Journal of Affective Disorders 130 (2011) 209–212 Contents lists available at ScienceDirect Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d Research report Occupational impairment and Social Anxiety Disorder in a sample of primary care patients Ethan Moitra a,⁎, Courtney Beard a, Risa B. Weisberg a,b, Martin B. Keller a a b Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, United States Department of Family Medicine, Alpert Medical School of Brown University, United States a r t i c l e i n f o Article history: Received 9 June 2010 Received in revised form 7 September 2010 Accepted 18 September 2010 Available online 12 October 2010 Keywords: Social Anxiety Disorder Primary care Occupational functioning a b s t r a c t Background: Social Anxiety Disorder (SAD) is the second most prevalent psychiatric condition in the US. Because of the inherent nature of SAD, it may cause impairments in workplace functioning, particularly compared to other anxiety disorders that do not necessarily lead to social impairments. In this study, we compared workplace functioning in primary care patients with SAD to patients with other anxiety disorders and comorbid Major Depressive Disorder (MDD). Methods: Data are obtained from the Primary Care Anxiety Project (PCAP), a naturalistic, longitudinal study of anxiety disorders in 539 primary care patients. We examined intake demographic and interviewer-assessed ratings of workplace functioning. Results: Results revealed that patients with SAD and MDD had significantly decreased workplace functioning, compared to individuals with other anxiety disorders. Furthermore, results showed that patients with SAD were greater than two-times more likely to be unemployed, but expected to work, than all other patients. Limitations: Workplace functioning was not measured objectively and the sample may not be representative of the general population. Conclusions: These findings highlight the particular need to assess for the presence of undereducation and underperformance at work and/or underemployment in individuals with SAD, as they are at most risk for these impairments. Additionally, early detection and intervention in individuals with or at risk for SAD may curb the future impact of social anxiety on occupational attainment. © 2010 Elsevier B.V. All rights reserved. 1. Introduction In the United States, the estimated annual cost of anxiety disorders is $42.3 billion (Greenberg et al., 1999). This estimate includes indirect costs, which measure the price of lost productivity at work and lower wages, among other factors. These indirect costs are particularly relevant to understanding the burden of Social Anxiety Disorder (SAD), ⁎ Corresponding author. Brown University, Box G-BH, Providence, RI 02912, United States. Tel.: +1 401 444 1935; fax: +1 401 455 0516. E-mail address: ethan_moitra@brown.edu (E. Moitra). 0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2010.09.024 the second most common psychiatric disorder in the U.S. (Kessler et al., 2005), with a lifetime prevalence ranging from 7 to 13% (Furmark, 2002). SAD usually begins in childhood or adolescence (Rapee, 1995) and can negatively affect school performance, relationships, and mood (Wittchen et al., 1999). Early SAD is a significant predictor of SAD in adulthood (Pine et al., 1998) and it has the lowest remission rate among Generalized Anxiety Disorder (GAD) and Panic Disorder with or without Agoraphobia (PDA; PD, respectively) (Bruce et al., 2002). Although SAD does not predict school failure, among the anxiety disorders, it is the only condition that is predictive of a person's failure to go on from high school to college 210 E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212 (Kessler, 2003), suggesting that early development of SAD leads to undereducation and most likely, underemployment. This interference is compounded by SAD's chronic, unremitting course (Beard et al., 2010). Not surprisingly, this early-developed, chronic disorder leads to long-lasting impairments in normative life roles, including in the workplace. Adults with SAD report lower employment rates, lower income, and lower socio-economic status compared to individuals without psychiatric morbidity (Patel et al., 2002; Stein et al., 2000). For those who are employed, SAD leads to decreased work productivity, increased absences, and other work impairments (Kessler et al., 1994; Kessler, 2003; Wittchen and Beloch, 1996; Wittchen et al., 2000). Workplace SAD-related impairment also manifests in refusal of promotions because of social fears (Stein et al., 2000) and severity of SAD is a significant predictor of lower hourly wages (Katzelnick and Greist, 2001). SAD not only presents a significant barrier to working full-time, but it can also be more disruptive to occupational functioning than depression (Tolman et al., 2009). Antony et al. (1998) found that SAD, Obsessive– Compulsive Disorder (OCD), and PDA/PD were associated with similar levels of work impairment. With the exception of this one study, though, little attention has been paid to the comparison of workplace functional impairments across anxiety conditions. These comparisons provide crucial context to the differential effects of these disorders and to the understanding of their relative impact on broad estimates of the effects of anxiety on public health concerns (e.g., Greenberg et al., 1999). For example, because of gaps in the literature, it is unclear if occupational impairments associated with SAD differ from those associated with GAD and if these disorders differentially contribute to the lost productivity associated with anxiety disorders. Because of the social impairments associated with SAD, it is likely that individuals with this disorder suffer increased occupational impairment compared to those with other anxiety conditions. Even less attention has been paid to comparing occupational impairment in SAD to Major Depressive Disorder (MDD), which itself, is associated with significant workplace impairments (e.g., Stewart et al., 2003). Refined knowledge of these differential effects may clarify epidemiological findings and better guide what life domains are most salient in assessment and treatment of anxiety disorders. The present study sought to refine knowledge of SAD's effects on occupation by comparing employment rates and workplace functioning in SAD to other anxiety disorders and comorbid MDD. In light of previous research, we hypothesized that patients with SAD would show equivalent occupational impairment to individuals with PD, PDA, and comorbid MDD. Because of SAD's influence on social functioning, we predicted that SAD-associated occupational impairment would be higher than in individuals with GAD and Posttraumatic Stress Disorder (PTSD). We predicted that unemployment rates would be higher in SAD, compared to other conditions. Lastly, we sought to explore the association between disability status (psychiatric or medical) and each of these disorders, without specific directional hypotheses. 2. Methods 2.1. Participants Participants were part of the Primary Care Anxiety Project (PCAP), a longitudinal, naturalistic study of 539 primary care patients with anxiety disorders. Inclusion criteria consisted of the following: participants were a minimum of 18-years-old, English was their primary language, they had an index anxiety disorder, and they presented at the primary care practice for a medical appointment on the day of recruitment. Index anxiety disorders were: SAD, PTSD, GAD, PDA, PD, Agoraphobia without history of Panic Disorder (AWOPD), or Mixed Anxiety Depressive Disorder (MAD). Due to too few cases, patients with AWOPD and MAD are not assessed here. Active psychosis and pregnancy at the time of intake were exclusion criteria (see Weisberg et al. (2005) for further details of PCAP methods). 2.2. Procedures Potential participants completed a screening questionnaire for symptoms of anxiety. Those who screened positive for the presence of anxiety symptoms were assessed with the Structured Clinical Interview for the DSM-IV (SCID-IV; First et al., 1996). Patients who indicated the presence of at least one index anxiety disorder as defined by the DSM-IV were invited to join the study. At baseline, these patients completed a number of measures assessing symptomatology, psychosocial functioning, and treatments received. Subsequent follow-ups were obtained at 6-month, 1-year, and annually thereafter. Only baseline data are analyzed here. 2.3. Measures 2.3.1. Structured Clinical Interview for the DSM-IV (SCID-IV; First et al., 1996) Diagnoses were established with the SCID-IV. Several diagnosticians conducted interviews in order to increase external validity. All interviews were audiotaped, and interrater reliability on a random sample of 30% of the interviews was high (intraclass correlation α = 0.96). 2.3.2. Longitudinal Interval Follow-Up Evaluation (LIFE; Keller et al., 1987) The LIFE is an interviewer-administered assessment that collects detailed information on disorder symptoms, psychosocial functioning, and treatment status. Baseline LIFE work status ratings, for those who were employed, are used here. These interviewer-assessed ratings represent the degree of impairment in work activities suffered in the past week. The quantity and quality of work carried out were assessed on a five-point Likert scale ranging from 1 (i.e., has worked as much as someone in his/her social situation would be expected to work, and worked at a high level) to 5 (i.e., has missed a great deal of work when someone in his/her social situation would have been expected to work and/or has been virtually unable to carry out his work activities when he did work). 211 E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212 3. Results 3.1. Descriptive analyses A total of 539 patients who met DSM-IV criteria for one or more anxiety disorders were enrolled into the study. One hundred and eighty-two of these patients met criteria for SAD (see Table 1 for a summary of demographic variables). Seventy-one percent met criteria for at least one other psychiatric disorder at intake and 100% met criteria for additional comorbid disorders at some point in their lifetime. Comorbidity patterns in the PCAP sample are described in detail elsewhere (Rodriguez et al., 2004). Results revealed SAD age of onset was significantly correlated with education (r = − 0.015, p = 0.045), with an earlier onset age predicting lower educational attainment. This trend was also observed in patients with PDA (r = −0.163, p = 0.046). Educational attainment and onset age were not significantly correlated in any other disorder group (ps N 0.05). 3.2. Primary analyses In a multivariate linear regression model controlling for educational attainment, results indicated SAD (β = 0.27, Social Anxiety Disorder Other Anxiety Disorders (N = 182) (N = 357) Characteristic N (%) N (%) Female Race/ethnicity Caucasian African American Hispanic/Latino Asian Native American Other Marital status Never married Married a Divorced/separated/ widowed Education bHigh school graduate High school graduate Some college College graduate Income ($ per year) b5000 5000–9999 20,000–4,999 35,000–49,999 N50,000 Not reported Employment Full-time Unemployed b Disabled c Other Age in years (M, SD) 134 (73.6) 278 (77.9) 147 (80.8) 13 (7.1) 11 (6.0) 3 (1.7) 2 (1.1) 6 (3.3) 300 (84.0) 28 (7.8) 8 (2.2) 4 (1.1) 7 (2.1) 10 (2.8) 51 (28.0) 82 (45.1) 49 (26.9) 96 (26.9) 185 (51.8) 76 (21.3) 20 46 78 38 (11.0) (25.3) (42.9) (20.8) 32 88 151 86 (9.0) (24.6) (42.3) (24.1) 42 (23.2) 66 (36.5) 35 (19.3) 16 (8.8) 16 (8.8) 7 (3.4) 56 130 69 51 37 13 (15.7) (36.5) (19.4) (14.3) (10.4) (3.7) 144 19 113 81 39.1 (40.3) (5.3) (31.7) (22.7) (12.0) a b c (35.7) (16.5) (33.0) (14.8) (11.0) 3.3. Secondary analyses We explored the relationship between diagnosis and disability (psychiatric or medical). Binary logistic regression revealed that patients with SAD were less likely to be disabled (Exp(B) = −0.63; OR = 0.53; 95%CI: [0.30, 0.95]; p = 0.03). This pattern was also observed in GAD (Exp(B) = −0.79; OR = 0.45; 95%CI: [0.22, 0.92]; p = 0.03). However, those with PDA were nearly three-times more likely to be disabled (Exp (B) = 1.04; OR = 2.82; 95%CI: [1.53, 5.20]; p = 0.001). All other disorders were not predictive of disability (ps N 0.05). 4. Discussion Table 1 Socio-demographic characteristics (N = 539). 65 30 60 27 39.1 t = 2.43, p = 0.02) and MDD (β = 0.51, t = 4.59, p b 0.0001) were unique predictors associated with lower workplace functioning ratings on the LIFE, whereas all other disorders were not (ps N 0.05). Binary logistic regression was used to assess likelihood of being unemployed depending on diagnosis. Results revealed that individuals with SAD were greater than two-times more likely to be unemployed and that individuals with other anxiety disorders were more likely to be employed. Furthermore, results revealed that MDD was not significantly predictive of unemployment status (see Table 2 for summary of odds ratios). Includes persons living with someone as though married. Unemployed but expected to work. Psychiatrically or medically disabled. Despite knowledge of SAD's chronicity and detrimental effects on occupational functioning, few researchers have compared impairment associated with SAD with that related to other anxiety and mood conditions. By nature, the workplace may trigger SAD symptoms in particular, and consequently cause more impairment than in conditions associated with less social interference (e.g., GAD). This study addressed this gap in the literature by comparing likelihood of unemployment and disability (psychiatric or medical) status, as well as overall workplace functioning in primary care patients with SAD, GAD, PTSD, PD, PDA, and comorbid MDD. Patients with SAD and MDD were significantly more impaired in the workplace than all other individuals, regardless of education level. Results also indicated that patients with SAD were 2.25 times more likely to be unemployed but expected to work, than patients with any other psychiatric condition. In fact, results suggested that the presence of PD, PDA, GAD, and PTSD made a patient more likely to be gainfully employed compared to patients with SAD. Exploratory analyses indicated that among the disorders Table 2 Effect of diagnosis on unemployment status a. Diagnosis Exp(B) OR 95% CI p Panic Disorder Panic Disorder with Agoraphobia Social Anxiety Disorder Generalized Anxiety Disorder Posttraumatic Stress Disorder Major Depressive Disorder −1.44 −1.63 0.81 −0.95 −1.33 0.01 0.24 0.20 2.25 0.39 0.27 1.01 [0.08, 0.75] [0.09, 0.43] [1.19, 4.26] [0.17, 0.87] [0.14, 0.50] [0.55, 1.86] 0.014 b.0001 0.013 0.023 b.0001 0.971 Note. OR = odds ratio; CI = confidence interval. a Unemployed but expected to work. 212 E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212 examined, individuals with PDA were most likely to be disabled. This finding suggests that PDA may be the most debilitating anxiety disorder overall, as these individuals were not working. Because of the inherent social nature of most occupations, it is not surprising that SAD is associated with occupational impairment and unemployment. However, these results are the first to the authors' knowledge that demonstrate a significant difference between SAD and other anxiety disorders in these important domains. These findings highlight the particular need to assess for the presence of undereducation and underperformance at work in individuals with SAD. Strengths of the current study include the large sample size and the range of comparison disorders. However, the current study also has limitations, including that it is not an epidemiological study. Some of the current sample's demographic characteristics (e.g., employment rates), though, are similar to those found in larger epidemiological studies (e.g., Davidson et al., 1993), suggesting that the current findings might generalize to samples outside of primary care. All participants had at least one anxiety disorder to qualify for study entry. Thus, all MDD was comorbid with an anxiety disorder, whereas not all cases of any of the anxiety disorders were comorbid. Therefore, the findings indicate that, among anxiety disorder patients, having comorbid MDD predicts worse occupational functioning than not having MDD. Finally, our measure of workplace impairment was an interviewer's subjective rating based upon patient report. Objective measures of workplace functioning would bolster the current findings and should be included in future investigations. Role of funding source Funding for this study was provided by an unrestricted grant from Pfizer, Inc. Pfizer had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Conflict of interest Disclosure for Risa B. Weisberg, Ph.D., Consultant Honoraria: Astra Zeneca, Eli Lilly and Company, Bristol Myers Squibb, and SciMed. Grants Research: Pfizer. Advisory Boards: None. Major Stockholder: None. Disclosure for Martin B. Keller, MD., Consultant Honoraria: Abbott, CENEREX, Cephalon, Cypress Bioscience, Cyberonics, Forest Laboratories, Medtronic, Organon, Novartis, Pfizer, Shire, Solvay, Wyeth. Grants Research: Pfizer, Wyeth. Advisory Boards: Abbott Laboratories, CENEREX, Cyberonics, Cypress Bioscience, Forest Laboratories, Neuronetics, Novartis, Organon, Pfizer. Major Stockholder: None. All other authors declare that they have no conflicts of interest. Acknowledgements The Primary Care Anxiety Project is supported by an unrestricted grant from Pfizer Inc. Dr. Beard's time and effort are supported by a post-doctoral training award from the National Institute of Mental Health (F32 MH083330). Dr. Weisberg's time and effort are supported in part by a Career Development Award from the National Institute of Mental Health (K23 MH069595). References Antony, M.M., Roth, D., Swinson, R.P., Huta, V., Devins, G.M., 1998. 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