The longitudinal relationship between mental health and employment: a systematic review of cohort studies

The relationship between mental health and employment may operate in both directions, through social causation and health selection mechanisms. This systematic review focused on longitudinal cohort studies examining the temporal direction of this relationship. A systematic review following PRISMA guidelines was conducted in PubMed, Embase, and PsycINFO, including a supplementary sensitivity search to improve sensitivity. Eligible studies were longitudinal cohort studies conducted in general populations and examining social causation, health selection, or both. The original search identified 4,288 records and included 44 publications. The supplementary sensitivity search identified 15 additional eligible publications, resulting in 59 included publications. Thirty-two studies on social causation generally reported that unemployment, job loss, unstable employment, underemployment, or adverse employment transitions were associated with poorer subsequent mental health. Evidence on mental health improvements after re-employment was more mixed and appeared context-dependent. Sixteen studies on health selection showed that individuals with mental health problems had higher risks of unemployment, sickness absence, disability benefit, labour-force exit, or reduced chances of entering or maintaining employment. Eleven studies examining both hypotheses simultaneously found that mental health is both a consequence and a risk factor for adverse employment trajectories. Moderating factors, such as gender, influenced the strength and direction of the association. This review highlights the bidirectional longitudinal relationship between employment status and mental health. The findings suggest that mental health and labour-market policies should consider both pathways, while further intervention and quasi-experimental studies are needed to assess the effectiveness of specific employment-related strategies.