A new ranking index to identify the work-related psychosocial factors most impacting mental health: a cross-sectional study

OBJECTIVES

In modern professional life, mental health prevention and promotion have become a major challenge for decision-makers. Devising appropriate actions requires better understanding the role played by each work-related psychosocial factor (WPSF). The objective of this study was to present a relevant tool to hierarchise WPSFs that jointly takes into account their importance (impact on mental health) and their prevalence (the proportion of the population exposed to WPSF).

DESIGN

A cross-sectional study was conducted in March 2018 among 3200 French workers which are representative of the French working population.

SETTING

France.

PARTICIPANTS

Individuals aged 18-80 years who declared currently having a job (even a part-time job) whatever their occupation or status (employee or self-employed) were eligible. We excluded students, unemployed individuals, housewives/husbands and retired people. The mental health level was assessed using the General Health Questionnaire-28 and 44 items were gathered from theoretical models of WPSFs. We assessed two distinct multivariate methods for calculating WPSF importance: (1) weifila (weighted first last) method in a linear regression context and (2) random forests in a non-linear context. Both methods were adjusted on individual, health and job characteristics.

RESULTS

The WPSF rankings obtained with the two methods to calculate importance are strongly consistent with each other (correlation coefficient=0.88). We highlighted nine WPSFs that are ranked high by both methods. In particular, irrespective of the chosen method, lack of communication, lack of social and hierarchy support and personal-professional life imbalance, emotional demands at work and dissatisfaction with the compensation received came out as top-ranking WPSFs.

CONCLUSIONS

A total of nine WPSFs were identified as key for decision-making. The easy-to-use tools we propose can help decision-makers identify priority WPSFs and design effective strategies to promote mental health in the workplace.

Harmonized definition of occupational burnout: A systematic review, semantic analysis, and Delphi consensus in 29 countries

Objective:

A consensual definition of occupational burnout is currently lacking. We aimed to harmonize the definition of occupational burnout as a health outcome in medical research and reach a consensus on this definition within the Network on the Coordination and Harmonisation of European Occupational Cohorts (OMEGA-NET).

Methods:

First, we performed a systematic review in MEDLINE, PsycINFO and Embase (January 1990 to August 2018) and a semantic analysis of the available definitions. We used the definitions of burnout and burnout-related concepts from the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) to formulate a consistent harmonized definition of the concept. Second, we sought to obtain the Delphi consensus on the proposed definition.

Results:

We identified 88 unique definitions of burnout and assigned each of them to 1 of the 11 original definitions. The semantic analysis yielded a first proposal, further reformulated according to SNOMED-CT and the panelists’ comments as follows: “In a worker, occupational burnout or occupational physical AND emotional exhaustion stateis an exhaustion due to prolonged exposure to work-related problems”. A panel of 50 experts (researchers and healthcare professionals with an interest for occupational burnout) reached consensus on this proposal at the second round of the Delphi, with 82% of experts agreeing on it.

Conclusion:

This study resulted in a harmonized definition of occupational burnout approved by experts from 29 countries within OMEGA-NET. Future research should address the reproducibility of the Delphi consensus in a larger panel of experts, representing more countries, and examine the practicability of the definition.

Work-related psychosocial risk factors and psychiatric disorders: A cross-sectional study in the French working population

Purpose

The study estimates the prevalence of probable psychiatric disorder in the working population, determines the proportion of people presenting a probable psychiatric disorder among people exposed to work-related psychosocial risk factors (PSRFs), and identifies which PSRF has the strongest association with having a probable psychiatric disorder.

Methods

A cross-sectional study conducted in March 2018 involved a representative sample of the French working population. The General Health Questionnaire 28 (GHQ-28) was used to estimate the prevalence of probable psychiatric disorder and 44 items were gathered from theoretical models of PSRFs. We used multiple logistic regression to estimate the association of each PSRF with having a probable psychiatric disorder, adjusted on individual, health, and job confounders.

Results

This study involved 3200 French participants. The proportion of probable psychiatric disorder was 22.2% [20.6; 24.0]. Ten PSRFs were significantly associated with it. The strongest association was for having problems handling professional and personal responsibilities (reported by 15% of the study population) (OR = 1.97 [1.52; 2.54]), with 45% pathological GHQ-28 scores (potential psychiatric cases) for people exposed to this PSRF versus 18% non-exposed. The next strongest association was lack of support of colleagues (reported by 28%) (OR = 1.63 [1.29; 2.06]). The third strongest association was feeling sometimes afraid when doing the job (reported by 63%) (OR = 1.53, [1.21; 1.93]).

Conclusions

Our study identified 10 PSRFs associated with psychiatric disorder, with substantial exposure rate among the population. The results of our research could help develop recommendations to improve work environment.

How to Identify and Prioritize Psychosocial Factors Impacting Stress Level

We develop a methodological approach to identify and prioritize psychosocial factors (stressors) requiring priority action to reduce stress levels. Data analysis was carried out on a random sample of 10 000 French employees who completed, during a routine interview with the occupational physician, a 25-item questionnaire about stress levels, as well as a questionnaire about 58 stressors grouped into 5 latent variables: job control, job context, relationships at work, tasks performed and recognition. Our method combines Importance-Performance Analysis, a valuable approach for prioritizing improvements in the quality of services, with Partial Least Squares-Path modeling, a Structural Equation Modeling approach widely applied in psychosocial research. Findings on our data suggest two areas worthy of attention: one with five stressors on which decision makers should concentrate, and another with five stressors that managers should leave alone when acting to reduce stress levels. We show that IPA is robust when answers to questions are dichotomized, as opposed to the initial 6-point Likert scale. We believe that our approach will be a useful tool for experts and decision-makers in the field of stress management and prevention.

Virtual Reality Therapy Versus Cognitive Behavior Therapy for Social Phobia: A Preliminary Controlled Study

Social phobia is one of the most frequent mental disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive behavior therapies (CBT). In this last case, graded exposure to feared social situations is one of the fundamental therapeutic ingredients. Virtual reality technologies are an interesting alternative to the standard exposure in social phobia, especially since studies have shown its usefulness for the fear of public speaking. This paper reports a preliminary study in which a virtual reality therapy (VRT), based on exposure to virtual environments, was used to treat social phobia. The sample consisted of 36 participants diagnosed with social phobia assigned to either VRT or a group-CBT (control condition). The virtual environments used in the treatment recreate four situations dealing with social anxiety: performance, intimacy, scrutiny, and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations. Both treatments lasted 12 weeks, and sessions were delivered according to a treatment manual. Results showed statistically and clinically significant improvement in both conditions. The effect-sizes comparing the efficacy of VRT to the control traditional group-CBT revealed that the differences between the two treatments are trivial.

Virtual reality exposure in the treatment of social phobia

Social phobia is one of the most frequent psychiatric disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive-behavioral therapies. Graded exposure to feared social situations (either in vivo or by imagining the situations) is fundamental to obtain an improvement of the anxious symptoms. Virtual reality (VR) may be an alternative to these standard exposure techniques and seems to bring significant advantages by allowing exposures to numerous and varied situations. Moreover studies have shown that human subjects are appropriately sensitive to virtual environments. This chapter reports the definition of a VR-based clinical protocol and a study to treat social phobia using virtual reality techniques. The virtual environments used in the treatment reproduce four situations that social phobics feel the most threatening: performance, intimacy, scrutiny and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors when coping with social situations, with the aim of reducing her or his anxiety in the corresponding real life situations. Some studies have been carried out using virtual reality in the treatment of fear of public speaking, which is only a small part of the symptomatology of most of social phobic patients. The novelty of our work is to address a larger group of situations that the phobic patients experience with high anxiety. In our protocol, the efficacy of the virtual reality treatment is compared to well established and well validated group cognitive-behavioral treatment.

Definition of a VR-Based Protocol to Treat Social Phobia

Social phobia is an anxiety disorder that is accessible to two forms of treatment yielding scientifically validated results: drugs and cognitive-behavioral therapies. Graded exposure to feared social situations is fundamental to obtain an improvement of the anxious symptoms. Traditionally, exposure therapies are done either in vivo or by imagining the situations. In vivo exposure is sometimes difficult to control and many patients have some difficulties in using imagination. Virtual reality (VR) seems to bring significant advantages. It allows exposures to numerous and varied situations. This paper reports the definition of a clinical protocol whose purpose is to assess the efficiency of a VR therapy compared to a CBT and to the absence of treatment for social phobic patients. It explains the illness' diagnosis and its usual treatments. It exposes all the architecture of the study, the assessment tools, the content and unfold of the therapy sessions. It finally reports first results of a clinical trial in a between-group design in 10 patients suffering from social phobia. The virtual environments used in the treatment reproduce four situations that social phobics feel the most threatening: performance, intimacy, scrutiny and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors with the aim of reducing her or his anxiety in the corresponding real situations. The novelty of our work is to address a group of situations that the phobic patient is most likely to experience and to treat patients according to a precise protocol.

[Controlled study of outcome after 6 months to early intervention of bus driver victims of aggression]

The aftermath of psychological trauma, long since studied in the context of war ("soldier's heart", "shell shock", etc.) can also occur as a result of trauma in civilian life. Bus drivers in large urban area are frequently aggressed. Over a period of 5 months, bus drivers who had been aggressed, employees of the largest French urban transport company (RATP), participated in a study designed to evaluate the effects of cognitive behavior treatment provided shortly after such aggression. A total of 132 bus drivers were included in the study divided into 2 randomized groups: a control group (67 subjects) received the usual medical-social care offered by the company, and a treatment group (65 subjects) who, in addition, benefited from 1 to 6 sessions of cognitive behavior intervention, including:evocation of the aggression, relaxation, role plays, cognitive restructuring. Subjects were evaluated by self-questionnaires a few days post-aggression and re-evaluated 6 months later. At follow-up, results showed a statistically significant decrease in anxiety levels (measured by the HAD scale) and intrusion of the traumatic memory (as evaluated by the Horowitz scale) in the treatment group. Hence, early and structured intervention appears to lessen the impact of the traumatic event on bus drivers attacked at work.

A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia

BACKGROUND

This multicentre study compared a 16-week buspirone treatment with placebo in patients presenting with panic disorder with agoraphobia and also receiving cognitive behaviour therapy (CBT).

METHOD

Double-blind testing was maintained until week 68, but not tested; 91 patients were included; 14 placebo-responders excluded; 77 patients randomised; 48 reached week 16 and 41 reached week 68.

RESULTS

At week 16, within-group analysis showed significant improvements in agoraphobia, panic attacks, and depression in both groups. Generalised anxiety improved only in CBT+buspirone. Between-group comparisons showed buspirone to have an effect on generalised anxiety and agoraphobia. Changes in degree of agoraphobia and depression were correlated in subjects on CBT+buspirone only. A significantly higher proportion of women, and of subjects showing high avoidance dropped out. Positive expectations regarding medication predicted success in both groups. At week 68, improvement was retained without significant buspirone effect.

CONCLUSION

Buspirone enhanced the effects of cognitive behaviour therapy on generalised anxiety and agoraphobia in the short term.

[Social phobia: clinical and therapeutic approach]

Although social phobia is a real pathological condition, it has often been neglected. In fact, social phobia is among the least studies of the major anxiety disorders. This is quite surprising, as approximately 2% of the population suffer from debilitating social phobia with devastating effects on career and quality of life, and as this disorder can now be considered as a treatable condition. After defining social phobia, the authors will describe the prevalence, clinical features and etiology of social phobia. Effective psychopharmacological and psychological treatments of social phobia will also be reviewed. The drugs that have been most studied are monoamine oxidase inhibitors and beta-blockers. Several controlled studies have also concluded that behavioral and cognitive therapies (exposure in vivo therapy, social skills training, cognitive restructuring) are beneficial for social phobics. The combination of psychopharmacotherapy and psychological interventions also seems promising. Finally, as it is necessary to distinguish among various subtypes of social phobia, further studies will have to investigate whether specific subtypes do better or worse with specific treatments.

[Behavioral and cognitive strategies in stress management]

Stress is a specific response of the individual to all nonspecific demands. However, this process of adaptation is very complex and varies considerably from person to person. The stress response or "stress reactivity" is triggered by various stressors, ranging from live events to daily hassles and including chronic stressors. These stressors need to be identified. The stress response is not univocal: it has physiological, cognitive and behavioral components. Most of the time, physiological, cognitive and behavioral responses are maladaptive and harmful for the individual. Stress management is directed at teaching individuals specific skills to modify parts of these responses in order to reduce stress. Relaxation therapies are the cornerstone of any stress management program. They mostly include autogenic training and progressive relaxation training, sometimes biofeedback. The relaxation response is a learned response. There are a variety of different methods of inducing this response. They share the common goal of countering the physiological aspects of the stress reaction. All the relaxation techniques involve long and exacting training. But proper training leads to a gradual reduction in time and effort required to relax. When properly pursued, these techniques produce a state of relaxation quickly and on demand. Cognitive approaches to stress management derive from the constatation that the individual's interpretation of events or situations which have been labeled stressful, the individual's anticipation of the consequences of the stressor and the individual's view of his or her ability to cope with the stressor or the stress reaction are fundamental in the stress process. There are a variety of cognitive theories and techniques, ranging from Beck's cognitive therapy to Ellis' Rational-Emotive Therapy. Initial phases of these therapies are directed at teaching the individual to recognize, record, analyse and modify maladaptive cognitions. The second phase is usually devoted to identifying and modifying the dysfunctional attitudes which give rise to the stressful cognitions. The basic behavioral stress response falls in line with the expectations of the fight or flight response, and a stressed individual will typically display a pattern of either aggressive or avoidance behavior (as shown in the "Type A Behavioral Pattern"). The relation between stress and behavior is bidirectional: some behaviors occur in response to stress, whereas others produce stress. Assertive training is often a component of stress management programs as it is accepted that behaving in an assertive manner (i.e. a non passive and non aggressive manner) results in an increased feeling of well-being.(ABSTRACT TRUNCATED AT 400 WORDS)

[Anticipatory Cognitions Questionnaire (ACQ). Presentation and validation]

The capacity of anticipation is fundamentally disturbed in depressed patients. These patients make negative predictions. Anticipation disturbances are reflected in different symptoms but also in the patient's cognitions. The cognitive approach is an operational way to deal with the concept of anticipation. The cognitive model of depression has been extensively studied and cognitive therapies have been validated as effective treatments of depression. A self-questionnaire has been elaborated, taking into account the different cognitive mechanisms disturbed in depressed patients. The "Anticipatory Cognitions Questionnaire" (ACQ) explores patient's cognitions in concrete daily life situations that require anticipation. The first version of this questionnaire contained 18 items. A previous study had led to reduce the number of items and to modify the form of the questionnaire. In its final version, the ACQ has 8 items. Each of them refers to a concrete situation (i.e. "I have no news from a loved one") and the patient is asked to say how a proposed cognition (i.e. "I will call him to get in touch") applies to him, choosing one of the four answers "true", "rather true", "rather wrong" and "wrong". The validation of this questionnaire has been carried out, in comparison with the MADRS and Pichot's QD2A. 151 subjects were included in this validation study, 72% of them meeting with the DSM III-R diagnostic criteria of clinical depression and 28% not having any psychiatric disorder. Statistical analysis shows that the ACQ is more sensible than the QD2A but less than the MADRS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Predictive factors of a good response to cognitive therapies in depression]

Thanks to Beck's cognitive model of depression, cognitive therapies for depressive disorders have been developed. Such therapies have been proven effective when used alone or in conjunction with antidepressant drugs. However, it seems that the effectiveness of such therapies depends on some factors related either to the type of depression itself or to the specificity of the cognitive therapy. Understanding these factors helps both to know under what conditions cognitive therapy is best prescribed and to improve the therapeutic procedures used. The nature of depression and the disturbed associated cognitions is likely to have more influence on the effectiveness of cognitive therapy than the intensity of the depressive syndrome. The type of cognitive therapy used does not appear to be an essential factor in predicting therapeutic success. Two factors, however, are fundamental: carrying out assigned homework tasks; establishing a therapeutic relationship based on trust and cooperation. This is not a surprise for anyone familiar with the "didactic" as well as "therapeutic" process of cognitive therapy.

[Cognitive approach to anticipation in depression]

There is an extensive philosophical and humanistic literature concerning anticipation. Behavioural and cognitive theories have approached the concept of anticipation and have led to therapeutic solutions. The Lewinsohn model enables prediction and restoration of the activities of mastery and pleasure. The social psychology model (Bandura) forms the basis of training in assertiveness, using role-playing in order to be able to produce the relational situations which the patient will encounter. Learned helplessness for action (Seligman), teaches the reattribution of failures or successes, which leads the depressed patient to once again become involved in the action concerned. Exposure to feared situations (Marks) modifies catastrophic anticipations. The social reinforcement model (Liberman) enables prediction by functional analysis of factors involved in the persistence of problems and their modification. The mechanisms of anticipation have been reviewed since Bartlett and Ellis and up to the work of Beck. Structured patterns during existence determine thought processes in face of the circumstances which provoke them. Thus, in the opinion of the authors, our past affects our future in terms of the manner in which these patterns deal with information and determine our thoughts (cognitive events) and our vision of the future. The experimental basis of the cognitive model and the validation of these therapeutic approaches are described. The depressed patient makes negative predictions. Negative cognitions vary in conjunction with mood. Modification of these cognitions changes mood. Numerous studies are presented. They establish the effectiveness of this model, comparable to the action of antidepressant drugs and appearing to have a prolonged effect. The evaluation and cognitive treatment of anticipation are described: cognitive rating scales and analysis are proposed.(ABSTRACT TRUNCATED AT 250 WORDS)

[A new therapeutic approach: the behavioral prescription of anxiolytics]

Nowadays, two major therapeutic approaches (pharmacological and behavioural) have proven their efficiency and efficacy in the treatment of anxious disorders. These two methods have been used separately, alternatively or simultaneously. The prescription of benzodiazepines is necessary, because they are efficient and fast-acting. But this is not enough and may be hazardous for a prolonged period. Behavioural methodology and therapeutics improve the assessment of anxious disorders and offer a large variety of specific techniques to the physician. The innovative and integrative behavioural prescription (BP) is pragmatic and reliable. For instance, drugs are markers for assessment of anxious behaviours, in an agenda and may be used both to support functional analysis, and as agents of therapeutic contracts. The synergic action of behavioural prescription is clear in three dimensions: BP deepens muscle relaxation and gives better self-control and self-regulation of arousal level. BP alleviates social inhibition by developing social skills. BP modifies cognitions and affective disorders, which is necessary for permanent results and drug withdrawal. Other applications of BP will be considered in the future.

[Behavior therapy of obsessive compulsive disorders]

Obsessive-Compulsive Disorders (OCD) were once considered a relatively rare condition and highly refractory to treatment. Behavioral treatments consisting primarily of various methods of exposure and response prevention are reported to be approximately 70% effective in treating this condition that may affect 2 to 3% of the population and, in many cases, the effectiveness of these interventions persists over a number of years. However much remains to be done in refining these strategies and determining which patients are most likely to respond to these interventions.