work for a long period. The survey items included: age, gender, presence/absence of a spouse and children, working and overtime hours, psychological stress experienced within the past six months in and outside the workplace, satisfaction with work, support from family and company, relationships with superiors, colleagues, and subordinates, and other background information. We used a questionnaire that had originally been developed by us, as well as the GHQ-30 (General Health Questionnaire-30)(3), MPS (Multidimensional Perfectionism Scale) (4, 5), NEO-FFI (6,7), and RSS (Rosenberg Self-esteem Scale) (8).

The GHQ-30, developed by Goldberg (3), is a shorter version of the GHQ-60, and includes the following six subscales: “general illness”, “somatic symptoms”, “sleep disturbance”, “social dysfunction”, “anxiety and dysthymia”, and “suicidal depression”. The questionnaire uses a four-grade Likert scoring method to assess mental health. Normally, the total score for the GHQ-30 is six or lower in 85% of healthy adults.

The MPS, developed by Frost et al (4), is a multidimensional assessment scale designed to evaluate the level of perfectionism. It consists of 35 question items, and includes the following six subscales: “concern over mistakes: CM”, “personal standard: PS”, “parental expectations: PE”, “parental criticism: PC”, “doubt about actions: DA”, and “organization: O”. The MPS uses a five-grade Likert scoring system ranging from “I completely agree” to “I completely disagree”. The Japanese version of the MPS was developed by Tanaka et al.(5), and its reliability and validity have been confirmed.

The NEO-FFI (60 items), a shorter version of the NEO-PI-R (240 items), is employed to measure five personality dimensions known as the “BIG 5”: neuroticism, extroversion, openness, agreeableness, and conscientiousness.

We used the Brief Job Stress Questionnaire (BJSQ) (9), published by the Ministry of Health, Labour and Welfare of Japan, to assess the levels of emotional strain experienced in and outside the workplace. The BJSQ, developed on the basis of the JCQ (Job Content Questionnaire) (10, 11) and the NIOSH job stress questionnaire (12, 13), is designed to measure the level of daily stress experienced within the last six months.

The present study was conducted with approval from the Ethics Committee of Tokyo Jikei University School of Medicine. We compared the results for POAWs and controls overall, and for males and females separately.

Statistical analysis

To compare differences in the demographic data between POAWs and controls, Mann-Whitney U Test was used with a significance level of 0.05 using the SAS software package version 9.1(14). All analyses were stratified for gender.

Results

Background factors

The diagnosis, age and GAF of the 72 POAWs are presented in Table 1. There were 36 POAWs (30 males and 6 females) in F3 and 37 (25 males and 12 females) in F4. Patients having both F3 and F4 disorders were categorized as F3.

Table 1:

Diagnosis, age and GAF of the psychiatric outpatients

ICD	Diagnosis	Male	Female	Total	Age (yr)	GAF
F3	Bipolar affective disorder	2	0	2	37.8±9.2	51.2±7.5
	Depressive episode	25	2	27
	Dysthymia	3	4	7
F4	Panic disorder	2	0	2	39.2±8.6	56.4±8.7
	Generalized anxiety disorder	0	1	1
	Adjustment disorder	23	8	31
	Somatization disorder	0	3	3
	total	55	18	73
Age and GAF are expressed as mean±SD

Table 2 shows sociodemographic characteristics including age, academic background, type of job, presence of spouse/child, working time, overtime hours, psychological stress in and outside the workplace, and relationship with superiors, colleagues and family. The average age did not differ between POAWs and controls for either males or females. Both the POAWs and the controls had a high education level. The proportions of male POAWs who had a spouse and one or more children were 54.5% and 49.1%, respectively, and the corresponding figures for females were 22.2% and 0%, respectively. The proportions of both male and female POAWs who had a spouse and child(ren) were lower than for the controls. With regard to job type, clerical staff/executive officers accounted for the majority of the POAWs and there were other various ones both in males and females.

Table 2:

Sociodemographic characteristics-1

		Male		Female
		POAW	Controls	POAW	Controls
Number		55	150	18	78
Average Age (Years Old: Mean±SD)		41.2±8.9	43.0±9.2	34.6±6.8	36.3±7.9
Academic Background (Number (%))	Junior High School Graduate	1 (1.8)	1 (0.67)	0 (0.0)	0 (0.0)
	High School Graduate	9 (16.4)	22 (14.7)	2 (11.1)	15 (19.2)
	Professional School Graduate	3 (5.5)	6 (4.0)	3 (16.7)	6 (7.7)
	Two-Year College Graduate	1 (1.8)	1 (0.67)	3 (16.7)	24 (30.8)
	University/College Graduate	41 (74.5)	120 (80.0)	10 (55.5)	33 (42.3)
Spouse (Number (%))	Yes	30 (54.5)	112 (74.7)	4 (22.2)	33 (42.3)
	No	25 (45.5)	38 (25.3)	14 (77.8)	45 (57.7)
Child (Number (%))	Yes	27 (49.1)	88 (58.7)	0 (0.0)	21 (26.9)
	NoClerical	28 (50.9)	62 (41.3)	18 (100.0)	57 (73.1)
Type Of Job (Number (%))	Staff/Executive Officer	19 (34.6)	74 (49.3)	11 (61.1)	51 (65.4)
	Planner	5 (9.1)	14 (9.3)	1 (5.6)	5 (6.4)
	Sales Representative	8 (14.5)	18 (12.0)	1 (5.6)	2 (2.6)
	Technician/Researcher Store	5 (9.1)	13 (8.7)	0 (0.0)	4 (5.1)
	Personnel/Service Business	0 (0.0)	0 (0.0)	3 (16.7)	0 (0.0)
	Specialist	1 (1.8)	3 (2.0)	2 (11.1)	11 (14.1)
	Financial Worker	3 (5.5)	0 (0.0)	0 (0.0)	1 (1.3)
	Creative Field	2 (3.6)	3 (2.0)	0 (0.0)	0 (0.0)
	IT-Related Worker	12 (21.8)	23 (15.3)	0 (0.0)	3 (3.8)
	Others	0 (0.0)	3 (2.0)	0 (0.0)	0 (0.0)
Working Time (Hours: Mean±SD)		209.5±97.5	189.6±26.7	204.0±41.8	164.9±23.2
Overtime Hours (Hours: Mean±SD)		38.0±31.3	25.9±22.3	46.7±46.4	12.4±12.9
Psychological Stress Inside The Workplace (Score: Mean±SD)		6.5±4.7	3.1±3.6	7.8±7.2	2.8±3.8
Psychological Stress Outside The Workplace (Score: Mean±SD)		3.7±3.4	2.3±2.5	3.8±2.9	2.3±2.7
Relationship With Superiors (Number)	Very Good	4	23	1	14
	Good	12	65	2	25
	Bad	30	50	11	32
	Very Bad	9	12	4	7
Relationship With Colleagues (Number)	Very Good	2	17	0	19
	Good	11	61	4	23
	Bad	32	66	10	33
	Very Bad	10	6	4	3
Relationship With Family (Number)	Very Good	14	57	5	37
	Good	25	52	5	26
	Bad	14	36	6	15
	Very Bad	2	5	2	0

Psychological stress both in and outside the workplace of POAWs was significantly higher than for controls, in both males and females, as shown in Table 2.

Relationships with superiors (Z=3.60; P<0.001) and colleagues (Z=4.15; P<0.0001) were significantly worse for POAWs than for controls among males (Mann-Whitney U test). No significant inter-group differences were evident for male relationships with the family. On the other hand, females showed significantly worse relationships with superiors (Z=3.33; P<0.001), colleagues (Z=3.01; P<0.001) and family (Z=2.49; P<0.05)(Mann-Whitney U test).

Results obtained using the GHQ, NEO-FFI, MPS and RSS

GHQ

Analyses of variance revealed significant differences between POAWs and controls for all of the GHQ subscales (GHQ score Z=8.46, P<0.0001 for males, Z=4.42, P<0.0001 for females; General illness Z=6.39, P<0.0001 for males, Z=4.40, P<0.0001 for females; Somatic symptoms Z=4.03, P<0.0001 for males, Z=2.21, P<0.05 for females; Sleep disturbance Z=6.88, P<0.0001 for males, Z=2.76, P<0.001 for females; Social dysfunction Z=8.98, P<0.0001 for males, Z=5.74, P<0.0001 for females; Anxiety and dysphoria Z=7.13, P<0.0001 for males, Z=3.60, P<0.001 for females; Suicidal depression Z=6.02, P<0.0001 for males, Z=4.12, P<0.0001 for females). See Table 3 for means and standard deviations.

Table 3:

The result of GHQ,NEO-FFI,MPS and RSS

		Male		Female
		POAW	controls	POAW	controls
GHQ	GHQ score	19.4±6.0*	8.4±6.3*	19.4±6.3*	9.6±6.7*
	General Illness	3.3±1.4*	1.7±1.3*	3.9±1.0*	2.1±1.4*
	Somatic Symptoms	2.9±1.7*	1.8±1.5*	3.1±1.7**	2.1±1.7**
	Sleep Disturbance	3.8±1.6*	1.7±1.5*	3.1±1.5**	1.9±1.7**
	Social Dysfunction	3.3±1.5*	0.7±1.8*	3.0±1.4*	0.7±1.2*
	Anxiety and Dysphoria	4.0±1.4*	1.8±1.8*	3.9±1.3**	2.1±1.8**
	Suicidal Depression	2.2±2.1*	0.7±1.5*	4.9±7.8*	0.8±1.5*
NEO-FFI	Neuroticism	30.3±6.5*	24.8±8.3*	31.8±8.3*	26.6±7.8*
	Extraversion	19.7±6.6*	23.8±6.5*	23.2±5.6	25.9±7.1
	Openness	27.7±5.6	28.5±5.5	29.7±7.7	30.0±4.4
	Agreeableness	29.3±5.6	30.4±4.7	32.4±4.9	31.9±6.1
	Conscientiousness	26.7±6.2	25.9±5.0	27.9±5.6	27.8±5.1
MPS	CM	27.9±6.7*	21.7±6.8*	25.5±12.1	21.9±6.9
	PS	20.6±5.6*	16.8±4.7*	19.2±8.5	16.2±5.0
	PE	11.8±4.5*	10.1±3.9*	13.5±6.6	10.9±5.0
	PC	9.5±3.5*	8.0±2.8*	9.6±4.3	8.1±3.7
	D	12.7±2.7*	11.2±3.1*	11.1±2.7	10.3±3.1
	O	18.7±5.2	17.6±4.7	16.7±4.9	17.8±4.2
RSS		31.5±3.0	33.3±5.8	31.2±4.7	33.4±6.5

Scores are expressed as mean±S.D.

P<0.0001

P<0.05

NEO-FFI

The results for NEO-FFI are shown in Table 3. The neuroticism score for POAWs was significantly higher than that for controls in both males and females (neuroticism: Z=4.37, P<0.0001 for males, Z=2.44, P<0.05 for females), but the score for extraversion was significantly higher for POAWs than for controls only in males (extraversion: Z=−3.72, P<0.001 for males).

MPS

Analysis of variance revealed significant differences between POAWs and controls for all of the MPS subscales (CM: Z=5.50, P<0.0001 for males, PS: Z=4.16, P<0.0001 for males, PE: Z=2.42, P<0.05 for males, PC: Z=2.71, P<0.01 for males, D: Z=3.14, P<0.005 for males). MPS subscale scores for POAWs, except for O, are shown in Table 3. The scores for POAWs were higher than those for controls, but the difference was not significantly significant.

RSS

As shown in Table 3, the RSS scores did not differ between POAWs and controls, for either males or females.

Discussion

Common mental disorders and long absence from work

Mental disorders such as adjustment disorder, depression and anxiety disorder in F3 or F4 in the ICD-10 occur frequently, and often cause work disability. A meta-analysis of 27 studies has estimated the 12-month prevalence of such disorders in the general population to be 12.0% for anxiety and 9.1% for affective disorder (15). Such psychiatric outpatients, including those with depression, have been increasing because of inability to adjust to the workplace, and these results in long absences from work. Many studies of depression among employees have shown that depression is related to long absence from work (16,17), and major depression has received attention as a risk factor for sick leave (17,18,19,20,21). Depression has also been associated with an increased risk of sickness absence for both men and women (22–24). Stansfeld et al (18) showed that minor psychiatric disorders, such as minor depression, were one of the most common reasons for sickness absence among civil servants. Also, many studies have shown that serious depressive symptoms are related to longer sickness absence (17, 25–27). In the NEMESIS (25), the median duration of major depressive episode was 3.0 months, and 50% of participants with major depressive episode recovered within 3 months, 63% within 6 months, 76% within 12 months, and nearly 20% had not recovered at 24 months. Therefore, a long period is required in order for patients to fully rest and recover from depression, and this necessitates a long absence from work.

Perfectionism at work

As perfectionism is needed for accomplishing work to a correct standard and for making an individual reliable, it is one of the characteristics that have a significant influence in determining professional success. Sometimes, however, it can be a hindrance to individuals. Perfectionism has been described as a dispositional tendency to set excessively high standards of performance and to elicit extremely critical self-evaluation (4, 28). In such cases, perfectionism is known as maladaptive perfectionism or clinical perfectionism. Bieling et al. (29) reported that maladaptive perfectionism was strongly related to symptoms of anxiety, and Blatt (30) emphasized the role of self-criticism as a psychological trait for understanding the nature of depression. He also discussed the similarities between negative aspects of perfectionism and self-criticism, and considered that self-critical individuals had “feelings of unworthiness, inferiority, failure, and guilt … achronic fear of disapproval, criticism, and rejection”. On this basis, it is considered that maladaptive perfectionism leads to psychological disorders (31). In the workplace, especially, perfectionists tend to undertake too much work and cannot delegate it to others. When added to the complex human relationships existing in the workplace, perfectionists tend to become exhausted because they also try excessively hard to keep such relationships balanced.

Gender difference

Pronounced gender differences have been reported in studies of sick leave due to depression, and most have shown that the risk is higher among women than among men (18,32–35). There are also discrepancies between males and females regarding the duration of sickness leave. Most studies have indicated that women are absent for longer than men (36–38), but a few have obtained contrary results (22,39). Also it has been shown that women use health services more frequently than men, express emotional symptoms more often than men, and that clinicians more often interpret female symptoms as being related to emotional problems (40–43). On the other hand, female employees often bear the main responsibility of household tasks, which increases their total work load and may cause difficulties in combining work and family life, and even contribute to mental and physical health problems (44,45). However, previous findings pertaining to associations of domestic obligations (46,47), the so-called “double-burden” (48,49), and work-home conflict (49–51) with sickness absence have been inconsistent. This “double-burden” concept for Japanese female employees is used to take into account caring for both children and also the husband’s parents. In fact for some Japanese female employees, such a “double-burden” may become a “triple-burden” if care of the woman’s own parents is also necessary. In a survey of white-collar workers, Nakamura et al. (52) reported close relationships between depression and psychological stress experienced outside, rather than inside, the workplace for both men and women. This means that psychological stress is extremely heavy for female workers with a double or triple care burden.

Among the 73 patients with common mental disorders that we studied, GAF for the F3 group was 51.2±7.5 (mean±SD) and that for the F4 group was 56.4±8.7, as shown in Table 1. This result supports the fact that all the GHQ sub-scale scores for POAWs were significantly higher than those for controls in both males and females. These results mean that the POAW group had mild or moderate mental impairment, and that POAWs had greater psychological stress than controls both in and outside the workplace. Therefore, their mild and moderate anxiety and depression were assumed to be related to psychological stress both inside and outside the workplace.

With regard to personal relationships, male POAWs had worse relationships with superiors and colleagues than their control counterparts. On the other hand, female POAWs had worse relationships with their family, as well as with their superiors and colleagues. This indicates that female POAWs were unable to rely on their family or their superiors and colleagues.

Among personal characteristics, “Neuroticism” in both male and female POAWs was significantly higher than in the controls, and only “Extraversion” in male controls was significantly higher than that in male POAWs. The results of the MPS indicated that perfectionism was significantly higher only in male POAWs, but was higher in both male and female POAWs than in controls except for “O”. It was inferred that the insufficient number of subjects did not allow adequate statistical comparison for females.

Our study suggested that male employees who had high perfectionism tended to be absent from work for a long time, because they undertook too much work and also became exhausted dealing with complex human relationships in the workplace. Perfectionism is needed for success, and adaptive perfectionism is characterized by the desire to excel and to set high but achievable standards, whereas maladaptive perfectionism involves a strong focus on avoiding error, adoption of overly high standards, feelings of self-worth dependent on performance, and responses to failure involving harsh views of the self (53). Males are also required to exercise extraversion in the workplace; in other words, males who do not have enough “extraversion” cannot survive in this type of environment. “Extraversion” leads to good relationships with superiors and colleagues. Therefore, for male workers, good human relationships in the workplace are needed so that they do not drop out or become absent from work for a long period.

On the other hand, the circumstances of females are a little more complicated. In addition to the circumstances described for males above, female employees with psychiatric disorders were found not to have good relationships with the family, and were isolated not only in the workplace but also at home. In general, it is suggested that people who are isolated would have a more perfectionistic attitude. Severer perfectionism would make the situation worse for female workers, causing them to become exhausted and depressive, and to drop out from the workplace. This vicious cycle would be further accelerated in Japanese women who have to cope with a “double-burden” of care, thus leading to common mental illnesses including depression.

In conclusion, psychiatric outpatients in Japan with common mental disorders including depression tend to have a high degree of perfectionism and become exhausted due to the demands of work and also their complex human relationships in the workplace. Japanese female POAWs in particular seem to be isolated not only in the workplace but also in the family. This vicious cycle of perfectionism together with adverse work and family situations, place a double burden on female employees, causing common mental illnesses and long-term absence from work.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.