Presenteeism and Mental Health: The Hidden Cost Employers Miss

Presenteeism is when employees come to work but cannot perform at their usual level because of physical or mental ill health. It is often more expensive than absence: Deloitte estimates presenteeism linked to poor mental health costs UK employers around £24 billion a year, and Australia's Productivity Commission put the national figure at A$7.0 billion in 2018-19.

Because people are physically present, presenteeism rarely shows up in attendance data. This guide explains what drives it, how much it costs across Asia Pacific and beyond, how to measure it with validated tools, and which interventions HR teams can put in place.

What is presenteeism?

Presenteeism means working while unwell, distracted or exhausted, so that output, quality or safety falls below a person's normal standard. The employee is logged in or on site, but part of their capacity is lost.

Mental health is a major driver. Symptoms of depression and anxiety, such as poor concentration, low energy, slower decision-making and irritability, reduce performance long before someone takes a sick day. Physical conditions, chronic pain, poor sleep and caring responsibilities add to the effect.

Presenteeism is different from quiet quitting or low engagement, although they can overlap. A presentee employee usually wants to do the job well but cannot, while a disengaged employee has chosen to give less. The response is also different: presenteeism needs health support and workload adjustment, not only motivation.

Why is presenteeism called the hidden cost at work?

Absence is recorded in HR systems, so it gets managed. Presenteeism is invisible in payroll and leave data, and many managers read it as a performance or attitude problem rather than a health one.

The research consistently finds that the hidden cost is larger than the visible one. A 2016 study by Evans-Lacko and Knapp in Social Psychiatry and Psychiatric Epidemiology surveyed 8,000 employees across eight countries, including China, Japan and South Korea. It found that presenteeism costs linked to depression were around five to ten times higher than absenteeism costs, and that combined losses ranged from 0.1% to 4.9% of a country's GDP.

The WHO estimates that 12 billion working days are lost every year to depression and anxiety, at a cost of US$1 trillion in lost productivity. Much of that loss happens while people are still at their desks.

How much does presenteeism cost employers?

Estimates vary by country and method, but they point in the same direction. The figures below come from primary reports and are not directly comparable, because each uses a different year, currency and scope.

• United Kingdom: Deloitte's 2024 analysis puts the total cost of poor employee mental health at £51 billion a year, with presenteeism the largest contributor at around £24 billion.
• Australia: The Productivity Commission's Mental Health inquiry report estimated presenteeism at A$7.0 billion and absenteeism at A$9.6 billion in 2018-19, within a total economic cost of mental ill health and suicide of up to about A$70 billion a year.
• Malaysia: The 2018 Malaysia's Healthiest Workplace by AIA Vitality survey, covering 117 organisations and 11,551 employees, found employers lost an average of 73.1 days per employee to ill-health-related absence and presenteeism, estimated at RM2.27 million per organisation per year.
• Eight-country study: Evans-Lacko and Knapp estimated that workplace depression across the eight countries studied cost almost US$250 billion, with presenteeism the dominant share.

The business case also has a return side. Deloitte's 2024 review found employers received nearly £4.70 back for every £1 spent supporting employee mental health, based on 26 sources published since 2011.

What causes presenteeism?

Presenteeism has individual and organisational causes. HR teams should look at both, because changing only one rarely works.

Health and personal factors

• Untreated or undertreated depression, anxiety and burnout.
• Chronic physical conditions, pain and poor sleep.
• Financial stress, caring responsibilities and major life events such as bereavement or divorce.

Work and culture factors

• Excessive workloads, understaffing and tight deadlines, which the WHO lists among the main psychosocial risks at work.
• Cultures that reward visible hours, or where taking sick leave feels risky for job security or promotion.
• Limited sick leave, no cover for absent colleagues, or managers who discourage time off.
• Stigma about mental health, which leads people to hide symptoms rather than seek help.
• Low psychological safety, so employees do not tell their manager they are struggling.

In many Asian workplaces, long-hours norms and stigma around mental health can make presenteeism more likely. An employee may take leave for a fever but keep working through a depressive episode because it feels harder to explain.

How do you measure presenteeism?

Presenteeism is measured with validated self-report questionnaires. They ask employees how health problems affected their work over a recent period, then convert the answers into an estimate of lost productivity.

WHO Health and Work Performance Questionnaire (HPQ)

The WHO HPQ, developed by Kessler and colleagues and published in 2003 in the Journal of Occupational and Environmental Medicine, estimates the workplace costs of health problems. It measures reduced job performance, sickness absence and work-related accidents. In validation, HPQ responses agreed well with employer records across four occupations.

Stanford Presenteeism Scale (SPS-6)

The Stanford Presenteeism Scale was published by Koopman and colleagues in 2002. The original 34-item version was reduced to six items, the SPS-6, which asks how health problems affected an employee's ability to concentrate and complete work. Its short length makes it practical for pulse surveys.

Mental health screening alongside productivity

Productivity scales tell you how much capacity is lost, not why. Pairing them with validated, anonymised mental health measures shows whether stress, anxiety or depression symptoms are driving the loss. ThoughtFull's Organisational Mental Wellness Assessment takes under seven minutes and uses PHQ-2, GAD-7 and the Edmondson psychological safety scale, giving HR a team-level view without identifying individuals.

How can employers reduce presenteeism?

The most effective programmes combine prevention, early detection and accessible treatment. Use these steps as a sequence.

1. Measure the baseline. Run an anonymised survey using the SPS-6 or HPQ alongside mental health screening. Break results down by team, role and location where numbers allow anonymity.
2. Fix the work, not only the worker. Review workloads, staffing and deadlines in the teams with the highest scores. Remove low-value tasks before adding wellbeing activities.
3. Make it safe to be unwell. Check that sick leave policies cover mental health, that cover exists for absent staff, and that leaders take leave when they are ill.
4. Train managers. The WHO recommends manager training so managers can recognise and respond to supervisees in emotional distress. Managers should learn to spot changes, start a supportive conversation and refer.
5. Provide fast, confidential support. An Employee Assistance Programme with text, video and phone options lets people get help without waiting until they need leave.
6. Offer reasonable adjustments. Temporary changes to hours, workload or location help people recovering from mental health conditions stay productive.
7. Re-measure every six to twelve months. Track presenteeism scores, absence, EAP trends and attrition together to see whether the programme is working.

For the support layer, ThoughtFull's corporate wellness programme brings together an EAP, text-based coaching with certified counsellors and psychologists, online therapy and monthly Activation Programmes, with support in 30 languages across Asia Pacific.

Presenteeism checklist for HR leaders

Use this checklist to judge whether your organisation is managing presenteeism or simply not seeing it.

• We measure presenteeism with a validated tool, not only absence data.
• We review results alongside anonymised mental health indicators.
• Sick leave policy explicitly includes mental health.
• Senior leaders visibly take time off when unwell.
• Teams have cover arrangements so absence does not overload colleagues.
• Managers have been trained to recognise distress and refer.
• Employees can reach confidential support within days, not weeks.
• Workload is reviewed when a team's scores worsen.
• We report presenteeism trends to the leadership team at least twice a year.

Does remote and hybrid work change presenteeism?

Hybrid work changes how presenteeism looks rather than removing it. Employees who would once have stayed home sick may now log in from bed, answer messages and attend video calls while unwell, because being online feels like an expectation.

This form is harder for managers to see. There are fewer cues such as a tired face across the desk, and output problems may only show up weeks later. Clear norms help: state that sick leave means being offline, avoid sending non-urgent messages after hours, and check in with remote team members by voice or video rather than only by chat.

Survey design should cover remote staff too. Ask presenteeism questions in the same way for office and remote employees, then compare the results to see whether one group is carrying more hidden strain.

How is presenteeism linked to burnout?

Burnout and presenteeism feed each other. People experiencing burnout often keep working because they feel they cannot step back, and working while depleted makes recovery slower.

The WHO's ICD-11 classifies burnout as an occupational phenomenon resulting from chronic workplace stress that has not been successfully managed, rather than a medical condition. That framing matters for HR: it places the main levers in workload, control and recognition. For early warning signs, read our guide to the five signs of employee burnout.

If an employee talks about self-harm or is in immediate danger, contact local emergency services straight away, for example 995 in Singapore, or the emergency number in your country.

What should HR do next?

Start by putting a number on the problem. A short anonymised survey with a validated presenteeism scale and mental health screening will show where capacity is being lost and why. From there, focus on two or three teams, fix the workload drivers and make support easy to reach.

To see how measurement, manager training and confidential support can work together for your workforce, speak to our team.