Estimating the Economic Benefits of Eliminating Job Strain as a Risk Factor for Depression

The aim of this study was to quantify the economic benefits of eliminating job strain as a risk factor for depression, using published population-attributable risk estimates of depression attributable to job strain (13.2% for men, 17.2% for women).  Cohort simulation using state-transition Markov modeling estimated costs and health outcomes for employed persons who met criteria for lifetime DSM-IV major depression. A societal perspective over 1-year and lifetime time horizons was used.  Among employed Australians, $890 million (5.8%) of the annual societal cost of depression was attributable to job strain. Employers bore the brunt of these costs, as they arose from lost productive time and increased risk of job turnover among employees experiencing depression.  Proven, practicable means exist to reduce job strain. The findings demonstrate likely financial benefits to employers for expanding psychosocial risk management, providing a financial incentive to complement and reinforce legal and ethical directives.

Related papers:

title: Psychosocial factors at work and risk of depression: a systematic review of the epidemiological evidence
abstract: Major depression is a leading cause of psychiatric morbidity and may be influenced by psychosocial factors in the workplace, although evidence so far remains circumstantial. This paper reviews follow-up studies addressing the risk of major depression and depressive symptoms relative to psychosocial stressors in the working environment and evaluates the evidence for causality.  Follow-up studies were identified by a systematic Medline search combining search terms for the outcome and measures of job-related psychosocial factors. The quality of the studies was evaluated using 22 criteria related to their potential for bias and confounding.  Sixteen company or population-based studies including some 63 000 employees were identified. Validated multi-item scales were used to measure perceived psychosocial stressors in most of the studies. Major depression was defined by clinical criteria in seven studies and by symptom scales in another seven. The follow-up period ranged from 1 to 13 years. The prevalence of depressive disorder varied substantially, suggesting a high degree of study heterogeneity. The adjusted relative risk for onset of a major depressive episode according to job stressors ranged from 0.5 to 1.5 in 44 of 61 reported associations with various psychosocial factor dimensions. Associations were strongest and most consistent for job strain defined as high demand and low decision latitude among men. Most studies shared common limitations such as lack of independent measures of exposure and outcome and potential confounding. Although a meta-analysis would technically be possible, heterogeneity across studies evidenced by variation in the prevalence of depression made this unfeasible.  This review provides consistent findings that perception of adverse psychosocial factors in the workplace is related to an elevated risk of subsequent depressive symptoms or major depressive episode; however, methodological limitations preclude causal inference. Studies implementing objective measures of job stressors or independent outcome ascertainment are warranted.

title: Psychosocial work environment and mental health--a meta-analytic review.
abstract: To clarify the associations between psychosocial work stressors and mental ill health, a meta-analysis of psychosocial work stressors and common mental disorders was undertaken using longitudinal studies identified through a systematic literature review.



The review used a standardized search strategy and strict inclusion and quality criteria in seven databases in 1994-2005. Papers were identified from 24,939 citations covering social determinants of health, 50 relevant papers were identified, 38 fulfilled inclusion criteria, and 11 were suitable for a meta-analysis. The Comprehensive Meta-analysis Programme was used for decision authority, decision latitude, psychological demands, and work social support, components of the job-strain and iso-strain models, and the combination of effort and reward that makes up the effort-reward imbalance model and job insecurity. Cochran's Q statistic assessed the heterogeneity of the results, and the I2 statistic determined any inconsistency between studies.



Job strain, low decision latitude, low social support, high psychological demands, effort-reward imbalance, and high job insecurity predicted common mental disorders despite the heterogeneity for psychological demands and social support among men. The strongest effects were found for job strain and effort-reward imbalance.



This meta-analysis provides robust consistent evidence that (combinations of) high demands and low decision latitude and (combinations of) high efforts and low rewards are prospective risk factors for common mental disorders and suggests that the psychosocial work environment is important for mental health. The associations are not merely explained by response bias. The impact of work stressors on common mental disorders differs for women and men.

title: Job Strain, Health and Sickness Absence: Results from the Hordaland Health Study
abstract: While it is generally accepted that high job strain is associated with adverse occupational outcomes, the nature of this relationship and the causal pathways involved are not well elucidated. We aimed to assess the association between job strain and long-term sickness absence (LTSA), and investigate whether any associations could be explained by validated health measures.  Data from participants (n = 7346) of the Hordaland Health Study (HUSK), aged 40–47 at baseline, were analyzed using multivariate Cox regression to evaluate the association between job strain and LTSA over one year. Further analyses examined whether mental and physical health mediated any association between job strain and sickness absence.  A positive association was found between job strain and risk of a LTSA episode, even controlling for confounding factors (HR = 1.64 (1.36–1.98); high job strain exposure accounted for a small proportion of LTSA episodes (population attributable risk 0.068). Further adjustments for physical health and mental health individually attenuated, but could not fully explain the association. In the fully adjusted model, the association between high job strain and LTSA remained significant (HR = 1.30 (1.07–1.59)).  High job strain increases the risk of LTSA. While our results suggest that one in 15 cases of LTSA could be avoided if high job strain were eliminated, we also provide evidence against simplistic causal models. The impact of job strain on future LTSA could not be fully explained by impaired health at baseline, which suggests that factors besides ill health are important in explaining the link between job strain and sickness absence.

title: Job strain and health-related quality of life in a national sample.
abstract: Studies of the health effects of job strain have focused on morbidity and mortality as outcomes. This is the first study to examine the relationship of job strain to more comprehensive health status measures that encompass health-related quality of life.



In a national cross-sectional survey, 1319 working men and women, aged 18 through 64 years, completed a modified version of the Job Content Questionnaire that classified workers' jobs into four categories: high strain, passive, low strain, and active. Subjects also completed the Medical Outcomes Study Short-Form Health Survey and a health distress scale. Logistic regression analyses were employed that controlled for age, race/ethnicity, gender, and education. Both work and nonwork variables were included.



Job strain was significantly associated with five of nine components of health-related quality of life: physical functioning, role functioning related to physical health, vitality, social functioning, and mental health. Job strain made a modest yet statistically significant contribution beyond the effects of chronic illness and psychosocial variables.



The results provide justification for further investigating the role of job strain as an independent risk factor for health-related quality of life.

title: Job strain — Attributable depression in a sample of working Australians: Assessing the contribution to health inequalities
abstract: BackgroundThe broad aim of this study was to assess the contribution of job strain to mental health inequalities by (a) estimating the proportion of depression attributable to job strain (low control and high demand jobs), (b) assessing variation in attributable risk by occupational skill level, and (c) comparing numbers of job strain–attributable depression cases to numbers of compensated 'mental stress' claims.MethodsStandard population attributable risk (PAR) methods were used to estimate the proportion of depression attributable to job strain. An adjusted Odds Ratio (OR) of 1.82 for job strain in relation to depression was obtained from a recently published meta-analysis and combined with exposure prevalence data from the Australian state of Victoria. Job strain exposure prevalence was determined from a 2003 population-based telephone survey of working Victorians (n = 1101, 66% response rate) using validated measures of job control (9 items, Cronbach's alpha = 0.80) and psychological demands (3 items, Cronbach's alpha = 0.66). Estimates of absolute numbers of prevalent cases of depression and successful stress-related workers' compensation claims were obtained from publicly available Australian government sources.ResultsOverall job strain-population attributable risk (PAR) for depression was 13.2% for males [95% CI 1.1, 28.1] and 17.2% [95% CI 1.5, 34.9] for females. There was a clear gradient of increasing PAR with decreasing occupational skill level. Estimation of job strain–attributable cases (21,437) versus "mental stress" compensation claims (696) suggest that claims statistics underestimate job strain–attributable depression by roughly 30-fold.ConclusionJob strain and associated depression risks represent a substantial, preventable, and inequitably distributed public health problem. The social patterning of job strain-attributable depression parallels the social patterning of mental illness, suggesting that job strain is an important contributor to mental health inequalities. The numbers of compensated 'mental stress' claims compared to job strain-attributable depression cases suggest that there is substantial under-recognition and under-compensation of job strain-attributable depression. Primary, secondary, and tertiary intervention efforts should be substantially expanded, with intervention priorities based on hazard and associated health outcome data as an essential complement to claims statistics.

title: A Systematic Review of the Job-stress Intervention Evaluation Literature, 1990–2005
abstract: Ninety reports of systematic evaluations of job-stress interventions were rated in terms of the degree of systems approach used. A high rating was defined as both organizationally and individually focused, versus moderate (organizational only), and low (individual only). Studies using high-rated approaches represent a growing proportion of the job-stress intervention evaluation literature. Individual-focused, low-rated approaches are effective at the individual level, favorably affecting individual-level outcomes, but tend not to have favorable impacts at the organizational level. Organizationally focused high- and moderate-rated approaches are beneficial at both individual and organizational levels. Further measures are needed to foster the dissemination and implementation of systems approaches to examining interventions for job stress.

title: The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions
abstract: To systematically review the health and psychosocial effects (with reference to the demand–control–support model) of changes to the work environment brought about by task structure work reorganisation, and to determine whether those effects differ for different socioeconomic groups.  Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions.  Seventeen electronic databases (medical, social science and economic), bibliographies and expert contacts.  Nineteen studies were reviewed. Some task-restructuring interventions failed to alter the psychosocial work environment significantly, and so could not be expected to have a measurable effect on health. Those that increased demand and decreased control tended to have an adverse effect on health, while those that decreased demand and increased control resulted in improved health, although some effects were minimal. Increases in workplace support did not appear to mediate this relationship.  This systematic review suggests that task-restructuring interventions that increase demand or decrease control adversely affect the health of employees, in line with observational research. It lends support to policy initiatives such as the recently enforced EU directive on participation at work, which aims to increase job control and autonomy.

title: The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organisational-level interventions that aim to increase employee control
abstract: Systematic review of the health and psychosocial effects of increasing employee participation and control through workplace reorganisation, with reference to the “demand–control–support” model of workplace health.  Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions.  Electronic databases (medical, social science and economic), bibliographies and expert contacts.  We identified 18 studies, 12 with control/comparison groups (no randomised controlled trials). Eight controlled and three uncontrolled studies found some evidence of health benefits (especially beneficial effects on mental health, including reduction in anxiety and depression) when employee control improved or (less consistently) demands decreased or support increased. Some effects may have been short term or influenced by concurrent interventions. Two studies of participatory interventions occurring alongside redundancies reported worsening employee health.  This systematic review identified evidence suggesting that some organisational-level participation interventions may benefit employee health, as predicted by the demand–control–support model, but may not protect employees from generally poor working conditions. More investigation of the relative impacts of different interventions, implementation and the distribution of effects across the socioeconomic spectrum is required.

title: Working for health? Evidence from systematic reviews on the effects on health and health inequalities of organisational changes to the psychosocial work environment.
abstract: To map the health effects of interventions which aim to alter the psychosocial work environment, with a particular focus on differential impacts by socio-economic status, gender, ethnicity, or age.



A systematic approach was used to identify, appraise and summarise existing systematic reviews (umbrella review) that examined the health effects of changes to the psychosocial work environment. Electronic databases, websites, and bibliographies, were searched from 2000-2007. Experts were also contacted. Identified reviews were critically appraised and the results summarised taking into account methodological quality. The review was conducted in the UK between October 2006 and December 2007.



Seven systematic reviews were identified. Changes to the psychosocial work environment were found to have important and generally beneficial effects on health. Importantly, five reviews suggested that organisational level psychosocial workplace interventions may have the potential to reduce health inequalities amongst employees.



Policy makers should consider organisational level changes to the psychosocial work environment when seeking to improve the health of the working age population.

title: Workplace mental health: developing an integrated intervention approach
abstract: BackgroundMental health problems are prevalent and costly in working populations. Workplace interventions to address common mental health problems have evolved relatively independently along three main threads or disciplinary traditions: medicine, public health, and psychology. In this Debate piece, we argue that these three threads need to be integrated to optimise the prevention of mental health problems in working populations.DiscussionTo realise the greatest population mental health benefits, workplace mental health intervention needs to comprehensively 1) protect mental health by reducing work–related risk factors for mental health problems; 2) promote mental health by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. We outline the evidence supporting such an integrated intervention approach and consider the research agenda and policy developments needed to move towards this goal, and propose the notion of integrated workplace mental health literacy.SummaryAn integrated approach to workplace mental health combines the strengths of medicine, public health, and psychology, and has the potential to optimise both the prevention and management of mental health problems in the workplace.

title: Which presenteeism measures are more sensitive to depression and anxiety?
abstract: Lost productivity from attending work when unwell, or "presenteeism", is a largely hidden cost of mental disorders in the workplace. Sensitive measures are needed for clinical and policy applications, however there is no consensus on the optimal self-report measure to use. This paper examines the sensitivity of four alternative measures of presenteeism to depression and anxiety in an Australian employed cohort.



A prospective single-group study in ten call centres examined the association of presenteeism (presenteeism days, inefficiency days, Work Limitations Questionnaire, Stanford Presenteeism Scale) with Patient Health Questionnaire depression and anxiety syndromes.



At baseline, all presenteeism measures were sensitive to differences between those with (N=69) and without (N=363) depression/anxiety. Only the Work Limitations Questionnaire consistently showed worse productivity as depression severity increased, and sensitivity to remission and onset of depression/anxiety over the 6-month follow-up (N=231). There was some evidence of individual depressive symptoms having a differential association with different types of job demands.



The study findings may not generalise to other occupational settings with different job demands. We were unable to compare responders with non-responders at baseline due to anonymity.



In this community sample the Work Limitations Questionnaire offered additional sensitivity to depression severity, change over time, and individual symptoms. The comprehensive assessment of work performance offers significant advantages in demonstrating both the individual and economic burden of common mental disorders, and the potential gains from early intervention and treatment.

title: Depression in Working Adults: Comparing the Costs and Health Outcomes of Working When Ill
abstract: Working through a depressive illness can improve mental health but also carries risks and costs from reduced concentration, fatigue, and poor on-the-job performance. However, evidence-based recommendations for managing work attendance decisions, which benefit individuals and employers, are lacking. Therefore, this study has compared the costs and health outcomes of short-term absenteeism versus working while ill (“presenteeism”) amongst employed Australians reporting lifetime major depression.  Cohort simulation using state-transition Markov models simulated movement of a hypothetical cohort of workers, reporting lifetime major depression, between health states over one- and five-years according to probabilities derived from a quality epidemiological data source and existing clinical literature. Model outcomes were health service and employment-related costs, and quality-adjusted-life-years (QALYs), captured for absenteeism relative to presenteeism, and stratified by occupation (blue versus white-collar).  Per employee with depression, absenteeism produced higher mean costs than presenteeism over one- and five-years ($42,573/5-years for absenteeism, $37,791/5-years for presenteeism). However, overlapping confidence intervals rendered differences non-significant. Employment-related costs (lost productive time, job turnover), and antidepressant medication and service use costs of absenteeism and presenteeism were significantly higher for white-collar workers. Health outcomes differed for absenteeism versus presenteeism amongst white-collar workers only.  Costs and health outcomes for absenteeism and presenteeism were not significantly different; service use costs excepted. Significant variation by occupation type was identified. These findings provide the first occupation-specific cost evidence which can be used by clinicians, employees, and employers to review their management of depression-related work attendance, and may suggest encouraging employees to continue working is warranted.

title: Cost of lost productive work time among US workers with depression.
abstract: Evidence consistently indicates that depression has adversely affected work productivity. Estimates of the cost impact in lost labor time in the US workforce, however, are scarce and dated.



To estimate the impact of depression on labor costs (ie, work absence and reduced performance while at work) in the US workforce.



All employed individuals who participated in the American Productivity Audit (conducted August 1, 2001-July 31, 2002) between May 20 and July 11, 2002, were eligible for the Depressive Disorders Study. Those who responded affirmatively to 2 depression-screening questions (n = 692), as well as a 1:4 stratified random sample of those responding in the negative (n = 435), were recruited for and completed a supplemental interview using the Primary Care Evaluation of Mental Disorders Mood Module for depression, the Somatic Symptom Inventory, and a medical and treatment history for depression. Excess lost productive time (LPT) costs from depression were derived as the difference in LPT among individuals with depression minus the expected LPT in the absence of depression projected to the US workforce.



Estimated LPT and associated labor costs (work absence and reduced performance while at work) due to depression.



Workers with depression reported significantly more total health-related LPT than those without depression (mean, 5.6 h/wk vs an expected 1.5 h/wk, respectively). Eighty-one percent of the LPT costs are explained by reduced performance while at work. Major depression accounts for 48% of the LPT among those with depression, again with a majority of the cost explained by reduced performance while at work. Self-reported use of antidepressants in the previous 12 months among those with depression was low (<33%) and the mean reported treatment effectiveness was only moderate. Extrapolation of these survey results and self-reported annual incomes to the population of US workers suggests that US workers with depression employed in the previous week cost employers an estimated 44 billion dollars per year in LPT, an excess of 31 billion dollars per year compared with peers without depression. This estimate does not include labor costs associated with short- and long-term disability.



A majority of the LPT costs that employers face from employee depression is invisible and explained by reduced performance while at work. Use of treatments for depression appears to be relatively low. The combined LPT burden among those with depression and the low level of treatment suggests that there may be cost-effective opportunities for improving depression-related outcomes in the US workforce.

title: Work, employment and mental health in Europe
abstract: In May 2004 the World Health Organization (WHO European Region) called a consultation meeting of its Collaborating Centres in Occupational Health to discuss mental health in the workplace. The meeting took place in Copenhagen. This paper presents an interpretation of the discussion that took place and the thinking that developed as a result. It was argued that increased interest and research and improved practice in the area of occupational mental health are required to promote good mental health in the European population. A framework of risk management and prevention based on sound evidence and good understanding could provide the basis for the translation of existing research knowledge into effective practice.

title: Sick but yet at work. An empirical study of sickness presenteeism
abstract: The study is an empirical investigation of sickness presenteeism in relation to occupation, irreplaceability, ill health, sickness absenteeism, personal income, and slimmed down organisation.   Swedish workforce.  The study group comprised a stratified subsample of 3801 employed persons working at the time of the survey, interviewed by telephone in conjunction with Statistics Sweden's labour market surveys of August and September 1997. The response rate was 87 per cent.  A third of the persons in the total material reported that they had gone to work two or more times during the preceding year despite the feeling that, in the light of their perceived state of health, they should have taken sick leave. The highest presenteeism is largely to be found in the care and welfare and education sectors (nursing and midwifery professionals, registered nurses, nursing home aides, compulsory school teachers and preschool/primary educationalists. All these groups work in sectors that have faced personnel cutbacks during the 1990s). The risk ratio (odds ratio (OR)) for sickness presenteeism in the group that has to re-do work remaining after a period of absence through sickness is 2.29 (95% CI 1.79, 2.93). High proportions of persons with upper back/neck pain and fatigue/slightly depressed are among those with high presenteeism (p< 0.001). Occupational groups with high sickness presenteeism show high sickness absenteeism (ρ = 0.38; p<.01) and the hypothesis on level of pay and sickness presenteeism is also supported (ρ = −0.22; p<0.01).  Members of occupational groups whose everyday tasks are to provide care or welfare services, or teach or instruct, have a substantially increased risk of being at work when sick. The link between difficulties in replacement or finding a stand in and sickness presenteeism is confirmed by study results. The categories with high sickness presenteeism experience symptoms more often than those without presenteeism. The most common combination is low monthly income, high sickness absenteeism and high sickness presenteeism.

title: Cost-of-illness studies of depression: a systematic review.
abstract: Depression is a very common disease with substantial economic consequences. This paper reviews all published cost-of-illness studies of depression worldwide.



A systematic search of cost-of-illness studies of depression in the databases MEDLINE, Web of Science, Cochrane Library, and PSYNDEXplus was conducted. Identified studies were classified by their basic characteristics. Costs reported were inflated in original currency to the year 2003 and then converted into US-dollar using purchasing power parities (US$ PPP). Additionally, national-costs were converted in costs per case and per inhabitant.



24 papers with notable methodical differences were identified and classified by their basic characteristics. Summary estimates from the studies for the average annual costs per case ranged from $1000 to $2500 for direct costs, from $2000 to $3700 for morbidity costs and from $200 to $400 for mortality costs. The basic quantity of interest in COI-studies of depression was stated.



Methodical differences limited comparison substantially.



Depression is associated with a high economic burden. Conducting COI-studies of depression along the line noted in the review could help provide the opportunity to expose differences in costs associated with different approaches to disease management.

title: Employment arrangements and mental health in a cohort of working Australians: are transitions from permanent to temporary employment associated with changes in mental health?
abstract: We investigated whether being in temporary employment, as compared with permanent employment, was associated with a difference in Short Form 36 mental health and whether transitions from permanent employment to temporary employment were associated with mental health changes. We used fixed-effects regression in a nationally representative Australian sample with 10 waves of data collection (2001-2010). Interactions by age and sex were tested. Two forms of temporary employment were studied: "casual" (no paid leave entitlements or fixed hours) and "fixed-term contract" (a defined employment period plus paid leave). There were no significant mental health differences between temporary employment and permanent employment in standard fixed-effects analyses and no significant interactions by sex or age. For all age groups combined, there were no significant changes in mental health following transitions from stable permanent employment to temporary employment, but there was a significant interaction with age (P = 0.03) for the stable-permanent-to-casual employment transition, because of a small transition-associated improvement in mental health for workers aged 55-64 years (β = 1.61, 95% confidence interval: 0.34, 2.87; 16% of the standard deviation of mental health scores). Our analyses suggest that temporary employment is not harmful to mental health in the Australian context and that it may be beneficial for 55- to 64-year-olds transitioning from stable permanent employment to casual employment.

title: Long working hours and health.
abstract: This article examines associations between long working hours, depression and changes in selected health behaviours. Based on an analysis of people followed over a two-year period, the relationship between changes in work hours and changes in health behaviours is explored.



The data are from the household longitudinal component of the 1994/95 and 1996/97 cycles of the National Population Health Survey, conducted by Statistics Canada. Results are based on 3,830 adult workers aged 25 to 54 (2,181 men and 1,649 women) who worked 35 hours or more per week throughout the year before their 1994/95 interview.


ANALYTICAL TECHNIQUES
Multivariate analyses were used to estimate associations between working hours and depression, and changes in weight, smoking, drinking and exercise, while controlling for potential socioeconomic and work-related confounders such as education, income, occupation, shift work and self-employment.



Women who worked long hours had increased odds of subsequently experiencing depression. Moving from standard to long hours was associated with unhealthy weight gain for men, with an increase in smoking for both men and women, and with an increase in drinking for women. No associations were detected for physical activity.

title: Workplace Stress in Victoria: Developing a Systems Approach
abstract: To compare patterns of job strain exposure with patterns of stressrelated Workers’ Compensation (WC) claims on a jurisdictional level.  Comparison between a cross-sectional population-based sample of Victorian workers and government compiled WC statistics from the same jurisdiction and calendar year.  The state of Victoria in south-eastern Australia Participants: Job strain exposures were determined by telephone survey of a random sample of White Pages listings. Quota sampling was conducted to reflect population proportions of upper white collar, lower white collar and blue collar workers (n=1,101 with a 66% response rate). Stress-related WC claims consisted of all accepted claims from Victorian workers in 2003, where the mechanism of injury or disease was classified as ‘mental stress’ (n=1725).  Job strain prevalence was higher among females than males, and was elevated 2-3 fold amongst lower occupational skill levels versus higher for both genders. Amongst females, job strain was also positively associated with being aged 3040 versus older, being a union member and for service versus manufacturing sector workers. Compared to the overall claims incidence rate for job stress, there were elevated job stress claims in upper occupational skill levels and workers aged 45-54. Both job strain exposure and claims rates were elevated for women and the health and community services sector.  Those most likely to be exposed to and thus adversely affected by job stress are the least likely to receive stress-related WC benefits. WC statistics do not provide an adequate evidence base to guide public health responses to job stress problems. Workplace Stress in Victoria: Developing a Systems Approach Page 70

title: Depressive symptoms as a risk factor for unintentional injury: a cohort study in a rural county
abstract: The authors used data from a population based prospective cohort study to determine if depressive symptoms predicted incidence of unintentional injury.  The Keokuk County Rural Health Study, based in Iowa, is a prospective cohort study of health status that includes injury outcomes. Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale at the beginning of the study on 1493 participants. Quarterly follow up phone calls were made to measure injury incidence.  471 injuries were reported for an overall injury rate of 9.8 per 100 person-years. Crude injury rates were significantly higher for those with depressive symptoms (p = 0.0003). Those with depressive symptoms had a 41% increased risk for injury after controlling for antidepressant medication use, gender, prior injury, income, and sleepiness (RR = 1.41, 95% CI 1.10 to 1.80). Depressive symptoms remained a risk factor for injury regardless of current antidepressant medication use (no medication use, RR = 1.43, 95% CI 1.09 to 1.88; medication use, RR = 1.31, 95% CI 0.76 to 2.26).  Depressive symptoms were found to be risk factors for unintentional injury. Medical practitioners should consider talking about safety with their patients, especially those reporting symptoms of depression, and recognize that an increased risk for injury remains until the depressive symptoms subside.

title: Job strain as a predictor of disability pension: the Finnish Public Sector Study
abstract: To examine whether high job strain (a combination of high job demands and low job control) is a risk factor for disability pension.  Ten municipalities and 21 hospitals in Finland.  A prospective cohort study of 20 386 female and 4 764 male Finnish public sector employees aged 19–50 using data from two surveys (baseline in 2000–2 and follow-up in 2005) and employers’ registers. In addition to self-reported job strain, we computed work unit-aggregated job strain for each participant (the average of scores of all workers of participant’s work unit except the participant him/herself).  93 employees (0.4%) retired because of disability during the follow-up. In multilevel logistic regression analysis adjusted for demographic characteristics and health risk behaviour, odds for disability pension was 2.60 (95% CI 1.26 to 5.34) times higher for employees with high self-assessed job strain than for those with low self-assessed job strain at baseline. The corresponding OR for passive job versus low job strain was 2.82 (95% CI 1.34 to 5.96). Analysis of work unit-aggregated scores replicated the association for high job strain, OR 2.25 (95% CI 1.17 to 4.35), but not that for passive job. The association between work unit job strain and disability pension remained significant after further adjustment for prevalent diseases, psychological distress and perceived health status.  Job strain is associated with risk of subsequent disability pension. If causal, this association suggests that organisational interventions to reduce job strain may also reduce early exit from work.

title: The impact of psychosocial work conditions on attempted and completed suicide among western Canadian sawmill workers
abstract: Using a large cohort of western Canadian sawmill workers (n=28,794), the association between psychosocial work conditions and attempted and completed suicide was investigated.  Records of attempted and completed suicide were accessed through a provincial hospital discharge registry to identify cases that were then matched using a nested case control method. Psychosocial work conditions were estimated by expert raters using the demand—control model. Univariate and multivariate conditional logistic regression was used to estimate the association between work conditions and suicide.  In multivariate models, controlling for sociodemographic (marital status, ethnicity) and occupational confounders (job mobility and duration), low psychological demand was associated with increased odds for completed suicide, and low social support was associated with increased odds for attempted suicides.  This study indicates that workers with poor psychosocial working conditions may be at increased risk of both attempted and completed suicide.

title: The psychosocial work environment and alcohol dependence: a prospective study
abstract: To examine whether a stressful psychosocial work environment predicts alcohol dependence.  Alcohol dependence of participants in the Whitehall II occupational cohort of London based civil servants (1985–88) was measured in 1991–93 using the CAGE questionnaire. The psychosocial work environment was measured by self report questions on the job demand-support-control model and on the model of effort-reward imbalance. Potential mediators including physical illness and poor mental health (GHQ) were measured at follow up in 1989.  Effort-reward imbalance at work was associated with alcohol dependence in men after adjustment for employment grade and other baseline factors related to alcohol dependence. Although effort-reward imbalance predicted future longstanding illness, poor mental health and negative aspects of close relationships, the association between effort-reward imbalance and alcohol dependence in men was only partially mediated through these health and social support measures. In women, low decision latitude was related to alcohol dependence to some extent, but alcohol dependence among women was more prevalent in higher occupational grades. Men with high job demands or with low work social supports had a slightly reduced risk of alcohol dependence. No association was found between objectively assessed demands, job control, and alcohol dependence in either men or women.  A stressful psychosocial work environment in terms of effort-reward imbalance was found to be a risk factor for alcohol dependence in men. In view of the public health importance of alcohol dependence in working populations these findings call for more emphasis on psychosocial factors in occupational health research and prevention.

title: A review of empirical studies on the model of effort-reward imbalance at work: reducing occupational stress by implementing a new theory.
abstract: The present study reviews empirical studies of a new occupational stress model of effort-reward imbalance at work to examine its validity as an occupational stress measure and the theory-based intervention approach to occupational stress reduction. The effort-reward imbalance model is valid for demonstrating a stressful work environment that reflects the current labor market and predicts health conditions among a wide range of working populations. The stressful aspects of work measured by the effort-reward imbalance model are different from those shown in the job demand-control model, and the adverse health effects are independent of each other, which suggests that the two models are complementary. The evidence indicates that it is efficient to select psychosomatic symptoms as short-range target outcomes and sick leave as a medium-range target outcome of the theory-based intervention. In addition, it would be preferable to simultaneously measure job satisfaction, morale, motivation, and performance as organizational level outcomes. Although employees engaged in diverse occupations can be target populations, high effectiveness is expected, particularly in service occupations that work shifts. Studies are necessary to determine how long and how intensely interventions are implemented. Target work environments are selected from the perspective of securing or improving employees' sense of fairness and reciprocity by approaching them. Since the theory-based intervention depends largely on organizational changes that are beyond the individual employees' ability, the cooperation of employers is necessary.

title: Workplace bullying and the risk of cardiovascular disease and depression
abstract: To examine exposure to workplace bullying as a risk factor for cardiovascular disease and depression in employees.  Logistic regression models were related to prospective data from two surveys in a cohort of 5432 hospital employees (601 men and 4831 women), aged 18–63 years. Outcomes were new reports of doctor diagnosed cardiovascular disease and depression during the two year follow up among those who were free from these diseases at baseline.  The prevalence of bullying was 5% in the first survey and 6% in the second survey. Two per cent reported bullying experiences in both surveys, an indication of prolonged bullying. After adjustment for sex, age, and income, the odds ratio of incident cardiovascular disease for victims of prolonged bullying compared to non-bullied employees was 2.3 (95% CI 1.2 to 4.6). A further adjustment for overweight at baseline attenuated the odds ratio to 1.6 (95% CI 0.8 to 3.5). The association between prolonged bullying and incident depression was significant, even after these adjustments (odds ratio 4.2, 95% CI 2.0 to 8.6).  A strong association between workplace bullying and subsequent depression suggests that bullying is an aetiological factor for mental health problems. The victims of bullying also seem to be at greater risk of cardiovascular disease, but this risk may partly be attributable to overweight.

title: Depression in the workplace: An economic cost analysis of depression-related productivity loss attributable to job strain and bullying
abstract: Depression represents an increasing global health epidemic with profound effects in the workplace. Building a business case via the quantification of potentially avertable costs is essential to convince organizations to address depression at work. Our study objectives were to: (1) demonstrate a process path whereby job strain and bullying are related to productivity loss via their effects on depression; (2) estimate the costs to employers of sickness absence and presenteeism that are associated with depression; (3) investigate the relationship between depression severity and costs; and (4) estimate the contribution of job strain and bullying to depression-related productivity loss. A population-based telephone survey was conducted across two Australian states (N = 2074), with a one-year follow-up (cohort design). Results confirmed job strain and bullying affected productivity via depressive symptoms. Total national annual employer costs for lost productivity due to depression were estimated at $AUD8 billion per annum, most of which was due to mild depression. We calculated a population-attributable risk (PAR) estimate of 8.7% for depression attributable to bullying and job strain, equating to $AUD693 million in preventable lost productivity costs per annum. Findings suggest that even sub-clinical levels of depression represent a significant productivity and economic burden not previously recognized.

title: Fractions of cardiovascular diseases, mental disorders, and musculoskeletal disorders attributable to job strain
abstract: aim of this study was to evaluate fractions of diseases attributable to job strain defined using Karasek’s model among the French working population for cardiovascular diseases (CVD), mental disorders, and musculoskeletal disorders (MSD).MethodsJob strain was defined as the combination of high psychological demands and low decision latitude. The prevalence of exposure (Pe) was estimated using the representative national sample of 24,486 employees of the French SUMER survey. Relative risks (RR) were estimated from a literature review (1990–2008) using the same inclusion criteria for the three health outcomes. Pe and RR estimates were used to calculate attributable fractions (AF).ResultsPe estimates were 19.6% for men, 28.2% for women, and 23.2% for men and women combined. The literature review led to a selection of 13 studies for CVD, 7 studies for mental disorders, and 11 studies for MSD. RR estimates were 0.63–2.45 for CVD (morbidity and mortality), 1.2–3.3 for mental disorders, and 0.94–2.3 for MSD. AF estimates for CVD morbidity were 4.9–21.5% for men, 0–15.9% for women, and 6.5–25.2% for men and women combined, for CVD mortality 7.9–21.5% for men, 2.5% for women, and 6.5–25.2% for men and women combined, for mental disorders 10.2–31.1% for men, 5.3–33.6% for women, and 6.5% for men and women combined, and for MSD 0–19.6% for men, 0–26.8% for women, and 3.4–19.9% for men and women combined.ConclusionThis study is the first one to provide fractions of diseases attributable to job strain for three health outcomes in France on the basis of a systematic review of the literature. These results could contribute to the estimation of the economic cost of diseases attributable to job strain.

title: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication.
abstract: Little is known about the general population prevalence or severity of DSM-IV mental disorders.



To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication.



Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview.



Nine thousand two hundred eighty-two English-speaking respondents 18 years and older.



Twelve-month DSM-IV disorders.



Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population.



Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.

title: Job stress as a preventable upstream determinant of common mental disorders: A review for practitioners and policy-makers
abstract: There is growing recognition of the important role of mental health in the workforce and in the workplace. At the same time, there has been a rapid growth of studies linking job stress and other psychosocial working conditions to common mental disorders, and a corresponding increase in public concern media attention to job stress and its impact upon worker health and well-being. This article provides a summary of the relevant scientific and medical literature on this topic for practitioners and policy-makers. It presents a primer on job stress concepts, an overview of the evidence linking job stress and common mental disorders, a summary of the intervention research on ways to prevent and control job stress, and a discussion of the strengths and weakness of the evidence base. We conclude that there is strong evidence linking job stress and common mental disorders, and that it is a substantial problem on the population level. On a positive note, however, the job stress intervention evidence also shows that the problem is preventable and can be effectively addressed by a combination of work- and worker-directed intervention.

title: Stakeholder perceptions of job stress in an industrialized country: Implications for policy and practice
abstract: We used a secondary, qualitative analysis of stakeholder perceptions of work stress in Australia to characterize the context for policy and practice intervention.  Individual versus contextual descriptions of stress; perceived ‘gender’ differences in manifesting and reporting of stress; the work/home interface; and perceived sectoral and occupational differences in compensation claim rates. We found that people often still perceive stress as an individual rather than organizational problem and view work stress as a stereotypically feminine weakness that affects only certain people. Organizations downplay and overlook risks, increasing worker reluctance to report stressors, creating barriers to job stress interventions. Our study may be relevant to other industrial countries where researchers currently study job stress interventions to improve their effectiveness. Comprehensive approaches can increase knowledge and decrease stigma about job stress and mental illness, and target both work- and non-work-related influences on mental health.

title: The role of workplace health promotion in addressing job stress.
abstract: The enormous human and economic costs associated with occupational stress suggest that initiatives designed to prevent and/or reduce employee stress should be high on the agenda of workplace health promotion (WHP) programmes. Although employee stress is often the target of WHP, reviews of job stress interventions suggest that the common approach to combating job stress is to focus on the individual without due consideration of the direct impacts of working conditions on health as well as the effects of working conditions on employees' ability to adopt and sustain 'healthy' behaviours. The purpose of the first part of this paper is to highlight the criticisms of the individual approach to job stress and to examine the evidence for developing strategies that combine both individual and organizational-directed interventions (referred to as the comprehensive approach). There is a risk that WHP practitioners may lose sight of the role that they can play in developing and implementing the comprehensive approach, particularly in countries where occupational health and safety authorities are placing much more emphasis on identifying and addressing organizational sources of job stress. The aim of the second part of this paper is therefore to provide a detailed description of what the comprehensive approach to stress prevention/reduction looks like in practice and to examine the means by which WHP can help develop initiatives that address both the sources and the symptoms of job stress.

title: Workplace prevention of mental health problems: Guidlelines for organisations
abstract: These guidelines consist of actions organisations can take to prevent common mental health problems in the workplace. It is hoped that they will be used to improve the practices of organisations as they work to reduce the risk of job stress and mental health problems in the workplace. The guidelines are intended to complement existing legislative requirements for occupational health and safety and the prevention and management of discrimination and harassment.

title: Development of guidelines for workpace prevention of mental health problems: a Delphi consensus study with Australian professionals and employees
abstract: The purpose of the research was to conduct a Delphi expert consensus study (with employer, health professional and employee experts) to develop guidelines for the workplace prevention of mental health problems. A systematic review of websites, books, pamphlets and journal articles was conducted; a 363-item survey developed; and 314 strategies were endorsed as essential or important by at least 80% of all three panels. The endorsed strategies provided information on: creating a positive work environment; reducing job strain; rewarding employee efforts; workplace fairness; provision of supports; supportive change management; provision of training; provision of mental health education; and employee responsibilities.