Psychosocial Occupational Exposures and Mental Illness

A Systematic Review With Meta-Analyses

Background: The purpose of this study is to investigate the exposure-risk relationship between psychosocial occupational stress and mental illness.

Methods: We conducted a systematic review with meta-analyses as an update of a systematic review published in 2014. The study protocol was registered in PROSPERO (CRD42020170032). Literature searches were carried out in the MEDLINE, PsycINFO, and Embase databases. All procedural steps were performed independently by two reviewers; discordances were solved by consensus. All of the included full texts were subject to a methodological appraisal. Certainty of evidence was determined with the GRADE procedure.

Results: The pooled risk of depression was found to be approximately doubled in workers exposed to high job strain, which is defined as high work demands combined with low job control (effect estimate [EE] = 1.99, 95% CI [1.68; 2.35], heterogeneity [I2] = 24.7%, n = 8). In particular, high work demands are associated with incident depression (ES = 13.8 [1.19; 1.61], I2 = 69.0%, n = 9) and with incident anxiety disorder (ES = 1.79 [1.44; 2.23], I2 = 48.1%, n = 5). There were only a small number of methodologically adequate studies available on burnout, somatoform disorders, suicidal ideation, and suicide. Thus, no pooled risk estimates were calculated, although some individual studies showed a considerably increased risk.

Conclusion: Psychosocial occupational stress is clearly associated with depression and anxiety disorders.

Unfavorable psychosocial working conditions may pose a risk for the occurrence of mental illness (1, 2, 3, 4, 5, 6). Insight into the exposure-risk relationship is crucial for developing targeted preventive measures. The so-called doubling dose is important for the recognition of a new occupational disease: if a specific exposure is associated with a doubling of the risk of disease, it can be assumed—as a rule of thumb—that an occupational causation of this disease is more likely than unlikely. Our systematic review with meta-analyses investigates the association between psychosocial working conditions and an increased risk of mental distress or illness and analyzes the corresponding exposure-risk relationship. In addition, we examined which job groups or work-related activities are associated with a particularly high risk.

Methods

We conducted a systematic review, building on the methodology used in a systematic review published in 2014 which was carried out on behalf of the German Federal Institute for Occupational Safety and Health (BAuA, Bundesanstalt für Arbeitsschutz und Arbeitsmedizin) (7, 8).The PRISMA statement was followed for quality assurance and reporting (9). The study protocol was registered in PROSPERO (CRD42020170032).

Inclusion and exclusion criteria

The PECOS criteria were used to specify the selection criteria (10):

• Population: the working population
• Exposure: job strain (defined as high work demands combined with low job control [or decision latitude]), gratification crisis, effort-reward imbalance (defined as high efforts spent and low rewards received), lack of social support, mobbing, negative work climate, workplace conflict, job insecurity, organizational injustice, low discretionary power, long hours, shift and night work, experience of violence, sexual harassment.
• Comparator: workers not subjected to the respective exposure
• Outcome: depression, anxiety disorder, burnout, somatoform disorder, suicidal ideation, suicide
• Study designs: cohort studies, case-cohort studies, case-control studies, and mortality studies with follow-up duration longer than one year and reporting of effect estimates of the relative risks of disease; exclusion of cross-sectional studies, case series and case studies.

Search strategy

We conducted a literature search in the MEDLINE, PsycINFO and Embase electronic databases for the period 1 January 2014 to 26 June 2020 and combined this literature search with the literature search carried out in 2014. Latin-script publications in scientific journals with German or English abstracts available online were included. The search strings and further methodological information can be found in the eMethods section.

Study selection

Title/abstract screening and full-text screening of articles published after 2013 were each carried out by two persons independently (SD, AF, FH, MS). The studies included in the systematic review published in 2014 were also reviewed by two researchers independently to determine whether they met the more stringent inclusion criteria of the current review (follow-up period of at least one year, reporting of effect estimates of the relative risk of disease). Discordances were solved by consensus.

Data extraction

Data extraction was carried out by two researchers independently. Study information on reference, methodology, population, exposure, outcome, and results were documented in standardized data extraction tables.

Rating of methodological study quality

The methodological quality of the included studies was assessed by two researchers independently (SD, AF, FH, MS; solving of discordances: AS) using a tool that was developed for the 2014 systematic review based on the SIGN (Scottish Intercollegiate Guideline Network) and CASP (Critical Appraisal Skills Program) tools (8, eMethods).

Statistical analysis

Only studies with adequate methodological quality were included in the synthesis of evidence. A random-effects model was used for the meta-analytical calculation of pooled effect estimates with 95% confidence intervals if at least three individual risk estimates were available for comparable exposure-outcome combinations. Heterogeneity was evaluated by I². The Stata metan package was used for the analyses. Presence of publication bias was examined using funnel plots (for at least 10 individual risk estimates). Confidence of evidence was determined with the GRADE procedure (11).

Results

Results of the literature search

The results of the literature search are shown in the PRISMA flow chart (eFigure 1). The literature search for studies published after 2013 yielded 17 713 hits. Title/abstract screening yielded 464 publications for full-text screening. The inclusion criteria were met by 41 publications which were included in the systematic review (eTabelle 1). An additional 18 publications were included from the 2017 review (7, 8) (eTable 1). The excluded publications with references and reasons for exclusion are listed in eTable 2.

eFigure 1

PRISMA flowchart (according to Moher et al. [9]) on search and inclusion of studies

Study characteristics

A total of 59 publications from 32 studies were available for evidence synthesis. With the exception of two studies on suicide risks, only cohort studies were included. Most of the included studies were from European countries, especially from the Scandinavian region, and usually included men and women with no limitation to a specific profession. eTable 1 provides an overview of the included studies, specifying the respective included population, exposure and outcome. Detailed extraction tables for the review update are presented in eTabelle 3 and for the 2014 review in the German Federal Institute for Occupational Safety and Health (BAuA) report (8) where the included confounders are listed, too.

Results of the rating of methodological study quality

No study was found to have a very low risk of bias. Study-specific information can be found in the eMethods section.

Results for depression

Jobs characterized by high work demands and low job control (high strain)

A total of ten studies investigated the association between job strain and depression (eTable 1). A more detailed definition of job strain can be found in the eMethods section. Eight studies were included in the meta-analysis (Table 1). Four studies used the traditional classification into low-strain jobs, passive jobs, active jobs, and high-strain jobs (12, 13, 14, 15). The results of these four studies show that working in high strain jobs is associated with a 73% increase in risk of depression compared to working in low-strain jobs (characterized by high job control and low work demands) (pooled effect estimate [EE] for risk of disease: 1.73; 95% confidence interval: [1.32; 2.27]; I² = 15.8%; n = 4, Table 2, eFigures 2a–c). A dichotomous analysis of job strain (based on the ratio of job control to work demands) found a doubling of risk of depression with high job strain (EE: 1.99 [1.68; 2.35]; I² = 24.7%; n = 8, Figure 1). The risk estimates for men and women were about comparable (eFigures 3a, b). When different courses of job strain over time were examined, continuously high job strain was associated with the highest risk (EE: 2.73 [1.96; 3.80]; I2 = 11.8%; n = 3) (Figure 2). The second highest risk was found for job strain levels that increase over time (eFigure 4a), followed by job strain levels that decrease over time (eFigure 4b).

Figure 1

Risk of depression for high vs. low job strain

Figure 2

Risk of depression and continuously high job strain

Table 1

Results of the meta-analyses—Research question 1

eFigure 2a

Risk of depression: high vs. low job strain

eFigure 2b

Risk of depression: Active job vs. low job strain

eFigure 2c

Risk of depression: Passive job vs. low job strain

eFigure 3a

Risk of depression and high job strain for women (dichotomous: high vs. low)

eFigure 3b

Risk of depression and high job strain for men (dichotomous: high vs. low)

eFigure 4a

Risk of depression and increasingly high job strain

eFigure 4b

Risk of depression and decreasingly high job strain

Most studies included various occupations without specifying them more precisely. In the study of Wieclaw et al. (16), the occupational groups with the highest job strain are laborers, tradespeople, and cleaners among both men and women, as well as jobs in construction, customer service, and operating machinery.

Nine studies investigated high work demands as one dimension of job strain (eTable 1). The result of the meta-analysis shows that with dichotomous evaluation, high psychosocial work demands increase the risk of depression by 38% (Table 1, eFigure 5a) compared to low work demands. In the gender-separated analysis, an increased risk is found in women but not (with marked heterogeneity) in men (eFigures 5b, c). The comparison of the highest with the lowest category of psychosocial work demands (eFigure 6a) finds an increase in risk of 53%, while the comparison of the second highest with the lowest category finds an increase in risk by 27% (eFigure 6b).

eFigure 6b

Risk of depression and high psychosocial work demands (dichotomous: second highest vs. lowest category

eFigure 5a

Risk of depression and high psychosocial work demands (dichotomous: low vs. high)

eFigure 5b

Risk of depression and high psychosocial work demands for women (dichotomous: high vs. low)

eFigure 5c

Risk of depression and high psychosocial work demands for men (dichotomous: high vs. low)

eFigure 6a

Risk of depression and high psychosocial work demands (dichotomous: highest vs. lowest category)

The dimension of job control is examined in 14 studies (eTable 1). The result of the meta-analysis shows that lower job control as a further dimension of job strain increases the risk of depression by 14% (eFigure 7). All meta-analyses are summarized in Table 1 and Table 2.

Table 2

Results of the meta-analyses—Research question 2

eFigure 7

Risk of depression and low job control (dichotomous: low vs. high)

Further psychosocial work-related strain

A job gratification crisis (effort-reward imbalance, ERI) is characterized by a mismatch between effort spent and rewards received at work in the form of recognition, salary and job security, among others. In the included studies, an effort-reward imbalance increased the risk of depression by 72% (EE: 1.72 [1.50; 1.97], I² = 23.9%, n = 4) (eFigure 8). Our meta-analysis found that low social support at work and high job insecurity are associated with increases in risk of depression by 39% (eFigure 9) and 51% (eFigure 10), respectively. Lastly, high emotional work demands were found to be associated with a 42% increase in risk of depression (eFigure 11).

eFigure 8

Risk of depression and gratification (effort-reward imbalance) (dichotomous: high vs. low)

eFigure 9

Risk of depression and social support (dichotomous: high vs. low)

eFigure 10

Risk of depression and job insecurity (dichotomous: high vs. low)

eFigure 11

Risk of depression and high emotional demands (dichotomous: low vs. high)

Results for anxiety disorders

Jobs characterized by high work demands and low job control (high strain)

For job strain, none of the included studies reported on the risk of anxiety disorder. The dichotomous analysis found for high psychosocial work demands, one dimension of high job strain, a 79% increase in risk of anxiety disorder (EE: 1.79 [1.44; 2.23], I² = 48.1%, n = 5, Table 1, eFigure 12). In the meta-analysis results, low job control, one dimension of high job strain, was associated with a 17% increase in risk of anxiety disorder (EE: 1.17 [1.00; 1.36], I² = 38.0%, n = 6) (eFigure 13).

eFigure 12

Risk of anxiety disorder due to high psychosocial work demands (dichotomous: high vs. low)

eFigure 13

Risk of anxiety disorder due to low job control (dichotomous: low vs. high)

Further psychosocial work-related strain

No study on the association between effort-reward imbalance and anxiety disorder could be included in our meta-analysis. For high job insecurity, the dichotomous analysis found a 55% increase in risk of anxiety disorder (eFigure 14).

eFigure 14

Results for further mental impairments and illnesses

Only two of the included studies on burnout found at times significant risk increases, especially with high job strain, high work demands and high emotional demands at work (17, 18). In one of the available studies, somatoform disorders were associated with (quantitative) work demands, in men with low job control and in women with emotional work demands (16).

For suicidal ideation (n = 5 studies) and completed suicides (n = 3), studies found in some cases significantly increased risks for high job strain and its dimensions “high work demands” and “low job control”, for effort-reward imbalances, for threats of physical violence, excessive working hours, psychologically stressful customer contact, and work that is monotonous or involves a high level of responsibility (19, 20, 21, 22, 23, 24, 25, 26).

Publication bias and confidence of evidence

Confidence of evidence with regard to the association between job strain and incident depression were rated as high, based on the GRADE assessment. The confidence of evidence with regard to the association between high work demands/low job control and depression/anxiety disorder is formally low (eTable 4). No evidence of publication bias was found (Egger’s test: p>0.30).

eTable 4

Determination of confidence of evidence with GRADE

eTable 5

PECOS criteria for inclusion and exclusion of studies

eTable 6

Study appraisal using SIGN (2008) and CASP (2008)

Discussion

Consistent with previous reviews (1, 2, 3, 4, 5), our systematic review with meta-analysis indicates that jobs with high psychosocial work demands and low job control are associated with a significantly increased risk of depression (high strain jobs) (1, 3). This high risk appears to be primarily attributable to the high work demands. In contrast, the increased risk of depression in the analysis of Madsen et al. (3) is driven by low job control, not high work demands. Consistent with Kivimäki et al. (27), the risks of depression associated with high strain jobs, which are significantly higher than those for high work demands and low job control alone, suggest a combined effect of these two components of job strain. A Finnish study (28), evaluating the impact of combined psychosocial work-related strain on the risk of depression-related “disability pension” found evidence of a particularly high risk of depression (hazard ratio: 4.40 [2.43; 7.96]) associated with high strain and effort–reward imbalance (28). In addition, if organizational injustice is perceived by employees, their risk of depression increases even further.

In our meta-analysis, the association between high strain and depression reached the level of a doubling of the risk. Other reviews report slightly lower (1, 3) or significantly lower effect estimates ([3] in a subanalysis that includes individual participant data [IPD] [29]).The higher risk estimates in our meta-analysis compared to the reviews presented above are largely due to the inclusion of more recent follow-up data from ongoing cohort studies or newer primary studies and to different inclusion and exclusion criteria (exclusion of studies with self-reported diagnosis of depression and of studies using treatment with antidepressants as the sole outcome definition, among others, in our review). For anxiety disorders, similar stressful factors as for depression were identified.

Exposure-risk relationship: psychosocial occupational exposures and mental illness

A major strength of this systematic review is that it evaluated not only the risk of mental illness associated with specific psychosocial exposures, but also its magnitude (the “dose”). The depression risk comparison across exposure categories (inclusion of the highest and the second highest exposure categories in separate meta-analyses) indicates a positive dose-response relationship with respect to depression risk for several psychosocial work-related exposures (inclusion of the highest and the second highest exposure categories in separate meta-analyses). There is some evidence that prolonged exposure also increases the risk of mental illness. However, in most cases it was only possible to perform a dichotomous analysis. Consequently, the risk estimates calculated in the meta-analysis may be significantly underestimated.

Strengths and limitations of our systematic review

A strength of our systematic review is that it included only epidemiological studies with a follow-up duration of at least one year. In this way, reverse causality (i.e., the comparatively unfavorable rating of working conditions by individuals with preexisting mental illness) was avoided to the greatest extent possible.

As a point of criticism, it should be noted that only a small number of primary studies met the relatively stringent inclusion criteria, one of which was adequate study quality. Since the included primary studies did not take into account the patients’ entire lifetime, results may be biased. New-onset mental illness cannot be clearly distinguished from further episodes of preexisting illnesses which occur at least once in the lifetime of at least half of patients with depression (31). However, our review included only studies in which the target illnesses (depression, anxiety disorder) were excluded at the time of the baseline survey; alternatively, the statistical models used had to have at least included adjustments for the target illness at baseline. As a further potential source of bias, mental illness with onset early in life could have led to selection into specific job groups.The impact of preclinical depression or anxiety disorders on the mostly self-reported psychosocial work demands could have resulted in an overestimation of the assessed associations, especially when self-report data were used in combination with survey-based outcome measurement (common method bias [29]). All included studies take at least age and gender as confounders into account; the fact that socioeconomic status was not considered in some studies may, in principle, have led to an overestimation of the associations. In contrast, long follow-up periods can lead to overestimation of the associations if changes in working conditions that have occurred in the meantime are not taken into account. None of the primary studies met the requirements for very high study quality (“++”)—equivalent to a very low risk of bias—thus, there is a need for further research. The question to what extent job-related risks of disease (in terms of effect modification) may be influenced by social/cultural background or history of migration (32), is another aspect requiring further research.

Conclusions

This systematic review shows a clear association between psychosocial occupational exposures and mental illness. A particularly high risk of depression is found among workers exposed to high job strain, i.e. high work demands combined with low job control.

For everyday clinical practice, the following conclusions can be drawn from our systematic review:

• The occupational history should include psychosocial working conditions, such as time-related and emotional work demands, job control, recognition, and job security, among others.
• Avoiding excessive work demands and ensuring job control can contribute to the prevention of mental illness.
• If there are signs of impending depression or anxiety disorder due to high levels of occupational stress, it is advisable to consult with the occupational physician responsible for the employee (in agreement with the patient).

Acknowledgement

This study was conducted on behalf of the Swiss National Accident Insurance Fund (SUVA, Schweizerische Unfallversicherungsanstalt).

Acknowledgement

The authors would like to express their sincere gratitude to Dr. Ida E. H. Madsen for performing an additional analysis of the Danish Work Life Course Cohort Study for our review. We also extend our sincere thanks to Prof. Reiner Rugulies for his expert and extremely helpful comments on our manuscript.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 14 March 2022; revised version accepted on 22 July 2022

Translated from the original German by Ralf Thoene, MD.

Corresponding author
Prof. Dr. med. Andreas Seidler, MPH

Poliklinik für Arbeits- und Sozialmedizin

Medizinische Fakultät der TU Dresden

Fetscherstraße 74, 01307 Dresden

Germany

Cite this as:
Seidler A, Schubert M, Freiberg A, Drössler S, Hussenoeder FS, Conrad I, Riedel-Heller S, Romero Starke K: Psychosocial occupational exposures and mental illness—a systematic review with meta-analyses. Dtsch Arztebl Int 2022; 119: 709–15. DOI: 10.3238/arztebl.m2022.0295

►Supplementary material

eReferences, eMethods, eTables, eFigures:
www.aerzteblatt-international.de/m2022.0295

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