Work and mental health

Transcription

1 Work and mental health Stephen Stansfeld Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & the London School of Medicine and Dentistry, London UK Social Medicine, The Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden October 25 th 2012

2 Overview Unemployment and mental health Psychosocial work environment and mental health Interventions to reduce mental ill-health at work

3 Depression and Disability Depression is associated with high levels of functional impairment and poor quality of life - as much as many chronic medical illnesses (MOS) Major depression now estimated by WHO to be the leading cause of diseaserelated disability among women in the world (Murray & Lopez 1996) Effectiveness at work decreased by 7x (Druss et al, 2001) (av 5.6h loss productive time/week) Average days lost due to depression 25.6 days/year (Goetzel et al, 2004) Depression predicts early retirement (McDaid et al, 2005) Depression often under-recognised and undertreated but is very treatable with CBT and antidepressants

4 Unemployment and mental health Individuals who are out of work have a higher rate of mental health problems than individuals who are employed This has been found throughout Europe, the US and Australia Most studies support the hypothesis that job loss and subsequent unemployment has detrimental effect on mental health But, the state of unemployment also has negative psychological effects not attributable to stress of job loss

5 Risk factors for CMD during unemployment Gender Men have higher risk of CMD during unemployment than women Single women and those who are the main wage-earner have a similar response to unemployment to men Age Middle-aged men experience higher distress than those who are younger or older Unemployment associated with greater financial strain and family commitment among this middle-age group Debt/Finances Financial strain acts as a mediator between unemployment and mental health problems Debt has also been found to mediate between low income and mental health

6 Unemployment and Common Mental Disorder - Clinical Interview Schedule (CIS-R) in APMS 2007 Unemployment Grouping N (%) Any CMD (weighted estimate) Working in reference week 601 (14.2%) Adjusted Odds Ratio for any CMD 95% CI Vs Not currently working 408 (28.0%) 2.05*** Employment Status: Employed 608 (14.3%) Vs Unemployed 62 (29.6%) 1.97* Vs Economically inactive 351 (28.1%) 2.05*** Had a job 895 (17.4%) Vs Never had a job 68 (19.8%) Employee 858 (18.1%) Vs Self-employed 78 (12.9%) Adjusted for sex, age, marital status, educational qualifications, ethnic group, BMI, debt, HRP and equivalised household income - APMS 2007 (Ford et al, Submitted)

7 Moderation by gender Grouping Men Weighted N Men OR (95%CI) Working Women Weighted N Women OR (95%CI) vs not working *** ( ) ** ( ) Employed vs Unemployed *** ( ) ( ) vs Economically inactive Time since last work (ref: currently working) - Less than 1 year *** ( ) ** ( ) *** ( ) ( ) - 1 year * ( ) ( ) - 2 years * ( ) ( ) years *** ( ) * ( ) - 6 years or more *** ( ) * ( ) No income benefit vs In receipt of any income benefit *** ( ) * ( ) No housing benefit vs In receipt of *** ( ) *** ( )

8 Duration of unemployment Grouping N (%) Time since last work (ref: currently working) Any CMD (weighted estimate) 600 (14.2%) Adjusted Odds Ratio for any CMD 95% CI - Less than 1 year 67 (23.8%) 1.80* year 31 (23.3%) years 29 (29.2%) years 66 (33.1%) 2.65*** years or more 139 (38.5%) 3.02***

9 Employment transitions, income change and psychological distress (GHQ) in the British Household Panel Survey (BHPS) Transitions from employment to * Men Women OR 95% CI OR 95% CI Unemployment Not worse off financially Worse off financially Retirement Not worse off financially Worse off financially Family care Not worse off financially Worse off financially Adjusted for current age - psychological distress, limiting illness, marital status, caring status, home ownership, manual occupational class at t-1 *Reference category stay employed (Thomas, Benzeval & Stansfeld, 2007)

10 Relationship between employment transitions and psychological distress Multivariate models men and women Transitions Men Women From employment to a OR 95% CI OR 95% CI Unemployment Retirement Family care To employment from b Unemployment Family care Adjusted for current age, psychological distress, limiting illness, marital status, caring status, home ownership, manual occupational class at t-1 a reference category stayed employed b reference category stayed non-employed

11 Unemployment in Finland persons Total Males Females Statistics Finland

12 Rate of psychotropic drug prescriptions by postdownsizing status Psychotropic drug = antidepressant, anxiolytics, hypnotics (Kivimaki, Honkonen, Wahlbeck, Elovainio, Pentti, Klaukka, Virtanen, Vahtera. J Epidemiol Community Health 2007)

13 Psychosocial Work Environment Job Strain Model (Karasek, 1979) (Demand/Control Model) Decision Latitude (Decision Authority, Skill Discretion) Psychological Job Demands Social Support (from colleagues and supervisors)

14 Karasek Job strain model Decision Latitude HIGH LOW Psychological Demands HIGH Active High strain LOW Low strain Passive

15 Effort-Reward Imbalance Effort-Reward Imbalance Model (Siegrist, 1996) Intrinsic Effort (innate competitiveness/hostility) Extrinsic Work Demands Reward (salary, promotion, esteem)

16 Effort-reward imbalance model effort Effort-reward imbalance reward (Seigrist 2000) Siegrist 2000

17 Work characteristics and mental health: Systematic review and meta-analysis Studies January 1994 to September 2005 Outcomes: ICD-10 neurotic disorders (F40-F42), depressive disorder (F32-F39), suicide Longitudinal studies of working age adults Studies from industrially established market economy countries Population at least 200 adults

18 Search strategy Initial search of Medline, PsycINFO and other databases and reference lists yielded 24, 939* citations Abstracts reviewed by two reviewers 50 suggestive of eligibility 13 excluded because they did not meet the inclusion criteria At full-text retrieval 38 papers met systematic review inclusion criteria 27 excluded: 13 excluded (result not suitable for metaanalysis); 6 (nonspecific work stress only); 3 (single-item stress measure); 2 (from same study) and 3 (single reports of work stressors) 11 papers met meta-analysis criteria

19 Meta-analysis of adverse psychosocial work characteristics and the risk of common mental disorders I (OR = odds ratio, 95% CI = 95% confidence interval) (Stansfeld& Candy, 2006) Group Estimates Point estimate Heterogeneity tests (N) OR (95% CI) Q-test p I sq Decision authority All ( ) Decision latitude All ( ) Psychological demands Men ( ) Women ( ) All ( ) Job strain All ( )

20 Meta-analysis of adverse psychosocial work characteristics and the risk of common mental disorders II (OR = odds ratio, 95% CI = 95% confidence interval) Group Estimates Point estimate Heterogeneity tests (N) OR (95% CI) Q-test p I sq Social support Men ( ) Women ( ) All ( ) Effort reward imbalance All ( ) Job insecurity All ( )

21 Summary of meta-analysis results Meta-analysis provides consistent robust summary evidence for associations between high job strain and effort reward imbalance and common mental disorder Low decision authority, low decision latitude, high job demands, low occupational social support, job insecurity are associated with moderate risk of common mental disorders Measurement issues (mediators, outcomes), publication bias

22 Risk of depression or depressive symptoms according to job strain Subgroup Ref Study Measure of Exposure Both genders 39 Ylipaavalniemi et al, 2005* JCQ 41 Wang et al, 2005* JCQ, sumscore workstress Men 37 Shields et al, 2008* medium strain high strain JCQ modified 28 Clays et al, 2007 JCQ 38 Virtanen et al, 2007 JCQ Women 37 Shields et al, 2008* medium strain high strain JCQ modified 28 Clays et al, 2007 JCQ 38 Virtanen et al, 2007 JCQ Summary estimates for job strain components: The average risk across all studies weighted by the number of participants was 1.31 (95% CI ) for demands, 1.20 (95% CI ) for job control and 1.44 (95% CI ) for social support." (Bonde, Occup Environ Med 2008)

23 Prevalence and ORs (95% CI) for repeated job strain and major depressive disorder: Whitehall II Study (n=3942) Major depressive disorder at phase 5 Job characteristic Prevalence (N) OR (95%CI) OR (95%CI) OR (95%CI) Adjustment Age and sex Covariates* Longstanding illness Job strain None 2.67 (46) occasion 4.16 (49) 1.56 ( ) 1.56 ( ) 1.53 ( ) 2-3 occasions 6.05 (63) 2.27 ( ) 2.19 ( ) 2.10 ( ) P-value for trend <0.001 <0.001 <0.001 * Covariates adjusted for are: age, sex, employment grade, education, marital status, smoking habit, alcohol intake, physical activity, confiding/emotional support, and social network. (Stansfeld et al, 2012)

24 Work-unit psychological demands, decision latitude and depression 4237 non-depressed Danish Public Employees in 378 work units 72% participated at follow-up: 58 new onset cases of depression diagnosed OR Low demands % CI Medium Demands High Demands Low Decision Latitude* * For a one-point decrease on the 5-point scale (Grynderup et al, 2012)

25 Criticisms of the Psychosocial Model Confounding by social disadvantage Blindness to the social context of work Self-report of work may be biased-influence of personality, negative affectivity Reciprocal effects of work and mental health

26 Reciprocal association of work and mental health Mental health may influence work characteristics Earlier psychological distress may lead to: Health selection into unfavorable jobs Choice of less demanding jobs Negative perceptions of current work (gloomy perception hypothesis) (de Lange et al, 2005)

27 Selection bias Poor mental health in adolescence might lead to selection into jobs with poorer work characteristics Poor mental health in adolescence is also associated with increased risk of mental disorders in adulthood Poor work characteristics Clinical depression Poor mental health in adolescence (Stansfeld, Clark, Caldwell, Rodgers, Power, Occup Environ Med 2008)

28 Childhood psychological distress and work characteristics in adulthood (prospective evidence) Having internalising problems at age 7 or 11 may lead to the choice of an undemanding job, possibly associated with less positive benefits (The 1958 British Birth Cohort). (Stansfeld et al. Occup Environ Med 2008) Not anxious at age 8 Anxious at age 8 Children with high anxiety at age 8, compared to their age-peers with low anxiety, were 2.4 times more likely to be in temporary employment at age 42. (Virtanen et al Soc Sci Med. 2005) 0.00

29 Early adult malaise predicting midlife work stressors: fully adjusted model: 1958 Birth Cohort Malaise at 23 High Demand Low latitude Low Support OR 95% CI OR 95% CI OR 95% CI No (n=7484) Yes (n=759)

30 Childhood internalising problems predicting socioeconomic group at 42y Socioeconomic Group Internalising Problems in childhood (Y vs N) OR 95%CI Employers/managers (large establishments) Professional workers (employees) Intermediate non-manual Junior non-manual Foreman and supervisors manual Skilled manual Semi-skilled manual Unskilled manual

31 Self-reported work characteristics Information bias Depressed mood is associated with people having a negative view of their surroundings, including the working environment Depressed mood is also associated with increased risk of mental disorders Perceived work stress Clinical depression Prodromal/unrecognised/untreated depression

32 Summary of results Psychological distress in childhood and early adulthood predicts work stressors at midlife Internalising disorders in childhood predict low adult job demands Internalising disorders in childhood predict lower status jobs High demands, low support, low decision latitude and high job insecurity were associated with increased risk of depressive and anxiety disorders at 45 Associations between work stressors and psychiatric diagnoses at 45 remained significant but diminished slightly in magnitude after adjustment for earlier psychological distress

33 The Public Sector Study- identifying OBJECTIVE indices of demands Subcohort of hospital ward personnel (n=7340) Participating hospitals routinely collect monthly figures on bed occupancy for each ward according to a standard procedure Data on the purchase of prescribed antidepressants for each employee were derived from the nationwide prescription register

34 Hazard ratios (95% CI) for the association between excess bed occupancy and future sickness absence due to depressive disorders (Virtanen et al. J Clin Psychiatry 2009)

35 Overcrowding and antidepressant treatment among staff (Virtanen, Pentti, Vahtera, Ferrie, Stansfeld, Helenius, Elovainio, Honkonen, Terho, Oksanen, Kivimaki. Am J Psychiatry 2008)

36 Other Health-threatening Aspects of Work Bullying Injustice in treatment Discrimination (age, sex, ethnicity) Long hours, shift work

37 Workplace Bullying and Depression 5432 Hospital employees, years At neither time 1.00* Incident Depression (214 cases) one time 2.27 ( ) twice 4.81 ( ) *Adjusted for sex, five year age categories, income (Kivimaki et al, 2003) Frequent bullying (1.8%) predicts long-term sickness absence in 9949 Danish elderly care sector workers (OR=1.92, 95%CI ) adjusting for psychosocial work characteristics (Ortega et al, 2011)

38 Bullying at work, health outcomes and physiological stress responses 437 employees from 5 different workplaces 5% of men and women reported bullying Bullied respondents had lower social support from co-workers and supervisors Reported more symptoms of somatisation, depression, anxiety Salivary cortisol lower at awakening in bullied respondents (Hansen et al, 2006)

39 Independent effects of racist experiences on CMD measured by the CIS-R adjusted for age, gender, marital status and social class: EMPIRIC Study Racist experiences Indian OR*, 95% CI, P value Bangladeshi OR, 95% CI, P Value Insults 3.4, , , 2-8.3, *Relative to those not experiencing discrimination (Bhui et al, 2005) (Bhui et al 2005)

40 Procedural Justice and Psychiatric Disorders 1786 female hospital employees Procedural justice - do decision making procedures include consultation with affected parties are they consistently applied, accurate, ethical and correctable? Low procedural justice Odds ratio for Dr diagnosed psychiatric disorder Self report 1.67 ( ) Unit group mean 1.69 ( ) (Kivimaki et al, 2002)

41 Association between working hours and major depressive episode: the Whitehall II study Working Hours At Baseline N Odds ratio (95%CI)* Odds ratio (95%CI)** P-value 7-8 hours hours ( ) 0.66 ( ) hours ( ) 1.27 ( ) hours ( ) 2.52 ( ) * Unadjusted ** Adjusted for age, sex, occupational grade, marital status, chronic physical disease, smoking, alcohol use, job strain, social support at work. (Virtanen et al, 2011)

42 Interacting with the public and psychological distress Study 1: Study 2: Study 1: Study 2: 11,259 employees of 58 large Australian firms 2,129 bank employees Kessler K6 to measure psychological distress Prevalence of psychological distress: 19% in those interacting with the public,15% in those who do not Employees <25 public contacts per week had significantly lower K6 scores than those with >25 contacts per week (mean K6 score 3.7 vs 5.3, p<0.016) (Hilton & Whiteford, 2010) Work overload, limited participation in decision making and client disability care positively associated with burnout in direct care workers (Gray-Stanley & Muramatsu, 2011)

43 Work and family roles and depression and anxiety Risk of depression and anxiety Women Men Partner role Parent role Work role Without children With children + (Plaisier et al, 2008)

44 Occupation and mental health

45 Occupation and mental health: ONS Survey of Psychiatric Morbidity in Private Households in the UK (2000) Sample: Sampling Frame: Interviewers visited: Adults, years living in private households in the UK Post code address file Includes England, Wales and Scotland 15,804 households Households eligible for interview: 12,792 Response rate to initial interview: 69.5% Common Mental Disorder: Clinical Interview Schedule

46 Occupations With High Prevalence of CMD by Minor SOC Group (Compared to Overall Prevalence (13%)) Clerks NES (27%) Sales (26%) General managers in government and large organisations (26%) Managers in transport and storing (24%) Professional and technical occupations NES (24%) Welfare associate professionals (21%) Catering (20%)

47 Occupations With Low Prevalence of CMD by Minor SOC Group (Compared to Overall prevalence (13%) Business, finance professionals (6%) Natural scientists (6%) Computer analysts, programmers (9%) Electrical and electronic trades (7%) Metal formers, welders (7%)

48 Occupations With High and Low Prevalence of CMD by Specific Additional SOC Unit Groups (Compared to Overall Prevalence (13%)) High rates: Barstaff (29%) Welfare, community, youth workers (21%) Nursing auxiliaries (19%) Care assistants (19%) Secondary teachers (19%) Primary teachers (18%) Security staff (18%) Waiters (18%) Low rates: Police officers (4%) Drivers of road goods vehicles (9%)

49 High and low risk occupations in the 2007 Adult Psychiatric Morbidity Survey (APMS) relative to all occupations OR + 95% CI Personal Service Managers and Senior Officials Administrative and Secretarial Sales and customer services Process, Plant and machine operatives MALE Process, Plant and machine operatives FEMALE Professional Personal Service Adjusted for age, gender, housing tenure and marital status (Stansfeld et al, 2012)

50 Adjusting occupational risk for work characteristics: APMS 2007 Unadjusted Adjusted + for Job Strain ERI Job security Social support Personal Service (relative to all occupations) 2.07 ( ) Adjusted for age, gender, housing tenure and marital status (Stansfeld et al, 2012)

51 Individual Placement and Support (IPS) Helps workless people with SMI get back to work Helps about 50% of people IPS worker supports patient and employer Disadvantages many are entry level, part-time jobs Long term outcomes unknown In UK in 18 mths 55% got into work vs 28% on standard programme IPS patients worked more days: 214 vs 108 days in controls Controls more likely to drop out and be readmitted to hospital Affected by perverse incentive of benefits, unemployment rate (Becker et al, 1994; Burns et al, 2007)

52 Conclusions There is increasing evidence that psychosocial work characteristics are important for mental health in the workplace There is need for organisational-level interventions to improve wellbeing in the workplace - focus needed on prevention, including work reorganisation There is room for more research on objectively measured work stressors

53 Acknowledgements I gratefully acknowledge the use of PowerPoint slides from Mika Kivimaki and Sam Harvey