Getting down to business: an examination of occupational outcomes in cognitive behavioral therapy for depression

ABSTRACT

Depression is associated with unemployment and poor occupational functioning. Although cognitive behavioral therapy (CBT) has been shown to reduce depressive symptoms, the degree to which it improves occupational outcomes has received little attention. We investigated change in job status and presenteeism (i.e., the inability to focus on and accomplish work) over the course of CBT. We assessed employment status, presenteeism, depressive symptoms, cognitive style, and CBT skills at intake and posttreatment in a sample of 126 participants enrolled in a 16-week course of CBT for depression. Employment status significantly improved from pre to posttreatment, with 11 of the 27 patients (41%) seeking to improve their employment status achieving this goal. Among the 59 consistently employed patients, presenteeism decreased significantly over the course of treatment (d_z = 1.13). We also found, even after controlling for changes in symptoms, reductions in negative cognitive style (but not changes in CBT skills) were associated with reductions in presenteeism. Our findings suggest CBT patients experience positive changes in occupational outcomes, both in finding work and being more focused and productive at work. Changes in negative cognitive styles appeared to partly explain this latter change. We encourage future work examining CBT’s impact on occupational outcomes.

KEYWORDS:

• Cognitive behavioral therapy
• depression
• occupational outcomes
• cognitive style

Depression is one of the leading causes of disability worldwide (James et al., 2018), accounting for hundreds of billions of dollars lost yearly in the US alone (Greenberg et al., 2015). Much of depression’s economic impact stems from its association with occupational outcomes. Depression increases one’s risk of being unemployed. In addition, employees with depression experience greater difficulties with presenteeism (i.e., being unable to concentrate and accomplish tasks at work; D. A. Adler et al., 2006; Dooley et al., 2000; Lerner et al., 2004). Understanding how depression may contribute to difficulties finding and performing well at work is especially important now, given the millions of jobs globally being lost during the COVID-19 pandemic (International Labour Organization, 2020). Cognitive behavioral therapy (CBT) for depression has been shown to effectively reduce symptoms and to provide protection against relapse and recurrence (Strunk et al., 2017). However, the degree to which occupational outcomes improve with CBT is not well understood. In this study, we examined changes in two occupational variables (viz., employment status and presenteeism) over the course of CBT for depression. We also examined correlates of change in these outcomes over the course of treatment.

As depression is negatively associated with occupational outcomes, it might be assumed that alleviating depressive symptoms will also improve occupational outcomes. It does not appear to be that simple. In a sample of primary care patients, those with a depressive disorder reported greater work impairment than comparison groups. Greater work impairment remained evident after 18 months, even among the subset of patients with a depressive disorder who had clinically improved (D. A. Adler et al., 2006). In their review of functional outcomes of depression treatments, McKnight and Kashdan (2009) found change in occupational outcomes was only moderately related to depressive symptoms at various points over the course of treatment. Although findings suggest occupational difficulties are an important problem associated with depression, they are not necessarily resolved by reductions in depressive symptoms alone.

CBT is an effective treatment with enduring effects (Strunk et al., in press), suggesting new learning from CBT helps patients manage their depression following treatment. One of the core goals of CBT is to help patients learn a set of cognitive and behavioral coping skills that help them counteract and modify the negative beliefs they tend to hold (A. D. Adler et al., 2015). Although these therapeutic changes are expected to have a broad array of positive effects, their impact on occupational outcomes has only recently received attention. In a naturalistic study of an internet-based CBT for those with substantial depressive symptoms, occupational impairment decreased significantly over the course of treatment (Richards et al., 2018). In a clinical trial comparing CBT and pharmacotherapy for depression, CBT outperformed pharmacotherapy in improving employment status, but this was true at only one of two sites (Fournier et al., 2015). While such findings suggest CBT may be related to positive changes in occupational outcomes, it remains unclear what aspects of CBT might be promoting improvements in occupational outcomes. To investigate these issues, we planned to examine changes in occupational outcomes over the course of CBT and whether such changes are related to change in key therapeutic targets.

Therapeutic targets of CBT

We consider two therapeutic targets of CBT that could promote positive occupational outcomes. The first is negative cognitive style, which is defined as the explanations individuals ascribe to negative life events (Safford et al., 2007). Negative cognitive style includes views such as that negative events are enduring (i.e., a stable attribution) and negative events will impact multiple aspects of the individual’s life (i.e., a global attribution). Negative cognitive style and its closely related predecessor attributional style (Abramson et al., 1978) have been shown to improve over the course of CBT (DeRubeis et al., 1990; Plate, 2019). Furthermore, in non-clinical samples, variables capturing some of the key aspects of negative cognitive style have been found to be associated with occupational outcomes. Prussia et al. (1993) reported that recently unemployed manufacturing workers who attributed their job loss to stable causes were less likely to find a new job over an 18 month-period. In another study, workers in China who endorsed stable and global causes for negative events were more likely to experience presenteeism (Hui et al., 2012). These findings are consistent with the possibility that reducing negative cognitive style may serve to improve occupational functioning.

The second therapeutic target we consider is CBT skills. These skills include identifying and re-evaluating negative automatic thoughts and leveraging specific kinds of activities to improve one’s mood (Beck et al., 1979). Several studies have shown increases in CBT skill use are associated with concurrent changes in symptoms over the course of CBT (see Hundt et al., 2013). In an unemployed sample not participating in CBT, naturalistic use of CBT skills predicted increased odds of receiving a job offer over a 3-month period (Pfeifer & Strunk, 2016). The CBT model suggests CBT skills could be helpful with engaging in the job search process as well as managing the disappointments the process often entails (Beck et al., 1979). CBT skills can be used to help patients make systematic progress on small tasks in pursuit of larger work goals. CBT skills are also well suited for helping patients manage day-to-day emotional difficulties at work.

In sum, previous research suggests CBT may be associated with improvements in occupational outcomes (Fournier et al., 2015; Richards et al., 2018), but more research is needed. There is some evidence cognitive style and CBT skills are associated with changes in occupational outcomes (e.g., Hui et al., 2012; Pfeifer & Strunk, 2016; Prussia et al., 1993). However, research has yet to examine if changes in cognitive style and CBT skills are associated with changes in occupational outcomes over the course of CBT.

This study

Drawing data from a naturalistic study of CBT for depression, we sought to examine change in two occupational outcomes (viz., employment status and presenteeism).¹ We also planned to examine the relation of change in cognitive style and CBT skills with these occupational outcomes. Based on previous findings, we hypothesized employment status would improve and presenteeism would decrease over the course of treatment. We also hypothesized that, even after controlling for depressive symptoms, improvements in cognitive style and CBT skills would be associated with improvements in employment status and decreases in presenteeism. Such relationships would bolster the case these CBT targets may directly affect occupational outcomes rather than only improve these outcomes indirectly through their impact on depressive symptoms.

Methods

Participants

The sample consisted of 126 adults who participated in a naturalistic study of CBT for depression. Among these participants, the mean age was 31.7 (SD = 13.4, range = 18–70), 60% were women, and the median annual household income was approximately 42,800 USD (SD = 50,500 USD). Regarding race and ethnicity, 83% identified as White, 8% identified as Asian, 7% identified as African American, and 2% identified as Hispanic American. Our analyses focus on two subgroups from this sample. One subgroup (n = 27) was composed of those who were seeking to improve their employment status (i.e., move from unemployment to employment, or from part-time employment to full-time employment). The second subgroup (n = 59) was composed of patients who were consistently employed (i.e., both at intake and at the posttreatment evaluation).²

Participants in this study met the following inclusion criteria: (a) primary diagnosis of major depressive disorder (MDD) as measured by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV (First et al., 2002), (b) 18 years of age or older; and (c) able and willing to give informed consent. Excluded from the study were those with: (a) a diagnosis of bipolar (I or II) or any psychotic disorder; (b) current disorder other than MDD if it constituted the predominant aspects of the clinical presentation and if it required treatment other than that being offered; (c) clear indication of secondary gain (e.g., court ordered treatment or compensation issues); (d) current suicide risk or significant intentional self-harm in the last six months sufficient to preclude treatment on an outpatient basis; or (e) history of substance dependence in the past six months. This study was approved by our institutional review board and all participants provided consent prior to participating in the study. For more study details, please see Schmidt et al. (2019).

Procedures

Five advanced graduate students provided CBT as described by Beck et al. (1979). Consistent with CBT principles, treatment goals were identified collaboratively. Whether a goal was identified related to employment was up to each therapist-patient dyad. Treatment was provided for 16 weeks, with sessions being provided twice-weekly for the first four weeks. After the fourth week, therapists and patients collaboratively decided when to switch to once-weekly sessions in the following eight weeks. The final four weeks of treatment consisted of once-weekly sessions. Though they were invited to do so, patients who dropped out of treatment (17%; n = 21) were unavailable or declined to complete posttreatment assessments.³

Measures

Beck depression inventory—2^nd Edition (BDI-II)

The BDI-II (Beck et al., 1996) is a 21-item self-report questionnaire that assesses depressive symptom severity. Participants are asked to describe the extent to which they have experienced symptoms of depression in the past week on a scale from zero to three. A total score is used, with higher scores indicating higher depressive symptom severity. Scores from 0 to 13 are suggestive of minimal symptoms, scores from 14 to 19 are suggestive of mild symptoms, scores from 20 to 28 are suggestive of moderate symptoms, and scores from 29 to 63 are suggestive of severe symptoms. This measure has repeatedly demonstrated excellent convergent validity (Beck et al., 1996) and internal consistency (Steer et al., 1998).

Competencies in cognitive therapy scale (CCTS)

The CCTS (Strunk et al., 2014) is a 29-item self-report measure that assesses use of CBT skills related to behavioral activation, coping with automatic thoughts, and awareness of schemas or core beliefs. Participants are asked to rate the extent to which they used various CBT skills on seven-point Likert scales (e.g., “I made an effort to evaluate my negative thoughts by considering just the facts”). The CCTS has demonstrated convergent validity with other measures of coping skills (e.g., Ways of Responding Inventory; Strunk et al., 2014). In the current study, the CCTS demonstrated excellent internal consistency at both intake and posttreatment (intake α = .94; posttreatment α = .98).

Expanded attributional style questionnaire short form (EASQ-SF)

The EASQ-SF (Whitley, 1991) is a self-report measure that assesses negative cognitive style or inferences about the cause, consequences, and implications of 12 hypothetical negative life events (i.e., “you experience a major personal injury”). Participants are instructed to imagine each of the hypothetical scenarios and then identify the likely causes for each of the events. Participants are then asked to respond to five questions following each scenario assessing the internality, globality, stability, consequences, and self-worth implications of the likely cause they identified for each event. Responses are made using seven-point scales. In line with previous research efforts (Haeffel et al., 2008; Pfeifer & Strunk, 2016), we averaged the items reflecting globality, stability, consequences, and self-worth implications (and not items from the internality subscale) to calculate a total score. Higher total scores indicated more negative cognitive styles. This short form has been shown to be highly correlated with the original version, as well as to have similar reliability and validity (Barnum et al., 2013). In the current study, the EASQ-SF demonstrated excellent internal consistency at both intake and posttreatment (intake α = .92; posttreatment α = .94).

Employment status

Employment status was assessed using 11 employment codes from the Longitudinal Interval Follow-up Evaluation (LIFE; Keller et al., 1987), which has been used in prior studies examining employment status in the context of depression and CBT (Fournier et al., 2015). In the current study, we categorized individuals with regard to whether they were seeking to improve their employment status. To be included as seeking to improve one’s employment status, patients indicated they were unemployed (and expected to work by self or others) or that they had part-time gainful employment (and desired to work full-time).

Stanford presenteeism scale (SPS)

The SPS (Koopman et al., 2002) is a six-item self-report measure that assesses participants’ presenteeism, or inability to concentrate and accomplish work while experiencing depressive symptoms.⁴ Participants are asked to respond to items such as “Because of my depressive symptoms, the stresses of my job were much harder to handle” using a Likert scale ranging from one to five to rate how often this was true of them. Higher scores indicated greater presenteeism. Because the measure assesses current experiences at work, only those who were employed at the time of the assessment completed this measure. The SPS has demonstrated strong psychometric properties, including high internal consistency and strong convergent validity with related measures (Koopman et al., 2002). In the current sample, the SPS demonstrated good internal consistency at intake (α = .80) and posttreatment (α = .78).

Analytic strategy

Our primary analyses examined whether two occupational outcomes, employment status and presenteeism, improved over the course of CBT. For patients seeking to improve their employment status, we utilized McNemar’s chi-square statistic to assess change in employment status improvement from pre—to posttreatment. McNemar’s chi-square statistic tests for change in a dichotomous characteristic across two time points in the same group of participants. To test changes in presenteeism from pre—to posttreatment, we used a paired t-test and necessarily limited the sample to patients with scores at pre—and posttreatment.

To examine correlates of improvement in employment status among patients seeking to improve their employment status (n = 27), we first obtained regressed change scores for the BDI-II, CCTS, and EASQ-SF. For each variable, regressed changes scores were the residuals from a model in which intake scores were entered as the predictor of posttreatment scores. Regressed change scores were then entered into a logistic regression model as predictors of improvement in employment status. All predictors were standardized in the subgroup of interest (M = 0, SD = 1) prior to testing using logistic regression.

Among patients who were employed consistently (n = 59), we obtained regressed change scores (from intake to posttreatment) for presenteeism. In a regression model, we examined regressed change scores on the CCTS and EASQ-SF as predictors of change in presenteeism, while controlling for regressed change in BDI-II.

Results

Our analyses focus on two subgroups of patients: (1) those who sought to improve their employment status, and (2) those consistently employed over the course of CBT. In Table 1, we provide descriptive statistics at intake and posttreatment for our predictor variables separately for these two groups. The table also includes results of paired t-tests evaluating change from pre—to posttreatment for these variables. We observed significant improvements in the BDI-II, CCTS, and EASQ for each patient group.

Table 1. Intake and Posttreatment Scores on Therapeutic Targets and Symptoms

	Intake			Posttreatment		Pre to Post Difference
Variable	n	M	SD	M	SD	t	p	dz
A. Patients seeking to improve their employment status
CBT skills	27	86.04	25.82	131.70	31.81	6.57	<.0001	1.26
Cognitive style	27	4.63	0.69	3.78	0.89	-4.31	.0002	0.83
Depressive symptoms	27	31.25	9.99	15.07	12.70	-6.41	<.0001	1.23
B. Consistently employed patients
CBT skills	57	89.78	26.25	142.16	31.92	11.87	<.0001	1.57
Cognitive style	56	4.69	0.73	3.63	0.93	-7.60	<.0001	1.02
Depressive symptoms	58	32.28	7.54	10.83	10.74	-14.26	<.0001	1.91

We also examined correlations among regressed change in two therapeutic targets and symptom change. Among patients who were consistently employed, change in skill use and change in cognitive style were moderately negatively correlated (r = −.39, p = .003). Change in each therapeutic target was moderately related to symptom change (CBT skills: r = −.53, p < .0001; Cognitive vulnerability: r = .57, p < .0001). Among those seeking to improve their employment status, corresponding correlations were in the same direction and similar in magnitude (CBT skills: r = −.45, p = .02; Cognitive vulnerability: r = .36, p = .06).

Change in occupational outcomes over the course of treatment

Among patients seeking to improve their employment status, we utilized McNemar’s chi-square statistic and found significant improvement in employment status from pre—to posttreatment (χ² (1) = 11.00, p < .001). Specifically, 11 of the 27 patients (41%) seeking to improve their employment status achieved such an improvement by the end of treatment. It is worth noting that one of these patients was employed initially but was no longer employed at the end of treatment. Among patients consistently employed, presenteeism significantly decreased (intake M = 19.88, SD = 5.12; posttreatment M = 12.50, SD = 5.04; t(58) = 8.70, p < .0001, d_z = 1.13).

Association of change in therapeutic targets with occupational functioning

Next, we examined change in negative cognitive style and CBT skills with concurrent changes in occupational functioning over the course of CBT. In these models, we included regressed change in depressive symptoms as a covariate. Among patients seeking to improve their employment status, we used logistic regression to test change in negative cognitive style, change in CBT skills, and change in symptoms as predictors. As shown in Table 2, neither cognitive style (OR = 1.22, p = .69) nor CBT skills (OR = 0.47, p = .16) were significantly related to improvement in employment status.

Table 2. Change in Therapeutic Targets and Symptoms as Correlates of Concurrent Change in Employment Status over the Course of CBT

Predictor	Odds Ratio	95% CI	b	p
CBT skills, regressed change	0.47	0.16-1.37	-0.76	.16
Cognitive style, regressed change	1.22	0.47-3.13	0.20	.69
Depressive symptoms, regressed change	0.41	0.13-1.34	-0.89	.14

Note. All predictor variables reflect regressed change from intake to posttreatment and were standardized (M = 0, SD = 1) prior to running this analysis. The sample for this analysis was limited to the 27 individuals seeking to improve their employment status at intake.

Among consistently working patients, we examined regressed change in CBT skills and cognitive style as predictors of concurrent regressed change in presenteeism over the course of treatment, including regressed change in depressive symptoms as a covariate. As shown in Table 3, change in cognitive style was significantly related to change in presenteeism, such that lower negative cognitive styles at posttreatment (adjusted for intake scores) were associated with lower posttreatment presenteeism (adjusted for intake scores). However, change in CBT skills was not significantly related to changes in presenteeism. The relation of change in BDI-II and change in presenteeism was significant, such that lower depressive symptoms at posttreatment (adjusted for intake scores) were associated with lower presenteeism at posttreatment (adjusted for intake scores).

Table 3. Change in Therapeutic Targets and Symptoms as Correlates of Concurrent Change in Presenteeism over the Course of CBT

Predictor	bstandardized	b	SE	t	p
CBT skills, regressed change	-0.02	-0.00	0.02	-0.15	.88
Cognitive style, regressed change	0.29	1.62	0.79	2.05	.045
Depressive symptoms, regressed change	0.33	0.16	0.07	2.20	.03

Note. All variables in this model reflect regressed change from intake to posttreatment. The sample for this analysis was limited to the 59 patients who were employed at both intake and posttreatment.

In exploratory analyses, we found change in cognitive style and change in CBT skills both significantly predicted change in presenteeism in single predictor models (cognitive style model: b_standardized = 0.49, b = 2.73, SE = 0.66, t(55) = 4.11, p < .001; CBT skills model: b_standardized = −0.33, b = −0.06, SE = 0.02, t(56) = −2.59, p = .01). However, only cognitive style remained a significant predictor when change in depressive symptoms was included as a covariate (cognitive style model: b_standardized = 0.29, b = 1.63, SE = 0.77, t(55) = 2.11, p = .04; CBT skills model: b_standardized = −0.08, b = −0.01, SE = 0.02, t(56) = −0.56, p = .58).

Discussion

We found evidence of two kinds of positive occupational outcomes over the course of CBT. Among patients seeking work, 41% of patients were able to make positive changes in obtaining a new position. Working patients experienced substantial reductions in presenteeism, being able to concentrate and accomplish tasks at work more successfully. Notably, the effect size of change in presenteeism was substantial. Combined with Fournier et al. (2015) findings, these results contribute to the notion that participation in a course of CBT may facilitate improvements in occupational impairments associated with MDD. Our study also adds to a growing literature suggesting occupational outcomes are limitedly associated with symptom outcome in the treatment of depression (McKnight & Kashdan, 2009).

To our knowledge, this study was the first to investigate relations of change in CBT’s therapeutic targets and occupational outcomes. First, we examined changes in negative cognitive style as a predictor of concurrent changes in employment status and presenteeism. Although negative cognitive style did not significantly predict change in employment status, it is important to note that our sample was small for this test (i.e., the 27 patients seeking work). In the more powerful test involving 59 consistently employed patients, decreases in negative cognitive style were associated with decreases in presenteeism. The model underlying CBT posits individuals with depression tend to have negative cognitions and interpretations of life events. Cognitive vulnerability models suggest negative cognitive style is a cause of depression (Abramson et al., 1989). Negative cognitive style appears to characterize patterns of thought across multiple life domains, including beliefs about one’s work performance. For instance, patients with depression may think their inability to perform well at work is their fault alone or that their suboptimal work performance will negatively impact other aspects of their life. CBT may help patients overcome these views by teaching them the experience of depression is not their fault and they can take steps to improve their concentration and accomplish work more successfully even when experiencing depressive symptoms (Beck et al., 1979).

We also examined CBT skills as a predictor of occupational outcomes. Although exploratory analyses revealed change in CBT skills was significantly associated with change in presenteeism in a single predictor model, change in CBT skills was not significant in the primary model (or in a model that simply included change in depressive symptoms as a covariate). Furthermore, CBT skills did not predict improvement in employment status. One possibility is that CBT skill use has little direct effect on occupational outcomes as its relation was accounted for by symptom improvement in our analyses. However, another possibility is that cognitive vulnerability emerged as a stronger predictor in our analyses because of the nature of these variables. Although CBT skills have been related to outcomes, CBT skill usage does not guarantee an individual will succeed in re-evaluating maladaptive beliefs. By contrast, measures of cognitive vulnerability assess patients’ beliefs more directly. Whether these beliefs require ongoing effort to maintain them or whether they now occur without substantial effort, they may predict positive outcomes.

To place our findings in context, it may be helpful to consider the typical duration of unemployment at the time this study was conducted (2014 to 2016). In those years, the average duration of unemployment in each year ranged from 29.2 weeks to 33.7 weeks. The median ranged from 10.6 weeks to 14 weeks (U.S. Bureau of Labor Statistics, 2015, 2016, 2017). Although not reported separately by the Bureau of Labor Statistics, the duration of employment is likely longer for those experiencing a depressive episode. Depressive symptom severity has been found to predict reemployment (Vinokur & Schul, 2002). Although evidence of the causal effects of CBT on finding work requires additional experimental comparisons, we take these estimates as consistent with the possibility that CBT hastens improvements in employment status for those who sought to improve their employment status.

Limitations and future directions

We note several limitations. First, the number of participants seeking changes in employment status in our study was low. As a result, our power to detect correlates of change in employment status was limited. This issue was less of a concern for our analyses of presenteeism, as a larger portion of our sample was employed. Second, occupational outcomes were only assessed at intake and posttreatment. Some patients may have experienced more than one change in employment status or after treatment ended. In future studies, it would be desirable to examine the possibility of multiple changes in employment status, during and after treatment. Third, there was no experimental comparison to CBT in this study. Neither the passage of time nor placebo effects can be ruled out as alternative explanations for the changes we observed. In addition, as our analyses were limited to those who completed treatment, it is possible that this group differed from those who dropped out (e.g., perhaps having lower motivation for treatment). Finally, our measure of presenteeism involves an individual’s personal assessment of their work performance, rather than their objective performance. Obtaining independent evaluations of work performance would be valuable.

We also note two future directions. First, our assessment of improvements in employment status relied on the distinction between part-time and full-time work. Workers who are full-time are more likely to have benefits, have greater stability of income, and are likely to have the opportunity to work a high number of hours consistently. Nonetheless, future studies might consider examining hours worked to offer additional contextual information. The assessment of employment status we used also did not assess patients’ reasons for their employment status. Future research may consider examining these reasons. Second, our study focused on two occupational outcomes. We encourage future researchers to examine other facets related to finding work and work performance. This may involve examining the specific therapeutic targets that help patients obtain a job offer and what targets promote more successful engagement in work.

Conclusions

Over the course of CBT, we observed improvements in employment status and reductions in presenteeism. We also found decreases in negative cognitive style were associated with decreases in presenteeism. These findings suggest CBT may play an important role in not only reducing depressive symptoms, but also addressing occupational outcomes. Our study uniquely contributes valuable insight into relations of change between CBT’s therapeutic targets and occupational outcomes. We encourage future research to continue examining how treatment strategies can remedy the functional impairments in employment associated with depression.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Absenteeism is another important aspect of occupational functioning. Nonetheless, the economic costs of presenteeism have been estimated to be 14 times that of absenteeism in the U.S. (Evans-Lacko & Knapp, 2016). In addition, the number of days people with depression miss work related to absenteeism is relatively low over short periods (2.4 days per month; Lerner et al., 2004). We were concerned that we might not be able to reliably detect changes in absenteeism over the course of treatment and did not assess absenteeism in this study. We encourage researchers to consider its inclusion in future studies.

2. Nineteen patients were included in both subgroups, for a total of 67 patients from the full sample of 126 being included in this study. The remaining 59 patients were not included in this study. Patients who could not be included because of missing data included: those who dropped out of treatment (n = 21) and those who had incomplete data (n = 4). The remainder were not included because they were neither looking for work nor currently employed (e.g., patients who indicated they were retired or unemployed students not looking for work). Among those excluded were three patients who were employed at intake (and not seeking to improve their employment status) who reported no longer being employed at the end of treatment. Overall, those included versus not included in the study did not differ on intake depressive symptoms, sex, age, or median annual household income (all ps > .05).

3. Those who completed and dropped out of treatment did not differ on intake depression symptoms, sex, age, or median annual household income(all ps > .05).

4. The authors of this scale defined presenteeism as a positive attribute (i.e., the ability to concentrate and accomplish work despite an individual’s depressive symptoms). However, presenteeism is generally used to describe a negative outcome (i.e., an inability to concentrate and accomplish work despite an individual’s depressive symptoms). Like other investigators who have used this measure (e.g., Hutting et al., 2014; Neto et al., 2017), we reversed the scoring of this scale so higher scores reflected the more often used definition of presenteeism.